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HEALTH BUSINESS

Cape Cod Hospital Settles Medicare Suit for $24.3M

Whistleblower cardiologist Richard Zelman will receive $4.36 million

By Christine Legere May 22, 2024

HYANNIS — Cape Cod Hospital has agreed to pay the federal government $24.3 million to settle allegations that it knowingly submitted hundreds of Medicare claims between 2015 and 2022 for transcatheter aortic valve replacement (TAVR) procedures without complying with government protocols for screening patients for the procedure.

The hospital will pay $14,075,983 in restitution and $10,317,524 in penalties over the next 12 months.

The settlement is the result of a suit filed in U.S. District Court in Boston in July 2022 by cardiologist Richard Zelman, a whistleblower who triggered an investigation by the Justice Dept. into the hospital’s evaluation and reporting practices.

Zelman filed suit under the False Claims Act, which allows private citizens to sue on behalf of the United States to recover money that was fraudulently obtained. He will receive 17.5 percent of the settlement money, or $4.36 million.

TAVR procedures became available at Cape Cod Hospital in 2015 for patients suffering from a serious condition that restricts blood flow from the heart to the rest of the body. The procedure involves replacing the damaged valve causing the problem with an artificial valve.

Federal investigators found that not enough doctors had examined each patient’s suitability for the procedure to meet Medicare requirements, and that physicians didn’t document and share their evaluations with the medical team responsible for performing the procedure.

“Medicare permitted coverage for this newly developed cardiac procedure only under certain conditions to ensure patient safety,” said Joshua Levy, acting U.S. attorney for the District of Massachusetts, in a written statement. “Cape Cod Hospital ignored those rules and received millions from Medicare to which it was not entitled. This conduct persisted for years despite internal warnings.”

Levy said the investigation and settlement “ensure that patient safety is prioritized over a hospital’s bottom line.”

False Claims Act

According to an online written explanation of the False Claims Act by Bryan Lemons, a senior legal instructor at the Federal Law Enforcement Training Center, a private citizen or “relator” can file a claim on behalf of the U.S., which the government then investigates. The government may opt to assume primary responsibility for the case in what is known as a “qui tam” action, or allow the relator to conduct the lawsuit.

In either case, the relator is entitled to a portion of the proceeds recovered by the lawsuit.

According to the settlement agreement, Cape Cod Hospital employed its own interventional cardiologists (including Zelman) but contracted with Brigham and Women’s Hospital to provide cardiac surgeons for procedures including TAVR. Cape Cod Hospital billed Medicare for the facility fee and the services of its staff, while Brigham and Women’s Hospital billed for the work of the surgeons.

The Independent reported in 2022 that Zelman had approached Brigham and Women’s with a list of concerns about its surgeons in October 2021, and that the Brigham had conducted a review of all the TAVR procedures its surgeons had performed at Cape Cod Hospital shortly afterward. In June 2022, Brigham and Women’s reimbursed Medicare for all payments it had received for the TAVR procedures its surgeons had performed at Cape Cod Hospital.

Meanwhile, Cape Cod Hospital did its own review of payments it had received for a sampling of 90 TAVR procedures and concluded that only four out of the 90 did not comply with Medicare’s standards for reimbursement. The hospital refunded the government for the four improper submissions.

When federal investigators reviewed 105 of Cape Cod Hospital’s reimbursement submissions, however, they concluded that more than half of the sample did not comply.

Based on that sample, federal investigators argued that at least half of the 800 reimbursement requests for TAVR procedures Cape Cod Hospital had submitted between 2015 and 2022 were not compliant.

Reactions to the Settlement

The Independent could not reach Dr. Zelman for comment.

In a statement posted to his website, Zelman’s attorney, Gregg Shapiro, wrote, “We understand the settlement amount represents the largest-ever False Claims Act recovery from a Massachusetts hospital.”

Asked for further comment, Shapiro said, “Dr. Zelman appreciates that the government conducted a thorough investigation and achieved a successful resolution.”

Cape Cod Hospital is part of Cape Cod Healthcare, which also owns Falmouth Hospital, six urgent care centers, a network of primary care and specialist practices, and home care and hospice programs.

The Independent asked Michael Lauf, president and CEO of Cape Cod Healthcare, to comment, but instead a spokesperson sent a statement from Cape Cod Healthcare: “The settlement contains no allegations or admissions that patients who received TAVR procedures at Cape Cod Hospital were harmed or that Cape Cod Hospital billed Medicare for procedures that were not performed or were not clinically indicated,” the statement said.

