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6-s_e Memorandum
z�. � : August 18, 1977
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• TO: Members of the CNCHSA Board of Directors
tsi June H. Twinam
Executive Director
FROM: Staff
Beth Jenkins
SUBJECT: Comments on the Oncology/Radiation Therapy President
V Section of the HSP
CJOn July 11, 1977 the Plan Development Committee approved a draft of the
bO Oncology/Radiation Therapy Section of the Health Systems Plan for submission
to the full Board. Since that date, a number of comments and suggestions
regarding the draft have been received. Most recently, written comments
(i were received from two members of the CNCHSA Board, June K. Steinmark,
5 Chairperson of the Board of Weld County Commissioners, and Dr. Franklin
D. Yoder, Director of the Weld County Health Department. Copies of both
0J C) letters are attached.
Y'.1 These letters raise two general concerns or suggestions. The first pertains
to service maldistribution and the concomitant accessibility problems for
rural patients. In this regard, reference is made to the document A Proposal
1.4 for Integrated Cancer Management in the United States: The Role of Radiation
40
Oncology, a report to the National Cancer Institute by the Committee for
1.8 Radiation Therapy Services, November, 1972. It appears that staff has
CJ interpreted this document differently than Ms. Steinmark. Staff interprets
Z the document as proposing a regional or "conjoint radiation oncology center"
approach to providing radiation therapy services. This concept requires the
® availability of the complete armentarium of radiation sources, supporting AAA-
Pt equipment and facilities, but does not require the availability of tele L
rd therapy equipment within each component of the "center". Consultation nd
;„t referral patterns then become the mechanism for assuring the—TiiiirgEttity
0 of optimal care for all cancer patients.
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® The July 11 draft does not classify or type facilities, but it does reflect
Vthe concepts of regionalization and appropriate consultation and referral.
The need for patient access to necessary care is recognized and emphasized
"~tin through support of radiation therapy services at Logan County Hospital and
Old Weld County General Hospital. The importance of consultation and appropriate
a) referral is further emphasized through the standards and criteria and the goal
INC statements which either require or strongly recommend both membership in the
via Colorado Regional Cancer Center, and accreditation of an institution's cancer
3.4 treatment program by the American College or Surgeons. The goal of both of
O these organizations is to assure optimal care for all cancer patients.
ZZ The second major point of these letters is the suggested formation of a
ry visiting cancer committee or traveling tumor board. Staff feels that the
fQ need for such a committee may be obviated by the requirements for an
iii, accredited cancer treatment program and membership in the CRCC. The American
•
0 College of Surgeons requires that an institution have a functioning cancer
0)
V 7290 Samuel Drive, Suite 316—Denver, Colorado 80221—Telephone (303) 427-8460
770510
Memorandum to the Board of Directors
August 18, 1977
Page -2
committee before it can he accredited. Staff recognizes that all of the various
medical specialties may not be available within the medical staff of any given
institution, but feels that membership in the CRCC could alleviate this problem
by virtue of that organization's commitments to provide technical assistance,
continuing education, and administrative support for oncology program develop-
ment and evaluation.
Staff appreciates the thoughtful comments of Ms. Steinmark and Dr. Yoder, and
hopes that this additional information will assist the Board in its consideration
of the Oncology/Radiation Therapy Section of the HSP.
Attachments
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Project Review Committee Report
t ; Presented to the Board
August 18, 1977
•
June H. Twinam
The Project Review Committee met on August 8th to review Executive Director
applications from Fort Morgan Community Hospital, Saint
Luke's Hospital and the Davis Institute for the Care and BethJenkins
Study of the Aging. Highlights of the applications, President
Committee discussion, and the actions taken are presented
; below for your consideration.
Fort Morgan Community Hospital is requesting a Certificate of Need and
Section 1122 approval to renovate and remodel their existing 40-bed
facility to bring it into conformance with Colorado Department of Health
UO building codes. Thirty-six of the existing forty beds are currently
E non-conforming by virtue of a lack of in-room toilet facilities,
inadequate ventilization or inadequate floor space. In addition to
Jcorrecting these problems, the Hospital proposes to remodel most
(10 ancillary areas. This proposal would not change the bed capacity of
the Hospital, nor would it add new services. Rather, service
capabilities would be improved through functional reorganization of
existing services and the provision of adequate work space.
The capital expenditure associated with this project is $592,000,
03 comprised of $550,000 for construction/renovation and $42,000 for new
GJ patient room furnishings. This proposal is subject to review under
Section 1122 of the Social Security Act by virtue of the dollar
amount of the capital expenditure, and is subject to Colorado's
O Certificate of Public Necessity Act due to the replacement of non-
conforming beds.
