The challenge is how to develop a superior high performing growth and sales strategy to grow your census in these living communities.  The “Days of Muffin Marketing” are over.  The goal is to become a partner and not just another hospice vendor!!

The prizes for those hospices that can grow their Senior Living Community census are:

• Longer Length of Stays. Would you rather have 10 admissions from an acute care referral source that live 3 to 5 days or 1 admission from a Senior Living Community that lives 100 days? Ideally, I want both As this would create a healthy patient mix.  The challenge is how to obtain admissions from Senior Living Communities to achieve that healthy mix.
• Improved Productivity. Having a nurse and home health aid taking care of 8 patients in a Senior Living Community is more desirable than visiting 8 home based patients that require travel downtown and mileage cost.
• Giving the Gift of Hospice. It is challenging to provide the true gift of hospice with patients that live less than a week. As opposed to applying all the talents of Interdisciplinarity Team members to provide the gift of hospice to a patient that lives 100 days.

Action Strategies

The three major dissatisfiers on the part of Senior Living Communities working with hospice providers are:

• Lack of Communication. Over the 20+ years I have been in the industry, this issue haunts hospices. Even if the communication issue was not the hospice fault (the hospice nurse looking for a facility staff person to report off to, but they are in a meeting).
• Spending More Time With Residents. Senior Living Communities complain that hospices do not spend enough time with their residents that are receiving hospice services.
• Stronger Sense of Urgency. The hospice’s biggest vulnerability is after-hours and weekends. Responding in person to calls from Senior Living Communities is imperative. Developing value added ways to be present on the weekend is critical.

Hospice Advisors has developed a “Senior Living Community Playbook” that provides the detailed steps to address the three major dissatisfiers listed above and much more. The Playbook contains tools and materials to move away from being one of many hospice vendors calling upon Senior Living Communities to a true partner.

A few of the tools provided in the Playbook are:

• A “Facility Enhancement Meeting.” The structure and process of how to assemble and run this type of meeting that results in a “Facility Care Plan.”
• A very simple technology driven solution that will completely resolve communication issues.
• A patient Sensory Enhancement Program. This Clinical program provides patients with a customized experience that focuses on enhancing the five senses and is provided by the Home Health Aid.

These are a few examples of the program and clinical differentiators provided in the Playbook.

To learn more call Kurt at 734.658.6162 or visit www.hospiceadvisors and schedule time for a complimentary strategic dialogue.

The challenge for hospices is how to prepare?  Obviously, you don’t want to be way out ahead of the curve not knowing the final model.  And at the same time, “Hope Is Not A Strategy” and responsible leaders need to prepare and anticipate change.

The questions we receive from hospices deal with how best to start preparing and developing growth related strategies in this new payer environment. This article will outline a number of growth strategies that make sense to pursue in a VBID environment.   The first step, however, is to understand what the new payment model most likely will value and be based on and how to strengthen your position in these key areas.

Developing a Culture of Growth that embraces the elements in the Value Formula below in my opinion will build a strategic framework to help your hospice prepare for change.

Value = Outcomes + Experiences/Cost

What is new in this formula is the emphasis on experiences.  Family experiences drive their level of satisfaction and willingness to recommend a hospice.  This provides an opportunity from a business development/marketing standpoint to have a positive impact. Achieving a 5-Star Rating becomes significant. VBID is being designed to improve quality and timely access to goal-concordant care (providing hospice care that honors a patient’s goals and values) and eliminates fragmentation. Several studies have shown a strong direct correlation between satisfaction and patient/family compliance to care plans.  Thus, high satisfaction levels will lead to better outcomes.

The specific outcome measures used in the model are still being refined.  There is collective thinking that the VBID model will have a transformative impact on end-of-life care which will drive hospices to focus on reaching patients sooner to improve outcomes.   The new payment model (no matter what final model looks like) will be designed to get “more upstream” of the traditional eligibility for hospice. The reasons some hospices are rushing to develop palliative care programs.

Delivering efficient cost-effective care will be more paramount than ever.  Honing your care model and organization to be “lean and mean” is essential. For not-for-profit hospices, bifurcating your cost between core care delivery items and other programs and services that relate to activities outside the core business, i.e., community-based bereavement, chronic disease management, etc. will be important to demonstrate a good cost position.  Learning how to value and honor your mission and charitable work while strengthening your business acumen will be a skill set worth developing!

Where to start!  We suggest your organization go through what ever planning process you have in place to take stake in your organization’s readiness. The strategies below are suggested as a framework to that planning process and supports growth in a value-based payment environment   Growth becomes much more than just a sales and community outreach function.

Strategy #1:  The Power of Differentiation.

More than ever, being able to differentiate your hospice on clinical, programmatic, partnership and professional elements will be key for growth. Both for the reasons of standing out from other hospices and developing programs/services that support better outcomes and patient/family engagement. Understanding your unique position in the marketplace will better prepare you for participating and being viewed as an asset to Medicare Advantage Organizations and others.

Some examples for consideration.  A clinical differentiator could be developing a concurrent care program to care for more complex patients. Concurrent care will make you a much more attractive partner to insurance companies as well as hospitals.   Another, for those hospices that have a home care associated with them, the development of an oncology specialty program would allow for the management of cancer patients and drive better clinical outcomes.

