n . GEORGIA DEPARTMENT ~)JI OF COMMUNITY HEALTH The Rural Hospital Stabilization Program A Comprehensive Report Background of the Rural Hospital Stabilization Grant Program and Outcomes of Phases One Through Three December 2019 0 ,Q!!J:!w. AD~i~on or!he Ge0 D111t1m1nl of Communi1y H11llh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Final Report to the Governor's Office The f ull report from t he Rural Hosp ital Stabilization Comm ittee was presented t o Governor Dea l in the February 23, 2015 Final Report to the Governor. As quoted in an excerpt from the report: In April 2014, Gov. Nathan Deal announced his appointments to the Rural Hospital Stabilization Committee, which was created to identify needs of the rural hospital community and provide potential solutions. "In March of this year, I proposed three revisions to the way we approach rural health care, with one being the Rural Hospital Stabilization Committee, 11 Deal said. "I recognize the critical needfor hospital infrastructure in rural Georgia and remain committed to ensuring citizens throughout the state have the ability to receive the care that they need. This committee will work to increase the flow of communication between hospitals and the state and Improve our citizens' access to health care. I am proud to welcome this team and look forward to what we stand to accomplish." One of the main areas offocus for the Rural Hospital Stabilization Committee was to address Emergency Department (ED) stressors in rural hospitals that can contribute and lead to their closure. Within the fin al report, the Committee provided a three-part recommendation to the Governor. These recom mendations were: 1. Implementation of a grant fund ed Rural Hospita l St abilization Pilot Program utilizing a " Hub and Spoke" model approach t o four designated hospital recipients 2. Legislative support to maintain and protect t he fragile rura l hosp ital infrastructu re 3. Budgeta ry support of $3,000,000 to be appropriated to t he Georgia Depa rtment of Com munity Healt h, State Offi ce of Rura l Health to grant the fundin g to the four designated hospital recipients and oversee th e Rural Hospital Pilot Program As a resu lt of th ese recommendations, Governor Dea l allocat ed $3,000,000 in state fundin g for Fisca l Year 2016 to support the Rural Hospital Stabilization Grant Pilot Program. 7 0 ,Q!!J;!,, ADivision of tho Giorgia D1p1rtm1n1 of Community HHlth ~ GEORGIA DEPARTMENT ~ ' OF COMMUNITY HEALTH A timeline for the Rural Hospital Stabilization Committee progress is noted in the graphic be lo w : Rural Hospital Stabilization Committee established Rural Free Standing Emergency Department Regulations approve April 2014 May 2014 Rural Hospital Stabilization Committee Final Report "Hub & Spoke" Model Published February 2015 Governor signed budget $3,000,000 May 2015 The goa l of the "Hub and Spoke" mod el is to best use existing and new technology to ensure th at patients are being treated in t he most appropriate setting thus relieving some of the cost pressures on the sma llest rural hospitals' emergency departments. Through the "Hub and Spoke" model, grantee hospitals will function as the " Hub" for the project. The "spokes" would include other local health care partners and stakeholders in each respective com munity, to in clude but not limited to, tertiary hospitals, physicians, nursing homes, pub lic safety agencies, public health departments, home health and behavioral hea lth facilities, educational institutions, loca l busin esses and industry, and faith-based partners. The Press Release and complete Rural Hospital Stabilization Committee Final Report to the Governor can be located in Appendix A and Appendix 8 of th is document. 8 0 ,Q!!lt. ADivilionol lho Giorgia 01p1nm1nt ofCommunityHu llh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH The Rural Hospital Stablization Grant Program The State Office of Rural Health was designated as the oversight entity for the proposed pilot program implementation and monitoring. Prior to implementation of the pilot program, the structure and performance metrics had to be determined to ensure thorough and consistent management, documentation and evaluation during the pilot phase. To ensure adherence to the Hub and Spoke model framework, Grantees wo uld be required to assemble community stakehold er groups to identify the root causes of th eir communities' health issues and develop recommendations for community action. Projects selected as a result of community engagement efforts had to depict a design that would ensure patients are provided with the appropriate level of ca re in a timely manner, and at the most appropriate facility equipped to meet their medical needs. Selecting Program Goals and Performance Measures The four pilot hospitals were brought togeth er on August 14, 2015 to discuss th eir strategies for meeting the goals set forth in the recommendations report (see Rural Hospital Stabilization Grantees section of this report for a listing of the pilot program grant recipients). Using the Hub and Spoke model framework, the hospital leaders started a brainstorming session with the premise, "What are we trying to accomplishr and worked through pertinent data regarding fin ancia l and operational performance, market share, federal penalty program performance, and the patient perception of care. To support the "Right Care, at the Right Time, and in the Right Setting" philosophy of the program, four overarching goa ls were estab lished: Increase market share Reduce potentially preventable readmissions Reduce non-emergency care and "super users" served in the Emergency Department Increase access to primary care During the funding period, grantees would be required to provide quarterly progress reports to the RHSGP Program Manager at SORH. Reporting would include data collected quarterly specific to a pre-determined set of core performance measures. Therefore, the perform ance metrics for the program were decided as follows: 9 0 ,Q!!Jl,. ADivision ol lh1 G1orgi1D1p1nm1n1 of Communiiy H11llh 0 GEORGIA DEPARTMENT OF COMMUNITY HE:AL TH M e tric Overall Proxy Measure of Financia l Stabilization - Hub Foc us Overall Proxy M easure of Financial St abilization Community Focus Access to Ca re - Inappropriat e Utilizatio n of Emergency Depa rtment Ca re Readmission Reduction - All Cause 30 Day Hospita lWide Read missions Menta l Hea lth -Average Daily Boa rding Hours fo r 1013 Hold Out-Migration Inpatient and Outpatient Improved Fidelity- Hospital Consumer Assessment of Healt hcare Providers and Systems (HCAHPS) Source for Data Collection Hospita l Financial Statement Hospital Financial Statement Hospital Claims Data Hospital Claims Data Hospital Claims/Medica l Record Review Hospita l Industry Dat a Institute Analytic Advantage Hospita l HCAHPS Vendor Report Question #22 (Willingness to Recommend) Commitment Funds The Rural Hosp ital St abilization Program Commitm ent Funds req uirem ent was est ablished as an indicator of each hosp ital's commun ity level commitm ent . This Co m mitm ent was dem onstrat ed through th e collection of funds fro m th e grantee hospital upon grant execution. A rest rict ed fu nd source was est ablished so t hat t he communit y com m it m ent proceeds ar e dedicat ed t o th e Rura l Health St abilizat ion proj ect. This restrict ed fun d source is not subject to lapse and surp lus f unds are protect ed from being return ed t o t he treasury. The commitment amo unt fo r the Pilot Program was set at $100,000.00 per co mmun it y. Au tho rity for th e co ll ection of fund s fro m each of the grantees was estab lished o n the signature page of t he executed Notice of Grant Award Agreement. Rural Hospital Stabilization Program Continuation of Funding As annu al fund ing fo r the progra m continued each fisca l yea r beyond the intial pi lot effo rt, the Department of Com m unity Health elect ed t o cont in ue using t he o ri ginal goa ls and perfo rm ance m easures identified for the pilot project fo r each subsequ ent phase of the program . Commit m ent f unds in the amount of t en percent of grant award cont inued to be collected from each grantee upo n execut ion of t he grant fo r each new fun ding cycle. 