OS
After a brief chronological history of the Hospital, Committee discussion
O focused on the following major points:
Pupil
V 1. Fort Morgan Community Hospital is committed to sharing services
with other local providers as demonstrated by their provision of
laboratory services to private physician clinics in Fort Morgan;
U) their provision of physical therapy services to the local nursing
O homes and to East Morgan County Hospital in Brush, and their
Q) cooperation in medical audit and utilization review activities
with the Brush facility.
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2. The projected increase in utilization of Fort Morgan Community
D Hospital could negatively impact the hospital in Brush. However,
there are four General or Family Practitioners located in Brush
1 who appear committed to the Brush facility. Consequently, that.
facility would probably maintain its current low occupancy
despite increased utilization of the Fort Morgan Hospital.
Moreover, the number of patients who go outside of Morgan County
i•i
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C ) 7290 Samuel Drive, Suite 316 —Denver, Colorado 80221—Telephone (303) 427-8460
Project Review Committee Report
August 16, 1977 -.
Page 2
for hospital services will probably be reduced because medical specialists
are now locating their practices in Fort Morgan.
The Committee voted 4 to 0 to forward this application with a recommendation
for approval for the following reasons:
1) This project would assure the accessibility of inpatient services for the
community.
2X This project would assure the community of an adequate facility.
3) There appears to be sufficient growth in the supply of physicians to
realize the projected growth in utilization.
4) This project appears to be financially feasible.
5) The per diem rate of Fort Morgan Community is favorable when compared with
other general acute inpatient facilities.
6) Fort Morgan Community Hospital has demonstrated a committment to regional
and county planning.
7) This project is necessary to bring the Hospital into conformance with
Federal Life-Safety and State Health Codes.
Therefore, at the direction of the Project Review Committee, I move that this
application be forwarded to the State Agency and the Health Facilities Advisory
Council with a recommendation for approval for the reasons stated.
The second application reviewed was from Saint Luke's Hospital.
Saint Luke's Hospital is requesting approval under the Colorado Certificate of
Public Necessity Act and Section 1122 of the Social Security Act to consolidate
and renovate the intensive care unit (ICU) .
At this time, the hospital has two physically distinct ICUs (a 6-bed unit and
a 14-bed unit) which will be consolidated into one 18-bed ICU. During the
renovation, windows will be installed in the unit to meet Federal Life-Safety
Codes.
The only major medical equipment required are patient monitors. The existing
monitors will be replaced with units which have computer interface capabilities.
The capital expenditure associated with this project is $791,590, comprised
of $591,590 for construction and renovation and $200,000 for equipment.
Factors considered by the Committee in reviewing this application are as follows:
1. The subsequent use of the 6-bed ICU extension was a main concern because
their continued use could result in an increase in the number of operational
beds at the Hospital. However, it was determined that while those six beds
would continue to be used, six semi-private roomo would he converted to
private rooms, thereby reducing the operating capacity of the facility by
two beds. The 6-bed ICU extension will be used as a post ICU area for
patients who still require cardiac monitors but do not require the intensive
services provided in the ICU.
Project Review Committee Report
August 16, 1977 _.
Page 3
2. Although not delineated within the application, the cost of the patient
monitors includes the cost of the computerized monitoring system.
3. The Saint Luke's Hospital will finance a portion of this project from donations.
The Hospital has on hand currently $45,695 in donations earmarked for this
project, but an additional $50,000 is projected to be raised through future
fund-raising efforts. If these efforts are not successful, the needed funds
are available internally, but they would need to be reallocated from other
proposed future projects.
4. Saint Luke's new cardiovascular laboratory and the addition of three cardio-
vascular surgeons to the medical staff should result in an increase in the
number of cardiovascular procedures performed, thereby increasing the utili-
zation of the ICU.
The Committee voted 9 to 0 to forward this application with a recommendation for
approval for the following reasons:
1) This consolidation is expected to improve the quality of care.
2) This project is necessary to meet Federal Life-Safety Code requirements.
3) Saint Luke's Hospital has considered other alternatives and found that this
was the most cost-effective.
4) This project will result in a reduction of ICU beds.
Therefore, at the direction of the Project Review Committee, I move that this
application be forwarded to the State Agency and the Health Facilities Advisory
Council with a recommendation for approval for the reasons stated.
The third application to be reviewed was from the Davis Institute for the Care
and Study of the Aging.
The Davis Institute has submitted an amended application seeking a Certificate
of Need and Section 1122 approval for the establishment of a 40-bed geriatric
self-care rehabilitation unit.
Davis Institute originally received a Certificate of Need and Section 1122 approval
for the construction of 15 geriatric ICU beds. These beds were to be complemented
by 80 residential beds which did not require review and approval.
In February, 1977 the Institute submitted a new application for conversion of
the 80 residential beds to 78 self-care rehabilitation beds. This request
resulted from further conceptual development of the Institute's envisioned
research and treatment programs, and apparently from financial consideration, i.e.
licensed rehabilitation beds would be eligible for third-party reimbursement.
