STATE AGENCY ACTION REPORT ON APPLICATION FOR CERTIFICATE OF NEED

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1 STATE AGENCY ACTION REPORT ON APPLICATION FOR CERTIFICATE OF NEED A. PROJECT IDENTIFICATION 1. Applicant/CON Action Number Halifax Hospital Medical Center d/b/a Halifax Health Medical Center/CON # North Clyde Morris Boulevard Daytona Beach, Florida Authorized Representative: Mr. Bill Griffin (386) Service District/Subdistrict District 4 (Baker, Clay, Duval, Flagler, Nassau, St. Johns and Volusia Counties) B. PUBLIC HEARING A public hearing was not held or requested regarding the proposed project. Letters of Support The applicant has 15 letters of support for the project that were dated during July 26, 2010 through September 27, Brooks Rehabilitation Hospital representatives provided four letters, Halifax Health (one), Volusia County physicians (nine), and two are from former Halifax patients who required rehab care at Brooks. Below is a summary of these support letters.

2 Carolyn Geis, M.D., Medical Director, Rehabilitation Medicine, Halifax Health and Assistant Clinical Professor, Florida State University College of Medicine, stated that she has two options for patients who require specialized rehabilitative care (patients with neurologic injuries, such as traumatic brain injury, spinal cord injury and stroke). Option one is to refer the patient to Brooks (Jacksonville, 90 miles away) and the other option is to refer the patient to the Shepherd Center (400 miles) in Atlanta, Georgia. Dr. Geis stated difficulties encountered include patient families not receiving critical patient care information which can lead to re-hospitalization, patient isolation from family and related support which can lead to depression, making the rehabilitation process less effective and increasing the difficulty with coordination of ongoing medical and rehabilitation needs. She indicated that many of the local vendors do not have branches in Jacksonville and this results in difficulty providing equipment maintenance and repairs. Dr. Geis stated that services for indigent patients are minimal and sometimes not available in Volusia County; and while Brooks is able to take a limited number of indigent patients, transportation to Jacksonville is typically not available. Because of this, the indigent patient often has a prolonged acute care hospital stay. Dr. Geis concluded that an inpatient rehab unit at Halifax will enable us to provide a comprehensive care continuum from acute care to outpatient rehabilitation. William Kuhn, M.D., a practicing Volusia County physician, boardcertified with the American Board of Neurological Surgeons, stated that with Halifax Medical Center accepting a large number of complex trauma and stroke patients, the lack of a nearby comprehensive rehabilitation facility hinders continuity of care, which results in the delay of rehabilitation intervention and creates significant hardship for families (due to distance). Dr. Kuhn also indicated many of these patients are placed in nursing homes with minimal therapy services due to the lack of a comprehensive rehabilitation center locally. Dr. Kuhn further stated he had been at Halifax Medical Center for approximately 20 years and that throughout that time, the lack of a comprehensive rehabilitation center in the area has been a significant detriment to patient care. J. Richard Rhodes, M.D., Atlantic Orthopedics, P.A., Orthopedic Surgeon, stated Halifax Health Center takes care of many complex neurosurgical as well as orthopedic patients and that once these patients are treated acutely, they have to find other specialized centers, usually out of the county. He indicated (as do all the local physicians) that the project would prove extremely beneficial for local patients by improving continuity of care. 2

