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  This is obsolete in today’s environment.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

Why would you spend one more dollar to make your phone ring any more than it already is if you cannot convert the business that is presenting? It is amazing how many hospices do not pay attention to this important growth element. The reasons for this are numerous:

1. Most organizations do not truly understand the anatomy of the referral inquiry to admission process.
2. The intake process is viewed as a gathering of information and verification function and not fully integrated into the fabric of the organization.
3. Fragmentation between staff that answers the phone, especially on the weekend and after-hours, scheduling not only for an admission but first-responders to inquiry calls.
4. A passive approach to a referral inquiry call = “let us know when you are ready” as opposed to “would 2 or 4 work to stop by?” Listening to their story, fears, concerns, all their families’ dynamics and then suggesting interventions to assist with those obstacles.
5. The eligibility process is inconsistent and isn’t a real process. We ask admissions nurses when you have a complex patient, if you could choose one of your medical directors to work with on a case like this – which one would it be? They almost always identify one of the physicians – and the answer should be that our physicians consistently evaluate patients for eligibility in the same consistent process.
6. There is not a sense of urgency!

Years ago, we worked with a mid-sized hospice organization that offered Hospice, Palliative Care, and Private Duty services. The CEO of the organization called us asking for help to develop an access center to address the six issues sighted above. Each one of these service lines had their own intake process.  When referral inquiry calls came into the organization, if there was not a clear idea of what service line should handle the call, the ability to serve fell in between the cracks. Instead of immediately sending someone to talk with the family to determine what service would best meet their needs, the opportunity to serve was lost. The three service lines were also very siloed. The sharing of resources rarely occurred. This cumbersome arrangement led to many waits. I hate the word wait. But in these situations, a great deal of waiting was going on. There was no inherent sense of urgency. This specific scenario is too common. Whether you strictly provide hospice services or other services, the analogy of “first to bedside wins” is a key component to a successful growth strategy.

When we work with hospices to improve their referral inquiry to admission process and increase their conversion rates, we start by assessing the structures and processes currently in place. The five areas assessed are below:

The autonomy of the referral inquiry/intake process consists of these elements.

1. Capturing ALL referral inquiries that present to your organization. Do you know, not believe or hope, that you are capturing every inquiry that presents? Does your hospice have an operating definition of what a “referral inquiry” is? Not just a professional referral.
2. First-to-bedside-wins!! Building capacity and first-responder abilities. Demonstrating a strong sense of urgency! Capacity can be increased without adding FTE!!
3. Eligibility process. Preventing single-points-of-failures.
4. Building and working a superior 90-day pending list. A well-developed 90-day pending list is a salesperson’s best friend and a way to obtain an admission NOW!
5. Organizational collective wisdom and commitment to the process. Hospice organizations use an interdisciplinary team to care for our patients and families. Why don’t we use an organizational team approach to eliminate barriers preventing people from receiving the care they need?

So where to start? Truly understand your current reality in the areas referenced above. First, complete or commission a Mystery Shopper program to take stock in how your referral inquiries are being handled. We have completed several mystery shopping projects for hospice companies, and it is amazing how much potential business is being lost because of not having a specific protocol in place. The objective here is to widen the top of the referral funnel and assist all the people that touch your organization. If your hospice received a call from someone asking about the hospice benefit, would you consider that a referral inquiry? The answer should be yes! People do not sit around wondering about their hospice benefit unless there is something going on in their home. It is up to the hospice company to start a respectfully proactive process to determine how we can assist.

Second, review all your data for the past 12-months to determine:

• How many referral inquiries are presented to your organization on a daily basis?
• How many visits per day are made to referral inquiries (both professional and soft referrals)?
• What is your throughput rate? What percentage of your visits are same day? How many days from time of referral to admission does it take?
• Do you have the capacity to respond the same day to all your referral inquiries?
• What is your rolling 90-day referral inquiry to admission rate?

Third, does your organization have a strong sense of urgency? Reviewing some of the data that you gathered will help answer that question. How would you respond to the following:

When a referral inquiry comes into a hospice organization, the primary objective is to immediately (same day) set up a visit to get in front of the patient and/or family. Whether during regular business hours, in the evening, or on the weekend, the person handling the referral inquiry needs to have the ability to make an appointment and have a representative from the hospice make a visit to determine how best to assist. To accomplish this, the organization must build capacity using existing resources. In addition to the intake staff, sales representatives, etc. who can make a visit?  We suggest creating a bullpen of first responders who are available to make a visit. Building a bullpen looks like this: each month, everyone from the Executive Director to the Volunteer Coordinator signs-up for 1 to 2 days per month to be in the bullpen and function as a first responder to make a visit if they are needed. This approach talks to the organization having a healthy culture of growth.

