STATE AGENCY ACTION REPORT ON APPLICATION FOR CERTIFICATE OF NEED

Transcription

1 STATE AGENCY ACTION REPORT ON APPLICATION FOR CERTIFICATE OF NEED A. PROJECT IDENTIFICATION 1. Applicant/CON Action Number Evercare Hospice of Manatee County, Inc./CON # Brooker Creek Boulevard Oldsmar, Florida Authorized Representative: Ms. Patricia Ford (888) HCR Manor Care Services of Florida, Inc./CON # North Summit Street Toledo, Ohio Authorized Representative: Mr. Bruce Schroeder (419) LifePath Hospice & Palliative Care, Inc./CON # Telecom Parkway Temple Terrace, Florida Authorized Representative: Ms. Kathy Fernandez (813) Odyssey Healthcare of Manatee County, Inc./CON # North Harwood Street, Suite 1500 Dallas, Texas Authorized Representative Mr. W. Bradley Bickham (214)

2 CON Action Numbers: & 9972 The Hospice of the Florida Suncoast, Inc./CON # Roosevelt Boulevard Clearwater, Florida Authorized Representative Ms. Mary J. Labyak Samaritan Care Hospice of Manatee, Inc./CON # Ridgebrook Road Sparks, Maryland Authorized Representative Ms. Melissa Warlow (410) Service Area/Subdistrict District 6, Hospice Service Area 6C, Manatee County B. PUBLIC HEARING A public hearing was not held or requested regarding the proposals to establish a hospice program in Hospice Service Area 6C. However, letters of support were submitted by the applicants, as discussed below. Letters of support for each applicant are detailed below. Evercare Hospice of Manatee County, Inc. (CON #9960) included 15 thank you letters and two letters of support with its application. The thank you letters and comments submitted in the application were from families who utilized Evercare s services in other states. Paul Malley, President, Aging with Dignity, Tallahassee Florida and J. Donald Schumacher, PsyD, President and CEO, National Hospice Foundation both submitted letters of support. None of the letters were from Manatee County health care providers or residents and the applicant did not submit any commitments from local health providers to contract for inpatient beds. 2

3 CON Action Number: & 9972 HCR Manor Care Services of Florida, Inc. (CON #9961) included 50 letters of support with its application in addition to two letters received by the Agency supporting this project. One letter each was received from: Peter Routsis-Arroyo, LCSW, President/CEO of Catholic Charities, Venice, Florida; Senator Michael S. Mike Bennett, The Florida Senate; Karla Evans, Assistant Administrator, Heartland Home Health Care & Infusion in Bradenton, Florida; Donna Haynes, County Commissioner, District 5, Bradenton, Florida; Cynthia Hughes Harris, PhD, OTR, FAOTA, Professor and Dean of Allied Health Sciences at Florida Agricultural and Mechanical University, Tallahassee, Florida; Susan Terry, C.E.O. Community Aids Network, Sarasota, Florida; Joseph J. Creevy, M.D., Intercoastal Medical Group, Sarasota, Florida; Melissa N. Guthrie, Casa Mora Rehabilitation and Extended Care, LLC, Bradenton, Florida; Loren Carlson D.O., University Family Healthcare P.A., Sarasota, Florida; Maureen S. Kelly, President/CEO of West Central Florida Area Agency on Aging, Inc.; Marshall D. Bedder, M.D. of Coastal Pain Management & Rehabilitation. Dr. Cynthia Harris, Florida A&M University, extends her full support to HCR Manor Care. Dr. Harris would like to establish a relationship between the proposed hospice and Florida A&M University s School of Allied Health Sciences in order to establish internship opportunities for students. West Central Florida Area Agency on Aging, Inc. believes that the citizens of Manatee will be well served by the proposed hospice provider and offers its full support. Included in these letters of support were letters of intent to contract for inpatient beds: Regional Washington, Administrator, Riverfront Nursing and Rehabilitation Center in Bradenton, Florida and Daniel J. Friedrich III, President and CEO, Blake Medical Center in Bradenton, Florida. All other letters of support were from doctors and providers in Manatee County and the surrounding area illustrating the applicant s ability to obtain referrals from area health care providers. LifePath Hospice & Palliative Care, Inc. (CON #9962) submitted 16 letters of support with its application. One letter each was received from: James Jennings, Resident Director, the Windsor (an assisted living residence) Bradenton, Florida; James J. Hanusa, M.D., Bradenton, Florida; N. Canada M.D., Bradenton East Medical, P.A., Bradenton, Florida; Cathy Emmett, BSN, MSN, ARNP, Manatee County resident; Britton Wright, MSW, Patient and Family counselor; Linda K. Dyer, Executive Director, Westminster Manor Bradenton, Florida; Maureen S. Kelly, President and CEO, West Central Florida Area Agency on Aging, 3

