Evaluation of the grant program for rural health care transition : fourth semi-annual progress report

82 Pages·1991·2.7 MB·English

by  Cheh, Valerie

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EVALUATIONOFTHEGRANTPROGRAMFOR
RURALHEALTHCARETRANSITION
FOURTHSEMI-ANNUALPROGRESSREPORT
July9, 1991
Authors:
ValerieCheh
KatherineCondon
CharlesNagatoshi
JudithWooldridge
Submittedto: Submittedby:
HealthCareFinancingAdministration MathematicaPolicyResearch,Inc.
6340SecurityBoulevard P.O.Box2393
OakMeadowsBuilding,Room2302 Princeton,N.J. 08543-2393
Baltimore,MD21207 [phone]
ProjectOfficer: ProjectDirector:
KathleenFarrell JudithWooldridge
CONTENTS
Chapter Page
EXECUTIVESUMMARY ' vi
INTRODUCTION
I 1
A. LEGISLATIVEHISTORYANDPURPOSEOFTHE
GRANTPROGRAM
1
B. NUMBERANDGRANTEESTATUS 2
1. 1989Grantees 2
2. 1990Grantees 4
II BACKGROUNDON1989GRANTEES 7
A. CHANGESINHOSPITALCHARACTERISTICSAFTER
1YEAR 8
1. ManagementChangesOverFirstYear 8
2. ChangesinPhysicianStaff 11
3. ChangesinNursingandOtherLicensedStaff 14
4. ChangesinNumberofBedsandServices 17
B. CONSORTIA 20
1. ConsortiumParticipationAmong1989Grantees 21
2. CharacteristicsoftheConsortiaFundedbytheProgram
forRuralHealthCareTransition 23
3. FactorsAffectingPotentialSuccess 24
4. Conclusions 32
III PROGRESSOF1989GRANTEES 33
i
CONTENTS(continued)
Chapter Page
III A. ACHIEVEMENTS 34
1. ProgressRelativetoSchedule 34
2. OperationalSuccessesandDifficulties 37
B. PROJECTMODIFICATIONS 41
C. EXPENDITURES 41
D. PROGRESSBYTHECONSORTIAHOSPITALS 44
E. HOSPITALCLOSURES 44
1. PatientOut-Migration 48
2. PrimaryReasonforClosure 49
3. CommunitySupport 52
4. ServicesPresentlyProvided 53
5. EffectoftheGrant 55
IV PROGRESSOF 1990GRANTEES 57
A. ACHIEVEMENTS 57
1. ProgressRelativetoSchedule 57
2. OperationalSuccessesandDifficulties 60
B. PROJECTMODIFICATIONS 63
C. EXPENDITURES 63
V SUMMARYOFHOSPITALPROGRESSFOR1989AND
1990GRANTEES 69
VI ACTIVrriESFORTHENEXTSIXMONTHS 71
A. MONITORING 71
B. SITEVISITS 71
C. REPORTS 72
REFERENCES 73
ii
TABLES
Table Page
1.1 1989GRANTEESTATUS ' 3
L2 1990GRANTEESTATUS 5
II.1 MANAGEMENTCHANGES: 1989GRANTEES 9
11.2 PHYSICIANSTAFFINGCHANGESOVERFIRST
YEAROFGRANT: 1989GRANTEES 12
11.3 NURSINGSTAFFCHANGESOVERFIRST
YEAROFGRANT: 1989GRANTEES 16
11.4 BED-SIZE/SERVICECHANGESOVERFIRSTYEAR
OFGRANT: 1989GRANTEES 19
11.5 CONSORTIUMPARTICIPATIONAMONGTHE 1989
GRANTEES 22
11.6 OWNERSHIPANDORGANIZATIONOFHOSPITALS
INTRANSITIONGRANTCONSORTIA: 1989
GRANTEES 25
11.7 GOALSOFCONSORTIA: 1989GRANTEES 27
IL8 COMMUNICATIONAMONGCONSORTIUM
HOSPTIALS: 1989GRANTEES 28
II.9 FINANCIALCHARACTERISTICSOF
CONSORTIA: 1989GRANTEES 30
11.10 COMPETITIONAMONGCONSORTIUM
MEMBERS: 1989GRANTEES 31
iii
TABLES(continued)
Table Page
111.1 DISTRIBUTIONOFPROJECTTIMELINESS
BYPROJECTOBJECTIVEANDWHO
DIRECTSPROJECT: 1989GRANTEES 35
111.2 PERCENTAGEOFGRANTFUNDSSPENTBY
PROJECTTIMELINESS: 1989GRANTEES 46
IH.3 CHARACTERISTICSOFCLOSEDHOSPITALS
ATTIMEOFGRANTAWARD: 1989GRANTEES 50
IV.1 DISTRIBUTIONOFPROJECTTIMELINESS
BYPROJECTOBJECTIVEANDWHODIRECTS
PROJECT: 1990GRANTEES 59
IV.2 PERCENTAGEOFGRANTFUNDSSPENTBY
PROJECTTIMELINESS: 1990GRANTEES 68
iv
FIGURES
Figure Page
111.1 TOTALEXPENDITURESAFTER 18MONTHS
BYCATEGORY: 1989GRANTEES 43
111.2 PERCENTAGEOF2-YEARFUNDINGSPENT
AFTER 18MONTHS: 1989GRANTEES 45
