The North Shore-LIJ Center for Comprehensive Care at Greenwich Village

1. The North Shore-LIJ Center for Comprehensive Care at Greenwich Village A New Hybrid Model of Care to Deliver 21st Century Medicine April 2011

2. North Shore-LIJ Center for Comprehensive Care • St. Vincent’s Catholic Medical Center • Community Health Needs Assessment Study • North Shore-LIJ Center for Comprehensive Care • Free-standing Emergency Department • Imaging Center • Ambulatory Surgery Center • Laboratory Services • Un-programmed physician and program space • Facilities • Building challenges • Conceptual Design

3. St. Vincent’s Catholic Medical Center – Timeline SVCMC Network files for Bankruptcy St. Joseph’s Hospital closed St. Mary’s Hospital closed - St. Vincent’s CMC files for Bankruptcy (4/6) - St. Vincent’s Med Ctr closed (4/30) St. Vincent’s merges with CMC Brooklyn/Queens and Sisters of Charity of Staten Island SVCMC Network formed SVCMC emerges from Bankruptcy Transfers St. John’s Queens and Mary Immaculate Hospital to Caritas Health System Community Needs Assessment Kick-off Bayley Seton transferred to Sisters of Charity 1849 2009 2010 2003 1999 2005 2007 2000 1980 St. Vincent’s founded by the Sisters of Charity St. Clare’s closed Acquires St. Clare’s Hospital Caritas files for Bankruptcy - St. John’s closed - Mary Immaculate closed St. Vincent’s takes control of St. Vincent’s Staten Island HEAL 16 awarded to NS-LIJ UCC planned with VillageCare NS-LIJ acquires SVCMC Homecare Transfers St. Vincent’s SI to Bayonne Medical Center

4. Post SVCMC Closure Activities April 2010 St. Vincent’s Closes May 2010 Lenox Hill Joins North Shore-LIJ Health System June 2010 HEAL Award to develop Urgent Care Center in Greenwich Village August 2010 North Shore-LIJ partners with community leaders and elected officials to conduct Community Health Needs Assessment Study January 2011 North Shore-LIJ receives CON approval for Urgent Care Center March 2011 Urgent Care Center opens SVCMC accepts North Shore-LIJ proposal for Center for Comprehensive Care

5. Community Health Needs Assessment • Steering Committee Activities • Discussion Paper #1 – Define Service Area (10/1/2010) • Discussion Paper #2 – St. Vincent’s CMC Medical Center (10/27/2010) • The Origin of its Patients • A Review of Communities Receiving Care • Discussion Paper #3 • Socio-demographic Description of the Service Area (12/3/2010) • Overview of Health Status Indicators • Discussion Paper #4 – Post Closure Review • Service Area Access to and Utilization of Inpatient and Emergency Services (2/3/2011) • Discussion Paper #5 – Projecting the Need for Inpatient Beds (In Draft) • To be completed • Discussion Paper #6 - Results of Community Health Survey • Discussion Paper # 7 - Identification of Service Area Health Needs and Service Gaps • Discussion Paper # 8 – Recommendations for Community Health

7. SVCMC Inpatient Discharges – Patient Origin 2009 SVCMC Inpatient Discharges Patient Origin 1 dot represents 1 discharge

11. North Shore-LIJ Center for Comprehensive Care • A new hybrid model combing the emergency department access of a community hospital with the specialized ambulatory services of a Diagnostic and treatment Center. • A destination facility licensed as a division of Lenox Hill Hospital • Located in the former O’Toole Pavilion of SVCMC (162,000 bgsf) • Anchor Programs will include: • New York’s first freestanding emergency center – 20,000 gsf • 24 Treatment bays; 320 -Slice CT; X-Ray • Imaging – 12,000 gsf • CT, MRI, Ultrasound, Angiography • Ambulatory Surgery – 14,000 gsf • 2 ORs • Un-programmed space of 43,000 gsf pending completion of Community Health Assessment • Beds for clinical decision making, patient stabilization and treatment • Center for Comprehensive Care wills serve as a new front door : • Integrate North Shore-LIJ health services into the fabric of the community; • Coordinate with existing providers and; • Triage patients to the most appropriate facility/providers

