Debate draws stark lines, but there may be a middle way
By Jim Shilander
Almost 200 residents, nearly all clad in red shirts emblazoned with “Save San Clemente Hospital,” began shouting “Save Our Hospital” before the start of an open house hosted by MemorialCare, the nonprofit owners of the San Clemente hospital, Monday at the Ocean Institute in Dana Point. When the open house began, a smaller, shorter version of the chant also started up, just as MemorialCare doctors and executives were preparing to tout the company’s proposal for an advanced urgent care facility at the San Clemente campus.
Since August, when MemorialCare announced it was studying a proposal that would raze the current hospital facility and replace it with an advanced urgent care facility, which would eliminate the in-patient facilities and emergency room, the choice has been cast as one between life and death on one side and a hospital and health care provider attempting to grapple with changing market forces on the other. Both sides claim to have support from the community.
The proposed facility would be built on four levels, with one below grade and three above grade. The proposal would add to the number of parking spaces utilized at the site. The basement level would include an outpatient surgery center, with urgent care, labs, imaging and a women’s health center on the first floor. The top floors would be reserved for primary and specialty care offices.
Point of the Spear
Before Monday’s meeting at the Ocean Institute, MemorialCare hosted another open house at Bella Collina Towne & Golf Club on Jan. 22. The San Clemente Times attended a review session of that meeting, held one week later, ahead of the meeting Monday.
Staff said they admitted they had some challenges in terms of selling the potential for the project to the public, which they said would be at the leading-edge of a changing medical field that is seeing more and more done on an out-patient basis.
“The difficult thing about this project is I can’t go point to something and say ‘It’s just like this,’ because there isn’t anything just like this close to us,” administrator Tony Struthers said. “That’s what makes it so exciting and so unique.”
They were also working to fight the notion of being simply another facility similar to the three urgent care centers already in the city.
“We hear that all the time ‘We have enough urgent care,’” Struthers said. “What we’re offering is completely different. It’s unfair to compare us to the current urgent care offerings in San Clemente… We’re hamstrung by the words ‘urgent care.’ We need to get past that and talk about the services available.”
The current plans for the facility going before the MemorialCare board in March for approval would also include a cancer center, imaging services, women’s health facilities and laboratories.
“It’s more than just a traditional medical office building,” said Todd Varney of NexCore, the company hired by MemorialCare to assist with planning the facility. “This is truly an advanced outpatient center, where a patient can do everything from their initial diagnostic to lab work to rehab.”
Karen Sharp, director of emergency services for MemorialCare, said while the hospital had a good record in terms of triaging patients suffering a heart attack or stroke, the best way to treat that was direct action, by calling 9-1-1 immediately. Due to the county’s regulations, patients suffering such maladies are supposed to be taken directly to specialized receiving centers.
“If you’re having a stroke or a heart attack, you should never drive yourself to the hospital,” Sharp said.” 9-1-1 has red lights and sirens and can bypass traffic easily.”
Sharp also said that would be the case even if a hospital was on “diversion,” when beds are full. Critics of the urgent care proposal have said the project would force more ER patients to go to other hospitals, increasing wait times and potentially putting people at risk.
“When Mission, Laguna Hills and San Clemente are on diversion, nobody is on diversion,” Sharp said, saying that in a true emergency situation, hospitals would not turn away cases brought to them by paramedics. “We don’t only see people having heart attacks. Most people we see are mostly urgent care, people who call 9-1-1 because they have a stomach ache. They’re treated and sent home. Just because it comes in by 9-1-1 doesn’t mean it’s an emergency.”
Staff also noted that many cases brought to emergency rooms are not dealing with necessarily life threatening issues, much of which can be treated at an urgent care facility, which they said would relieve the pressure on other ERs. They also said the proposed facility would be open 24/7.
They also noted that a pilot project was underway that allows paramedics to take patients that did not require an emergency room visit to be taken to urgent care facilities instead. The company is participating in the study at a different facility, but the proposal does include infrastructure to support such drop-offs, as well as the potential to add a free standing emergency department if it were made legal, which they are not currently in the state. Any emergency room would require an attached in-patient hospital under current law.
Staff also said they believe people would be attracted to lower cost care and the “one-stop-shop” nature of the proposed facility.
“We hear that we’re going to flood Mission Hospital with 15,000 patients. No,” Struthers said. “If we don’t double our volumes, we’ve done something really wrong. We’ll probably maintain that and take patients who are coming back to this community.”
Staff also believe the proposal would bring in more specialist care as a result of improving the facilities, as well as improving care for chronic illness. Saddleback CEO Steve Geidt said that the Affordable Care Act includes penalties for hospitals that had patients coming back for more treatment of the same case within 30 days of treatment.
Geidt also noted that as the population of the area has grown, the average patient census was actually less than in previous years, both due to changes in the way patients are cared for as well as insurance demands of where to send patients. He noted that at a presentation at the neighboring San Clemente Villas, he’d had several residents tell him they had Kaiser Permanente health plans and preferred it, despite having the closest Kaiser facility being in Irvine.
“When I came here (to Saddleback Laguna Hills), the population of the Saddleback Valley was about 200,000 and our census was about 160 patients (daily average). Now it’s 800,000 and the census is 130,” he said. “We’re a little out front. We do 14,000 surgeries at Saddleback and 11,000 are done in outpatient surgery centers. It’s amazing what can be done if we set our minds to it.”
