Primary Plan’s Obstacle: Broken Bus System

Given New Haven’s broken bus system, how would car-less New Haveners get to a new primary care center planned for Long Wharf?

Yale-New Haven Hospital and the city’s two community health centers will have to answer that question over the next two weeks to win state permission to transform the way that New Haven’s poor get medical care.

That was the main takeaway from a three-and-a-half-hour hearing Wednesday afternoon and evening held by the state Office of Health Strategy’s (OHS) Health System Planning Unit. OHS held the public hearing as it weighs the proposal byYale-New Haven Health (YNHH) to relocate its three existing primary care services to a hospital-owned building at 150 Sargent Dr. and turn over management of the facility to Fair Haven Community Health Care and Cornell-Scott Hill Health Center.

The hearing was one of the last steps in the hospital’s application for a state-sanctioned Certificate of Need (CON), which is required for YNHH to make its plan a reality.

Around 75 neighbors, hospital employees, and other local healthcare providers filled the Betsy Ross Arts Magnet School’s Parish House on Kimberly Avenue for the meeting.

In a wide-ranging discussion about a complex proposal that would see YNHH team up with the city’s two longstanding neighborhood health centers to deliver primary care services out of a single centralized location on Long Wharf, the problem that vexed Wednesday night’s conversation was a familiar one: the city’s inconsistent and incoherent public bus system.

After years of pleas from city officials and residents to fix the system, the state’s Department of Transportation recently completed a decade of research that found that, yes, the outdated system needs many additional runs and new routes to enable most people to rely on buses to travel to work or school or the doctor when and where they need to get there. The state has no immediate funded or approved plans to fix it. Now YNHH and its partners will need to contribute some ideas to make change happen faster, at least for people getting to Long Wharf.

Concrete Ideas Demanded

In particular, state inquisitors Wednesday asked how YNHH and the two community health centers will ensure that their low-income primary care patients who may not own cars can access a relatively remote new facility. The current existing clinics are in residential neighborhoods, so patients can walk to them.

“We are still 10 months away from operationalizing the change,” YNHH Vice President of Operations Cynthia Sparer told the panel.

She said that, even if the state were to approve Yale’s CON application in January, the hospital and its partners still have time to figure out how to make sure that the 25,000 patients that YNHH sees each year at its current primary care facilities on York Street, Chapel Street, and Whitney Avenue have an easy way to get out to Sargent Drive.

Not good enough, OHS Attorney and Hearing Officer Micheala Mitchell responded.

“Without details,” she said, ​“it’s hard for us to analyze” the efficacy of the hospital’s transportation plan for its primary care patients.

At the end of the hearing, Mitchell ordered the hospital to submit a detailed transportation plan (or at least a timeline describing when it will have a detailed transportation plan) to OHS by Dec. 12.

Then OHS will close the record submission period, evaluate the hospital’s application in its entirety, and issue a verdict on the primary care consolidation proposal within the subsequent 60 days.

Yale’s proposal now hinges, at least in part, on whether or not it can convince the state that it can solve in 10 months a problem that city and state transit officials and bus riders have banged their heads against for the past 10 years: how to fix a broken bus system.

The Proposal

In a half hour opening statement, Sparer, Fair Haven Community Health Care CEO Suzanne Lagarde, Cornell Scott-Hill Health Center CEO Michael Taylor, Yale School of Medicine Associate Dean Stephen Huot, and YNHH Vice President of Legal Affairs Jennifer Wilcox described the contours of the proposed venture, which is called the New Haven Primary Care Consortium.

YNHH seeks to relocate its three primary care clinics — for Adult Medicine, Women’s Health, and Pediatrics — to a single building at 150 Sargent Dr. All three are currently located at much more bus-and-pedestrian-friendly neighborhood spots.

The hospital’s adult primary care services are currently based out of a campus at 20 York St. and out of the hospital’s Saint Raphael campus at 1450 Chapel St. Its pediatric primary care services are currently based out of York Street, Saint Raphael’s, and out of a Hamden satellite campus at 2080 Whitney Ave. And its women’s primary care services are based out of the hospital’s Women’s Center on York Street.