The statement went on to say that “many of the individuals who provided the services at issue are no longer employed or contracted to provide services at Cape Cod Hospital.”

Cape Cod Healthcare’s board chair, Bruce Johnston, sent a statement on behalf of the board: “Though it is unfortunate to be in this situation, the Board of Trustees remains confident in and supportive of the organization’s leadership. During Michael Lauf’s tenure, Cape Cod Hospital has been recognized numerous times for its excellent care and has significantly enhanced its operational and financial position.”

The board’s statement continued: “Under Lauf’s leadership, Cape Cod Hospital has grown both in reputation and in size and now eagerly anticipates the opening of the Edwin Barbey Patient Care Pavilion, which will house a new cancer center, consolidate the hospital’s cardiology programs, and add 32 more medical/surgical beds to address increasing demand.”

The Other Lawsuit

Zelman had been medical director of Cape Cod Hospital’s Heart and Vascular Unit and had also sued the hospital in Barnstable Superior Court in December 2022, alleging he had been improperly fired in retaliation for whistleblowing. Zelman’s concerns in that lawsuit were not limited to the TAVR procedures and included an allegation that Lauf had directed the hospital to prioritize private insurance patients over “managed care” patients, including those on Medicare and Medicaid, when it came to the allocation of new cardiac “sentinel” devices.

According to his lawsuit, Zelman brought that information to a former chair of Cape Cod Healthcare’s board of trustees, who informed the then-current chair, who then held a meeting with Lauf on the subject.

Lauf then agreed to assign the devices to all high-risk patients, including those on Medicare, but went on to retaliate against Zelman, according to his suit.

Cape Cod Healthcare denied that and other claims in Zelman’s December 2022 complaint, and that lawsuit was withdrawn a few months after it was filed.

HEART ATTACK

Cape Cod Hospital Suspends Cardiologist’s Privileges

Dr. Richard Zelman blasts ‘sham peer review’

By Sophie Mann-Shafir Dec 28, 2022

HYANNIS — Cardiologist Richard Zelman, who says he was fired by Cape Cod Hospital after he wrote a letter expressing concerns about patients’ safety and loose credential requirements, has now had his hospital privileges suspended.

Zelman filed suit against the hospital, parent company Cape Cod Healthcare (CCHC), and CEO Michael Lauf on Dec. 6, seeking damages for lost wages and benefits, physical harm, and emotional distress. Zelman said he had been employed by CCHC for 30 years. He was medical director of the hospital’s Heart and Vascular Unit for the last four years.

At the time of his suspension, there were “three patients that I had done complex, critical procedures on that were still in the intensive care unit,” Zelman told the Independent. Another procedure that he was supposed to conduct on the morning of Dec. 22 was canceled because of the suspension, he said.

Zelman circulated his initial letter on Sept. 20 and expressed particular concern about left atrial appendage closures via the installation of a quarter-sized Watchman device, he said. The procedure prevents strokes in patients with atrial fibrillation by preventing clots from entering the bloodstream. It is an elective procedure that entails “significant risk,” Zelman said, “if it’s not done by somebody who has done high volumes and is expert in it.”

Zelman said he objected to the hospital giving credentials to doctors who should not have received them.

Zelman said that the standard recommendation is that “if you haven’t done more than 12 procedures in the last two years that you not be credentialed.” He said it has taken him hundreds of these procedures to feel comfortable conducting the operation, and that the physicians at the hospital who will now be operating without him on staff “haven’t done any procedures in three years.”

On Sept. 29 the hospital offered to renew Zelman’s contract at $1 million per year on the condition that he issue a statement expressing unequivocal support for all of the hospital’s cardiac services, including the one he had specifically expressed concern about, Zelman told the Independent.

Zelman said he refused to write such a letter, and his contract was not renewed. But he continued to see his private-practice patients at the hospital.

At about 5 p.m. on Dec. 21, Zelman told the Independent, he received a call from CCHC trustee Molly Sullivan notifying him that his hospital privileges had been provisionally suspended. Chief Operating Officer Lori Jewett was also on the line, Zelman said.

The suspension means that Zelman is prohibited from entering Cape Cod Hospital in any capacity other than as a patient, he said.

