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

90-Day Rolling Conversion Rate

If your 90-day rolling conversion rate is below 85% there is immediate opportunity to improve your census without making the phone ring more than it already is. This is one of the most misunderstood and correctly managed success factors. In the 100s of organizations I have worked with, there is a wide variation and interpretation of what is even considered a referral, the value of the pending list, etc. It is very difficult to improve your conversion rate if you cannot operationalize what your organization considers a referral. A review of the conversion rates I have encountered in organizations I have started to work with ranged from 58 to 78%. The NHPCO Gold Standard is 85% for a 90-day rolling conversion rate. This link provides further detail.

Medical Director Involvement

Is your Medical Director one of your top 5 referral sources? Your Medical Director, in addition to providing your organization excellent hospice and palliative care leadership, should be a champion in helping your organization serve more people and grow. This can be accomplished by your Medical Director making direct referrals to your organization and/or your Medical Director helping you expand your physician circle of referral influence. By being able to introduce your organization to physicians who start to refer is a wonderful thing. Read more on how to maximize your Medical Staff investment.

50 Quality Account Visits Per Week

To make a fire you need to rub two sticks together! To generate a predictable stream of referrals, you need to have your Sales Representatives be disciplined to make at least 50 account visits per week. Not just “milk runs” but quality well thought-out visits that deliver value to a referral source. Here is an overview of “The Happy Feet On The Street” strategy.

I hope your 2016 is filled with your ability to serve more patients and grow!

Looking back on my business life within organizations I have lead, and the 100s of organizations I have helped coached and consulted with, I am struck by the correlation in the cycle life of both businesses and individuals. They share many of the same needs, deficits, joy and pain as aging occurs. One of the biggest challenges I see is staying present no matter where you are in your life cycle. I learned to take the NOW out of my last name, “KazaNOWski” to stay present and enjoy the day. I highly recommend this approach as it helped create an organizational “lifestyle” or culture needed for where the organization is positioned in its development.

Generally speaking, most organizations dislike the planning process. It seems to steal too much from their present (time and resources, etc.) with little or no time to think and plan. It can be overwhelming. NOW is really about inspiring, connecting and engaging your organization to evolve, serve more people and grow. It can actually be fun and help shape your organization’s culture of growth.

True, you need to plan and make that a part of both your present and future. NOW is not just being present as much as it is about what to expect (managing your organization’s expectations) and what to do NOW (for today, this year and planning for future years). Understanding, creating and enjoying your own organization’s “aging” manifesto will help lead organizations to advancing both their mission and business objectives. It’s about living organizational life in the context of your own organization’s life journey (it’s past), it’s health (the fact the business world is changing as you read this), and most importantly your organization’s successfulness.

Where is your organization right at this moment? Are you a start-up focused on the NOW of getting services in place to drive revenue? An established business looking to up-level and grow? A mature business that needs to be adding and expanding service or product offerings? Or is it time to exit and wind down the business? In some cases, the business needs to be placed on “hospice” rather than pouring money and time into what has “aged,” on its ability to add value to a market place.

No matter where your organization is you must ask yourself, are you learning from your past to make both the NOW and future what you want? Are you able to stay present to enjoy and honor your organizations mission and business accomplishments? Can you envision a wonderful, happy and healthful future for your company? These are simple but powerful questions worth our time, thought and actions.

All these questions and more came rushing to me as I started my work with organizations on “Creating A Culture of Growth,” to assist these companies advance their objectives. Taking the “NOW” and better understanding the past, present and future of your organization’s maturation process, will help you develop a “Growth Manifesto” contributing to your organization and the freedom to achieve and create a culture of growth.

The Best

The potential impact of these trends will vary by market, and post-acute providers are struggling to understand how their market will be affected before setting a strategic direction. The questions they are grappling with:

• What is the market size of pre and post-acute referral sources?
• How much business comes from community-based programs versus hospitalizations?
• Who are the primary competitors trying to gain a seat at the “network” table and what is their market share?
• What are the levels of patient satisfaction or dissatisfaction and quality, as evidenced by patient transfers and re-admission levels?

Further, readmission penalties imposed under the Affordable Care Act mean that hospital administration is more invested than ever in caring about what happens to the patient, post-discharge. The challenges of understanding market demands and the resources to meet these needs is a “front and center” organizational effort. In some markets, economically incentivized programs, such as Accountable Care Organizations (ACO’s) and bundled payment initiatives will add to this pressure. I believe ACO will play themselves out and bundled payment more of the driver. The level of complexity in identifying, implementing and maintaining this network means that there will be little tolerance for innumerable post-acute “partners.” By necessity, hospital administration will have to consolidate its post-acute referrals into a manageable few “best of the best” providers, thereby creating a network.