10 0 .Q!!J;!,,, AOivilion of!he Georgia 01p1r1mtnl of Communlly Hnlih 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Rural Hospital Stabilization Grantees Hospitals se lected to participate each year in t he Rural Hospital Stabilization (RHS) Program are det ermin ed at t he legislative leve l. The Departm ent of Community Health is notified of the selected participants and the Executive Director of the State Offi ce of Rural Health communicates with the Chief Executive Officer (CEO) of each hospital to determin e interest in participation in the program. Hospitals m ay choose to participate or decline the offer. Particip ating hospitals for phases one through three of the Rural Hospital St abilization Grant Program are described below, indicating the phase of participation, funding amount, and th e fundin g period. A description of the hospital and services offered, as well as description of the county in which t he hospita l is located is also included. A color-coded map denoting the location of each site ca n be locat ed in Appendix C of this document. Rural Hospital Stabilization Grant Program Sites: Phase 1 {Pilot) Four Sites Selected Fiscal Year Funding: 2016 Appling Healthcare System $3,000,000 (annual) award Crisp Regional Hospital Emanuel Medical Center $750,000 award to each site Project Period: July 2015 - December 2016 Union General Hospital Appling HealthCare System 163 East Tollison Street Baxley, Georgia 31513 Opened in 1951, Appling Hea lthCare Syst em is a non-profit acute care medical facility which continually dedicates its purpose of providing patients with the highest quality of medica l care. Appling Healt hCare System is licensed for 64 beds (of which 30 are ded icated t o the Geri atric Behavioral Health Unit) and offers a vari ety of technologica lly advanced and high-quality impatient and outpatient hea lth care services to Appling Co un ty. Appling Hea lt hCare System is located in the city of Baxley, which is the county seat of Appling County. As of the 2010 census, t he county's population stood at 18,236 resid ents, comprised of 8,512 housing units and 4,894 families residing in the county. Appling County has a total of 5 12 square miles w it h 507 square miles of land and five square miles of water. 11 0 ,Q!!IL. AOivi,lonollho Gt"'9io DDJ)WMIII orCommuni1Y Hallh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Crisp Regional Hospital 902 7th Street North Cordele, Georgia 31015 Esta blished in 1952, Crisp Regiona l Hospital offers Crisp Cou nty and surrounding areas high-q uality hospital and outpatient care fo r fam ily and emergency medicin e, obstetrics/gynecology and over 20 other specialties. With a Level Ill t rauma center and more t han 50 physicians who practice in a high-tech hospitalist environment, Crisp Regional offers a comprehensive network of facilities t hat incl ude a 143-bed nursing home, retirement home, dialysis faci lity, home hea lt h program, hospice and home care program and rural hea lth clinic. Crisp Regional Hospital is in th e city of Cordele, which is t he county seat of Cri sp County. According to the 2010 census, t he co unty's pop ulation stood at 23,439 residents, comprised of 10,734 housing units and 6,295 families residi ng in the cou nty. Crisp Cou nty has a total of 281 sq uare miles with 273 square mil es of land and approximately eight sq uare miles of water. Emanuel Medical Center 117 Kite Road Swainsboro, Georgia 30401 Emanuel Med ical Center feature s a hea lt hca re team of over 450 employees, over 40 physicians and provides quality care, close to home, for fam ilies in Emanuel County and surrounding communities. The hospital is eq uipped with 18 patient rooms, all furnished w ith full bathrooms, tel ephones and televisions, 15 Senior Behaviora l Health private room s, 49 nursing home beds and eight Critica l Care rooms. Ema nuel Medical Center is located in the city of Swainsboro, w hich is the county seat of Emanuel County. As of the 2010 census, the county's population stood at 22,598 residents, which is comprised of 9,968 housing units and 5,833 families residing in the county. Emanuel County has a total of 690 sq uare miles with 681 square miles of land and approximately nine sq uare miles of water. Union General Hospital 35 Hospital Road Blairsville, Georgia 30512 Located in North Georgia, Union General Hospita l serves all commu nit ies in t he North Georgia area with high-qu ality ca re. Due to its location, Union General Hosp ital is in t he 12 0 ,Q!!Ji!,m AOMslon of iht Gtotgla OeptrlmtntofCommunlly H11lth 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH unique position of providing a plethora of healthca re needs to citizens in Blairsvill e and Gainesville, as we ll as Murphy, North Carolina, Greenville, South Carolina and Chattanooga, Tennessee. From its humble beginnings as a small outpatient clinic that opened in 1959, Union General Hospital has advanced into one of Georgia's most stateof-the-art and technologically advanced hospitals. Union Genera l Hospita l is located in the city of Blairsville, which is the county seat of Union County. As of the 2010 census, the county's popu lat ion stood at 21,356 resid ents, comprised of 14,052 housing units and 5,833 families residing in the county. Union County has a total of 329 sq uare miles with 322 square miles of land and seven square miles of water. Rural Hospital Stabilization Grant Program Sites: Phase 2 Four sites selected; one declined Habersham Medical Center Miller County Hospital Upson Regional Medical Center Fiscal Year Funding: 2017 $3,000,000 (annual) award $1,000,000 award to each site Project Period: September 2016 - June 2018 Habersham Medical Center 541 Historic Highway 441 North Demorest, Georgia 30535 Habersham Medical Cente r is a 53-bed not-for-profit acute care medical faci lity that prides itself in offering award-winning health care to more t han 80,000 residents in Habersham and surrounding counties. Habersham Medical Center employs more than 600 healthcare workers who strive daily to meet and exceed patient expectations. Habersham Medical Center is located in the city of Demorest. Per the 2010 census, the county's population stood at 43,041 residents with 18,146 housing units and 11,307 families residing in the county. Habersham County has a total of 279 square miles with 277 square miles of land and two square miles of water. Miller County Hospital 209 North Cuthbert Street Colquitt, Georgia 39837 Open ed in 1957, Miller County Hospital is a 25-bed critical access not-for-profit hospital named by HomeTown Health as "The Hospital of the Year" in both 2000 and 2015. 13 0 .Q!!IL AOiv~lonof 1h, (l0()19la Oepa'1tntnl ofCommuniiy Health n~ J J ' GEORGIA DEPARTMENT OF COMMUNITY _H E ALTH Miller County Hospital delivers a spectrum of inpat ient and outpatient services to th e resid ents of Co lquitt and surrounding areas and is dedicated to deliverin g high-quality hea lth care for Sout hwest Georgia residents. Miller County Hospita l is located in th e city of Colq uitt, which is th e county seat of Mill er County. As of t he 2010 census, t he county's population stood at 6,125 resid ents, m ade up of 2,426 housing units w it h 1,674 families residing in t he county. M iller County has a total of 284 square miles, w it h 282 sq uare miles of land and t wo square miles of wat er. Upson Regional Medical Center 801 West Gordon Street Thomaston, Georgia 30286 Upson Regional M edical Center is an acute care hospital t hat is home t o more t han 500 employees w ho daily strive to ma intain "the cleanest hospital in the stat e" by listening to th eir customers and cont inually improving based on feedback. Upson Regional M edical Center is const ant ly adding new services, includ ing cardiology, new t echno logy and new physicians, w ho st rive t o offer t he highest quality care on a daily basis. Upson Regional M ed ica l Center is locat ed in t he city of Thomaston, w hich is th e co unty seat of Upson County. As of t he 2010 census, t he county's population stood at 27,153 residents made up of 12,161 housing units and 7,382 fa milies residing in th e count y. Upson County has a tota l of 328 square miles, w ith 323 square miles of land and approximately fi ve sq uare miles of water. Rural Hospital Stabilization Grant Program Sites: Phase 3 Twelve sites selected; One declined Fiscal Year Funding: 2018 Bacon County Hospital Chatuge Regional Hospital Cool< Medical Center $3,000,000 (annual) award $250,000 award t o each site Project Period: July 2017 - June 2018 Effingham Health System Irwin County Hospital Jasp er M emorial Hospital Liberty Regional M edical Center M emorial Hospital & Manor Mitchell County Hospital 14 0 .Q!!J:L. A Divilion of tho G101gi1 01p1itm1n1 of Communil)' Htellh n GEORGIA DEPARTMENT ~)JI OF COMMUNITY HEALTH South Georgia M edical Center-Lanier Campus Washington County Regional Medical Center Bacon County Hospital 302 South Wayne Street Alma, Georgia 31510 Bacon County Hospital is a 25- bed, acute care general medica l-surgical hospital which is part of a medical complex that comprises 11 acres and over 25,000 square feet. Bacon County Hospita l prides itself on providing compassionate ca r e mat ched w ith up-to-date technology and services to th e community of Bacon and surrounding counties. Bacon County Hospital is located in the city of Alma, which is t he county seat of Bacon County. As of the 2010 census, the co unty's population stood at 11,096 residents, comprised of 4,801 housing units and 2,960 families residing in the county. Bacon County has a total area of 286 squ are miles, w ith 259 square miles of land and 27 sq uare miles of wat er. Chatuge Regional Hospital 110 South Main Street Hiawassee, Georgia 30546 Chatuge Regional Hospital is located along Highway 76 North, tucked into the beautiful North Georgia Mountains. An affiliat e of Union General Health System, Chatuge Region al Hospital features a state-of-the-art Emergency Center with an air ambulance service providing access to m ajor trauma and ca rd iac facilities. First named Lee M . Happ Jr. M emori al Hospital, the hospita l changed its nam e to Chatuge Regional Hospital in 1994. Chatuge Regional Hospital is locat ed in the city of Hiawassee, t he county seat for Towns Cou nty. Accordin g to the 2010 census, Towns County has a population of 10,471 r esidents w ith 7,731 housing units and 2,981 families residing in th e county. Towns County has a total of 172 square miles, w ith 167 squ are miles of land and approximately five square miles of water. 