STATE AGENCY ACTION REPORT ON APPLICATION FOR CERTIFICATE OF NEED

Transcription

1 STATE AGENCY ACTION REPORT ON APPLICATION FOR CERTIFICATE OF NEED A. PROJECT IDENTIFICATION 1. Applicant/CON Action Number Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center/CON # East Marion Avenue Punta Gorda, Florida Authorized Representative: Mr. Jose Morillo Chief Executive Officer (941) Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier Blvd./CON # Collier Boulevard Naples, Florida Authorized Representative: Mr. Scott Campbell Chief Executive Officer (239) Venice HMA, LLC d/b/a Venice Regional Medical Center/CON # The Rialto Venice, Florida Authorized Representative: Mr. Peter Wozniak Chief Executive Officer (941) Service District District 8 (Charlotte, Collier, Desoto, Glades, Hendry, Lee, and Sarasota Counties)

2 B. PUBLIC HEARING A public hearing was not held or requested regarding the proposed projects. Letters of Support Punta Gorda HMA, LLC, d/b/a Charlotte Regional Medical Center (CON #10186), (CRMC), submitted 17 letters of support signed and dated during January 21 through April 1, One letter was undated. William F. Albers, Mayor of the city of Punta Gorda, states that Charlotte County has the second highest number of residents over the age of 65 in the state of Florida many of whom require CMR services or care for someone who does. Mayor Albers states that the closest facility providing these (CMR) services is Fawcett Hospital in Port Charlotte, which can be a significant burden on the elderly because of travel and the patients physicians not being on staff at Fawcett. Richard H. Satcher, Charlotte Market Chief Executive Officer at Peace River Regional Medical Center, states the Fawcett unit is not an alternative as our patients and physicians would prefer to support a unit in one of our campuses. Denise Barnett-Stuckey, CPHQ, LHRM, CPHRM, and Director of Case Management over Charlotte Regional and affiliate HMA hospital Peace River Regional Medical Center, states that daily we experience the difficulty in placing patients with rehabilitation needs into the appropriate setting within our community boundaries. Ms. Barnett- Stuckey emphasized that many patients awaiting placement due to the lack of rehabilitation beds/services within the community are forced to transfer out of the area leaving many senior citizens with a long drive to visit their loved one and without the addition of in hospital acute rehabilitation beds we cannot provide timely therapeutic treatment services to those difficult to place patients due to bed availability. Thomas W. Noone, MD, Chairman of CRMC s Utilization Committee and Physician Advisor to the Case Management Department, writes that in my Physician Advisor role I am acutely aware of the difficult process steps to ensure a safe discharge for all patients the addition of in-hospital acute rehabilitation beds will allow those difficult to place patients a place to begin their therapeutic treatment. 2

3 The local physicians listed below signed variations of a form letter 1 : Mark Davis, MD, Chief of Staff and Joint Academy Medical Director, Charlotte Regional Medical Center* Joseph Ravid, MD*, Chief/Chairman Department of Medicine, Charlotte Regional Medical Center Amy Mellor, MD, Neurology Associates of Charlotte County Robert T. Getter, MD, orthopedic spine surgeon, MIDISC Spine Care* Saeed Shahzad, MD, Neurology Center of Southwest Florida* Jose I. Cabrera, MD, Neurosurgeon, Peace River Neurosurgery* Elias Quintos, MD, Cardio/Thoracic Surgeon, Charlotte Harbor Cardiac Surgical Associates* S. Cary Huber, MD, Charlotte Harbor Cardiac Surgical Associates* Jeffrey G. Bentson, MD, PLLC, Orthopedic surgeon, Associates in Orthopedics. This letter contends that need for a CMR unit at CRMC is supported by the following reasons: There is a gap in service for comprehensive medical rehabilitation beds in the Charlotte County area. The federal directive for managing patients throughout the clinical process necessitates CMR beds as part of comprehensive medical care. The nearest CMR facility, Fawcett Memorial Hospital, is not an option for CRMC patients because it isn t within the HMA hospital system. Stephen P. Schroering, M.D*., Gulf Pointe Surgery Center, an orthopedic surgeon, expresses concern for the present situation requiring postoperative patients to be discharged to a diversity of facilities because it is impossible to see my patients in multiple facilities an in-patient rehabilitation center at Charlotte Regional removes and addresses these concerns (the project) would allow me to see my post-operative patients while making rounds on in-patients. Janet Burbank, R.N., RPT, a 21 year employee in the rehabilitation department of CRMC, submitted a handwritten letter in which she states that through the years we have had very skilled, talented, and caring therapists and I have felt that patients could and would benefit from, and improve their physical capabilities, if we could offer them post critical care right here. An HMA physical therapist assistant submitted a 1 The reviewer notes that physicians marked with an * have privileges at Fawcett Memorial Hospital (see which has a 20-bed CMR inpatient unit. 3

