The announcement earlier this year that Mercy Hospital in Fort Scott would close by the end of the year was a surprise and shock to the community, which will lose several hundred jobs and more than a century of community health care legacy.

But it was not necessarily unexpected to those in the industry.

Many hospitals across Kansas, as around the country, have struggled the past decade with declining patient numbers amid rising costs.

According to the Kansas Hospital Association, of the state's 127 hospitals spread across 91 counties, more than two-thirds had negative operating margins in a recent national study.

Most were reporting increases in bad debt, more charity cases and increases in the use of emergency care at the same time there were cuts in state and federal health care reimbursements.

As a result, hospital owners, other health providers and health care organizations for the past several years have been exploring alternatives to traditional systems for providing care, particularly in the state's rural areas, which face some of the most significant challenges.

A move to primary care

One example is the response to the decision in Fort Scott, which was similar to that in Independence when another Mercy Hospital closed there in 2015.

Community Health Centers of Southeast Kansas (CHCSK), a federally qualified health care center headquartered in Pittsburg, will take on providing primary care services to patients in the Fort Scott region once the hospital closes.

The nonprofit organization will assume the operation of four free-standing care facilities that were also operated by Mercy. The facilities include primary care and urgent care facilities in Fort Scott, and clinics in Arma and Pleasanton, said Jason Wesco, CHCSK CEO.

United Methodist Health Ministry Funds is supporting the shift by adding two more “patient navigators” to help coordinate care for new patients, said David Jordan, president of UMHMF.

Community Health Centers, which started with a clinic in Pittsburg in 1997 as an outreach of Mt. Carmel Regional Medical Center and then became a separate nonprofit in 2003, will grow to 17 sites with the Mercy transfers, which also include Olathe Health in Mound City.

“What we provide is integrated primary care, which is a different model” than the current services offered by Mercy," Wesco said. “We’re not only primary care but offer behavioral health, dental services and pharmacy.”

Their services also are offered on a sliding scale for the uninsured.

“So you can access care for as little as $15, including medical and vision,” he said. “So, in many ways, access to primary care in Fort Scott will improve. We’re focused on helping people access care but at the appropriate level at the right time.”

A significant concern with the loss of a hospital is the loss of its emergency room.

Though the hospital closed Dec. 31, Mercy has agreed to keep the emergency room operating through at least January, and it is in talks with the Ascension Health, owner of the Via Christi hospitals, to take over the ER after that.

“Via Christi has shown strong interest in operating the ER,” Wesco said. “Hopefully there will be no interruption in ER service.”

Notably, a Kaiser Family Foundation study following the closure of Mercy Hospital in Independence found as many as 90 percent of visits to the emergency department there were for non-emergencies.

The local ambulance service, meanwhile, which had contracted with Mercy, will also continue to be run locally, with patient transfers “dictated by location and patient preference,” Wesco said.

Not sustainable

Two Sisters of Mercy nuns founded Fort Scott's Mercy Hospital in 1885 as a 10-bed hospital. A new 45-bed hospital opened at its current location in 2002.

A significant part of the hospital’s issue was the small percentage of the population using the hospital.

“Their market share, the last time I talked to someone at Mercy, was somewhere around 20 percent of the people were using the hospital locally,” Wesco said. “They were going to Kansas City. Some were coming to Pittsburg, some over to Nevada, Mo.”

A study on patient migration by the Kansas Hospital Association in 2017 found 20 Kansas counties had hospitals that retained 25 percent or less of their county discharges, accounting for about a fifth of hospitals in the state.

It was easy to drive the hour north or east to a much larger hospital that offered more specialists and services, Wesco said. Mercy was even drawing patients away from its own hospital after it built a new one in Joplin, Mo., to replace a facility destroyed by a tornado.

The Fort Scott hospital also was not a “critical access hospital,” a designation from the Center for Medicare and Medicaid Services, which provides additional operating subsidies for hospitals with no more than 25 beds and that keeps patients four days or fewer.

There are 85 so designated hospitals in the state, according to a list from Flex Monitoring, a service-monitoring team formed by a group of universities.

“Any hospital that is not in a major urban area that is not a critical access hospital is at risk,” Wesco said. “You never want to see a hospital close, which brings with it that loss of jobs and often some of the highest wages in a community. But people should understand, the majority of health care they received in Fort Scott will still be there. And when you look to the future, what you’re going to see is what Mercy has done in Oklahoma. You don’t build a full-blown hospital; you build an emergency department or a surgery center that can do outpatient, and you do primary care.”

