Comprehensive,
Quality and
Innovative Care
in your backyard…
TULARE REGIONAL MEDICAL CENTER
Background





112 Bed Acute Care Hospital
Serving approximately 170,000 people in the
Tulare County and its surrounding area
Provides emergency, diagnostic, elective and
surgical care
Operates 4 rural health clinics, 1 wellness center
Future expansion will include a new medical tower,
an FQHC, and an additional rural health clinic
TRMC's Current Situation: SWOT Analysis
STRENGTHS
-Commitment and dedication of employees,
physicians, and leadership
-Accessibility
-Health clinics
-District funding
-Pediatrics/ obstetrics services
-New facilities to open in early 2013
-Capital investments in technology such as robotic
surgery
OPPORTUNITIES
-Physician recruitment and retention
-Quality improvement of health care services
-Performance improvement initiatives for
improved -charge capture, reduced readmissions
rates, and reduced bad debt
-Improve hospital reputation and image
-Improve market share in specific service lines
WEAKNESSES
-Low market share in desirable service lines and
payer categories
-Loss of insured patients to other hospitals
-Dependency on Medi-Cal patient base
-Difficulty attracting and retaining physicians
-High cost structure; low revenue
-Financial burden of the uninsured and
underinsured
THREATS
-Competition from surrounding facilities and
hospitals
-Defection of key physicians, unsuccessful
recruitment
-Potential resistance of medical staff to change
-Potential for poor financial performance
threatening expansion
-Continuation of negative public image
Financial Snapshot
2006-2007
Gross patient Revenue
$ 147,933,171
Provision for bad debt $ 5,797,842
Total contractual adj. $ 84,929,348
DSH funds
Charity other $
900,995
All other deductions
Total deductions from
revenue $ 91,628,185
Capitation premium revenue
Net Patient Revenue
$ 56,304,986
Other operating revenue
$
617,025
Total operating expenses $ 60,696,426
Net from operations
($3,774,415)
Non-operating revenue
$ 4,874,867
Non-operating expenses $
604,776
Net Income
$
495,676
Source: CA OSHPD
2007-2008
$ 169,524,455
$ 7,242,659
$ 99,371,655
$
2008-2009
$ 237,528,661
$ 9,767,597
$ 142,437,679
($985,965)
1,391,501 $ 1,366,276
$ 13,550,074
2009-2010
2010-2011
$ 253,412,890 $ 267,526,211
$ 13,156,331
$16,851,090
$ 155,440,984 $ 159,627,809
($5,291,579)
$ 5,468,836 $ 6,754,192
$ 7,438,460 $ 10,352,541
$ 108,005,815 $ 166,135,661 $ 181,504,611
$ 61,518,640 $ 71,393,000
$
766,842 $
673,721
$ 65,062,641 $ 72,634,498
($2,777,159)
($567,777)
$ 4,566,523 $ 9,640,063
$
48,748 $ 3,933,781
$ 1,740,616 $ 5,138,505
$
$
$
$
$
$
$
71,908,279
2,744,238
72,849,437
1,803,080
12,790,190
4,477,770
10,115,500
$188,294,053
$112,004
$ 79,344,162
$ 1,878,170
$ 78,074,747
$ 3,147,585
$ 13,897,152
$ 3,872,312
$ 13,172,425
Strategic Plan Overview
•
Performance Improvement Initiatives
Clinical processes
Financial processes
o
o
•
Physician Recruitment and Community Development
•
“Be Healthy Tulare” Marketing Campaign
Performance Improvement Initiative
Performance Improvement Initiatives


Two performance improvement initiatives for both
clinical and financial processes
Focus clinical QI initiative on the following areas:
 Readmissions:
 Heart
attack- 19.8%
 Heart failure- 27.3%
 Pneumonia- 21.8%
 TRMC
is not be paid for episodes of care resulting from
readmission within 30 days
Performance Improvement Initiatives

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
Poor quality of care scores will soon have a
financial impact on TRMC
Starting in October 2012, Medicare’s Value-Base
Purchasing will withhold 1-2% of TRMC payment
Will track and reward performance based on:
 12
process of care measurements
 8 patient satisfaction scores from HCAHPS
 30-day mortality rates
 8 hospital acquired conditions
Financial Process Improvement

Critically important to address weakness in financial
processes now before the payment environment
changes


Disproportionate Share Hospital(DSH) fund payments will
be gradually decreasing due to ACA from 2014-2020
need to ensure financial viability without
additional payments
Three areas of financial management that need to be
closely monitored and actively improved in order to
retain financial stability:
Occupancy Rate
 Bad Debt Rate
 Days in Accounts Receivable

Financial Process Improvement
Change due to increased number of licensed acute beds
Financial Process Improvement
Financial Process Improvement
Fiscal Year
Physician Recruitment & Community
Development
Physician Recruitment and Community
Development
Challenges:
•
•
TRMC in rural, lower income area - presents challenge to
physician recruitment
25 admitters account for 87% of all referrals, leaving TRMC
vulnerable to change
Areas of particular concern - Cardiology, Ob/Gyn, Family
Practice, Orthopedic Surgery
Revenue at risk at minimum $16 million
In Summary - Physician recruitment needs to be addressed
and relationships with referring physicians need to be fostered
o
o
•
Physician Recruitment and Community
Development
Solution:
 Immediate - Use NHSC loan forgiveness programs
as a draw for primary care providers

