When Howard County’s hospital opened in 1973, Columbia Hospital and Clinics Foundation, as it was called, only served members of the Columbia Medical Plan in Jim Rouse’s burgeoning city.
A year later as residents continued to pour into the county, the hospital incorporated as the independent Howard County General Hospital and served a county with 84,711 residents. In 1998, Johns Hopkins Medicine bought the hospital for $142 million and added it to its health care network.
Since then, the hospital’s patient-care numbers have ballooned. In 2007 the hospital admitted 13,799 patients. Last year it admitted 24,496.
Howard County’s population has also aged. The population has climbed to more than 320,000 and nearly 40 percent of residents are projected to be over 50 by 2035, according to county estimates.
To care for them and their increasingly complex medical needs, the 244-bed hospital is looking to join forces in a new way with the county government.
For the first time, the hospital this year sought county funding for its operating budget, an uncommon move for a well-performing facility, according to Dylan Roby, who follows health-care issues as an associate professor in health services administration at the University of Maryland.
Faced with a growing population coupled with a shift in services at the Laurel Regional Hospital, just across the county line, Howard County’s hospital is straining to meet demand, and needs new sources of funding, a case that hospital president Steve Snelgrove has been making to county leaders for months.
“We just see huge growth and need going forward,” Snelgrove told the County Council last September. “The aging of the population alone is going to more than consume probably any capacity we can develop in the short term. We really need to get on this now.”
County Executive Allan Kittleman included $389,000 in his proposed 2019 operating budget for the hospital’s operations. The money, less than the $3 million the hospital requested, would go toward hiring new positions and planning for the hospital’s future.
Maryland operates a unique payment system for hospitals. The state limits how much hospitals can charge both public and private insurers for services and also sets a cap on revenues.
If the hospital were to exceed the cap due to an increase in patient volume, it must lower the amount that it charges for services, according to Paul Parker, director of the state’s Center for Health Care Facilities Planning and Development. That setup can be a disincentive for hospitals to increase their patient volume, according to Parker, because it won’t lead to an increase in revenue.
Howard County General is one of the few hospitals in the state that is faced with the task of serving an entire county, Roby said, creating another specific challenge.
“Howard County is a unique situation in that the hospital isn’t in any danger of closing without an influx of county dollars,” Roby said. “But they are the only game in town and because of the closure of Laurel, people in Howard County and nearby areas are probably pretty reliant on that facility.”
The payment system, combined with the county’s population change, has created a tough situation for the hospital and was one of the factors that led to the request for county funds, said Elizabeth Kromm, the hospital’s vice president of population health and advancement.
“We can’t control how many people come through our doors and we’ll never turn anyone away,” Kromm said. “So I think we’re really challenged to be able to best serve this growing and graying population in a capped environment.”
Kittleman had stated that he was not in favor of providing county funding to the hospital, which does not receive any funding from Johns Hopkins, but said that after discussing the hospital’s needs with Snelgrove, he came around.
“Howard County General Hospital has been put in a very difficult position, they’re basically responsible for the health of Howard County … and that’s not really fair,” Kittleman said at a recent public town hall meeting. “So I think it was something where Howard County needs to say, ‘How can we be a partner, how can we help you make sure that our population health gets stronger?’ So we’re starting it this year, it may not sound like a lot with $389,000, but it is a big deal.”
If the County Council approves the request, $238,000 would be used for three new positions: a social worker and two behavioral health navigators, all to serve in the hospital’s emergency room, according to Kromm. The new workers are in response to a growing number of psychiatric emergencies, Kromm said.
From 2016 to 2017, Kromm said the hospital had a 50 percent increase in the amount of time children stay in the emergency department for psychiatric-related issues, now up to an average of 41 hours.
The increase, according to Kromm, is due to multiple factors, including a rise in patient volume and the intensity of their needs, the hospital’s lack of an inpatient pediatric psychiatric unit and a disparity in existing plans for community resources.