4 handwritten letter stating inpatient rehab would contribute to therapists, and other associates, to better use our knowledge and skills (to the) benefit of our patients which builds a strong community. A. Jill C. McCrory, attorney with the McCrory Law Firm in Punta Gorda, states CRMC is the only hospital in Punta Gorda, Florida, one of the oldest median population areas in the country. Ms. McCrory cites the challenges facing an elderly patient population having no option but to seek rehabilitation services often in other counties and cities and often from doctors and nurses who do not know the patient history is a significant detriment to our community and the level of health care provided. Naples HMA, LLC, d/b/a Physicians Regional Medical Center - Collier Boulevard (CON #10187), (PRCB), provided 14 letters of support signed and dated during March 20 through April 4, Two letters were undated and one was unsigned. Representative Matt Hudson, Florida House of Representatives District 80, states that he would like to Strongly Advocate for an inpatient rehabilitation unit at Physicians Regional Medical Center and notes that Physicians Regional has a Comprehensive Stroke Program. Representative Hudson states that patients in my community will experience improved outcomes and more rapid recovery in the (CMR) unit and that it is important for patients to have ready access to this level of care close to home. Donna Fiala, Collier County Commissioner for District 1, states need for CMR beds at PRMC due to the Comprehensive Stroke Program, the only such program that exists between Sarasota and Miami-Dade County. Joan Colfer, MD, MPH, states she serves as the Florida Department of Health Director in Collier County. She states that Collier s population was 324,422 in 2011 (and that) 87,144 or 27 (percent) were people over the age of 65. Dr. Colfer supports the applicant s CMR unit because she wants to be sure we have sufficient facilities to serve our ever increasing number of older residents. Dennis Hidlebaugh, MD, Chief of Staff, Physicians Regional Healthcare System, states that with the current federal directive for managing patients throughout the clinical process, it is important for our patients to have ready access to a CMR level of care. The NCH unit is not an alternative. Our patients need this service in one of the two local HMA hospitals. These sentiments were shared by Frederick Buechel Jr., MD, and Director, Robotic Joint Replacement Center of Naples; and Mark A. Liberman, MD, surgeon at Liberman Advanced Surgical in Naples. 4

5 Michael Finkel, MD, FAAN, states he has been practicing neurology in Collier County for more than 13 years and if Physicians Regional establishes an inpatient CMR, my patients outcomes would improve and functionality would be restored to a greater level in a more rapid time frame. Sandy Zsuppon, RN, BSN, CCM, and System Director of Case Management at Physicians Regional Healthcare System, states there is one existing comprehensive medical rehabilitation provider in Collier County and the four providers in Lee, Charlotte and Sarasota Counties have no relationship to services, referral patterns, physicians or patients/families of Collier County (and) referring (patients) to facilities that distant is not even considered, when it is a challenge to have the elderly patient and family consider going to a hospital on the other side of Collier County when their physician doesn t go with them. In reference to Collier County s CMR provider, she notes that it is owned by NCH Healthcare System and states that while some physicians may have staff privileges at both systems, the reality is that physicians in this community either practice at NCH or Physicians Regional, not both. Ms. Zsuppon further states that the NCH North Naples is generally not a resource for Physicians Regional patients and even when it (CMR unit) was at the downtown NCH hospital, it was very rare to refer a patient for services. This is largely due to the patient-physician relationship and physician discharge instructions and alternatives presented. Ms. Zsuppon indicates that an error in discharge coding by the Physician Regional hospitals resulted in inaccurate rehabilitation discharge data during the 12 months ending June 30, She notes that the Agency s hospital discharge database indicates there were a total of 81 discharges to a rehabilitation facility six from PRCB and 75 from Physicians Regional Medical Center-Pine Ridge. She indicates that she reviewed each of these 81 patient records and found that only two Collier Blvd. and 27 PRMC Pine Ridge patients were discharged to a rehab facility. She contends PRMC has a significant need to establish a CMR unit when we consider the fact that we discharge about two patients per month to rehab yet have hundreds and hundreds of stroke, hip fractures, joint replacements and other orthopedic and neurological admissions each year. She also states that with PRMC Pine Ridge s comprehensive stroke center designation, it is even more incumbent on our hospital system to provide CMR services. Donna Hierta, RN, Director of Nursing for medical surgical areas at PRCB, also cites PRMC s Comprehensive Stroke Center as an important factor demonstrating need for CMR services. 5

6 Five physical therapists practicing in the Physicians Regional Medical System Lisa Ceto, MPT, Director of Rehabilitation at PRMC, Jared Cornegia, DPT; Chelsea Winslow, OTR, Occupational Therapist; Anthony Valente, P.T.; and John Salka, PT contend that CMR services are needed because: The continuity of care for PRMC patients would enhance their recovery process. PRMC s role as an established Comprehensive Stroke Program. Increasing caseload of patients in need of rehabilitation services. Current federal directive for managing patients throughout the clinical process makes additional CMR beds necessary. Venice HMA, LLC, d/b/a Venice Regional Medical Center (CON #10188), (VRMC), submitted 12 letters of support dated during February 14 through March 19, One letter was undated and three were unsigned. Bob Daniels, Vice Mayor, City Vice-Mayor praises Venice Regional s quality of care, cites the Venice area s Medicare population and states that the project would fill a need that is not currently being met. Jeanette F. Gates, Venice city Councilmember, states that due to an aging population, a CMR unit at Venice Regional Medical Center would provide our community with a quality, convenient service for those who desperately require it. Emilio Carlesimo, Venice City Councilman, states that the aging community of Venice is prime population for orthopedic procedures as well as stroke care and other neurological conditions and that due to their health care needs, a CMR Unit at VRMC would provide a solution for these challenges while giving patients the best opportunity for good outcomes and better quality of life. Juliette E. Coleman, MD, Stroke Director, Gulf Coast Neurology Associates, which has four neurologists in the group, states she and her colleagues treat an average of or more acute stroke patients at Venice Regional Medical Center per month and about percent of these patients require inpatient rehab. She states that a CMR unit at VRMC would allow patients to begin their aggressive rehab program sooner, enhance their recovery, and decrease overall length of stay. Jeffrey R. Blood, MD, Physical Medicine and Rehabilitation specialist (physiatrist) at Gulf Coast Medical Group, and Joseph Noah, MD (orthopedic surgeon) submitted letters which indicate the project is needed for the following reasons: 6

