On a frigid February morning in Bedford-Stuyvesant, the pediatric emergency room at Interfaith Medical Center was nearly full. Most of the people waiting were adults. Not everyone appeared to be waiting for treatment. While two television screens scrolled through a seemingly endless parade of commercials, a bevy of little girls peeked shyly around their parents. A woman, an infant in her arms, quietly made a phone call, while across the room, in a row of chairs lining the window, a man in a fedora and trench coat – a white hospital wristband still on one wrist–rested upright in his chair, legs crossed, eyes closed, a small red suitcase on wheels by his side.
In all the talk about whether and how Brooklyn hospitals will have to retrench and realign in order to survive, hospital workers from nurses to administrators know their biggest task still lies ahead of them: finding help for the people who come to the ER for assistance that has nothing to do with medical treatment.
In a 2011 study on emergency room overcrowding spearheaded by SUNY Downstate, SUNY medical students interviewed close to 12,000 people across six hospitals in North and Central Brooklyn over two weeks in the winter and the summer; of that number, interviewers discovered that 43 percent of people in the emergency room were there for non-emergent conditions. An astonishing 77 percent had some form of insurance, but preferred the emergency room for reasons ranging from easy access to being able to get all their follow up work done in one place, in one visit.
While members of the Brooklyn Healthcare Improvement Project (B-HIP), a cross section of hospitals, community based organizations, health insurance companies and chambers of commerce that collaborated on the 2011 study have been working to find ways to redirect people from ERs as well as strengthen Brooklyn’s primary care network, members of the B-HIP project acknowledge that one of their hardest jobs is to find help for people who use the ER as a safety net, when life at home becomes untenable.
People come to hospital emergency rooms to sleep, to sober up, to get warm, to stay in between other shelters. They come if someone is violent at home, or back on drugs, or if they’ve lost their job.
“As long as they’re not disruptive, there’s no reason to think something else is going on,” says one hospital administrator, who requested anonymity. “There are certain circumstances where you do pay attention: Someone comes in with a family, sits down there for three or four hours.” Then, something needs to be done. But for the most part, people use it as a quick stay, to “sober up, sleep” and then move on.
What might be a curious fact of life in most hospitals is all the more serious for safety-net hospitals, hospitals that are described by the nonprofit advocacy group Commission on the Public’s Health System as facilities where at least 50 percent of all the patients across all the hospital’s services are either on Medicaid or uninsured. At these hospitals, like Interfaith Medical Center in Bed-Stuy, Brookdale Medical Center in East New York, and SUNY Downstate in East Flatbush, there is no financial cushion to offset caring for people who can’t or won’t go home.
Hospital administrators say people are often admitted from the emergency room into the hospital who have no underlying medical problem, because the patient’s need for social services is so great. And the problem isn’t confined to Brooklyn.
“Thirty percent of the patients we see don’t have an underlining medical condition,” says Dr. David Newman, Associate Professor of Emergency Medicine at Mt. Sinai Medical Center. “We have people who show up in an emergency department and literally need a place to stay for the night. We have people who ran out of their medications and can’t get to the pharmacy and their only and best option is to call an ambulance and come to the emergency room. They are not ambulatory or they are frail and infirm and they don’t have another option.” Newman acknowledges that the hospital commonly admits patients with no underlining medical condition. “A substantial portion of any urban center’s [medical] admissions are due to the failure of the social safety net around the regions,” says Newman. “In a setting where social services are so spare and primary health care infrastructures is so decimated, we’re all that anyone has.”
At Interfaith Medical Center, the problem can be particularly acute, observes Ari Moma, a psychiatric nurse who has worked at the hospital for the past 18 years. Many times, people end up at Interfaith after they have bounced around other hospitals, been treated and released rather than admitted, because they have no insurance. “They come to Interfaith and they are sicker. They have nowhere to go.” The hospital assigns a caseworker, the patient is often admitted and then is allowed to stay while the hospital looks for a safe place for the patient to be discharged to. In some instances, they are provided with new clothing, even shoes, and are allowed to go out and look for a new place to stay, all while staying in the hospital.
In an effort to recoup the costs of caring for the uninsured, the hospital applies for emergency Medicaid funding. But the money often isn’t enough to cover the hospital’s costs.
And a difficult situation is about to get even more difficult: Under a tentative agreement with the federal Health and Human Services Administration and the Center for Medicaid and Medicare Services, CMS is waiving regulations on how New York State can use its Medicaid monies, allowing the state to apportion upwards of $8 billion in Medicaid funds to hospitals, and primary care networks, as it sees fit. As part of the waiver allowance, New York State hospitals have a five-year timeline to reduce ED admissions by 25 percent, along with showing how they are being innovative in improving quality of care.
This is a lot of pressure, observes Anthony Feliciano, director of the Commission on the Public’s Health System. Safety-net hospitals are in the bind they are in for two main reasons: first, “their charity care policies tend to be much better, are not as onerous in terms of documentation” that other hospitals demand. So it’s easier for people to be admitted. Then, too, safety-net hospitals in New York City have historically not been getting their fair share of federal money specifically set aside for charity care, known as Disproportionate Share Hospital funding–to improve. Now, under the waiver guidelines, the hospitals have to reduce admissions as well as improve quality of care, observes Feliciano, without the dollars that non safety-net hospitals have had access to all along.
So the borough is under a timeline, and safety-net hospitals, for all intents and purposes, are under the gun. “This is a major, major problem for the hospitals right now,” says Grace Wong, a member of the B-HIP executive committee and a vice president at SUNY Downstate. “This is their biggest headache. You have to really reduce your unnecessary admissions.” But where to start, wonders Wong. Being a medical provider, a hospital has a responsibility to provide services, she says. In a typical hospital, a normal discharge means the patient has “family support, resources, means of care.” In a safety-net hospital, people can’t be so easily discharged. Many times the support network is fractured, or nonexistent. Then the discharge becomes more complicated.
Hospitals can only release people when they know they’ll be safe, stresses Wong. “We cannot discharge a patient if someone is not home to take care of them.”