Primary Care Gets a Boost

The following article appeared in our 2014 Annual Report.

primary care in Randolph VT

Family nurse practitioner Christina Harlow shares a laugh with Mary Williams of Randolph Center during a recent visit.

A family unable to afford dental care. An uninsured mother-to-be. A loved one suffering from depression. These are some of the people who will be helped by Gifford’s new status as a Federally Qualified Health Center.

The memo to staff was dated November 7, 2013, and sprinkled with exclamation points. It came from administrator Joseph Woodin and was entitled “A Must Read!” The message: Gifford had just been named a Federally Qualified Health Center (FQHC)—an event that Woodin characterized as “some of the biggest news I have ever shared with staff since working at Gifford!”

Gifford's primary care

Christina Harlow consults with family medicine physician Dr. Marcus Coxon.

The FQHC designation is a coveted one, opening the gate to a stream of federal dollars for primary care. The funding comes from the Health Resources and Services Administration (HRSA), the primary federal agency for improving access to health-care services for people who are uninsured, isolated, or medically vulnerable. Of particular interest to Gifford: support for dental care and mental health services for Medicaid patients and the uninsured.

“This assistance from the federal government allows us to develop programs for dentistry, psychiatry, and mental health that are hugely important for the community,” says Medical Director of the Hospital and Medicine Divisions Dr. Martin Johns. “It also allows us to place a bigger focus on primary care. It means we can take better care of our Medicaid patients, offering them services that we couldn’t before because of finances, and that’s huge.

“We’re finding out almost weekly that we can offer things to patients that we didn’t even know about, let alone have the capacity to apply for. The designation was designed to help small groups of physicians serving in rural communities. Our mission has always been that.” Gifford's mission To qualify for FQHC status, a community health center must be open to all, regardless of ability to pay. It must offer a sliding fee scale with discounts based on patient family size and income in accordance with federal poverty guidelines. The federal money is intended to offset these obligations.

Over the past year, Gifford has laid the groundwork necessary to begin drawing on those funds. Among the steps: conducting a search for a psychiatrist to join the medical staff, working out agreements with area dentists to provide care to Medicaid patients, and completing a transition to electronic medical records.

“HRSA is really concerned that they make these health centers as feasible as possible,” says VP of Finance Jeff Hebert, “so there’s a lot of grant opportunity that impacts our financial stability. We get support every year as long as we keep up with the requirements.

“Probably the biggest benefit is that we get bigger reimbursement for our Medicaid patients. Reimbursement is cost-based, and not fee-based, so instead of paying a percentage of the fee for x, y, and z, the government looks at how much it costs to provide those services. It’s a better reimbursement methodology for Medicaid.” Other perks of the designation are: insurance coverage for primary care physicians and relief from staggering medical-school debt, a powerful recruitment incentive.


Dr. Marcus Coxon

The new FQHC designation allows primary care physicians like Dr. Marcus Coxon (left) to offer Gifford patients increased access to mental and dental health services.

The Gifford model is an unusual one: a community health center with satellite clinics and a small hospital at its hub. As such, it provides both primary and critical care to a rural population. It would thus seem eligible for both FQHC funding and the benefits it receives as a Critical Access Hospital, a designation conferred in 2001. But would the feds see it that way?

The FQHC “duck test” was a laborious application process that involved many hospital departments and years of preparation, followed by months of waiting. With acceptance, Gifford the health center became the “parent” of Gifford the hospital—one of only three FQHC/CAHs in the country.

“Our primary-care services—which include internal medicine, family practice, pediatrics, and ob-gyn—are all part of that community health center parent,” explains Woodin.

“The concurrent designation is tremendous for us,” says Johns. “It enables us to provide the most possible benefit to the community while being a small hospital, and it protects us from a lot of the changes going around the state and the region with regard to accountable care: As an FQHC, we cannot be purchased by or absorbed by a larger organization.”

“I look at health-care reform as being primary-care focused,” says Hebert. “It’s that primary-care provider who keeps you healthy and works with you to make sure you as a patient are getting what you need. If you’re prompting that patient to come in for a physical, and to develop healthy behaviors, you’re going to keep that patient a lot healthier at a manageable level than a model that doesn’t focus on primary care. I use myself as an example of what not to do: I only go to a health-care provider when I get to the point when I’m ready to go into the hospital and that’s an extremely expensive proposition. It’s not as efficient, and you as a patient aren’t as satisfied because you’re looking at a long recovery time. By making Gifford Health Care the parent of our organization, we’ve set ourselves up for the future, and I feel we’re in a really good place.”

After eight months of administrative work, Gifford was ready to start drawing on its new funds. The first bill went out in July. “It’s probably going to take most of 2015 to really understand all the levers and dynamics,” says Woodin.

“My thanks and appreciation go out to the staff behind the scenes who made this happen. It was a huge amount of work, and yet strategically, it positions us well, given health-care reform both in the state of Vermont and nationally. It helps us to have the right focus again around primary care, taking care of Medicaid and the uninsured, and looking to build from there.”

