The Scotland County Memorial Hospital (dba Scotland County Hospital) Board of Directors met in regular session on Thursday, February 28th.   Board members present: Curtis Ebeling-Chairman, Joe Doubet- Vice Chairman, Judy Wilson-Secretary, Robert Neese-Treasurer, Members Dwight DeRosear and Lori Fulk.

Others present:  Dr. Randy Tobler; CEO, Dr. Jeff Davis, CMO, Michael Brandon, Controller, Elizabeth Guffey, RN, CON, Angela Schmitter, RHIT-Compliance, Lori Nelson, RN, RHC (Rural Health Clinics), Terri Schmitt, QI, Missy Smith, HR and Brenda Prather, recording secretary.

Guests:  Lee Shultz, Joni Lloyd, SCH Employees: Ashley Harvey, Barbara Dunnett, Abby Manco, Olivia Steele, Ashley Tharp, Kathy Miller, Lacie Snyder, Alisa Kigar and Brandi Glass.

The meeting was called to order at 5:40 pm.  Public comment was offered by Lee Shultz, RN, BSN.  Mrs. Shultz exited at 5:50 pm.

Under the Quality Corner Agenda item, Randy Tobler, MD, Chief Executive Officer, introduced both Terri Schmitt, Director of Quality Improvement and Safety and Brandi Glass, Virtual Health Coordinator and Quality Improvement Data Abstractor. Terri Schmitt explained the S.T.R.E.T.C.H. (Safety, Transparency, Respect, Excellence, Trust, Compassion, Honesty) L.A.P.S. (Leadership, Accountability, Professionalism, Synergy) that will replace the monthly Safety Walks and the role STRETCH plays in the Quality Improvement, Safety and Risk Assessment programs for the Hospital and Clinics.

Michael Brandon, Controller, presented the Financial Report for January:  

Gross patient revenue for January was $$3,853,440;

Bad Debt, Charity Care and other Deductions for January was: ($157,550);

Net Patient Revenue, January: $2,106,420;

Net Patient Revenue Per Day, January: $58,855;

Total Operating Expenses for January $1,793,765

Expenses per day for January was $59,480;

Total Operating Profit/Loss January: $285,870;

January Tax Revenue: $ 43,816;

Net profit/loss before depreciation for January 2019 was $408,610

Net loss YTD ($361,465); Net loss YTD January 2018 was ($1,366,392)

Dr. Tobler gave an administrative report, starting with OPERATIONS. He reported on the Revenue Cycle Reorganization and a productive 3 day visit from the Senior Revenue Cycle, Billing and Information Technology/Troubleshooting personnel at AVEC on 2/20-22. The focus was on meetings with Patient Access (Registration and Financial Navigation), Billing, Coding and Clinicians at Scotland County Hospital and Clinics to refine workflows, ensure compliant charge capture and documentation, and enable the most efficient, patient-friendly and productive processes. 

He reported on evaluating the possibility of partnering with other organizations to replace one of the Rural Health Clinics formerly operating in Edina that closed on 12/31. Leaders from the Knox County Economic Development organization contacted Scotland County Hospital officials late last year and reported that the area is struggling with access with only a Rural Health Clinic in Knox County and the Health Department remaining.  Due diligence with regard to market research, space availability and renovation, staffing and financial impact is in progress. 

At January’s meeting, the prior 6 month’s diversion due to staff shortages was presented. To expand, there have been previous other instances where due to staffing shortages, and on rare occasion a critical equipment outage, brief periods of implementation of the diversion protocol we unavoidable. The Quality Improvement Committee will be reviewing every instance of diversion plan activation, whether or not a patient is diverted (after the fact), and it will be implemented going forward. 

Dr. Tobler reported that the Ambulance District is busy working through the details of their assumption of services.  He attended their Board meeting recently, and presented information as requested. He reported both parties will be working on inventory evaluation, and appropriate allocations of assets and other matters set out by contract.  Date for assumption of independent Ambulance Service operations is not set yet.