4 CON Action Numbers: & 9972 Inc., Tampa, Florida; Anthony T. Pizzo, M.D., F.A.C.C., F.A.C.P., Bradenton Cardiology Center; Horacio J. Argeles, M.D.; Elaine M. Slocumb, PhD, RN-BC, Assistant Professor University of South Florida; Sandra A. Macomber, area resident; Stephanie Ohme, area resident. Dr. Elaine Slocumb, University of South Florida, states LifePath hospice has served Hillsborough County for over 20 years; its Department of Research has partnered with the University of South Florida s End of Life Center to ensure that evidence-based care is identified and practiced. None of the letters submitted were from hospitals or nursing homes in Manatee County offering commitments to contract for inpatient services. The letters of support were predominately from Manatee County residents, employees of LifePath, providers and assisted living facilities, illustrating the applicant s ability to obtain referrals. Odyssey HealthCare of Manatee County, Inc. (CON #9963) submitted four letters of support with its application. One letter each was received from: Dr. Gail Van Diepan; Dr. Jerrold Ecklind; Diane Boodram, Administrator; Dr. Paul Todd. All supporters state Odyssey HealthCare s presence in their communities (Flagler and Volusia Counties) has made other Hospice programs increase their level of care. The above letters of support are from physicians who refer their patients to Odyssey Healthcare, Hospice of Palm Coast which is in Service Area 4B. None of the letters submitted were from hospitals or nursing homes in Manatee County offering commitments to contract for inpatient services. No letters were submitted for Manatee county residents to illustrate the applicant s ability to obtain referrals. The Hospice of the Florida Suncoast, Inc. (CON #9964) submitted 31 letters of support with its application. One letter each was received from: Sharon M. Kimball, RN, MS, MBA, Vice President of Patient Care Services/Chief Nursing Officer, St. Petersburg, Florida; Karol Kerr, M.D., Pediatric Hematology/Oncology Associates Sarasota, Florida (other locations); Lynda Walker, Hematology-Oncology Case Manager; Susan Senecal, RN, MSN, Pain Management Team Member, All Children s Hospital; Elizabeth Weltman M.D., Hospitalist Program, all Children s Hospital; Charlotte M. Curtis, R.N., B.S.N., C.P.M., Director, Partners in Care, Children s Medical Services; Donna Sicilian, LCSW, Ed.S, Supervisor, School Social Work; Jane Parker, B.A.N., R.N., I.C.D., Coordinator, Perinatal Loss Doula Service; Jay Wolfson, Dr. P.H., J.D., 4

5 CON Action Number: & 9972 Director, Florida Health Information Center, Principal Investigator, Florida Family AIDS Network; Jeffery L. Paonessa, M.D., Gulfcoast Oncology Associates; Renee L. Teal, RN, Senior Clinical Coordinator; Belinda G. Alexander, Case Manager; Dr. Tim Passmore, Senior Pastor, Woodland, The Community Church Bradenton, Florida; Stan Stead, M.D., M.B.A., President, Stead Health Group, Inc., Encino California; Scott Thomas, area resident; Albert W. Keyser, Pastor, Redeemer Lutheran Church; Ann Sullivan, R.N.; Clayton Garrett Ball, M.D., West Florida Anesthesia Consultants, P.A., Bradenton, Florida. One supporter states the Hospice of the Florida Suncoast s six-week bereavement group helped them cope with the death of a child. None of the letters were from hospitals or nursing homes in Manatee County offering commitments to contract for inpatient services. The majority of the letters submitted were from Manatee County residents, providers and past employees, illustrating the applicant s ability to obtain referrals. Samaritan Care Hospice of Manatee, Inc. (CON #9972) submitted four letters of support in its application. One letter each was received from: Katie Holton, Director of Case Management, Lakewood Ranch Medical Center; David J. Parsons, M.D., P.A. Orlando, Florida; Stephen J. Quaning, M.D., M.B.A. Orlando, Florida; Ebbie Diaz, R.N., Palliative Care Team Manager, Florida Hospital East Orlando. Writers have either referred patients or had direct contact with Hospice of Orange-Osceola (owned by Samaritan Care Hospice) and commend the organization for its quick response time, compassion, as well as support that is given to the family as well as the physician. The Lakewood Ranch Medical Center support was in the form of an e- mail and the Director of Case Management states that Manatee County hospital does not have any preferred relationships that she believes there is need for chemo/radiation treatment after being admitted to a hospice, and believes competition is good. There was no suggestion that the applicant has asked for a commitment to contract for inpatient beds. None of the letters were from hospitals or nursing homes in Manatee County offering commitments to contract for inpatient services. Other than the from the Lakewood Ranch case manager, no letters of support were submitted from residents, doctors, or providers in Manatee County to illustrate the applicant s ability to obtain referrals. 5