A professional differentiator could be a Physician Advisory Board (PAB). A PAB is a group of 12 or so community physicians that agree to be members of the PAB which meet 3 times per year.  This strategy is an excellent tool to better engage community physicians and obtain their input and ideas on services and programs that can enhance your position in a VBID environment.

Your planning process will assist you identify other unique differentiators.

Strategy #2:  Strengthen your Technology

Strengthening your technology for the purpose of gathering, analyzing and reporting outcomes and cost data will be vital.  Now is the time to evaluate and make needed improvements.

Here are three examples of how technology can be used as an accelerator in a Value Based payment environment.

1. Accurate, timely data will be critical in a VBID environment. Assess your ability to easily gather and report outcome and data. How are your current data gathering and reporting efforts coming with HCI, CAHPS, etc.? How well is your EMR talking to your CRM?
2. The ability to conduct remote monitoring will also be an important tool to support clinical outcomes and deliver cost effective care. Some of the benefits of remote monitoring include, improved data driven clinical decision making, helping patients with self-management and patient/family compliance to care plan. Remote monitoring has also demonstrated a reduction in patient care expenses, building patient engagement and proving a boost to net revenue.
3. Technology can also be used to improve communication which is a key element to improving the overall patient/family experience. I have learned that if you don’t give families information, they make it up.  And it usually doesn’t work in your favor.  There is a communication app that provides real time communication between family members, hospice staff and other professional involved in the patient’s care.  Please do feel free to reach out to me and learn more.

Strategy #3: Improving Your Referral Inquiry to Admission Process:  Reimagining Access

Ease of use and access for any company is an important pillar for growth and satisfaction.  In hospice, there are five fundamental elements required for a superior Access Center.

• Being able to assure you are capturing ALL your referral inquiries. Not hoping that you are capturing them, but knowing you are.
• First-to-bed-side wins. A strong sense of urgency! Building the capacity to respond in-person to all your inquiries with within 24-hours.  Creating a team of “first-responders” who can meet a family and say “you’re not alone anymore” establishes a foundation for trust, positive communication and high levels of satisfaction.
• Eligibility Process. Having a “bullet-proof” eligibility process is critical. Eliminating single points of failure by having an eligibility team or committee in place will assist here.  Eligibility training and education for your physicians and nurses so they are on the same page is a staple of this process.
• Building and Working a Superior 90-Day Pending List. For ALL your referral inquiries that do not admit within 24-hours place them on a pending list which identifies the barriers to why they did not admit. Then over the next 90-days work to eliminate those barriers.
• Organizational Wisdom. Building a culture where everyone in your organization can assist eliminate barriers and leave no patient behind.

The first 24-hours when a patient/family reaches out to your hospice is critical to establishing satisfaction.

Strategy #4: Building a Professional Sales Model.

VBID will require sales staff to be true hospice consultants.  Hospice sales associates will need to have clinical knowledge that will lead them to more informed sales calls.  The Days of Muffin Marketing are over. A professional sales team built on a keen knowledge of hospice, clinical savviness and understanding how hospice will work in a value-based model will be “table stakes” for success in serving more people and growing.

Building a knowledgeable sale team that understands how to sell on value to key referral segments will be an important pillar to support growth.  Each referral segment, i.e., hospitals, senior living communities, personal care home health agencies, etc. have a unique value proposition regarding their use of hospice. Sale professionals must be able to distinguish and clearly understand how to deliver value to a variety of referral sources.

Invest in the skill set development, training and hospice knowledge development for your sales professionals as much as you do for your clinical staff!!

Strategy #5:  Palliative Care Programming.

Palliative Care is considered a clinical differentiator and a stand-alone strategy. The current challenge with Palliative Care is a stable reimbursement source. While efforts are under way to improve reimbursement, no solution is yet in place.

There are numerous hospice based Palliative Care models in place across the country.  Here are three examples, Hospital inpatient palliative care consultation, community-based programming or what is referred to as “bridge program.”  These are a few examples with many variations on these models in existence.

Most hospices who have started a Palliative Care Program did so as a strategy to begin dialogue sooner with patients and families to transition them to hospice more smoothly. Some of these programs however became run-way trains in that they turned into Chronic Disease management program.

Palliative care programs that are well defined, have a strict set of criteria for admission and can demonstrate a 60-70% conversation rate from palliative to admissions can realize success. In a VBID environment, having a well-defined palliative program can be an asset.

Strategy #6: Formalize Your Partnerships

Build and strengthen your relationships with insurers, hospitals, and other hospices in your community. Try your best to understand what your insurers are experiencing.  Share your outcome data as a method to start a dialogue.  What potential needs or gaps can you fill.  Seek opportunities to formalize a relationship with them.

Approach the hospitals you do work in and share with the C-Suite your data on the referrals you received from them and how long these patients lived.  I’m sure your data will show a portion of these patients died before they were admitted or within a day or two.  I have used this strategy many times and I can assure you the C-Suite people will have some epiphanies.   This will lead to dialogue that can assist structure a better a relationship.

