October 9, 2008

1. Welcome to theLee Memorial Health SystemCommunity Health Visioning 2017 Steering Committee Status Meeting October 9, 2008

2. Purpose Convene Steering Committee of Community Health Visioning 2017 to review evolving market forces and progress toward achieving recommendations

3. Desired Outcomes • Build understanding of key changes in market trends over the past year and review implications for Community Visioning 2017 recommendations • Build understanding of progress achieved in the eight prioritized recommendations • Celebrate national recognition of community engagement process • Consider feasibility of developing a community health scorecard • Discuss how to take the community engagement effort to the next level

4. What a Difference a Year Makes October 2008

5. Community Themes • Behavioral Health • Primary Care Alternatives • Electronic Medical Record • Workforce Shortage • Public Awareness of Services • Preventive Healthcare • Chronic Disease • Focus on Quality

6. Economic Trends Lee County Population Projection Future Growth Uncertain

7. Inpatient Volume & Growth Percentage 67,000 5% Volume Growth % 66,000 4% 65,000 3% 64,000 2% 63,000 62,000 1% 61,000 0% 60,000 -1% 59,000 -2% 58,000 57,000 -3% FY 2004 FY 2005 FY 2006 FY 2007 Projected Budget FY 2008 FY 2009

8. Cost of Charity & Uncompensated Care 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 2004 2005 2006 2007 Cost of Uncompensated Care Cost of Charity

9. Patient Mix Patient Mix by Category FY 07 data

10. The Hidden Tax 35% 41% 12% 12% 160% Percent of Cost Reimbursed 140% Medicaid 10% Private Payer 120% 35% of patients = 100% profits + Medicare/Medicaid/ Uninsured shortfalls 50% 100% 80% Medicare 39% 60% 40% 20% 0% 0 10 20 30 40 50 60 70 80 90 100 Uninsured 1% Percent of Revenues

11. Now 9% FL U65 Uninsured 1999 vs. 2004 +14% District 14 19.8 24.4 +27% Lee County >2.5% unemployment

12. August ‘08 9.0% 3-County Unemployment Trend When will this level off or come back down? Source: Florida Agency for Workforce Innovation, Labor Market Statistics, Local Area Unemployment Statistics

13. Lee County Uninsured • Uninsured increased 8% • Insured but unable to pay out-of-pocket expenses increased 23% • Uninsured emergency department patients increased by 4% (25% of all ED visits)

14. Operating Margin Realistic??????

15. LMHS Turnover & Vacancy Rates

16. Physician Shortage • 2004 Physician Need Study • Indicated need of 225 • Primary Care need - 63 • Medical need - 102 • Surgical need - 60 • New Study Complete – August 2008 • In collaboration with Lee County Medical Society • Results due next month • Initial feedback indicates an increase in need

17. Impending physician Medicare cuts

18. Declining Physician Reimbursement I can’t make a living “seeing” patients anymore.

19. Technical component income as a % of total income Focus on technical component 38.20% 45.00% 40.00% 29.40% 35.00% 27.40% 30.00% 25.00% 20.00% 15.50% 15.30% 15.00% 10.00% 5.00% 0.00% 2000 2001 2002 2003 2004 Craig D. Pederson, Health Care Futures LP, Minneapolis

20. Impact on Physician Income Percent Change in Average Physician Income, Adjusted for Inflation, 1995-2003 10% 5% Primary Care Surgical Specialists All Physicians Medical Specialists 0% Professional/ Technical Workers -5% -10% -15%

21. LMHS Outpatient Market Share • LMHS 2007 outpatient market share: 21.1% • Health systems … national average: 40% • LMHS market share for most outpatient services: 10% - 15% • Exceptions: cancer, breast health and cardiac rehabilitation • LMHS 2007 outpatient services accounted for 91% total operating margin versus 9% for inpatient services

24. Community Themes • Behavioral Health • Primary Care Alternatives • Electronic Medical Record • Workforce Shortage • Public Awareness of Services • Preventive Healthcare • Chronic Disease • Focus on Quality

25. Business & Community Physicians Health & Social Services LMHS Community Collaboration Community Care

26. Community Health Visioning 2017 Presentations Brad Pollins, System Director, Organizational Effectiveness

27. Priorities for 2017 • Behavioral Health • Primary Care Alternatives • Electronic Medical Record • Workforce Shortage • Public Awareness of Services • Preventive Health Care • Chronic Disease • Focus on Quality