6 CON Action Numbers: & 9972 C. PROJECT SUMMARY Evercare Hospice of Manatee County, Inc. (CON #9960) (Evercare) proposes to establish a hospice program in Hospice Service Area 6C, Manatee County. Evercare is a newly formed corporation but is part of a much larger organization, United Health Group. According to the applicant, United Health Group, an affiliate, has 10 licensed hospice programs; eight of which are Medicare-certified in eight states excluding Florida. While United Health Group does not currently operate a hospice program in Florida, the applicant states that it does have experience and an established presence in Florida. United Health Group employs: physicians (providing access to broad range of medical and surgical specialties), independent laboratories, physical therapists, rehabilitation centers, medical supply firms, diagnostic centers, and home health agencies, are located throughout the county with offices in Bradenton, Ellenton, Holmes Beach, Long Boat Key, Palmetto, Parrish, Sarasota, and University Park. The applicant has agreed to condition award of the CON upon providing non-covered services, such as, but not limited to palliative radiation therapy and palliative chemotherapy (related to the terminal diagnosis) as well as other therapies (music, massage, aroma and other holistic therapies). The applicant will also provide at least 1.5 percent of care as indigent/charity care. Hospice programs are required by federal and state law to provide services to everyone requesting them and therefore the Agency would not place conditions on a program to provide legally required services such as palliative radiation and chemotherapy and care to the indigent and charity patients. The applicant is proposing total project costs to be approximately $649,450 in year 1 and year two costs of 2,435,413. The project does not involve any construction costs. HCR Manor Care Services of Florida, Inc. (CON #9961) (HCR Manor Care) proposes the establishment of a new hospice program in Hospice Service Area 6C, Manatee County. HCR Manor Care Services of Florida, Inc. is a Florida for-profit corporation that is affiliated with Manor Care, Inc. a publicly traded company and a provider of nursing home, assisted living, home health and hospice services throughout the United States. Through its operating group Heartland Home Health and Hospice, Manor Care operates over 50 hospice and home health agencies in 23 states, including six home health care agencies in Florida. Also through the HCR Manor Care operating group, Manor Care operates over 300 nursing home and assisted living facilities in 30 states, including 48 in Florida. In addition to a home health care agency in Manatee County, HCR Manor 6

7 CON Action Number: & 9972 Care has four skilled nursing facilities and two assisted living facilities in adjacent Sarasota County. The applicant is proposing project costs of approximately $297,956 and year two operating costs of $3,067,900. There are no building or construction costs with this project. The applicant has not agreed that any measurable condition be placed on the CON. Rather it has stated that it will serve anyone seeking services as required by state and federal regulations for hospice services and if the state places a condition on the CON, it will annually report on that condition. LifePath Hospice & Palliative Care, Inc. (CON #9962) (LifePath) proposes the establishment of a new hospice program in Hospice Service Area 6C, Manatee County. The proposed hospice s office will be in Bradenton, Florida. LifePath Hospice also has programs in Hillsborough County, Hospice Service Area 6A, and Polk, Hardee, and Highlands Counties which is Hospice Service Area 6B. LifePath Hospice is a not-for profit, 501 (c) (3) charitable organization. The proposed project costs are $383,773 in year 1 for project development costs and start-up costs with year two costs at approximately 5,277,500. The applicant has agreed to conduct education and outreach programs in Manatee County aimed at enhancing access to non-cancer patients and to cancer patients who require expensive palliative therapies and increasing the lengths of stay of hospice patients as a condition, if awarded the CON. The applicant did not offer any way to measure this commitment. Odyssey HealthCare of Manatee County, Inc. (CON #9963) (Odyssey) proposes the establishment of a new hospice program in Hospice Service Area 6C, Manatee County. Odyssey currently provides hospice services in Hospice Service Area 4B and 11. 7

8 CON Action Numbers: & 9972 The proposed project cost is $464,720. This amount includes equipment costs of $68,000, project development costs of $46,720, and start-up costs of $350,000. There are no building or construction costs with this project. The applicant also agrees to condition award of the CON upon providing non-covered services, such as, but not limited to: palliative radiation therapy and palliative chemotherapy (related to terminal diagnosis) as well as other therapies (music, massage, aroma, and other holistic treatments). The applicant will spend at least $25,000 during the first two years of operation to provide or fund public education programs dealing with end-of-life planning. It also agrees to report the Department of Elder Affairs detailed set of data to the Agency on an annual basis. Hospice programs are required by federal and state law to provide services to everyone requesting them and therefore the Agency would not place conditions on a program to provide legally required services such as palliative radiation and chemotherapy. The Hospice of the Florida Suncoast, Inc. (CON #9964) (Suncoast) proposes the establishment of a new hospice program in Hospice Service Area 6C, Manatee County. The Hospice of the Florida Suncoast, Inc. is a non-profit hospice. Hospice of the Florida Suncoast currently operates a hospice program in Pinellas County, Hospice Service Area 5B. The proposed project cost is $228,225 in year 1. This cost includes equipment costs, healthcare consulting, and start-up costs. There are no building or construction costs with this project. The applicant states that it is willing to condition award of the CON upon the following: Commitment of $250,000 annually for the first two years of operation of Manatee Hospice specifically designated as seed money for programs and services outside of Medicare hospice benefit. The commitment of 0.5 FTE the first year of operation for the development efforts of a children s hospice program in the Manatee County communities. The commitment of 0.5 FTE in the first year of operation for the development efforts for community bereavement programs in the Manatee County communities. 8

