Case Study: Ensuring Access By Converting a Hospital to a Freestanding ED

It was January 2016 when Atlanta-based
 SunLink Health Systems informed the community of
 its intention to close North Georgia Medical
 Center in Ellijay, Ga. The Gilmer County Board of Commissioners expressed skepticism and sought assurance that the medical facility would remain. But its members openly believed that the best local residents could hope for was to have the emergency department open for one final year.

Gilmer County has a population of about 29,700. It has a median age of 45.1, significantly higher than the state median of 36.4, and its poverty rate of 23.5 percent is also higher than the state average of 17 percent. Gilmer County ranks highest among Georgia counties for diabetes (12.4 percent), obesity (29.7 percent), smoking (16.9 percent) and deaths by motor vehicle (25.5 per 100,000 residents). In Gilmer County, the largest share of households have a median annual income of less than $10,000.

On March 1, 2016, SunLink closed the NGMC ED. Hospital leaders hoped the closure was temporary but acknowledged that it allowed the medical center to maintain a financial position to continue its mission and provide key services. Hospital leadership had reviewed the proposal and confirmed that it would not create any change to its licensure status. Additionally, hospital leaders confirmed that it would not affect the hospital’s accreditation status with the Joint Commission, which accredits hospitals for Medicare participation.

The change did not affect Gilmer Nursing Home or the physicians based at the Medical Offices of North Georgia. Most hospital services remained the same, including outpatient and inpatient care, surgery, swing-bed rehabilitation and nursing home care. Departments such as laboratory, radiology and respiratory continued to operate and see patients with only a change in the hours that those services were available.

Three months later, in June, SunLink Health Systems closed the facility despite opposition from every government agency in Gilmer County and most of its residents. Its reason for closing NGMC was that expenses exceeded revenue due to low volume, a high public payer percentage and a large increase in charity and indigent care. NGMC had averaged about six inpatients a year. It appeared that Gilmer County residents wanted a hospital but did not use it.

Piedmont Mountainside Hospital Emergency Services

Piedmont Mountainside Hospital in Jasper, Ga., a subsidiary of Piedmont Healthcare and about 20 miles away from NGMC, approached the state with a plan for a freestanding ED and simultaneously began negotiating with SunLink to lease hospital space and assume operation of the Ellijay hospital’s ED, medical office building and community center. PMH agreed to lease the ED for five years and the medical offices for 10 if the state approved the freestanding ED letter of determination.

PMH had established a footprint in Ellijay in 2008 when it opened a cardiac imaging center adjacent to the Piedmont Heart Institute cardiology group. In 2009, it opened an outpatient diagnostic center and in 2011 added MRI services and a sleep center. In 2016, about 27 percent of PMH patients traveled from Gilmer County, so establishing a freestanding ED in Ellijay seemed practical. Despite PMH’s commitment to the community, the uncertainty and public distrust generated by NGMC and an exodus of physicians and clinical staff from the NGMC facility left local residents doubting whether they would have access to necessary care.

Initially, PMH agreed to lease and operate the existing ED upon licensing and approval by the Georgia Department of Community Health, a process that was expected to be completed by Sept. 1, 2016, with the ED reopening by Nov. 1 of that year. Piedmont Mountainside Hospital also would lease the Medical Offices of North Georgia effective July 1, 2016.

On May 23, 2016, PMH received approval from the state department of health to move forward with the first freestanding ED in Georgia. Freestanding emergency departments operate as extensions of a hospital ED, providing 24-hour access to emergency physicians, nurses, labs and radiology technicians. They offer many of the same services as EDs that are attached to a hospital, such as moderate-complexity blood testing and advanced imaging, and they care for most emergent illnesses, such as heart attacks, strokes and minor trauma.

PMH proposed its design and then ran a gantlet of bureaucratic and legal obstacles as it crept toward approval. Because it was the first of its kind, multiple state and federal agencies had to conduct their own respective due diligence, a process that involved organizations and requirements including:

  • The state fire marshal.
  • The state architect.
  • A certificate of occupancy.
  • The state board of pharmacy and drug enforcement agency.
  • The state laboratory.
  • A Centers for Medicare & Medicaid Services administrative contractor.
  • State licensure.


In addition, PMH had to respond to challenges from WellStar, a competing provider and the largest health system in Georgia, as well as representatives from the cities of Ellijay and East Ellijay joining an appeal process with Gilmer County commissioners, who remained skeptical of the motives of the new operators. Although they had already approved moving forward in the appeals process, the Greater Gilmer Joint Development Authority took steps toward potential legal action and possible hiring of legal representation. 

Piedmont reached out to David Ralston, speaker of the Georgia House of Representatives, who was born in Ellijay and whose district includes Gilmer County and North Georgia Medical Center. He helped to build trust and bridge the gap in communication between the county and the new operators.

It took 20 weeks to receive approvals from the agencies and clear any legal appeals. Consequently, renovation of the building and construction for the ED began in November — the original goal for the ED opening — and was completed 21 weeks later. That included nine weeks for construction and another 12 weeks for state and federal approvals.

Up and running

On April 3 of this year, the ED opened for patients. It is known as Piedmont Mountainside Hospital Emergency Services. The 24-hour facility houses a CT scanner, X-ray and ultrasound machines, pharmacy and lab. Piedmont hired 35 people to staff the ED.

Since opening, the ED averages about 30 patients a day and in six months’ time has seen more 5,000 emergency visits. Additionally, PMH is working collaboratively with the local Gilmer County EMS/ambulance service to ensure that patients are transported to the most appropriate facility for their care.

As a community-focused hospital, PMH recognized the immediate need and acted to expand its services in Gilmer County and deliver the same level of patient-centered care expected of the Piedmont name. Now, patients in Ellijay who require admission or transfer will follow the same process as they would if they were entering PMH’s emergency room in Jasper.

John Supplitt is senior director of the American Hospital Association’s Constituency Sections.