15 0 ,Q!!It. ADivision of!ht Gtorgl1 Otpa~m,nt of Cammuniiy H..lth 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Cook Medical Center 706 North Parrish Avenue Adel, Georgia 31620 Cook Medical Center, now renamed Southwell Medical, recently moved to a new location as part of t he new Cook Med ical Plaza. The new 120,000-square-foot facility is fu lly operational w ith a rehabi litation department, sleep center, and a fu ll-service laboratory with outpatient surgica l se rvices to be offered soon in a variety of specia lti es. Southwell Medical now also offers an extensive medica l imagi ng department as well. The hospital is located in the city of Adel, which is the county seat of Cook County. As of the 2010 census, the popu lation stood at 17,212 resid ents, with 7,287 housing units and 4,594 fami lies residing in the county. Cook County has a total area of 233 square miles w ith 227 square miles of land and six square miles of water. Effingham Health System 459 Georgia Highway 119 Springfield, Georgia 31329 Effingham Health System is a Level IV Trauma Center, with state-of-t he-art treatment roo ms for trauma, stroke, and cardiac patients with a proven track record of providing high-quality advanced trauma life support. Effingham Hospital prides itself on having an entire team of resid ency-trained, boa rd certified Emergency Medicine Specialists prepared to treat all patients, from newborn through geriatric. The nursi ng staff of Effingham Hospital is Trauma Nursing Core Certified, all with training in the rapid discovery of life-threatening injuries and comprehensive patient assessment. Effingham Health System is located in the city of Springfield, w hich is the county seat of Effingham County, As of the 2010 census, t he county's population stood at 52,250, with 19,884 housing units and 14,139 fami lies residing in the cou nty. Effingham County has a tota l area of 483 squa re miles, w ith 478 sq uare miles of land and five square miles of water. Irwin County Hospital 710 North Irwin Avenue Ocilla, Georgia 31774 Irwin County Hospital is a 34-bed acute care facility offering a wide range of medical services to Irwin and surrounding counties. Governed by a seven-member Board of Directors, Irwin County Hospital is a non-profit corporation backed by a 66 member staff 16 0 .Q!!I!,,. AOMiionollho Gto,gla Otpat1men1olComrnunily Htollh n~ Y..' GEORGIA DEPARTMENT OFCOMMUNITYHEALTH who is committed to promoting healthier lives for patients by emphasizing core va lues such as quality, teamwork and a patient-centered perspective. Irwin County Hosp ita l's emergency department hand les more than 5,000 visits annually while its Birthing Place delivers over 400 babies a year. Additionally, th e on-site nursing hom e mai ntains fu ll capac i t y . Irwin County Hospita l is located in the city of Ocilla, which is the county seat of Irwin County. As of the 2010 ce nsus, the county's population stood at 9,538 residents, with 4,033 housing units and 2,475 families r esiding in the county. Irwin County has a total of 363 square miles with 354 miles of land and eight sq uare miles of water. Jasper Memorial Hospital 898 College Street Monticello, Georgia 31064 Designated in Janu ary 2000 as a Critical Access Hospital, Jasper Memorial Hospital is a licensed, 17-acute-care bed facility, with a 24-hour emergency room that offers highqua lity care provided by contract physicians staffing through Schumacher Clinical Partners. Equipped with advanced cardiac monitoring, Jasper Memorial Hospital offers outpatient and ambu latory ca re services and prides itself on having an average wait time of less than 30 minutes for all emergency room services. Jasper Memorial Hospital is located in the city of Monticello which is the county seat of Jasper County. As of the 2010 census, the county's population stoo d at 13,900 residents, w ith 6,153 housing units and 3,779 families residing in the county. Jasper County has a total of 373 square miles, with 368 square miles of land and approximately five sq uare miles of water. Liberty Regional Medical Center 462 Elma G. Miles Parkway Hinesville, Georgia 31313 Opened in 1961 as Liberty M emorial Hospital, Liberty Regiona l Medica l Center is a 28bed acute care hospital serving over 50,000 patients a year in Liberty County and surrounding areas. Liberty Regional Medical Center prides itself in its use of advanced technology and teams of top-notch physicians and nurses backed by a caring staff of other clinica l and non-clinical personnel. 17 0 .Q!!lt. AOMw nol \ht Go1gia Opat11,,en1 ol Comn1unity Health 0 ~ GEORGIA D EPARTMENT OF COMMUNITY HEALTH Liberty Regional M edical Center is located in the cit y of Hin esville, w hich is the county seat of Liberty County. As of the 2010 census, t he county's population stood at 63,453 residents, w it h 26,731 housing units and 16,566 fa milies res iding in the county. Lib erty County has a total of 603 sq uare miles w it h 490 sq uare mil es of land and 113 squa re m iles of water. Memorial Hospital & Manor 1500 East Shotwell Street Bainbridge, Georgia 39819 Open ed in 1960, M emoria l Hospital & M anor employs over 450 hea lth care personnel and offers a w id e range of hea lth ca re services to Bain bri dge and the surrounding areas. An 80-bed acute care hospital, M emori al Hospital & M anor has expa nded its faciliti es t hroughout t he years t o accommodat e needs of a growing com m unity, including opening M emori al M anor, a 67-b ed Long-Term Care Facility, in 1972 followed by M anor II in 1979 which added another 40 beds to t he nursing hom e. M emorial Hospita l & M anor also offers an intensive care unit and m aintains continuous renovations of patient rooms in the hosp ital as well as resident rooms in th e Manor. Plans are current ly underway for a Sa me Day Surgery center at th e hospital, w hich w ill expand t he faci lit ies for Radiology, Laboratory and other va ri ous departm ents. M emorial Hospita l & M anor is located in th e city of Bainb ridge, w hich is t he county seat of Decatur County. As of t he 2010 census, the county's populatio n st ood at 27,842, w hich is made up of 12,125 housing units and 7,255 families residing in the co unty. Decatur County has a t otal of 623 sq uare miles w ith 597 sq uare miles of land and 26 squar e miles of water. Mitchell County Hospital 90 East Stephens Street Camilla, Georgia 31730 Mitch ell County Hospital is a 25-bed critica l access hospital t hat offers personalized inpatient and outpati ent services t o M itchell County residents and surrounding areas. As part ofthe Archbold network, Mitchell County Hospital is a critical part of a syst em w it h a ded icated staff r egarded for high-quality, co mpassionat e medical care. Mitchell County Hospital is located in the city of Camilla, which is th e count y seat of Mitchell County. As of th e 2010 census, t he cou nty's population stood at 23,498 18 0 ,Q!!,!!u,, ADivision of Ut, G10rgi1 01p1rtm1nl of Community H11ltt1 n GEORGIA DEPARTMENT ~)JI OF COMMUNITY HEALTH r esidents wit h 8,996 ho using units and 5,761 families residing in th e cou nty. Mitch ell County has a total of 514 square miles, w ith 512 sq uare mi les of land and approximately two square miles of water. South Georgia Medical Center Lanier Campus 116 West Thigpen Avenue Lakeland, Georgia 31635 Sout h Georgia Medical Center (SGMC)-Lanier Campus, form ally the Louis Smit h M emorial Hospital, operates as a 25-bed critical access hospital w hi ch provid es acute and sub-acute ca re to Lakeland and surrounding communities. W it h the distinction of being the largest employer and economic generat or in the Lakeland community, SG