Four of the 23 hospitals will lose the maximum amount allowed under the federal policy: 1 percent of their base Medicare reimbursements. They are the Hospital of St. Raphael in New Haven, Griffin Hospital in Derby, Masonic Home and Hospital in Wallingford, and MidState Medical Center in Meriden.

Three others will lose close to the maximum amount: Yale-New Haven Hospital, Bristol Hospital and St. Vincent’s Medical Center in Bridgeport, according to data compiled by the Centers from Medicare & Medicaid Services (CMS) and Kaiser Health News.

Eight of the state’s 31 hospitals, including Hartford Hospital, Middlesex Hospital and Backus Hospital, will face no penalty.

The 23 Connecticut hospitals are among more than 2,200 nationwide that will be penalized by the federal government, starting in October, under provisions in the 2010 federal health care law. A total of 278 hospitals nationally will lose the maximum amount allowed; others will lose fractions of 1 percent of their Medicare funding.

Federal officials have been concerned about 30-day readmission rates for patients who are hospitalized for three conditions: pneumonia, heart attacks and heart failure. The health reform legislation allows CMS to withhold a portion of Medicare payments to hospitals that have excessive readmissions, starting with up to 1 percent in fiscal year 2013 and rising to 3 percent in 2015—penalties that could reach millions of dollars for some hospitals.

Because the penalties are based on readmissions between July 2008 and June 2011, officials of many Connecticut hospitals said they had anticipated losing some Medicare funding. Most hospitals in the state have committees working on initiatives to reduce readmission rates, with a focus on improving the transition from inpatient to community care.

At St. Raphael’s, which is merging with Yale-New Haven, Jim Judson, director of quality improvement said in an earlier interview that an interdisciplinary team is working to improve the transition to post-hospital care and is providing patients with easy-to-understand information about the symptoms and care of pneumonia and heart conditions. Judson and other administrators have noted that inner-city hospitals often treat patients with co-morbid conditions that can land them back in the hospital after discharge. Readmissions are counted no matter why the patient returns within 30 days. That means if a patient discharged after treatment for pneumonia returns to the hospital within 30 days with a broken hip, the new admission is counted against the hospital.

Nationally, about 20 percent of hospitalized Medicare patients are back within 30 days, at an estimated cost of $17 billion a year, according to the Medicare Payment Advisory Commission.

Some health care experts have said they expected hospitals that serve large numbers of low-income people to be hit hardest by the penalties, because of problems ensuring that patients follow through with doctors and medication after discharge.  A number of such hospitals show up among the 278 that received the maximum penalty, including, St. Elizabeth’s Medical Center in Boston and Montefiore and Maimonides medical centers in New York.

The other Connecticut hospitals that faced no penalties were: the Hebrew Home and Hospital in West Hartford, Manchester Memorial Hospital, Rockville General Hospital, Sharon Hospital and Windham Community Memorial Hospital.

To read previous report: Hospitals To Face Penalties For Higher Readmissions click here.

“It really was a cesspool,” said Mary Mushinsky, a state legislator from Wallingford and former science educator for the Quinnipiac River Watershed Association.  Mushinsky remembers a river full of old tires, shopping carts and untreated sewage.  “In the old days parents would warn their children to stay away from the river,” she said. “It’s come back in a big way.”

Not far enough, though.

State environmentalists have now taken aim at phosphorous. The Connecticut Department of Energy and Environmental Protection (DEEP) released new limits on phosphorous in 2011, triggering an uproar in some towns along the river that will have to spend millions to meet the new mandates.

Phosphorous, unlike the PCBs, heavy metals and sewage that have historically contaminated the Quinnipiac, is not a public health threat, although it occasionally spurs the growth of toxin-producing blue-green algae.

So why is the state pouring so much time and energy into cleaning it up?

“It’s been an evolution,” said Betsey Wingfield, DEEP’s Bureau Chief, Water Protection and Land Re-use.  “First we got the solids out.  Then we worked on dissolved oxygen and bacteria and heavy metals.  Then it was nitrogen, and now it’s phosphorous.”

DEEP environmental analyst Mary Becker insists that the new focus on phosphorous doesn’t mean that the state is neglecting Quinnipiac’s other pollution problems.  While industrial chemicals remain an issue, tougher regulations, closing factories and remediation have reduced their levels.