9 CON Action Number: & 9972 The commitment of one FTE to be operationalized the first year for the provision of caregiver services to hospice patients. The provision of caregiver services will be provided up to an amount of $33,750 (an estimated cost of $2.23 per day for a five-year period). The provision of programs for the Hispanic populations which will include support from or involvement of bilingual staff, translated literature, training on cultural differences and competencies and flexible programming to meet their unique needs. Bereavement services will include special outreach to Hispanic children. The provision of three FTEs to allow for uninterrupted 24-hour care seven days a week to be dedicated to evening and weekend services whose sole responsibility and oversight is that of evening and weekend care. Provision of an AIDS program that will collaborate with existing AIDS Service Organizations in Manatee County in meeting the needs of hospice patients with HIV. The development in one year of a community resource library. This library will include various lay and professional education pieces related to chronic illness, death, dying and bereavement. Within the first two years will hire a full-time physician who will develop physician services including palliative care consults within area hospitals, nursing homes and the community. The implementation of a teen volunteer program within the first two years of operation. The expansion in year 1 of The Hospice of the Florida Suncoast s current children s and family retreat programs to the residents of Manatee County. Beginning in year 1, a minimum budget of $1,200 per interdisciplinary team for the provision of special wish funds for hospice patients and families. The development, in year 1, of a minimum of one community advisory committee to be composed of residents reflective of the community whose purpose is to provide input and feedback about he needs of the Manatee County community and whose recommendations will be used in the future program development. In year 1, the formation of a Manatee Council of Hospice Ambassadors to lead fundraising efforts on behalf of The Hospice of the Florida Suncoast in Manatee County. 9

10 CON Action Numbers: & 9972 It is noted that recent changes to the Florida Statutes require hospice programs to meet their CON conditions or loose their license unless good cause is demonstrated. 1 Samaritan Care Hospice of Manatee County, Inc. (CON #9972) (Samaritan) proposes to establish a hospice in Hospice Service Area 6C, Manatee County. Samaritan Care Hospice of Manatee County, Inc., a wholly owned entity of Samaritan Care Hospice, LLC, is a newly formed corporation. Samaritan Care Hospice was organized to consolidate all of the hospice care activities of Fundamental Long Term Care Holdings, LLC, which through its subsidiaries, is a diversified provider of postacute and other long-term care, including skilled nursing homes, assisted living facilities (ALFs), and long-term hospitals in addition to hospice services. According to the applicant, Samaritan owns, or manages, through various operating entities, a total of nine licensed and fully certified hospices in five states. Four of these are relatively new. There are five more mature programs, including Hospice of Orange- Osceola, which has been providing hospice care in Hospice Service Area 7B for more than a decade. The proposed project cost is $415,087. Of this 320,000 is anticipated to be equipment, leasehold improvement, and pre-opening costs, and $95,087 is development costs. There is no construction cost associated with this project. The applicant states that it does not wish to accept any conditions placed upon the CON, should it be awarded. D. REVIEW PROCEDURE The evaluation process is structured by the certificate of need review criteria found in Section , Florida Statutes, rules of the State of Florida, and Chapters 59C-1 and 59C-2, Florida Administrative Code. These criteria form the basis for the goals of the review process. The goals represent desirable outcomes to be attained by successful applicants who demonstrate an overall compliance with the criteria. Analysis of an applicant's capability to undertake the proposed project successfully is conducted by evaluating the responses provided in the application, and independent information gathered by the reviewer. 1 s (7), Florida Statutes. The Agency may deny a license to an applicant that fails to meet any condition for the provision of hospice care or services imposed by the Agency on a certificate of need by final Agency action, unless the applicant can demonstrate that good cause exists for the applicant's failure to meet such condition. 10

11 CON Action Number: & 9972 Applications are analyzed to identify various strengths and weaknesses in each proposal. If more than one application is submitted for the same type of project in the same district (subdistrict or service planning area), applications are comparatively reviewed to determine which applicant best meets the review criteria. Section 59C-1.010(2) b, Florida Administrative Code, prohibits any amendments once an application has been deemed complete. The burden of proof to entitlement of a certificate rests with the applicant. As such, the applicant is responsible for the representations in the application. This is attested to as part of the application in the certification of the applicant. As part of the fact-finding, the consultant, Cheslyn Green, analyzed the application in its entirety with consultation from the financial analyst, Ryan Fitch, who evaluated the financial data. E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA The following indicates the level of conformity of the proposed projects with the criteria found in Florida Statutes, Sections and ; applicable rules of the State of Florida, Chapter 59C-1 and 59C-2, Florida Administrative Code. 1. Fixed Need Pool a. Does the project proposed respond to need as published by a fixed need pool? Chapter 59C-1.008, Florida Administrative Code and Chapter 59C , Florida Administrative Code. In Volume 32, Number 40 of the Florida Administrative Weekly, dated October 6, 2006, the Agency for Health Care Administration published a need for one additional hospital program in AHCA District 6, Hospice Service Area 6C. for the January 2008 Hospice Planning Horizon. Hospice Service Area 6C is currently served by Tidewell Hospice and Palliative Care, Inc. Each co-batched applicant is applying in response to published need for a hospice program in Hospice Service Area 6C. 11

