Has anyone read this?

Specialties Hospice

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req_read

296 Posts

Specializes in Med-Surg, ER, ICU, Hospice.

BeExcellent…

I looked at your profile & see we are peers… but I’ll take the “Coot” designation since it probably has more to do with temperament than age.

In terms of: Has Anyone Read This… I recommend the Rand study on the Hospice Benefit. I found it via NHPCO’s website… but I don’t see it there now. That doesn’t mean it isn’t there somewhere… legally blind guys don’t see lots of things. But if you can’t find it and want to read it send me an email and I will forward it to you (PDF file.) It’s a little dry as reading goes, but the stats are telling.

river1951

Moving from large metro to rural aye? It is a different world!

For one thing, what are the demographics? Some ethnic & religious groups are inclined to “take care of their own.”

Second… if your population is small your hospice population will be small and erratic… which means your income will be small and erratic. You will have to do more of everything yourself and rely as much as possible on volunteer help. Securing required team members (doctor & MSW) can be a really big problem. The bereavement person is much easier.

Another key is understanding the cap. I keep mentioning this and no one ever responds so I don’t know if it is well understood or not. Suffice to say, when I started running a rural hospice I sought advice from experienced hospice people and they gave me bad info. It took a couple of years to figure it out on my own… but here is a clue to what I am hinting at (if you understand this you will know what I mean.) DO pick up patients you know will probably die within a day or two. You will lose money on them but gain in the long run. The shortest time I ever had one patient was one hour… and he signed himself in.

The good thing about rural hospice is the down home, friendly attitude. People who live out in the boonies really appreciate someone coming out there and spending time with them. They also tend to be self reliant. If they weren’t, they wouldn’t be out there in the first place. Teaching is extremely important with them because you probably won’t have time to get there when death is imminent… especially when you will probably be the only nurse and may be on the opposite side of the county when that occurs.

You will get to sample some really good home cooking.

Get a pickup… you may be delivering some DME. Also, find a place to store donated commodes, wheelchairs, bedside tables, etc. so you don’t have to keep buying/renting them.

Once a JCHO agent asked me what we did with dirty sharps. I told her we dropped them in the cattle guards on our way back to the office.

Ha, ha, ha.

req_read

296 Posts

Specializes in Med-Surg, ER, ICU, Hospice.

Oh yea... one more P.S.

Get used to people having a rifle & shotgun leaning in or corner or a pistol hanging on the wall. That is SOP.

doodlemom

474 Posts

BeExcellent...

I looked at your profile & see we are peers... but I'll take the "Coot" designation since it probably has more to do with temperament than age.

In terms of: Has Anyone Read This... I recommend the Rand study on the Hospice Benefit. I found it via NHPCO's website... but I don't see it there now. That doesn't mean it isn't there somewhere... legally blind guys don't see lots of things. But if you can't find it and want to read it send me an email and I will forward it to you (PDF file.) It's a little dry as reading goes, but the stats are telling.

river1951

Moving from large metro to rural aye? It is a different world!

For one thing, what are the demographics? Some ethnic & religious groups are inclined to "take care of their own."

Second... if your population is small your hospice population will be small and erratic... which means your income will be small and erratic. You will have to do more of everything yourself and rely as much as possible on volunteer help. Securing required team members (doctor & MSW) can be a really big problem. The bereavement person is much easier.

Another key is understanding the cap. I keep mentioning this and no one ever responds so I don't know if it is well understood or not. Suffice to say, when I started running a rural hospice I sought advice from experienced hospice people and they gave me bad info. It took a couple of years to figure it out on my own... but here is a clue to what I am hinting at (if you understand this you will know what I mean.) DO pick up patients you know will probably die within a day or two. You will lose money on them but gain in the long run. The shortest time I ever had one patient was one hour... and he signed himself in.

The good thing about rural hospice is the down home, friendly attitude. People who live out in the boonies really appreciate someone coming out there and spending time with them. They also tend to be self reliant. If they weren't, they wouldn't be out there in the first place. Teaching is extremely important with them because you probably won't have time to get there when death is imminent... especially when you will probably be the only nurse and may be on the opposite side of the county when that occurs.