M C Lanier Campus is proud to offer a variety of quality services w ith the personal touch of a small community hospital including program s for preventive and wellness m edicine, acute and chronic disease management, immunizations, healt h coaching and minor emergencies. South Georgia M edical Center- Lanier Ca mpus is located in the city of Lakeland, which is the co unty seat fo,: Lanier County. As of the 2010 census, the county's populat ion st ood at 10,078, which consist ed of 4,249 housing units and 2,626 families residin g in the county. Lanier County has a total of 200 square miles w ith 185 square mil es of land and 15 square miles of water. Washington County Regional Medical Center 610 Sparta Road Sandersville, Georgia 31082 Opened in 1961, Washington County Regional M ed ical Cent er (WCR MC) is a licensed genera l acute ca re 56-bed hospital which provides a scope of services including comprehensive inpatient and outpatient surgery, a 24-hour physician staffed emergency room as well as an Imaging Center, Rehabilitation Se rvices and Ambulance Services. WCRMC serves patients from five counties and it committed to providing their patients w ith the highest quality care and play an instrum ental role in the community' s hea lth and happiness. Washington County Region al M edica l Center is located in th e city of Sandersville, which is the county seat of Washingt o n County. As of the 2010 census, t he county's population stood at 21,187 w ith 9,047 housing units and 5,269 fa milies residing in the county. 19 0 .Q!!J;!/t/, AOiv~ionol!ht Geo,gia01p1rtm1n1 of CommuMy Health ~ GEORGIA DEPARTMENT ~ ' OF COMMUNITY HEALTH Washingt on Cou nty has a t otal of 684 square miles w ith 678 squ are miles of land and six square miles of water. Phase Four and Phase Five of the Rural Hospital Stabilization Grant Program Tw o addit ional phases of the Rural Hospital Grant Program have been fund ed in fi sca l yea r 2019 and fi sca l yea r 2020. Rural Hospital Stabilization Grant Program Sites: Phase Four Four Sites Selected Fiscal Year Funding: 2019 Burke Medical Center Clinch County Hospital Elbert Memorial Hospital $3,000,000 (annual} award $750,000 award to each site Project Period: July 2018 - June 2019 Evans Memorial Hospital Rural Hospital Stabilization Grant Program Sites: Phase Five Ten Sites Selected; Two Declined Fiscal Year Funding: 2020 Candler County Hospital $3,000,000 (annual} award Dodge County Hospital $300,000 award to each site Dorminy Medical Center Project Period: September 2019 - August 2020 JeffDavis Hospital Jefferson Hospital Stephens County Hospital Wayne Memorial Hospital Wills Memorial Hospital A det ailed evaluat ion using t he same methodology describ ed in th e next section of this report w ill be completed for Phase Four and Ph ase Five Grantees and will be provided as an add end um to this document in December 2021. 20 0 ,Q!tt!"" ADivisionorlh Gtoigla 01p1rtm1nlolCommunity Health 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Where Are They Now? A Retrospective Evaluation of Outcomes for the Rural Hospital Stabilization Grant Program Phases One Through Three The " Hub and Spoke" model, described previously il'.1 this report, is the foundation for th e Rural Hospital Stabilization Grant. Grant deliverables require Hospita l Grantees to select projects that will support the "Right Care, at the Right Time, and in the Right Setting" philosophy of the program. Grantees are also expected to design the projects with input from the commun ity obtained through community engagement meetings, and develop budgets appropriate for project needs. Eighteen hospita ls participated in phases one through three the RHS Grant Program. The number of projects per site was left to the descretion of the gra ntee and guided by the amount of the fundin g award. In April 2019, the Stat e Office of Rura l Health began compilation of a comprehensive report to eva luate the RHS Grant Program outcomes for grantee hospitals that had pa rticipated in phases one through three. Th e purpose of the eva luation was to determine the overall benefit of the gra nt to each hospital and the surrounding community, and the sustainabi lity of the projects funded through the program. As a requirement of the grant, each site had designated a Project Manager r esponsible for oversight of the grant and providing quarterly and fina l reports and invoices to the State Office of Rura l Hea lth. The Chief Executive Officer, the Chief Financia l Officer, and the Project Manager at each site were asked to partner togeth er to provide the requested information for the report. Methodology A comprehensive questionnaire was designed to collect qualitative and quantitative data specific to: benefit, outcomes, and sustainability of the proje~ts select ed by each grantee hospital financial, operational, and statistical data prior to and after funding period The questionnaire, referred to as the "Rural Hospital Stabilization Grant Program: Where Are They Now?" document, provided instructions for completion of the survey an d a deadline for submission of the completed docum ent to SORH. 21 0 ,Q!tt!,1, ADivision ol lh, G101gl Otpanm,ntolCommunity Heollh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH The questionnaire was divid ed into four sect ions: 1. General Grantee Information 2. Project Specifi c Details 3. Overall Impression and Benefit of RHSGP 4. Financial Data Collectio n The questionnaire was distributed t o th e CEO at each Grantee Hospital by way of electronic m ail commun ication. Section Two of the questionnaire required th e Grantee to respond to a serie s of questions specific to each project that had been selected and fund ed through the RHS Grant. The number of projects chosen by each Grantee varied, however the qu estionnaire was not considered to be properly complet ed without including t he req uested information specific t o each project funded. Specific to Section Four of the questionnaire, SORH obtained written permission from the Chief Executive Officer or t he Chief Financial Officer at each Grantee Hospital to allow Draffin Tucker, LLP, to utilize and summ arize the hospit al's fin ancial data from audited fin ancial statements and other grant-specific financial information provided for this report. A copy of the questionnaire temp late used for th e collection of this information ca n be locat ed in Appendix D of this document. Findings: Proj ect M anager Th e RHS Grant allowed Grantee Hospitals to select a Project Manager from within or hire from outside the organization. Grant fund s cou ld be used as sa lary support for a current ly existing employee or fun d a portion, or all, of a new emp loyee's sa lary. Questions specific to the status of the Project Manager Question Findings/ Results Was th e Proj ect Manager selected from 72% of Project Managers were already employed by staff already employed with your faci lity or t he Grantee Hospital hired from outside of your orga nization? 28% of Project Managers were hired specifica lly to manage the grant Is the Project Manager still an employee of 78% of Project Managers were still employed by t he your organization? If so, in what capacity? hospital as of June 2019 22 0 ,Q!!.!!,, ADivisoo of lh1 Georgie D1p111tn1n1ofCcmmun;cy H11llh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Specific to the Project Managers' employment status after termination of the grant, those Project Managers who were em ployed with the organization prior to receiving the grant continued in their sa m e ro le after grant termination. Those Project Managers who were hi red from outside the organization were either placed into an open position with in the organization, or a position was created/modified, most often in a community outreach or marketing rol e. Findings: Specific Projects Funded Section Two of the questionnaire required that each respondent complete an "Attachment A" document (see Appendix D) for each individual project that had been selected by the Hospital Grantee and funded through the RHS Grant. The number of projects selected by each site varied with some hosp itals se lecting only one project and some hospitals selecting as many as six projects. For the purpose of data collection, the following information is specific to the com bined number of project s for all eighteen sites. Collectively, the projects were grouped based on similarity of design allowing an opportunity to evaluate the most common ly select ed project s as well as the most unique. A combined total of 52 projects were funded through the grant during thi s evaluation period. The categories in which the projects were grouped are listed below: Grouping of Projects Telehea lth/Telemed icine Community Paramed icine Emergency Department Renovations Upgrades New Service Lines New