Many health systems go through a “make” or “buy” process regarding their management of the patients outside the hospital. Here is a strategy I would like to make you aware of that could be a solution. Evolution Health is a health care company that specializes in the management and development of post-acute care continuums www.evhealth.net/. What I like about this company is that they create partnerships with health systems and assume risk as they work with the health care system.

Evolution Health is a care coordination and transitional care management solution to help reduce gaps in care, enhance patient experience and improve overall financial performance. They recently partnered with a large Catholic Health System to operate and manage their post-acute care continuum.

Today’s challenges require health care executives to explore all option as they address their patients once they leave the hospital campus.

– The Best

In the past, hospital administrators had no vested interest in what happened to patients once they left their facilities. Sad, but true. However, with the new Medicare readmission penalties, hospitals’ bottom lines are now at risk if certain benchmarks on patient readmissions within the first 30 days after discharge aren’t achieved.

Additionally, the establishment of Accountable Care Organizations (ACOs), as well as pilot programs in post-acute bundling, have further reinforced the message that hospitals will become financially engaged in the entire episode of patient care. What does this all mean…… recommending the “right” hospice and home health (both skilled and personal care) agencies to serve their patients has become a much more important issue than ever for hospitals today. So hospital management will now make this decision, no longer leaving it up to the discharge planners and social workers.

So what does this mean to your business development and sales efforts? As the sales targets for all home based companies shift from the discharge planner to the C-suite, you’ll find selling at this level requires a whole new skill set and knowledge levels. The days of pitching your services to a clinician over a muffin, donut and tchotchkes are over.
The following are five things you will need to explore with your business development leadership:

Gaining access to top hospital management versus discharge planners is more difficult. Although getting past the receptionist in a doctor’s office or onto the hospital floors may have been difficult, you usually could garner a brief impromptu meeting with a physician and/or discharge planner. Access to the C-level individuals, however, is much more restricted and involves more layers of organizational structure. Bureaucracy tightly controls the calendars of top hospital administrators, and tracking them down in the hallways of their institutions is usually impossible.

There are more people involved in the decision-making process. Due to the hospital’s finances are at risk, the number of individuals potentially impacted by this brand decision is greater than in the clinical sales process. More people means more messaging and communicating to have your message heard and understood.

Additional sets of agendas and different motivations now impact the decision. There are more people involved, which means there will also be more points of view, since each person could be affected differently by the decision. The chief financial officer may consider only the agency with the lowest readmission rate, for example, while the case management director may be primarily concerned about an agency’s responsiveness. Compared to a physician or discharge planner, top hospital administrators typically are:

• More concerned about business issues because they aren’t involved with patient care on a day-to-day basis.
• More analytic about their decisions and want proof or numbers to validate a proposed course of action.
• More focused about the impact on the entire organization – not on individual patients, as a clinical person might be.
• New thinking strategically.

Making a choice and implementing the final decision takes more time. Due to the magnitude of the potential impact on the organization and an increase in the number of parties involved, the decision may take longer than in clinical sales. In clinical sales, if the referral sources were swayed by your presentation, they could react by sending you a referral for their next patient. Implementing a C-level decision may take more time, since it often involves working through a number of people to affect frontline change – which also requires more messaging and communication.

Sales Force Skill-Set Training. Sales staff and Liaisons that work in hospital settings will need to do a “deep-dive” into understanding not only the value proposition on how to sell but as training in new phraseology and approaches to use. Your training and education focus and dollars will need to be change.

Wishing you the best!

• Decreasing their Mortality Stats (the actual number and related Length-of-Stay)
• Maximizing their DRG payments
• Reducing inappropriate hospitalizations
• Creating a new stream of revenue

Has anyone else experienced these challenges?

To some degree I understand this, having worked in a large complex health system for 16 years. While many hospital/health systems espouse system thinking that drives their behavior, you would be hard pressed to see that in action. Case in point, hospitals have a hard time of collaborating with hospice. Why? Who knows, but hospitals are working extra hard to develop their post-acute care continuum.

Here is a little case study. This one hospital has a Mortality LOS of 8.8 days. The LOS on all the hospice referrals made were 8.2 days. These two metrics in and of themselves you would think would capture the hospital executives attention. We tried to use this data as a respectful call to action and set up a meeting to have a dialogue.