Zelman said he hopes to continue caring for his patients at his office in Hyannis and at St. Elizabeth’s Medical Center in Boston and Beth Israel Deaconess Hospital in Plymouth, where he retains privileges. He said he is applying for privileges at Beth Israel Medical Center in Boston.

Cape Cod Healthcare issued a statement on Tuesday about Zelman’s suspension, saying that the action “was taken independently by the hospital’s medical staff and neither Mr. Lauf nor the hospital had any role in the process, deliberations or final decision.”

The statement continued, “While Dr. Zelman will likely characterize this latest development as further retaliation against him, the facts will show that it has been Dr. Zelman’s own actions that gave rise to the decisions which he seeks to legally challenge.”

Dr. Nate Rudman, chief of emergency medicine at Cape Cod Hospital, confirmed on Tuesday that the medical staff had met and voted to suspend Zelman. Rudman also issued a letter defending Lauf, referring to him as an “outstanding leader,” and maintaining that “there has never been a single instance where any one of us has been asked to do anything other than to act in our patients’ best interest.” The letter was signed by 25 other physicians — all but two of the doctors in the hospital’s emergency department.

According to Zelman, the suspension of his hospital privileges was the result of a “sham peer review.” Those on the review committee, he said, were afraid of losing their jobs, and the review in this case was used to silence his concerns about “excessive surgical mortality.”

Zelman said that the death of a “low-risk patient” occurred in October and that he believes it could have been prevented had his concerns been taken seriously.

Dr. Lawrence McAuliffe, a CCHC cardiologist and former colleague of Zelman’s, told the Independent that he was “very supportive of Zelman, his skills, his vision, energy, his patient care. I think it’s a terrible loss.”

Zelman said there are hospital bylaws that “stipulate that they cannot provisionally suspend privileges unless the physician is an immediate threat to patients or other individuals.” He maintained that the hospital administration believed his Sept. 20 letter posed “economic harm to physicians.”

“They say I’m disruptive because I speak out,” Zelman said. “Well, I’m the same person I’ve been for 30 years.”

Zelman said that other doctors have been fired by Cape Cod Hospital, have been involved in lawsuits, and have accepted hefty settlements. “I’ve been the one person so far that’s not been willing to accept a million-dollar contract to buy my silence,” he said.

Zelman said he spent last weekend working in Florida to “maintain an income to afford lawyers and protection.”

COURT REPORT

Doctor Sues Cape Cod Hospital

Cardiologist claims he was fired for blowing whistle on poor care

By Christine Legere Dec 14, 2022

BARNSTABLE — A prominent cardiologist says he was fired by Cape Cod Hospital after reporting his concerns about poorly done heart surgeries and cost-saving practices that compromised patients’ health.

Dr. Richard Zelman, who was medical director of the hospital’s Heart and Vascular Unit for the last four years, has filed suit in Barnstable Superior Court claiming he was unlawfully fired by officials of Cape Cod Healthcare, the nonprofit that operates both Cape Cod and Falmouth hospitals. Zelman says he should have been protected by the health care whistleblower statute.

A cardiac interventionist who performs procedures like angioplasty and stenting but not surgery, Zelman seeks damages for lost wages and benefits, physical harm, and emotional distress in his Dec. 6 filing. He requested a jury trial.

In a written statement to the Independent, Zelman said that during his long career he has been instrumental in bringing advanced cardiac care to Cape Cod and has been dedicated to providing the same high-quality outcomes and safety that patients expect to receive in Boston.

“Unfortunately over the past five years, there has been inadequate oversight by the hospital administration, and problems have occurred that in my opinion have led to serious patient consequences,” Zelman said in the statement. His concerns were ignored, he said, and resulted in retaliation against him.

Zelman has sued Cape Cod Hospital, Cape Cod Healthcare Inc., and Michael Lauf, the company’s president and CEO.

Under Lauf’s leadership, Zelman argues, the organization “placed profit above all else, including prioritizing revenue generation over patient safety and public health, and frequently retaliated against health care whistleblowers,” according to court documents.

Cape Cod Healthcare issued a statement denying the claims made in Zelman’s complaint “and in particular denies any allegations of retaliation against him for raising patient safety issues or that the hospital failed to take action, when appropriate to continue to improve the quality of the hospital’s cardiac care and services.”

Court documents show that trouble between Zelman and Lauf started in 2019, when the CEO acquired a limited number of cardiac sentinel devices, used in some valve replacements to filter out stroke-causing debris. Lauf prohibited the use of the devices on “managed care” patients such as those on Medicare and Medicaid, preferring patients whose insurance reimbursed at higher amounts, says Zelman in his suit.