Sparer said that the three primary care centers currently see over 25,000 patients each year, and that a vast majority of its patients are uninsured or on Medicaid.

Under the hospital’s new proposal, YNHH would move its three primary care clinics to Long Wharf and turn the operations of the integrated primary care facility over to Cornell Scott-Hill and Fair Haven Health. Yale would lease its current primary care doctors, residents, attendings, and staff out to the two community health centers, and would pay the latter an annual Community Benefit Grant to help cover the cost of operations.

Sparer said that, for the first year of operations, the hospital plans on paying a combined sum of $8.9 million to the two community health centers. YNHH also plans to invest $15.7 million in capital improvements at 150 Sargent Dr., as well as another $4 million in bringing the hospital, Cornell Scott-Hill, and Fair Haven Health under the same Electronic Records Management (ERM) system.

“What we are looking to do is really preserve and respect and retain the best of what we do today,” Sparer said, ​“and also learn from and gain the extensive experience that each of our partner institutions have.”

Lagarde and Taylor said that their community health centers do not plan on closing down any of their current clinics in Fair Haven and the Hill.

Two-Thirds Drive

During her presentation, Sparer singled out transportation access to the Sargent Drive facility as a consistent concern raised by neighbors dubious of the value of moving primary care services to a section of the city inconvenient for those who don’t own their own cars.

Sparer said that what looks like a drawback is actually an asset. She said the hospital conducted a transportation survey of its primary care patients this summer, and learned that two-thirds of them access primary care by car. That is a source of stress at the York Street and Chapel Street campuses, she said, because patients there have to pay to park. She said they are always worrying about filling the meter or overstaying at a parking garage.

That won’t be a problem at the Long Wharf location, she said, because of its ample on-site parking lot.

“At the new site,” Sparer said, ​“we will have free parking for our patients.” The Sargent Drive facility currently has nearly 280 on-site parking spots, she said. After the conversion of some spaces in handicap accessible spots, she said, the final New Haven Primary Care Consortium building should have around 250 parking spots, all free to use for its patients.

But if two-thirds of Yale’s primary care patients drive, she said, that leaves another third who do not.

“We also know that bus routes today,” she said. ​“Sometimes those routes and their frequencies can be daunting, and we’re committed to advocating for the improvement of bus routes that serve Long Wharf Drive and specifically this site.”

She said that YNHH currently has a system contract with the rideshare service Uber. The hospital and the consortium may explore working with that kind of an on-demand car service to bring carless patients to and from Sargent Drive, she said.

OHS Associate Research Analyst Shauna Walker asked Sparer to elaborate on the hospital’s transportation plans: How exactly will it advocate for better bus service? What exactly would a contract with Uber look like?

Sparer reiterated that two-thirds of the hospital’s current primary care patients travel to clinics by car, and that 150 Sargent Dr.‘s ample, free, on-site parking meets that vehicular need.

As for the other third of the low-income primary care patients who use the bus or other transportation means … the hospital and the consortium are still working on that.

“Those are the things that we’re continuing to work on as a steering group to best understand what we need to make available in addition to the asset” of free parking, she said. ​“And that will include the advocacy for enhanced bus access as well as the opportunity we have for other patients at the hospital to use supplemental transportation mechanisms.” That might mean a contract with Uber, she said. It might mean some type of shuttle service. ​“We still have that before us,” she said.

Walker asked when the consortium plans to have those alternative transportation details worked out.

“We’re 10 months away from operation,” she said. So, sometime in the next few months.

“Serious Transportation Concerns”

During the public testimony section of the night, several members of the public expressed their frustration with the hospital’s lack of details on an issue as critical as accessibility.

“There are serious transportation concerns with the proposal,” said Ellen Andrews, a health policy instructor at Southern Connecticut State University (SCSU) and the founder and chair of the CT Health Policy Project. ​“Sargent Drive is not in a residential neighborhood.”