“That’s just not something that anyone would want to have their loved one go through or be a part of,” Kromm said. “So we certainly can’t fix the inpatient, for pediatrics we don’t have an inpatient psychiatric unit, but we can’t magically create more beds at the state level or magically can’t create more community providers necessarily, but we do have resources in the community and we need to better connect people to them.”
Behavioral health navigators could help cut down that time, Kromm said, by working more with families to figure out their next treatment steps outside the emergency room.
Much of this work is now taken on by the emergency room’s sole social worker, Kromm said. If the hospital is able to hire another social worker, Kromm said they would be able to spend more time helping patients create treatment plans, which would also allow them to get in and out of the hospital faster. The social worker would also specifically be trained to work with both pediatric and adult patients.
Institutions across the county are increasing their focus on behavioral and mental health care in response to mounting mental and behavioral health concerns. The school system has requested funds to hire three social workers to provide more support for students and connect them to community resources. The health department is seeking to hire a behavioral health ombudsman to connect residents to affordable care and the police department hopes to add a mental health liaison officer.
Twenty-five thousand dollars is in the request for developing a strategy on how to better use more behavioral health professionals in the area, Kromm said, whether by establishing a financial incentive program to bring in new professionals or a program to better use the existing professionals in the county.
The final major funding initiative is $126,000 to help close a gap in the county’s primary care services. Howard County faces a deficit of approximately 80 primary care physicians, Kromm said, a result in part because of doctors who are nearing retirement and closing their practices.
Howard County General wants to use the money to launch Practice Howard, an incentive program to bring primary care physicians to the county. The program, which if funded would bring two physicians to the county next year, would offer student loan repayment assistance in exchange for at least five years of service in the county, according to Kromm.
The hospital hopes to fund the program over multiple years and to add roughly 16 doctors over a five year period, closing 20 percent of the primary care physician deficit.
Had Kittleman fulfilled all of the hospital’s request, Kromm said some money would have gone towards creating more robust aging patient care management services and to increase the scale of Practice Howard and number of new hires. She’s optimistic that more funding to grow these initiatives will come in future years.
“We are making an investment together to really change the trajectory of primary care and components of behavioral health that we know are problems in our community over the next several years, which is kind of groundbreaking in many ways and the first time that we’ve seen as the hospital this level of commitment outside of [the health department],” Kromm said. “It’s a whole different mindset as our sole community hospital as your partner in health.”
In years past, the county has committed capital funding to the hospital, including $1.25 million to expand emergency room facilities. Kittleman has also proposed in this year’s budget to increase the county’s support for the hospital’s capital improvement project to add 30 inpatient beds and an inpatient psychiatric unit and observation unit; he has proposed $5 million over five years.
Work has started on a $45 million, two-story expansion and renovation project on the hospital’s Columbia campus.
Still, that funding will only address what Kromm said are the hospital’s current needs and do not address a host of long-term needs the hospital will have in attending to its changing population.
As Maryland overall focuses more on community level health care and directing residents to the best provider, often outside the hospital, Kromm said it’s likely that over the next decade hospital facilities will need to be equipped to handle more complex acute needs.
“This campus is going to need to look different because there will need to be more highly acute clinical services rendered, because at this point the people coming to us will be very ill and much older. How do you design a unit that addresses not only the clinical needs of an individual that are highly complex, but also the cognitive issues that go along with that?” she said.
To meet those more complex patient needs, Kromm said she wants to see the hospital become a “one stop shop” where residents can get services such as medical testing as well as visit necessary specialists, or even receive wellness care and classes such as yoga.
Most importantly, Kromm said she wants the hospital to offer personalized care. She aligns it to precision medicine that can target individualized cells based on a person’s genetic makeup.
“I really want our health care across the continuum to be that personalized and that tailored, so that we are able to meet a person where they are with their needs,” Kromm said. “We count the county as a key partner in this.”