Zelman says he believed Lauf’s actions violated professional standards of practice and expressed his concern to the CEO, who he said “angrily castigated” him and threw him out of his office.

Zelman then brought his concern, he says, to a former chairman of Cape Cod Healthcare’s board of trustees, who in turn raised the issue with the board’s current chair who then met with Zelman. Lauf then agreed to acquire devices for use on all high-risk patients, including those on managed care, according to the suit — but he retaliated against Zelman.

At Lauf’s direction, Zelman claims, hospital officials attempted to intimidate him, “threatening to destroy his career and reputation for bringing patient safety concerns to the Board.”

Lauf chastised Zelman in a group meeting for whistleblowing to the board and told him he would be fired if he did it again, according to Zelman’s complaint.

Then, in 2021, Zelman reported to Lauf and other hospital officials what he believed were dangerous practices by the two cardiac surgeons at the hospital. His concern was based on three postoperative deaths and a fourth patient being placed on extended life support following bypass surgery. All the patients had been considered low risk and were expected to have uncomplicated surgeries.

Zelman also cited two failed valve repairs in young patients and the death of a young patient being transferred to another hospital on life support when a tube, sutured in place by one of the cardiac surgeons, fell out en route.

In his response to Zelman, Lauf reminded him that supervision of cardiac surgeons was not Cape Cod Hospital’s responsibility because they were hired by Brigham and Women’s Hospital under a contractual relationship with Cape Cod Healthcare.

Lauf and hospital officials refused to remove the two surgeons, “citing the potential of substantial lost revenue,” according to the court documents. Promises to improve oversight of the two were not honored, Zelman argues.

In October 2021, Zelman took his concerns to Dr. Ralph Bueno, Brigham and Women’s chief of thoracic and cardiac surgery, who promised to send more experienced surgeons to oversee the surgeons at Cape Cod Hospital. Zelman reported to Bueno a few weeks later that “cardiac surgical outcomes appear to have deteriorated,” and he and his fellow cardiac intervention doctors had become “largely reluctant to refer cases directly to either surgeon.”

Ultimately one of the two surgeons was fired for showing up at the hospital with an automatic rifle.

Brigham and Women’s no longer has a contract with Cape Cod Healthcare. Cape Cod Hospital is now affiliated with Beth Israel Lahey Health.

Contacted by the Independent, a Brigham and Women’s spokesperson said the hospital was aware of the suit. “We are reviewing what was filed and evaluating the merits of the connection to Brigham and Women’s Hospital that were made by this individual,” said communications specialist Aaron Sanborn in an email.

Tensions escalated further in November 2021 when Brigham and Women’s reported billing irregularities to the Centers for Medicare and Medicaid Services, arising from the failure of its cardiac surgeons at Cape Cod Hospital to properly document valve replacement procedures. Such deficiencies can result in mandatory refunds of federal reimbursements.

In June 2022, the Brigham issued a full refund to the Centers for Medicare and Medicaid Services for reimbursements related to valve replacement procedures at Cape Cod Hospital for the previous six years. The Boston hospital’s refund “increased the risk that CMS would require Cape Cod Healthcare to issue a similar refund,” says Zelman’s suit. According to court documents, a hospital attorney told Zelman that the Brigham’s decision to self-report the irregularities was based on a fear that “Zelman would become a whistleblower or words to that effect.”

On June 13, Lauf notified Zelman that his employment would end in September, at the expiration of his contract.

According to the documents, Lauf was willing to continue Zelman’s employment if Zelman provided a written statement endorsing the quality of cardiac programs at the hospital. While it represented a million-dollar contract, “no amount of money was going to buy my silence,” said Zelman in his statement to the Independent.

While Zelman is no longer employed by Cape Cod Hospital, he continues to hold medical staff privileges and can perform cardiac procedures as a private practitioner, according to a hospital spokesman. But Zelman maintains in his suit that he continues to experience harassment.

Brian O’Malley, a retired doctor who lives in Provincetown, said of Zelman, “He is someone I trust and has one of the best records in the country.” He added that there are “good people” on both sides of the case.

“I don’t put it personally on Mike Lauf,” O’Malley said. “It’s the way the system is structured these days. It’s a business, and hospitals are treated as independent competitors in the marketplace.”