Designations Mental/Behavioral Hea lth Chronic Condition/Care Coordination Unique/Miscellaneous Number of Projects 13 5 3 2 9 4 5 7 4 The top four most commonly selected group s of projects are detailed below: 1. Telehea/th/Telemedicine The most commonly selected projects were those involving telemedicine as a primary component. These projects included telemedicine utilized w ithin school-based clinics, behavioral health facilities and nursing homes. Two projects included telemedicine 23 0 ,Q!!J;,t , ADivision of the Gtorgl 01p1rtm1nl olCommunity Hnllh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH utilization in the field to enhance triage and destination selection for patients presenting with signs of a stroke, and one project w as specific to consultation with a Nephrologist, allowing patients to report to their local hospital for follow up evaluation and treatment inst ead of t raveling several hours to a faci lity in an urban area. 2. Community Paramedicine and Chronic Condition/Care Coordination Care coordin ation projects were the seco nd most commonly selected. For the purpose of the data collected for this report, "ca re coordination" included a variety of methods in w hich patient care was m anaged in an effort to ensure the "right care, at the right time, and in the right setting". Therefore, two groupin gs have been combined for this report. Five of the proj ects were provided through an arrangement with the loca l Emergency M edical Service t o provide care to the patient in their hom e environm ent to reduce unnecessary 9-1-1 calls and emergency department visits, as well as reduce th e number of hospital readm issions w ith in a 30-day period. Other types of car e coordination projects includ ed Patient Care Coordinat ors, in w hich hospital staff worked w ith patients after discharge to ensure discharge instructions were followed and follow-up appointments were met. Other projects included hospital emergency department triage to re-direct nonurgent/non-emergency patients to walk-in clinics, Nursing Home roun_ds provid ed by advanced practice providers to prevent unnecessa ry transports to the emergency department, and th e utilization of Commun ity Hea lth Workers and Community Hea lth Coaches. 3. New Services Funding from th e grant program was used t o create new services offered by Hospital Grantees. These new services included the co nstruction of new facilities such as wa lkin/non-em ergency and charity ca re clinics (som e in cluded expanded hours of operation), remodeling existing structures to offer Geriatric Psychiatric in-patient facilities, occupationa l medicine, and weight loss/wellness progra ms. One Hospita l Grantee used fund ing to reopen the Intensive Ca re Unit w ithin the hospital, w hich had been closed for several years. 4. M ental/Behavioral Health The fourth m ost commonly select ed type of projects were those designed to provide o r enhance mental and behaviora l health ca re w ithin the community. All Grantee Hospita ls acknow ledged these projects led to a strengthened relationship w ith the local Com munity Service Board during the design of the proj ect. Project s included t he provisio n of both outpatient and in-patient services (in som e cases where non e had exist ed previously). Projects 24 o ~.Q!!Jt. ADivitblof!ht ~14 Depeltnlot ofCemmuftify Hullh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH w it h a specifi c patient-popu lation focus included servi ces for se nior ad ults (age 55 and older), adolescent/youth programs, or programs d esigned specifically to address opioid addiction. The questionnaire also included questions specific to the benefit and sustainability of the proj ects. Project Specific Details Question Is this project still on-going? Was/ls t his project financially sustainable after t ermination of the gra nt? Would your hospital have selected/fund ed this project if the RHSGP had not been ava il ab le? Did t his project lead to relationship development w ith other partners and subsequent addit ional projects? Findings/ Results 83% of original projects were still on-going as of June 2019 67% of original proj ects were conside red fin ancially sustainable post-grant 20% of th e projects would have been done at some (later) point 75% of the projects led to project-specific new relationships As indicated above, th e RHS Grant Program allowed twenty percent of Gra ntee Hospit als the opportunity to implem ent programs wh ich had been ident ifi ed for future efforts, as w ell as allowing eighty percent of Hospital Grantees the opportunity to explore new ideas and initiatives. With Hospital Grantees reporting that eighty-three percent of th e project s were still on-going, and sixty seven percent of those projects were fin ancially sustainable post ~grant, it is evident that communities have benefited from the effort to design programs to address specific community need s. Overall Impression and Benefit of the Rural Hospital Stabilization Grant Program Section three of the questionnaire was designed to collect information specific to the RHS Grant Program as a w hole and det ermin e which projects Hospital Grantees f elt had the most and least impact. 25 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Specific to the overall benefit of the program, the following question s were asked: Question Based on your experi ence with the RHSGP, do you fee l this program met its intended objective to ensure patients receive the "right care at the right time in the right setting"? Did your facility seek other grants/funding so urces to expand or sustain any work begun through the RHSGP? Based on your experience w ith the RHSGP, if given the opportunity to start your project over, would you have made the same decisions, choices, done anything differently, etc.? Findings/Resu lt s 100% (18/18) of recipients felt the RHSG Program did meet the objectives. 44% (8/18) of recipients did choose to seek additional f unding to continue or strengthen projects begun with RHSGP funds. 83% (15/18) of recipients would have made different decisions or choices about some aspect of their projects or selected an entirely different project all together. Based on your experi ence with the RHSGP, what suggestions or advice would you offer to a new RHS grant recipient? 17% (3/18) of recipients would have made no changes at all to decisions or projects. See Appendix Efor a complete list of responses Hospital Grantees who indicated they wou ld have made different decisions or choices about projects exp lained their positions in a commentary format. Most respondents felt they chose too many, or too ambitious projects specific to the time constraints of the funding period. Other comments refl ected a desire to have been more selective when choosing vendors for the projects. Clarification for this question is reflected in many of the suggestions or advice that was collected and reported in Appendix. Specific to the overall impact of th e program, two questions were asked : Question #1. "Overall, what do you feel was the most beneficial or impactful component of your projects? Please explain." 26 0 .QJ!J;!,, ADivi~onollht Gto,via Dtptruntol olCommunily H11llh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Specific to the most beneficial or impactful component, overwhelmingly, re spondents indicated that community engagement and sta keholder collaboration was the most beneficial result of the program. Hospital Grantees indicated that, due to the " Hub and Spoke" model design, new and improved relationships with their co mmunities had resulted in an increase in utilization of services, improved perception and reputation of the hospital, and a rebuilding of "faith and trust" in the providers and system in general. Specific to the most beneficial group of projects funded through the grant, respondents cited Commu nity Paramedicine/Care Coordination projects as having the most positive impact for patients. Commentary provided with the responses indicated that working directly with patients in a one-on-one capacity resulted in improved patient comp liance with discharge instructions, increased follow up with primary care providers, improved ab ility for self-ca re, increased utilization of other re sources avai lable to the patient, and decreased dependency on emergency services, both fixed and mobile. Question #2: "Overall, what do you feel was the least beneficial or impactful component of your projects? Please explain." Interestingly, while Tel emedicine/Telehealth projects were the most commonly se lect ed, Telemedicine was also identified as the least beneficial or impactful project funded through the program. Commentary provided by respondents indicated that, while t elemedicine had been identified as one of the most promising servi ces for the provision of health care in rural areas, provid ers and patients were slow to embrace th e concept. Also, estab lishing relationships with specialist s could be time consuming and costly in the initial phases of building telehealth programs between rural and urban providers. Another barrier was described as the "failu re of a 360-degree commitment". Telemedicine requires a two-party agreement between those who w ill present patients to the provid er, and the provider who treats the patients presented. For both sides of the relationship to work effectively, guidelines and processes must be estab lished, equipment must be purchased and maintained, and presenters and providers must be trained and proficient in the use of the equipment. Some respondents indicated that a less-than-enthusiastic attitude demonstrated by either one of the required parties resu lted in failure of the program. Other challenges were described as frequent turn-over by trained staff participating in the program without proper training for new staff, and a lack of overal l understanding of the technology. 