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May 2007 issue
Hospice Care: End of the
Continuum
Three Ways to Add Hospice Services to Your Senior Facility
Three organizations followed different routes when adding hospice services
to their existing senior care facilities.
...
‘Aging in
Community’ A Hit in Boston
Beacon Hill Village Helps Elders Stay in Their Own Homes
Member services offered by Beacon Hill Village, a neighborhood group, help
elders remain in their own homes.
...
Q&A With
Don Gilmore
The CEO of Otterbein Retirement Living Communities talks about new
approaches to senior living and care.
...
People in the News
New faces in new places...Wesley Enhanced Living, Life Care Services.
...
Book Review: Old Age in a New Age
Beth Baker’s new book on “the promise of transformative nursing homes” is a
good read on an important topic.
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Business.
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Companies Mentioned in this issue:
May 2007
Beacon Hill Village p1
Brookdale Senior Living p5
DuPont p3
Life Care Services LLC p3
Otterbein Retirement Living Communities p2
Pioneer Hi-Bred International p3
Rest Haven Christian Services p4
Sunrise Senior Living p1
Trinity Hospice p4
Wesley Enhanced Living p3
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Hospice Care: End of the
Continuum
Three Ways to Add Hospice Services to Your Senior Facility
Email Editor
Adding hospice care to the services
offered in a senior facility is an additional benefit for residents — one
that means they don’t have to move to receive end-of-life care. Moving is
one of the greatest fears of seniors diagnosed with a life-limiting
illness. "It’s very stressful for a person to leave the place where he or
she has been living either for a lifetime or, in the case of a senior
living community, for two, three, four, or five years," says Jamison
Gosselin, external communications manager at Sunrise Senior Living
(NYSE: SRZ). Sunrise delivers hospice care to residents of its communities
in their own suites — just as a patient might receive hospice care in his
or her own home.
In fact, "trauma transfer," an accepted psychological
term that refers to a set of symptoms and outcomes that result from a
transfer from one environment to another, can increase mortality rates by
two-to-four times the rates for otherwise comparable residents without
transfer, according to controlled studies on which the U.S. Dept. of Aging
based its "Emergency Preparedness Manual for the Aging Network (1995)."
Further findings indicate that death frequently occurs
within hours or days of transfer and that the mortality risk is higher
following inter-facility rather than intra-facility transfer. So if moving
can be avoided, it’s generally helpful to the patient.
Hospice care and assisted or independent living are
very different business models in terms of management, operations, and
staffing, and different options for providing hospice care are available
to senior care facilities. Following are examples of three such options:
1. Operate hospice units in an existing facility.
Rest Haven Christian Services, founded and
supported by local Reformed and Christian Reformed churches, offers the
complete spectrum of senior services in nine facilities that the
organization operates in Illinois and Michigan. Rest Haven has a Home and
Community-Based Services Division that incorporates a hospice agency and
which has provided hospice care to residents for a couple of years now as
part of the organization’s continuum of care. "We provide hospice care
primarily through our three skilled nursing buildings," says Scott Kolzow,
vice president, home and community-based services. "Very few of our
hospice patients reside outside those buildings."
About 20 Rest Haven residents per month receive hospice
care — a relatively small operation. Specially trained caregivers provide
the hospice services, because the care requires skills that differ from
general nursing skills. While general care nurses may have a rapport or
relationship with the family, their primary focus is the patient. On the
hospice side, 50 percent of the effort is patient-related and 50 percent
is family-related. The bereavement care and counseling, for example, may
continue for 12-13 months after the patient has passed away. "Hospice care
integrates much more of the family dynamics than does skilled nursing," Kolzow says.
"We’re very careful, though, not to give our nursing
staff the feeling that its responsibilities are being taken over by
another group," he adds. "The nurses may have known and worked with the
patient and a key family member for years, but they’ve got to understand
that the physician is on board, the family is on board, and the
specialized care is in the best interest of the patient. We’ll even sit
down with the nursing staff to explain the direction we’re taking with the
patient and let them express any concerns."
To deal with staff turnover, Kolzow continuously runs
training sessions in which the new people discuss end-of-life issues, the
benefits of hospice, and the hospice services that Rest Haven provides.
"We try to alleviate any angst that a staff member may have and any
personal belief issues such as the disconnection of feeding tubes. We try
to be as proactive as possible and initiate new staff members regarding
who we are and what we do with regard to hospice care."
Only one independent hospice operates in the state of
Illinois, according to Kolzow, so offering hospice services in a
free-standing building that Rest Haven would operate — or perhaps turning
a wing of one of its skilled facilities into a 15- to 20-bed hospice unit
— are options that he’s considering to broaden Rest Haven’s horizons.
"Those ideas are on the table right now," he says.
2. Acquire or contract with a hospice provider.
Sunrise Senior Living currently operates more than 440
senior living communities throughout the United States, Canada, the United
Kingdom, and Germany. Last fall, Sunrise acquired Dallas-based Trinity
Hospice, which provides hospice care and services to patients where
they live, whether that’s in a senior living community or in a
single-family home. When Sunrise residents get to the point where they
need hospice care, they remain in their own units and hospice care comes
to them.
Sunrise operates residential communities, primarily
independent living and assisted living facilities, that focus on wellness
and living. That’s very different from the clinical mindset required for a
hospice. "Hospice providers offer a significantly different skill set from
what we typically provide in our communities," Gosselin says. "Our care
and services revolve around activities of daily life, recuperation, and
wellness. Hospice services comfort a person who is unlikely to get better;
they help to relieve the pain and symptoms that are part of the dying
process."