The steep drop in elective procedures due to Covid has strained hospital finances, said O’Malley. Emergency rooms are meanwhile overwhelmed with patients with mental health and substance use disorder issues, he said.

HEALTH CARE

Need for Rooms at Cape Cod Hospital Exceeds Capacity

Patients face difficult choices about elective surgeries

By Jasmine Lu Dec 22, 2021

HYANNIS — Cape Cod Hospital has been dealing with a triple threat: a recent swell in incoming Covid-19 patients, a backlog of inpatient discharges, and a pandemic-driven staffing shortage.

The fact that these challenges are faced by hospitals across the state prompted the Mass. Dept. of Public Health (DPH) on Dec. 15 to advise facilities to cut back on nonessential elective procedures by half. But last week, when Cape Cod Hospital’s inpatient population swelled past its maximum capacity, officials here opted to cancel elective surgeries altogether on Dec. 16 and 17.

Over the weekend, patient volume dipped, said Patrick Kane, senior vice president of communications for Cape Cod Healthcare, which owns the hospital, in an email. “All cases are back on the books for this week,” he wrote on Monday, Dec. 20.

The next day, however, the statewide swell in Covid-19 cases pushed the DPH to update its strategy. Effective Dec. 27, “all hospitals are directed to postpone or cancel all nonessential elective procedures likely to result in inpatient admission in order to maintain and increase inpatient capacity,” said Gov. Charlie Baker at a Dec. 21 press conference.

The hospital on Tuesday would not confirm whether another round of cancelations was slated post-Dec. 27. Hospital officials were “digesting” the new state guidelines, according to Dr. William Agel, the chief medical officer. “But we’ve been dealing with this for 21 months,” he added. “We’ve gotten pretty good at adjusting our schedules accordingly.”

The hospital uses a scoring system that ranks cases based on the level of attention each one is likely to need from staff. Urgent procedures, like the removal of a diseased gall bladder or a cancer surgery, would fall in the “nonelective” category. Certain cosmetic procedures and joint replacements, by contrast, verge more on “elective” and so are more likely to be delayed.

In between, there are cases that don’t fit neatly into either category, such as neurosurgery procedures for chronic back pain.

“It depends on the level of discomfort and the level of disability the person has,” Agel told the Independent. In these cases, he said, patients and their physicians need to discuss whether alternatives to surgical intervention, like continuing physical therapy, could be appropriate in the interim.

“It’s hard to tell someone that their pain is ‘elective,’ ” Agel said. “It requires a frank and honest conversation between the surgeon and the patient. Some folks have been waiting a while to begin with, so they’re usually a little disappointed because they’ve made some preparations. But our patients understand we’re in the middle of a pandemic.”

Exceeding Capacity

The Cape Cod Times reported last Friday that Cape Cod hospital had admitted 20 patients more than the 259 beds prescribed by its license, placing these people in surge areas. Meanwhile, Falmouth Hospital, with 95 beds, was operating at 85 percent capacity.

While the surge in Covid-19 cases has added new patients to Cape Cod Hospital’s population — as of Tuesday, there were 33 Covid-19 patients in the hospital, two of whom were in the ICU —the facility has also been managing the care of numerous non-Covid-19 patients needing longer stays before being discharged.

“In terms of what kinds of illnesses we’ve been seeing, it’s been acutely exacerbated chronic diseases,” explained Agel. “These are people with heart disease who may have put things off. Or people with diabetes who maybe didn’t take care of themselves during the pandemic. And then, there’s also the consequences of prolonged social isolation, like depression.”

When discharges do occur, some patients need to be transferred to a skilled nursing facility — where they encounter another widespread problem: a health care staffing crisis, driven by the pandemic.

“With the current labor shortage, those nurses just aren’t available,” Agel said. “So, you have some patients who end up staying in the hospital, just waiting for those nursing facility beds.”

Mass. Health and Human Services Secretary Marylou Sudders in a Dec. 21 press conference put it this way: “There remains a critical staffing shortage in many jobs and many roles to meet the needs of our patients.”

With workers nationwide leaving health care, Cape Cod Hospital is grappling with staffing shortages of its own.

“These are people who don’t want to be exposed or get overrun by 40 or 50 sick patients, so they’ve said, ‘It’s too much. I’m going into another business,’ ” Agel told the Independent. “That’s really what’s hurting us.

“Last I checked, we were at about 500 openings,” he added, “which is about 10 percent of our workforce.”