Here is a story of a unique way to build your first responders and bullpen. When I was President of Hospice Care of the West, we had a man named Tom whose wife passed away on our services. Several months after the passing of his wife, he came and met with me and said he wanted to volunteer. Tom went on to say that he did not want to push papers, but would like to be able to interact with families and patients. Tom was a ex-Silicon Valley Executive. He presented very well and was a very intelligent man. I spoke to my Chief Clinical Officer and Director of Volunteers to ask if we could train Tom to be a first responder. They thought it was a good idea and after we had legal sign off, we trained Tom and he turned out to be an outstanding representative for our hospice. Tom connected immediately with the families he visited because of his own personal story. Tom worked about 10 days per month and he made a significant difference in our ability to provide same-day visits.

Fourth, is your admission and eligibility process a best practice? In other words, is your eligibility process just that: a process as opposed to an individual making decisions on eligibility? If your eligibility process is not well thought out with key structures in place to support it, you are vulnerable to single points of failure. A process that is driven more by an individual’s own opinions and not a set of eligibility processes can be dangerous. In one hospice I worked for, there was an eligibility committee in place that reviewed all admissions that were occurring. The eligibility committee was made up of a Medical Director, Chief Clinical Officer and the Admissions Nurse who was performing that admission. With any questionable eligibility concerns, the Eligibility Committee would come together to discuss the admission and determine how to approach it.

Other aspects of the admission process to assess are:

1. What is the length of time it takes to complete a full admission? Best practice is between 3-4 hours when using technology accelerators and a training process for admission nurses that will assist them to be efficient.
2. What does your admission packet look like? Is it a clean, well put together booklet? Or a folder with loose papers? Many organizations want to include everything in their admission packet, but you should carefully review everything in your packet to ensure they all serve a particular purpose. This is an admission, not a time to present other pieces of information. Patients and families are overwhelmed to begin with.

The fifth element is my favorite and the one that holds the most potential for growing your census! Having a workflow for a 90-day pending list in place. A pending list is made up of all those referral inquiries that do not admit within 24-hours. The only referral inquiries that do not make the pending list are:

1. We receive a referral inquiry, and the patient dies before we get there. A sin!
2. The referral inquiry lives outside the service area.
3. There is an administrative reason not to accept the referral.
4. The patient and/or family threaten bodily harm if we follow-up.

Every other referral inquiry that does not admit within 24-hours goes on to the pending list. Even a referral inquiry that selects another hospice. In this case we would give the family a few weeks to experience the other hospice and then make a courtesy call that would go like this: “Hello, this is XZY Hospice, and we received a referral several weeks ago regarding your interest in hospice. I am calling to make sure you have all you need” The family will respond one of three ways:

1. “Oh my god, I made a mistake. I am unhappy with the current service. They are not doing what they said they would do.” This is specifically most likely to happen if the hospice is hospital owned. In this case, we tell the family we would be happy to stop by and talk with them about their options:  “Would 2 or 4 this afternoon be comfortable with you to have a representative stop by and talk with you”
2. They respond that all is well and the hospice is great. In this case, we would remove this patient from the pending list.
3. The patient has passed and we offer our condolences.

Following are the typical barriers that prevent an immediate admission and the counter measures to employ.

The Intake Coordinator functions as that of an air-traffic controller of the pending list and has the responsibility for managing that list. They assure the counter measures for the barriers are being addressed. The Intake Coordinator does not do all the follow-up, but rather assures actions to eliminate the barriers that are occurring. This person also keeps track of the progress of all the people on the pending list.

The last key element is that of drawing upon the collective wisdom of the organization to eliminate barriers and assist in any way possible to facilitate an admission. In doing so, the organization takes on the ability to create a culture of growth. Here are a few examples of how to accomplish this:

1. Each morning, the Intake Coordinator holds a brief group meeting to review all the referral inquiries received the past 24-hours. Let’s say 5 referral inquiries occurred and 3 of these referrals were admitted. Celebrate those admissions! Then ask what the barrier(s) are for those referral inquiries that did not admit and execute a plan of actions on what steps will be taken to eliminate those. Draw upon the collective wisdom of the organization.
2. Each Friday, hold a group meeting to review everyone on the pending list. Review the barriers and determine what the appropriate next steps would be.
3. Every day at 4:00 pm the Intake Coordinator sends out a group text to people in the organization and asks, “Has anyone today talked with someone about hospice?”  The purpose is to grow the pending list and capture people we can assist and give the gift of hospice.