Copper levels, for instance, which serve as a marker of industrial processes, have decreased from an average of 9.6 parts per billion (PPB) in 1982 to an average 3.18 PPB in 2011, according to the United States Geological Survey. Companies, such as Solvents Recovery Services of New England in Southington, which sat 500 feet from the Quinnipiac and discharged lead, mercury, PCBs and other toxic chemicals into the river, have shut down.

Toxins remain in the soil and sediment – some PCBs, especially, do not decompose easily and can linger for decades – but state and federal programs are slowly cleaning them up.

“There are still remaining remediation sites along the Quinnipiac, but we have established programs to handle the toxics,” said Becker, who says that these cleanup programs will continue as before, despite the new focus on phosphorous.  “If we want a healthy river, we have to focus on nutrients as well.”

One of the key differences between historical pollutants on the Quinnipiac and phosphorous is their source.  Historically, toxins leaked into the river from hundreds specific “point” sources and more diffuse “non-point” sources alike.  Phosphorous is different.  According to DEEP, 93.5 percent of the river’s phosphorus comes from just four sources: water treatment plants in Southington, Cheshire, Meriden and Wallingford.

While other sources, such as fertilizer runoff, likely contribute to the Quinnipiac’s phosphorous burden as well, it’s clear that the water treatment plants pack the biggest punch, so the new rules hit them hard. Each of the four facilities must reduce their daily phosphorous discharge to .2 PPM per day, except for Meriden, which must get down to .1 PPM per day.

“We want to be good stewards of the Quinnipiac,” said Southington Town Manager Garry Brumback.  “But to go from 2.8 parts per million of phosphorous to .2 parts per million is a $18 million proposition, and we don’t even know if it will fix the problem.”

DEEP scientists argue that their science is sound.  Plants need phosphorous to grow, but excess causes an overgrowth of plants and algae.  By late summer, algae blooms cover the surface of the Quinnipiac like a blanket, making it impossible to canoe or kayak through certain parts of the river. In the fall, when the algae die and sink to the bottom, they consume dissolved oxygen in the water, making it unhealthy for fish, frogs and other river species.

According to DEEP calculations, when a freshwater river reaches an “enrichment factor” of 8.4 – that’s 8.4 times the natural level of phosphorous – algae blooms are triggered.  The Quinnipiac, at about 38 miles long, is one of the worst affected rivers in the state, with an enrichment factor of 31 to 68, depending on sampling time and location.  Getting the Quinnipiac to 8.4 will require a four-to-eightfold reduction in phosphorous.

Meeting the new limits will be expensive.  Reducing phosphorous to .3 or .4 PPM can usually be done with lower-cost chemical or biological methods.  But getting it lower than that requires large, expensive filters usually housed in a separate building.  For the town of Southington, for instance, lowering phosphorous output to .7 PPM would cost about $50,000, according to town manager Brumback, but getting down to the required .2 PPM would cost an estimated $18 million, leading to a 20-23 percent rate increase for consumers.

“Below .2 is where it gets into major money,” said Frank Russo, superintendent at the Meriden Water Pollution Control Facility.  Russo noted that adding phosphorous filters will cost his town $13 million, leading to a 22 percent rate increase for customers.  This would be an especially painful financial burden for Meriden, which just completed a full plant upgrade in 2010, leading to a 27 percent rate increase for customers.

“It’s not like the phosphorous in the water is a health hazard or anything,” said Russo, who noted that their new system has already dropped phosphorous levels in the plant’s effluent by 70 percent.  “Right by the outfall pipe we have 24-inch trout swimming around, the water’s so clear.”

Russo noted that in May, the state passed a law limiting the amount of phosphorous fertilizer that homeowners can use on their lawns.  He and others argue that these new regulations, along with some water treatment control of phosphorous, might fix the river.

Scientists and advocates say this reasoning is faulty, however.

“Partway isn’t good enough,” said Mushinsky. “If the goal is to stop the algae blooms, then we need to respect the science.  And what the science says is that the blooms are triggered by an enrichment factor of 8.4.  There’s no reason to think that the science is not accurate.”