7 A large elderly population in Venice; according to the U.S. Census Bureau, over 57 (percent) of the population of Venice is over the age of 65 and hip fractures, replacements and neurological conditions such as stroke are prevalent in this population. Patients often choose to forego rehabilitation at HealthSouth or Sarasota Memorial after an acute inpatient hospitalization, utilizing alternative treatment such as Home Health Therapy or Skilled Nursing that will not optimize recovery Patients choose these options due to accessibility, limited travel by their spouse or family support members, and the desire to maintain continuity of care with their primary physician. Rosanne DiBello, RN, CCM, and Director of Resource Management at VRMC, states during calendar year 2012, we referred 228 patients to HealthSouth we had more than 450 stroke discharges last year; we had more than 300 hip fractures; we had nearly 100 joint replacements for elderly 85 years of age and older; and nearly 1,200 rehab appropriate discharges even if one half of these patients were admitted to rehabilitation that would equate to 600 admissions not the limited referral number of 228. Our ability to admit patients to rehabilitation is limited by distance to beds and the availability of beds on a regular basis. Melissa Reifschneider, PTA, and Rosalie Pyra, OTR/L, therapists cite their first-hand experience working with patients at VRMC and indicate that the patients and the facility would greatly benefit from having a CMR unit. They contend the project will improve quality of care, and benefit all patients who want to remain close to family and familiar medical staff. William E. Patton, DDS, a volunteer at VRMC, states that Venice Regional is willing to convert available space in the facility to a Comprehensive Rehab Unit, eliminating need for travel by the patient and their families and providing access by their treating physicians and therapists. Stephen K. Boone, a practicing attorney in Venice, cites the excellent reputation of VRMC providing quality care, which he states could be enhanced with the addition of CMR beds. Two letters submitted by Venice residents indicate that CMR beds are needed at VRMC due to limited availability requiring residents to either forgo much needed rehabilitation or travel to facilities far from home, family, and familiar physician support. 7

8 Letters of Opposition R. Terry Rigsby, an attorney, submitted a letter on behalf of Naples Community Hospital, Inc. d/b/a NCH North Naples Hospital Campus, in opposition to the proposed 15-bed CMR unit at Physician s Regional Medical Center - Collier Blvd. (CON #10187). Mr. Rigsby cites eight reasons for opposing the project. These reasons are listed below: CMR is a tertiary health service and with respect to access and availability for the criterion in rule, the two-hour drive time standard establishes that the proposal is without merit. Granting additional CMR beds in close proximity (17.4 miles and 19 minutes ground travel under normal circumstances) to Naples Community Hospital (NCH) North s existing (54-bed) program would result in a dilution of service and CMR is a resource intensive patient group. The Centers for Medicare and Medicaid requires a minimum of 60 percent of admissions to any CMR program to fall within 13 specific conditions. NCH North s existing program may be threatened with financial penalties that reduce reimbursement to MS-DRG payment if dilution of the existing patient pool threatens NCHs ability to comply with the CMR 60 percent rule. Results from fixed need pool-district 8 occupancy rates of licensed CMR beds was percent (61,264 patient days) for the 12-month period ending June 30, This is below the 85 percent standard in rule. NCH North also cites the three year decline in CMR occupancy from the 12-month period ending June 30, 2010 of percent and 62,198 patient days compared to the 12 months ending June 30, 2012 cited above. Relationship with other acute hospitals for CMR referrals-the location of PRCB is the farthest south of all hospitals in Health Planning District 8, and Physician s Regional Collier Blvd. is remote from other acute care hospitals that could serve as a referral base. PRCB is not within a population base of sufficient size to support a CMR program, and PRCB is proximate to NCH North s 54 CMR beds. Fallacy of the HMA model for Forecasting Demand for CMR-HMA hospitals applying for CMR services have stated 3.5 percent of acute care admissions are appropriate for CMR services. However, only.08 percent of acute care patients from two District 8 PRCB hospitals were discharged to rehabilitation facilities during the 12-month period ending June 30, NCH North indicates that a review of CY 2010 Hospital Financial Data for acute care hospital discharges to CMR indicates that HMA s 3.5 percent is well above the state s average of 1.1 to 1.6 percent. 8