The unfilled positions go beyond the roles of doctors, nurses, and technicians. Cape Cod Hospital has also been searching for people to clean patient rooms, deliver food, work in environmental services, and answer phones at the reception desk.

“We need everything,” Agel said.

In the Emergency Room

Most hospitals, when overwhelmed, go on diversion, directing ambulances to ferry patients to the next closest hospital. Cape Cod Hospital can’t fall back on that option.

“There’s really nowhere to divert to,” said Mary Johnson, who has served as the hospital’s associate vice president of nursing and emergency services since 2020. “We just use our triage process, and we’ve opened up other areas of the hospital to move admitted patients.”

Johnson aims to get patients who need inpatient care upstairs within four hours following an initial screening in the emergency room. On Monday, Dec. 20, the average wait was 6½ hours.

“Over the last few months, we definitely haven’t been able to move patients through the system as quickly,” Johnson said. “We’re having to use hallway spaces during peak times to see patients.”

For the E.R. staff, a busy hospital means double shifts in personal protective equipment, plus overtime. “Being a nurse, in particular, is not a job — it’s a calling,” Agel said. “The large majority of the staff has said, ‘You know, we’re the safety net hospital for this community.’ They’ve stepped up in ways that put their families’ lives in danger.”

In the midst of crisis, the E.R. has held steady. “We’re a really strong, great team,” Johnson said. “We’re like a family, so we support each other.” If family matters crop up, coworkers offer to pick up extra shifts. “Some registered nurses who moved to administration have come down to help in times of need,” Johnson added.

Looking Ahead

“There’s no question the next few weeks will be enormously difficult for our health care community,” Gov. Baker said at his Dec. 21 press conference.

To support health care workers amid the state’s recent rise in cases, Baker, as of that day, activated 500 members of the Mass. National Guard. Of these, 300 people will be deployed to 55 acute care hospitals and 12 ambulance service providers.

Some Guard members will drive ambulances and transfer patients between hospitals and nursing homes; others will commandeer wheelchairs and stretchers, ferrying patients between the E.R., X-ray rooms, and the inpatient floor. Other roles include providing security support, delivering meals, and observing patients who may pose a risk to themselves.

The remaining 200 Guard members will be providing Covid-19 testing support or administrative support for the deployment or standing by until needed.

This week, the Guard members are undergoing training, and by Monday, Dec. 27, they will be dispatched to their assigned locations. Cape Cod Hospital does not yet have plans to use National Guard troops at this time, according to Agel.

VISITING THE SICK

Hospitals Can Be Flexible on No-Visit Policy

But sometimes you have to fight to get them to do it

By Tessera Knowles-Thompson Dec 17, 2020

Among all the challenges of the Covid-19 pandemic, perhaps the greatest is not being able to visit elderly loved ones. In some cases, Covid patients have died in health-care facilities without family members present.

“It has been one of the most difficult and heartbreaking consequences of the pandemic,” said Chris Hottle, director of the Provincetown Council on Aging.

But the issue of leaving loved ones at the front door of a facility goes far beyond end-of-life separation.

For people with cognitive impairment, for example, including a large population of dementia and Alzheimer’s disease patients, the no-visitor policy at hospitals means that patients lose their spokesperson at a time they need it most. There can be dire medical consequences.

In recent weeks, the number of hospitalized Covid-19 patients on Cape Cod has more than doubled. As of Dec. 13, Cape Cod and Falmouth hospitals reported 37 patients with Covid, eight of whom were in the I.C.U. Less than three weeks earlier, on Nov. 24, there were 15 cases in the two hospitals, and zero in the I.C.U.

For people living with dementia or Alzheimer’s, going to the hospital without a caregiver can be like sending someone to a place where they don’t speak the language, said Melanie Braverman, co-founder of the Alzheimer’s Family Support Center of Cape Cod.

Caregivers of dementia patients are not just visitors, said Alan Johnson, a Provincetown resident and an Alzheimer’s and dementia social worker with Cape Cod Healthcare. Without a caregiver, dementia patients are unable to explain their own medical history, how they feel, or their exact symptoms. Elderly patients often have many pre-existing conditions, making it hard for doctors to know their baseline, he said.

That is why, this spring, at the urging of patient advocates, Cape Cod Healthcare — which operates both Cape Cod Hospital in Hyannis and Falmouth Hospital — broadened its initial Covid-19 policy, which prohibited all visitors, to add special circumstances, including caregivers of patients with dementia or Alzheimer’s, Johnson said.

