Health Care Delivery System

The Health Care Delivery System in the USVI was greatly impacted by the effects of Hurricanes Irma and Maria in 2017.  The Charles Harwood Complex on St. Croix was shut down in 2018, and the Governor Juan F. Luis hospital suffered major damages.  JFL struggles to meet the medical needs of population with the displacement of the Emergency Room, one functional operating room at times, limited in-patient services.  As a result of damages to the hospital, some units have been scaled back, relocated, and/or combined (the labor and delivery and postpartum wings were combined).  The hospital hopes to have their modular units operational by 2020.

Schneider Regional Medical Center, the hospital on St. Thomas that also serves St. John in USVI, has resumed operations for most services. Schneider is able to provide surgery, emergency, and ancillary services such as pharmacy, occupational and physical therapy, nutritional services, and radiology. However, hurricane damage keeps the hospital’s 51-bed inpatient unit and its cancer center closed, limiting both inpatient bed capacity and oncological services. The hospital is delivering chemotherapy on an outpatient basis but transporting patients needing radiation to Puerto Rico for treatment. As of late July 2018, all 49 hemodialysis patients who had been medically evacuated from St. Thomas had returned to the island (Kaiser, 2018).

Juan F. Luis Hospital on St. Croix in USVI has two functional operating rooms, down from six, and is able to provide only emergency surgical services a year after the hurricanes. The hospital is in the process of preparing three donated trailers to serve as additional operating units. Due to this limited surgical capacity, non-emergency surgical patients must be transferred to St. Thomas or the continental U.S. for elective procedures. Juan Luis had also evacuated its dialysis patients to the continental U.S. following the storms. As of early September 2018, 21 of these medical evacuees have returned to the island and are receiving treatment from a private provider, while 37 evacuees remain in Atlanta, Georgia. Temporary trailers for dialysis services have faced construction delays but now target a completion date of October 2018 (Kaiser, 2018).

Both Schneider and Juan Luis hospitals are awaiting the outcome of FEMA’s assessment of their facilities for either repair or replacement. In the February 2018 Bipartisan Budget Act (BBA), the territories received statutory permission to rebuild “critical services,” including hospitals, regardless of their pre-hurricane condition. Under the BBA permission, the USVI hospitals may be able to rebuild to a higher standard than their pre-hurricane facilities if the FEMA assessments call for complete replacement. However, since rebuilding can only commence after a final assessment from FEMA that a facility cannot be repaired, the USVI hospitals have employed short-term mitigation efforts to support delivery of services while they await permanent solutions (Kaiser, 2018).

USVI’s clinics vary in operability and capacity. Myrah Keating Smith Community Health Center on St. John, part of the same health system as Schneider Regional Medical Center, was still closed as of July 2018 as it awaits federal assessment of its damage. Patients are receiving services from temporary trailers, although capacity is limited. Frederiksted Health Care, a nonprofit primary care clinic on St. Croix, has resumed delivery of all of its health care services but operates with a smaller staff, particularly for behavioral health and dental services. The clinic reported an increase in overall patients due to the limited capacity of Juan Luis and the outmigration of some private providers. More broadly, the USVI Department of Health has faced challenges delivering public health services such as immunizations, dialysis, and emergency care due to shortages in staff and functional facilities. The Department is continuing work to acquire hard-sided modules as a temporary solution to expand capacity (Kaiser, 2018).

Historical Overview

The Virgin Islands health care system consists of two semi-autonomous hospitals, nursing homes, outpatient clinics, home health care services, hospices, providers, and health educators among others. As a public health department, the goal is to improve the health status of every Virgin Islands resident and to ensure access to quality health care. This includes helping each person live a life free from the threat of communicable diseases, tainted food, and dangerous products. To assist in this mission, activities include regulation of health care providers, facilities, and organizations, and management of direct services to patients where appropriate.

The VI Department of Health (VIDOH) serves the community as both a local and state health department. It consists of two major divisions – Public Health Services and Health Promotion & Statistics. Unlike other state health departments on the U.S. Mainland VIDOH provides health services in three community health centers territory wide. In addition, the department has nine boards that license and regulate health care professionals. The central office is located on St. Thomas.

The Department of Health’s mission is to provide quality health care, regulate, monitor and enforce health standards to protect the public’s health. This is achieved by openly communicating with the public, informing them of health care options, thus serving as a catalyst to assist them in making educated choices on receiving the highest quality of health care. As mandated by Virgin Islands Code, Titles 3 and 19, the Department of Health (DOH) has direct responsibility for conducting programs of preventive medicine. The agency is committed to building a sound policy and program infrastructure through employing providers and administrators from every aspect of health care.  The Department is the sole state agency responsible for coordinating and providing a focal point for territory wide public health efforts on behalf of Virgin Islanders and visitors to the territory.