9 Lack of Sufficient Demand Within PRMC-for the 12-month period ending June 30, 2012 the two PRCB District 8 Hospitals discharged 81 adults to CMR services, only six of which came from the applicant s facility. Direct Adverse Impact on Naples Community Hospital-NCH s internal records indicate that during the 12 months ending June 30, 2012, Physicians Regional Hospital referred 87 patients to NCH s CMR service and 54 were admitted. Twenty two percent of these patients were unfunded or lacked a payer source to cover the admission, estimated at $19,259 each. NCH North contends that if the applicant s program is more about Physicians Regional Hospital Systems increasing utilization and revenues, unfunded and underfunded referrals to NCH would negatively impact Naples Community Hospital. Negative Impacts on Over Supply of Health Care Resources-these can include compromised physician coverage, difficulty meeting financial requirements of federal mandates by small CMR facilities, duplications of staffing and medical equipment, shortages of specialists, as well as concerns regarding a surge in HMA applications during the same batching cycle which, if approved, may flood the market. Other Health Planning Factors Yield No Benefit to the Proposalthe applicants proposal will not benefit patients through competition of payer choice or patient choice, will not reduce cost of care due to redundancy of services within the same coverage area, insufficient patient pool to support the program, and does not resolve access issues as coverage exists already within the service area. R. Terry Rigsby, an attorney, submitted a letter on behalf of HealthSouth Rehabilitation Hospital of Sarasota in opposition to the proposed 22-bed CMR unit at Venice Regional Medical Center (CON #10188). Mr. Rigsby cites nine reasons for opposing the project. These reasons are listed below: CMR is a tertiary health service and should be provided in a limited number of facilities in a given medical market. There are currently two providers of CMR services in Sarasota County, and there is no valid health planning reason to add a third at this time. HealthSouth meets the needs of the medical market for CMR services as demonstrated by high discharge ratios, patient outcomes, quality of staffing and services. The Agency s need formula does not show a numeric need whether applied at the district or county level. The addition of CMR beds would be an unnecessary duplication of services already available in the county and throughout the district. 9

10 There are no special circumstances such as geographic access, financial access, or special services that justify approval of this application. Venice Regional Medical Center is less than 18 miles driving distance from the two existing providers in Sarasota County. CMR hospital units in general are more costly and less effective than HealthSouth CMR hospitals, as measured by cost per discharge and change in FIM scores. Small general hospital units cannot provide the same quality of staff, equipment and facilities as a specialty hospital. The most recent CON applications filed by HMA to establish new CMR units proposed spending under $2 million in total project costs, an indication that their proposed units would lack the necessary state-ofthe-art equipment crucial for achieving superior outcomes. VRMC does not meet the comparative review criteria of Florida Administrative Code Rule 59C-1.039(3)(f), (5)(f) and (g) Florida Administrative Code. VRMC is not a low income pool participating hospital or a disproportionate share hospital. Nor is VRMC a certified trauma center. C. PROJECT SUMMARY Punta Gorda HMA, LLC, d/b/a Charlotte Regional Medical Center (CRMC) (CON #10186), a 208-bed Class I general hospital, proposes to develop a 15-bed comprehensive medical rehabilitation unit (CMR) within its existing infrastructure in Punta Gorda, Florida, located in Charlotte County. CRMC has a total licensed bed complement of 156 acute care and 52 adult inpatient psychiatric beds. If approved, the project would increase the total facility bed count to 223 beds. CRMC states that the hospital specializes in neurological, spine, and joint care. Charlotte Regional Medical Center is a primary stroke center. The project involves 8,918 GSF of renovation. The construction cost is $1,293,110. Total project cost is $1,836,379. Project cost includes building, equipment, project development and start-up costs. The applicant proposes the following conditions to CON approval on CON application #10186 s Schedule C: CRMC will provide seven percent of its CMR patient days to a combination of Medicaid, Medicaid HMO and charity care (including self-pay) patients. This will be measured by submittal of CMR utilization data by payor to the Agency. 10

11 CRMC will offer a comprehensive outpatient rehabilitation program for all patients discharged from the CMR unit at the hospital. This will be measured via a signed affidavit by the applicant and submitted to the Agency. CRMC will maintain its Joint Commission accreditation. This will be measured by submitting its Joint Commission accreditation certificate to the Agency. CRMC will seek Joint Commission accreditation as a designated stroke rehabilitation provider. This will be measured by submitting its Joint Commission accreditation certificate to the Agency. The medical director of the CMR until will be a board-certified or board-eligible physiatrist with at least two years of experience in the medical management of all inpatients requiring rehabilitation services. This will be measured by submitting a copy of the medical director s board certification and/or credentials indicating eligibility. Therapy services will be readily available to all CMR patients seven days a week. This will be measured via a signed affidavit by the applicant and submitted to the Agency. Patients will be evaluated and admitted to the CMR unit seven days a week. This will be measured via a signed affidavit by the applicant and submitted to the Agency. The CMR program at CRMC will have an activities of daily living (ADL) suite for occupational therapy. This will be measured by submittal of schematic drawings to the Agency and via a signed affidavit by the applicant and submitted to the Agency. Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier Boulevard (PRCB) (CON #10187) proposes to establish a 17-bed CMR unit at Physicians Regional Medical Center-Collier Boulevard in Naples, (Collier County) Florida. PRCB has a total licensed bed complement of 100 acute care beds. If approved, the project will increase the bed count to 117 beds. The applicant indicates that Physicians Regional Medical Center - Collier Blvd. offers a women s center with obstetrics, orthopedic hand surgery and an inpatient hospice unit whereas, Physicians Regional Medical Center Pine Ridge (10.3 miles north of PRMC - Collier Blvd.) has a joint replacement program and is certified by the Agency as a comprehensive stroke center 2. Together, these facilities are referred to in this report as Physicians Regional Medical Center (PRMC). 2 Agency records confirm that Physician s Regional Medical Center Pine Ridge, the applicant s sister facility, received comprehensive stroke center designation effective 11/19/12 and is the only hospital in Collier County so designated. 11