3 Jeffrey Johns, M.D., Associate Hospital Medical Director, Spinal Cord Injury Medical Director, Brooks Rehabilitation Hospital, expressed firsthand knowledge or how important and invaluable social, family and spiritual support can be to a patient. Dr. Johns stated the project should improve medical outcomes as well as functional outcomes for patients in the Daytona area. Kerry Maher, M.D., Admissions Director, Brooks Rehabilitation Hospital, indicated that Halifax patients who would benefit from specialized inpatient rehabilitation services are unwilling or unable to make the trip to Jacksonville. Patients seem averse to traveling to Jacksonville to receive specialized rehabilitation services due to the transportation challenges for elderly patients and/or for their caregivers. Dr. Maher stated that the project would allow patients to remain in familiar surroundings and still benefit from the highly specialized expertise and experience that Brooks Rehabilitation can offer. Patricia debear, Senior Vice President and Administrator, Brooks Rehabilitation Hospital, stated three reasons the project should be approved: rehabilitation services and life-long support required for successful community reintegration should begin immediately and be coordinated through a full continuum of services beginning at the acute treatment phase Halifax will be able to offer the needed full service rehabilitation continuum by providing a wide array of comprehensive and state-ofthe-art approaches and programs needed to maximize each person s recovery a community-based rehabilitation unit will eliminate the disconnection and isolation from family and friends during a long rehabilitation process so that prompt reintegration is possible. Ms. debear further commented that partnering with her facility will provide Halifax access to Brooks extensive body of knowledge in rehabilitation specialty services and post acute settings; ongoing education and research through Brooks partners including the University of North Florida, the University of Florida and Duke University; and resources for building the kind of robust community support programs needed to become a leader in rehabilitation. 3

4 Louise McEachern, MSW, CRC, Case Manager, Brooks Rehabilitation Hospital, described some continuity of care issues that result when a patient from Daytona receives care at Brooks Rehabilitation Hospital. Ms. McEachern also stated she has been working as a case manager at Brooks Rehabilitation Hospital for 25 years and that distance has always been a factor for patients from Daytona or other parts of the state who receive care at her facility. The former Halifax patients who received rehab at Brooks also addressed the travel and separation from family issues incurred. C. PROJECT SUMMARY Halifax Hospital Medical Center d/b/a Halifax Health Medical Center (CON #10101) proposes to establish a 40-bed comprehensive medical rehabilitation (CMR) unit at its existing facility located in Daytona Beach (Volusia County), District 4. Halifax Hospital Medical Center is the largest hospital under Halifax Health - a legislatively-chartered taxing health care organization governed by a board of commissioners appointed by the governor of Florida. Halifax Health is a member of the Safety Net Hospital Alliance of Florida 1. The applicant is also licensee for Halifax Health Medical Center Port Orange (80 acute care beds) and Halifax Psychiatric Center North (30 child/adolescent psychiatric beds). Halifax Health Medical Center s licensed bed complement consists of 553 acute care beds, 92 adult psychiatric beds and nine Level II NICU beds. The applicant has notification #N to add 204 acute care beds at Halifax Health Medical Center. Halifax Health Medical Center has a Level II adult interventional cardiovascular program, is a designated comprehensive stroke center and has an adult kidney transplantation program. The applicant has CON #9956 approved to establish an adult pancreas transplantation program. Halifax Health Medical Center is a Florida Department of Health (DOH) authorized Level II Trauma Center 2 and a DOH designated acute care center provider for Florida s Brain & Spinal Cord Injury Program pdf. 3 4

5 The applicant proposes to condition project approval to establish the 40- bed CMR unit through the delicensure of 88 acute care beds at Halifax Health Medical Center and to provide a minimum of 5.3 percent of the 40-bed CMR unit s total annual patient days to Medicaid and charity care patients, combined. The project involves a total cost of $12,336,382. Total project cost includes: building, equipment, project development, and start-up costs. The project involves 33,800 gross square feet (GSF) of renovation at a construction cost of $8,000,000. D. REVIEW PROCEDURE The evaluation process is structured by the certificate of need review criteria found in section , Florida Statutes, and Chapters 59C-1 and 59C-2, Florida Administrative Code, and local health plans. These criteria form the basis for the goals of the review process. The goals represent desirable outcomes to be attained by successful applicants who demonstrate an overall compliance with the criteria. Analysis of an applicant's capability to undertake the proposed project successfully is conducted by evaluating the responses and data provided in the application, and independent information gathered by the reviewer. Applications are analyzed to identify strengths and weaknesses in each proposal. If more than one application is submitted for the same type of project in the same district (subdistrict), applications are comparatively reviewed to determine which applicant(s) best meets the review criteria. Rule 59C-1.010(3) (b), Florida Administrative Code, prohibits any amendments once an application has been deemed complete. The burden of proof to entitlement of a certificate rests with the applicant. As such, the applicant is responsible for the representations in the application. This is attested to as part of the application in the Certification of the applicant. As part of the fact-finding, the consultant, Steve Love, analyzed the application with consultation from the financial analyst, Everett (Butch) Broussard, who reviewed the financial data and architect, Scott Waltz, who evaluated the architecturals and the schematic drawings. 5

