BENNINGTON — About seven years ago, the leadership team at Southwestern Vermont Medical Center realized, because of dwindling numbers of people being admitted as patients, they were going to need to rethink the hospital’s staffing system.
Inpatient care, a main source of revenue for many hospitals at the time, have been declining for years. SVMC flipped from 80% inpatient and 20% outpatient in 2000 to 79% outpatient and 21% inpatient in 2014.
The downturn could have spurred the hospital to cut staff, but instead, it redeployed nurses who previously cared for patients in the hospital to new programs.
Those initiatives have helped SVMC reduce unnecessary hospitalizations by more than half.
SVMC also won recognition: The hospital is the state’s highest-rated hospital on the Lown Institute Hospital Index and recently won the Rural Leadership Award from the American Hospital Association.
The Bennington hospital was the only recipient of the award, chosen from several dozen applicants in a crowded field. The top reason for the award, a member of the American Hospital Association said, is a nursing team dedicated entirely to transitional care.
Ironically, successful advanced medical treatment was to blame for the downward trend in inpatient demand. Patients no longer need to stay in the hospital for stretches of time. A patient who undergoes surgery can now go home on the same day.
At the time, SVMC employed a number of advanced practice nurses with master’s or doctoral degrees, all of whom were focused on inpatient services.
“It’s very unusual for a hospital this size to have one clinical nurse specialist,” said Barbara Richardson, who won the Magnet Nurse of the Year Award in 2016 for her work as a transitional care nurse at the hospital. “We had five, and we have for the entire 20 years that I’ve been working here. The organization valued us, or they would not have kept us, because we were a pretty expensive resource.”
As the system moved from mostly inpatient to mostly outpatient, the fee-for-service health care model — in which hospitals and doctors are paid for the amount of care they deliver, instead of the quality — began to deteriorate.
That market switch could have severely affected SVMC, which serves Bennington and surrounding communities. The same dynamic contributed to the demise of many other hospitals, particularly in rural areas. Nationwide, 135 rural hospitals have shuttered since 2010.
Transitional care: wave of the future?
“The state was looking at health reform for the future, and payment reform. I think we all came to the conclusion that there has to be a better way,” said Thomas Dee, CEO of SVMC.
But as the hospital transitioned, OneCare Vermont, a company also working to switch the state’s health care model to “value over volume,” came into play. SVMC saw an optimal window for a transition.
“That was kind of the underpinnings for us to go down this road of creating some new programs that really were, at the time, pretty cutting-edge, especially for smaller rural hospitals,” Dee said.
Dee said the change gave them an opportunity to think deeply about the needs of the community.
“Vermont oftentimes is rated the most healthy state in the country,” he said. “That’s really driven a lot by the Burlington region. We have an area that is very rural, has access issues and has health status problems.”
SVMC’s advanced practice nurses, led by Billie Lynn Allard, started to review work by Mary Naylor, an expert nurse at the University of Pennsylvania. Naylor designed a system in which nurse specialists partner with other community organizations to help at-risk patients, many of whom frequently visited the hospital.
Transitional care nursing — a broad term that defines several different models of care — takes place when nurses provide care as patients shift from one physical setting to another, like a hospital to a home, or from one provider to another. All of the models are designed to provide continuity of services so that at-risk patients don’t slip through the cracks.
Richardson remembers hearing about some of Naylor’s work at a conference when the hospital started to make staff changes.
“I remember thinking at the time, ‘Oh my God, that’s my ideal job,’” Richardson said. “It was just so exciting and innovative, what she was doing. But it was not anything anybody around here was doing.”
Nurses at SVMC got together for a retreat, then began to outline how a transitional care model might look at the hospital. As they began to provide free care to at-risk patients in the community, unnecessary hospitalizations at SVMC decreased by 55%.
That number is what sets SVMC apart, according to John Supplitt, senior director for rural health services at the American Hospital Association, who gave the hospital its Rural Leadership Award this year. He said transitional care, as a concept, isn’t new, but the fact that a rural health care center reduced hospitalizations to such an extreme extent makes SVMC an outlier.
“I think the model helps Southwestern Vermont organize and focus on their approach toward transitional caregiving in a very deliberate way, which brought very measurable results,” he said.
Supplitt said he hopes that, in the same way SVMC took Naylor’s model and retrofitted it for a rural facility, other hospitals around the country might be able to learn from SVMC.
“It is something that can be replicated in other communities, if you’re willing to commit the time and energy and some resources to the strategy behind transitional nursing,” he said.
Closing the gap in health care
In her role as a transitional care nurse, Richardson said her day typically starts with interdisciplinary rounds, where nurses survey the patients in the hospital. Along with other transitional care nurses, she finds out who needs extra care, and who their primary physicians are.
If a patient doesn’t have another plan to transition out of the hospital, a nurse will introduce the program. Typically, the nurses carry a panel of between 15 and 25 patients, and most of these patients don’t qualify for other long-term care programs.
“For the most part, people who are coming to the hospital are usually so sick that they will meet our criteria for having some follow-up when they leave the hospital,” Richardson said.
