The state Department of Public Health on Friday asked Lawrence & Memorial Hospital to explain recent changes to its outpatient psychiatry, obstetrics-gynecology and AIDS clinics, and said the changes may require state approval.

In a letter to hospital President Bruce Cummings, the health department's Office of Health Care Access, which regulates hospitals, gave L&M until Jan. 16 to respond to six questions about "the on-going provision and operational status of these three outpatient clinic service lines."

The letter - from principal health care analyst Karen Roberts - asks how recent layoffs are affecting services, whether the hospital will continue to be the entity that bills for and receives reimbursement for services and is legally liable for the patient care provided, and how patients have been informed of the changes.

The health department's letter came after at least two parties raised concerns with the agency about the changes. AFT Connecticut, the union that represents 1,500 nurses, technical, service and maintenance workers at L&M, in a Dec. 19 letter said it believes L&M is violating a 2005 OHCA ruling requiring the hospital to maintain the services of the OB-GYN clinic. On the same date, Dr. Julia Chase-Brand, former medical director of outpatient psychiatry at L&M, wrote to the public health department with concerns that decentralizing outpatient psychiatric services from the main hospital to the offices of primary care physicians who are part of L&M Physicians Associates will shortchange low-income patients covered by Medicare and Medicaid.

L&M spokesman Mike O'Farrell said Friday that L&M sent OHCA a letter on Nov. 6 informing them of the pending changes. The hospital believes it is within its purview to make the changes without the state's approval, he said.

"We notified them of our intent," he said. "Now they want more information, and we will provide it."

O'Farrell said services to AIDS patients, which had been provided at L&M's Infectious Disease Clinic, are still being provided, although some of the clinic's staff were among the 22 workers laid off last month.

"It's still there, providing the same services," he said.

Moving outpatient mental health services from the hospital to five primary care offices that are part of L&M Physicians Associates will continue to provide at least the same level of care, the hospital said previously. The change is slated to take effect Jan. 21.

O'Farrell said the OB-GYN clinic, which had provided care to Medicare, Medicaid and uninsured women at the hospital 2½ days a week, has been moved to an office at 470 Bank St. A registered nurse and two registration staff who worked at the clinic were among the 22 workers laid off. But the relocated office is staffed by the same two obstetrician-gynecologists who cared for patients at the hospital clinic, he said.

"It's the same patients, the same providers, the same care," he said. "It's actually increased access because the doctor's office is open more than the clinic was."

The relocated clinic, however, is no longer sponsored financially by L&M, but by L&M Physicians Associates, a hospital subsidiary.

Dr. Henry Amdur, one of the two doctors at the clinic, said the office is open five days a week, treating both clinic patients and those with private insurance.

"We're seeing the same number of patients as before," he said. "The clinic is alive and well. It's just a change of venue."

In addition to the two doctors, the clinic also is staffed by a nurse-midwife, he said.

Eric Bailey, spokesman for AFT Connecticut, said the union is concerned that the hospital inappropriately avoided OHCA's Certificate of Need process, in which the proposed changes would have been aired at a public hearing before the state gave its approval.

"The whole purpose behind OHCA is to ensure that patients' needs are being met," he said. "These are clearly critical services in the community."

Bailey said the union also is raising concerns with Rhode Island hospital regulators reviewing L&M's bid to acquire The Westerly Hospital, which has been in receivership. Specifically, he said, the union believes that L&M does not intend to continue providing obstetrics care at Westerly Hospital. Once L&M's application is deemed complete and Rhode Island officials begin their review, "we plan to be there to speak out on behalf of making patient care and public health a top priority in the region," Bailey said.

Henry Rodriguez, president of the L&M Healthcare Workers Union Local 5123, said L&M, as a nonprofit community hospital, has a responsibility to ensure that care is provided to the most vulnerable populations.

"Nonprofit hospitals like L&M have gotten into a bad habit of putting profits ahead of patients," he said.

Steven Hartford, Westerly's town manager and head of the residents' committee formed as part of the receivership, said his group has asked state regulators, L&M and Attorney Mark Russo, the special master in charge of the receivership, to work to preserve obstetrics services at Westerly Hospital. Currently, there are just two obstetrician-gynecologists working there, and the volume of births - about 300 per year - is not enough to sustain the practices without substantial subsidies, Hartford said.

"But we feel it's really important there be some kind of OB services available at Westerly after the merger," he said.

One proposal is that high-risk births be sent to L&M, which has a neonatal intensive care unit, and a "birthing center" be established at Westerly Hospital for low-risk births and mothers who prefer a less clinical setting.

"We will be challenging L&M to develop a feasible plan to maintain the service," Hartford said. "But we still feel (the acquisition of Westerly Hospital by L&M) is the best chance for survival of the hospital and, overall, support their efforts."

j.benson@theday.com