Statutory Authority: The Department of Health functions as both the state regulatory agency and the territorial public health agency for the U.S. Virgin Islands. As set forth by the Virgin Islands Code, Titles 3 and 19, the Department of Health (DOH) has direct responsibility for conducting programs of preventive medicine, including special programs in Maternal and Child Health, Family Planning, Environmental Sanitation, Mental Health, and Drug and Substance Abuse Prevention. DOH also is responsible for health promotion and protection, regulation of health care providers and facilities, and policy development and planning, as well as maintaining the vital statistics for the population.

DOH provides Emergency Medical Services, issues birth and death certificates, performs environmental health services, and conducts health research and surveys. The Department is also responsible for regulating and licensing health care providers and facilities, and assumes primary responsibility for the health of the community in the event of a disaster.

The department employs providers and administrators from every aspect of health care, and manages several programs, both federal and local; to meet the needs of the community it serves.

Services are focused towards accomplishing the Department’s aim and are administered by 34 activity centers under the following four (4) divisions:

* Office of the Commissioner

* Division of Fiscal Affairs

* Division of Administrative Services and Management

* Preventative Health Services

The department includes three health care facilities, two district offices and field offices, as well as the central office, located on St. Thomas. Public Health Services and Health Promotion & Statistics reach out to many vulnerable residents, including those suffering from HIV/AIDS, mental illness and alcohol and drug dependency. The Bureau of Health Insurance and Medical Assistance Program assists those who cannot afford to pay for needed medical and prescription services.

DOH is a critical component of the Virgin Islands Territorial Emergency Support Function-8. Under ESF-8, DOH directs the provision of health services for the Territory in the event of a natural or manmade disaster such as bioterrorism. This role includes coordinating and managing territorial resources to assist victims affected by a disaster.

The overall mission of VIDOH is to reduce health risks, increase access to quality health care and enforce health standards. The five major performance goals guiding the department encompass all legal mandates as spelled out in the V.I. Code. These goals also address the focus areas for achieving the department’s mission.

• Improve health outcomes and access to quality health care

• Provide health education, health promotion and community-based programs

• Enhance mental health and substance abuse services

• Achieve excellence in management practices

• Enforce laws and implement rules and regulations

 The three main facilities for primary care services are MCH & CSHCN Clinics, PHS 330-Community Health Centers, and hospital-based Community Health Clinics. On St. Thomas MCH’s principal facility is located in the western district, the Community Health Clinics at the Roy L. Schneider Hospital serve the mid-island district, and the East End Health Center is located in the east district.  On St. Croix, the Frederiksted Health Center is located in the western end of the island, and the MCH & CSHCN principal facility is located in the east at Charles Harwood Complex.   On Cruz Bay, St. John, the Morris De Castro Clinic is the site for the MCH & CSHCN monthly Infant/Pediatric high-risk clinic. 

Hospitals: The two public hospitals are under the management of a Territorial Board and two District Boards established under Bill No. 20-0366. The Schneider Regional Medical Center (SRMC) is the umbrella entity for three facilities under one health care system on St. Thomas. The Roy Lester Schneider Hospital (RLSH) is a 169-bed acute care facility located on St. Thomas. Since 1982, it has served the residents of St. Thomas and nearby St. John, St. Croix residents who have required its services, as well as 1.2 million visitors who arrive by air and cruise ships each year. Meeting the health care needs of its community has required constant expansion of medical services, and recruitment of highly qualified and board certified medical professionals. The hospital is a popular provider of choice for the USVI community, and, given the services now offered, it is the convenient option for many patients from throughout the Eastern Caribbean region who are referred here for treatment. As a Joint Commission accredited facility, RLSH is committed to maintaining a superior standard of performance in all areas. Staff education and training are continuous, and an organization-wide focus on coordinated customer service is maintained.

Myrah Keating Smith Health Center: Located on St. John, this center serves as an ambulatory facility. In 1999, management of this facility was turned over to the Roy L. Schneider Hospital and the Hospital’s Board. The Center is the island of St. John's only 24-hour outpatient health center that offers primary and preventative care health services. This facility also provides services in women's health, high-risk OB/GYN, well woman examinations including PAP smears, complete pelvic exams, pre and post-natal care. well baby care, immunizations, minor surgery, and community education programs. The facility is staffed to provide many other services, including adult medicine, radiology, opthalmology, laboratory, and nutrition counseling.