At Sunrise, for example, care managers from the hospice
service come into the facility to provide physical, emotional, and
spiritual care. Young children, spouses, and even grandparents may be
involved. To help everyone work through the process, a chaplain provides
spiritual services and a social worker provides counseling to the
resident, family members and loved ones, and perhaps even the facility’s
non-hospice caregivers.
Sunrise opted to buy its own hospice services company
in order to better manage the hospice services and meet resident
expectations. Prior to the acquisition, Sunrise partnered with various
hospice services companies around the country, both national and local
hospices. One difficulty that Sunrise experienced initially was that the
provider partners didn’t understand the cultural differences among
different kinds of senior living facilities. "They didn’t understand that
assisted living offered a homelike environment with comfortable
accommodations and not the clinically oriented environment of a skilled
nursing facility," says Gosselin. "The caregivers showed up in scrubs!"
Hospice care has evolved just as the entire senior
living field has evolved; but when partnering with a hospice company, make
sure that the provider’s operation is in line with your mission and your
service environment.
3. Lease space to a hospice provider.
Brookdale Senior Living
(NYSE: BKD), which operates
547 properties in 35 states, offers hospice services to its residents by
leasing space in some of its facilities to hospice providers. "The only
in-patient hospice units that we have are operated by outside hospice
companies that lease the space," says H. Todd Kaestner, executive vice
president, corporate development. "Hospice providers know how to operate
hospices, deliver the care, and market the services." As part of the lease
agreement, Brookdale provides basic services such as meals, housekeeping,
and general building security in the building — but the care, the nurses,
and the administrative staff are all provided by the hospice provider. The
economic benefit for Brookdale, then, is the lease itself, along with
reimbursement from the hospice provider for the basic services that
Brookdale provides.
The outside hospice provider may have its own patients,
but it also provides services to Brookdale’s eligible patients, as well.
"When our residents need hospice care, we arrange for the hospice provider
to deliver it to the patient," Kaestner says. "The patients may move into
the hospice unit, or the hospice care will be delivered to them in their
rooms. In either case, we make the referral, and the hospice bills
Medicare for the services. In one case, where we directly lease out units,
the facility was oversized. We walled off a corner and leased it to a
hospice company, which runs the unit there."
In another case, Brookdale donated three acres of land
on a large CCRC it owns in Florida to a not-for-profit hospice company
that built a small, eight-bed hospice on the property to serve patients
from the CCRC and also from outside. "The average stay is about a week in
that particular hospice," says Kaestner. "Turnover is about 25 patients
per month." The hospice enrolls patients early on but transfers them into
the hospice unit and cares for them there in the last days of life. Other
hospices, of course, have different philosophies and different average
lengths of stay in the in-patient units.
"Hospice care is a very specialized business and not
one where you need a lot of patient beds," Kaestner adds. "Hospices also
have different ways of delivering care." Generally, hospice care is
delivered in the patient’s residence, either a private home or a room in a
senior facility. Other times the patient moves to the hospice. Some
hospice stays lasts weeks or months; in other cases, the patient spends
only a few final days in the hospice.
All that said, Kaestner doesn’t think hospice care is
an opportunity for long-term care providers to suddenly decide to take up.
"It’s a much-needed service that a lot of people don’t coordinate very
well," he notes, "but it’s also a completely different orientation to
patient care — one that most nursing homes and most nurses can’t handle
very well. It takes a very special kind of staff to run a hospice."
The business of hospice care
From a business standpoint, offering hospice services
obviously extends the average length of stay per resident — an important
metric for for-profit companies. "Helping our residents stay in their
homes longer is a win for our company but also for the resident," says
Gosselin. "But you must have the resources, the expertise, and the
business platform from which to operate the hospice business."
Finances are not the ultimate driving factor for Rest
Haven, a not-for-profit organization. "We’re mission-driven," says Kolzow,
"but hospice care is a legitimate part of the overall continuity that we
offer. Our hospice services actually do very well financially."
Hospice care is 100 percent reimbursable by Medicare,
whereas most other senior care services are not. So adding hospice
services to an organization’s continuum of care results in an extra
benefit to offer residents with no added fee attached. For the facility,
however, the additional financial platform requires a different accounting
process, so it’s important to have someone on board with expertise in
Medicare reimbursement and experience working with the government
regulations.
Medicare also mandates a huge list of requirements for
the person referred to hospice care. An attending physician must certify
that the patient has only about six months to live and then make the
referral to the hospice. Hospice organizations, therefore, "live or die"
by their physician referral base. In order for a hospice to succeed, its
physician referral base must be very strong.
Kolzow points out one other difficulty when first
opening a hospice: "You literally eat the cost until you’re certified," he
says. "When we opened up our hospice, for the first four-to-six months we
provided without any reimbursement everything that you would normally
offer once you’re licensed and operational. For organizations that may not
have a strong financial backing, that’s a pretty tough pill to swallow.
With 20 residents a month getting hospice care, the cost might be $85,000
to $100,000 a month. That adds up rather quickly."
A for-profit provider may have a greater level of
available resources than a not-for-profit provider, but either type of
business should be able to accomplish the goal of offering hospice care as
long as the mission is to serve and help people through the last stages of
life. "That’s really the bottom line," says Gosselin.
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