You will get to sample some really good home cooking.

Get a pickup... you may be delivering some DME. Also, find a place to store donated commodes, wheelchairs, bedside tables, etc. so you don't have to keep buying/renting them.

Once a JCHO agent asked me what we did with dirty sharps. I told her we dropped them in the cattle guards on our way back to the office.

Ha, ha, ha.

If you would explain the cap that you are speaking of that would be helpful. Are you speaking of capitation as in how hospitals are paid by insurance companies? Hospitals get paid a lump sum of money for a certain diagnosis or procedure and if the hospital needs to keep the patient longer than what the insurance company pays for, it's too bad for the hospital. If they keep them less, then it's great for the hospital and they make money. That is why hospitals want to get pt's out as quickly as possible. Hopsices are paid per diem - same rate for every patient. Some private insurances have a "cap" of how long they will pay for or how much money they will put out for a patient on hospice, but again this is paid for on a per diem rate - not a lump sum. If we have a patient on service for one day, we've paid for 3-4 hours of a nurses time, DME, and medication. If the pt is on Medicare/caid, we get somewhere around 120 for that day. With most private insurance, we get about 90. We are far outspending what the insurance company has paid us. I don't see how that could be beneficial in the long run.

req_read

296 Posts

Specializes in Med-Surg, ER, ICU, Hospice.

Forget about privates insurance… they are all different. Most hospice income is via Medicare or Medicaid anyway (because most hospice pts are old enough to qualify… thank goodness!) So you do your basic figuring on Medicare.

Medicare pays per diem… same amount every day. Your first 3 days (admission days) are high cost/labor intensive and your last 3 days (discharge/death) are high cost/labor intensive. You lose money on those days… the per diem does not cover the costs. When I first started I was told I had to have a patient around two weeks to make it pay. I was advised to avoid picking up short-term patients. You make your money in hospice in between admission & discharge when everything is lined out and your patient/family is cruising. The longer that in between period, the better you make out.

HOWEVER…(and this is a HUGE however) that’s talking about just one patient. Your annual cap includes ALL (Medicare) patients for the WHOLE year. You have to think in terms of averages.

First of all, the cap (there are actually 2 caps but this is the important one) is a specific dollar amount… but its an average… an average of all the (Medicare) patients in an agency for the whole year.

Here is an interesting point: the cap is less than 6 months. Isn’t that weird? A program designed for “6 months or less” caps out in less than 6 months?

If you have only 1 patient in your agency and that patients lives 6 months, you will cap out at a little over 5 months and have to pay the last month back.

HOWEVER… (another big however) the average length of stay for most hospice patients is way under the 5 month mark… so most hospices never get near the cap.

Look at it this way… say you have 1 patient for 1 year… that’s it… no more. You will get paid for only 5 months. At 5 months you have reached your annual cap and will have to provide care to that patient for the other 7 months of the year for free.

Now let’s say you have 3 patients. 1 lives 1 year and the other 2 each live one day. That’s 367 total patient days for the year. Then divide that by your 3 patients and your average length of stay = 122 days… which is well within the cap. You are now getting paid for every day of every patient. Sure… you lost a little money on those 2 one-dayers, but averaging them into your total allows you to get paid for the last 7 months on your long-term patient… which you would otherwise have lost.

After I figured this out I admitted patients no matter how close to dying they were… and I never came close to hitting my cap. I had one patient for 2.25 years and still never came close to hitting the cap (that pt was a COPDer by the way… I swear, she operated on some kind of anaerobic metabolism.)

The big guys (hospices) have apparently figured out how to get their average lengths of stay higher & higher. Which in some ways would be okay… as long as they were doing something useful… like teaching dying process for example and not just collecting the per diem. Some hospices go over the cap… over an average length of stay of 5 months (to the tune of 96 million dollars in 2004!) That just boggles my mind because I always had a hard time getting my average length of stay over 2 months, much less over 5 months! But they are doing it… I have no idea how.