The new rules will be imposed when facilities renew their water permits, though the state will offer them extra time to comply with the new phosphorous rules.  Currently the permits for all four plants are awaiting renewal.  The affected municipalities have formed a coalition to oppose the new phosphorus limits.

DEEP’s Wingfield is sympathetic to the towns’ plight, but noted that the Connecticut limits are generally less strict than those imposed by the EPA in states like Massachusetts and New Hampshire.  She also pointed out that the sewage treatment plants could get financial assistance through the Connecticut Clean Water Fund.  In fact, the town of Cheshire dropped out of the coalition after receiving Clean Water Fund support for their upcoming $32 million treatment plant upgrade, $7 million of which will be for phosphorous reduction.

Even with the new limits, the Quinnipiac has a long way to go before it’s truly clean.

“It’s not like you get the phosphorous turned off and it’ll be perfect.  It’s a long-term project,” said Becker, who calls the Quinnipiac watershed a “challenging” one.

“Someday it would be nice to think about kids going down to the Quinnipiac for fishing and boating, and not being grossed out by algae coming after them like the blob from the deep,” she said.

Indeed, in the 1890s, tourists traveled from across the region to swim at Dossin Beach and enjoy the park at Hanover Pond.

“I’m probably being idealistic,” said Becker, “but I’d like to think that people might be able to use the river in that way again.”

Data compiled in the report by the Commonwealth Fund shows that the state’s three hospital referral regions—Hartford, New Haven and Bridgeport—ranked 255th out of 306 regions in 2010-11 in the percentage of home health care patients whose ability to walk or move around improved. The state also was in the lowest quartile nationally for the percentage of home health patients whose wounds healed or improved after an operation.

And Connecticut ranked in the bottom 25 of the 306 regions on the rate of keeping home health patients out of hospitals. The statewide rate of home care patients with a hospital admission was 33.5 percent—meaning one in three Connecticut home health clients landed in the hospital in 2010-11. The national median was significantly lower: 26.6 percent.

The indicators are recorded by the federal government in an attempt to measure the quality of home health care services provided by licensed agencies across the country.

“Interestingly, many areas in the Northeast—particularly in Connecticut, western Massachusetts and upstate New York—tend to have lower-than-average hospitalization rates among nursing home residents, but have the highest (or worst) rates of hospitalization among persons receiving home health care,” the March report by the Commonwealth Fund says.

Connecticut has a lower-than-average rate of long-stay nursing home residents being admitted to hospitals, according to federal data.

Home health advocates said they are aware that the state’s hospitalization rate is high, and that the mobility improvement rate is low. They said efforts are underway to address those issues, which they attributed to several factors:  Connecticut has an older population of home health clients, high rates of hospital readmissions after discharge, and one of the lowest statewide “length-of-stay” rates for hospice care, meaning sicker patients remain in regular home health care.

“People are going back and forth from hospitals to home health care, from home care to hospitals, before they’re getting into hospice care,” said Tracy Wodatch, vice president of clinical and regulatory services for the Connecticut Association for Home Care and Hospice (CAHCH). “With a chronic population, you will see high rates on some of these (quality) measures.”

Gov. Dannel Malloy’s proposed budget expands efforts to move people out of nursing homes and into home-based care, which is generally less expensive. Among the elements of the governor’s proposal are reducing the waiting list for one of the state’s home care waiver programs; retraining some nursing home staff for home care work; and allowing trained, non-licensed home health workers to administer medications to people at home.

State officials are working to expand the “Money Follows the Person” program, which provides federal money to states for moving patients from nursing homes into residences. Malloy’s plans call for moving 2,250 nursing home patients on Medicaid into residential settings by 2013 and a total of more than 5,000 patients by 2016. To date, about 900 people have participated in the program, said Anne Foley, under secretary for policy and planning for the Office of Policy and Management.

Deborah Hoyt, president of the CAHCH, said the state’s home health providers are “quickly getting up to speed” to handle the increased demand. “When it comes to improving quality measures, we’re ready,” she said.

But she also said some agencies are struggling to make ends meet, as state Medicaid reimbursements have remained flat in recent years, Medicare rates have been cut, and agencies face a workforce shortage. Three non-profit VNA agencies—in Stamford, Wallingford and Greater Bristol—closed within the last year.

