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September 17, 2018

Maine coastal hospitals rely on visiting doctors to meet seasonal demands

Photo / Jason Paige Smith
Photo / Jason Paige Smith
Art Blank is president and CEO of Mount Desert Island Hospital, where the hospital's roster of doctors grows in the summer to meet the demands of the island's 3 million visitors.

How MDI Hospital created partnership with Penn Medicine

Every summer, Bar Harbor's Mount Desert Island Hospital hosts third- and fourth-year residents from the Perelman School of Medicine at the University of Pennsylvania. They work two-week rotations at the hospital as part of a professional and teaching exchange established in 2011.

The benefit goes both ways, all parties agree.

At MDI Hospital, the residents fill out staff and provide a teaching experience for medical professionals. In turn, Penn Med residents get a great education in a rural setting with fewer resources and smaller teams, says Dr. Jill Baren, a Penn Med professor of emergency medicine.

"It helps shape their medical decision-making," says Baren. "It's great exposure that requires a different set of skills. For example, we infrequently transfer patients to another institution. But at MDI, the resident learns how that's done, if a patient needs care that can't be provided there. They have to learn how to advocate for the patient, what method of transport to use and how to get them to the next level of care they need."

MDI Hospital President and CEO Art Blank agrees.

"When an emergency medicine resident in Philadelphia sees a patient with a kidney problem, they've got a nephrologist looking over their shoulder," he says. "When they walk into our emergency department, that nephrologist is still in Philadelphia. Of course, we have the systems to make sure they get the expertise they need, because we have relationships in Bangor and beyond. But it's a very different situation for those residents. They've got to do more critical thinking."

Patient volume in the emergency department at Mount Desert Island Hospital in Bar Harbor spikes 400% in the summer and strains capacity, thanks to an influx of 3 million visitors and the island's summer community.

The hospital deals with the spike by adding seasonal practitioners. Although year-round hiring can be just as challenging here as it is nationally, summertime hiring is easier, thanks to the hospital's location in a prime coastal community known for Acadia National Park, hiking and camping, yachting and water activities and tourist amenities.

"The ocean's been helping us," says physician Nathan Donaldson, director of the emergency department.

Last year, a physician who's an avid sailor literally sailed into Bar Harbor and cold-called the hospital for a summer job. A physician assistant did the same. Both were hired and lived aboard their boats for the summer. The physician returned this year.

Being in Bar Harbor for the summer is so desirable that the Perelman School of Medicine at the University of Pennsylvania, which sends third- and fourth-year residents to MDI Hospital for two-week training rotations, had to institute a lottery for those vying for spots. Traveling nurses, hired through staffing agencies, also ask for assignments in Bar Harbor.

"So it's actually not hard to get people to come here in the summer," says Donaldson.

Summer surge

MDI Hospital's emergency department averages 300 patients in December and 1,200 in August. With six patient rooms, the ER in August operates at 150% of capacity, up to 10 patients at once. Two additional beds and two patient areas accommodate overflow, says Donaldson.

When it comes to year-round staff, MDI Hospital has the usual hiring challenges. It's an ongoing struggle to find certified nursing assistants and registered nurses. MDI Hospital has been searching for a child and adolescent psychiatrist for two-and-a-half years and a general surgeon for a year.

To compensate for staff shortages, MDI Hospital sends patients to other hospitals, asks staff to work extra hours and hires fill-ins through an agency (at a cost two to three times higher than staff hires), says MDI Hospital President and CEO Art Blank.

Summer staffing is easier. Overall, Blank seeks a balance that accommodates the summer surge but doesn't add more resources than necessary, "recognizing you're going to have to sustain those resources year-round," he says. As with those sailors, he says, the area's attractions make it relatively easy to find an additional ER physician, physician assistants and nurses for the summer, adding to the ER's year-round complement of one physician, five physician assistants and nurses. Penn Med residents fill out the team.

Dealing with the surge is also aided by improved ER efficiency: "door to provider" time has been cut to less than 10 minutes throughout the summer and is faster in the winter, says Donaldson.

"In some city hospitals, you're waiting for hours. So if you're coming with that expectation and are seen within 10 minutes, it's a pleasant surprise," he says.

Winter and flu surges, too

Fluctuating patient volume can occur for different reasons, says Maine Hospital Association President Steven Michaud. In the winter, volume might increase due to flu outbreaks or increased numbers of recreationists in popular snow areas. Coastal communities like MDI, Blue Hill and Camden-Rockland tend to see a spike in patient volume due to increased tourism, he says. At the same time, he notes, hospital staffers going on summer vacations might create a need for seasonal hires.