Another service option

The Kansas Hospital Association, with significant input from stakeholders over a four-year process, developed a proposed new health care model for rural communities called a Primary Health Center.

The model is designed to fill the gap between a rural clinic or federally qualified health care center and full-service hospitals, according to a report on the KHA website.

Core functions of a Primary Health Center include emergency room and urgent care services; primary health care; emergency and non-emergency transportation; patient observation as part of transitional care; care coordination; and telemedicine.

The model, officials said, also allows for optional services to be determined by each community. Those could include dentistry, rehab, mental or behavioral health, specialty care via telemedicine and more transitional care.

There have been numerous discussions at the state and national levels since a large Rural Health Visioning Technical Advisory Group formed by the KHA unveiled the Primary Health Center idea in 2015.

The model includes both 12- and 24-hour facilities that would provide assessment and interventional services for however many hours in the day the center is open.

A critical part of such a venture, the study noted, is a relationship with a partnering organization that could handle patients referred from the health center. Medical transportation is also vital.

“We’ve done a lot of education with our members about the changing landscape, and many are starting to see the ways these new models can benefit a community, based on their needs,” said Jennifer Sindley, Kansas Hospital Association vice president. “We have not been successful, however, in getting a demonstration to test this model to see how it would work in the real world.”

The association did a “paper test” using detailed data from a group of five hospitals around the state that indicated it could work, but they’ve not received approval from the Centers for Medicare and Medicaid Services to try it.

Lengthy process

“There are a couple of different ways we can get a demonstration project,” Sindley said. “One is to have legislation to direct CMS to create a model that looks like this one. Another is for CMS to decide they want to test something new. They’ve done that from time to time, and put out the opportunity for those interested in a demonstration project.”

The third, she said, is through the CMS Innovation Center, an agency that’s part of CMS created through the Affordable Care Act, which develops its own models based on stakeholder input and then solicits organizations to do pilot projects using grants through a competitive process.

“We’ve had conversations with a division to do a project like we want, but we’ve not been invited to formally apply,” Sindley said. “It’s a very thoughtful and long process to get through the approval to get something like this. From turning in an application to going live can take a year or two.”

The organization has also been talking to lawmakers at the state and federal levels, “to get it on their radar screens,” Sindley said.

“We’ve been working all avenues,” she said. “We’re talking to anyone willing to talk to us.”

That’s included Kansas health officials and care providers.

“We had three hospitals step forward and say they were interested in doing a demonstration,” Sindley said. “One of the three, interestingly, was Fort Scott, which is off the list now.”

She declined to identify the others but said they are proactive organizations in smaller communities.

District merger

When confronted with the reality their two hospitals just 10 miles apart in the same county faced possible closures, board members from both organizations "came to a brave decision," said Jordan, at the United Methodist Health Ministry Fund — "merge."

Harper Hospital District No. 5 and the Anthony Medical Center agreed to do so in November 2017, creating Hospital District No. 6, and representing “one of only a few hospital district mergers in Kansas,” Jordan said.

The decision, however, was significantly helped along by Neal Patterson, the late CEO of Cerner and former Harper County resident, who challenged the two communities before his death last year to join and come up with a new more comprehensive health care approach.

His estate and Family Foundation pledged $35 million toward construction and equipping costs of the new Patterson Health Center. UMHMF provided the first outside dollars to support the planning and development activities for the project, Jordan said.

A groundbreaking for a new $41 million joint campus located between the two communities was Dec. 10, 2017. Officials previously projected the first phase of the multiphase development would open in the spring of 2019.

The 62,500-square-foot complex will consolidate services offered in Harper and Anthony under one roof, including a 15-bed critical access hospital, neighboring health clinic, physical therapy and rehab center, and a wellness center.

The campus will also feature a public cafe that will also serve the hospital, as well as an open community center, public green space for community events, a community garden and various trails.

Officials estimate cost savings from the consolidation will be $2.1 million a year once the new facility is fully completed by 2021.

“As a result of the merger, the provider clinic patient experience will be improved using recommendations of the Oklahoma State University Innovation Center,” Jordan noted. “Senior behavioral health, rehabilitation, diabetic and telemetry programs will be enhanced.”

“Our hope is that this experience of two communities coming together create a health system that makes sense for the size of their communities will serve as a model for other communities,” he added.

Pre-emptive health measures

Besides looking at alternative operating models, many hospitals and health organizations are working to improve community health proactively, said Tatiana Y. Lin, a senior analyst and strategy team leader at the Kansas Health Institute.