Gifford’s Record of Success Continues for 15th Straight Year

Randolph hospital ‘makes’ budget, operating margin

Gifford 2014 budget

President Joseph Woodin and CFO Jeff Hebert announce via video that Gifford closed the books with a 3.2% margin for the 2014 fiscal year.

In a feat that has not been replicated by any other hospital in Vermont, Gifford Medical Center announced that it has achieved its state-approved operating margin for the 15th straight year, by managing its expenses and the budget process.

In a “reality TV” video announcement sent to staff on Monday, November 3, President Joseph Woodin and CFO Jeff Hebert announced what auditors have confirmed – Gifford closed the books with a 3.2% margin for the 2014 fiscal year.

“This is all thanks to the hard work and dedication of our staff,” said Woodin. “Without their diligent focus, always trying to manage quality and costs, we would not be able to have accomplished this.”

An operating margin is the money the medical center makes above expenses – needed to reinvest in programs, staff and facilities. Sixteen years ago, Gifford ended the fiscal year with a negative 16% margin ($2.9 million loss), after having lost money 4 out of 5 years. At that time, the future of the hospital was uncertain, with some state officials even asking if the hospital should be closed.

Today, Gifford is known as one of the most successful and innovative hospital and health care organizations in New England. They are designated a CAH (Critical Access Hospital), as well as an FQHC (Federally Qualified Health Center); one of only three in the nation to carry that dual designation. They also operate a nursing home (Menig) that is rated one of the top 1% in U.S., and are currently constructing the first phase of a five-phase senior living community in Randolph Center, VT.

Consistently achieving the operating margin can be an indicator of an organization’s success. Despite record shortfalls in revenue for Vermont hospitals, including Gifford, Woodin noted the medical center was able to make up for revenue shortfalls through managing expenses and due to support from federal programs like 340B, a drug pricing program that in part generates revenue when Gifford patients fill non-generic, non-narcotic prescriptions at participating pharmacies.

“This news is exciting for Gifford and for the community,” said Woodin. “It is an indicator of Gifford’s health as a medical center, community organization, and employer. Primarily it means we’re stable, and we’re able to provide consistent care and services without facing cuts and uncertainty.”

The achievement is especially remarkable within the current economic climate and amid so many changes in health care, hospital officials also noted.

Responding to Community Needs

Vermont Blueprint for Health

Gifford’s Blueprint for Health Team has expanded to include additional mental health and addiction counselors offering one-on-one care at all Gifford primary care locations. In this file photo, from left, care coordinator Keith Marino, Health Connections (financial assistance) case worker Michele Packard and certified diabetes educator Jennifer Stratton discuss a patient at the Bethel Health Center.

In 2012 as part of the federal Patient Protection and Affordable Care Act, Gifford Medical Center completed a Community Needs Assessment.

Less than two years later, the Randolph-based medical center has already made huge strides addressing many of the needs found in that study.

In a survey of Town Meeting attendees in nine communities in 2012 plus feedback from other groups, community members’ described their priorities for a healthy community, perceived health problems and risky behaviors in the community, and their health needs or lacking services.

Among factors for a healthy community were good jobs and a healthy economy, access to health care, good schools, and healthy behaviors and lifestyles. Top health problems listed by survey respondents included addiction, obesity, and unhealthy lifestyle choices. Top health needs, or services community members have tried unsuccessfully to access, within the community were assisted living and nursing home care, alcohol and drug counseling, and dental care.

Today, Gifford is preparing to break ground in the spring on a senior living community in Randolph Center that will, over time, provide a full spectrum of housing options including the relocation of its award-winning nursing home and newly created assisted and independent living. Gifford has earned the coveted Federally Qualified Health Center (FQHC) designation, making it one of only three hospitals in the country to be both a Critical Access Hospital and an FQHC. This means expanded access to care, including dental and mental health care. And the medical center’s Vermont Blueprint for Health Team has greatly expanded over the past year to include more mental health and addiction counselors, providing services at all Gifford primary care locations.

chronic illness support group

Among Gifford’s free community services is a chronic illness support group. Here Gifford pharmacist Jane McConnell provides medication advice to past participants.

“Each of these major initiatives, which have taken substantial work, targets an identified community health need. Meeting these needs and addressing the community’s feedback defines the future of Gifford and its expanding role,” says Ashley Lincoln, director of development and public relations at Gifford.

The Community Needs Assessment process is required every three years, but Gifford’s efforts are ongoing. The medical center continually provides community outreach initiatives to meet care needs, many of which are offered for free. These include classes, support groups, and health fairs. Additionally, many initiatives support local economic health, including a buy local approach.

The medical center also continues community outreach daily through a boots-on-the-ground approach that has Blueprint Community Health Team working directly with individuals and community organizations to address health and socioeconomic needs, particularly for the chronically ill.

“The Blueprint for Health is a statewide initiative. Gifford has placed extra focus on meeting community members’ needs so they can successfully manage their health,” says Blueprint Project Manager LaRae Francis. “This approach means not waiting months or years for needs to be determined, but matching resources and needs today to create an ongoing healthier community for all.”

A grant from through the Vermont Department of Health helped support the costs of the 2012 report. The full report is available on Gifford’s website in the “About Us” section under Community Reports.