Like MDI Hospital, MaineHealth can attest to the coastal surge. Of MaineHealth's 11 facilities, surges occur at four, each one in coastal community: LincolnHealth, with an urgent care campus in Boothbay Harbor and a hospital/ER in Damariscotta; Pen Bay Medical Center, serving Rockport, Rockland and Camden; and Waldo County General Hospital in Belfast.

"We see a 30% percent increase through the summer," Cindy Wade, regional executive vice president and chief operating officer for Pen Bay Medical Center, Waldo County General Hospital and LincolnHealth, says of the four facilities.

LincolnHealth's emergency department, for example, sees an average 27 patients per day in the winter and 48 to 49 in the summer. In Boothbay Harbor, LincolnHealth's 12-hour urgent care facility averages nine patients per day in the winter and spikes to 26 or 30 in the summer. Pen Bay Medical Center has MaineHealth's busiest emergency department, due to the size of the area it serves. In the winter, Pen Bay Medical Center's emergency department sees an average of 53 patients per day and in the summer an average 70 per day. Waldo County General Hospital's emergency department also spikes, from an average of 40 per day in the winter to 60 per day in the summer.

For its Boothbay Harbor facility, LincolnHealth hires an extra nurse to accommodate the surge: the facility has relationships with two nurses who, like the larger summer community, spend summers in Maine and winters elsewhere. Being part of a larger group also helps. When the summer surge comes to Pen Bay Medical Center, "we might call down hospitalists or house supervisors from other parts of the organization to help with patient care," she says.

And temporary staff is used as needed. For example, an additional physical therapist is hired at LincolnHealth's Damariscotta campus each summer due in part to increased numbers of recreational injuries.

In southern Maine, York Hospital sees moderate seasonal fluctuation. In the past year, York's ER saw 1,020 patients in January and 1,354 in July. The hospital's emergency and walk-in care facility in Wells saw 804 in March and 1,513 in July. CEO Jud Knox says the hospital brings in temporary hires at both its York and Wells facilities. Many of them are returnees who, like the LincolnHealth nurses, work winters in the south. Staffing agencies provide per-diem hires over the summer, especially to cover for regular physicians taking summer vacation time.

More injuries

In the summer, hospitals say they see more recreation-related injuries and tick-borne illness, plus more primary-care ailments due to the return of the summer population.

"We have a lot of folks along the midcoast who come to live here for three to six months," says Wade. "It makes their care more complicated because you've got their primary care physician in another part of the country and yet you're providing care here for part of the year." To address that situation, MaineHealth seeks to establish its own primary-care relationship with summer residents, and to coordinate care with the patient's physician in their winter community.

MDI Hospital has the same situation.

"We're the primary care providers for the 3 million people who come on the island to visit. So we see a lot of primary care ailments," says Donaldson. "And then, also, a lot of orthopedic injuries — more ankle sprains and broken wrists."

Summer community donors

For hospitals, Maine's summertime influx also represents a larger donor community that adds to the year-round base. Coastal summer communities can be significant players in the financial health of local hospitals, says Michaud.

"There are people of means who have summer homes in those areas, so there's a donor effect," he says. All hospitals have fundraising campaigns, he notes. But in areas like Aroostook County and northern Penobscot County, sustainability remains a struggle that's more significant than for popular summer communities.

"They have donors, but nowhere near what MDI and other coastal town have," Michaud says. "For coastal communities, it's significant."

"Many of our donors are from the year-round community, but many of the large gifts come from the summer community," says Lani Naihe, MDI Hospital's director of advancement. One example is the hospital's new palliative care program, now in its second year. Talks with a previous donor, who is a summer resident, resulted in partial funding for a three-year pilot program from the Atlanta-based Wilbur and Hilda Glenn Family Foundation, which has funded other Maine organizations.

"They're based in Atlanta and summer on the island," says Naihe. "They've slowly developed a relationship with us and have learned about what we're doing. They made an initial investment in our oral health program," a dental center in nearby Southwest Harbor. "They got to know one of our physicians, who was spearheading that project, and he's the same physician who spearheaded the palliative care project."

"It's about the word 'relationship,'" says Blank. "It always goes back to whether the donor is comfortable that the values exemplified in the work that gets done are consistent with their values and what they think is important."

Summer residents in midcoast Maine are eager to ensure their community's health care system is stable, says MaineHealth's Wade.

"A lot of people, whether they're here for three months or for vacation, want to make sure there's good-quality health care in the region in which they're living," she says. "And many are looking to retire here. So they're very much invested in the health care system."

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