One clue was the post by the nurse in Florida telling of patients who everyone knows are not terminal being cared for in a long term care facility with hospice involvement. I have no idea what kind of doctor would keep certifying patients who are not terminal… but it seems it would be a good way to lose a medical license if anyone squealed. And I never did get involved with long-term care facilities. That was just coming in when I was going out, so I have no idea about the “opportunities” there.

doodlemom

474 Posts

I never knew that. We've never turned any patients away based on how imminent they were. We just want to make sure that the family has our support and breavement services.

The mega corporate hospices - Vitas, Odyssey, Vistacare, all do about 80% of their business in nursing homes where the length of stay is much longer. They mostly invest their marketing dollars in the nursing facilities. They hire nursing home medical directors to be their medical directors which gets them more patients at an earlier time. All of the mega hospices tell you that they do charity care and they do, but this is very limited because patients in nursing facilities are 100% funded.

aimeee, BSN, RN

932 Posts

Req read, thank you for explaining the cap. Very interesting. I hadn't realized that. We are in no danger of even coming close. But even if there weren't a financial reason to take on those imminent death patients we would...its just the right thing to do. The other reason for admitting those short stay patients is that even though WE know we could have done so much more if we had gotten the patient earlier, the family is often extremely grateful for the intense help they get in that last day or so. They tell everyone they know how grateful they are. That generates both memorial contributions and gets other people thinking about it too, and having heard about it, hopefully they may ask for a referral earlier when they have a family member in the dying process.

indigo girl

5,173 Posts

Specializes in Too many to list.
EmptytheBoat...

Old Coot! Old Coot!

Well... getting old beats the alternative I guess.

Don't complain about the price too much. Last year my net income was 0. The year before that I netted $176... probably about what you make in a day. But I am slowly building up my infra-structure.

Who knows... maybe someday I'll start a hospice and make some REAL money (before HCFA stamps on the whole thing like a roach in the kitchen... which probably won't be too much longer by the way.)

I have not read Final Gifts. I would like to but am legally blind and can't read (I'm an illiterate write.) I did not read it before my eyes went bad because I did not want it to influence my writing.

Leslie...

I am glad to hear my writing and that of other authors is in general agreement. I expected that it would because I have found that people are people and go through the same process... so any serious student of dying process should discover similar things. Dying is like life; i.e. everyone charts a unique course but the rules and stages are the same for all.

A couple of my favorite authors/speakers are Fred Allen Wolf & John Hagelin. They are both quantum physicists who have branched out into studying consciousness as well. Both were involved in the movie What The Bleep Do We Know... which I recommend highly by the way. Lots of quasi-scientific thinkers contend that the possibility of life transcending death is "unscientific." Well, leading thinkers in the field of quantum physics do not think so. According to them the physical universe is an illusion... a manifestation lf "unified consciousness," of which we are but a part.

When I first wrote Crossing The Creek I knew I was going out on a limb (spirituality wise) but can now relax knowing that quantum physics is on my side.

Quantam Physics is definately on your side! This is exciting and wonderful.

How are you reading and writing with your eyesight being so bad?

leslie :-D

11,191 Posts

One clue was the post by the nurse in Florida telling of patients who everyone knows are not terminal being cared for in a long term care facility with hospice involvement. I have no idea what kind of doctor would keep certifying patients who are not terminal... but it seems it would be a good way to lose a medical license if anyone squealed. And I never did get involved with long-term care facilities. That was just coming in when I was going out, so I have no idea about the "opportunities" there.

i think i wrote about a committee i once was on.

an aggressive attempt to initiate hospice services in a ltc facility.

they analyzed ea and every chart w/a fine tooth comb.

they would be eligible for hospice services based on different criteria, i.e., ftt, wt loss, decline in function, major illness, etc.

i felt nauseated as i listened and observed.

it felt like slaughterhouse 5 and i walked out.