That application was withdrawn following a public hearing. Primary concerns of
the Health Facilities Advisory Council about that application were the lack of a
clearly defined target patient population, the possibility of duplicating already
existing rehabilitation services, and the contractual relationship between the
Institute and the City and County of Denver.
The current application is apparently an attempt to allay those concerns, and to
receive approval for a smaller self-care rehabilitation unit. Other significant
aspects of this application are:
Project Keview Committee Report •
August 16, 1977
Page 4
1. The Institute is now conceptualized as a full service gerontological hospital
offering a continuum of services from geriatric medical education and compre-
hensive health assessment on an outpatient basis, through intensive inpatient
care;
2. A time-phased conversion of the additional 38 independent living units to
rehabilitation beds is planned as need dictates. This conversion is recognized
as requiring a subsequent review and approval. This conversion is currently
targeted for January 1, 1979; and
3: The previous contractual relationship between the Institute and the City and
County of Denver has been modified through two new contracts. The first
established the Institute as a totally independent corporate entity, and the
second provides for the contractual purchase of clinical services for the
medically indigent by the City of Denver from the Institute, subject to a
$400,000 annual ceiling.
It is important to relate the circumstances resulting in the review of this
application by CNCHSA. Davis Institute is scheduled to appear before the Health
Facilities Advisory Council on September 1, 1977. CNCHSA Staff was contacted by
the Office of Medical Care Regulation and Development within the Colorado Depart-
ment of Health in the latter part of July, and asked if a review of this applica-
tion could be conducted before September l.st, even though the application would
not be available until August 1st. Staff responded that every effort would be
made to comply.
Staff received the application on August 2, 1977. Since it had been accepted for
review by the HFAC, staff was obligated to review the application in its present
form. However, if routine procedures for submission had been followed, it is
staff's opinion that this application would have been rejected as incomplete.
Before beginning the actual review of this application, the process for its review
was discussed. The applicant was concerned that he would not be able to respond
adequately to the staff analysis and requested that his application be reviewed
before the full Board, thereby allowing time for him to formulate his responses.
The applicant was informed of the normal process for review of an application,
and of the fact that both the applicant and the Board had the opportunity to
discuss further any questions or information that they felt was not adequately
considered by the Committee. Following this, Committee review of the application
occurred.
Major points of discussion were as follows:
1. The intent of the Self-Care Rehabilitation Unit is to make the patient
responsible as a full-fledged partner in his care and his ultimate return
to independent living in the community. The patient will be taught self-care,
and no services will be provided for him that he can provide for himself.
2. The applicant stated that he could not strictly define his target patient
population by type of diagnosis or disease entity. Rather, the Institute
proposed a modality for treating elderly patients who had combinations
of physical, mental and social problems.
3. The applicant was asked whether any alternatives to a Self-Care Rehabilitation
Unit have been considered, and specifically why a rehabilitation license as
opposed to a "new" type of licensure classification is necessary to provide
the care which is to be offered. The applicant responded that after describing
Project Review Committee Report
August 16, 1977
•Page 5
The proposed treatment program to the State Licensure Division, they had stated
that a rehabilitation unit most closely approximated the applicant's proposal.
Consequently the applicant applied for a rehabilitation license.
4. The Committee asked why other existing facilities could not be used to provide
the clinical aspects of the proposal, with the research conducted at or through
those other facilities. The applicant responded that such an arrangement would
be difficult in that the conceptualization of the Davis Institute as full
service gerontological hospital such as that being proposed, required all
aspects of the program to be in one place.
5. Several Committee members voiced their opinion that the $400,000 allocated to
purchase services from the Institute could be better spent on more immediate
needs of the indigent elderly, specifically dentures. The applicant responded
that that was a Denver City Council decision.
6. A verbal review of the costs indicated that the per diem costs for these
services will approximate $125 rather than the $57.50 charge which was indicated
in the application.
7. A question was raised regarding whether attempts had been made to secure a
special reimbursement mechanism from Medicare and Medicaid for the proposed
services. The applicant stated that this was contemplated for the apartment
units but not for the self-care rehabilitation beds.
8. The applicant stated that this proposal involved providing a service which
is not presently available to the elderly. It was stressed that this is a
clinical service, not a research proposal.
The Committee voted 6 to 1 with one abstension to forward this application with
a negative recommendation for the following reasons:
1) The applicant has not demonstrated adequately that this project will not
result in an unnecessary duplication of services.
2) It does not appear that the applicant has pursued adequately alternatives to
this proposal, either for providing service or for reimbursement.
3) This project does not appear to be a cost-effective use of public tax dollars
to meet the needs of the elderly population.
T. Scott Meiners
8/16/77 •
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