It is those organizations that strive to improve and install these key elements to the referral inquiry to admission process that excel at serving more people, growing, and giving the gift of hospice.

Here is a case study that demonstrates potential results.

Case Study

This is an opportunity statement for a hospice with a census of 105 and the benefits that will result from improving the referral inquiry to admission process.

The Why

The ability to increase XYZ Hospice’s referral inquiry to admission process is the most direct way to serve more people, improve census and profitability. This is because you are focusing on people who have already touched the organization as opposed to looking for a new referral. By strengthening the organization’s skillsets, structures, and processes to convert people who already have a health challenge occurring, allow an immediate ability to serve more people, grow, and strengthen financial performance.

A quick review of XYZ Hospice’s referral inquiry to admission process showed many opportunities for improvement. For example, several mystery shopping calls demonstrated the system is underperforming and calls were not captured and potential ability to serve was lost. The pending list was not being worked to the degree possible. There was a lack of capacity to achieve steady same-day-admissions.

Following is an ROI analysis based on a set of assumptions. XYZ Hospice can adjust the information used based on your own data.

Assumptions

1. Five incremental admissions per month from improvements in the process. This number is based on performance results we have achieved with other organizations.
2. LOS of 68 based on average LOS in the State.
3. A blended reimbursement rate for a routine day of care of $168
4. Sixty-eight percent direct care cost

ROI

5 incremental admissions (month 1) x 68 LOS = 340 days-of-care x $168 = $57,120. 68% direct care cost $38,842 which would generate $18,278 in free cash flow.

Annualized

• 5 admissions x 12 mo. = 60 admissions
• 60 admissions X 68 LOS = 4,080 days of care
• 4,080 DOC x $168 = $685,440
• Sixty-eight percent direct care cost = $466,099
• Free Cash Flow = $219,341.

Should the process improvement only achieve 50% results, the free cash flow would be $109,671.

Other Benefits From Improving This Process

• Improvement in LOS as patients will be admitted sooner.
• Increase in referral source, patient and family satisfaction because of improved communication and demonstrated sense of urgency.
• Use this work as a QAPI project.

Kurt A. Kazanowski, MS RN CHE
Managing Partner
Hospice Advisors
296 S. Main Street, #202
Plymouth, Michigan 48170
1.734.658.6162
www.hospiceadvisors.com
https://kurtkaz.com/referral-inquiry-to-admission-conversion-rate/#more-271

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

The first point Collin made was this- “No System, No Business!” What he meant by this was that if you don’t have a system in place to drive business, you don’t have a business. The philosophy here is “structure can be liberating.”

Consulting with hospice organizations has taught me that the business development (referral inquiry, marketing, sales and referral development structures) do not have the sustainable systems in place to drive steady predictable growth. As I have said many times before, “everyone wants to serve more people and grow, but not everyone does what is necessary to grow.” The discipline required to develop and sustain systems are just not reached. Question: Can you and your organization clearly articulate what your systems and processes are for referral inquire to admission, marketing, sales and referral development?

Collin also suggested 3 specific “secrets” that an organization is serious about growth consider. They are:

Secret #1 Determine What You Want To Be. Understand your Brand. Not all hospices are created equal. Do you offer all 4 levels of hospice care in a service focused and quality manner? Understand that marketing/sales is different than branding. Branding means to differentiate yourself. You need to have a solid positive Branding Statement. Marketing is getting people to notice you are different by appealing to their senses.

Secret #2: Your MUST Have a System. A requirement for success lies in your ability to have a system for your referral inquiries to admissions that is built around a 90-day rolling conversion rate. Your funnel, a sales system that is more than your sales team making milk rules.

Secret #3: Create Community. Does your organization work with your referral sources to create “win-win” situations and opportunities. Give your expertise away to build community and drive future revenues. Giving free seminars, workshops, etc. that connection to your SYSTEM, drive people into you funnel and help create business ($$) opportunities.

When you look at your systems, do you have specific ways to follow up on those patients NTUCed (Not Taken Under Care) so that you keep them in your funnel? This is part of a well-developed Referral Inquiry to Admission process. How about those patients that revoke? What is your system for engagement and follow-up? The same question applies to those patients that leave your organization as live-discharged?

Developing those systems starts with a solid Business Development plan focused on serving more patients. This plan helps advance both mission and business objectives.