After several attempts and many months we finally were able to secure a meeting with the CEO, CFO, CNO and CMO. Our objective was to establish a more collaborative (not exclusive) working relationship. We started our meeting by getting a better understanding of how the group perceived the data we shared with them. To our amazement, this was new information. And of course they didn’t totally believe our data (which actually came from them). Our dialogue then turned to specific programming we could offer to assist with both their mission and business objectives. We proposed the following:

1. Implement a GIP Scatter bed program.
2. A Hospice Emergency Department Diversion program
3. An ICU Collaborative Education program.

What amazed me the most was instead of being interested in how these programs could help, the C-Suite folks gave reason after reason why the timing was not right. These are relatively simple programs. This is one example that unfortunately plays itself out with far too many hospitals I work with.

There was a silver lining, however, as we were able to identify a physician champion who was instrumental in helping the hospital recognize how hospice could help. We were able to implement the programs listed above with the result after a year being:

1. Mortality LOS declined to 5.1 days.
2. Hospice referral patients LOS declined to 5.5 days.
3. $72,500 in revenue from the GIP Scatter Bed Program.

Has anyone else out there have a story to share?

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The Homewatch client was an 84 year old woman Joann who has an 89 year old husband, George suffering from metastatic cancer. George has been in and out of the hospital for multiple issues and was now in a Rehab Unit and scheduled to be discharged in a week. Joann called me to prepare for her husband’s homecoming. She requested 24-hour live in care and also help getting her husband onto the hospice. I suggested three-quality hospices in the community. Joann told me she was referred to one of the hospices by the Social Worker in the Rehab Unit and did not like them. After discussing what Joann’s concerns were, I recommended one of the other hospices. Joann asked if I would call them to get the ball rolling.

It was a Sunday evening about 7:00 p.m. I called the hospice and was connected with their intake department. I explained the situation and that Joann would like to talk with a representative about her husband. I gave the basic information and I painted the picture of what the needs were. The woman on the phone said they needed George’s physicians name so they could contact him to get an order for an evaluation. I paused and told the woman in the Intake office that all I was requesting was for a visit to Joann so she could make a decision on whether to go with this hospice or not. At this point in the dialogue, I thought maybe I had made a mistake recommending my favorite hospice to her. Trying to give the Intake person the benefit of the doubt, I thought maybe she was new and asked to talk to the supervisor on duty. At this point I identified myself and kindly requested to be transferred.

Things went from bad to worse as the superior insisted that they could not talk to Joann till they had more information. The supervisor went on to say she needed to check to see if they had a contract with the Rehab Unit where George was a patient. I told the woman on the phone that services would be delivered at home and I asked what difference it made whether they had a contract with a facility the patient was going to be discharged from. Now I started to get mad as I knew this was not the procedure. The reason I knew this was because I had helped developed it!! After being scolded by the supervisor, she told me she would handle it and thanked me for the referral and hung-up. I was in shock as to how I was treated and how painful the process was. I also wondered if they treated all their referral sources this way?

I ended up calling my colleague at this hospice who supervised the Intake Department and told her what had just happened. She was also in shock as that was not the procedure or approach this hospice had in place to handle a referral inquiry. Simply put, the procedure calls out for this action:

Name…Location…GO!!

In today’s competitive hospice world it is “first to bedside” who wins. Far too many hospices (especially the nurses) hide behind wanting more information as oppose to listening to the caller. All Joann wanted was someone to come talk with her. You DO NOT need a physician’s order to go talk to anyone about hospice. Yes, you need an order for an evaluation. That was not the case here.

So how would your hospice have handled this call? Do you “ghost-shop” for Intake processes during all different days of the week and times? Lastly, on a scale of 1 which means none to 10 which means high, rate your hospice on their sense of urgency to get to a referral inquiry within 2 to 4 hours.

By-the-way, George was admitted to hospice and Joann has a much improved peace-of-mind.

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I was on a conference call today with a group of hospice executives discussing this exact subject. There was a common theme with this dialogue that showed that there was not a consistency in the approach. Families and patients are scared just because hospice is hospice. Further, the fear of the unknown on how hospice works adds to the anxiety. All this is compounded if the patient is coming home from the hospital.

Patient satisfaction surveys showed that the first 24-hours are critical. When I was President of Hospice Care of the West, we embraced a strategy to enhance the patient experience and came up with these actions.