27 0 .Q!!JI". ADivi>lon of11,e G.o111la D1p1r1m1n1 ol Commun;,y H11llh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Findings: Financial Analysis Section Four of t he questionnaire was comp leted by Draffin Tucker, LLP. As previously deta iled in this report, permi ssion to access hospital financia l records was obtained from each Grantee Hospital prior to beginning th e analysis. Methodology Financial, operational, and statistica l data was gathered from all of the hospitals in phases one through three. This data was obtained from audited finan cial statem ents, cost reports, and other sources provid ed by the hospitals. The individu al hospital data was su mmarized to ca lculate and present finan cial ratios, indicat o rs, and other information . The most recent five years of available data is presented with reporting to the closest corresponding fisca l year. All hosp ital data was presented w it hout consideration for the va riou s start dates of the three phases. For reference, st art dates and number of hosp itals for the va riou s ph ases are as follows: Ph ase One - July 2015 - four hospitals Phase Two - Sept ember 2016 - three hospitals Phase Three - Oct o ber 2017 - eleven hospitals The most recent fiscal year dat a was utilized if any of th e years were incomplete for an individu al hospital. For example, if Hospital X's 2018 audited financial st at ements were not completed, then Hospital X's 2017 audited financial statements wou ld be used for 2017 and 2018 without any adjustments. Certain individual hospital data elements were excl uded if the data element was not consistently prepared. This reflects t he practice where some hospitals are report ed as departm ents and do not prepare individual stand-alone balance sheets separate from th e overall multi-hospital syst em consolid ated ba lance sheets. Cert ain data elem ents from two individual hosp itals was excluded as a result. Compar ative ratios are presented w here app licable and are from t he 2019 Almanac of Hospital Fin ancial and Operating Indicators (the Almanac) published by Optum360. The ratios refl ected in this report prim arily reflect s 2017 data from Medicare Cost Report fi lings as published in the Almanac. Almanac ratios for specific cat egories includ e: Georgia - average of all Georgia hospitals National Rural - average of rural hospitals with revenues less than $90 million 28 0 ,Q!!It. ADi\ltslon orthe Giorgia D1p1rtm1nt ofCommunlly Health n GEORGIA DEPARTMENT ~J)I OF COMMUNITY HEALTH As applicable, each ratio presented w ill includ e several key pieces of inform ation: Ratio Type Desired Trend Definition Formula Overall Summar y Findings Over the past five yea rs, the hospitals in these first three phases have faced a vari ety of fa ctors including changing or declining demographics, varyin g patient pref erences, shifts in service pattern s from inpati ent to outpati ent, introduction of new reimbursement m echanisms and models, increasing salary and other cost s, and adjusting regulat ory or pol icy impact s. The hospitals are working to address th ese challenges and adapt to this changing healt h ca re environment. Hospitals are compelled to grow revenue to offset in cr easing expenses, develop new service lines, reduce cost s, and implement other operat ional and fin ancial actions to keep the hospitals' doors open and continue to serve the community. Overall, t he hospitals in Ph ases One through Three refl ect rel atively st able result s considerin g the significa nt changes they have encountered in the past five years. None of th ese hospitals have closed during th e period under review . These hospitals w ill continu e t o be evaluat ed on an annual basis, and future reports wi ll incorporat e the results of Ph ase Four and Ph ase Five hospitals. 29 0 ,Q!!J;!,1, ADiv~lonof lhoGoo,vla D1p111mon1 of Ccmmuney Htallh Detailed Analysis 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Average Daily Census Ratio Type - Volume Desired Trend - Increasing Definition - Measures the average number of adu lt and pediatric inpatient days over a fisca l year. Excludes swingbed and nursery days. Formula - Total Adu lts and Pediatrics Inpatient Days/ 365 Average Daily Census 25 20 l? 15 C Q) .-1 10 &. 5 0 - - - - - A.ll Phase-s Phase 1 Ph~se-f cl>iiasef - - - 2014 11 18 . 19 6 - 2015 - 11 18 22 --- 6 - - - - 2016 2017 11 - 10 2-018- - - 10 17 - 22 6 - - -17 18 5 -- - -- ---- 17 18 5 ~Draffin Tucker As reflected in the data, the number of patients reported as inpatient is not a large number for all phases or the individual phases on average for the year. These numbers will fluctuate based on surgica l cases, flu season, or other reasons, and the hospital wi ll have to adjust its staffing, medical supplies, and other items to meet the varying demand for services. Th e trend for these five years reflect an overall decrease in average daily census from 2014 to 2018. 30 0 ,Q!!J;!,, AOlvis<>n of the Georgia Otp1rtmen1 of ~muniiy Hetlth n~ Y J G EORGIA DEPARTMENT OF COMMUNITY HEALTH Patient Mix - Inpatient Days - Payer Percent age and Days Patient Mix - 1/P Days - Medicare % 50.0% . 45.0% 40,0% 35.0% ~0.0% 2014 42.3% 43.7 % 42.7% 41.7% 2015 __ - ... 42,..2__%_ 4 2.4 % 4Q:!'!b 42.8% -it!- --- !i -r~ itii -- 2016 - 4ti:'0%-.. 201 7 4 2.3% 1 201a i 44.1 % -")Draffin Tucker Patient Mix - 1/P Days - Medicare Days 12,0,00 I 10,000 8,000 ~co 6,000 0 4,000 2,000 , I 0- .. 9,009. 9,006____ _ 8,471 <5.Droffin Tucker For M edicare, t he inpat ient days m ix is increasing from 42% to 44%, but the actual patient days declined 6% fo r Phase One, 7% for Phase Two, and 14% for Phase Three. 31 0 .Q!!J!,, AO~i,ion of the Georgia Otptltn1tnl of Community Hnllh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Patient Mix - 1/P Days - Medicaid % 20.0% 15.0% .5.0% 0.0% All Phases Phase 1 Phase 2 Phase 3 2014 'jo1o 11.4% 8.4% 2015 9:6io" 12.8% 11.2% -w--- - -- 7.9% 2016 . _9...9..%........ ... 15.3% 12.0% 7.3% 2017 2018 8.8% 9.5% - ... -1-0-.9--%-- 10.6% 13.2% 18.5% 7.3%- -. ,.... 8.8% ")Draffin Tucker Patient Mix - 1/P Days - Medicaid Days 3,500 3,000 2,500 ~ 2,000 ~ 1,500 1,000 500 O 2014 2015 2016 -----~ 2,607 - _ _ 3,138 ---- . 2, 243 _ - - - ~376--- - - 2,330 1,904 2017 2018 2,077 2,137 ., - - - 1973--- .2,485 ,_.,_, 1,808 1,959 <5Draffin Tucker For M edica id, the overall inpatient days mix is increasing from 9% to 11%. However, in patient days mix stayed relatively consistent for Ph ase One and Three. Phase Two M edica id inpatient days mix went from 10% to almost 19%. Actual M edi ca id patient days declined 26% for Phase One and 24% for Phase Three w hile Ph ase Two increased 36%. 32 0 .Q!!IL ADivisionof lht Gtotgla Ooptrtmantof Community H11lth n~ y , GEORGIA DEPARTMENT OF COMMUNITY HEAL TH Patient Mix - 1/P Days - Other % 55.0% 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 2 01 4 Alf Phases --- ~-~~. --- .. Prase l ... Phase 2 a Phase 3 44.8% 17-.~~~- 49.8% < ' 5 o r o f f i n Tucker Patient Mix - 1/P Days - Other Days 1Moo 14,000 12,000 V> 10,000 r>o- a,ooo Cl 6,000 4,000 2,900 0 . aPhase 1/ i5iiase2[ a Phase 3: 12/315 . ~Q(2J_!!' 14,103 .. 12,751 _ _12,951,_ 12,998 } 1,02 ~~~62_~ 12,442 12,157 10,061 . ii,892 - _9,'141 .