Photo by: Karla Ann Cote

The 287-bed Interfaith Medical Center in Bedford-Stuyvesant. Among the causes of its financial crisis was excessive usage of the emergency department—a problem faced by many hospitals.

With little fanfare and fingers crossed, the pre-fab modular clinic inside SUNY Downstate Medical Center at 450 Clarkson Street opened like a children’s pop-up book last May across the hall from the emergency department, and within hours security guards had to be dispatched to escort overflow patients out of the clinic. With readymade walls and a full complement of medical supplies, the clinic was mobbed by patients seeking faster access to care.

Six months later, the pre-fab clinic is still open and ED visits have gone down overall.

Squeezing money out of an expiring state grant this past summer, administrators at Brookdale Hospital in East New York began building a new urgent care center across the street on Rockaway Parkway in the hopes of cutting the hospital’s annual 100,000 ED visits by as much as 40 percent. This comes on top of more modest changes, such as installing a greeter inside the hospital’s emergency waiting room to briefly interview people about why they have come and prioritize the most urgent cases.

While hospital administrators at both institutions are careful to say they have not formally studied the results of their ongoing operational changes, the unofficial consensus is that the changes are (slowly) triggering a switch in patient psychology, with more and more people using the ED for its true purpose: care for life-threatening conditions.

“It’s about people,” observes one SUNY administrator, of the hospitals’ joint effort to draw patients out of the ED and into less-urgent care settings. “To change someone, the way they live their lives, is very difficult. This is about a transition plan.”

And not a moment too soon. With near-weekly court battles over the fate of Long Island College Hospital in Brooklyn Heights, and the 287-bed Interfaith in Bedford-Stuyvesant fighting for its future in a court-ordered mediation, SUNY Downstate, Brookdale and Kingsbrook Jewish Medical Center in East Flatbush are working quietly to improve their physical plants, partner for more effective care and position themselves to survive in the uncertain future that is Brooklyn’s health care landscape.

To that end, the hospitals have been involved in under-the-radar round robins of discussion about which patients would be best served at which institutions.

On Nov. 14, SUNY board chairman H. Carl McCall met with Brookdale officials to discuss the possibility of the hospital expanding its residency practice to create 40 new slots for SUNY medical students. Brookdale in turn is considering turning over the running of its nursing and rehab facility on Rockaway Parkway to Kingsbrook Jewish, while Kingsbrook Jewish is currently scheduled to take over Interfaith’s primary care clinics when Interfaith closes.

With up to 300,000 patients in its catchment area and 100,000 in ED visits annually, “we’re an attractive partner, especially with the Affordable Care Act in play,” points out one Brookdale administrator. Writ broadly, under the full implementation of the ACA, all qualifying patients will be moved into health care exchanges, state or federal, in which hospitals will receive a lump sum to treat so many numbers of patients. For Brooklyn hospitals, at least, the challenge is to capture the benefits of treating the greatest number of patients, while ensuring that unnecessary visits to the ED—a significant drain on hospital finances—are drastically diminished.

Last year, SUNY administrators released the results of a nearly two-year study of emergency department usage, concluding that at least 43 percent of ED visits were for non-emergent or non-emergency conditions. Contrary to the conventional wisdom that only uninsured people use the ED for non-emergency care, 77 percent of those in the ED did in fact have some kind of insurance.

“There needs to be a cultural change in the way people look at health care,” says the Brookdale administrator. When “emergency rooms are used for primary health care, it puts a strain” on the whole hospital’s operations, because the hospital has to provide the “same care for someone with a cold as someone with a gunshot wound.” And as more hospital resources are tied up with carrying for non-emergent conditions, the greater the threat to the hospitals financial bottom line.

“Right now, we’re in a stand-alone situation,” observes the Brookdale administrator. That was a precarious place to be. “The governor says he doesn’t want to see any Brooklyn hospitals standing alone.” Rather than waiting to see whether Brooklyn hospitals will get any of the $10 billion in estimated savings the state says it has generated in realigning its Medicaid reimbursements, Brookdale, SUNY and Kingsbrook are trying to figure out the services they do best, and refer or coordinate care with one another.

All of the hospitals are going to shrink in the future, so “we have to really figure out a way to repurpose ourselves,” says the SUNY hospital administrator. One idea the hospitals are talking about is reconfiguring care, with Brookdale focusing on primary care, SUNY Downstate maintaining an intensive care unit and Kingsbrook Jewish focusing on rehabilitative and geriatric care.

At the same time, SUNY administrators have applied for a federal grant to help the hospitals retool by creating patient navigation centers at the hospitals in Brooklyn’s poorest neighborhoods, both to reduce ED admissions and to connect patients with vital social-medical services by referring them to social workers, nutritionists, dentists and mental health workers.

So far, the plan has the support of most of the borough’s healthcare institutions, including seven health insurance companies that are willing to increase their reimbursement rates if the hospitals can lower their overall costs and admissions rates.

It can work, say the hospital administrators; it’s just a question of will – both on the part of the people working in the hospital and on the part of the patients. Hopes the Brookdale executive: “Once people start to understand and change the way they see hospitals, it’s going to change. It should change a lot.”