When patients leave the hospital, nurses help them understand how to take their medications, how to follow their doctors’ instructions and how to obtain other social services. They’ll connect with patients’ primary care providers, too. Nurses typically make home visits, but during Covid-19, these visits take place remotely.
“(Primary care physicians) call us and say, ‘Can you go see what’s going on?’ And if we can solve the issue, or collaboratively work with (the patients) to manage it, we might be able to prevent an admission into the hospital,” Richardson said. “Our goal is to find those little gaps in health care.”
The program, which is free, can serve anyone, but Richardson sees many elderly people and people living in poverty.
“What we found very quickly was that people who don’t know if they’re going to be able to afford food at the end of the month, or buy their prescription, or have fuel oil to heat their home next month,” Richardson said, “they can’t think about, ‘How do I manage my chronic disease?’”
“We didn’t know, initially, just how much those social barriers impact health,” she said. “But we found that out very quickly.”
Nurses will continue to see a patient until both the patient and the nurses agree that the patient is ready to end the service. Because the service is free — insurance isn’t involved — that decision rests entirely between the nurse and the patient.
Nothing is off the table
The creation of the transitional care nursing program sprouted other programs that are now helping the hospital decrease hospitalizations and improve the health of the community.
Allard said that, when the program began, it gave nurses a front-row seat to some of the multifaceted problems that patients faced. The team members held weekly meetings to compile what they were seeing.
“Suddenly, we had a gap list of all these things that needed to be different,” Allard said. “Some of them were quick and easy, that we could fix. But some of them took years for us to figure out — was there a cost-effective way to create a new program, or to partner?”
One program that came out of the brainstorming session is the “community care team,” which presents the cases of patients who, for example, have mental health or substance use disorders to a roundtable of social service providers in Bennington.
The program has connected patients to social services that help with addiction and housing, for example. It’s geared toward people who come to the emergency room seeking help, but don’t need to be hospitalized, and it’s decreased unnecessary, expensive hospital visits for this population by 30%.
“Nothing is off the table, pretty much, with this program,” said Kim Warren, a health promotion advocate in the emergency department.
Warren said she served between 250 and 300 patients in 2020.
Another program, which has focused on diabetes education, has measurably reduced A1C hemoglobin levels by an average of 11%, and hospitalizations for people with diabetes have decreased by 20%.
“I think improving the social aspect of it definitely helps the health aspect,” Warren said. “And people in general will have better outcomes.”
Now, the hospital is looking toward another problem in the community: ensuring that all patients receive the same access to care.
While the hospital has been recognized nationally for its care model, and the Lown Institute Hospital Index rated SVMC first in the state, that same index also gave the hospital a “C” for civic leadership, and it ranks last out of 10 hospitals in the state for inclusivity. The inclusivity rating “measures the extent to which patients being served are demographically similar to those in the surrounding community.”
Paula Seaman, the hospital’s director of quality, safety and value, said the rating will help staff improve. She pointed to the hospital’s Diversity and Inclusion Committee, whose job is to create programs that specifically address the needs of marginalized populations, and measure the hospital’s progress.
Patricia Johnson, a Black emergency room nurse at the hospital, serves on the committee, and has helped marginalized patients learn about the Covid-19 vaccine. She said the hospital is making progress.
“We’re looking at a few different models currently to implement into our hiring process, and how to evaluate our (current) policies to make sure that they don’t create boundaries for that risk population,” she said.
Loss and gain
Allard, who led the first team of transitional care nurses, said the program initially lost money for the hospital.
“My success with this program was causing decreased revenue for the hospital,” Allard said. “Those were some interesting phone calls with the CFO.”
A more patient-centered model was a leap of faith in the beginning, Dee said, particularly in a fee-for-service market.
“You have two canoes, and one leg in one canoe, and another leg in another canoe,” he said. “Both are different systems, and you’re trying to navigate those canoes.”
Still with one leg in that fee-for-service model, managing the budget requires creativity. The facility relies in part on philanthropy, and is part of a broader company, Southern Vermont Health Care, that provides a number of services to southwestern Vermont.
SVMC is moving ahead: The emergency department will soon undergo a $26 million renovation that will double its square footage. The department was designed to serve between 12,000 and 13,000 patients per year, but now has twice that. The hospital will pay for it with $6.9 million carried over from a former project that didn’t go through, $14.5 million in fundraising and $4.3 million in net debt financing.
SVHC, the hospital’s parent company, also recently purchased the former Southern Vermont College campus. The hospital announced on Thursday that, through a fund drive, it received $566,000 in donations to the Grateful Bennington Fund, which will be used to repurpose the campus. The group is collaborating with other community partners on a long-term plan for the property that will be rolled out throughout 2021.
Watching the hospital’s progression over the last decade, Allard said she hopes officials at other health care centers will feel emboldened to take on the patient-centered model.
“I think one of my goals right now is to get the message across the country that more places need to do this,” she said, “because this is the right thing to do for communities, and for patients, and for health care.”