Approaching other hospices in your community to develop alliances can be beneficial.  This strategy particularly applies to not-for-profit hospices. Meet with your fellow not-for-profit hospices and seek aways in which to partner.  This strategy will make the group much more attractive in a value-based payment model.  A few examples of this are the California Hospice Network and four not-for profits hospices that collaborated in Florida called the Synthase Collaborative.

So Where To Go From Here

Remember, Hope is NOT a Strategy.  Change is coming in one form or the other.  Stay abreast of what is evolving with VBID.  Communicate with your State and National Associations to both obtain current news and ask the question, “What Does This Mean For My Hospice?” Set up Google Alerts for Hospice Value Based Payment, Hospice Medicare Advancement to stay on top of breaking updates.

We suggest going through whatever strategic planning process you have in your organization as a good place to start.  Taking stock in the six strategies sighted here to determine how you can improve will serve you well no matter what the final VBID model looks like.

Determine the best methods to enhance your patient and family experience will take on more importance in a VBID environment. There are several strategies mentioned here that are easy to work on. Investing in customer service training.  Starting with your Access/Admission staff. Remember, the 5-Star Rating System will carry much more weight.

Once your strategies are in place, execute, execute and execute some more!

Kurt A. Kazanowski MS RN CHE
Managing Partner
Hospice Advisors
www.hospiceadvisors.com
www.kurtkazanowski.com
296 S. Main Street, Ste. 202
Plymouth, MI 48170
1.734.658.6162

Today’s Strategy Planning (SP) process is not your father’s SP process!  SP use to be a 3-to-5-year planning window.  This is obsolete in today’s environment.  Now, SP is all about creating annual rolling operating plans that are updated yearly and are truly helpful tools to assist hospice organizations navigate a complex environment and strengthen performance in the areas of quality, growth, and finance.

Hospice Advisors works with non-profit hospice organizations to develop a simple but powerful approach to strategy, objective, tactic, and deployment.  With the emphasis on deployment and execution.

This article is a case study of a SP development and deployment process for a non-profit hospice company that was at cross-roads in its development as an end-of-life provider.  Shared will be the journey took through the SP process, methodologies used, a framework for the strategic plan and benefits from the process.

Why Bother with Strategic Planning?

For non-profit hospices, the world continues to change.  Since the “provider flip” started to occur in the earlier 1990s, non-profit hospices have been threatened.  When the hospice benefit was first enacted in the mid-1980s, 90% of the hospice providers were non-profit and only 10% were for-profit.  Today, 90% of the hospices in the USA are for-profit and only 10% non-profit. The last non-profit hospice that opened was 14-years ago and during this time, several non-profit hospices have actually closed! There is a slow extinction of non-profits occurring in the country.  2020 demonstrated the largest amount of hospice acquisition and consolidation in recent years.  This is a function of the tremendous amount of equity investment money in play and this phenomenon further threatens non-profit hospices.

The reason to complete a SP for non-profit hospices is so that the organization can maintain and embrace their non-profit mission and charitable work.  While at the same time start to function with a for-profit mentality to compete in a every changing and competitive marketplace. Yes, we said for-profit to non-profits and that is not a bad thing!  You have heard from lots of folks the ole’ saying no margin, no mission.

The biggest challenges facing non-profit hospices come from within by attempting to do many things that take away from strengthening and growing the base business of hospice. The goal should first and foremost be a great hospice, but many hospices can be very distracted by focusing on continuum of care and programs that fall far outside of hospice and end of life care. Because non-profits have so many internal competing programs and services, the ability to execute and complete any level of strategic work required is difficult.

While we appreciate and understand branding many non-profits decided to change their names and loose the word “hospice”.  Many of these programs had very rich history and had referral name recognition but decided that by losing hospice in their name may in fact increase their hospice business. On the flip side we hear from hospices that they we wish consumers would use “hospice” sooner and understand “hospice.” Not understanding consumer behaviors related to death and realization that our primary hospice customer is our referral sources is a big mistake that many have non-profits have made.  Check out the national data and you will see non-profit market share has steadily decreased since 2014.

Additionally, non-profit Boards while very well meaning, generous and compassionate community leaders, lack in depth and expertise in end-of-life care.  Primarily because the Board does not truly understand the business of hospice, the changing health care environment, and the complexities of competing in an ever-increasing competitive marketplace this causes a dilution of focus and accountability. Driven many times by services and programs that are charitable in nature but fringe in the ability to serve more hospice patients.  Engaging the Board in a SP process enhances their ability to better understand the challenges facing hospice organizations and support the important work required to go from good to great hospice care!

Hospice Advisors SP focuses intensely on strategy deployment as well as development. Our model of SP emphasis deployment and execution.

The Hoshin Model and Approach to Strategic Planning

The beauty of the Hoshin method of planning is how it draws upon the collective wisdom of the organization in both the development and deployment of strategy.  Most SP stall-out because they do not have a strong mechanism and process for execution and deployment of strategy. The Hoshin approach when followed assisted organizations with execution to achieve desired results.

Below is an illustration of the Hoshin process.