yet if these pts became hospice-eligible, this was indeed a money-maker. :stone

leslie

weetziebat

775 Posts

forget about privates insurance... they are all different. most hospice income is via medicare or medicaid anyway (because most hospice pts are old enough to qualify... thank goodness!) so you do your basic figuring on medicare.

medicare pays per diem... same amount every day. your first 3 days (admission days) are high cost/labor intensive and your last 3 days (discharge/death) are high cost/labor intensive. you lose money on those days... the per diem does not cover the costs. when i first started i was told i had to have a patient around two weeks to make it pay. i was advised to avoid picking up short-term patients. you make your money in hospice in between admission & discharge when everything is lined out and your patient/family is cruising. the longer that in between period, the better you make out.

however...(and this is a huge however) that's talking about just one patient. your annual cap includes all (medicare) patients for the whole year. you have to think in terms of averages.

first of all, the cap (there are actually 2 caps but this is the important one) is a specific dollar amount... but its an average... an average of all the (medicare) patients in an agency for the whole year.

here is an interesting point: the cap is less than 6 months. isn't that weird? a program designed for "6 months or less" caps out in less than 6 months?

if you have only 1 patient in your agency and that patients lives 6 months, you will cap out at a little over 5 months and have to pay the last month back.

however... (another big however) the average length of stay for most hospice patients is way under the 5 month mark... so most hospices never get near the cap.

look at it this way... say you have 1 patient for 1 year... that's it... no more. you will get paid for only 5 months. at 5 months you have reached your annual cap and will have to provide care to that patient for the other 7 months of the year for free.

now let's say you have 3 patients. 1 lives 1 year and the other 2 each live one day. that's 367 total patient days for the year. then divide that by your 3 patients and your average length of stay = 122 days... which is well within the cap. you are now getting paid for every day of every patient. sure... you lost a little money on those 2 one-dayers, but averaging them into your total allows you to get paid for the last 7 months on your long-term patient... which you would otherwise have lost.

after i figured this out i admitted patients no matter how close to dying they were... and i never came close to hitting my cap. i had one patient for 2.25 years and still never came close to hitting the cap (that pt was a copder by the way... i swear, she operated on some kind of anaerobic metabolism.)

the big guys (hospices) have apparently figured out how to get their average lengths of stay higher & higher. which in some ways would be okay... as long as they were doing something useful... like teaching dying process for example and not just collecting the per diem. some hospices go over the cap... over an average length of stay of 5 months (to the tune of 96 million dollars in 2004!) that just boggles my mind because i always had a hard time getting my average length of stay over 2 months, much less over 5 months! but they are doing it... i have no idea how.

one clue was the post by the nurse in florida telling of patients who everyone knows are not terminal being cared for in a long term care facility with hospice involvement. i have no idea what kind of doctor would keep certifying patients who are not terminal... but it seems it would be a good way to lose a medical license if anyone squealed. and i never did get involved with long-term care facilities. that was just coming in when i was going out, so i have no idea about the "opportunities" there.

req_read,

thanks so much for explaining that. i'm just starting in hospice and had no idea about any of this. very, very interesting. :thankya:

EmptytheBoat

96 Posts

Specializes in Med-Surg, Rehab, MRDD, Home Health.

Yall have an excellent thread going here! Thanks req reader for your input,

your facts are both educational and enlightening. I hope you didn't take that

"old coot" comment too hard, I've been to your website several times, viewed

your bio and photos and the "old coot" was my attempt at tongue-in-cheek humor. As I mentioned in my "old coot" thread your publication "Crossing the

Creek" is excellent and highly recommended to both Hospice providers and

Hospice caregivers. I have not purchased your other two publications but

I should expect those to be excellent also. Thanks for your efforts!

I have been in Hospice only a few years, and in that time, I've tried to learn

about taking care of Hospice patients. I had very little knowledge about the

"Business" of Hospice especially how the cap system worked with Medicare.