1. The admissions nurse had a checklist to things the family could expect would happen during the first 24-hours. Such things as; how medications will arrive, a visit from the Nurse Case Manager, etc.
2. The Patient Care Manager called the family to introduce him/herself and talk about the care team who would be taking care of them and answer any questions.
3. The after-hours service was described in detail and we made sure the family/patient knew the number.
4. We told the family/patient we would be calling the patient’s primary care physician to provide a status report.
5. The purpose of the Emergency Care pack was reviewed and a location of the packet in the home was assigned.
6. A tuck-in call was made to the family to check in and see how things were going. This would happen sometime between the 24th to 48th hour.

Several people on the conference call looked at the following metrics to measure the impact of an enhanced first 24-hour strategy.

• The Cost Per Day for the first 24-hours. To determine if the start of care cost were less when a “first 24-hour” strategy was in place.
• Patient Satisfaction. Several questions were included to measure satisfaction during the first 24-hours.
• Revocation. While a broader measure, declines in revocations were measured.

The byproduct of the first 24-hour strategy was that it helped in the creation of a “Culture for Growth” which I have written about in past post.
So what are your thoughts on a focus during the first 24-hours of hospice service? Does it contribute to a better patient/family experience?

The Best!

So how do you know if you had a strong or weak culture of growth working in your organization? There are few ways to complete a diagnostic exam. From a quantitative perspective, we all have KPI (Key Performance Indicators) in place in our organizations. Those dash-board indicators that allow you to measure the “vital signs” of how your organization is doing. An example would be the referral inquiry to admission conversion rate. A low conversion rate (70% and below) suggest that those “invisible velvet gloves” are at work turning your spigot of growth off. Lack of creative problem solving, fractured staffing, etc. are some of those “invisible velvet gloves” at work to turn your growth spigot off. For conversion rates of 71% or higher, there are usually internal factors such as a pro-active problem solving, working as a team, a clear shape focus, etc. that helps keep the spigot of growth open. It is important that you understand how open or closed your growth spigot is.

From a qualitative perspective, one of the best ways to get a feel for your culture of growth and whether the “invisible velvet glove” is opening or closing your growth spigot is to look at your Google, Yahoo or Yelp on-line reviews. In his book “Good To Great” Jim Collins talks about embracing the brutal facts before true change can occur. Taking to heart reviews that your customers write about you will give you another piece of data to help you size up your culture of growth. Today’s social media can give you instant feedback on your organization.

Understanding what type of culture you have in your organization directly relates to whether the invisible velvet gloves working in your organization are helping you serve more people and grow. Once you understand your current reality, you can drill down and put into place improvement initiatives targeted at strengthening your culture and opening your spigot of growth.

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The conflict in the Ukraine caused by Mr. Putin’s quest to re-assemble the old Soviet Union is wreaking havoc on the medical systems both in Russia and Ukraine. The traditional health care systems are funded by government money and with the sanctions the Russia’s are facing from the world, the infrastructure in Russia is starting to crack; including health care. The private health care sector is also suffering as people in these countries are seeing their incomes threatened and causing them to select between basic living and addressing health issues. In short, the health care status continues to decline. One of the consequence being that Global Medical Tourism for people that can afford it continues to grow.

Unfortunately, addressing hospice and palliative care needs in Eastern Europe continue to be a struggle. People are dying in pain; especially those dying from cancer. Most all these people could have experienced a comfortable, peaceful death and, yet, little is done. The good work started in Russia in the early 1990’s by the British Russian Hospice Society and Victor Zorza to develop hospice and palliative care programs is further endangered by the political climate in Russia.

In Ukraine, an organized hospice movement is basically non-existent. I wrote in a past blog that hospice and palliative care is approached as a human rights issues to prevent people from dying in pain. There have been several end of life conferences in Ukraine over the years but unfortunately they did not lead to any sustainable efforts. And with the current conflict occurring in Ukraine I am sad to say I do not see much progress in this area.

The work that Kseniya Shapoval has started in Ukraine in the area of Palliative Care is a solid foundation to build on. Her work to change the use of morphine was one of the largest steps to help improve the quality of life at end of life.

I will be back in Ukraine soon and hope to meet with Ms. Shapoval to further work on ways to improve the delivery of hospice and palliative care. I will also be back in Moscow this summer where my company will continue to work with several hospices in Moscow to seek ways we can collaborate to serve more patients and families in need.

The Best!