6 E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA The following indicate the level of conformity of the proposed project with the review criteria and application content requirements found in sections and , Florida Statutes, and applicable rules of the State of Florida, Chapters 59C-1 and 59C-2, Florida Administrative Code. 1. Fixed Need Pool a. Does the project proposed respond to need as published by a fixed need pool? Or does the project proposed seek beds or services in excess of the fixed need pool? ss (1)(a), Florida Statutes, Rules 59C-1.008(2) and 59C-1.039(5), Florida Administrative Code. In Volume 36, Number 29, dated July 23, 2010 of the Florida Administrative Weekly, a fixed need pool of zero comprehensive medical rehabilitation beds was published for District 4. District 4 has 183 licensed and 14 CON approved CMR beds at Brooks Rehabilitation Hospital in Duval County via exemption # Brooks Rehabilitation Hospital licensed the 14 beds effective August 25, The applicant is applying outside of the fixed need pool, under special circumstances. District 4 s 183 licensed CMR beds averaged percent occupancy during the 12-month period ending December 31, District 4 Comprehensive Medical Rehabilitation Bed Utilization Calendar Year Month Total Occupancy % Facility Beds County Bed Days Patient Days Brooks Rehabilitation Hospital 143 Duval 52,195 41, % Florida Hospital-Oceanside 40 Volusia 14,600 8, % Total District Beds/District Utilization ,795 50, % Source: Florida Hospital Bed and Service Utilization by District published July 23, The table below contains the Agency s Population Estimates for District 4 counties, total District 4, and the State for July 1, 2009 and January 1, 2016 (the planning horizon date). 6

7 Halifax Hospital Medical Center (CON #10101) Population Estimates July 1, 2009 and January 1, 2016 Total January 2016 Age 65+ January 2016 Age 65+ Percent Change County Total July 2009 Percent Change Age 65+ July 2009 Baker 26,049 28, % 2,917 3, % Clay 185, , % 22,017 30, % Duval 908, , % 102, , % Flagler 95, , % 26,556 36, % Nassau 73,732 86, % 11,845 17, % St. Johns 186, , % 29,722 43, % Volusia 508, , % 109, , % District Total 1,984,223 2,198, % 304, , % State Total 18,818,998 20,274, % 3,302,610 3,990, % Source: Agency for Health Care Administration Population Projections, published September As shown above, the expected growth in the elderly population by 2016 for Volusia County is the lowest by percentage of any other District 4 county. However, of the seven counties in District 4, Volusia County is expected to have the second highest increase of elderly residents (an increase of 19,646 elderly residents from July 2009 to January 2016). The district overall is expected to experience a higher population growth rate than the state by 3.08 percent and a higher elderly population growth rate than the state by 9.49 percent. AHCA population projections for July 1, 2009 show an age 65 and over population in Volusia County of 109,260, which is projected to increase to 128,906 by January 1, 2016 or by percent. This compares to the district age 65+ population projected increase from 304,851 in July 2009 to 397,264 by January 2016 or by percent. The increase in the elderly population for the state is projected to go from 3,302,610 to 3,990,155 or by percent. Volusia County s population age 65+ accounted for 5.51 percent (109,260/1,984,223) of the July 2009 district total and 5.86 percent (128,906/2,198,815) of the 2016 projected district total. 7