12 The project involves 5,800 GSF of new construction and 6,005 GSF of renovation. The construction cost is $2,376,000. Total project cost is $4,093,736. Project cost includes building, equipment, project development and start-up costs. The applicant proposes the following conditions to CON approval on CON application #10187 s Schedule C: PRCB will provide six percent of its CMR patient days to a combination of Medicaid, Medicaid HMO and charity care (including self-pay) patients. This will be measured by submittal of CMR utilization data by payor to the Agency. PRCB will offer a comprehensive outpatient rehabilitation program for all patients discharged from the CMR unit at the hospital. This will be measured via a signed affidavit by the applicant and submitted to the Agency. PRCB will maintain its Joint Commission accreditation. This will be measured by submitting its Joint Commission accreditation certificate to the Agency. PRCB will seek Joint Commission accreditation as a designated stroke rehabilitation provider. This will be measured by submitting its Joint Commission accreditation certificate to the Agency. The medical director of the CMR until will be a board-certified or board-eligible physiatrist with at least two years of experience in the medical management of all inpatients requiring rehabilitation services. This will be measured by submitting a copy of the medical director s board certification and/or credentials indicating eligibility. Therapy services will be readily available to all CMR patients seven days a week. This will be measured via a signed affidavit by the applicant and submitted to the Agency. Patients will be evaluated and admitted to the CMR unit seven days a week. This will be measured via a signed affidavit by the applicant and submitted to the Agency. The CMR program at PRCB will have an activities of daily living (ADL) suite for occupational therapy. This will be measured by submittal of schematic drawings to the Agency and via a signed affidavit by the applicant and submitted to the Agency. Venice HMA, LLC, d/b/a Venice Regional Medical Center (VRMC) (CON #10188), located in the city of Venice, Florida, in Sarasota County, proposes to establish a 22-bed CMR unit through the conversion of 22 existing acute care beds. VRMC has a total licensed bed complement of 312 acute care beds, provides Level II Adult Cardiovascular Services and is a primary stroke center. 12

13 The project involves 17,569 GSF of renovation. The construction cost is $2,970,000. Total project cost is $4,564,819. Project cost includes building, equipment, project development and start-up costs. The applicant proposes the following conditions to CON approval on CON application #10188 s Schedule C: VRMC will provide four percent of its CMR patient days to a combination of Medicaid, Medicaid HMO and charity care (including self-pay) patients. This will be measured by submittal of CMR utilization data by payor to the Agency. VMRC will offer a comprehensive outpatient rehabilitation program for all patients discharged from the CMR unit at the hospital. This will be measured via a signed affidavit by the applicant and submitted to the Agency. VMRC will continue to operate Easy Street as a benefit for all of its patients, including the patients who will be admitted to the CMR program. This will be measured via a signed affidavit by the applicant and submitted to the Agency. VRMC will maintain its Joint Commission accreditation. This will be measured by submitting its Joint Commission accreditation certificate to the Agency. VRMC will seek Joint Commission accreditation as a designated stroke rehabilitation provider. This will be measured by submitting its Joint Commission accreditation certificate to the Agency. The medical director of the CMR until will be a board-certified or board-eligible physiatrist with at least two years of experience in the medical management of all inpatients requiring rehabilitation services. This will be measured by submitting a copy of the medical director s board certification and/or credentials indicating eligibility. Therapy services will be readily available to all CMR patients seven days a week. This will be measured via a signed affidavit by the applicant and submitted to the Agency. Patients will be evaluated and admitted to the CMR unit seven days a week. This will be measured via a signed affidavit by the applicant and submitted to the Agency. The CMR program at VRMC will have an activities of daily living (ADL) suite for occupational therapy. This will be measured by submittal of schematic drawings to the Agency and via a signed affidavit by the applicant and submitted to the Agency. 13

14 Specific to the applicants proposed conditions Section (4), Florida Statutes prohibits accreditation by any private organization as a requirement for the issuance or maintenance of a certificate of need, so Joint Commission and accreditation will not be cited as conditions to approval. The CMR medical director is required by administrative rule and as such does not require a report. Should a project be approved, the applicant s conditions would be reported in the annual condition compliance report as required by Rule 59C (3) Florida Administrative Code. D. REVIEW PROCEDURE The evaluation process is structured by the certificate of need review criteria found in Section , Florida Statutes; and applicable rules of the State of Florida, Chapters 59C-1 and 59C-2, Florida Administrative Code. 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, applications are comparatively reviewed to determine which applicant(s) best meets the review criteria. Rule 59C (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, Jessica Hand analyzed the application with consultation from the financial analyst, Derron Hillman, Bureau of Central Services, who reviewed the financial data and Said Baniahmad of the Office of Plans and Construction, who reviewed the application for conformance with the architectural criteria. 14

15 E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA The following indicate the level of conformity of the proposed project with the criteria and application content requirements found in Florida Statutes, Sections , and and applicable rules of the State of Florida, Chapter 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? ss (1) (a), Florida Statutes. Rule 59C-1.008(2), Florida Administrative Code and Rule 59C-1.039(5), Florida Administrative Code. In Volume 39, Number 13, dated January 18, 2013 of the Florida Administrative Register, a fixed need pool of zero beds was published for CMR beds in District 8 for the January 2018 planning horizon. District 8 has 264 licensed and zero approved CMR beds. During the 12-month period ending June 30, 2012, the district s licensed CMR beds experienced percent utilization. 3 b. According to Rule 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. As shown in the table below, District 8 s licensed CMR beds experienced percent occupancy during the 12-month period ending June 30, Florida Hospital Bed Need Projections & Service Utilization by District, January 2013 Batching Cycle. 15

