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 Compassionate Care Hospice of Florida, Inc./CON # Lanidex Plaza, Suite 2101 Parsippany, New Jersey Authorized Representative: Judith Grey (973) Service Area/Subdistrict District 11, Hospice Service Area 11, Miami-Dade and Monroe Counties B. PUBLIC HEARING A public hearing was not held or requested regarding the proposal to establish a hospice program in Hospice Service Area 11. However, Compassionate Care Hospice of Florida, Inc. has 47 letters in support of its application. Forty-three of these are from Service Area 11 including representatives of eight hospitals (one dated December 2008) 23 skilled nursing facilities, 16 assisted living facilities, three community organizations, the Borinquen Health Care Center, Inc. and four physicians. Three letters are from out of state. Three physician letters are dated December Norman J. Ginsparg, Director of Legal Affairs of four skilled nursing facilities in Miami-Dade County (Nursing Center at Mercy, Harmony Health Center, Fair Havens Center, and Oceanside Extended Care) states, we understand Compassionate Care has a successful track record in educating Hispanic patients and families on selecting hospice services during the end of their life and believe relevant experience could assist in increasing the relatively low penetration rate in Miami-Dade County.

2 Palmetto General Hospital CEO, Ana Mederos, M.B.A., Lower Keys Medical Center CEO, Nicki Lyn Will, Ph.D., Fishermen s Hospital CEO, Kimberly Bassett, Kindred Hospitals South Florida, Executive Director, Theodore L. Welding (representing Kindred Hospital Coral Gables), and Larkin Community Hospital CEO, Jack J. Michel, M.D., indicate that they are willing to enter into agreements with Compassionate Care to provide inpatient hospice care and specific to Kindred, provide Compassionate Care as an option in the discharge planning process. Six Miami-Dade County community nursing home executives indicate their willingness to enter into agreements for inpatient services and/or the possible creation of an inpatient unit. These include Norman J. Ginsparg, Director of Legal Affairs on behalf of The Nursing Center at Mercy, Harmony Health Center, Fair Havens Center, Oceanside Extended Care Center; Michael Bokor, CEO of Southern SNF Management on behalf of Palmetto Rehabilitation and Health Center; Aaron Hollander, CFO, on behalf of Claridge House Nursing and Rehabilitation Center and Regents Park at Aventura; David Gold, NHA, Administrator of North Beach Rehabilitation Center; Samuel Tate, Administrator, Hampton Court Nursing & Rehabilitation Center and Verma Johnson, Administrator, Homestead Manor. Claudia Pace, NHA, Administrator for Courtyard Manor Retirement Living (an 86-bed assisted living facility), La Hacienda Gardens (a 48-bed assisted living facility), and South Hialeah Manor, a 67-bed assisted living facility, and executive manager for Eden Gardens (a 118-bed assisted living facility), Flamingo Park Manor (a 72-bed assisted living facility), and North Miami Retirement Living (a 50-bed assisted living facility), states that she is willing to execute an agreement with Compassionate Care for each of the six facilities to enable them to care for their hospice appropriate residents. The applicant had letters from eight ALF operators of facilities ranging from six to 12 beds. C. PROJECT SUMMARY Compassionate Care Hospice of Florida, Inc. (CON #10091) proposes to establish a new hospice program in Hospice Service Area 11, Miami- Dade and Monroe Counties. Compassionate Care Hospice was founded in Over the past 17 years Compassionate Care Hospice has developed 24 hospice programs in 16 states: Delaware, Georgia, Illinois, Kansas, Massachusetts, Michigan, Minnesota, Nebraska, New Jersey, 2

3 New York, Pennsylvania, South Carolina, South Dakota, Texas, Virginia and Wisconsin. Compassionate Care Hospice has been approved to establish a hospice program in Subdistrict 6B, Polk, Hardee, and Highlands Counties. The applicant is proposing total project costs of $141,950 with year one operating costs of $1,527,651 and year two costs of $4,561,439. Schedule C includes the following conditions: As required by law, Compassionate Care Hospice is willing to accept any such conditions on its CON-based on any representations made through this CON application. Compassionate Care will provide all the required components of hospice care, and meet all Medicare conditions of participation, and Florida hospice licensure requirements, including the provision of all levels of service (routine home care, continuous care, general inpatient, respite) to all types of patients without regard to race, ethnicity, gender, age, religious affiliation, diagnosis, financial status, insurance status, or any other discriminating factor. 1. Compassionate Care Hospice of Florida will implement a concentrated outreach program for assisted living facilities (ALFs) and will visit all licensed ALF providers, regardless of size, in the first year of operation, and will provide educational information to such ALFs in the language suitable for the facility staff and residents. Compliance will be measured by a signed declaratory statement submitted to the Agency. 2. Compassionate Care Hospice of Florida will implement its Hispanic Outreach Program immediately upon licensure. Compliance will be measured by a signed declaratory statement submitted to the Agency. 3. At least 50 percent of all interdisciplinary team members in District 11 consisting of physicians, registered nurses, home health aides, social workers, chaplains, and volunteers, will be bilingual (English and Spanish). Compliance will be measured by a signed declaratory statement submitted to the Agency. 3