The process starts by validating the mission and vision for the organization.  In most cases, the vision holds true along with the mission. If adjustments and modifications are required, a process would occur with Hospice Leadership and the Board to accomplish this.

The SP process includes an internal and external environmental scan. This scan involves a review of data and information, a survey of the employees and interviews with key people.  This information is analyzed and prepared to be presented to the Hospice Leadership and Board.

A wonderful benefit of Hoshin Planning is the ability to inform and educate the Board (and Leadership) on the current hospice environment and challenges facing the organization.  We share the information obtained from the environmental scan in a Hospice Board and Leadership in a SP Advance. We do not hold planning Retreats, but rather Advancements. Looking to the future.  An important us of words!  Board education and development assists the Board on how best to guide, focus and support the organization. A big plus is using a passionate hospice centric group (like ours) with many years of experience to deliver this challenging news to your board.

By engaging the Board and Leadership in an education and work session, a compelling internal business statement and set of key Break-through objectives are identified and become the architecture for the SP.

Compelling Business Statement

The compelling business statement supports the mission and vision of the organization and becomes a filter by which the Hospice can measure the rightness of its actions and the resources applied to advance the SP.  Following is an example of a compelling business statement.

As a non-profit provider of end-of-life services, we are committed to our mission and community work. We recognize however that the rapidly changing environment requires we have a laser focused plan on how we advance our core business of hospice.  This means that every strategy developed should originate from a basis of value to our healthcare community, our overall business and financial performance.

From the compelling business statement flow a set of break-through objectives.

Break-Through Objectives

Usually, three to five high level break-through objectives are identified that support the compelling business statement. These objectives then provide an opportunity to tap into the collective wisdom of the organization to start to develop tactics and actions that will advance the objectives over a 36-month period.  The first 12-months of the SP become the operating plan for the hospice. Following are an example of some break-through objectives:

1. Grow the hospice census by increasing the number of hospice patients admitted, improving length-of-stay and converting patients and families from other parts of our continuum of care to hospice.
2. Expand our continuum of care offerings to ensure we provide value to the greater healthcare continuum in our community while assisting us to grow our core business.
3. Develop and intensify financial controls, hold people accountable to performance targets and expand alternative revenue sources.
4. Invest in our employees by innovating how we can stay competitive with all the healthcare institutions in our community.

Tactical Development

The development of tactics and actions are the “guts” of the SP. And one of the more fun parts of the process.  Work groups are formed around each break-through objective. Using a variety of brainstorming exercises, a set of tactics and actions are identified. Using “Catchball” (a technique for creating and maintaining open feedback loops across all levels of your organizational hierarchy) the tactics and actions are refined.  Following are a few examples of tactics and actions.

Refocus and Strengthen the Sales Model and Approach

Assess current sales resources (Account Executives and Clinical Liaisons)

Re-assign and/or hire sales staff to achieve tighter, more manageable territories with a deeper penetration into referral segments, which yield longer length-of-stay

Continue to install a professional sales model (move away from “Muffin Marketing)

• Skill set development of 7-step sales process. Strengthen “Cold Call” approach. Learn to “Weed the Garden”
• Selling on value to 10 key segments
• Use of value-added collateral materials, i, e, Case Study, relevant articles, trigger sheets, etc.
• Phraseology development

Each AE to develop, work, and update a Quarterly Growth Plan 

• Focus on referral segments that will yield longer length-of-stay

Start to focus on referral segments that yield longer-length-of-stay

• Start a process to work Personal Care/Private Duty companies; follow protocol for working this segment; include in quarterly growth plans
• Start a process to work Assisted Living Communities. Initial focus to be on CCRC (Continuing Care Retirement Communities); Apply “Facility Care Planning” process; Include in quarterly growth plans
• Start working the Disease Management Associations; Implement sales process tailored to this segment; Include in quarterly growth plans

Redesign the Palliative Care Program to be tighter in scoop and with a key performance measure of conversion to hospice

New PC Program Vision and Definition

• PC Model description
• Target Populations
• Geography/Referral Source
• New Screening Criteria and Tools

Intake/Conversion Process from PC to Hospice

• Start with Identified patients that have long lengthens of stay. Hold a dialogue.
• Target clinical indicators to begin to introduce hospice.  Triage patients
• Determine how to identify and remove hospice barriers for PC patients and their families
• Transition plan for patients with prognosis of +1 1⁄2 year off PC.

Marketing

• Evaluate the ability with SNF for PC and Hospice
• Create a well-defined sales and marketing plan based upon goals of the new PC program
• Strategic use of RN Liaisons

Deployment and Execution

This is where most organizations fall-down. The Hoshine approach to SP places a strong emphasis on deployment and execution. There are several key elements that are focused on during this step in the SP process.