But now, as hospitals and other health care centers are locking down again, there is confusion about the shifting policies. Johnson said it’s critically important to advocate for your loved ones. Staff members of large medical complexes like nursing homes and hospitals are not always able to keep up with the rapidly changing rules.

Magic Word: ‘Lawyer’

Johnson runs a support group for dementia caregivers. One of his clients reported that she had recently been denied entrance into an emergency room in Brockton with her loved one. She demanded to talk to someone in charge, Johnson said. She was turned down by the first receptionist, but kept pushing, eventually dropping the word “lawyer,” and that made the difference, Johnson said. A higher-up was summoned and she made it in.

lauf — CCHC CEO Michael Lauf received $2.9 million in compensation in 2018.

According to Cape Cod Healthcare’s printed policy, effective Nov. 30, visitors are prohibited at all of CCHC’s 17 facilities, including Cape Cod Hospital. But exceptions include cases when a caregiver is considered “of benefit to either the patient or the provider.” Under this policy, one caregiver is allowed to accompany a patient with cognitive impairment, memory impairment, or dementia.

Although the most recent policy includes some leeway for special cases, visits are not guaranteed. Clinical staff evaluate patient needs for accompaniment on a case-by-case basis, said CCHC spokesperson Christina Peaslee.

The Independent’s senior reporter, K.C. Myers of Wellfleet, experienced first-hand the confusion created by the policy when her mother, Cate, was admitted to the hospital two days before the Nov. 30 policy went into effect. Since Cate has dementia resulting from a stroke, Myers was concerned that, without a familiar voice and face in the room, her mother could get hospital-induced delirium — which had occurred in April when the hospital prohibited all visits.

Hospital-induced delirium is among the most common complications among older patients resulting from hospitalization, occurring at rates ranging from 26 to 94 percent. When it is not addressed, it can result in long-term health problems. People with dementia are more likely to develop delirium while hospitalized. Having a caregiver or family member close can help prevent it.

Before the ambulance arrived on Saturday, Nov. 28, Myers looked at the visitor policy on the CCHC website and called the hospital to make sure she could visit her mother. A nurse told her she would most likely get an exemption under the new policy. The following day, another nurse wouldn’t guarantee she could visit her mother, but told her to explain the situation to the shift supervisor.

On the day the policy went into effect, Myers spoke to the shift supervisor over the phone and was told that neither she nor another caregiver could visit her mother. The policy for accompaniment, she was told, was for patients coming into the hospital for procedures.

Eventually, Cape Cod Hospital staff made a special allowance and a caregiver was allowed to stay with Cate. The nurses were kind and supportive, said Myers, but she had to make multiple phone calls over the course of two hours to make it happen.

A Lack of Training

Johnson said it appears that Myers was a victim of the lack of hospital-wide training about dementia — something that every Massachusetts hospital is required to implement by 2023. According to the 2018 Act Relative to Alzheimer’s and Related Dementias in the Commonwealth, all hospitals are mandated to have an operational plan “for recognizing and managing individuals with dementia.”

“Imagine the number of encounters at Cape Cod Healthcare where people need lab work, or to use the E.R., or hip surgery,” said Johnson, “and every one of those departments is focused on hips or labs and they are not focused on dementia.”

Johnson said the hospital needs to do that training. And, in the meantime, people should know that he and a nurse run a program to help guide and support caregivers. The Cape Cod Healthcare Dementia & Alzheimer’s Caregiver Support Program offers group support session classes, telephone advice, referrals, respite care grants, and counseling sessions.

PANDEMIC

Study Suggests Cape Is More Ready for Covid-19

Two hospitals’ capacity compares well to Boston’s in expected surge of patients

By Devin Sean Martin Apr 16, 2020

Health care facilities around the country are scrambling to deal with the influx of Covid-19 patients, but hospitals on Cape Cod are better off than most.

A recent study by the Harvard Global Health Institute and ProPublica suggests that 40 percent of the American adult population in every community is likely to contract the virus over the next 12 months. The permanent population of Barnstable County as of 2017 was 213,444, according to the U.S. Census. That would mean roughly 85,000 people in the county will contract the virus over the next year.

About one-fifth of those infected are expected to need hospitalization, and about one-fifth of those hospitalized will need intensive care. This means about 17,000 people will seek hospital care in Barnstable County for Covid-19; about 3,400 of them will require an ICU bed.