- 10,640 - 45 Q 40 35 2014 2015 2016 2017 All Phases 50 49 47 49 Phase 1 49 55 55 53 Phase 2 40 41 44 43 CPhase 3 53 48 45 50 Georgla-53 Nat'I Rural - 58 2018 49 49 41 52 -,Draffin Tucker Net days i~ net patient accounts receivab le stayed relatively consistent on an overall basis with some variations w ithin the phases during the five year period. The data indicates it takes an average of 49 days for hospitals to receive payment for se rvices for the most recent year. 36 0 ~,Q!!,t!,,, AOivi1lon of l/10 GtorglaDop,rtmont of Community Ht1llh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Average Payment Period Ratio Type - Liquidity Desired Trend - Decreasing Defin ition - Measures the average time that elapses before current liabilities are paid. The denominator is an estimate of the hospital's average dai ly cash expenses minus depreciation. Creditors regard high values for this ratio as an indication of potentia l liquidity problems. Formul a - Current Liabilities/ [(Total Expenses - Depreciation)/ 365] Average Payment Period .Georgia - 50 Nat'I Rural - 54 90 80 70 6P ~ so . ~ 40 30 20 10 O ... 2014 2015 60 61 --8531 ,,. - 47 62 si "57 2016 2017 2018 58 66 68 52 - - 49 _., 50 50 48 46 64 79 84 <5Draffin Tucker Average payment period is a liquidity measure which shows the average time it takes the hospital to pay its vendors. The trend for this ratio should be decreasing; however, the data reflects the ratio at an average of 68 days in 2018 w hich is a 13% increase from 2014. In 2018, the in dividual phases range from a low of 46 days for Phase Two to a high of 84 days for Phase Three. Phase One is at 50 days for 2018. 37 O ~.Q!!lt. AOlviolon ol 1h Gtorgl Oapartmtnl ol Commun/I}' Healih 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Average Age of Plant Ratio Type - Asset Effici ency Desired Trend - Decreasing Definiti on - Measures the average age of the hospital's fixed assets in yea rs. Lower va lues indicate a newer fixed asset base and thus less need for near term replacement. Form ul a -Accumulated Depreciation/ Depreciation Expense Average Age of Plant Georgla- 13 Nat'I Rural - 13 22 20 18 ~ m 16 14 ~ 12 10 8 6 - 2014 AfPhases 13 Phase 1 ... ----- 13 o Phase fihase 2 I " . - - -1i40 - - --2-015- 14 - 2016 2017 --- 16 '" - - -18---H - - - - -1-3- - - - 1i60 _ _ _ - --- 15 , 4oh 11 16 - - - -12-- 18 20 _... .._ - _____ 2.0...1...8 18 1-7- - - - 12 2i <5Dfaffin Tucker Average age of plant is an indicator for how old th e equipm ent, building, and other fixed asset s of t he hospit al are and shows the potential need for replacement or updating. From 2014 to 2018, there was an overa ll agi ng of fixed assets from 13 to 18 - an increase of 5 yea rs or 39% increase in th e average age of plant. 38 0 ,Q!!,!,t, AOivi1lon of lht Georol Otpttlmtnl ofCO(llmunlly Hnllh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Total Operating Revenues Total Operating Revenues $350,000 $300,000 $250,000 1$200,000 $150,000 $100,000 $50,000 $0 - Phase 1 II Phase 2 CPhase 3 2014 $200,052 - -$139,139 $267,384 - <')Draffin Tucker Total operating revenues includes revenue from patient services and reflects the gross charges of the hospital adjusted down to the amounts actual ly expected to be collected from payers and patients. There is an increase in all phases from 2014 to 2018. Phases One and Two report a 26% increase or approximately 5% per year over this time period. Phase Three reflects an 11% increase or less than 3% increase per year over the t ime period under review. 39 0 ,QJ!JI,. AOivislO!Iof1/lt Georgia Oepar1menl of Communlly H11llh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Operating Margin Ratio Type - Profitability Desired Trend - Increasing Defin ition - Reflects the proportion of operating revenue retain ed as income and is a measure of a hospital's profitab ility from the provision of patient car e services and other hospita l operations. Formula - (Operating Revenue -Total Expenses)/ Operating Revenue Operating Margin Georgia - Positive 0.2% Nat'I Rural - Negative 3.3% 4.0% - 2 .0 % 0.0% -2.0% 4.0o/o -6.0% -8.0% All Phases Phase 1 Phase 2 Phase 3 2018 --- __ 4.0% ,,__ -1.3% 2.9% -5.3% =-)Draffin Tucker Operating margin is a profitab ility measure focused on t he provided hospital services and generally does not include investment income, donations, nonoperating amounts, or unusual adjustments. Overa ll operating margin hovered around a loss from 3% to 4% with mixed r esults by individua l phases with all phases ending up at t he same or decreased margins in 2018 as compared to 2014. 40 O ~,Q!!IL. ADivision ol lhe Gtorgle Oep1r1men1 ol Community Hnllh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Total Margin Ratio Type - Profitability Desired Trend - Increasing Definition - Defin es the percentage of total revenue that has been realized in the form of net income or excess revenu es over expenses. Used by many as a primary m easure of hospita l profitability. Formu la - Excess of Revenues (Expen ses)/ Total Revenue Total Margin Georgia - Positive 1.8% Nat'I Rural - Negative 1.9% 6.0% 4.0% 2.0% 0.0% -2.0o/o -"4.0% -6.0o/o All Phases Phase 1 Phase 2 Phase 3 2014 -0.9% 2 .5% '1.5% -3.6% io1s -0.3% 4.5% 5.1% -3.5% 2016 2017 2018 ---0.9%--" -o--.3--o/-a- -- - - -0.5-%- - - 2 .0% 2.5% - - ---210-..-.876%%%- - <-5Draffin Tucker Total margin includes all revenue and expenses, in cluding donations and investment in com e. Overall result s for all phases went from -0.9% (negative margin) in 2014 to 0.5% (positive margin) in 2018. Positive margins are reflected in Phases One and Two and an improving m argin in Phase Three . 41 0 .Q!!I!,1, AOivi1lon orlho Goorglo Oop1<1monlofCommunil)' HHIU1 0 GEORGIA DEPARTMENT 'OF COMMUNITY HEALTH Current Ratio Ratio Type - Liquidity Desired Trend - Increasing Definition - Measures the number of dollars held in current assets per dollar of current li abilities. Most widely used measure of liquidity. High values imply a good ability to pay short term obligations and thus a low probability of technical inso lvency. Formu la - Current Assets/ Current Li abilities Current Ratio 3.5 3.0 2.5 . 2.0 1.5 1.0 0.5 0.0 -=-- An P;h~l~els Phase 1 2014 -2-.s- - - 2.1 i --PP-hhaassee 3 - - -12-..99- --- 2015 2.3 - 2.s - 2.0 - 2.4 2016 21""'" 2,0 2.3 2.0 Georgia - 2.1 Nat'I Rural - 1,.5 2017 2018 2.1 1.8- - - 2!~ _ _2,!.~. . -- -- 2.3 -- 1.8 ... -2.3- 1.5 ... :')Draffin Tucker Current ratio reflects liquidity of the hospital w ith two times current assets over current liabilities. Phases One and Two hovered around 2 between 2014 and 2018 whi le Phase Three dropped from approximately 3 to 1.5. 42 0 .Q!!J:t, ADivl1lonor lht Gto,glaDep1run1nt orCo,nmunity H11l1h n GEORGIA DEPARTMENT ~)JI OF COMMUNITY HEALTH Days Cash on Hand - Short-Term Sources Ratio Type - Liquidity Desired Trend - Increasing Definiti on - M easures the number of days of average cash expenses that the hospital m aintains in cash and market able securities which ar e cl assifi ed as cur rent asset s. The denominat or m easures the average da ily cash expenses less depreciation. High va lu es usually imply a great er ability to meet short-t erm obligations and are viewed favor ably by cr editors. Formula - (Cash + Short-Term Investments) / [(Total Expenses- Depreciation) / 365] Georgla-9 Days Cash on Hand - Short-Term Sources Nat'I Rural - 15 60 50 40 r~o 30 0 20 10 0 - -AllPhases - Phase 1 Phase 2 OPhase 3 2014 35 20 42 39 2015 38 22 53 - "'u- 41 - 2016 32 - - -2017 34 - - 2.01-8 - 26 21 ...-~- ---,..-- 25 n 18 -F- -- F - - - 41 34'' .. 40 36 ... . ... . .. 37 'i6 .. - <._, Draffin Tucker Days cash on hand from short-t erm sources show declines over the time period w ith 35 in 2014 t o 26 in 2018, a 26% decrease in liquidity. All individual phases showed de.clin es in this ratio w ith decreases of 10%, 12%, and 33% in Phase One, Phase Tw o, and Phase Three respectively. 43 0 ,Q!!It. ADivision oftilt GeorgiaDepartmanl ofCommunity Heollh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Long-Term Debt to Capitalization Ratio Type -Capital Structure Desired Trend - Decreasing Definition - M easu res the relat ive importance of long-term debt in the hospita l's permanent capital structure. Net assets and long-t erm liabilities are often referred to as permanent capital since they will not be repaid within one year. Hospitals with high va lues have relied extensively on debt as opposed to eq uity to fin ance their assets and are said to be leveraged. Meaning risk may be viewed unfavorably by many cred itors. Formula - Long-Term Debt/ (Long-Term Debt+ Net Assets) Georj)ia - 34% Long-Term Debt to Capitalization Nat'I Rural- 6% Other Nat'I Rural- 36% 70.0% 60.00/o 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 2014 An Pii-ases 32% Phase Phase 21-_ _ _ _2_~0~ 59% i:i Phase 3 24% -- - ___ 2915. 2016 2917 2.0. 18 -- - ____ -3-3-%- 28%._ 57% -_---+-------?3.~8'.%'!,~.- 53% - - ----- -~e7'.Io:'/~o----~ 47% , - - - 35% -4276.%.% - - - - 27% 37% 38% 35% ')Draffin Tucker Long-term debt to capitalization reflects if the hospital is using debt to f inance its operations. The expected trend for this ratio is decrea sing; however, for all phases, the ratio went from 32% in 2014 to 35% in 2018. Both Phase One and Two showed declines from 2014 to 2018, but Phase Three went from 24% in 2014 to 35% in 2018 resulting in the overall summary increase for all phases. 