Long Term - Reorient physician recruiting efforts
towards a community development approach
Physician Recruitment and Community
Development
1) Immediate - Use NHSC loan forgiveness programs as
a draw for primary care providers
•
4 Rural Health Centers and Future FQHC are eligible under National Health
Services Corps Loan Forgiveness Program
•
•
Notify current staff of eligiblity to apply for loan repayment assistance.
Inform primary care providers when interviewing them for positions that TRMC site
is NHSC-approved and therefore they may be eligible to apply for loan
repayment if they accept your open position.
Utilize NHSC Recruitment Site to alert prospective and current Corps members to
TRMC open positions.
ACA expands funding for FQHCs and the NHSC program - this opportunity is
growing
•
•
Physician Recruitment and Community
Development
2) Long Term - Reorient physician recruiting efforts
towards a community development approach
• Modeled after a successful rural recruitment program in
Arkansas funded by RWJF
• Combines traditional recruiting/retention and community
development
o Mobilize community members; with long-term goal to
develop community into more attractive place for
providers
• In RWJF funded pilot, average recruitment fees with this
approach were $18,750 per provider – our projection is
approximately $30,000 per provider due to CA labor costs
Physician Recruitment and Community
Development
Recruiter Position:
•
•
•
•
•
•
•
Works with residents/primary care providers/health care facilities to
design and implement community improvements that make the area more
attractive to new and existing providers
Builds relationships with local health care providers and residents and
works to unite them into action groups
Provides technical assistance to enhance local capacity to self-assess
needs and map resources
Informs community about alternative solutions to increasing access to
primary care, such as use of nonphysician professionals (nurse practitioners
and physician assistants)
Assists in developing grant proposals to bring needed resources to the
community
Nurtures new providers to ease their transition into their new community
Links new providers with resources to improve practice retention.
One more thing… Marketing
Marketing Campaign
A reminder of what we are facing…
• Hospital’s historical reputation and public perception
and the continuation of that negative public image
• Low market share in desirable service lines and
payer categories
• Growing competition with other regional providers
and the need to differentiate
• Little philanthropic support from the community
• Growing need for chronic disease management and
strategies to address obesity
Be Healthy Tulare!
“Be Healthy Tulare!” Marketing Campaign
The Campaign AIMS to…
 Revitalize TRMC’s public image as a leader in the delivery of
healthcare in the community by highlighting recent
performance improvement work and addressing drivers of
health in the Tulare community
 Advance re-branding of TRMC’s approach to healthcare
(Emphasis on Prevention/Wellness and Quality)
 Enhance TRMC’s visibility within and outside of the county
 Improve community goodwill/customer loyalty
 Position TRMC as the principal partner in advancing the total
health of the communities it serves
“Be Healthy Tulare!” Marketing Campaign
Identifying our approach…
“Be Healthy Tulare!” Marketing Campaign
Strategic Focus Areas
Care
Delivery
Workforce
Wellness
Community
Wellness
“Be Healthy Tulare!” Marketing Campaign

Care Delivery
“Comprehensive, Quality and Innovative Care in your
backyard…” is the key message
 Heavily market Maternal and Child Health services
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Highlight recent performance improvement initiatives
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Focus on pregnant women
Aggressively capture stories and share
Cardiac and Respiratory care
Share patient stories- videos are extremely effective
Key Message: Show the community we are the
leading healthcare provider in the region
“Be Healthy Tulare!” Marketing Campaign

Workforce Wellness
Internally-focused campaign to motivate TRMC employees
and physicians to be “healthy eating, acting living” role
models in their community
 Explore possibilities of extending Evolution Fitness and
Wellness Center membership to TRMC staff, if not done
already
 Quarterly wellness event – “Get-Fit Challenge”
 Capture the experience and share
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Key Message: TRMC’s commitment to health care is
not limited only to its patients
“Be Healthy Tulare!” Marketing Campaign
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Community Wellness Campaign:

Investment and/or development of local healthy eating,
active living initiatives
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ID and collaborate with local community partners (e.g. schools)
Targeted Employee and Community Engagement
 Targeted community service activities with TRMC Senior
Leadership and community partners (year-long projects)
 Employee-driven community service projects
 Retired Physician Program (Transition to Public Health
Wellness Advocates)
Key Message: Demonstrate TRMC’s commitment to the
total health of the communities it serves
“Be Healthy Tulare!” Marketing Campaign
Graphic depicting Marketing Strategy Overview
Strategic Plan Summary
Ongoing
Main Issues Tackled
Benefits
Performance Improvement
Quality; Financial Stability
Increased Net Income; Financial
Stability
Marketing Campaign
Public Image; Visibility
Improved reputation; customer
loyalty; community presence
Short-Term
Main Issues Tackled
Benefits
NHSC loan forgiveness
programs
Sustainable Physician
Recruitment
Strong physician recruiting tool
Long-Term
Main Issues Tackled
Benefits
Reorient physician recruiting
efforts towards a community
development approach
Physician Recruitment and
Retention
Strengthened referral network;
community capacity
development
Appendix 1: Value-Based Purchasing
Appendix 2: Revenue at Risk
Revenue at Risk
Net Patient
Revenue
$79,344,162.00
High Estimate
(87% referrals)
$69,029,420.94
Low Estimate
(21% referrals)
$16,662,274.02
Appendix 3: Recruiting Budget
Projected Program Budget