12. Long Term Care Social Services Community Organizations Substance Abuse Hospitals Physicians ACCESS to SERVICES North Shore-LIJ Center for Comprehensive Care Front Door to Healthcare Home Care Mental Health Senior Care Schools A New Hybrid Model of Care to Serve as the Front Door for Community Residents to Access Health Services

13. North Shore-LIJ’s Vision for a Connected Community To support clinical integration across the care continuum by sharing of clinical data to support safe, effective and efficient practice and an enhanced experience for patients by: Hospitals RHIOs NS-LIJ CCC • Connecting patients and physicians in the community to support delivery of cutting-edge care • Coordination of care across practitioners, communication among practitioners, and seamless transitions in care between environments • Management of entire “episodes of care” across practitioners and environments supported by proven care guidelines • Improvements in the quality of care delivery and facilitate participation in quality initiatives Home Care NSLIJ CCC Patients & Families Labs Pharmacies Radiology Community Physicians Other Health Providers 13

14. Service Area • Defined by the Community • Population of 385,000 residents • 13.2% age 65 and over • 2.2% population growth next 5 years • Payor Mix • 39.7% Medicare • 29.7% Medicaid • 22.8% Commercial • 7.8% Self-Pay Legend Primary Service Area (PSA) Secondary Service Area-I (SSA-I) Secondary Service Area-II (SSA-II) Former SVCMC site Community Board border

15. SVCMC and Service Area Inpatient Discharges, 2009 • Service Area residents accounted for 41,000 Inpatient Discharges • 17% went to SVCMC • Service Area accounted for 35% of SVCMC Inpatient Discharges • 50% of SVCMC Inpatient Discharges came from outside Manhattan SVCMC Inpatient Discharges (N = 19,388) Inpatient Market Share (N = 40,915) Source: SPARCS ver06.10.10jpl

16. SVCMC and Service Area Treat & Release ED Visits, 2009 • Service Area residents accounted for 100,000 Emergency Visits • 87,172 were Treat and Release Visits • 38% Medicaid • 24% Self-Pay • Almost 20,000 occurred at SVCMC • Another 28,400 Treat and Release visits seen at SVCMC were from outside the Service Area SVCMC T&R ED Visits (N = 47,822) Service Area T&R ED Visits (N = 87,172) Source: SPARCS ver06.10.10jpl

17. Service Area ED Visits, 2009 – NYU Algorithm 2009 Service Area ED Visits (Treat & Release) (n = 87,172) 2009 Service Area ED Visits (Treat & Release) of SVCMC (n = 19,410) 3,472 9,507 1,916 19,837 9.9% 10.9% 17.9% 22.8% 16,722 5,281 19.2% 27.2% 18.4% 3.6% 3,576 21.1% 3,175 6.0% 18,364 3.4% 5.9% 5,247 9.5% 6.9% 8.9% 8.4% 652 1,139 8,286 6,034 1,737 1,637 Non-Emergent Emergent/PCP Preventable Emergent/PCP Treatable Emergent Drug Alcohol Psychiatric Injury Other Sources: NYU Algorithm; NYS DOH SPARCS ver01.03.11

18. Free-Standing Emergency Departments • FSED have existed for almost 40 years • As of 2008 there were 222 operating in 16 states • 191 of these are satellites /divisions of hospitals • Traditionally, developed in response to access in rural areas, growing suburban, overcrowding and where a hospital has closed • Open 24 /7 – 365 Days • Most accept all patients regardless of insurance income • Don’t offer trauma services • 911 Receiving Facility • CMS certifies as off-campus Emergency Department • Joint Commission accreditation provided through the affiliated hospital

19. Center for Comprehensive Care Free-Standing Emergency Department • Division of Lenox Hill Hospital • 24-hour access to Board-Certified Emergency Physicians; • 24-hour access to specialist consultations through North Shore-LIJ’s physician network; • Inpatient beds for stabilization and clinical decision unit; • 911 receiving facility based upon protocols developed with EMS medical control; • Rapid transfer via the North Shore-LIJ ambulance network to an appropriate receiving hospital chosen by the patient or Lenox Hill Hospital; • On-site imaging, diagnostic and laboratory testing capabilities; • A Picture Archiving and Communication System (PACS) that will transmit images to North Shore-LIJ radiologists, who will quickly interpret results; • An inter-operable Electronic Medical Record accessible to all providers in North Shore-LIJ network who provide post-visit care to the patient; • The ability for patients to actively participate in their care and decide which doctors or hospitals they will go to for follow-up care