28. Presentation Format • 12 minute presentation • Original Recommendation • Key Accomplishments • Barriers/Challenges • Critical Success Factors • Next Steps • 4 minute Question & Answer

29. Community Health Visioning 2017 Behavioral Health Update Brian Lucas, Vice Chairman, Bonita Bay Group Greg Gardner, Vice President, Allocations & Planning, United Way

30. Behavioral Health Convene a community collaborative to develop a comprehensive continuum of care for Behavioral Health, based on a current needs assessment for Lee County. The collaborative should identify a champion and incorporate successful models for both leadership structure and service. (Key elements may include inpatient beds, access to assessment, availability of medications, case management, supportive/affordable housing, staffing, criminal justice partners/resources, preventative care, and unique needs of adults , adolescents and children.)

31. Status Report: Key Accomplishments • Assembled a community Mental Health and Addiction Coalition which chaired by Bob Janes, Jim Nathan, and Brian Lucas • Developed a strategic plan for the coalition • Purpose: Improve the lives of individuals with mental health and addictions needs • Mission: Define workable solutions to end the mental health crisis in our community

32. Status Report: Key Accomplishments Goals: • Implement a mental health and addictions delivery model to meet the existing and future needs of the consumers (Carol Conway) • Obtain and responsibly allocate funding adequate to meet the needs (Richard Riley) • Develop a community leadership group to implement the strategic plan (Bob Janes, Brian Lucas, Jim Nathan) • Create awareness of mental disorders as a serious health issue (Lance McKinney)

33. Status Report: Key Accomplishments • Created a task force for each goal with community ownership • Implemented Triage Center • Converted 15 beds at Lee Memorial Hospital to a Geriatric Psychiatric program • Launching the development of The Pavilion at HealthPark • Expanded Services

34. Status Report: Barriers/Challenges • Fragmented delivery of services and silos • Restructure of DCF leaving no local presence • Allocation and reallocation of funds to support the coalition goals • Lack of doctors • Merging of medical and recovery model of psychiatric care • Community understanding and treating mental illness as a legitimate medical condition • Ongoing community volunteer leadership to drive strategy implementation • Expanding Triage Center to a full 24/7 operation • CON approval of The Pavilion at HealthPark

35. Status Report: Critical Success Factors • Community awareness • Leadership structure • Boundarylessness of all providers • Funding • Merging of the models • Appropriate number and type of psychiatric physicians • Bed availability • The structure of a Policy Board and a Management Council for the Triage Center • The Pavilion brings clinical competency, management experience, and new funding sources to Lee County for psychiatric care. • Waiting on Medicaid Provider number for reimbursement for Jennings Behavioral Health

36. Status Report: Next Steps • Review and define the best practices for mental health delivery which will be driven by evidence-based psychiatric practices incorporating medical and recovery models • Develop and implement a comprehensive communication/marketing plan to build the desired level of awareness in our community • Complete and implement other details of the strategic plan • Expand leadership structure

37. Status Report: Next Steps • Triage Center - Continue operational improvements, data collection and evaluation. Seek long term funding solutions. • LMHS Geriatric Psychiatric beds/The Pavilion - Complete construction and open in 2009. • Jennings Behavioral Health - Continued expansion from current 35 patients, 2 psychiatrists, and 4 therapist in O/P treatments.

38. Questions & Answers • What are your top of mind reactions to what you have heard? • Are there other accomplishments for this area you would like to share?

39. Community Health Visioning 2017 Primary Care Alternatives Lalai S. Hamric President/CEO Family Health Centers of Southwest Florida, Inc.

40. Primary Care Alternatives Convene stakeholders to develop a comprehensive, community-based system of primary care alternatives to the Emergency Room, targeting areas of greatest need. (Key elements may include neighborhood centers/clinics, mobile units, 24/7 access, service for under/uninsured, and possible roles for retired physicians and major employers.) Develop a method for educating non-emergent patients to use the appropriate care settings.