8 Halifax Hospital Medical Center (CON #10101) Population Profile July 1, 2009 and January 1, 2016 Total January 2016 Age 65+ January 2016 Age 65+ Percent Change County Total July 2009 Percent Change Age 65+ July 2009 Baker 26,049 28, % 2,917 3, % Clay 185, , % 22,017 30, % Duval 908, , % 102, , % Flagler 95, , % 26,556 36, % Nassau 73,732 86, % 11,845 17, % St. Johns 186, , % 29,722 43, % Volusia 508, , % 109, , % District Total 1,984,223 2,198, % 304, , % State Total 18,818,998 20,274, % 3,302,610 3,990, % Source: Agency for Health Care Administration Population Projections, published September Volusia County population at 508,844 of the district s 1,984,223 total as of July 1, 2009, accounts for percent of the district total. Volusia is projected to have 540,492 of the district s 2,198,815 population by January 1, 2016 total or percent of the district total. Volusia County has the second largest total population and age 65+ population of any county in the district for both 2009 and The following is a map of District 4 s licensed CMR facilities and Halifax Health Medical Center. 8

9 District 4 Comprehensive Medical Rehabilitation Facilities and Halifax Health Medical Center (CON #10101) Source: Microsoft MapPoint

10 The following table illustrates the driving distance in miles between the existing facilities and Halifax Health Medical Center (CON #10101). Driving Distance in Miles Existing Facilities and Proposed Site Halifax Health Medical Center (proposed site) Florida Hospital- Oceanside Brooks Rehabilitation Hospital Halifax Health Medical Center (proposed site) Florida Hospital-Oceanside Brooks Rehabilitation Hospital Source: MapQuest The applicant responds to need based on what it categorizes as four sections: conformity with the fixed need pool, reasons for the project, analysis of need, adverse impact, and about Halifax and Brooks Rehabilitation Hospital-The CMR Unit Manager. Each of these four sections is briefly discussed below. Conformity with the Fixed Need Pool The applicant recognizes the Agency published a fixed need pool of zero comprehensive medical rehabilitation beds for District 4, for the current batching cycle. Halifax states that the zero net need was determined in part upon 14 CON approved CMR beds at Brooks Rehabilitation Hospital and that Brooks has historically implemented bed additions to expand the supply to ensure resident needs are met. The applicant contrasts this to the other licensed CMR provider in District 4, Florida Hospital- Oceanside s 40-bed CMR unit which it states has grown slowly though population increases have occurred. Halifax states that the existing hospital based CMR unit does not provide for any specialized programs and the consequence to this approach is that access is limited to patients with certain types of conditions. The applicant presents the published CMR need methodology for January 2016 and notes that the state has a negative need of 554 CMR beds based on the need formula showing 1,781 beds projected as needed and the state having 2,335 licensed and approved CMR beds. The formula indicates District 4 has a gross need for 180 CMR beds and has 197 or a negative need of 17 beds. The applicant notes that the state has an overage of 31 percent (554/1,781) while District 4 is at nine percent (17/180). Halifax contends this indicates the Agency approves and licenses far greater numbers of CMR beds than would have been forecasted using the methodology. The applicant alleges this establishes a pattern of recognizing special or not normal circumstances in the allocation of CMR beds and that project approval would bring the CMR 10