16 Comprehensive Medical Rehabilitation Bed Utilization District 8 July 1, 2011 June 30, 2012 Facility Beds Total Occupancy % Naples Community Hospital* % NCH Healthcare System North Naples Hospital Campus** % Fawcett Memorial Hospital % Lee Memorial Hospital % HealthSouth Rehab Hospital of Sarasota % Sarasota Memorial Hospital % District 8 Total % Source: Florida Hospital Bed Need Projections & Service Utilization by District, January 2013 Batching Cycle. Note: * Naples Community Hospital delicensed 60-bed CMR unit & NCH Healthcare System North Naples Hospital Campus licensed 54-bed CMR unit effective 11/15/11. District 8 s last five years of utilization for these facilities are illustrated below. District 8 CMR Providers Utilization for the 12-Month Periods Ending June 30, Facility Beds Naples Community Hospital 60* 65.51% 71.36% 61.73% 50.47% 20.40% NCH Healthcare System North Naples Hospital Campus 54* 56.83% Fawcett Memorial Hospital % 45.40% 39.47% 29.67% 36.17% Lee Memorial Hospital % 55.87% 52.50% 53.43% 61.33% HealthSouth Rehab Hospital of Sarasota 96** 90.84% 91.21% 85.75% 85.88% 81.51% Sarasota Memorial Hospital % 67.31% 70.06% 68.38% 68.92% District 8 Total % 71.05% 66.61% 63.61% 63.45% Source: Florida Hospital Bed Need Projections & Service Utilization by District, January ( ) Batching Cycles. Notes: *Naples Community Hospital delicensed 60-bed CMR unit & NCH Healthcare System North Naples Hospital Campus licensed its 54-bed CMR unit effective 11/15/11. **HealthSouth Rehab Hospital of Sarasota added 10 CMR beds in CY 2009 and an additional 10 CMR beds in CY 2011, both times by exemption. The map below shows District 8 s licensed CMR providers and the locations of the applicants. 16

17 District 8 Comprehensive Medical Rehabilitation Providers and CON application #s 10186, and Source: Microsoft MapPoint

18 The table below shows driving distance and travel times for the cobatched applicants and the five nearest existing CMR facilities. Facility CRMC (CON #10186) PRCB (CON 10187) VRMC (CON #10188) Fawcett Memorial Hospital Charlotte Regional Medical Center CON# miles 1.6 hrs 29.4 miles 42 min 5.6 miles 9 min 25.4 miles 33 min 48 miles 51 min Driving Distance Miles and Travel Times Existing CMR Facilities and Proposed Sites Physicians Regional- Collier Boulevard CON # miles 1.6 hrs 101 miles 1.39 hrs 73.8 miles 1.15 hrs 45.2 miles 50 min 113 miles 1.47 hrs Venice Regional Medical Center CON # miles 42 min Lee Memorial Hospital HealthSouth Rehab Hospital of Sarasota NCH Healthcare System North Naples 56.9 miles 17.2 miles Campus 54 min 24 min Sarasota Memorial 52.5 miles 117 miles Hospital 58 min 1.54 hrs Source: Google Maps NOTE: Drive times shown above as hour decimal- minutes 101 miles 1.39 hrs 24.3 miles 36 min 60.6 miles 1.6 hrs 18.3 miles 27 min 90.7 miles 1.27 hrs 17.6 miles 30 min Fawcett Memorial Hospital 5.6 miles 9 min 73.8 miles 1.15 hrs 24.3 miles 36 min 29.6 miles 38 min 45.1 miles 52 min 64.1 miles 1.4 hrs 41.7 miles 1 hr Lee Memorial Hospital 25.4 miles 33 min 45.2 miles 50 min 60.6 miles 1.6 hrs 29.6 miles 38 min 71.7 miles 1.15 hrs 26.8 miles 39 min 76 miles 1.22 hrs HealthSouth Rehab Hospital of Sarasota 48 miles 51 min 113 miles 1.47 hrs 18.3 miles 27 min 45.1 miles 52 min 71.7 miles 1.15 hrs 102 miles 1.36 hrs 11 miles 24 min NCH Healthcare System North Naples Campus 56.9 miles 54 min 17.2 miles 24 min 90.7 miles 1.27 hrs 64.1 miles 1.4 hrs 26.8 miles 39 min 102 miles 1.36 hrs 106 miles 1.45hrs Sarasota Memorial Hospital 52.5 miles 58 min 117 miles 1.54 hrs 17.6 miles 30 min 41.7 miles 1 hr 76 miles 1.22 hrs 11 miles 24 min 106 miles 1.45 hrs The reviewer notes the two closest existing CMR facilities for each of the co-batched applicants as follows: CRMC, CON #10186, is 5.6 miles (nine minute drive) from Fawcett Memorial Hospital and 25.4 miles (33 minutes) from Lee Memorial Hospital. PRCB, CON #10187, is 17.2 miles (24 minutes) from NCH Healthcare System North Naples Campus and 45.2 (50 minutes) miles from Lee Memorial Hospital. VRMC, CON #10188, is 17.6 miles (30 minutes) from Sarasota Memorial Hospital and 18.3 miles (27 minutes) from HealthSouth Rehab Hospital of Sarasota; and 24.3 miles (36 minutes) from Fawcett Memorial Hospital. Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center (CON #10186) data is shown below, beginning with the total number of Charlotte County residents discharged or transferred to an inpatient rehabilitation provider (regardless of whether CMR freestanding or an inhospital CMR distinct unit) by CRMC during the 12-month period ending June 30,