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This hospital made 201 hospice referrals during a 12 month period. The LOS on these hospice referrals was 13.3 days, ouch! The hospital’s overall LOS is 4.9 days. Why the big difference? A few thoughts are below along with some possible measure on how to lower that LOS.

Before we review these thoughts, this large difference in LOS between hospice referred patients and other patients provides a significant opportunity for hospices to bring value to hospitals. Knowing how to first understand a hospital “pain” in this area and secondly how to work to lower it will give a hospice an inside track in developing a strategic relationship with the hospital.
Following are some potential reasons as to why and counter measure to address.

A suggested approach to start the process is to find a way to talk with someone in the hospital’s C-Suite. Either the Chief Financial Officer or Chief Medical Officer. You are most likely to get the attention of these people! Then ask to have the hospital share the following:

1. The Mortality LOS for the hospital.
2. The number and LOS for hospice referral made from the hospital.
3. The hospital’s overall LOS.
4. The average cost per day for the hospital.

Once you have this data the trick is to do a basic analysis and show the number of excessive days for those patient that had a hospice referral made. Then simply multiply these excessive days by the average cost per day. This dollar amount is the opportunity in how you can assist the hospital improve its efficiency.

If you would like to talk though more of the detail, please feel free to give me a call, 734.658.6162.

The Best!

My initial efforts started with a traditional sales model. I had three sales people working the segments of Geriatric Case Managers, ElderLaw Attorneys, Assist Living Communities and the well. Maybe I didn’t have the right people and/or I didn’t do a good job with training, but the results were poor.

So I changed my direction and and came up with a new plan. I implemented an Internet and social media strategy and saw that after 8 months my billable hours grew from 3,500 billable hours to over 6,000 billable hours per month. I’d like to share what I did.

The rationale for this move was supported by an article I read in the Wall Street Journal which sited that next to Adult Content, the next thing people search for on line is health and medical information and resources.

The first thing I did was build a great online presence for my brand, but more importantly I took the time to educate myself and invested financial resources toward serious Search Engine Optimization (SEO). I met an expert in web development, digital marketing and SEO, Al Baiocchi, the President of FrontPage Interactive. Al helped me develop my website with a focus on maximizing the opportunities to rank all of my website 127 pages on the first page of a the major search engines. SEO is a long term process and requires patience and long term commitment, but here is just one example how my site pages are displaying in the “organic” results of Google:

This type of “organic” or natural search traffic is highly targeted and generally results in better lead conversion than Pay-Per-Click advertising. Recent statistics show that an “Organic” search result is 8.5 times more likely to be clicked that a pay-per-click ad.

The second thing I did was invest in working with Caring.Com, an online referral service. I made sure we obtained clients reviews and posted them on Caring.Com which helped strengthen our position. Last month we received 16 referrals from Caring.Com of which 3 converted to a Start-of-Care. One was a 24-hour Live In Case. I also work with ElderCare Link which is another online referral service. The other referrals are on our pending list which we are working on.

The third thing I did was to hire a publicist. The objective was to help enhance our visibility and establish Homewatch as an authority (not just an expert) in personal care services. This lead to people both accessing our website and directly calling the office.

Lastly, I employed a Public Relations/Communication professional to help support the publicist work occurring as well as establish our presence on Facebook and LinkedIn.

While I have not given up on direct sales, I am firmly putting into place our internet and social media strategy.

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If you achieved your 1st QTR growth goals, congratulations! I hope the rest of 2015 brings you the best! If your growth was flat, or even worse, has declined, it is time to act. If your growth goals were not achieved, it is time to quickly “re-group” and “re-tool” as the rest of the year will fly by and before you know it you’ll be asking (or your boss) “Why didn’t we grow? What happened?”
Here are a few things to assess (and if broken) fix!

• Go back and look at your Not Taken Under Care (NUTC), and audit those cases to determine which ones should have NOT been NUTC. A referral is only NUTC if: they died, are outside your service area, tell you never ever to call them again or you do not accept their insurance or payer source. This is a QUICK fix to serving more patients.
• How many direct or indirect referrals did your Medical Director help secure for your hospice? If it was less than 9, it is time to sit down and chat with your Medical Director.
• What is your 90-day rolling conversion rate of referral inquiries to admission? To figure that out, add up all the referral inquiries received in January, February and March, and divide them by the admissions for the same period. This will be your April 90-day rolling conversion rate number. If it is below 75%, please call me, 734.658.6162, I can help.
• If you have sales people working for you that have been with you 6 months of more, these folks should have contributed at least 15 admissions in the 1st QTR. When was the last time you had a sale training program to work on skill set development and sales tool development?
• Do you have at least 5 Senior Living Communities with at least 3 or more patients in them? Pull together a cross-functional group from your organization and have a dialogue around this opportunity.
• Have you held at least one growth meeting with as many people in your organization to identify and discuss both barriers and opportunities to grow? Having a guided dialogue about growth is the first step in creating a culture of growth in your organization.
• If you have a Home Health company as part of your hospice company, how many referrals did you receive from Home Health as part of their discharge planning? For every 100 Home Health census, the rule of thumb would be 2 to 3 per month.

