Monday, January 12, 2015

Valuable Experiences of a Hospice and Palliative Medicine (HPM) Fellowship


When asked by HPM fellows what experiences one should seek to strengthen skill set, I'll recommend the following (a currently practicing HPM physician would also do well to gain these experiences):

-Actively participating in any end-of-life care coalitions in the community, and if one doesn't exist, assemble several HPM practitioners in the community to start a coalition. Coalitions working to change the model of  late-life care in the community are a common element in those regions known for their exemplar practices in late-life care.

-Engaging in initiatives aimed at reducing late-life care clinical variation within the community. These often take the form of  interdisciplinary work groups standardizing protocols or tools, either within a palliative care organization or the community at-large.

- Joining with other clinicians in institutional or community-wide intiatives to ensure safe transitions across settings and reduce hospital readmissions. There is a strong palliative care component in prevailing readmission  reduction programs, among those the commonly used Interact (Interventions to Reduce Acute CareTransfers) tool.


The skills and competencies gained from these experiences will hold an HPM physician in good stead in securing the most attractive professional opportunities emerging in the HPM sector (see this previous post  for more on the emerging role of HPM physicians).

I'm curious to hear from current and recent fellows about what experiences you've found most valuable.

Tuesday, March 26, 2013

Stranger than Fiction: SDHIPC Demise a Painful and Difficult Story to Understand

Posted by Shelley Sansbury, health care strategist

This is a difficult story for everyone involved, most certainly the patients and their families and physicians, as well as many hundreds of ex-employees and volunteers, donors and creditors.

It is a difficult story to report…like chasing chickens…particularly when transparency doesn’t appear to be a value embraced by the current regime. Local reporters must rely on the Freedom of Information Act to get past the obfuscation of the spokesman for the distressed organization.

 
How and why a hospice practically venerated as an industry leader after 35 years could disintegrate in a matter of months is more than a little perplexing. Here, in broad brush strokes, are a few of the major milestones associated with the rapid devolution of one of the largest and most respected hospice and palliative care organizations in the U.S.

 


Jul 1, 2010 –
                        The Board Chairman announces the appointment of a former public relations and fundraising functionary with the San Diego Hospice Foundation as President and Chief Executive Officer, succeeding Jan Cetti who has retired after 14 years at the helm of SDHIMC



 
Feb, 2011 –
            A team of 8 Medicare auditors spend 5 days on site reviewing 149 charts of patients admitted to service between 1/1/09 and 11/30/10, the results of which are, more than 2 years hence, yet to be disclosed, according to CEO Pacurar.


Sept, 14 – Sept 22, 2011 –

            A team of 4 surveyors arrive from the CA Dept of Public health arrive to                     conduct a routine Medicare re-certification survey. Initially 20 patients are  sampled. The survey which lasts 8 days includes home visits to 5 patients.  Nine deficiencies are cited including agency leadership for failure to assure reporting of Adverse Events including errors in the use of a Computer-aided Drug Delivery (CADD) pump resulting in a patient  receiving 5x the prescribed dose of morphine sulfate. In the course of the survey the agency spontaneously reports two additional similar recent events. The survey sample is amended to include these patients. According to the survey:                                              

 

                        The facility failed to implement immediate corrective actions to prevent                                  reoccurrence of CADD pump (continuous ambulatory delivery device                                        used to deliver narcotic analgesia) narcotic overmedication incidents,                                             after the first incident on 8/7/11. Within 40 days of the first incident, 2                                      more patients were involved in CADD pump narcotic overdose incidents.                                         The Vice President of Inpatient & Nursing Services and the Manager of                                     Pharmacy were notified of an Immediate Jeopardy on 9/16/11 at 5:05P.M.

 

  Less than two hours after the Immediate Jeopardy designation, the Vice President of Inpatient & Nursing Services.presents a 7-point plan of  correction. Surveyors respond favorably and the Immediate Jeopardy is abated at 6:40 P.M.

 
Dec 12, 2011 -

            State surveyors return to verify implementation of the Plan of Correction

 
Jan 12, 2012  - 

            A senior official of the Survey and Certification Division of Medicare                                       writes:

 

Contrary to your allegations of correction, however, this resurvey, completed on December 12,2011, documented your continued noncompliance with Federal health and safety requirements. More specifically, as detailed on the enclosed the Statement of Deficiencies (Form CMS2567), the contents of which are incorporated by reference herein, the survey completed on December 12, 2011, documented deficiencies that, on balance, reasonably support a conclusion…of continued noncompliance with Federal health and safety requirements”.