IV.1 TOTALEXPENDITURESAFTER6MONTHSBY
CATEGORY: 1990GRANTEES 64
IV.2 PERCENTAGEOFFIRSTYEARFUNDINGSPENT
AFTER6MONTHS: 1990GRANTEES 66
v
EXECUTIVESUMMARY
TheHealthCareFinancingAdministration(HCFA)waschargedbyCongcesswith
implementingaprogramofRuralHealthCareTransitionGrants(OmnibusBudget
ReconciliationActof1987:P.L. 100-203)andexpandingtheprogram(OmnibusBudget
ReconciliationActof1989:P.L. 101-239). Thegoalofthisprogramistoassistsmall
ruralhospitalstoincreasetheirlongtermfinancialstabilityandmanagementcapacity.
Awardsofupto2yearsdurationandupto$50,000ayearperhospitalwere
madeonSeptember 15, 1989,to 181hospitalsrepresenting 184grantawards.
Additionalawardsofupto3yearsandupto$50,000ayearperhospitalweremadeon
September 15, 1990,to211hospitals,representing212grantawards. Grantswere
awardedbasedontechnicalmeritandwiththegoalofachievinggeographicdispersionof
thegrantfunds. Congressappropriated$8,254,442tofundthefirstyearofthe 1989
granteesand$16,798,351tofundthesecondyearofthe1989granteesandthefirstyear
ofthe 1990grantees. Congressappropriatedanadditional$24,398,000tofundthethird
yearofthe 1989grantees,thesecondyearofthe 1990grantees,andthefirstyearofthe
1991grantees.
ThelegislationmandatedthattheHCFAAdministratorreporttoCongressevery
6monthsontheprogressoftheprogram. Thisisthefourth6-monthreport. This
reportisbasedonbackgroundreportsandmonitoringreportssubmittedbythegrantee
hospitalscoveringtheperiodSeptember 15, 1990,throughMarch31, 1991. Thereport
describeschangesinthemanagementandstaffingofthe 1989grantees,andtheir
progressafter18months. Specialfocusisgiventothe 1989granteehospitalconsortia
projectsandhospitalclosuresamongthe 1989grantees,plannedandunplanned. This
reportalsodescribestheprogressofthe 1990granteesaftertheirfirst6months.
1989Grantees. Eighteenmonthsaftertheawards, 169ofthe 181hospitalsthat
receivedgrantsareoperatingtheirgrantprojectsasplanned,whilefivehavecompleted
theirprojects. Eighthospitalsarenolongerintheprogrambecauseofvoluntary
withdrawal(fourhospitals),nonrenewalbyHCFA(onehospital),andfacilityclosure
(threehospitals).
Slightlyunderhalfoftheactiveprojectsareonoraheadofscheduleinallaspects
oftheirprojects. Sincemostprojectsincludeseveralactivities,manygranteesarefurther
aheadwithsomeactivitiesthanothers. Forexample,after18monthsthegranteeshave
madeconsiderableprogresscompletingtheirconstructionandrenovationactivitiesand
convertingacutecarebedstoswingbeds. (Sixmonthsago,mostconstructionand
vi
renovationactivitieswerebehindschedule). Healthprofessionaltrainingandpatient
educationactivitiesarepredominantlyonschedule.
Hospitalscitetheavailabilityoffunds(grantandother),cooperationwithother
providersorgovernmentagencies,dedicationofthehospitalstaff,andtheprojectfillinga
localhealthcareneedaskeystosuccess. Conversely,hospitalscitedifficultyrecruiting
healthcareprofessionalsasakeyfactorslowingtheprojects. Theconsortiumprojects
areprogressingverysmoothly,with70percentofthehospitalsinvolvedintheseprojects
reportingthattheyareonschedule.
Sevenofthe 1989granteehospitalshaveclosed,butfourofthemusedtheirgrants
toplantheirtransitionfromanacutecareinstitutiontoanothertypeofhealthcare
provider. Thesehospitalsappeartobemaintainingaccesstoprimarycareintheirareas.