41. Status Report: Key Accomplishments • Establishment of the Dunbar United Way House… • Opening of the East Fort Myers United Way House… • Renewal of Lee We Care as the Volunteer Health Care Connections specialty referral program serving patients living below poverty level… • Establishment of a pediatric Healthy Living and Weight Management Clinic utilizing fixed sites and a regional Ronald McDonald mobile van… • Regional expansion of the CenteringPregnancy pre-natal care program… • Launch of Area Health Education Centers smoking cessation program… • Institution of new emergency room patient follow-up referral process… • Doubling of breast and cervical cancer screenings for uninsured low-income women under the Healthy Body-Healthy Soul Program… • Offering of pre-school dental exams and annual school physicals… • Launch of three First Choice Pediatrics offices in Lee County.

42. Status Report: Barriers/Challenges • Current provider shortages, particularly for adult medicine, as a function of a physician “unfriendly” professional environment… • Rapid growth of the number of uninsured people in Lee County @ 30%+ • Rising level of uncompensated care given by primary care providers in Lee County (e.g.-LMHS = $68 million/FHC = $14.2 million)… • Uncertainty of revenue sources to pay for uninsured patient care (e.g.- Low Income Pool, DSH, Medicare reimbursement, etc.)… • Lack of adult medicine specialists to provide care for working uninsured patients earning income just above the poverty level… • Lack of a regional electronic health records “network” to promote medical homes and access to preventive medical care for all patients… • Limited hours of primary care providers coupled with patient work schedule and transportation challenges.

43. Status Report: Critical Success Factors • Establishing a local primary care “network” that maximizes the coordination and use of existing and future provider resources… • Development of a regional health information system that improves patient care and health outcomes through improved sharing of clinical data among local care givers… • Creation of the medical home concept that encourages all patients living in Lee County to have a local provider of primary, preventive and chronic disease care… • Building a community consensus on how best to fund uninsured patient care via existing and proposed public and private revenue streams… • Expansion of the specialist care network for uninsured patients… • Recruitment and retention of primary care physicians and critical area specialty providers (e.g.- orthopedics, cardiology, oncology/chemotherapy, dermatology, gastroenterology, rheumatology, endocrinology, etc.).

44. Status Report: Next Steps Convene a local stakeholder task force to create a model community-based primary care system by pursuing… • Achieve connectivity of existing electronic medical records systems utilized by local primary care providers… • Creation of a medical home initiative to include examination of appropriate emergency room use by all patients… • Study of how to finance care for the uninsured/working uninsured… • Examination of local provider service networks that use a capitated fee approach to providing managed care that allows residual funds to be used for uninsured patient care… • Expansion of existing neighborhood-based “clinics” to emphasize preventive medicine and chronic disease management programs… • Development of a regional physician recruitment/retention strategy.

45. Questions & Answers • What are your top of mind reactions to what you have heard? • Are there other accomplishments for this area you would like to share?

46. Community Health Visioning 2017 Electronic Medical Record Mike Smith Chief Information Officer, Lee Memorial Health System

47. Electronic Medical Record Develop a method for transferring electronic patient information among physicians, caregivers, and facilities to improve delivery of care and transition of patients between acute care settings and other locations. LMHS implements infrastructure and platform to establish a universal medical record, which may include smart card technology.

48. Status Report: The Broader Context • The Broader Context - • National focus on the issue of electronic medical records, interoperability across care settings • A critical success factor to improving patient safety, healthcare cost efficiency • Until recently, this couldn’t be accomplished • Much work being done nationally on this topic • Very complex • Integrated patient medical record more relevant, needed more than ever before

49. Status Report: Challenges Nationally • No sustainable financial model for Regional Health Information Exchanges (RHIOs) • No appetite for a national patient identifier number • Concerns about competition/data sharing • Security/confidentiality concerns • Patient information custodial concerns • Inadequate focus on clinical intuitiveness/usability

50. Status Report: Successes Locally • Community Communication Infrastructure Success with Embarq • County patient identifier numbering system – managed by LMHS - exists, 1 million + citizens, very high integrity • Managed, secure, reliable IT environment in place • Successful track record with physicians – Net Access, Heartlab, etc. • Community Healthcare IT Draft Strategy defined, Integrated Software Platform Selected - 1st phase of the install underway – Epic for Lee Physician Group • Significant interest from some non-employed physicians to take advantage of the LMHS Next Generation integrated Electronic Medial Record in their practice • Additional strategy of building interfaces for non-integrated physician electronic records in our community • We have largely overcome the National RHIO challenges in our community