1. Accountability is assigned to the deployment and execution of each objective and high-level tactics. A staff member is given responsibility and accountable for advancing the objective/high-level tactics to assure work is occurring and movement is taking place. Assigned staff are accountable to Leadership for what is occurring and needed support.
2. Key Performance Indicators (KPI) are assigned to each break-through objective. Leadership and Management reviews the KPI monthly and uses this information to modify and adjust actions and approaches to better advance the objectives. These KPIs are shared with the Board as a method to update them on progress.
3. Project Management. The most valuable tool for deployment and execution is a project management tool!! The project management tool holds all the objectives, tactic/actions, who is accountable and timeframes. The entire plan can be viewed and provides an ability to determine what adjustments need to be made.  Leadership and management use this tool to monitor the plan monthly progress. Using a project management tool is key to success.
4. Work Groups. Work groups are formed around each objective and those large “meaty” tactics. These groups make sure “the-work-of-the-work” gets done, use the Project Management tool to guide and update the work and report directly to Senior Management for support and as a point of accountability.
5. Annual Review and Update. On an annual basis, the SP is reviewed and the existing and/or new tactics roll-forward into the new planning cycle.  In essence the SP rolls forward and build on what has occurred year-to-year.

Conclusion

Hoshin SP can assist non-profit hospice organizations further advance their mission and charitable work while developing the business acumen to serve more people, improve operations and finance, grow and give the gift of hospice.  Through the development of a compelling business statement that is supported by break-through objectives and tactics a clear path to organizational improvement will occur.  Coupled with a superior deployment and execution plan and set of tools, the rigor and cadence required is achieved to be successful.

Kurt A. Kazanowski MS RN CHE

Greg Grabowski

Hospice Advisors

296 S. Main Street, #202

Plymouth, MI 48170

www.hospiceadvisors.com

1.734.658.6162

At our last Hospice Advisors Boot Camp in Atlanta, Bill McArdle, the Owner and CEO of Trinity Home Care and Hospice out of Texas shared a strategy on how hospices can bring greater value to home care companies and increase hospice referrals along the way.

This strategy also assists home care companies strengthen their financial performance.  A true win-win for both hospices and home care companies.  Hospice companies can develop a new source of referrals and home care companies perform better.  Bill’s experience in both home care and hospice provides him a great deal of insight and expertise on the topic.

Bill started by saying that many home care companies truly don’t know the details to their census.  He went on to say, “a big census does not always equate to profitability.  More sometimes can be less!”  Embedded in home care companies census are those patients who have been on service a long time and may have increasing service needs. These patients, from a financial perspective, do not strengthen the overall position for the home care company.  Some home care Administrators of smaller and medium size home care companies do not drill down to the extent necessary to understand what patients are in a loss position financially.  This provides hospices a strong talking point to open a dialogue on how hospice can assist better care for these patients.  Bill went on to say, “this is going to become even more significant in 2020 when the Patient-Driven Groupings Model (PDGM) hits home care companies”.  This value-based reimbursement model will drastically change how home care companies are reimbursed.  This will further drive home care companies to better understand the make-up of their census and how best to case manage these patients.  Bill gave the example that non-institutional referrals will be more challenging then every before not only in terms of a lower reimbursement rates, but the length of time to bill.  Home care companies will need to better case manage these types of patients of which some could be hospice eligible.  By doing so the home care company provides better care and along the way strengthens their financial performance.

By a hospice companies understanding the “pain-pleasure points” of their home care colleague’s business, they become a more valuable resource to the home care company.  Once home care companies understand this, they all a soon become interested in learning how to work with hospices.  The hospice that can better craft a value proposition and deliver upon it will “win”. Following are some recommendations and steps for a hospice to follow to develop this information into a growth strategy.

1. You need to get in front of the Administrator and/or CFO who are accountable for financial management. The biggest challenge is building trust. Trust can be built by first demonstrating that you understand the challenges home care companies face.  Second, is by articulating and showing the home care company how hospice can assist improve the performance of their economic engine.  The engine being a quality low cost number of visits in a care episode that drives improved financial performance.  Remember, all home care census is not good census.  If a home care company acknowledges this point a working relationship will emerge.
2. Bill indicated as you work with a home care company, respectfully ask them to share what their average cost per visit is. This will help get the dialogue flowing.  To calculate this figure, you simply add up the total monthly expenses and divide by the number of visits. This will give you an average cost per visit.  It’s that straight forward.  Then determine what the per visit reimbursement is. (this will be discussed below).  Once this is complete, you can drill down by patient to identify outliers. For example, an average cost per visit may run between $105 to $130. If you are averaging 15 to 20 visits for that case, you would generate a cost on the low end of $1,575 to the high-end of $2,600.  And if service needs are higher, the cost will increase. If your reimbursement was $2,200 you could be in a loss position for the case. Helping a home care company find those costly patients and providing them an alternative care path is where the sweet-spot is at.
3. Bill in his years of home care experience, stated about 5-6% of home care patients are in a loss position in the company’s overall census. By trimming this census, a home care company will improve their overall performance. These patients and families could benefit from an alternative care path such as hospice and palliative care. Helping the company identity such patients delivers a strong value proposition first and foremost.  Once these patients have been identified, determine if a hospice and palliative care path is most appropriate. Have the home care and hospice clinical teams agree upon the best approach to assess hospice eligibility. The value proposition for the hospice to the home care company is helping them move eligible hospice patients off their census that are hurting financial performance.
4. Become more knowledgeable on how the home care reimbursement world works. This is vital!!   Start with understand the Home Health Resource Group (HHRG) by Metropolitan Statistical Area (MSA). The Home Care Resource Group (HHRG) is the code that results from the point tabulations from responses provided on the OASIS – C1 document following a comprehensive assessment of the patient. Once these points are tabulated, they are plugged into the Four Equation Model and the results = HHRG.  Understanding the reimbursement model will help you compare the cost per visit to what is being reimbursed. Here is a link to a PDF which will get you started, https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2017-01-18-HH-Presentation.pdf
5. Bill suggested that if you can walk into a home care company with a worksheet tool they can use to “plug and play” it will help build trust and accelerates the process. Here is a website Bill suggested and a group you could work with to construct such a tool, http://www.mlacpas.com/
6. Finally, Bill indicated that hospices should talk with home care companies about patients that meet the criteria for dual-diagnosis. There are usually a hand-full of patients in a home care census that meet criteria for accessing their hospice benefit while still being able to receive skilled home care services. Once trust is developed with the home care company explore this opportunity.