12 CON Action Numbers: & Agency Rule Criteria and Preferences a. Rule 59C (4)(e) Preferences for a New Hospice Program. The agency shall give preference to an applicant meeting one or more of the criteria specified in the below listed subparagraphs: (1) Preference shall be given to an applicant who has a commitment to serve populations with unmet needs. None of the co-batched applicant clearly demonstrated that any population in the service area had unmet needs. Each applicant is responding to published need for an additional hospice program for the January, 2008 planning horizon. Although none of the applicants receive preference for this criterion because they have not clearly demonstrated there are populations of unmet need, each applicant has discussed serving populations they believe to be underserved. Evercare Hospice of Manatee County, Inc. (CON #9960) will provide hospice services to all patients who meet the criteria for admission to hospice; including populations whose hospice needs are currently not being met. Evercare states that the hospice utilization rate in Hospice Service Area 6C has been consistently below the statewide average, particularly for patients with a noncancer diagnosis. It is noted that when there is an average, there are usually providers both above and below the average. Utilization trends alone are not an indication that the needs of non-cancer patients are not being met. Similar to co-batched applicant HCR Manor Care, the applicant also identifies a patient population that it serves in its programs outside of Florida where it offers treatment along with traditional hospice benefits such as tube feedings and therapy that is considered aggressive or experimental, etc. 2 It is noted that Hospice is defined in the Florida Statutes as: a centrally administered corporation providing a continuum of palliative and supportive care for the terminally ill patient and his or her family. Palliative care is defined as services or interventions which are not curative but are provided for the reduction or abatement of pain and human suffering. 2 CON #9960, page 46. HCR Manor Care Services of Florida, Inc. (CON #9961) states that it has identified several populations with unmet needs in 12

13 CON Action Number: & 9972 Hospice Service Area 6C based primarily upon declining penetration rates that have now reached below the state average and the shorter lengths of stay for hospice patients than the average length of stay in Florida. HCR Manor Care asserts under service to these patient populations with cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and Acquired Immune Deficiency Syndrome (AIDS) is identified through the proportionately low numbers of hospice patients in Hospice Service Area 6C compared to the state rate of hospice patients to deaths, or the penetration rate by disease state. However, as noted earlier, this is not a clear indication of an unmet need. HCR Manor Care makes a commitment to serve these populations and all populations, including minorities, are educated about benefits of hospice care through community education seminars, distribution of multi-lingual educational materials, and direct counseling utilizing trained staff and volunteers. Interpreters are also made available when needed. Members of the hospice care team will also become involved and coordinate educational events with the local chapter of the Cancer Society, Heart Association, Alzheimer s Association and others. HCR Manor Care asserts that through its established relationships and proposed marketing and public outreach efforts for hospice care, access will improve throughout the service area, reaching minorities and other patient populations in need. It is noted that the applicant has not agreed to condition award of the CON upon this commitment in some measurable way. Like co-batched applicant, Evercare, utilization trends alone are not an indication that the needs of cancer, CHF, COPD and AIDS patients are not being met. Additionally, there is no clear utilization trend pattern as shown in the applicant s chart from page 1-10 of the application. As shown below, the existing Manatee hospice provider s rate is above the state average in 2004 and below it in 2005, for example. 13

14 CON Action Numbers: & 9972 Hospice Admissions and Penetration Rate as a Proportion of Deaths For the Most Recent Three Years in Hospice Service Area 6C and Florida Deaths Annual Admissions Penetration Rate Increase in Rate Year 6C Florida Period 6C Florida 6C Florida 6C Florida , ,697 7/96-6/ , % 29.6% , ,830 7/97-6/98 1,062 48, % 31.5% 3.1% 1.9% , ,160 7/98-6/99 1,253 52, % 33.3% 4.7% 1.8% , ,122 7/99-6/00 1,262 58, % 36.1% -0.1% 2.8% , ,839 7/00-6/01 1,320 65, % 40.5% 0.9% 4.4% , ,181 7/01-6/02 1,356 70, % 42.3% 1.5% 1.8% , ,702 7/02-6/03 1,352 76, % 45.5% -0.2% 3.2% , ,980 7/03-6/04 1,677 84, % 50.0% 9.2% 4.5% , ,937 7/04-6/05 1,716 86, % 51.4% 2.8% 1.3% , ,023 7/05-6/06 1,683 91, % 54.0% -2.1% 2.7% Source: Florida Need Projections for Hospice Programs and Florida Vital Statistics Annual Reports. Another area in which the applicant suggests need exists and is not being met is an area where the applicant appears to have demonstrated that it distinguishes itself from all other applicants and the existing Manatee County hospice provider. The applicant states that: A fundamental distinction between HCR Manor Care Services of Florida and all other applicants and the existing provider is that the person who is terminally ill DOES NOT HAVE TO RELINQUISH HOPE in order to be served. In other words, the patient is met where he or she is psychologically, medically, spiritually and physically and with the hospice team develops a plan of care. 3 In an informal survey of existing applicants in this batching cycle operating hospices, including Tidewell Hospice, were asked if enrollment could occur if the person seeking enrollment, whose physician had given a terminal prognosis, would be enrolled EVEN IF HE OR SHE continue to explore curative means. The answer given was NO. 4 Further: a patient does not have to have made a decision not to try and recover. 5 Section , Florida Statutes provides the legislative findings and intent regarding hospice regulation as: 3 Page 1.3 CON # Ibid. 5 Page 1.4 CON #