11 bed surplus for the district at par with the state overall. Halifax s 40 beds would result in a surplus of 32 percent (57/180), which is consistent with the state. However, existing CMR providers can add beds by exemption based on 80 percent occupancy regardless of need projections. It is not clear how approving a CON to add beds in the absence of projected need in a district so that district would come more in line with the bed supply in other districts could be considered a special circumstance. Reasons for the Project The applicant states that the fundamental reason for the project is that availability and access to CMR services is not uniform, indicating improvements can occur in Flagler and Volusia Counties. The applicant indicates five observations to warrant project approval: a decline in the CMR use rate while population increases have occurred dependence on a sole provider, Florida Hospital-Oceanside for CMR services in the southern portion of the district, with only slight growth in occupancy over the years, less than 60 percent occupancy in 2009 and absence of specialty rehabilitation programs a pattern of CMR service use that ranks the district below others in the state Agency discharge destination data showing markedly lower CMR utilization for residents in the southern counties of the district data show much higher utilization of skilled nursing facilities (SNFs) for residents in the southern counties of the district in lieu of inpatient rehabilitation compared to residents in the north and studies show better outcomes for stroke and complex hip fractures treated in CMR facilities, which poses concern with quality of care, when SNFs are the most available and accessible post-discharge option. 4 4 The applicant cites three studies to support this Inpatient Rehab Facilities Benefit Post-Stroke Care, Type of Facility Providing Rehabilitation Care Affects Outcomes, Robert Wood Johnson Foundation, and Analysis of rehabilitation activities within skilled nursing facilities and inpatient rehabilitation facilities after acute hip fracture ; AM. J. Phys. Med Rehab, 2010 July; 89(7); The applicant s attachment 10 included the first article & Poststroke Rehabilitation Outcomes and Reimbursement of Inpatient Rehabilitation Facilities and Subacute Rehabilitation Programs, 11

12 Halifax provides a comparison of District 4 s CY 1999 and 2009 licensed CMR beds, bed days, patient days, and occupancy as a starting point for its need discussion. Below is a table to account for these changes. District 4 Comprehensive Medical Rehabilitation Bed Utilization Calendar Years 1999 and 2009 Calendar Year Month Total Occupancy % Facility Beds County Bed Days Patient Days Brooks Rehabilitation Hospital 127 Duval 46,355 35, % Florida Hospital-Oceanside 40 Volusia 14,600 7, % Total District Beds/District Utilization ,955 43, % Calendar Year Month Total Occupancy % Facility Beds County Bed Days Patient Days Brooks Rehabilitation Hospital 143 Duval 52,195 41, % Florida Hospital-Oceanside 40 Volusia 14,600 8, % Total District Beds/District Utilization ,795 50, % Source: Florida Hospital Bed and Service Utilization by District published July 28, 2000 and July 23, As shown above, Brooks Rehabilitation Hospital added 16 beds between CY 1999 and 2009, while Florida Hospital-Oceanside remained at 40 beds. District 4 s CMR patient days increased from 43,115 to 50,280 or a net increase of 7,165 days. Brooks reported 5,781 of the additional 7,165 days or percent compared to Florida Hospital Oceanside s 1,384 or percent of the total. Halifax indicates that Brooks evidences growth in both supply and demand for CMR services. Population estimates were examined and the percent change per year calculated to determine if growth occurred at a higher rate than CMR utilization. The chart below provides a comparison of District 4 s population by county for July 1999 and July

13 County Total Pop. District 4 Population Estimates July 1, 1999 July 1, 2009 Pop. Age 65+ Pop. Age 75+ Total Pop. Pop. Age 65+ Pop. Age 75+ Average Annual Percent Increase Baker 21,495 1, ,049 2,917 1, % 4.7% 5.6% Clay 137,334 13,375 5, ,678 22,017 9, % 6.5% 6.8% Duval 768,104 80,703 37, , ,534 48, % 2.7% 3.1% Flagler 47,565 13,836 5,407 95,214 26,556 13, % 9.2% 14.1% Nassau 55,994 7,008 2,591 73,732 11,845 4, % 6.9% 8.7% St. Johns 118,283 19,233 8, ,142 29,722 14, % 5.5% 6.9% Volusia 436,271 97,356 46, , ,260 57, % 1.2% 2.2% Total 1,585, , ,044 1,984, , , % 3.1% 3.9% Source: AHCA Population Estimates, September 2007 and September Total Pop. Pop. Age 65+ Pop. Age 75+ As shown above, District 4 s total population between CY 1999 and 2009, had an average annual increase of 2.5 percent and the age 65 and over group had 3.1 percent. Duval County s total population increased by 1.8 percent compared to Volusia s 1.7 percent and Flagler s 10.0 percent. Volusia and Flagler Counties combined averaged 2.5 percent. Halifax next compared the CMR use rate by thousand population by dividing CMR days by 1,000 residents to arrive at 27 CMR days per thousand in CY 1999 compared to 25 CMR days per l,000 in CY The applicant contends the decline in use rate as supply increased at Brooks and the district s population increased, indicates that impediments exist to CMR services. The applicant then provides this analysis by District for CYs , which shows CMR use per thousand population declined at an average of four percent per year over the last five years. According to Halifax, districts had declining use rates with the exceptions of District 3 (1.62 percent) and District 5 (0.95 percent). Halifax contends this suggests two possibilities or a combination of both: CMR services are not needed at the same rate they were in the past. Does that mean that patients and physicians (and payers) are not seeking CMR services for conditions patients have, or does it reflect a constriction of supply to the extent that patients, physicians, and payers have less choice and pick other options? 13