The Charlotte Kimelman Cancer Institute is a patient centered, 24,000 square foot state-of-the-art, comprehensive cancer center which provides a range of comprehensive out-patient diagnostic and treatment services, combining clinical, research, educational, and patient support under one roof. Oncology services include radiation therapy, chemotherapy, and pediatric oncology. CKCI’s diagnostic capabilities include Interventional Radiology, Nuclear Medicine, CT Scan, Mammography, and Diagnostic Pathology. CKCI’s resources are made available for community use, as well, as part of the strategy to educate the community, and to promote greater public awareness of cancer prevention and treatment methods.

The Governor Juan F. Luis Hospital and Medical Center, located on St. Croix US. Virgin Islands is a 188 bed facility. As the only full service hospital, it offers acute emergency and ambulatory care in a wide range of services including, general and specialty medicine, surgery, pediatrics, obstetrics, gynecology, psychiatry, physical medicine, hemodialysis and others. The facility is accredited by the joint commission on the accreditation of health care organizations (JCAHO), certified by the Center for Medicare and Medicaid (CMS), a member of good standing with the National Association of Public Hospitals and American Hospitals Association. The hospital pharmacy and blood bank are licensed by the Drug Enforcement Agency and the Pathology and the Clinical lab are also certified by JCAHO.

330-Funded Community Health Centers: An affiliate agreement was signed by the Governor of the Virgin Islands, which placed the governance of the health centers under the authority of governing boards. The health centers are incorporated as not-for-profit entities. Both 330 centers are private corporations independent of the Department of Health.

The Frederiksted Health Center, (FHC), serves approximately 25,000 (USVI 2000 Census tract) on the western side of St. Croix. Adjacent to FHC is the Ingeborg Nesbitt Urgent Care Center (INC), which provides walk-in services to patients of all ages. Critical patients are transferred to the Governor Juan F. Luis Hospital and Medical Center. Laboratory services and pharmaceutical services are provided on site. FHC services include: Family Practice, Family Planning, Prenatal, Pediatrics, Women's Health, Social Services, and Immunizations.

The facility is partially federally funded under a Section 330 Rural Health Initiative and Ryan White Title III - Early Intervention Services Grant Program through the U.S. Public Health Service and partially locally funded through the Virgin Islands Government to provide accessible, quality, primary health care for the people of Frederiksted and the identified surrounding residential areas. The facility serves Medicaid (MAP), Medicare, third party Insurance, self pay and indigent clients.

The St. Thomas East End Medical Center (STEEMC), on St. Thomas, serves the medically under-served population of approximately 24,000 on the heavily populated eastern end of the island. STEEMCC provides a cadre of services for its patients but its main focus is on providing primary and preventive health care. These services include, but are not limited to, medical primary care, walk in services, oral health, psychiatric referrals, HIV testing and counseling, pediatrics and prenatal care, hypertension, cholesterol and diabetes screening and counseling, family planning services, breast and cervical cancer screening and prostate testing. Ob-Gyn care includes gynecological care, prenatal care, antepartum fetal assessment, referral for ultrasounds, genetic counseling and testing, and postpartum care. Oral health care services include preventive, restorative, and emergency based on availability of providers.

Community Health Clinics: The Community Health Centers conduct comprehensive programs of preventive and curative medical care by means of direct clinical services. The St. Thomas Community Health Clinic is located at the Roy Lester Schneider Community Hospital. This clinic provides prenatal, gynecology, family planning services, and pediatric services. On St. Croix, the Community Health Clinic is located at the Charles Harwood Complex. Services include eye clinics, diabetic clinic and primary care for adults. This activity center screens, diagnoses and treats patients with medical problems such as diabetes, hypertension, cardiovascular disease and arthritis. Sub-specialty clinics which provide services in neurology, urology, podiatry, orthopedics, minor surgery, wound management and allergic/dermatologic disease are conducted.

Emergency Medical Services: The Emergency Medical Services (EMS) is the agency charged with the provision of pre-hospital emergency medical care. Inter-island patient transfer services between St. Croix - St. Thomas and Puerto Rico or the continental United States are privately arranged. Patient transfer services between St. John’s Myrah Keating Smith Clinic and St. Thomas Roy Schneider Regional Medical Center are via EMS Ambulance Boat. This agency is responsible for management of the ambulance system, and participates in the delivery of emergency care within the hospital emergency department and the Health Department clinics. EMS provides training for all health care providers, Physicians, Nurses, EMTs and Paramedics. Their training including Pediatric Advanced Life Support (PALS), Advanced Cardiac Life Support (ACLS), Emergency Vehicles Operators Course (EVOC), and Basic Cardiac Life Support courses for the public. The Virgin Islands Emergency Medical Service is a franchise of the American Heart Association.