15 CON Action Number: & 9972 The Legislature finds that terminally ill individuals and their families, who are no longer pursuing curative medical treatment, should have the opportunity to select a support system that permits the patient to exercise maximum independence and dignity during the final days of life. The Legislature finds that hospice care provides a cost-effective and less intrusive form of medical care while meeting the social, psychological, and spiritual needs of terminally ill patients and their families. The intent of this part is to provide for the development, establishment, and enforcement of basic standards to ensure the safe and adequate care of persons receiving hospice services. (bold underline added for emphasis). The Florida Legislature has clearly intended hospice care to be received by patients not seeking curative treatment. Hospice is defined in the Florida Statutes as a centrally administered corporation providing a continuum of palliative and supportive care for the terminally ill patient and his or her family. Palliative care is defined as services or interventions which are not curative but are provided for the reduction or abatement of pain and human suffering. 6 LifePath Hospice & Palliative Care (CON #9962) states its commitment to serving all eligible hospice patients. LifePath intends to establish a new office in Bradenton and contractually arrange inpatient and respite care services in Manatee County available to support the residents of Hospice Service Area 6C. However, the applicant did not provide letters of commitment to contract with any Manatee County Hospitals or nursing homes for inpatient care or with other health care providers for respite or residential services. LifePath states that non-cancer patients in Service Area 6C are especially underserved but did not support that statement with evidence. The applicant states that it believes it will raise the length of stay for hospice care by admitting patients earlier. However, evidence was not provided to demonstrate that the existing provider failed to admit patients as early as possible. Odyssey HealthCare of Manatee County, Inc. (CON #9963) states that it has identified populations with unmet needs in Hospice Service Area 6C to include patients who desire the end-oflife experience offered by hospice, but who are not able to receive hospice services because they do not know how or because their physician does not refer them to hospice care, and a need to increase community and physician education in the African- American community in Manatee County and minority hospice 6 Section , Florida Statutes 15

16 CON Action Numbers: & 9972 access. However, the applicant did not demonstrate that the needs to these populations are not currently being met. In addition, Odyssey also intends to conduct local educational campaigns that promote hospice care and seek to increase public awareness of hospice care. Among the applicant s stated conditions should it be awarded the CON was spending at least $25,000 during the first two years of operation to provide or fund public education programs dealing with end-of-life planning. Although the applicant has committed to providing this education and made that commitment measurable, it has not demonstrated that there are populations with unmet hospice needs in Manatee County. The Hospice of the Florida Suncoast, Inc. (CON #9964) proposes to serve what it believes are the unmet needs of children, residents with HIV/AIDS, patients without caregivers in the home to include paid caregiver placement and residential services in group homes, assisted living and nursing homes, Hispanic patients, and bereavement programs that extend beyond hospice patients and their families. Suncoast has agreed to condition award of the CON upon a number of non-core services and programs and the commitments made by the applicant are measurable. Among these commitments is employing a nurse with pediatric grief experience. Services to be offered in Manatee would include working with the school system, developing groups with grieving children, providing PIC services in collaboration with Children s Medical Services and providing counseling to children and families of children and young adults dying of cardiac disease, AIDS and other causes. The Hospice intends to replicate its HEART (Hospice Education and AIDS Resource Team) program in Manatee, providing expert care through their team, education in the community and mental health services. Suncoast is also currently providing case management services through Ryan White Title IV funding to residents and will have a case manager on site in the Manatee Hospice center. Suncoast states that it has a longstanding history of provision of care to homeless persons and people without caregivers. At the onset, The Hospice will employ one (1) full-time equivalent (FTE) caregiver to provide services to people without caregivers. 16

17 CON Action Number: & 9972 Additional charitable donations will be sought to increase the service as needed. Bilingual staff will be hired to serve the Hispanic community with particular attention being paid to systematic outreach, education, support groups and recruitment of volunteers and staff in the Hispanic community. Bereavement support for the community will initially employ a social worker to develop and provide individual counseling and groups throughout the community for bereaved persons who are grieving the loss of a loved one not served in hospice. However, the applicant did not demonstrate that there was any population in Manatee County with unmet needs. Samaritan Care Hospice of Manatee County, Inc. (CON #9972) stated that it has identified delays in response time in following up on referrals to hospice care as the unmet need for Hospice Service Area 6C. Samaritan reports that there have been delays of more than 24 hours and sometimes extend beyond 48 hours for patient admissions. Samaritan proposes to address this unmet need through a follow-up by phone or in person with every referred patient or family within two hours, and will meet with them face to face within 24 hours. This is the current standard among existing programs, and Samaritan will emphasize these standards in the proposed Manatee County program. Although the applicant has not agreed for conditions to be placed upon award of the CON, should the CON be awarded, this stated intent would be placed as a condition upon its CON under the authority of section (1)(a), Florida Statutes: The agency may issue a certificate of need, or an exemption, predicated upon statements of intent expressed by an applicant in the application for a certificate of need or an exemption. However, although the applicant states that it confirmed with area providers that admission to the existing program is delayed more than 24 hours, no evidence to support that statement was provided. Evidence that might have been provided includes letters from individuals or agencies contacted by the applicant stating that admission was delayed more than 24 hours. 17