14 Factors exist that inhibit the availability and access. Again, is supply shrinking? Are providers implementing new policies for the use of CMR services? The applicant notes that use rates show wide variability among the 11 districts. Halifax contends that the state average is not representative of a common experience because the use rates are so variable and concludes that external factors are impacting CMR services. One of these is that the number and location of available beds within a given area affects availability and access. The applicant presents an analysis of bed counts by district and concludes that a reduction in bed supply produces a reduction in patient days, whereas the addition of beds is generally associated with increased patient days. Halifax contends that other factors also influence the use of beds. The applicant notes that changes in federal Medicare reimbursement rates impact patient admissions and utilization of CMR services. Halifax states that CMS requires 60 percent of CMR discharges are represented by 13 specific conditions, defined by diagnosis codes, therefore the CMR provider has to carefully scrutinize admissions to ensure the facility will not be subject to financial penalties. The applicant indicates the most common reasons for unfilled beds (lower occupancies) are: A majority of patient rooms are semi-private, hence gender matching is a factor in admission. CMR patients have many different conditions, with neurological and orthopedic dominating those who are treated but even within these two categories, conditions vary markedly (patients with a similar clinical and treatment match will likely be placed similarly whereas patients with a dissimilar clinical and treatment match will likely be placed differently). Therefore, an unoccupied bed may not be available if it would not afford an appropriate clinical and treatment match. A critical mass of beds must be reached in order to form a system of treatment to maximize staff efficiencies and justify the range of therapeutic modalities, smaller units cannot accommodate all CMR patients needs and treat those with less severe, general rehabilitation needs. Few small units have specialty accreditations. 14

15 Medicare prospective payment, the Case Mix Groups (CMGs), is rigorous. The facility must document the medical necessity of each admission to avoid potential repayment penalties. Conditions admitted to CMR must meet a three-prong test: (1) age, (2) motor, and (3) cognitive assessment criteria for the condition treated. Assessment also includes the capability of the patient to attain functional improvement by time of discharge. The applicant believes all CMR providers would likely take these factors into consideration in CMR operations but factors other than these external considerations contribute to a disparity in use rates. The applicant states that as for District 4, Duval County has 1.6 beds per 10,000 persons, whereas Volusia County has 0.8 beds-per-10,000 persons. Based on this beds-per-10,000 persons calculation, the applicant contends that Volusia County (the second most populated county in the district) does not have sufficient numbers of beds to offer required services and that this lack of beds leads to lower utilization in the southern end of District 4. The applicant believes that the lack of specialty rehabilitation services at Florida Hospital-Oceanside also contributes to lower utilization. The applicant indicates that Duval County has the highest use rate ( per 1,000 residents who meet CMS 13 conditions and are discharged from acute care to CMR facilities) in the district, and Volusia County, the second largest populated county, has the second lowest use rate ( per 1,000 residents). The applicant also detailed higher use rates in Duval County for four very high demand rehabilitation conditions brain injury, hip fracture, spinal cord injury and stroke, and correspondingly lower use rates in Volusia County. Based on the applicant s review of data, there is a lack of access to inpatient rehabilitation for residents of the southern counties of the district, and Volusia County residents in particular. The presence of a CMR unit does not necessarily improve access; considering that impediments exist that limit access to care. The applicant concludes that patients in Volusia County are either going without care or are substituting another form of care for inpatient rehabilitation. The applicant states that there is an over-reliance on SNF services in the area but that SNFs are not necessarily an equivalent substitute to CMR facilities. Therefore, quality is raised as an issue. The applicant provides data showing CY 2009 the SNF discharge rate of Duval County residents at 2.84 per 1,000 persons, Volusia County s 4.32 per 1,000 residents and Flagler County s 3.68 per 1,000 residents. Halifax concludes that 15

