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Pediatric ERs on the Road

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A growing number of both children’s and community hospitals are discovering that ER partnerships can benefit both organizations.

St. Louis Children’s Hospital draws patients from around the world to its organ transplant program and enjoys a national reputation for cardiac procedures, cochlear implants, craniofacial plastic surgery, an innovative cerebral palsy treatment, and other services. But when St. Louis Children’s opened a new location earlier this year, it was looking for a different type of patient.

Through a partnership with a suburban community hospital about 15 miles from its main campus, St. Louis Children’s will provide services that are high volume and low severity: radiology, laboratory services, outpatient subspecialty care, same-day surgeries. Todd P. Sklamberg, St. Louis Children’s former vice president of pediatric services and development, says the partnership will give St. Louis Children’s “the ability to provide those services much closer to home” using its pediatric nurses, pediatric surgeons and pediatric anesthesiologists.
Prominently branded as St. Louis Children’s Hospital at Barnes Jewish West County Hospital, the new location is St. Louis Children’s third partnership with a community hospital--and one of a growing number of such relationships between pediatric hospitals and their community counterparts around the country.

The partnerships reflect business realities that are transforming the delivery of pediatric hospital care, says Lawrence A. McAndrews, president and chief executive officer of the National Association of Children’s Hospitals and Related Institutions. Children make up nearly 25 percent of the population in most communities, but they account for only 5 percent of hospital admissions (subtracting normal newborns). Because of the shortage of pediatric subspecialists, pediatric hospitals must serve a large number of children to attract those pediatric nephrologists, rheumatologists and other specialists to their institutions.

“If you want the same depth and breadth of services for children that you do for adults, you have to reach out to a much larger population to make that economically feasible,” McAndrews says. 

Meanwhile, community hospitals have seen pediatric admissions decline in recent years, as advances in ambulatory care and pharmaceuticals have combined with managed care policies to keep children out of the hospital. The low volume of pediatric cases in most community hospitals, McAndrews says, limits their ability to provide the resources, such as pediatric anesthesiologists, needed to provide appropriate care even for minor procedures.

“Because you’re squeezing out all the routine stuff, the kids who get admitted to the hospital are going to be sicker,” he says. “They are going to see more specialists, and the specialists are going to be organized around the children’s hospital.”

Thus, pediatric hospitals and community hospitals both benefit from partnerships that allow routine services to be provided at a community facility and drive higher-acuity cases to the pediatric hospital.

Sandy Melzer, MD, senior vice president for strategic planning and business development at Children’s Hospital and Regional Medical Center in Seattle, has placed Children’s physicians in about 25 locations across the hospital’s four-state service territory using on-site doctors and telemedicine technology. The hospital serves patients in Washington, Alaska, Montana and Idaho, prompting a wide range of partnership arrangements.

The core business of a pediatric hospital is highly complex specialized care, so Melzer wants partnerships that increase the likelihood that very sick children are referred to Seattle Children’s. Because complex health problems often stem from birth defects or newborn crises, a pediatric hospital likes to partner with hospitals that have a high number of deliveries.

“This can be a distribution strategy of sorts, where you try to put your presence in another place,” Melzer says.

Another motivator for children’s hospitals, he says, is capacity. “Today we have 248 patients in our 250-staffed-bed hospital, and they are really sick,” he says. Being able to serve lower-acuity patients in distant community hospital settings frees up beds for children who must be treated at the pediatric hospital.

Seattle Children’s is planning an expansion that will double its inpatient capacity in the years ahead, but additional partnerships will also be key to its future growth. Melzer says there is no standard partnership relationship, as each is developed to accommodate the needs of the community hospital and Children’s. Two examples:

  • A visiting physician program in which Seattle Children’s specialists fly to an Anchorage hospital to consult on complex cases. For example, a team of physicians and genetics counselors goes to Alaska four or five times a year to see genetics patients, and a urologist goes to operate in conjunction with a local surgeon. In that relationship, the visiting physicians are paid as consultants--and children too ill to be adequately treated in Alaska are likely to be referred to Children’s.
  • Joint venture ownership of a Level III neonatal intensive care unit at Providence Everett Medical Center, a 362-staffed-bed community hospital about 30 miles north of Seattle. Children’s provides the physicians and nurse practitioners who staff the NICU and it staffs a pediatric hospitalist program and operates an outpatient specialty clinic on Providence Everett’s campus. That relationship provides the community hospital with a financial partner, and it generates a new revenue stream for Seattle Children’s. “In a joint venture relationship, you are not cutting off your toes every time you support the care of a patient at that other institution,” Melzer says.

Providence Everett is willing to share the revenue from that NICU in exchange for the expertise. David Brooks, the hospital’s CEO, says when Providence Everett decided its delivery volume justified upgrading its basic NICU to a Level III unit, a partnership with Seattle Children’s offered access to a deep and broad pediatric expertise that would be hard for a standalone hospital to develop on its own.

Through the partnership, Providence Everett is served by not only the pediatric specialists from Children’s but also neonatologists and perinatologists affiliated with the University of Washington Medical Center.

 “What was the most responsible way for us to serve the community? In our case it was partnering with someone who already had the demonstrated competency,” Brooks says. “You have to rise above ‘we should do it on our own’ and ‘we don’t want to collaborate.’”
St. Louis Children’s focus on partnerships is equally strategic to that of Seattle’s Children’s, but its approach is quite different. St. Louis Children’s is one of 13 hospitals in the huge BJC HealthCare system. When BJC opened Progress West Healthcare Center, a new hospital in a fast-growing St. Louis suburb, in early 2007, its partnership with St. Louis Children’s provided an immediate brag factor because the St. Louis Children’s brand “brings credibility, while Progress West, as a brand-new facility, had not developed a reputation,” says Sklamberg, who is now the chief operating officer for Sunrise Children’s Hospital in Las Vegas.

St. Louis Children’s, in partnership with Washington University School of Medicine in St. Louis, provides neonatologists, pediatric hospitalists and pediatric nurses and provides coverage for two emergency department bays that are dedicated to pediatric patients. In 11 months in 2007, St. Louis Children’s physicians treated more than 4,000 pediatric visits in the ED, Sklamberg says--a number that is expected to grow.

Children who need care from multiple subspecialists are transferred to the main St. Louis Children’s campus.

“Many of those patients would have gone to a large community hospital in St. Louis County,” Sklamberg says, referring to a group of suburbs outside the city of St. Louis. “So this truly is incremental business for St. Louis Children’s Hospital.”

Patients who are served at the community hospital are patients of Progress West. Physicians bill and collect for the services they receive.

St. Louis Children’s has had a similar relationship at Missouri Baptist Medical Center, another BJC sibling, for a decade. In that partnership, St. Louis Children’s is responsible for eight bays in the ED and five dedicated inpatient rooms. Also, the pediatric hospital provides neonatologists for Missouri Baptist’s special care nursery and maintains subspecialist outpatient offices at the community hospital.

That partnership works to strategic advantage for the community hospital and children’s hospital alike, Sklamberg says. Missouri Baptist is located across the street from a competitor that boasts the largest maternity program in the market and the only Level III neonatal ICU in St. Louis County. Having St. Louis Children’s specialists on site around the clock has helped keep Missouri Baptist competitive in the baby game, delivering more than 4,000 babies a year.


Lola Butcher is a Springfield, Mo.-based freelance writer and a frequent contributor to HealthLeaders magazine.