18 CON Action Numbers: & 9972 (2) Preference shall be given to an applicant who proposes to provide the inpatient care component of the hospice program through contractual arrangements with existing health care facilities, unless the applicant demonstrates a more costefficient alternative. Evercare Hospice of Manatee County, Inc. (CON #9960) plans to provide inpatient care through existing agreements with licensed hospital and skilled nursing facility beds to serve patients in need of hospice services. However, the applicant did not provide letters or sample contracts form any local hospital or nursing home to demonstrate its ability to contract for inpatient beds. HCR Manor Care Services of Florida, Inc. (CON #9961) proposes to provide the inpatient care component of its hospice program through contractual arrangements with existing health care facilities, including the acute care hospitals in the service area, and skilled nursing facilities. It is noted that HCR Manor Care intends to establish an inpatient hospice facility when stabilized occupancy in the proposed hospice program (pending approval) is attained. It is understood that HCR Manor Care Services of Florida, Inc. would need to be awarded a second CON for a freestanding inpatient facility in order to establish this facility. Two letters of intent to enter into the provision of inpatient service were provided in the application: one from Riverfront Nursing and Rehabilitation Center, Bradenton, Florida and the other from Blake Medical Center, Bradenton, Florida. The applicant has demonstrated its ability to contract for inpatient beds. LifePath Hospice and Palliative Care (CON #9962) proposes to provide inpatient hospice care through contractual arrangements with existing nursing homes and hospitals. However, the applicant did not provide letters or sample contracts form any local hospital or nursing home to demonstrate its ability to contract for inpatient beds. 18

19 CON Action Number: & 9972 Odyssey HealthCare of Manatee County (CON #9963) proposes to use existing licensed hospital and skilled nursing facility beds to serve patients in need of episodic and respite care services rather than developing new long-term/inpatient facilities exclusively for hospice services. Although the applicant states that it will contract with acute care providers and skilled nursing facilities in Manatee County no evidence was presented to support that statement. The Hospice of the Florida Suncoast, Inc. (CON #9964) commits to provide inpatient care to hospice patients at the onset through contractual arrangements with existing providers. Suncoast states that it has secured a verbal commitment of a likely unit from Lakewood Ranch Medical Center. It is Suncoast s intent to initially contract for scatter-beds in hospitals and nursing homes with the 24-hour RN staffing available and to proceed with a contract for a hospice inpatient unit with Lakewood Ranch Medical Center. The applicant states that it foresees no difficulty in securing such contacts in Manatee County. However, like all co-batched applicants except HCR Manor Care, its ability to do this was not demonstrated. Samaritan Care Hospice of Manatee County, Inc. (CON #9972) plans to provide approximately two to three percent of its total patient days to inpatients. According to the applicant, this proportion of inpatient care is consistent with Samaritan s experience in its existing operations in Florida. In any event, Samaritan Care Hospice states that it will establish all necessary agreements with hospitals and nursing homes upon initiation of services in Manatee County, and expects to provide all of its Manatee inpatient hospice care through such agreements. However, like all co-batched applicants except HCR Manor Care, its ability to do this was not demonstrated. (3) Preference shall be given to an applicant who has a commitment to serve patients who do not have primary caregivers at home; the homeless; and patients with AIDS. Evercare Hospice of Manatee County, Inc. (CON #9960) will provide services to all patients who meet the criteria for admission to hospice; including patients who do not have primary caregivers at home; the homeless; and patients with AIDS. Evercare Hospice s admission policy states: 19

20 CON Action Numbers: & 9972 Services are available to all terminally ill persons and their families without regard to age, gender, national origin, sexual orientation, disability, diagnosis, cost of therapy, ability to pay, or life circumstances. Evercare Hospice shall no impose any value or belief system on its patient or their families and shall respect the values and belief systems of its patients and families. The applicant did not describe how it plans to take care of the homeless and those without caregivers. HCR Manor Care Services of Florida, Inc. (CON #9961) states that it has a longstanding policy that expresses the company s commitment to serving patients who do not have primary caregivers at home, the homeless, and patients with AIDS. The applicant asserts that when a patient can no longer care for him or herself, the Hospice s plan of care works with the individual to assure that a primary caregiver can be designated. The applicant indicates that the lack of a home or a primary caregiver will not result in a person foregoing the hospice benefit. HCR Manor Care commits to provide hospice services to all, without discrimination: HCR Manor Care Hospice Services will not discriminate on the basis of ability to pay, race, ethnic origin, sex, sexual orientation, handicap status, age, or other category that may classify a person as medically underserved. The proposed hospice services will be provided to all hospice appropriate patients based on physician orders and the hospice plan of care. Hospice services will be available 24 hours per day/seven days per week. The applicant provided letters of support from a nursing home facility and hospital stating it could contract services with those local providers. LifePath Hospice and Palliative Care, Inc. (CON #9962) states that it serves all eligible patients and their families without regard to primary caregiver status, homelessness or HIV status and commits to extend these practices to support the residents of Hospice Service Area 6C. The applicant provided a description of its hospice caregiver program. 7 The applicant did not provide evidence that they can contract with local providers for beds to ensure that it can provide care to the homeless. Odyssey HealthCare of Manatee County, Inc. (CON #9963) states that it provides services to all patients who meet the criteria 7 Appendix S-18 description of the LifePath Hospice Caregiver Program CON #