16 higher SNF use rates in Volusia and Flagler (and to some extent St. Johns) Counties is evidence that there is a lack of access to CMR services for residents of the southern portion of the district. The applicant states that its need projections are based on corrections undertaken to conform Volusia and Flagler County to that for Duval County. Halifax contends using rates associated with Duval County will provide an expectation of the demand for CMR services if more beds were available. The table below includes the applicant s population projections. Population Estimates District 4 July 2009, July 2013 and July 2014 CON application #10101, page #1-23, Table 1-13 from AHCA Population Estimates published September Halifax notes that the population 65 years of age and older, as a percent of total population, is greater for both Volusia and Flagler Counties than for Duval County. The applicant states that the discharge rate for Duval County is appropriate to correct for the CMR bed under-service existing in the southern portion of District 4. The use of the Duval County CMR discharge rate increases Volusia County s projected cases by 230 in year one and 234 in year two, whereas using the current rate the result would be 158 for year one and 162 for year two (see table below). Use of the Duval County CMR discharge rate applied to Volusia and Flagler results in 388 CMR cases by 2013 and 396 CMR cases by The use of the Duval County SNF discharge rate for CMS 13 conditions results in shifting some nursing home patients to the CMR facility. The applicant explains that during CY 2009, Flagler County had 350 residents admitted to SNFs having CMS 13 conditions. Adjusting the 350 baseline forward by population growth to 2013, results in an estimated 392 SNF admissions. 16

17 The difference between the 392 admissions expected and 302 admissions resulting from lowering the use for CY 2013 is 90 admissions. These admissions are then added to the CMR projections. Halifax s table below shows these as SNF Cases Shifted. The applicant forecasts a total of 1,251 CMR cases in 2013 and 1,275 cases in CON application #10101, page #1-24, Table 1-14 (partial). The applicant contends that having enough beds available is associated with increases in use. Halifax indicates that the addition of 40 beds in Volusia County will result in 1.51 CMR beds per 10,000 population for Volusia County and a 1.63 per 10,000 for Duval County. Halifax concludes that it will capture 35 percent or 438 of CY 2013 s (year one) 1,251 cases and 45 percent or 574 of CY ,275 cases. The applicant indicates the unit will have an ALOS of 15.3 days in years one and two. Patient days are projected at 6,698 in year one and 8,776 in year two. The resulting occupancy for the 40-bed unit computes to percent in year one and 60.1 percent in year two. Adverse Impact The applicant estimates the project would have little adverse impact on existing District 4 CMR providers (Florida Hospital-Oceanside and Brooks Rehabilitation Hospital). Halifax indicates that its data showed 72 Volusia County and 25 Flagler County residents were admitted to CMR facilities during CY 2009 with 62 treated at Brooks. The applicant indicates its data show 33 Flagler County and 118 Volusia residents (150 total in CMS 13 diagnosis) were discharged from acute care hospitals to CMR hospitals. Halifax indicates that there were 7,126 Volusia/Flagler resident acute care discharges in the CMS 13 categories. The applicant contends that its project will have little adverse impact because there will still be sufficient numbers of cases for existing CMR providers and nursing homes. Halifax concludes that the project corrects for lack of available beds and for reduced access experienced by residents in Volusia and Flagler Counties. 17

