TOWNSHEND-When the Green Mountain Care Board (GMCB) released a report on Sept. 18 that listed Grace Cottage Hospital (GCH) as one of four hospitals financially "at-risk" and in need of "major restructuring," it came as a surprise to Chief Executive Officer Olivia Sweetnam.
Sweetnam, who took over the leadership of Grace Cottage on July 1, said she had spoken with Bruce Hamory, a physician and partner with consultancy Oliver Wyman, which prepared a report for the GMCB that included recommendations for the future of the 19-bed hospital.
But Grace Cottage - the smallest hospital in Vermont and one of the smallest in the country - had no inkling of the final recommendations until the release of the report on Sept. 6.
Sweetnam told The Commons that the 19-bed hospital's leadership and staff were not pleased with what they heard.
"It was shocking and frustrating," she said. "These are ideas, and we would say they are ill-conceived ideas."
In Sweetnam's view, much of the data and conclusions in the report "are not well thought out" and are "incomplete, inaccurate, or misleading."
Even worse, she added, the report "includes no implementation analysis, financial or practical, and the health of patients and the economic health of communities would be negatively impacted if these recommendations were implemented."
Emergency Department busier than ever
Sweetnam said that offering round-the-clock coverage in its Emergency Department is one of the most important services that Grace Cottage offers to the West River Valley. The GMCB report recommended that GCH reduce that service to a 16-hour-a-day Urgent Care clinic, with cases between the hours of 10 p.m. and 6 a.m. steered to other hospitals, including Brattleboro Memorial Hospital (BMH).
"We have a very skilled clinical team that stabilize nearly anything that comes through the door," she said. "It would be hard for me to imagine that we would reduce the time we are open or the skill set we have so that we're doing not lifesaving treatment."
Sweetnam said the GCH Emergency Department is busier than ever, with 4,251 patient visits between Oct. 1, 2023 and Sept. 30, 2024 and 695 of those visits coming between 10 p.m. and 6 a.m.
She is concerned that the data the report used only counted the people whose primary residence is in Vermont, meaning the consulting firm didn't take into account the number of vacationers and second-home owners in the area who also need emergency care.
She also says that the report didn't take into account that BMH's emergency department is also very busy and would not necessarily be able to pick up the overflow from GCH.
Sweetnam said "we try to be very collaborative" with BMH and Dartmouth Hitchcock Medical Center, with Rescue Inc., and with Senior Solutions. Those collaborations have improved care for Grace Cottage patients, she observed.
A designation that doesn't fit
Sweetnam said acute inpatient stays make up a "very" small of Grace Cottage's total inpatient volume and that most of the people who fill the beds are "swing" patients - those who receive intensive physical and occupational therapy as part of the process of transitioning from acute care in a hospital to more routine treatment in their homes.
"Rehab is really our bread and butter," she said. "That's what actually reduces health care costs: getting people to return home successfully. It's an incredibly valuable service, and Brattleboro can't absorb that. They send us their patients who need inpatient rehab."
Also a big part of GCH is Messenger Valley Pharmacy, which is run by the hospital and is the only full-service pharmacy within 20 miles. It fills approximately 5,200 prescriptions per month.
The report's proposal for GCH is to seek federal designation as a Rural Emergency Hospital, a designation that went into effect in 2023, which would force the hospital to discontinue the swing bed program and end its operation of the pharmacy.
Sweetnam said current federal rules would not allow GCH to do either, which she called a "complete non-starter for us, our board, and for anyone in the community, It is just not going to work."
Another report recommendation that she views as a non-starter is for GCH to be become an inpatient mental heath and/or geriatric psychological hospital. With the Brattleboro Retreat just 18 miles away, Sweetnam supports that facility expanding its inpatient mental health care instead of GCH filling that role.
The same sentiment applies to another recommendation that GCH provide outpatient ambulatory surgery. Sweetnam says that BMH provides excellent surgical services, and that GCH doesn't have the need, nor the capacity, to support such a venture.
It's not all bad
However, Sweetnam didn't dismiss the whole report out of hand, noting some recommendations they do support.
One example is the recommendation that hospitals increase their use of telemedicine and outpatient rehab. She said GCH is already using Dartmouth Health's telemedicine network, and the hospital will open an expanded Outpatient Rehabilitation Center in the Heins Building next month.
Sweetnam also supports the development of a statewide shared electronic medical records system, which she said would greatly reduce the amount of time spent tracking down, scanning, and faxing paper records. Such a system would require state coordination and funding.
Planning and fundraising has been underway for the past two years on another priority for GCH: building a new primary care clinic with urgent care capabilities. The hospital has raised about half of the project funding.
Community support still strong
Since the report's release, Sweetnam said there was concern in the West River Valley about the hospital's future.
She said Grace Cottage is not going anywhere, and "will continue to work closely with our health care partners in the Windham County area to continue to deliver excellent quality care."
Sweetnam also urged those in communities served by GCH to contact the Windham County legislative delegation and ask them to oppose any legislation that supports the hospital closure recommendations in the Oliver Wyman report, to reject expanding the funding and scope of the GMCB, and to use the Legislature's authority to provide stronger oversight of the GMCB.
She would like to see a sharper focus at the state and federal levels on "access to care, quality of care, and affordability."
The report, Sweetnam said, projects that for many hospitals in Vermont, costs will exceed revenue in the next four years.
"Grace Cottage has had negative operating margins," she said, but as a Critical Access Hospital - a special Medicare and Medicaid designation that recognizes the economic challenges of creating economy of scale at rural hospitals - "we receive federal funding to make up for that and we also have an incredible philanthropy department that is very successful in working with the community to keep us whole and generally come to a flat margin."
The problem, she said, is that the report used a worst- case scenario in making its financial conclusions and then issued its estimate of how much state government would have to subsidize Vermont's hospitals - something the state has never done.
"We have never been subsidized by the state of Vermont," Sweetnam said. Despite being a tax-exempt charitable nonprofit, the hospital pays the state's Health Care Provider Tax, projecting this to be more than $1 million by the end of 2024, according to the hospital's second-quarter filings with the GMCB.
"We feel frustrated because [the report] is misleading the public and making them believe your taxes are going to go up to subsidize these failing hospitals," she said. "It paints a very, very untrue picture of hospitals in Vermont."
Nationally, she said, 2024 is seeing the highest-ever number of closures of critical care hospitals in the United States. Grace Cottage is in good shape right now, and she hopes the GMCB report does not scare people away from continuing to use, work at, and financially support the hospital.
"It's very difficult to look at the recommendations and know that so many of them are so far outside the realm of reasonable recommendations for us," Sweetnam said. "We are interested in things that can make us better and stronger, but these recommendations are not helpful for us."
This News item by Randolph T. Holhut was written for The Commons.