“We’re seeing a movement toward trying to avoid readmission and avoid utilization of emergency rooms,” Lin said. “Hospitals have started engaging more in population health, looking at both clinical and non-clinical approaches to address issues in the community, such as housing and transportation.”

“With that movement the hospital becomes a very important champion in the community, impacting population health,” she said.

The effort was prompted by requirements in the Affordable Care Act for non-profits to do community needs assessments, to address some of the issues that contribute to poorer health, and it expanded from there.

The KHA recently highlighted things eight hospitals around the state are doing, including helping in trail development and assisting restaurants and schools in offering healthier food choices.

At Wilson Medical Center in Neodesha, for example, they’re working with the city to form a transportation advisory board to make the city more pedestrian and bike friendly and hired an athletic trainer to help improve student health in the local school district.

At St. Catherine Hospital in Garden City, they’ve supported transportation needs of patients and worked to address food insecurity, while Kearny County Hospital, among its numerous measures, has built greenhouses for year-round produce and helped launch a free bike-share program with the city. The hospital in Lakin is also encouraging the development of new moderate-income housing by partnering with developers to guarantee units are rented for the first year.

Housing is an issue because people in homeless populations, or those with unstable housing, are more likely to end up in emergency rooms or come back within 30 days of release from a hospital because they don’t adhere to treatment plans, Lin said.

“Some hospitals are looking at how to connect a patient who presents with certain issues with social services in the community that can help with those needs,” she said.

It’s also important for hospitals to recognize changing demographics and add or change service delivery for those populations.

Networking

Several small, rural hospitals in the state have formed a sharing network called the Kansas Frontier Community Health Improvement Network.

The group’s goal, UMHMF’s Jordan said, is to create a way for small, rural hospitals to share best practices and lessons learned, to discuss how they can improve quality and to report on projects.

“Ultimately, we see this partnership as creating an opportunity to improve how care is delivered with an eye towards sustainability and patient experience,” Jordan said. “The group is refocusing its attention on a potential shared quality measurement project.”

At Minneola District Hospital, CEO Debbie Brunner said the network helped it integrate behavioral health services into its primary care practices and to set up a process for transitional care management, both of which they’d not been able to explore without the network and support of the United Methodist Health Ministry Fund.

“We routinely email each other and do conference calls,” Brunner said. “We’re getting ready to embark on a new Frontier Network project through a workshop at the Dallas School of Medicine in Austin on redefining how we measure the value of our operations to patient and taxpayers.”

“It’s really a paradigm shift in thought processes as leaders and providers in health care, designing processes with a much better understanding of what patients hope and pray are going to be their experience at the end of care process,” she said.

Hospital leaders attended sessions in Dallas for a week in September and in October and are now working to develop partnerships with programs at the Dallas School of Medicine.

“Together we’ll work on one project, so it’s a learning and teaching experience,” Brunner said. “And then we’ll each have resources to keep going in our individual organizations.”

Other frontier network participants include hospitals in Lakin, Tribune, Phillipsburg, Oakley, St. Francis and Ashland, as well as a couple of others recently joining, Brunner said.

The group formed six years ago and generated a lot of ideas, but only in the past year or two have they been able to translate into changes at her hospital, Brunner said.

“It’s given us tools and resources to be able to do things internally, to make performance improvement part of our everyday work and get it going well,” she said. “In larger hospitals, they’ve been doing this a long time, but it’s more difficult in small, critical access hospitals.”

“I wouldn’t say it has kept us from closing, but in Minneola we want to be an example for rural health care,” she said. “We’re always looking for new opportunities and ways to do things better, to work more efficiently.”

Care Coordination

Besides funding two patient navigator positions for CHC SK in Fort Scott, the United Methodist Health Fund supported Kearney County Hospital in expanding its care coordination team to provide services to the refugee and immigrant population that in the region.

The care coordinator makes in-home visits, participates in patient rounding for acute care hospital patients and visits with emergency room patients who are triaged as non-emergent by medical providers, Jordan explained.

“All of these activities help reduce non-emergent ED use while increasing appropriate clinic use,” he said. “Additionally, the care coordinator assists patients with Medicaid applications and accessing patient assistance funds so patients can receive medications that are otherwise unaffordable.’

The care coordination team makes referrals to community-based services and provides some transportation services for patients having difficulty attending behavioral or other social services.

“This work played a significant part in reducing non-emergent visits to the hospital’s emergency room by 88 percent in a single year — from a monthly high of 110 visits down to 14 — by following up with each patient to provide education about more appropriate health care resources,” Jordan said.