But, I think yall are correct in your pessimism, too much greediness for such

a serious occupation. I've worked for both for-profit and not-for-profit and I

actually had more constraints with the not-for-profit, so I'm not sure if it isn't

more a battle of survival at this point in time.

I would suspect, as with Home Health, that the powers-to-be will step in shortly and take control of Hospice, and us caregivers will be smothered with

paperwork and unable to adequately take care of patients.

It has been my experience that Hospice caregivers do tend to throw too much

medication at patients for symptom management, and I do believe they're

more practical methods, and I try to be open to alternatives. But, if I'm to err,

I would much rather err on the side of comfort, than to err on the side of

being open. Common sense helps.

I hope that yall (I'm using the term "yall" because I'm from the South and I'm trying to be ethnic) continue this thread, others contribute, and we can help

each other through this maze Hospice has become. Thanks for reading!

req_read

296 Posts

Specializes in Med-Surg, ER, ICU, Hospice.

The business about LTC facilities helps explain a lot of things. Like I said, I got out when that was coming in so am totally ignorant.

I took the 1st patient in a brand new (little) hospice so was kind of worried about the financials initially… whether or not our little hospice project work make it. But after a couple of years I realized the hospice benefit is very user friendly… that if you do what was right and not worry about the money, everything will break about even. But I also realized if you pushed it… really pushed it… you could make some real money.

I was hospital based… in the same office as home health. In fact, when I first started and hospice patients were scarce I filled in in Home health. That gave me the opportunity to see first hand what happened when HCFA smashed its fist down on home health… not to mention what happened with the paper work. I HATE paper work and what I saw home health nurses going through horrified me. Half of the home health agencies in New Mexico shut down during that time. If that happens to hospice… God help y’all. If you are lucky it will just be the LTC facilities that are targeted… that whole deal sounds really, really fishy!

Yes… learning the meds is extremely important and when in doubt keep them flowing. I once had a gal with a rare and extremely painful disease who was getting truly industrial strength morphine via PCA pump. A 3 day weekend was coming up and I wanted to have plenty of spare cassettes at the house. While the pharmacist was signing them over to me he said, “Do you realize when you’re driving down the rode with this stuff you will have more morphine in your pickup than we have in the whole rest of hospital?”

But what I really took personal satisfaction in were things like the time when intensive teaching got a 16 year old boy (with a progressive, degenerative disease) and his family to elect to stay home, hold hands and just be with him as he crossed… instead of rushing off to ER one more time. And they did this all on their own because I could not get out there in time. Talking a 16 year old into letting go (and his family into allowing it) takes a little doing. Heck, I worked ICU for years and have seen lots of 86 year olds (with 2 or 3 different terminal diseases) refusing to let go.

But it is obvious that many of you work in excellent hospices of high integrity… and that many of you are highly, highly skilled, knowledgeable, compassionate and committed. It is very comforting to see that there are still lots of idealists in the field… its just that the system was set up for idealists and is vulnerable to those who are not.

PS: I don’t mind “old Coot.” I thought it was pretty funny.

PPS: I read using a very large monitor screen… and by copy & pasting text into Word I can have it (Word) read to me. The voice is computer generated so takes some getting used to, but it works very well. Also, for those of you who don’t see too well, the Mozilla Firefox browser is much, much better at enlarging fonts than Microsoft Internet Explorer (free download.)

leslie :-D

11,191 Posts

admittedly, i never paid close attention to the ins and outs of payors, payees and how the system works.

i know i should taker a keener interest in the business aspects.

i am that eternal ostrich with her head in the sand.

yrs ago i met this woman who was marketing her agcys' hospice services throughout the state.

one of her selling points was how lucrative hospice could become; for those clients who had private insurance and medicare, that you could apply the hospice benefit to both...." BUT IT'S NOT DOUBLE-DIPPING" as she 'ssshhhed' herself w/finger to mouth, followed by a wink of the eye.

is this true? double-dipping? can one get away w/billing private insurance and medicare?

i promise to remove my head from the sand, in order to listen....and learn.

leslie

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