In conclusion, there is a place for hospices to work with home care companies and deliver a great value. The value comes from helping home care companies move census that is costing them money!  It starts by understanding what the home care business economic engine is.  And how hospice can assist strengthen that engine.  Bill suggested that by simply working with a home care company to calculate the cost per visit and comparing that to reimbursement rates, you can assist a home care company develop more appropriate care paths for the patients and along the way strengthen financial performance.

In today’s competitive hospice environment, the ability to unlock a new referral source by delivering value and being a partner and problem-solver is truly a win-win.  Further, this growth strategy is very agnostic.  You could work with ten home care companies to assist them strengthen quality and financial performance. This is because you are  working within a company’s framework to achieve improvement.  You are not forced into showing favoritism and get caught in the middle.

This in not a “silver-bullet” strategy but is a way to incrementally find a new source of referrals and serve more patients and grow.

Hospice Advisors hopes you found this paper helpful as you explore your growth strategies!!

About Hospice Advisors

Hospice Advisors is a boutique hospice and home care consulting, coaching and training company.  Principles Greg Grabowski and Kurt Kazanowski along with their Associates have a passion for assisting organizations serve more people, growth and strengthen financial performance. To lean more about Hospice Advisors, please visit, www.hospiceadvisors.com and/or call Kurt Kazanowski at 734.658.6162

Some of the best lessons I have learned to serve more people, grow and strengthen financial performance have come from my mentors of the past.

People like Bill Sanger who is a brilliant health care entrepreneur and taught me valuable lessons in strategic business thinking.  Mary Ellen Howard, RSM taught me how to strive for excellence while balancing mission and business objectives.  Bob Beyer my CEO of 12 years in the Trinity Health System taught me much need patience and how to take the art of the long-view.  Most recently Todd Stern, the owner and CEO of Seasons Hospice and Palliative Care.  I had the honor and privilege to work with Todd in several different capacities as he developed and grew Seasons Hospice to the 4^th largest hospice in the country. Todd taught me that by focusing on giving the gift of hospice and leaving no patient behind, you cannot help but serve more eligible hospice patients and grow.

I took these lessons learned and working with my partner Greg Grabowski have developed our consulting company Hospice Advisors into a resource for hospice and home care companies searching for state-of-the art best practice solutions to better give the gift of hospice.   Our practice revolves around 7 important elements that support an organizations ability to grow.  These key elements have their roots in my lessens learned and were refined as Greg and I worked together.  Those 7 elements are:

• Creating a Culture of Growth. It all starts here
• Moving the needle on the referral-inquiry-to-admission conversion rate
• Maximizing your Medical Director(s) investment
• Sales team skill set development: “Happy Feet on the Street”. The Days of Muffin Marketing are Over.
• Segment-based selling. Nine referral segments and their value propositions
• The Art of Differentiation
• The Discipline of the Quarterly Growth Plan. Execution and deployment of strategy.

Starting this March and running through the end of April, I will be sharing short articles on each one of these key elements.  I hope you find these upcoming articles useful ideas, inspirational, and a framework from which to serve more people, grow and strengthen financial performance. If you would like to discuss any of this material with me further, please contact me.

Greg and I offer regular Boot Camps where we teach and share best practices around these key elements.  We are offering a Boot Camp this April in Phoenix Arizona.  A 2-day Sales Intensive on April 2th and 3^rd and a 1-day referral inquiry to admission Intensive on April 4^th (a selfless promotion ) if you are interested, here is a link for further information, https://hospiceadvisors.com/product-category/boot-camps/

Kurt Kazanowski MS RN CHE

Hospice Advisors
734.658.6162
www.hospiceadvsiors.com
kurtkazanowski@gmail.com

A hospital is a “mini-city” and understanding all the subsegments that make up a hospital is critical to serving more people and growing.  Each subsegment in the hospital has a unique value proposition.  Clearly understanding each sub segments Value Proposition is a first-step to developing a marketing strategy.