20. Center for Comprehensive Care Free-Standing Emergency Department • Coordinated follow-up care to either the patient’s physician, a neighboring primary care provider or a range of specialists; • For those returning home who require in-home assistance, access to the home care provider of their choice or services provided through the North Shore-LIJ Home Care Network; • Follow-up referrals to manage a patient’s chronic conditions or other medical issues discovered during the course of treatment; • Referrals to preventative care or education and support programs that will help avoid illnesses or injuries from worsening; • An emergency care center that is accountable and meets all the same regulatory standards as traditional on-site hospital emergency departments (The Joint Commission Accreditation, NYS Article 28 and US Centers for Medicare and Medicaid Services).

21. Compliance with Regulatory Requirements • An emergency care center that is accountable and meets all the same regulatory standards as traditional on-site hospital emergency departments • EMTALA • 911 Receiving and EMS • NYCRR Title 10 • Emergency Department and Services • 405.19 • 708.5 (h) • New Hospital Construction • 712-2.4 • CMS hospital off-campus Emergency Department Regulations • 42 CFR 413.65 • The Joint Commission Accreditation

22. Free-Standing Emergency Departmentwill meet the same NYS regulatory standards as an on-site hospital emergency departments

23. Recognized by the Centers for Medicare and Medicaid Services (CMS) • CMS provides requirements for Provider-based Off-campus Emergency Departments • Must demonstrate compliance with the hospital Conditions of Participation and with the provider-based regulations at 42 CFR 413.65. • Demonstrate how the off-campus emergency department will meet the emergency needs of its patients in accordance with accepted standards of practice for hospital emergency departments.

24. North Shore-LIJ Emergency Department Capabilities Similar to that of a community hospital, including advanced life support services, our emergency clinicians will be able to treat a full range of illnesses and injuries, including—but not limited to—the following: • Chest pain • Other cardiac symptoms • Early-onset stroke • Shortness of Breath • Respiratory illnesses • Asthma • Pneumonia • Chronic Bronchitis • Emphysema • Concussions • Fractures and joint injuries • Minor motor vehicle injuries • Severe cuts and burns • Abdominal pain • Allergic reactions • Ear infections • Gastrointestinal illnesses • Influenza (flu) • Occupational injuries • Sports injuries • Behavioral health

25. Triage, Treatment Protocols and Transfer Agreements • Will work with DOH and EMS to develop medical protocols with respect to which patients are appropriate to receive care at the Center. • Exclusions as per 405.19 (3): • Trauma and multiple injury patients; • Burn patients (moderate to major); • High-Risk maternity patients; • Neonates or Pediatric patients in need of intensive care; • Head-injured or spinal-cord injured patients; • Acute psychiatric patients; • Replantation patients; • Dialysis patients, and; • Acute myocardial infarction patients including those with ST elevation. • Transfer Agreements will be developed with Beth Israel, Bellevue (Trauma), NYP-Weill/SIUH (Burns)

26. Free-Standing ED Demand Model 1 In 2009, SVCMC ED Inmigration was 59% 2 In 2009, SVCMC Admitted 22% of ED visits

27. FQHC, DTC, Extension Clinics and Comprehensive Clinics West Midtown Management Group 311 West 35th Street, NY 10001 Beth Israel Medical Center Chelsea Medical Practice and Sr. Health (PCP Clinic) 277 8th Avenue, NY 10001 Mount Sinai Hospital Bayard Rustin Education Complex (PCP Clinic) West 18th Street, NY 10011 Callen Lorde Community Health Center 356 West 18th Street, NY 10011 Village Care Health Inc 121A West 20th Street, NY 10011 There are 41 Article 28 licensed providers in the Service Area. Most of the licensed ambulatory providers are north and east of Center for Comprehensive Care. VillageCare and North Shore-LIJ have a strategic partnership for the provision of urgent care services. Legend ABC Primary Service Area ABC Secondary Service Area Diagnostic and Treatment Centers (DTC) Comprehensive Clinics Hospital-based Extension Clinics Source: NYS DOH (http://www.health.state.ny.us/nysdoh/hcra/provider/provamb.htm); accessed August 2010 Federally Qualified Health Centers (FQHC) Center for Comprehensive Care