 
As a result of continued non-compliance with Medicare Conditions, a warning of de-certification is re-instituted.

 
Feb 2012  -

            Medicare lifts its decertification warning, as a result of a revised Plan of  Correction, which perhaps includes engagement of an outside clinical  compliance team. It is unknown whether a formal Medicare Compliance Plan exists, or if this represents the advent of such.

 
Aug 2012 –

            Pacurar implements a patient care staff retraining program, presumably in response to the findings reported by the outside clinical review team she has engaged.

 
Nov 8, 2012 -

            A moratorium on patient admissions is imposed for a weekend

 
Nov 12, 13, 2012  -

            In apparently the first press report(s) (SD Union Times) of the organization’s distress, several almost contradictory claims are attributed to President and Chief Executive Officer Pacurar.

o   Although post payment audit results are still unknown, Pacurar said she believes there will be enough financial pain to require layoffs of up to 200 of the hospice’s 870 employees. “The organization, after the first of the year, will look different than it does today,” Pacurar said. “It will be smaller. It will focus solely on the great care of hospice patients.”

o   Pacurar said she believes the hospice is vulnerable to millions in rebates to Medicare because the program has not been strict enough in making sure that its patients are truly suffering from an illness likely to cause death within six months. She said doctors and care givers operated for decades on an “open access” policy that kept patients on hospice care for longer than six months, sometimes without being able to demonstrate that their condition was worsening.

o   The executive said she also dismissed the hospice’s previous chief medical officer (also the Chief Financial Officer…reported elsewhere) and instituted a new compliance department that will regularly audit patient charts before requesting payment from Medicare.

o   It remains to be seen, she said, how much of that amount the federal government will want back. At first, officials said they worried that the number could be as high as 60 percent. However, a recent conversation with a Medicare official gave them hope to believe any rebate will not be so high that it will cripple the operation.“I’m quite excited about moving forward. I have recently added new leadership to help me execute the plan that we’ve developed to take us through this difficult time,” she said

o   Within weeks of that report, Medicare notifies the organization they will be subject to 100% pre-payment claims review, but that decision is almost immediately revised to 100% post payment claims review is instituted; serious payment interruption is averted

 
Dec, 2012 –

      In a December meeting of the Board of Directors, the month-old  Hospice Chief Operating Officer, who as subsequently revealed in a Bankruptcy Court deposition has no operational health care experience, much less hospice, presents an "analysis" to the Board of Directors and the CEO, ostensibly a strategic plan that features  two very grim options: (a.) continue to operate as best as possible,  under intensified regulatory scrutiny and possible financial damage as may potentially result from the Medicare audits, repair the organization and  maintain the 35 year-old mission or (b.) accept the second option which the gentleman admits he favors: Shut it down…

 
Feb 4, 2013 –

San Diego Hospice and Palliative Care Corporation files Chapter 11.  Subsequent reports reveal the Board of Directors decision made in  December to close the organization. Reports also cite some type of  affiliation arrangement with Scripps Memorial Hospital that provides (a.) SDHIPC a $5M operating loan, (b.) an offer to purchase SDHIPC-owned   real estate for $10.7M subject to bankruptcy court approval (c.) absorption of remaining employees as well as (d.) patients (subject to Scripps      qualification of eligibility) into a small (2012 unduplicated census: 86 patients), for-profit, licensed and certified hospice in Poway, which Scripps has acquired in the preceding days and weeks.

Mar 12, 2013 –

Deposition of San Diego Hospice & Institute of Palliative Care Chief Operations Officer:

 read here:

 

 
This is a troublesome story with substantial ramifications for free-standing community-based not-for-profit hospice and palliative care organizations across the country. More to follow.

 

 

 

 

Friday, March 15, 2013

A Closer Look at San Diego Hospice (continued)

Contributor Shelley Sansbury responding to comment (below) about CEO's effort to change culture:


Please be assured my intention was not to cast aspersions on anyone. Rather it was to question the necessity of the decision to shut down the very highly regarded San Diego Hospice and Institute for Palliative Medicine in the wake of a Medicare Post-Payment Review of 149 patients.