Hospitalssubmittingprogressreportsintimeforinclusioninthisreporthadspent
mostoftheir2-yeargrantaward. Ofthegrantfundsthathavebeenspent,45percent
wasspentonpersonnel,22percentoncontracts,and 18percentoncapitalexpenditures.
Afewgranteeshavespentlessthan50percentoftheirawardandmostofthesegrantees
arebehindschedule.
fewer19ap9p0liGcraatnitoensest.haInni1n99109,895.02OanppSleicpatteimonbserwe1r5e, 1r9e9c0e,ivHedCfFrAomaw4a8r1dheodsp2it1a2lsg:ran2t0s2to
211hospitalsforatotalgrantfundingof$9,389,649. Sixmonthsaftertheawards,209of
the211hospitalsthatreceivedgrantsareoperatingtheirgrantprojectsasplanned,while
twovoluntarilywithdrewfromtheprogram.
The 1990granteeshadaslowstart. Sixmonthsafterreceivingtheirgrantawards,
61 percentreportthattheyarebehindschedule. Aswiththe 1989grantees,progresshas
beenslowedbydifficultiesrecruitinghealthcareprofessionals. Activitiesthattendtobe
onoraheadofschedulearepatienteducation,outpatientcaredevelopment,hospice
servicedevelopmentandswingbedconversion. Hospitalsattributesuccessfulstartupto
strongstrategicplans,cooperationwithotherprovidersorgovernmentagencies,andthe
availabilityoffunds.
Liketheir1989counterparts,the 1990granteesarespendingmostoftheirfundson
personnel(35percent),capital(23percent)andcontracts(19percent). Overhalfofthe
granteeshavespent25percentorlessoftheirfirstyearaward,and 11percenthave
spentmorethanhalfoftheiraward(comparabletothe 1989granteesatthesamestage
oftheirprojects).
vii
INTRODUCTION
I.
A. LEGISLATIVEHISTORYANDPURPOSEOFTHEGRANTPROGRAM.
Congressionalconcernsabouttheproblemsofruralhospitalsandaccesstohealth
carefortheresidentsofruralareasledtotheenactmentoftheGrantProgramforRural
HealthCareTransition. Inthelegislation,CongressmandatedthattheHealthCare
FinancingAdministration(HCFA)"establishaprogramofgrantstoassisteligiblesmall
ruralhospitalsandtheircommunitiesintheplanningandimplementationofprojectsto
modifythetypeandextentofservicessuchhospitalsprovideinordertoadjustforoneor
moreofthefollowingfactors:
(1) Changesinclinicalpracticepatterns
(2) Changesinservicepopulations
(3) Decliningdemandforacute-careinpatienthospitalcapacity
(4) Decliningabilitytoprovideappropriatestaffingforinpatienthospitals
(5) Increasingdemandforambulatoryandemergencyservices
(6) Increasingdemandforappropriateintegrationofcommunityhealthservices
(7) Theneedforadequateaccesstoemergencycareandinpatientcareinareasin
whichanumberofunderutilizedhospitalbedsarebeingeliminated."1
OmnibusBudgetReconciliationActof1987(P.L. 100-203),Section4005(e).
1
Thelegislationfurtherstipulatesthat"agrantmaynotexceed$50,000ayearand
maynotexceedatermoftwoyears."2 Fundsmaybespentforanyexpensesincurredin
planningandimplementingtheprojectwithtwoexceptions: nopartofthegrantfunds
maybeexpendedtoretiredebtincurredbeforeSeptember15, 1989;3andnotmorethan
one-thirdofthegrantfundsmaybeusedforcapital-relatedcosts. Thelegislation
mandatedthatgranteeshadtobenon-Federal,nonproprietary,short-term,generalacute
carehospitalswithfewerthan100bedsandfurthermoretheyhadtobepaidasrural
hospitalsunderMedicare'sProspectivePaymentSystemtobeeligiblefortheprogram.
IntheOmnibusBudgetReconciliationAct(OBRA)of1989(P.L. 101-239),
CongressmodifiedtheRuralHealthCareTransitionGrantProgramintwoimportant
ways. First,themaximumgrantperiodwasextendedfrom2to3years. Second,
hospitalsthatusethegranttoconverttoaruralprimarycarehospitalsarenotlimitedto
theone-thirdcapitalexpendituremaximum.
B. NUMBERANDGRANTEESTATUS
1. 1989Grantees
Thevastmajorityofthe 184RuralHealthCareTransitiongrantsHCFAawarded
onSeptember15, 1989,remain active 18months later. (SeeTable1.1.) Asof
2Ibid.
3Dateofgrantaward.
2