19 Total Charlotte County Resident Discharges Total All Other County Resident Discharges Charlotte Regional Medical Center Discharges to a CMR Provider 12-Month Period Ending June 30, 2012 Total Charlotte County Resident Discharge Percent Total All Other County Resident Discharge Percent Total Discharge Percent Total Discharges % 27.85% 100.0% Source: Florida Center for Health Information and Policy Analysis, July 1, June 30, 2012 database. CRMC includes DeSoto County in its need argument, and it is noted that CRMC discharged four DeSoto County residents to CMR during the 12-month period ending June 30, The table below shows the total number of Charlotte County adult residents discharged from a Florida CMR provider (CMR freestanding or an in-hospital CMR distinct unit) during the12-month period ending June 30, Total Charlotte County Adult Residents Discharged from CMR Providers 12-Month Period Ending June 30, 2012 Percent Total Discharges Total Patient Days Percent Total Patient Days Facility Name Facility County District Total Discharges Fawcett Memorial Hospital Charlotte % 1, % HealthSouth Rehab. Hospital of Sarasota Sarasota % 1, % Sarasota Memorial Hospital Sarasota % % Lee Memorial Hospital Lee % % All Other Florida CMR Providers % % Total % 3, % Source: Florida Center for Health Information and Policy Analysis, June 30, MS-DRGs 945 and 946. Note: Two of the All Other Florida CMR Providers discharges were from NCH Healthcare Systems CMR units in Collier County. The following table shows Desoto County adult residents discharged from a CMR facility during the 12-month period ending June 30, Desoto County Adult Residents Discharged from CMR Providers 12-Month Period Ending June 30, 2012 Facility Name Facility County District Total Discharges Percent Total Patient Days Percent HealthSouth Rehab. Hospital of Sarasota Sarasota % % Fawcett Memorial Hospital Charlotte % % Lee Memorial Hospital Lee % % All Other Florida CMR Providers % % Total % % Source: Florida Center for Health Information and Policy Analysis, July 1, June 30, 2012, MS-DRGs 945 and 946 discharges. 19

20 Naples HMA, LLC d/b/a Physicians Regional Medical Center-Collier Blvd. (CON #10187) data is shown below, beginning with the total number of Collier County adult residents discharged or transferred to an inpatient rehabilitation provider (CMR freestanding or an in-hospital CMR distinct unit) by PRPR during the 12-month period ending June 30, Physicians Regional Medical Center-Pine Ridge Discharged to a CMR Provider 12-Month Period Ending June 30, 2012 Total Collier Total All Total All Other County Other County County Resident Resident Resident Discharges Total Discharge Discharge Discharges Percent Percent Total Collier County Resident Discharges Total Discharge Percent % 41.33% 100.0% Source: Florida Center for Health Information and Policy Analysis, July 1, June 30, 2012 database. MS-DRGs 945 & 946. The reviewer notes that Physicians Regional Pine Ridge discharged 24 Lee County residents to CMR providers during the reporting period. The applicant s facility, Physicians Regional Medical Center- Collier Blvd. discharged four Collier County residents to CMR providers during the reporting period. The applicant indicates that Collier Blvd. discharged a total of six patients to CMR during the 12-months ending June 30, The table below shows the total number of Collier County adult residents discharged from a Florida CMR provider (CMR freestanding or an inhospital CMR distinct unit) during the 12-month period ending June 30, Total Collier County Adult Residents Discharged from CMR Providers 12-Month Period Ending June 30, 2012 Total Patient Days Percent Patient Days Facility Name Facility County District Total Discharges Percent Discharges NCH Healthcare System North Naples Collier % % Naples Community Hospital Collier % 1, % Lee Memorial Hospital Lee % % All Other Florida CMR Providers % % Total % 6, % Source: Florida Center for Health Information and Policy Analysis, July 1, June 30, MS-DRGs 945 and 946. Note: One of the All Other Florida CMR Providers patients was treated at HealthSouth Rehabilitation Hospital of Sarasota (District 8). Venice HMA, LLC d/b/a Venice Regional Medical Center (CON #10188) data is shown below, beginning with the total number of Sarasota County adult residents discharged or transferred to an inpatient rehabilitation provider (CMR freestanding or an in-hospital CMR distinct unit) by VRMC for the 12-month period ending June 30,