He reported that he and other area Hospital and System leaders talk quarterly to discuss areas of common interest and that conference call took place on 2/25. He met with Lewellen’s housekeeping contractor to discuss operations thus far. He offered many thanks to many departments that provide patient care and critical support services that stayed in-house for several extra hours and shifts or braved the roads during the poor weather conditions.  This was an extreme demonstration of dedication to our patients and the Hospital’s mission. Dr. Tobler further wanted to praise the staff by reporting on these achievements: SCH has been awarded a Vulnerable Rural Hospital Technical Assistance Grant from the Center for Optimizing Rural Health at Texas A & M. This will help with intensive technical assistance through mentoring, webinars, educational materials, facilitated networking based on a needs assessment of the facility and community. Completing our mid-project CHNA (Community Health Needs Assessment), developing a Crisis Intervention Team, identifying Rural Health Clinic service enhancements, accelerating virtual health innovations are other projects that might be proposed.  Mammography was accredited for 3 years by the American College of Radiology. He reported that the Hospital received word that we received the Gold Level Quality Improvement Award from TMF Quality Innovation Network Quality Improvement Organization for data reporting and readmissions reduction. 

Under MEDICAL STAFF/ALLIED HEALTH, Dr. Tobler reported that the medical staff visited with an Internal Medicine/Pediatrics/Allergy & Immunology specialist to be considered for joining the medical staff. The medical staff heard a presentation about adding additional pain management services from a Certified Registered Nurse Anesthetist. Dr. Tobler reported that Teresa Kirchner, will be moving out of the area and her last day is 4/26. Dr. Brigitte Cormier submitted notice that she will no longer be providing OB service at Scotland County Hospital after 4/30. 

Under PERSONNEL, Dr. Tobler reported Terri Schmitt, MHA, CPHQ (Certified Professional Health Quality) is the new Quality Improvement and Safety Director and she will be assisted by Brandi Glass, LPN, who is moving from Memphis Medical Services to serve as the Virtual Health Coordinator.  Risk Management will be anchored by Angela Schmitter, Health Information Management and Compliance Supervisor. Tracy Folker has been hired as Patient Access and Financial Navigation Manager. LaDonna Stauffer has been hired as Financial Navigator. Crystal Klocke has been hired as Patient Registration staff.  Kim Smith Certified Pharmacy Technician, joins us in the Hospital pharmacy. Nicholas Herrmann Pharm D., joins the Hospital as Clinical Pharmacist and Assistant Pharmacy Director. His services will be leased by Scotland County Community Health Development Services Corp. d/b/a Memphis Community Pharmacy in addition to his support for the Hospital’s in-patient pharmacy.

Jeff Davis, DO, Chief Medical Officer, reported on meeting with the new Quality & Safety staff to organize a plan to move forward in that department. He met with the Senior Leadership team to discuss service line analysis, 340B Pharmacy, and Urgent Care statistics. He is working with the Information Technology Department and Clinical Informatics Department on Meaningful Use Part 3. He reported that Kelsey Davis Humes, DO, is working part-time covering inpatients. He and Dr. Tobler interviewed an Nurse Practitioner. Dr. Davis reported he has been contacted by the State of Missouri to serve on the Medical Marijuana Task Force.

Under Old Business, Dr. Tobler gave an update on the 340B Pharmacy Purchase. To summarize what has occurred, the Hospital District approved the following: (1) purchase of the pharmacy hard assets from the departing provider (including all equipment); and (2) authorized establishment of the Foundation; and (3) provided the Foundation with funding; and (4) directed the Foundation to make a program investment to support the Hospital District by investing a portion of that funding in the establishment of a corporate entity that would conduct the pharmacy operation with the Hospital District with the same service features as the departing vendor, including the 340B Program on the Hospital District campus and at the RHCs and for hospital campus outpatients; and (5) in view of (4) entered into contractual arrangements with the pharmacy entity.  The contracts involved are a Facility Space, Personnel Lease and Support Services Agreement under which the Hospital District will provide the equipment (it purchased from the departing provider) and support services, and lease the personnel to the pharmacy entity and a 340B On-Site Contract Pharmacy Services Agreement. This business model, authorized by the Board, ensures sustainable, Hospital assured provision of affordable, life-saving prescriptions, comprehensive real-time onsite consultation services for both the Hospital and Clinic clinicians with an onsite pharmacist and was necessary in order to sustain quality of care and patient compliance realized with the pervious operator. The Hospital District engaged in the foregoing because it concluded that to properly fulfill its statutory healthcare mission, a 340B dispensary that can also dispense to patients on its campus, with the consultation features it had established with the departing provider must be maintained on its campus and at the RHC’s.

