— by Susan McBain, Orcas Issues reporter —
After months of negotiations, commissioners of the Orcas Island Health Care District (OIHCD) agreed to sign a contract with UW Neighborhood Clinics (UWNC) for UWNC’s 2020 fiscal year, running from July 1, 2019 through June 30, 2020. The contract does not include agreements on after-hours care at the UWNC clinic; however, the commissioners, in a 4–1 vote, agreed that it solidifies “the foundation between the two entities and how we’ll interact, including if we separate,” according to Commissioner Patty Miller. [1]
Hoping to encourage attendance and participation by additional community members, the commissioners also voted to change the time of their regular meetings to 5–7 p.m. through August, rather than 4–6 p.m. The scheduled days remain the first and third Tuesdays of the month.
But most of the discussions at the meeting were about different models of staffing at the UWNC clinic and the associated subsidy required from OIHCD. Mark Bresnick, associate director of operations for UWNC’s northern region, and Dr. Mike Alperin, UWNC clinic medical director, attended the meeting and provided information on both topics. The discussions covered three possible staffing models:
- Staffing at the level of funding OIHCD is currently proposing for FY 2019–20, which would support one RN working a 0.9 full-time equivalent (FTE) number of hours (that is, 90%)
- Staffing at the current level, which would maintain the existing two 0.9 FTE RNs, but at an additional cost of almost $130,000 over the current level
- UWNC’s desired staffing, which would include two FTE nursing positions divided among three people, plus one additional medical assistant to help with rooming patients and other tasks, at an additional cost of nearly $249,000 over the current level
Both the commissioners and the UWNC staff agreed that the first model was not adequate. Alperin described the extent of the “tails of the work,” pre- and post-visit administrative tasks, which have increased greatly with the advent of electronic medical records and more-stringent administrative requirements. RNs can fill a variety of roles in clinic operations, more than MAs are licensed to perform, and the division of RN hours among three people would provide flexibility and forestall burnout, he said.
Miller reworked OIHCD’s five-year forecast based on these options. For FY 2019–20, she estimated the District could meet expenses for the third option—just barely at a levy rate of 0.65, and more comfortably at a levy rate of 0.70. However, UWNC’s personnel costs rose 12–17% over last year’s, and those rates are unsustainable for the District over five years. Commissioners had concerns about that rate of increase; about having no control over the overall financial policies of UWNC’s parent, UW Medicine; and about the chance of decreases in District revenues in an economic downturn. And, importantly, none of the options includes after-hours care.
On the positive side, UWNC’s budget projections are likely much more accurate after one full year of operation; appropriate staffing is likely to improve the patient and provider experience and could lead to increased revenues; and the District’s year-to-date expenses are not as high as budgeted.
The commissioners asked UWNC staff to look for efficiencies they might find in clinic operations to make the second model more workable, and to summarize their ideas by the next OIHCD meeting. The commissioners need to determine the level of subsidy to UWNC for FY 2019–20 by the next meeting in order for UWNC to begin hiring for open positions.
The next OIHCD regular meeting will be held Tuesday, June 18, 5 p.m. at the Eastsound Fire Hall.
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It is most important to note that the “tail end work” or “aftercare“ is not just administrative keystroke bookkeeping. It is central to the definition of what “Primary Care” IS, and it falls unequally on UW’s RN staff skills. Furthermore, in other clinics some of these tasks are left to be dispersed across the broader local healthcare network, saving the clinic expenses for prevention ~ screening ~ follow-up that are part and parcel of Quality in Primary Care.
Since we live on a small rural island, this easy spreading around of the broad duties of Primary Care to other nearby partners in the healthcare system is not possible. This is very costly to the isolated clinic, and the aftercare required to create quality is further intensified for recipients with complex clinical pictures, like many older folk.
So this is Orcas healthcare in a nutshell.
It is why after-hours and walk-in care is so important here. We cannot just drive down the road to another facility for this care any more than we can go find Prevention ~ Screening ~ Follow-up services. The only other alternative is the Orcas Fire Dept. who’s calls are skyrocketing, and who are forced to deal with contributory but non-emergent care of the same type: what shall we call it? It’s costing us so much that it threatens the integrity of our Orcas “healthcare system.“
The answer for rural communities is collaboration. That the same level of skilled care under a physician’s oversight is available from the many combined potential resources on Orcas, and that they can make up the absent “local healthcare network” is the key to the critical piece in cost-effective, quality Primary Care.
The need for Prevention ~ Screening ~ Follow-up does not make Orcas unique, just uniquely at-risk because our situation, including our history of conflict, heightens the mismatch between demographic need and systemic dysfunction that is well described across US healthcare but recently acute, right here.
As the Orcas Healthcare Commission contemplates our possible futures, let us remember part of the answer lies not in finding that nifty regulatory loophole or funding dollar, but in reconsidering patterns of resource utilization contingent upon conquering our long long history of infighting and exclusion, my colleagues.
1. The advent of EMRs should not increase the burden of nursing staff; physicians are responsible for almost everything in the records, and we paid UW a large amount of money to convert existing paper records to UW’s EMR system. Likewise, there has been no great increase in “administrative requirements” applicable to outpatient services in the recent past. I simply do not understand this justification proposed by UW for even more tax money.
2. The possibility of an economic downturn and a repeat of last decade’s decreased property values and lower tax revenues should be a major consideration in any final agreement.
EMRs and financials are forensic, not the issue.
Medical record entries are merely the tracks which follow an improvised dance of coordinating ongoing care.
The medical record mentioned above is shorthand for all the work that must go on in a clinic to leverage the brief costly time that a Doc spends with a patient. Much of it is done or coordinated by an RN:
“prevention ~ screening ~ follow-up” .. it is highly skilled work that few appreciate enough.
The medical and operations directors testified at length to the Commission on the implications of this essential core of Primary Care to Orcas’ specific needs related to how UW runs its clinics. They did not talk about the EMR.
I must add that there is solid research by the IOM that links the health of an institution’s nursing role to the health of its patients. RNs are the glue, the wiring the motherboard, and when it’s so hot they start to smoke, problems are systemic longstanding and require serious attention.
I’m with Leif.