What you call a 15 year long cultural disregard for the compliance requirements of Medicare mischaracterizes the Open Access policy pioneered by HSDIPM and now employed by more than one in four hospices throughout the country. Medicare eligibility rules clearly do not allow hospices to serve patients who seek curative care, and both the hospice physician as well as the patients’ physician must certify (and periodically re-certify) that the patient is terminal with a prognosis of less than 6 months to live. Within this framework however hospices are permitted to establish their own policies, procedures and criteria for admission and discharge. Whether a patient has a willing and able caregiver available at home can affect whether a hospice accepts or declines to serve a patient who meets all Medicare Hospice eligibility requirements. Abundant research has examined restrictive enrollment policies as barriers to hospice care. (The Debate in Hospice Care, J Oncol Prac, May 1, 2008: 153-157 http://jop.ascopubs.org/content/4/3/153.full). It appears to me SDHIPM's efforts to maintain an Open Access policy is commendable. You ascribe the fate of this organization to a new CEOs attempt to change the culture, purge the executive team, but it was too late…for what? Too late to manage to achieve proper alignment between a commitment to provide the best possible hospice care and Medicare regulatory compliance, an intention the executive expressed in a Nov 13 press report.

I am familiar with the financials, as reported to the CA Office of Statewide Health and Development (and available to anyone with an internet connection). In 2011 this hospice, with an annual unduplicated census of 4,665 patients spent $320K in palliative radiation therapy alone. In total for 2011, net operating expenses of $81M exceeded net patient revenue of $71M. Non-operating revenue including community support such as “donations and contributions” amounted to $12.5M, producing a positive total fund balance.

Another interesting item included in this report is the 78,375 “Medicare Reportable Hours of Volunteer Services”. While this may be of little relevance to the bankruptcy court, it is, and I hope you would agree, a genuine asset, and perhaps one more small reason to hope that those involved in the governance of this voluntary non-profit organization would muster the devotion to emerge from Chapter 11, rather than permanently abandon operations and put an end to the mission on which the organization was built.

 

Friday, March 8, 2013

A Closer Look at San Diego Hospice, Part 2


Posted by Blog Contributor Shelley Sansbury, health care strategist and former hospice and home care executive
 
Here are the facts according to 2011 SDH Annual Report furnished to the state. (Please note these data exclude services provided to patients in the SDH Acute Care Center, the license for which is in suspense.) SDH admitted 3,759 patients to hospice care in 2011. Including patients already on service their unduplicated census for 2011 amounted to 4,665. A total of 3.157 deaths occurred (67.5%). 543 non death discharges were reported. including 51 for whom prognosis was extended. The report specifies that 4,505 patients were actively served, and this unduplicated census accounted for a total of 363,629 Total Patient Care Days, including 346,350 Days of Routine Home Care (95.2%) and 12,059 Days of Inpatient Care (3.5%).

 
One of the measures I believe is useful in an assessment of a hospice is resource consumption as expressed in visits per patient-day

 

Discipline
Visits
Costs
Cost per Visit
Visits per Patient
Visits per Routine Home Care Day
RN & LVN
77,017
 
$17,743,679
$230.39
17.1
0.22
Social Services
22,435 
$3,520,629
$156.93
5.0
0.06
Hospice Physician Services
23,930 
$3,808,858
$159.17
5.3
0.06
Homemaker and Home Health Aide
60,020
$1.286,740
$21.44
 
13.3
 
0.17
Chaplain
16,968
$1,951,767
$115.03
3.8
0.05
Other*
 
 
 
 
 
 
 
 
 
 
Total
200,370
 
 
44.5
0.58

 

 
A review of the financial data for SDH represents what one might expect of an eleemosynary organization, with a service mission. That is, an operating loss subsidized by non-operating income, including memorials, donations, gifts and grants. Although the 28.2 % administrative cost burden seems possibly excessive,  nothing in this report suggests anything other than the performance associated with an industry leader.

 

 

REVENUE
 
 
 
 
 
Medicare
$104,918,252
83.3%
Medi-Cal
$12,022,848
9.6%
Other 3rd Party
$7,274936
5.8%
Private Pay
$1,413,167
1.1%
Other
$337,818
0.2%
Total Gross Patient Revenue
 
$125,898.449
 
Total Write-offs & Adjustments
<$54,722,163>
 
 
Net Patient Revenue
 
$71,176,286
 
 
EXPENSE
 
 
 
Visiting Services
$30,150,474
37.2%
Admin & General
$22.810,068
28.2%
Inpatient General Care
$8,915,012
11.0%
Hospice Service Cost Centers
$11,221,369
13.9%
Other Costs
$5,059,371
 
 
Total Operating Expenses
$80,980,525
 
Net Operating Margin
<$9,804,239>
 
Non-Operating Revenue including Memorials, Contributions, grants, etc.
$12,471,646
 
NET INCOME
$2,667,407
 

 I invite your comments. Anything extraordinary I'm missing?