These are a few quick things that you can address now, to make your 2nd QTR growth goals successful.

The Best!

In working with hospice around the country there are two things that contribute the most to nurse burn-out and dissatisfaction ultimately leading to nurses leaving an organization and this weakening the core. Those things being after-hour call duty and doing admissions. These two factor have been identified as issues related to nurse retention.

Here are a few counter measures to help solve the problem. What are your thoughts?

There is an on-call company that specializes in handling after hours and weekend hospice calls. Hospice-On-Call is a Chicago based company that works with 100s of hospices across the country to handle after hours calls. They can alleviate call volumes as about 60% of after-hours and weekend calls are non-clinical in nature. The other 40% clinical calls are triaged so as to achieve better outcomes. The cost to this service is between $11-$12 per patient per week or $1.57 to $1.71 PPD. I not only view this as a cost for a good service but a nurse retention expense to ensure a strong core. A strategy worth exploring.

The other core building strategy applies to those hospices who have a census approaching 60 to 70. These hospices are in a position to develop an admission nurse function which does a few things. One, eases the pressure for Nurse Care Manager from having to do an admission. An admission function would handle 70% to 80% of the admissions. Case Managers will be able to focus more on managing their 12 to 14 patient caseloads. These factors will also help enhance retention. The other benefit of having a dedicated admission function is an ability to get a patient admitted sooner. If a Case Manager gets an admission request the end of the day or even better Friday afternoon, there is a chance that admission will be pushed off a day or two. This is not only a loss of revenue but an opportunity to serve a patient and family in need. Case Managers recognize this and it contributes to their stress and burn-out and potential leaving the organization.
These are two strategies worth pushing to help build the core strengthen of your hospice, the Nurse Case Manager. What are your thoughts?

The Best!

As the quest for enhanced productivity and performance in hospice organizations are being looked at, obviously, the management of our labor pools is at the top of the list. Home care nurses are paid on a per visit bases. So some management folks are asking “why not look at pay for visit for hospice nurses?”

Some of the people I have spoken with feel that applying a pay for visit to a hospice model of care flies right in a face of the hospice philosophy. Managing a hospice case load with a variety of patients at different stages of end-of-life requires longer and more intense visits for some patients/family than other. Most home care patients and visits are more predictable in terms of the care plan and path where this is not necessarily so with hospice patients.

The theme I discovered from hospice executives I have spoken with is that if you force a hospice nurse to make a “quota” of visits that the unintended consequence and subsequent outcome will lead to patients and families being “short-changed” on the care, attention, and services necessary to provide the best patient care. I agree with this thinking.

The other concern from hospice executives is that by opting for a pay for visit model the nurse turn-over will increase. Nurses who may be required to do on-call, admissions, etc. will burn-out. In communities where it is difficult to recruit and retain hospice nurses, a pay for visit model could make it extremely difficult to meet the demand for nurses.

The other issue related to a consideration of a pay for visit model with hospice nurses is how to handle the pay for visits related to GIP and Continues Care visits. The four-levels of care require a variety of staffing patterns. Applying a pay for visit model to a multi-level care approach would be challenging.

Do you have any experiences with hospice nurse pay models? What are your thoughts on a pay for visit hospice nurses model?

The Best

Savvy business people are increasingly using LinkedIn as a primary source of new leads and tangible revenue. In fact, for business to business, LinkedIn is a critical tool that can make your prospecting faster, smoother and, ultimately, more profitable. With over 150 million members worldwide, LinkedIn is one of the major social and business networks. What I am sharing with you, I leaned from a colleague who help me re-design my LinkedIn profile and also how to better use it. I have already recognized the benefits of my improved use of LinkedIn through both new business and an expanded network approaching 20,000 people. There are several great articles you can find on the internet on how to better use LinkedIn. Take the time and look around. Here are 10 tips I recommend you consider as you start your journey to becoming a super-user of this valuable tool.