“While the industry wants to be part of the solution and work collaboratively across the health care system, we need to make sure the state of Connecticut is not going to cut us so close to the bone that we’re not going to be able to be there,” Hoyt said.

Rebalancing The System

Foley, of OPM, said the governor’s budget includes nearly $2 million targeted to improving the transition to home care — $250,000 for the development of a web-based tool to help people identify home care options;  $300,000 to create a standardized care assessment for people moving out of nursing homes; $400,000 for retraining of workers; and $1 million to help people moving out of nursing homes modify their residences.

Elderly care advocates said addressing the key quality-of-care measures, such as mobility improvement and re-hospitalizations, will require more resources and collaboration.

Julia Evans Starr, executive director of the Connecticut Commission on Aging, said the high hospitalization rate is “an indicator we are definitely tracking. Bouncing back and forth to hospitals is not a good situation.”

She and other advocates said they hoped the lagging home-care measures would not detract from the state’s plans to “rebalance” long-term care—away from institutional settings and toward home-based care.  Starr said the rebalancing could entail the reduction of 7,000 to 9,000 nursing home beds. She said she hoped some of the savings from the shift to home care would be invested back into the home-health system.

“If we’re saving money, that’s wonderful—but let’s re-invest some of that money back into the home and community system. That’s essential,” she said.

Federal data shows that in Connecticut, the New Haven region fared worst in the percentage of home health care patients whose ability to move around or walk improved, with agencies reporting that 49.7 percent of clients showed improvement. The median nationally was 53.4 percent. The state’s average was in the bottom 15 percent of all 306 regions—worse than areas including Boston, Philadelphia and Newark.

All three Connecticut regions also logged higher-than-average numbers in 2010-11 for home health patients being admitted to hospitals. New Haven’s rate was 34.1 percent; Bridgeport’s was 32.5 percent; and Hartford’s was 31.8 percent. Nationally, fewer than 27 percent of home health clients have a hospital admission, the data shows.

Although some hospital admissions are planned or necessary, many stem from preventable events, such as falls or acute exacerbations of chronic conditions. Experts say home health agencies can reduce such adverse outcomes—and costs of care—through proactive needs’ assessments and coordination with patients’ physicians.

Medicare-certified home health agencies, like nursing homes, are licensed and inspected by the state Department of Public Health. But penalties for shoddy care—in the form of consent orders or Medicare terminations—are rare in Connecticut.

Connecticut Community Care, Inc. of Bristol, has run a pilot “care transition intervention” program at the Hospital of Central Connecticut that has reduced hospital readmissions by training patients and their caregivers to better manage health problems at home. That program is now slated to be expanded to nine hospitals.

Wide Swings In Measures

Statewide data from 2008 shows Connecticut ranked 45th of 50 states in avoiding hospitalizations; data from 2007 shows Connecticut ranked 38th in mobility improvements. Those numbers stand in stark contrast to the state’s high rates on other health-quality indicators, including the percentage of adults 50 and older receiving recommended screening and preventive care, and the percent of children 17 and under who have insurance.

Overall, on all 43 indicators measured in the new Commonwealth Fund report, the three Connecticut regions ranked in the top quarter of the 306 regions, with Hartford ranked 18th highest, Bridgeport at 31, and New Haven ranked 44th.

Julie Robison, associate professor at the Center on Aging at the University of Connecticut Health Center, said she could not speculate on why the state fared poorly in some key home health measures. But she said results of a survey of participants in the Money Follows the Person program show “a very much improved quality of life” for people who move from nursing homes into home settings.

She said her main concern was about “barriers” to home care that steer people who don’t need institutional care into nursing homes. Only one in three people who enter a nursing home returns to the community within six months, she said.

An analysis of federal data shows a wide swing in the rates of individual home health care agencies on the mobility and hospitalization measures.

While some agencies reported that fewer than 25 percent of their clients had to be admitted to hospitals, others reported rates of more than 50 percent. Agencies with the highest hospitalization rates included Continuum Home Health, Inc., of New Haven, at 74 percent; Quality Visiting Nurses, LLC, of Watertown, at 60 percent; and Advanced Home Health Care Agency of West Hartford, at 54 percent.