She said that her own research into city bus schedules showed that travel from YNHH’s three current clinics to 150 Sargent Dr. by bus during the day can take between 20 and 45 minutes, including up to 29 minutes of walking and two buses. She said that longer commutes could encourage YNHH primary care patients to shift their care to closer federally qualified health center (FQHC) clinics sites, exacerbating already long wait times.

“In the CON” application, Andrews wrote in her notes but did not say aloud in her rush to get through her testimony on Wednesday night, ​“YNHH states that they would consider options to ease travel, but no plans or promises are provided and transportation costs are not included in the proposal.”

Howard Avenue resident and Mothers & Others for Justice activist Claudette Kidd was skeptical of the hospital’s parking-focused transportation plans.

“I look at the healthcare service now,” she said, ​“and I feel it’s lost its sense of care. All of it seems to be centered around what they want and not the needs of the patient.” She said she is concerned that the impetus for the move to Long Wharf is actually the prospect of cutting costs and increasing state Medicaid reimbursements, as opposed to improving care for New Haven’s low-income patients.

New Haven Legal Assistance Association (NHLAA) Attorney Sheldon Toubman told the Independent about his own concerns with the proposal in during a brief recess in between the public testimony section and the resumption of the state’s questioning of the consortium members.

“For lower income folks,” he said, ​“the transportation issue is huge.” As for Sparer’s references to advocating for bus improvements over the next 10 months, he said, ​“Everything we heard was vague on that.” What he would like to see instead are long-term, ironclad commitments from the hospital to fund and ensure some kind of viable alternative transportation solution for low-income primary care patients who do not drive. That commitment could be voluntary or it could be mandated by OHS as a condition of approval, he said. But it needs to happen if this plan is going to go through.

“When Will You Have Details?”

After the public testimony wrapped up, Mitchell resumed her questioning of Sparer. She asked about what kind of public outreach the hospital has engaged in around this proposal.

“We have been very active in speaking with our patients,” Sparer said. She called to the table Rebecca McCray, the hospital’s director of ambulatory operations and the supervisor of this summer’s transportation survey of YNHH primary care patients.

McCray explained that the survey provided the hospital with an opportunity to talk with many of its patients about the proposed move, as well as about how patients get to and from the existing clinics, which neighborhoods they live in, and whether or not they’ve ever missed an appointment because of a bus-related delay.

That survey, she said, revealed that 66 percent of patients drive to the current primary care clinics, and that one of the paramount needs for the population the hospital serves is free and nearby parking.

Mitchell told Sparer that it is difficult for her to fully assess the potential impact that the proposed move will have on patient populations without knowing any details about how the hospital will serve its carless patients.

“When will you have details on the transportation plan?” she asked.

Wilcox and Sparer said that they will submit to OHS within the next two weeks at the very least a timeline outlining when they will have more concrete plans in place to address alternative transportation needs for the primary care patients.

Mitchell requested that the hospital submit that late filing to its CON application by Dec. 12. Public testimony on the application will be accepted up until Dec. 5, and can be submitted here.

Mitchell also requested that by Dec. 12 the hospital submit details on its Hardship Fund plan, which will help cover primary care visit costs for qualifying low-income patients.

She also pushed the consortium members to better prepare for how they will communicate to female patients about reproductive health services if the Trump administration follows through on his promises to apply a ​“domestic gag rule” that would prohibit healthcare providers who receive certain federal funds from even referring a woman to abortion providers.

Click here to read here to read a Hartford Courant op-ed by Yale Law School student Rachel Kogan about what the proposed primary care move could mean for local women’s health options. And click here to read testimony that Kogan and two fellow Yale Law School students read into the record at Wednesday night’s hearing.

And click here to read an overview of the primary care proposal as written by Sparer, Lagarde, Taylor, and Huot.

Below are links to previous articles about the proposed New Haven Primary Care Consortium.

• Plan Reimagines Primary Care For Poor
• West River Questions Primary Care Move
• Harp Backs Primary Care Move

Also below are Facebook Live videos of portions of Wednesday’s night’s public hearing, and of an interview earlier this year with Lagarde and Taylor on WNHH’s ​“Dateline New Haven.”