Value propositions usually revolve around the following:

1. Strengthening quality
2. Revenue enhancement
3. Reduction in expenses
4. Reduction is inappropriate re-admissions
5. Reduction in mortality stats
6. Increase in patient satisfaction
7. Lowering litigation risk
8. Case management

One excellent part of the hospital to work is the Emergency Department.  There are several reasons.  First, everyone works the “middle”.  Those Social Workers, Discharge Planners, Case Managers who interface with patients the most. This isn’t the case in this area of the hospital.

The Emergency Department however is an excellent way to both “break into” a hospital as well as meeting end of life care needs. Developing a marketing plan to add value to an Emergency Department will make you a valuable partner.  The Value Propositions for the Emergency Department are many.  From the list above, here is where the value is at: Numbers 1, 4, 5, 6, 7 and 8.

Below is a gift from Hospice Advisors.  It is a Power Point video presentation you can use to start a dialogue with the Emergency Department.

Best wishes!

The 11-Year Snapshot

• Across the 11-year period, there is a wide variation in average hospice utilization growth rates among states. For example, utilization growth rates were as low as 17% for Colorado but as high as 849% for Alaska.
• Generally speaking, while the first 6 years were characterized by robust growth and increased utilization, in year seven that growth plateaued, then picked up modestly in 2009 only to plateau again in 2013.
• Some states, such as Arizona, Florida and Kansas, are already seeing hospice utilization declines, rather than growth for the last three years.
• Other are in decline for the last two years: New Jersey, Delaware, Iowa and South Dakota.
• Only a few have been able to turn 2012 declines into modest 2013 growth: Oklahoma, Rhode Island and Wyoming.

2013 Breakdown

• The 2013 national average hospice utilization rate is 2.46%.
• There is a wide variation in 2013 hospice utilization rates among states, ranging from Alaska with the lowest rate of 1.16% to Utah with the highest rate of 3.6%.
• For 2013, the states in the top quartile of hospice penetration rates use hospice 75% more often as states in the bottom quartile: 3.23% (on average) versus 1.85% (on average).

So the big question is, what does the future hold for hospice use nationally and in your local market? Clearly, hospice utilization gains are becoming more challenging and securing hospice growth significantly becomes more complicated. Once upon a time, geographic expansion held the key to solid growth. This isn’t the case today as some markets are over-saturated, CON still plays a role in a number of states and others are leveling off on their utilization rates.

There are, however, still many opportunities to serve more people and grow!

Chesney’s research illustrates that that 7% of the Medicare patients who are discharged alive from a hospital die within 30 days. That is a larger number of patients than could receive the gift of hospice.

Still too many patients, who die in LTAC’s or SNF’s, are hospice candidates. All these factors are compounded by the fact that hospice’s median length-of-stay has barely budged in the past several years.

One innovative program approach to help startup hospice utilization is Palliative Care. Many Insurance Companies, ACOs and large organized physician groups are exploring Palliative care aggressively. This is an opportunity for a hospice company to develop key strategic partnership. Another growth strategy is to “up your patient care game” so as to quickly, safely and easily care for this 7% of patients who die after being discharged from a hospital. Along with this, create GIP programming with your acute care colleagues with significantly help them achieve their mission and business objectives.

Lastly, work on improving your LOS, consider targeting and creatively working with segments like Senior Living Communities, Disease Management Group, Geriatric Community Case Managers and Geriatric Assessment Centers, to name a few.

Please go back and review my past post as I provide for specific thoughts and recommendations on way to increase Length-of-Stay.

The Best

I own an in-home care company in Michigan called Homewatch CareGivers and we are receiving more referrals than ever that look like this:

• Tube feeding 3x day
• Track cleaning every day and replaced once a month. No vent but is oxygen dependent.
• Foley care
• Bed bathing

A very challenging complex personal care case. This specific case exhausted her eligibility status for Skilled Home Care. The client did, however, meet hospice eligibility and accessed her Medicare Hospice Benefit. Her family wanted a personal care giver in the home 4 hours a day/ 7-days per week to assist.

My staff was very apprehensive to take this case because it was so complex. They were uncomfortable because they had not managed a case like this before. While I wanted to support my staff I also wanted to help this family receive the care they required. What to do???

The first thing I did was call upon a certified skilled home care company that we have a strategic partnership with and spoke with their Director of Nursing. She agreed to help us manage the case by providing the three CNAs we assigned to the case. This collaboration was a great way to both meet the family’s need and help my staff get comfortable in accepting these type of cases thus allowing us to grow. Further, we were able to provide a care setting that was less expensive and become an attractive option to Care Managers.

The second thing we did was use this case as a learning lab so we could be better prepared for the next such case. We started a process to recruit qualified LPNs and CNAs who could manage these complex personal care cases. We also started to focus on training and education of our existing caregivers who wanted to improve their skill sets and competencies.

Here is how the economics worked on this case. We charged the client $30 per hour. We paid our CNAs $12/hour and I shared the remaining revenue with our strategic up to 6%.

Our next effort in my company will be working more closely with hospice companies. This will help us both advance our mission objective of helping people age more comfortably in their home and help us advance our business objective of growing billable hours. There are several empirical studies which show that people who are in house live longer. So, by addressing our mission will we grow our billable hours without starting a new case of care!

The lessons learned for me and my staff is how to work more collaboratively with our skilled home care and hospice colleagues.