Scotland County Hospital Foundation (a Missouri non-profit corporation) owns MCP, but will have no contracts with it.  The Hospital District and MCP entered into a 340B On-Site Contract Pharmacy Services Agreement. Under the agreement, the pharmacy entity will dispense (for a dispensing fee) the 340B Program Drugs owned by the Hospital District. Under the structure, the Hospital District owns the pharmacy’s equipment, controls the pharmacy’s services, and owns all of the 340B drugs. 

The Foundation’s purpose is solely to engage in activities for benefit of the Hospital District.

Through its ownership of MCP, the Foundation is providing support to the Hospital District by providing the 340B program savings benefits, and the essential, exclusive and immediate on-site comprehensive consultative medication services the clinicians and patients of SCH and its clinics received under former ownership of the pharmacy. The pharmacy services will generally be confined to patients of the hospital, its clinics and patients of the physicians and dentists on its campus, who are on staff at the hospital – all activities within the mission of the Hospital District. The pharmacy will accept prescriptions from patients already on campus who might have a prescription from an out of town specialist, for example.  But, MCP will not seek out off campus business and does not expect this to be more than an immaterial source of business.  A motion was moved and approved to ratify funding for MCP purchase from ImgRx East for and for SCH Foundation in consideration of the expected services the Foundation will provide to support the Hospital.  

Dr. Tobler gave a presentation relating data from the National Rural Health Association, Missouri Hospital Association and BKD (SCH Auditors) Strategic Readiness Assessment communicating the utilization, financial and resource challenges facing Scotland County Hospital today, which reflect similar trends state- and nation-wide for rural hospitals.  The trend toward affiliation with larger organizations by Critical Access Hospitals and the operational and financial benefits were documented. A motion was moved and approved to enter into discussions of potential closer alignment with Blessing Health System, pursuant to the current affiliation agreement in effect since 2014 to be developed by the SCH Affiliation Committee for presentation to the Board for approval. A motion was moved and approved to authorize CEO Tobler to engage BKD to serve as consultant as affiliation negotiations proceed.

Under New Business, Abby Manco, Director of Tiger Cub Care (Employee Child Care Facility), gave an update on the project. She reported that the building renovations are finished. The facility is taking applications for childcare workers. The consensus of the Board was to approve current hourly employee wages and recommended Tiger Cub Care fees. There was discussion regarding payment options to be offered to employees. Ms. Manco reported that the facility recently had a building inspection and the expected opening date was May 28, 2019.

The Service Line Performance Committee reported that they discussed the process for analyzing department operating costs and the committee recommends to engage BKD (Hospital Auditors) to expand and refine the service line & departmental analyses. A motion was made and approved to have an engagement letter with BKD and authorize CEO Tobler to enter into a contract with BKD to implement a cost analysis.

Urgent Care was discussed and Dr. Tobler reported that physician/provider coverage remains a continuing challenge and Sunday utilization is low. Additionally, if Urgent Care were located in the exam rooms of the clinic there may be less claims denials and write offs of ancillary tests associated with services provided. Motion was made and approved to discontinue Sunday Urgent Care hours and see patients in the clinic exam rooms, making the marketing clear that patients will still enter through the Main/South/ER entrance for registration & waiting room.

And, finally under New Business, Michael Brandon, MBA, Controller, reported on a program called Cleargage Patient Financing that is available to provide financing to patients for out-of-pocket expenses and eliminate Accounts Receivable delays to the Hospital’s revenue cycle. This arrangement can be rapidly determined at point of service, increasing access to care for patients with significant out-of-pocket obligations. Consensus was for CEO Tobler and Mr. Brandon to investigate further and pursue references.

Executive Session:

Those present for closed session were Ebeling, DeRosear, Doubet, Neese, Fulk, Dr. Tobler, Dr. Davis, Missy Smith and Brenda Prather, Recording Secretary.

The following items were discussed:  Legal actions and contracts in negotiation. Personnel.

A motion was made and approved to exit Executive Session. The Board discussed Mrs. Shultz’s question from the Letter to the Editor to hold a public forum. Consensus of the Board was to continue offering public comment on the agenda at all open sessions of Scotland County Memorial Hospital District meetings and to reiterate that anyone is welcome to request meetings with Administration to answer questions of facility/District concerns.

Meeting adjourned at 10:10 pm.