At Monday’s event a pair of MemorialCare physicians supporting the proposal, Dr. Robert Realmuto, who practices in Fountain Valley but lives in San Clemente and Dr. Shilpa Gaikwad of Dana Point, said they felt the proposal was a better one for the community than what was currently offered.
“For a lot of specialized services, people have to go away from the community,” Gaikwad said. “There’s a lot of focus on what’s missing versus what’s being added. We don’t have anything like this anywhere in the county.”
Realmuto, who previously worked at the hospital, said that if a certified emergency room physician could be put in the urgent care facility at all times, he feels residents would receive essentially the same level of care, just without the paramedic receiving capabilities.
At Tuesday’s City Council meeting, Struthers disputed claims that the company was intentionally degrading the spending and the quality of services at its San Clemente campus.
“(The claims are) vicious, malicious and do nothing to support the hospital operationally,” Struthers said.
Current Facility a Lifesaver, Says Supporters
Dr. Steve Cullen has been among the public faces of the opposition to the proposal to change the hospital. He said his experiences at the open houses have been different, based on who was in attendance. At the first open house, he said, there was more confusion from residents he’d heard from, since they were hearing from both MemorialCare and from opponents in the same meeting. The meeting at the Ocean Institute, he said, featured more people who were opposed to the closure, which he said “overwhelmed MemorialCare,” and were telling hospital staff that they do not want to lose the emergency room and in-patient facility, noting that the hospital was more than welcome to build additional facilities above its current offerings. The group presented thousands of signatures on petitions to Geidt at the start of the meeting urging him and the board to keep the facility open.
Cullen called much of what was in the proposal a “shiny version of what people have access to,” in terms of urgent care in an attempt to maximize financial returns.
Cullen said he felt people’s confusion was heightened by hearing opposing viewpoints from doctors, who they tended to take at face value on matters of health.
“I think that’s what makes things more frustrating for people,” Cullen said. “But I’m speaking as someone who knows this hospital and who’s admitted people for 18 years.”
Cullen said opponents have felt frustrated with a lack of access to the hospital’s board during the process, and felt that their message was not being conveyed to the full body. He said he was able to talk to one board member Monday.
A number of others in the Save San Clemente Hospital Foundation group have said they’ve heard differing information from MemorialCare staff in terms of how a 24/7 urgent care would be staffed, which lead to fears that significant medical issues would not be dealt with in a way they should be. They also said the current facility does stabilize cardiac and stroke patients if they come in before sending them to another facility.
Dr. Nick Karahalios said he’s heard hospital staff say they preferred staying open because they know the quality of care and because it is a home to them. He noted that a number of physicians had contributed to the cause of keeping the hospital open financially. Residents, he said, needed a place close by, not just for peace of mind, but also as a place to see their loved ones when they were sick.
Among those in the now ubiquitous red shirts at Monday’s meeting were Roger and Christine Jolicoeur and Debbie Weddle. Weddle said she was a 33-year employee of the hospital and was there to support the current facility.
“I’m very much aware of the number of lives we’ve saved in the emergency room, including several children,” Weddle said. On one recent day, six hospitals were on diversion and the hospital admitted a patient who had to come in from Fountain Valley due to a lack of space elsewhere to the north.
Roger Jolicouer said one of the primary reasons he and his wife had moved to the city was the presence of a local hospital. He said closing the hospital with a population base of “maybe over a 100,000 people in the area makes no common sense at all.”
Hospital administrators, project opponents and city officials met with Assemblyman Bill Brough and Senator Pat Bates Friday to discuss the project. Brough and Bates issued a joint press release Monday calling for all sides to work together and announcing they would be open to pursuing legislation to allow for free-standing emergency rooms.
Brough said he and Bates want to see the project “slow down” in order to get more information on the impact on emergency services in order for legislative options to be pursued. The three year figure is consistent with previous statements on the potential time it would take to move such legislation forward and get it passed in order to keep emergency services open in the area.
“That’s clearly a heavy haul,” Brough said. “I understand MemorialCare’s position that health care’s changing. But this has a big impact on the region.”
Bates said at the meeting that she had pressed Geidt for a commitment to keep the facility open for three years, in order to pursue the legislation. Having spent time in the State Assembly, she said she believed there is a strong potential for moving a proposal more quickly than that. She did say, however, that she felt any bill would require provisions for a place where patients could stay overnight.
San Clemente City Councilman Bob Baker was at the meeting as well and said he felt the session was “informational” on both sides. However, Baker said he felt there was a difference between the community wanting to see improvements in the facility and support for the model chosen by MemorialCare.
“I think that MemorialCare has a different perspective of community support than I do,” Baker said. “When you ask someone if they want something new up there, they’ll say yes. But it doesn’t have to be only an out-patient center.”
Baker said he feels the most support would be for an option to expand the current facility to include many of the features of the out-patient pavilion but to keep the emergency room, even with a smaller in-patient center.
Struthers said MemorialCare is interested in pursuing the legislative options as well. However, he also said he would not compromise the quality of care provided by the hospital in order to meet a deadline.