The Best

To create better understanding and a common language, home Care refers to skilled Medicare companies that provide intermediate home care services such as nursing, physical therapy and occupational therapy. Personal care refers to those non-medical companies that provide companion, personal care and complex personal care services and are usually private pay. Hospices are those companies that provide palliative and end-of-life care services paid for by Medicare or insurance companies.

If a nursing home or assisted living facility doesn’t create and maintain these partnerships with home care, personal care and hospice companies, they are severely disadvantaged when working with hospitals. From the hospital’s perspective, without these vital partnerships, there is a loss of quality outcomes and an unnecessary increase in inappropriate readmissions. If your community cannot overcome these stipulations, you could potentially lose referrals as well as the ability to participate in accountable care organizations.

In addition, strong partnerships will allow you to have the ability to help people age in a place which advances both your mission and business objectives. Most senior community’s economic engines are fueled by keeping a strong census in their facility. “Closing the back door” is critical to maintaining and building a strong census and creating a strong relationship with home care, personal care and hospice. All of these functions will assist in your efforts to differentiate your community in an ever increasingly competitive marketplace, and having the ability to offer home care and palliative medicine services will help you promote yourself through referral sources and the community at-large.

The value proposition matrix below will help you identify those companies that will bring you the most value and be good partners.

Below is a value proposition matrix to identify companies that would bring the most value, while also providing a great partnership. A senior living community with skilled nursing and assisted living can effectively go about developing several strategic partnerships if using this matrix and using it as a checklist.

A real world example

A senior living community with skilled nursing and assisted living developed several strategic partnerships. But first it had to correct one big problem: too many cooks in the kitchen.
This senior community had nine hospices, 10 home care companies and eight personal care home health companies all vying for the same referrals. The variances in the services delivered were all over the map as well as the ability to get and manage reliable data.

Several processes were put in place to help this senior living community improve its operations.

Mini RFP process

The first thing the executive director in this community did was make all these companies aware he was going to select three providers in each category. A bold move, but it worked. He went through a mini RFP process using the value proposition matrix to select his team.

If a patient came to the facility already working with another provider, he continued to allow them to work in his building; however, the referrals from within the building went to one of the pre-approved team facilities. This process set a precedent for better team work, data sharing, use of EMR and better overall outcomes.

Worked together to reduce unnecessary ER visits and inappropriate hospital readmissions
When the team could, they looked for opportunities to avoid an emergency department visit and sent appropriate patients directly to one of the “team” members. Home care, personal care, and hospice companies worked creatively to keep patients safe and secure in the home setting.

If a patient did go to the ER, the team worked diligently to send them right back allowing that company to better manage their care. If the patient was a fall risk, a personal care referral was made. If the patient met hospice eligibility guidelines, the appropriate referral was made.

There are continuous process improvement initiatives around ER transfers inside the post-acute setting (the team). Using this approach, this senior community learned to master CHF, pneumonia and myocardial infarction. Now this facility is better prepared for the next set of penalized diagnosis-related groups.

Developed a general inpatient (GIP) hospice program

One of the three hospice team members worked with the senior community to develop a GIP cluster bed program. This was an excellent development of a program element that greatly improved the community’s ability to reduce readmissions and create a new revenue stream.

This was accomplished by turning two beds at the end of a wing into palliative care suites. For patients in the community that met GIP criteria, they were cared for in one of these palliative care suites to treat and get their breakthrough pain or out of control symptoms under control. This helped make a discharge home more manageable.

Instead of going to the hospital, those patients discharged home who developed GIP related issues could be admitted to the palliative care suite for care. All appropriate care was handled by the team, and the facility was reimbursed $375 per day from the hospice for the use of the bed and facility’s services. The GIP level of care is allowed and encouraged by CMS. Ultimately this provided the community the ability to generate $260,000 in one year from the hospice providing GIP care, in addition to driving better outcomes.

Data Tracking

One of the final steps was data tracking. The senior community monitored the team members as well as physicians’ data and compliance through benchmarking.

This facility started to share the data with hospitals, which resulted in the facility becoming part of a hospital’s post-acute provider networks. This benefited all the members of the “team” and allowed the facility to customize their data, and actually provided more information than is often requested to help create a clear picture of the efforts and results.

The senior community took advantage of what the home care and hospice CMS conditions of participation allowed, and from that built its delivery model and service mix. The best example of this is how the senior community and the hospice company entered in a GIP contract, and then used that contract to develop a GIP cluster bed/ palliative care suite program.

The partnership with the personal care company was creatively used in a number of ways. One example is how a small office space was given to the three personal care companies that rotated its use, so that a caregiver was on the campus seven days a week, 10 hours per day. The personal care company paid for this staffing and, in part, the caregiver would provide a number of services such as helping with discharges home, assisting with transportation home (if needed), and providing three hours of “tuck-in” service at home. This safe discharge home program was paid for either by the family or the facility.

Though this is one study, the results provided prove that when applied correctly, a senior community can create longstanding and worthwhile partnerships with home care, personal care and hospice companies. The opportunities to work with not only these three types of organizations, but other community resources will help senior living communities be stronger and more financially viable companies.