21 CON Action Number: & 9972 for admission to hospice. This includes patients who do not have a primary caregiver at home, the homeless, and patients with AIDS. Odyssey HealthCare s non-discrimination policy states: Odyssey offers palliative care to terminally ill patients and support to those patients and their families without regard for diagnosis, gender, sexual orientation, national origin, race, creed, disability, age, place of residence or ability to pay. The applicant states that in a case where a patient is impaired with physical problems and can no longer be managed at home, or if a patient is homeless, Odyssey s nurse evaluates the patient for possible inpatient admission to a hospital or long-term care facility. However, the applicant did not provide evidence that they could contract with local providers. The Hospice of the Florida Suncoast, Inc. (CON #9964) states its longstanding history of provision of care to homeless persons and people without caregivers in Pinellas County. At the outset, the applicant states that it will employ one (1) FTE caregiver to provide services to people without caregivers. Additional charitable donations will be sought to increase this service as needed. Suncoast will also be providing, through its interdisciplinary team, services to residential patients in assisted living and group home environments. As the program matures, the applicant plans to investigate the feasibility of building a hospice residence or contracting for space in an assisted living facility. The applicant did not provide evidence of its ability to contract with assisted living facilities or group homes in Manatee County. However, as noted earlier, the applicant has agreed to condition award of the CON upon providing caregiver services. Suncoast plans to extend its HEART (Hospice Education and AIDS Resource Team) program in Manatee, providing expert care through our team, education in the community and mental health services. Also through its affiliate, AIDS Service Association of Pinellas (ASAP), the Manatee service center will house an ASAP case manager currently providing case management services to Manatee residents. Samaritan Care Hospice of Manatee County, Inc. (CON #9972) seeks to make services available to all who need them, regardless of circumstances. The applicant states its approach to hospice care is to actively seek to reduce and remove barriers to care whenever they may arise for a prospective patient, whether internal or external barriers. It is Samaritan s goal to respond to every 21

22 CON Action Numbers: & 9972 request for assistance by offering some level of support, including information, education, counseling, referral to community resources, and (if appropriate) direct care by palliative team. At the most basic level, Samaritan s approach is that everyone who wants hospice care and meets service area requirements and physician certification is admitted. Throughout its operations the applicant states it strives to prevent denial or delays of admission to hospice caused by restrictive admission criteria, caregiver status, diagnosis, type and nature of palliative treatments, preferences for resuscitation, complexity of care, site of care, reimbursement source or cost of care. The applicant states that it has a continued commitment to serve the homeless, persons without caregivers, and persons with AIDS, as well as all others for whom hospice and palliative care is appropriate and beneficial. The applicant did not describe how it plans to take care of the homeless and those without caregivers. Evidence was not provided demonstrating the applicants ability to contract with local providers and unlike co-batched applicant Suncoast, has not agreed to condition to provide services to ensure this occurs beyond what is required by hospice regulation. (4) In the case of proposals for a hospice service area comprised of three or more counties; preference shall be given to an applicant who has a commitment to establish a physical presence in an underserved county or counties. Hospice Service Area 6C consists of one county, Manatee. This criterion is not applicable to this review. (5) Preference shall be given to an applicant who proposes to provide services that are not specifically covered by private insurance, Medicaid, or Medicare. With the exception of HCR Manor Care and Samaritan, each cobatched applicant has agreed to condition award of the CON upon providing uncovered services. It is noted that LifePath s did not offer a way to measure its proposed condition. 22

23 CON Action Number: & 9972 Evercare Hospice of Manatee County, Inc. (CON #9960) has conditioned this CON application such that it will provide noncovered services, such as, music, massage, aroma, therapies and other holistic treatments. Evercare states that it also provides other services that are not specifically covered, including but not limited to: (1) Bereavement services for more than one year, (2) Face to Face personalized bereavement services, not just letters and telephone calls, (3) Educational in-services to the medical community on end-of-life issues, (4) Attending all patient deaths, (5) Evercare nurse practitioners will insure seamless care and encourage the NP to remain involved in the care of the patient and family. HCR Manor Care Services of Florida, Inc. (CON #9961) indicates that it works with each patient, and if hope for a cure is held, will help provide the options, and will cover the cost of care that the individual seeks as part of the exploration of options. As noted earlier, the applicant s commitment to offer services to patients who want to receive curative treatment suggests that it intends to operate outside of the statutory definition of a hospice program. 8 In addition to the core hospice services including continuous care during periods of crisis and bereavement services, the applicant has established a program of Sincerus Care. Sincerus Care, according to the applicant, is a philosophy of both attitude and action that helps sustain the highest quality of life, even under challenging circumstances. The Sincerus Care concept helps to emphasize the positive aspects of body, mind and spirit as individuals, and as a connected community. Outcomes of Sincerus Care Management according to the applicant include: (1) Comfort for the patient (2) Care delivered in home or in a facility, including assisted living and skilled nursing (3) Quality of life (4) 8 Florida Statutes Chapter Legislative findings and intent.--the Legislature finds that terminally ill individuals and their families, who are no longer pursuing curative medical treatment (emphasis added), should have the opportunity to select a support system that permits the patient to exercise maximum independence and dignity during the final days of life. The Legislature finds that hospice care provides a cost-effective and less intrusive form of medical care while meeting the social, psychological, and spiritual needs of terminally ill patients and their families. The intent of this part is to provide for the development, establishment, and enforcement of basic standards to ensure the safe and adequate care of persons receiving hospice services. Section (3), Florida Statutes defines "hospice" as a centrally administered corporation providing a continuum of palliative and supportive care for the terminally ill patient and his or her family and (4) defines "palliative care" as services or interventions which are not curative but are provided for the reduction or abatement of pain and human suffering. Section (3), Florida Statutes defines "hospice" as a centrally administered corporation providing a continuum of palliative and supportive care for the terminally ill patient and his or her family and (4) defines "palliative care" as services or interventions which are not curative but are provided for the reduction or abatement of pain and human suffering. 23