18 About Halifax and Brooks Rehabilitation Hospital-The CMR Unit Manager The applicant discusses designations/certifications of both Halifax and Brooks Rehabilitation Hospital and that the project will address the following issues: Serve the needs of patients who require a hospital level of care for rehabilitation Enhance patient care and management that includes: Daily Physician coverage Attending and Consultative Physicians Hospital-level nurse staffing ratios Depth of therapy services including PT, OT, ST, Psychology, Cognitive, etc. Highest intensity of therapy of an post-acute setting Produce lower readmissions to the acute care hospital setting than other inpatient post-acute settings (the applicant cites inpatient rehab s 11.6 percent rate (SNF 21.9, LTC 17.2) per national data). b. According to 59C (5)(d) of the Florida Administrative Code, need for new comprehensive medical rehabilitation inpatient services shall not normally be made unless a bed need exists according to the numeric need methodology in paragraph (5)(c) of this rule. Regardless of whether bed need is shown under the need formula in paragraph (5)(c), no additional comprehensive medical rehabilitation inpatient beds shall normally be approved for a district unless the average annual occupancy rate of the licensed comprehensive medical rehabilitation inpatient beds in the district was at least 80 percent for the 12-month period ending six months prior to the beginning date of the quarter of the publication of the fixed bed need pool. District 4 s 183 licensed CMR beds experienced percent occupancy during the 12-month period ending December 31,

19 2. Agency Rule Criteria Please indicate how each applicable preference for the type of service proposed is met. Refer to Chapter 59C-1.039, Florida Administrative Code, for applicable preferences. a. General Provisions: (1) Service Location. The CMR inpatient services regulated under this rule may be provided in a hospital licensed as a general hospital or licensed as a specialty hospital. Halifax Hospital Medical Center is a licensed general hospital. (2) Separately Organized Units. CMR inpatient services shall be provided in one or more separately organized units within a general hospital or specialty hospital. The applicant proposes to renovate space on the 8 th and 9 th floor of Halifax Hospital Medical Center to create the required separately organized unit for the project. (3) Minimum Number of Beds. A general hospital providing comprehensive medical rehabilitation inpatient services should normally have a minimum of 20 comprehensive medical rehabilitation inpatient beds. A specialty hospital providing CMR inpatient services shall have a minimum of 60 CMR inpatient beds. The applicant proposes a 40-bed CMR unit at Halifax Hospital Medical Center. (4) Conformance with Criteria for Approval. A CON for the establishment of new CMR inpatient services shall not normally be approved unless the applicant meets the applicable review criteria in Section , Florida Statutes, and the standards of need determination criteria set forth in this rule. See discussion in E.1. above. 19

20 (5) Medicare and Medicaid Participation. Applicants proposing to establish a new comprehensive medical rehabilitation service shall state in their applications that they will participate in the Medicare and Medicaid programs. Halifax Hospital participates in both the Medicare and Medicaid Programs. The applicant proposes to condition Halifax Health Medical Center s 40-bed CMR unit to a minimum of 5.3 percent of the total annual patient days to Medicaid and charity care patients, combined. Schedule 7A shows the applicant projects Medicaid and Medicaid HMO will be 5.8 percent and charity care two percent of the 40-bed CMR unit s year one and year two total annual patient days. b. Required Staffing and Services. (1) Director of Rehabilitation. CMR inpatient services must be provided under the medical director of rehabilitation who is a board-certified or board-eligible physiatrist and has had at least two years of experience in the medical management of inpatients requiring rehabilitation services. Carolyn Geis, M.D., Medical Director, Rehabilitation Medicine, Halifax Health and Assistant Clinical Professor, Florida State University College of Medicine, will serve as the medical director of the proposed unit. (2) Other Required Services. In addition to the physician services, CMR inpatient services shall include at least the following services provided by qualified personnel: 1. Rehabilitation nursing 2. Physical therapy 3. Occupational therapy 4. Speech therapy 5. Social services 6. Psychological services 7. Orthopedic and prosthetic services The applicant proposes all the services listed above, with additional services, some of which include the following: case management, recreation therapy, chaplaincy, audiology, biofeedback, cognitive therapy, community re-entry outings, pain management, adapted driver education/training and others. 20

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