Hospital leaders gave themselves a checkup this week, and while no crisis was detected, there was a prescription - for more work.

Indeed, in four separate presentations at Wednesday night's public forum, leaders of the Martha's Vineyard Hospital and Windemere Nursing and Rehabilitation Center laid out the fiscal realities and called for more lobbying to gain status as a critical access hospital, more fundraising, more streamlining of the operation and more efforts to build an Island-based work force of trained nurses.

On the topic of spending Island tax dollars to subsidize the hospital emergency room, the head of the Dukes County Health Council, Cynthia Mitchell, explained changes in the plan that could see public funds being devoted to more than just emergency services and specifically earmarked for patients with financial need.

Over the last year, voters were asked to support the concept of an intermunicipal agreement that would funnel $500,000 a year in public funds to the private hospital. According to the plan, the towns would commit the funding and then advertise for providers to offer the emergency medical services. Most likely, the Martha's Vineyard Hospital would be the only provider to bid, and the public money could help fund the emergency room.

Edgartown and Chilmark voters have agreed to fund the plan. At least five of the six Island towns must commit to the funding for it to take effect.

With the changes approved earlier this month by the county health council, the new plan could center on a concept of charity care, under which state law would allow towns to give money to the hospital without going through the complex procurement process, according to Mrs. Mitchell. That change could also make towns eligible for a 50 per cent reimbursement of funds from both state and federal programs.

Still, Mrs. Mitchell boiled the whole issue down to a few questions that still need to be answered if Islanders are expected to embrace the plan. "Some voters are confused. They don't understand the terminology," she said. "They want to know, should I vote money for the hospital? Do they really need it, and will the ER be there when I need it?"

Hospital chief executive officer Kevin Burchill began to answer some of the those questions when he explained that the emergency room cannot operate at a break-even rate with roughly 12,000 visits a year. But he added that the losses have been trimmed from $900,000 to about $500,000 annually.

"What we are left with is a gap," he said. "That's the gap that this proposed intermunicipal agreement attempts to bridge."

The bottom line would be improved if hospital leaders are sucessful in their quest to get status as a critical access hospital (CAH). With higher reimbursement rates, the hospital could see another $300,000 to $500,000 in revenue each year, according to Mr. Burchill. But pursuing that status has already taken more than a year of lobbying. Without being specific, Mr. Buchill said, "CAH is right around the corner."

With the hospital's fiscal year ending on April 1, chief financial officer Tim Walsh offered a peek into how the institution fared over the last year. In raw numbers, the first 11 months of the year saw 817 in-patient admissions, a decline of six per cent from the previous year. The hospital, he said, generated about $34 million in revenue. But after operating expenses, the losses totaled $330,000 for the year. That deficit was offset by fundraising, which topped out at at some $1.3 million, meaning the hospital ended up in the black with a gain of $1 million.

Windemere was not so fortunate this year from a financial standpoint, but last December's buy-out by the hospital of a $2.5 million bond has eased the pressure at the nursing home. The hospital acquired the bond at steeply discounted $1.5 million and passed on those savings to Windemere's repayment plan.

Although Windemere's losses for the year will total about $300,000, board chairman John Mackenty said that changes under way with new director, Tom Dresser, should stem losses for the next year. Among those changes are a more thorough claims processing system and a better mix of patients who are covered by Medicare, which pays better than Medicaid or private-pay arrangements.

But paramount for Mr. Dresser is the issue of staffing. Nursing shortages on the Island have forced Windemere to hire staff from off-Island agencies at what Mr. Dresser called "exorbitant rates." His solution has been to set up training for certified nurse assistants here on the Island and send some staff to the Cape for training.

"We have to hire our own people," he asid. "Staffing is a big headache. We had to close a unit last summer because there was no staff." When asked if there is an unmet demand for beds at Windemere, Mr. Dresser said that he has to be very careful about who he admits. "People call and want to put a patient in right away. But if you take people in too quickly and don't look at the payer service, you can get burned," he said. "We can't be all things to all people." Overall, the message coming from hospital leaders spoke to changes and improvements, intended to meet needs of patients while remaining fiscally sound. For West Tisbury resident Tad Crawford, the difference was noticeable. "I've been attending these meetings for the last five years," he said. "There's a whole new level of cooperation taking place. You deserve the appreciation of the people."