44 0 .Q!!J;!,,, ADivision oflho G,orglo 01p1rtme,I ofCommunity H11llh 0 Net Position Net Position $250,000 $200,000 l $150,000 s $100,000 $S0,000 GEORGIA DEPARTMENT OF COMMUNITY HEALTH <"5 Draffin Tucker Net position is comparative to stockholders' equity and reflects how the hospital's overa ll net assets are performing. Both Phase One and Phase Two have increased over the time period with 26% and 18% increases, respectively. Phase Three declined 17% over the same t ime period. 45 0 ~.Q!!,.!!"" ADivision ol lhe Georgia 01putment ol Community Ht11th 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Findings: Other Through additional commentary collect ed within the qu estionnaire, as well as meetings and discussions with Grantees during t he fun ding period, it was recogni zed th at th e RHS Grant Program reinforced th e need to focus on som e basic business practices and principals. Som e of t he ge neralized recomm endations offered as a result of the " lessons learned" fro m this program are: Every hospital should build and/or improve existing relat ionships with the community; don' t ta ke the community for granted. Recognize t he importance of engaging (and st aying engaged w it h) st akeholders, providers, and community partners. Re-evalu at e services offered by your hospit al; eliminate or add services based on need, utilization, cost, and ability to generat e revenue. Don't continue "doing w hat has always been done" simply due t o 'tradition' or out of 'f ear of change'. Marketing is extremely important; don't assume your community is aware of t he servi ces you offer or the qu ality of your care. M arketin g, promoting your services, and educating your co mmunity on w hat you have to offer is th e first st ep in reducing outm i grat i on . Invest in your employees. Improve employee morale and workplace satisfa ct ion. Solicit input from st aff and implement reasonable suggestions. M aintain high expectations for professionalism, productivity, compet ency, and quality of work. Above all, lea d by exa m p l e. Show pride in th e facility. Improve the appea rance of the hospital, parkin g lot, and surrounding areas. Sometimes huge improvements can be made by simply cutting the grass, trimming t he bushes, perking up the flower beds and picking up trash in the parkin g lot. First_impressions are lasting. And last, ensure all st aff underst and the importance of creatin g a fri endly and w elcoming environment for vi sitors and co-workers alike. Offering a smile, being kind and polite, professional and respectful, and "going the extra mile" ca n improve the reputation of a hospital w ithout the need for a budget increase. The St at e Office of Rural Healt h asked t he Chief Execut ive Offi cers of Grantee Hospitals to provid e a st at em ent regardin g their experi ence w ith th e grant program . A full listing of responses can be locat ed in Appendix F of this document. 46 0 .Q!!IL. AOMslon ollht Gt orgla Oopt rtmontolCommunity Hfllil> 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Summary The spot light on the rural hospital closure crisis across the country and t he conversations th at began because of th e closures brought t his situat ion t o the Nation's attention. Georgia is fortun at e that Governor Deal chose t o add ress t his cri sis in an aggressive m ann er. Continuing into Govern or Kemp's Administration, Georgia is providing on-going support for rural hospita ls t hrough the Rural Hospital Sta bilization Grant Program and other rural-focused initiatives. The RHS Grant Program has al lowed an opportunity to det ermin e which grant fund ed project s have or have n't w orked, and all hospitals, even those that have not been part of the Stabilization program, can and wil l continue to benefit from the results of this funding. Grantees acknowledged th at due to the requirements of the grant, th ey bega n evaluating their day-t o-day pr act ices and reviewing hospital dat a from a different perspective . M any rural hospitals had been fun ctioning in a "survival" mode for so many yea rs that selecting proj ect s and making decisions about effective ways to spend grant fund s was surpri singly ch allenging to some. The va lue of an up-t o-dat e Strategic Plan was recognized by Hospital Grantees through this program. The St ate Office of Rural Hea lth reports frequently on the RHS Progra m in loca l, region al, and state level m eetings. As th e goals of th e program and the results of proj ect s select ed by grantees is spot lighted in these public forum s, all hospitals are encouraged t o place a higher emphasis on intern al assessments and st rat egic planning. Oth er st at es have now taken the lead in hospita l closures, but t he visibilit y and success of the Rural Hospital Sta bilization Grant Program has allow ed ot her stat es to bring this program into their conversat ions as they begin to address these problems in t heir own st at es. The Stat e Office of Rura l Hea lth is fortunate t o have the responsibility of adm inist erin g this gra nt and w ill provid e follow up information on Phase Four and Phase Five outcom es as an add endum to this report in December 2021. 47 0 ,Q!!Jil/, A OMtloo of lht Oto,gl1 01p1r1m1nt of Community H111lh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Sources 2019 American Hospital Association Rural Report, www.aha.org. Georgia: 2010 Population and Housing Unit Counts 2010 Census of Population and Housing. U.S. Department of Commerce, www2 .census.gov/library/publications/decennial/2010/cph-2/cph-212.pdf. "About Appling HealthCare." Appling Healthcare, www.ahcs.org/. "About Crisp Regional Health Services." Crisp Regional Hospital, www.crispregional.org/about/ . "Welcome to Emanuel Medical Center." Emanuel Medical Center: About, www.emanuelmedica l.o r g / a b o u t /. "Union General Hospital, Inc." Hospital in Blairsville, GA / Union General Hospital, www.uniongenera lhealthsystem.com/ugh . "Get To !ion ol tht GeorgiaOeptllffltntof Communit/ Hoallh n~YJ. GEORGIA DEPARTMENT OF COMMUNITY HEALTH "Community Param edicine - this service ca n be a benefit to the community and patients at risk. However, there is no reimbu rsement for this costly service." "Need to work closely with primary care physicians and pediatricians as they feel threatened by this project and think you are t rying to stea l their patients." "One of the most valuab le lessons has been commu nication and education regarding our local CSB. We didn't know them and t hey didn't know us before now. We are working together for the benefit of ou r mental health patients." "ED throughput, this is our most successful project to date. Simply taking the t ime to research your most problematic areas from a perception standpoi nt and t hen focusing on solutions was all we had to do." "One-year time frame was unrealistic because it takes months for so me projects, maybe a year to just get the projects off the ground and up and running. You then need time to impl ement and monitor. A 2-year time frame is probably more realistic." " I do feel that a year is not enough time to truly get an accurate picture on ROI for each project as we are nine months in and are just now overcoming some obstacles, w that said, I would like to continu e to monitor progress through our performance measures." 0 ,Q!!l!1, ADivision ofthe G,orgi Oopair1mon1 of Commvi,ity H11llh 0 GEORGIA DEPARTMENT OF COMMUNITY HEALTH Acknowledgements The Georgia Departm ent of Community Health, State Office of Rura l Hea lth would like to thank the fol lowing for their dedication, commitment , and support of the Rural Hospital Stabi lization Grant Program (RHSGP): Govern o r P. Brian Kem p, State of Georgia Nathan Dea l, Former Governor, State of Georgia Commissioner Frank W . Berry, Georgia Departm ent of Commun ity Health Clyd e L. Reese 111, Former Com missioner, Departm ent of Communit y Health Patsy Wha ley Hodge, Executive Director, State Offi ce of Rural Hea lth Charles Owens, Form er Executive Director, State Office of Rural Health Senator David Lucas, Georgia Stat e Senate Representative Terry England, Chairman, House Approp riat ions Committee Members of th e Rura l Hospital St abilization Committee RHSGP Recipients, Chief Executive Officers, Chief Financial Officers, and Project Managers Lisa Carhuff, Former RHSGP Project M anager Nita Ham, Director, SORH Progra m, RHSG P Project Manager Cole Edward s, SORH Program Operations Specia list Draffin Tucker, LLP Authors: Nita Ham, Director, SORH Program Department of Community Health State Office of Rural Health Sarah M. Dekutowski, CPA Partner DraffinTucker, LLP Cole Edwards, Program Operations Specialist Department of Community Health State Office of Rural Health 51 0 .Q!!.lL. ADM,lonoflht Giorgi Oopor1/nonlolCommunily Htallh