Primary Care Changes Proposed in New Haven Amid Concerns
By Rosana G. Ferraro |Photo from New Haven Independent article “Plan Reimagines Primary Care for Poor“
Last week the state held a public hearing on the proposed changes to how primary care is delivered in New Haven, and several concerns for patients and the community arose.
What’s the proposal?
Yale New Haven Hospital is proposing to close three primary care clinics that serve mostly low income residents, and shift the care provided to one location, under the management of two community health centers – Fair Haven Community Health Center and Cornell Scott Hill Health Center. This new arrangement creates the New Haven Primary Care Consortium.
The hospital proposed to renovate 150 Sargent Drive in the Long Wharf area of New Haven to centralize and integrate care for the patients once served by their three primary care clinics. Medical students who served patients at the Yale clinics will also move to the new location, continuing the primary care training program in the hospital’s partnership with the Yale School of Medicine.
So what’s the process?
A change like this has to be reviewed under the certificate of Need (CON) program, by the newly renamed Health Systems Planning Unit (or HSPU, formerly the Office of Health Care Access or OHCA), which is now part of the Office of Health Strategy (OHS). The application process is very involved, and once the application is considered complete, a hearing, like the one last Wednesday, November 28, 2018, is scheduled.
In a hearing, the applicant – in this case Yale New Haven Hospital – presents about the proposed change. The hearing officer and HSPU and OHS staff then ask questions. In this past hearing, the public then had an opportunity to comment, followed up by more questions from HSPU and OHS staff addressing the concerns brought up by the public comment period.
After the hearing is over, and the file is closed, the HSPU will make a decision on the application for the change. In the past, decisions or agreed settlements are conditioned on commitments from the applicant. These can address different concerns HSPU may have about the proposal.
So is this change a good thing?
The proposal has the potential for positive change – newly renovated facilities, integration of behavioral health services into primary care, and patients being served by the combined expertise of the community health centers and medical students in training under experienced doctors.
But there are still unaddressed concerns from patients, the community, and advocates; the jury’s still out, so to speak, on this one.
In the past five years, the Foundation has often spoken up at Certificate of Need hearings, especially about the impact of consolidation on everyday people, including costs to patients and the need to maintain local community input.
True to form, Universal Health Care Foundation of Connecticut submitted comment to the HSPU to express our concerns with the proposed change, and offered suggestions for 6 conditions.
Vigilance and monitoring are critical
Ongoing monitoring of this change will be critical. Many commitments were made by Yale-New Haven Hospital, but without vigilance these commitments may not fully materialize or benefit the patients and the community health centers as intended.
We suggested that this change be independently monitored over time, at least five years, if not longer. We also suggest that a condition of this transaction include that patients will have various opportunities in place to speak up if their care is being negatively impacted by the change.
Transportation and the challenge of access
Three primary care clinics at Yale-New Haven Hospital will be moved from their current locations into one unified location at 150 Sargent Drive. The hospital surveyed patients and found that 66% of patients get to their appointments via a car. There is plenty of parking at the new site for these patients, but care will be less accessible to the 34% of patients who walk or take the bus to their appointments.
Yale stated that they did not yet have a transportation plan in place for those patients without vehicles. We suggested that approval of the CON be conditioned on a robust, practical transportation plan.
Costs to patients
Patients of Yale Primary Care have access to free care if they qualify. This option is not available for patients of the community health centers, which use a sliding scale fee schedule. Leaders of the community health centers explained that despite the assessment of a fee, patients are not denied care if they cannot pay.
We suggested that approval of the CON be conditioned on a clear plan for those patients who previously received care for free to continue to receive free care.
NARAL Pro-Choice Connecticut, Yale Law School’s Reproductive Rights and Justice Project Clinic, and Planned Parenthood of Southern New England submitted testimony regarding the impending change to the federal regulations governing Title X family planning funds. In brief, these proposed regulations would put a “gag rule” on providers receiving Title X funds (which includes the federally qualified health centers involved in this transaction), banning them from referring a woman to access safe, legal abortion.
Yale-New Haven Hospital’s response to this concern at the hearing was two-fold:
- While primary care services will be terminated, family planning services, including abortion services, will remain in place at Yale-New Haven Hospital.
- The final regulation has not been promulgated, so an appropriate response cannot be determined.
Still, it is likely that once the new regulations are finalized, the change could have a negative impact on a woman’s access to abortion services in New Haven. We suggested that once the final regulation on Title X funds is issued, the Office of Health Strategy’s Health Systems Planning Unit require Yale-New Haven Hospital and the FQHCs to determine how they will address the challenge of access to abortion services after the change.
Consistent funding and investment
Yale-New Haven Hospital has committed to community benefit grants to the community health centers, in addition to the capital investment in the new location. These funds will be critical to ensure the success and sustainability of the newly-conceived New Haven Primary Care Consortium.
We suggested that a long-term commitment of Yale-New Haven Hospital’s community benefit grants to the community health centers be a condition of the change. Without those funds, it is unlikely the community health centers would be able to sustain the additional facilities, care, and patients they will serve in this arrangement.
Outreach to the community
At the hearing, the community expressed concerns that they did not know about the impending change. While some good faith outreach has been conducted, the outreach to date may not be sufficient to inform patients, the community, and future patients regarding the change.
We suggested that the CON approval be conditioned on a more expansive patient and community outreach plan that is culturally, linguistically, and ability appropriate, reach people where they are, and allow for more information to be requested.
A major change needs a watchful eye
This is a major change in how primary care is delivered in the New Haven community, and only time will tell if this is a positive or challenging change for patients and the community. We hope to see some of the conditions we suggested incorporated into the final decision – so that the positive potential of this change is truly realized – and challenges are addressed.
Plan Reimagines Primary Care for Poor (New Haven Independent, 1/23/2018)
Yale New Haven Hospital teaming up with community health centers (New Haven Register, 11/27/2018)
Primary Plan’s Obstacle: Broken Bus System (New Haven Independent, 11/29/2018)
State wants details of Yale clinic deal (New Haven Register, 11/29/2018)
Farwell Questions Primary Care Move’s Impact On Poor (New Haven Independent, 12/4/2018)