The average hospital stay for someone infected with Covid-19 is one week, according to ProPublica. These estimates predict roughly 328 people seeking care per week, with 65 needing ICU care.

Cape Cod and Falmouth hospitals have 354 beds between them, according to the American Hospital Directory. In response to the coronavirus outbreak, Cape Cod Healthcare (CCH) has set up three “stand-up” hospitals at Joint Base Cape Cod, the Royal Falmouth nursing center, and the Wingate nursing home in Brewster. Among the three locations, CCH has added 320 new beds.

Both hospitals are running at about 50 percent capacity, according to CCH president Mike Lauf. This means Barnstable County will have about 497 available beds to accommodate an anticipated 328 new Covid-19 patients every week.

For ICU beds, however, the situation is not as reassuring.

Hospitals on the Cape have a total of 34 ICU beds to accommodate an expected 64 weekly patients requiring them. None of the 320 new beds are ICU beds.

The estimated number of weekly patients requiring ICU care does not take into account the fact that Barnstable County has the oldest average age in Massachusetts. About 35 percent of residents are over 60 and more likely to require intensive care should they contract the virus.

Nevertheless, Cape hospitals are better off than elsewhere in Massachusetts.

The Harvard-ProPublica study investigated the preparedness of hospitals in all 306 hospital referral regions (HRR) in the U.S. The Boston HRR includes the counties of Middlesex, Essex, Norfolk, Suffolk, Bristol, Plymouth, Barnstable, and Dukes.

Excluding data from Barnstable County, the Boston HRR is expected to receive about 4,807 coronavirus cases every week for which it has about 2,550 available beds. And Boston needs 5.5 times the number of ICU beds it currently has to accommodate the expected influx of critically ill patients, according to ProPublica.

As of April 9, Cape Cod and Falmouth hospitals had a total of 35 Covid-19 patients, 10 of which were in ICU care.

These figures indicate that the Cape has not yet experienced the predicted surge of patients. But after more than doubling the number of hospital beds on the Cape, the county is far more prepared than other counties if the surge comes.

HEALTH

Come Aboard the Health Bus

New service connects Outer Cape to medical facilities

By K.C. Myers Nov 14, 2019

The Cape Cod Regional Transit Authority, Cape Cod Healthcare, and the Peter Pan bus company have partnered to create a bus route to bring patients from Provincetown to the hospitals and medical centers in the mid-Cape.

The Peter Pan bus service already has two buses scheduled from Provincetown to Hyannis. One leaves Provincetown at 6:30 a.m. and arrives at 8 a.m. The other leaves Provincetown at 1:35 p.m. and gets to Hyannis at 3 p.m.

In partnership with the transit authority and Cape Cod Healthcare, Peter Pan CEO Peter Picknelly has agreed to tweak those routes to make stops at the Outer Cape Health Services clinic in Wellfleet, at the Fontaine Medical Center in Harwich, and then continue to directly to Cape Cod Hospital, said Tom Cahir, executive director of the transit authority.

The program uses the bus services already funded by Mass. Dept. of Transportation and enhances it by offering the stops at the health clinics and the hospital.

Mike Lauf, the CEO of Cape Cod Healthcare, said he is also arranging a voucher program so that patients will not have to pay for the bus rides.

The program is expected to begin by Jan. 1, said Cahir.

Both Peter Pan and Outer Cape residents stand to benefit. Peter Pan hopes to increase ridership, while those living on the Outer Cape can get to specialists in the Hyannis area.

“I believe everyone should have primary care 15 minutes away, specialists should be 30 minutes away and hospitals an hour — that’s how long it takes to get from Provincetown to Cape Cod Hospital,” Lauf said during a Friday public appearance at Outer Cape Health Services.

health

Childbirth on the Edge

For expectant Outer Cape parents, medical options are few

By Susannah Elisabeth Fulcher Aug 9, 2019

Lisa Holmes with baby Elliot Kai — Lisa Holmes with her son, Elliot Kai, in Wellfleet. Now expecting a second child, she braves the August drive to Hyannis for prenatal care. (Photo Justin Lynch)

“Will we make it to the hospital in time?” That’s one of the big questions faced by young families living on Outer Cape Cod and expecting a baby.

As intimidating as Route 6 traffic can be in the summer, it turns out that there are even more daunting issues facing prospective parents here — including a lack of prenatal care and childbirth alternatives and the distance to the nearest neonatal intensive care unit in case of complications.