21 Venice Regional Medical Center Discharges to a CMR Provider 12-Month Period Ending June 30, 2012 Total Sarasota Total All Other Total All Other County County County Resident Resident Resident Total Discharge Discharge Discharges Discharges Percent Percent Total Sarasota County Resident Discharges Total Discharge Percent % 15.12% 100.0% Source: Florida Center for Health Information and Policy Analysis, July 1, June 30, 2012 database. Per the database, the applicant also discharged 27 Charlotte County residents, two Lee County, one Desoto, one Hillsborough and eight residents from unknown counties during the reporting period. The following table shows the total number of Sarasota County adult residents discharged from a Florida CMR provider (CMR freestanding or an in-hospital CMR distinct unit) during the 12-month period ending June 30, Total Sarasota County Adult Residents Discharged from CMR Providers 12-Month Period Ending June 30, 2012 Facility Name Facility County District Total Discharges Percent Total Patient Days Percent HealthSouth Rehabilitation Hospital of Sarasota Sarasota 8 1, % 16, % Sarasota Memorial Hospital Sarasota % 6, % Fawcett Memorial Hospital Charlotte % % All Other Florida CMR Providers % % Total % 23, % Source: Florida Center for Health Information and Policy Analysis, July 1, June 30, 2012 database. MS-DRGs 945 & 946. Note: Four patients in the All Other Florida CMR Providers were discharged from Lee Memorial Hospital (District 8). c. Other Special or Not Normal Circumstances Punta Gorda HMA, LLC d/b/a Charlotte Regional Medical Center (CON #10186) states nine not normal circumstances that justify need, as follows: Charlotte and Desoto Counties have the lowest CMR discharge use rate per 1,000 population age 65 and older compared to the other District 8 counties and 11 health planning districts in the state. The Charlotte and Desoto resident to rehab bed ratio far exceeds the statewide and District 8 resident to rehab bed ratios and is one of the highest in the state with just one rehab bed for every 8,276 residents. CMR beds are geographically and programmatically inaccessible to residents of the CMRC service area. This is evidenced by the CRMC and Peace River Regional Medical Center (PRRMC) Case Management Department s internal review of medical records which supports the argument that patients do not get transferred to any of the district s rehab hospitals. 21

22 Hospital-based CMR units are primarily supported by referrals that come directly from within the acute care hospital or system. This is the case with the existing 20-bed unit at Fawcett Memorial as will be the case with the proposed 15-bed unit at CRMC. Clinical continuity between acute care providers and programming, and post-acute providers and programming is imperative but is, unfortunately, not the case for many service area residents. As the case mix index (severity rating) of patients admitted to CMR programs continues to increase, rehab appropriate patients at CRMC always experience a break in continuity of care as this level of care is not currently available for the service area population. Evidence of a break in continuity is supported by the Case Management Department s analysis of sample medical records for those acute care patients who would have been appropriate for admission to a CMR bed. As a designated primary stroke center by the Agency and a Joint Commission accredited Stroke Program, CRMC is committed to fulfilling the continuum of care for its stroke patients in a post-acute setting of a CMR program, and being accredited as a stroke rehabilitation program. There is a large percentage of elderly population in the CRMC service area compared to the state average. There is a gap in CRMC s continuum of care; the missing component is inpatient rehabilitation. In light of the Affordable Healthcare Act, and its initial selection for the CMS Bundled Payment pilot, the Applicant must position itself for the future where CRMC will be able to offer a full array of services to compete effectively in providing quality services. The applicant is able to fully support a CMR program based on the CRMC and PRRMC internal volume of rehab appropriate patients who reside within its distinct service area. Service Area Characteristics CRMC and its sister facility, 254-bed Peace River Regional Medical Center, six miles to the north of the applicant, report serving primarily Charlotte and Desoto Counties as a two acute care hospital system, with shared medical staff. Agency discharge data for the 12-month period ending June 30, 2012, indicates that there was one DeSoto County zip code (34269) with 142 discharges or 2.27 percent of the facility s total, in Charlotte Regional s primary service area 4. The reviewer notes that a Sarasota County zip code accounted for 198 discharges (3.17 percent) 4 The primary service area consists of 75 percent of the facility s total discharges. Taking the zip code review to percent of the facility total, there were two more Sarasota and no other DeSoto County zip codes. The applicant s remaining zip codes had less than 50 discharges (or approximately 0.8 percent) of the facility s total. 22

23 and there were no DeSoto County zip codes with more than 50 discharges in Charlotte Regional s remaining zip code service area. The reviewer notes PRRMC is located 0.3 miles (2 minutes) from Fawcett Memorial Hospital. Per the applicant, the populations of these two counties (166,831) comprise 12.6 percent of District 8 s total population (166,831/1,322,746). The applicant concludes that 38.7 percent (64,483/166,831) of the adult service area is age 65 years and older, the age group most likely to utilize CMR services. Below are three tables the applicant provides to account for service area population, age cohort, and growth changes. District 8 Population Ages 18 and Older As of January 2013 County Ages Ages 65+ Ages 18+ Charlotte 81,807 58, ,825 Collier 176,844 92, ,318 Desoto 20,541 6,465 27,006 Glades 7,396 2,833 10,229 Hendry 23,675 4,670 28,345 Lee 360, , ,929 Sarasota 201, , ,094 District 8 872, ,573 1,322,746 Charlotte/Desoto 102,348 64, ,831 Source: CON application #10186, page #14. CRMC Service Area Population Growth Ages 18 and Older 2013 to 2016 County 2013, Ages , Ages 18+ Incremental Growth Charlotte 139, ,941 3,116 Desoto 27,006 27, Service Area 166, ,022 3,191 Source: CON application #10186, page #15. CRMC Service Area Percent Growth Ages 18 and Older 2013 to 2016 County Ages Ages 65+ Ages 18+ Charlotte (1.4%) 7.3% 2.2% Desoto (0.6%) 3.2% 0.3% Service Area (1.2%) 6.9% 1.9% Source: CON application #10186, page #16. Per the applicant, the forecasted growth in the service area will be primarily in Charlotte County, the location of the proposed CMR facility, with a combined service area percentage increase in population of more than two percent annually during years 2013 to