Agencies with the best reported rates of avoiding hospitalizations included: Roy & Aline Friedman Home Care, of Fairfield, at 18 percent for hospitalizations; and BAYADA Home Health Care, of Norwalk, at 21 percent.

Some agency representatives said their high hospitalization rates were driven by the at-risk populations they serve. Continuum has a large caseload of patients with psychiatric needs, while Advanced Home Health takes on patients with complex medical needs.

“We are a small agency,” said Fedor Gitman, director of Advanced Home Health. “Just to survive, we have to be flexible and take on difficult cases.”

Similarly, while three-dozen agencies exceeded the national median of 53.4 percent of patients whose ability to move or walk improved, eight fell below 40 percent. They included Avery Heights Home Health of Hartford, at 22 percent, and Health at Home of Branford, at 25 percent. Some agencies with low rates of mobility serve geriatric patients with advanced, chronic disabilities, their representatives said.

Agencies with the best reported rates of improving mobility included: Stratford VNA, at 62 percent; Visiting Nurse Services of Connecticut, of Bridgeport, at 61 percent; Ledyard Regional Visiting Nurse Agency, at 61 percent; and Equinox Home Care, LLC, of Stratford, at 61 percent.

Then, in 2003, he got the news firsthand—he had both diseases – and began to connect the dots.

“I never had boots on the ground in Vietnam, but I know for a fact that they were spraying Agent Orange” at Udorn base in Thailand, about 10 miles from where Gow was stationed from 1967 to 1969. “A lot of the guys who are sick have filed claims with the VA, but they’ve all been rejected. It doesn’t seem right.”

{media_1}Gow was among about a dozen veterans who met Tuesday in Rocky Hill for an informal discussion of Agent Orange exposure with U.S. Sen. Richard Blumenthal, D-Conn., state veterans affairs Commissioner Linda Schwartz, and Rick Weidman, executive director for policy & government affairs for Vietnam Veterans of America. Blumenthal and Schwartz convened the meeting to begin forming an action plan to help Vietnam veterans suffering from health problems connected to Agent Orange exposure get compensation from the VA.

“The health problems of our veterans who were exposed to substances used in Vietnam, without any real knowledge, are something we should not ignore,” Blumenthal told the group. “This is a step towards educating us to see what we can do.”

The group said that while the VA has taken steps to expand the list of illnesses linked to Agent Orange exposure in Vietnam, the agency has yet to recognize claims from veterans who did not serve in-country, but were exposed to residual toxins in the U.S. and other countries. That issue is of special interest in New England, where many Air Force reservists from Connecticut and Massachusetts flew out of Westover Air Force Base on planes that had been used to spray the herbicides.

A C-HIT story earlier in September examined the claims of Westover veterans who say they suffer prostate cancer, diabetes and other illnesses that they believe are connected to their work on contaminated “spray planes” at Westover.

{media_2}At Tuesday’s meeting, two of those former reservists – Dee Holliday of Windsor Locks, and Archer Battista of Belchertown, Ma.—spoke of the need to spread information about possible exposures to their crewmates who flew out of Westover between 1972 and 1982. They said many veterans have not made the connection between their illnesses and their work on the spray planes.

“More than half of the veterans today who are fighting prostate cancer have no clue that it has anything to do with their service in Vietnam,” said the VVA’s Weidman. “Their families receive nothing, and they have no idea that their spouses died for their country.”

The VVA is pushing for policy changes that would afford all veterans exposed to Agent Orange toxins, regardless of where they served, the same benefits as those who served in Vietnam.

“Just because you weren’t there when they were spraying doesn’t mean you weren’t exposed,” said Schwartz.

Schwartz told Blumenthal that she would like Connecticut to establish a “health registry” for all state veterans that would catalogue which veterans are sick with which illnesses, in the hopes of identifying clusters or trends.

Weidman said his group also is hoping to catalogue exposures to Agent Orange outside of Vietnam, in order to make its case to the VA. He said the federal government prefers to “add people in small chunks” to VA’s benefits’ caseload, “so you don’t have to go to the Senate for a big amount of money… If you add incrementally, then there’s not an explosion.”

Blumenthal said he planned to meet with more veterans around the state to discuss possible policy changes that could assist the veterans in receiving compensation.