Tip 1: Never miss a chance to connect

The first piece of advice I received was get serious about LinkedIn and take a long hard look at your contacts. Contacts are the currency of LinkedIn. If your contacts are predominantly family, friends and old school pals, you’ve got some work to do. I went from spending a few hours a week on LinkedIn to a few hours a day!! I start and end my day on LinkedIn. Connections be-get connections. Your first level contacts open up a route to a wide range of second and third level connections. This is how you scale your network and grow it. Whenever you meet anyone always follow up quickly with a connection request while you are still fresh in their mind.

Tip 2: Discover the power of Relationship Mapping

Follow the rule of “the six degrees of Kevin Bacon”. Use LinkedIn to map out the decision makers within the organizations you are targeting. I deal with large complex health systems and organizations, so there can be numerous people involved in making and influencing a decision. This approach is also useful for smaller B2B sales. You’d be surprised how much information people put in their profiles. What projects they are working on. The strategic directions the company is taking, etc. With a little detective work, you can quickly create a clear picture of the opportunities.

Tip 3: Better quality calls

Cold calls will become a thing of the past! With LinkedIn, there really is little or no excuse for going into any call totally cold. With LinkedIn, you can almost always learn enough about someone to make your call more meaningful, focused and relevant. When you make an invite to join your network, make the note you send personal. And away thank the person for accepting your invite. I find it helps break the ice. Plus it shows I’ve gone to more trouble than 90% of the other people who call them. I pay particular attention to changes in profile, status updates, connections we have in common and anything they’ve posted to a group (which can be reason enough to call them in the first place). Also, with a paid account, you can see expanded profiles of everyone on LinkedIn (not just those of your immediate contacts). This provides even more useful insights you can use to make a real-life connection.

Tip 4: Avoid the Gatekeeper!

IN Mail is LinkedIn’s internal email system and allows you to send an email to any LinkedIn user without requiring an introduction. Basically, it ensures your email gets through to their inbox. LinkedIn claims that an IN Mail is 30 times more likely to get a response than a cold call. IN Mails are only available on paid accounts so consider an upgrade. The higher level the account you have, the more you get. On the entry-level business account you’ll get three IN Mails each month. Get serious and upgrade as it is well worth it.

Tip 5: A smarter way to search

LinkedIn has a fabulous search facility. With their advanced search you can find people by title, company, location or keyword. Grab a paid account and you can add company size and seniority level also. By intelligently mixing the different filters you can get really deep and identify key individuals quickly and easily.

Tip 6: Keep an eye on what is going on with your account

People come and go, especially in health care. Keep an eye of what is going in the organizations you are targeting. LinkedIn makes discovering these changes easy. You can follow any organization that has a LinkedIn page. That way you’ll see anything that changes directly in your updates. It’s an easy way to stay up to date and spot new opportunities.

Tip 7: Become a “groupie”

Join as many groups as you can. The dialogue in these groups is a wonderful way to learn about industry trends as well as people. Groups are incredibly useful in three other ways:

1. They can give you further insights into what’s happening within a prospect Organization – how active they are, whether they’re hiring etc.
2. They allow you to learn more about the individual details of folks you are interested in.
3. Group membership gives you both the reason and capability to make more connections.

Tip 8: Put your profile to work for you!

Make sure you include current links to your company site, your Twitter account and Facebook page. Completely fill out all the areas in your profile. Don’t shy. The goal here is to achieve high-visibility. You should also get some high quality recommendations – especially from existing folks you work for!! This will give people visiting your profile a better idea of what you’re like as a person. Remember, people buy and refer to people!! Finally, always add a photo and video. It makes you more tangibly real and creates a good impression. Make sure it’s a good quality shot!!

Tip 9: Who is looking at you??

The first thing I do every time I sign onto LinkedIn is to look back at who has looked at my profile. Unless someone sets their profiles to anonymous, you can click on the “Who’s viewed your profile?” link and see a list of them. The free account limits how many you can see while paid accounts give you the whole list. Here is how to use this “look-back-trick”:

1. The fact that someone looked at your profile is a good excuse to reach out with a connection request.
2. If you look at other people’s profiles, a certain proportion will always look back.

Tip 10: Participate

As I said in the begging, spend time nurturing your “garden” Participate in on-line dialogue with your groups. Express your opinions and become a though-leader. Update your profile as often that makes sense. Seek out new people to invite to your network. You only will get out what you put in.

Come and connect with me on LinkedIn.

The Best

Kurt Kazanowski