28. Redeveloping a Landmark for 21st Century Healthcare Reconciling two public goals: • Landmark – Preserve this historic structure • Healthcare – Design for 21st century medicine

29. HISTORICAL CHALLENGES • Iconic design, dating to 1964, designed as a union hiring hall • Subsequent SVCMC adaptation to clinic not workable to today’s HC delivery • Subject of intense community attention and support • Original design is largely unchanged, and has aged • Deteriorating exterior materials • Building envelop is not energy efficient

30. LANDMARKS PRESERVATION • Subject to LPC review, seeking “Certificate of Appropriateness” • Restrictions on modifications to building exterior • Cannot demolish and replace with a more efficient building • LPC process will impact renovation costs • Vertical expansion is severely limited

31. Original floor plan Elliptical Plan Difficult to Secure DESIGN CHALLENGES • Significant structural work needed to insert ambulance bay • Need to reshape first floor to insert ambulance bay and public entrance • Shear wall element frustrates adaptation

32. DESIGN CHALLENGES • Double façade (concrete panels and window wall behind) costly to repair • Minimal fenestration at upper floors

33. INFRASTRUCTURE CHALLENGES • Mechanical / Electrical systems need replacement • Low floor to floor heights (first & second floors) • Significant abatement scope • Need structural reinforcement to support major equipment • Elevators need replacement and relocation • Need to replace/relocate two stairs

34. INFRASTRUCTURE • Mechanical / Electrical systems need replacement • Low floor to floor heights (first & second floors) • Significant abatement scope • Need structural reinforcement to support major equipment • Elevators need replacement and relocation • Need to replace/relocate two stairs

35. SITE CHALLENGES • Open space to the south makes the building very visible from afar • Proximity to subway inhibits entry design at 7th Avenue • Proximity to subway entry requires extra care during construction • Lot line adjacency to neighboring buildings • Existing plinth/fence need replacement

36. Preliminary Study PROGRAM • Emergency Department • Imaging Diagnostic and Treatment unit (MRI, CT, US, Radiology, Mammo) • Ambulatory Surgery and future Angiography • Physicians Practices (future) • Clinical Services and Building Support

37. Preliminary Study PROGRAM • Emergency Department • Imaging Diagnostic and Treatment unit (MRI, CT, US, Radiology, Mammo) • Ambulatory Surgery and future Angiography • Physicians Practices (future) • Clinical Services and Building Support

38. Preliminary Study DESIGN CONCEPT • Ensure easy comfortable access for patients and ambulances • Continuing and improving use of natural light with new glass block / windows • Developing access to upper floors with a new entrance/lobby at W. 13th st. • Ensuring patient/visitor comfort with building environmental control systems

39. 7th Avenue – Walk-in Entrance Preliminary Study DESIGN CONCEPT • Ensure easy comfortable access for patients and ambulances • Continuing and improving use of natural light with new glass block / windows • Developing access to upper floors with a new entrance/lobby at W. 13th st. • Ensuring patient/visitor comfort with building environmental control systems

40. Preliminary Study W. 13th Street – Patient Entrance DESIGN CONCEPT • Ensure easy comfortable access for patients and ambulances • Continuing and improving use of natural light with new glass block / windows • Developing access to upper floors with a new entrance/lobby at W. 13th st. • Ensuring patient/visitor comfort with building environmental control systems

41. W. 12th Street – Ambulance Entrance Preliminary Study DESIGN CONCEPT • Ensure easy comfortable access for patients and ambulances • Continuing and improving use of natural light with new glass block / windows • Developing access to upper floors with a new entrance/lobby at W. 13th st. • Ensuring patient/visitor comfort with building environmental control systems • Considering inclusion of skylight to bring natural light to the upper floors

42. North Shore-LIJ Comprehensive Care Center A New Hybrid Model of Care to Deliver 21st Century Medicine • To better align community needs and resources, the Commission recommends that the state and industry collaborate to test and develop new “hybrid” delivery models. • Such hybrids would maintain features of a traditional hospital determined to be necessary while eliminating redundant and unneeded features. • Creative and financially viable alternatives, such as free standing emergency rooms or community health centers with urgicare capabilities, could advance the achievement of a right sized and restructured health care delivery system. • The benefits could include enhanced access to services, less duplication, and amelioration of the economic impact of full hospital closures. ~Page 79