4 4. Compassionate Care Florida will work with local Hispanic organizations including The Borinquen Health Care Center, The League Against Cancer and the South Florida Hispanic Chamber of Commerce to enhance the overall hospice penetration amongst Hispanics through education and awareness. Compliance will be measured by a signed declaratory statement submitted to the Agency. 5. Compassionate Care Florida will implement its Cardiac Connections Program in District 11 within year one of operation. Compliance will be measured by a signed declaratory statement submitted to the Agency. 6. Compassionate Care Hospice of Florida has conditioned approval of this application on the provision its main office will be located in Hialeah, Miami-Dade County, a city that is more than 81 percent Hispanic. The applicant received eight letters of support for its application from facilities in Hialeah. Compliance will be measured by a signed declaratory statement submitted to the Agency. 7. Compassionate Care Hospice of Florida has conditioned approval of this application to the provision it will open a satellite office in Marathon, Monroe County during its first year of operation. Compliance will be measured by a signed declaratory statement submitted to the Agency. 8. Compassionate Care Florida has conditioned approval of this application on the provision it will provide one FTE life enhancement specialist. Compliance will be measured by a signed declaratory statement submitted to the Agency. 9. Compassionate Care Florida has conditioned approval of this application on the provision it will provide one FTE homemaker. Compliance will be measured by a signed declaratory statement submitted to the Agency. 10. Compassionate Care Florida will condition approval of this application on the provision it will become accredited by CHAP upon certification. Compliance will be measured by submission of accreditation certificate to the Agency. 4

5 11. Compassionate Care Hospice Group, Ltd will implement its Pathways to Compassion Program immediately upon licensure of Compassionate Care Hospice of Florida, which will be made available to all eligible District 11 residents. Compliance will be measured by a signed declaratory statement submitted to the Agency. 12. Compassionate Care Florida will provide a home health aide ratio above NHPCO guidelines at an average of 10 hours per patient per week. Compliance will be measured by a signed declaratory statement submitted to the Agency. 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. The applicant s proposed conditions are as it stated. However, Section (4) Florida Statutes states that Accreditation by any private organization may not be a requirement for the issuance or maintenance of a certificate of need under ss Should the project be approved, the applicant s proposed conditions would be reported in the annual condition compliance report as required by Rule 59C (3) Florida Administrative Code. Section (5) Florida Statutes states that 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. 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. 5

6 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(3) 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 financial analyst, Derron Hillman, 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 36, Number 13 of the Florida Administrative Weekly, dated April 2, 2010 the Agency for Health Care Administration (the Agency) indicated a hospice program net need of zero for Hospice Service Area 11 for the July 2011 Hospice Planning Horizon. Hospice Service Area 11 is currently served by Catholic Hospice, Inc., Hospice Care of South Florida, Hospice of the Florida Keys, Inc., VITAS Healthcare Corporation of Florida, HospiceCare of Southeast Florida, Inc., Douglas Gardens Hospice, Inc., and Odyssey Healthcare. 6

7 HCR Manor Care Services of Florida II, Inc. has CON #10043 approved but yet to be licensed to establish a hospice program in Service Area 11. Rule 59C (4)(c) Florida Administrative Code, states that the Agency shall not normally approve another hospice program for any service area that has an approved hospice program that is not yet licensed. Regardless, the applicant is applying to establish a hospice program in the absence of published numeric need. b. Approval Under Special Circumstances. In the absence of numeric need shown under the formula in paragraph (4)(a), the applicant must demonstrate that circumstances exist to justify the approval of a new hospice. Chapter 59C (4)(d), Florida Administrative Code. Evidence submitted by the applicant must document one or more of the following: 1. The specific terminally ill population is not being served. 2. That a county or counties within the service area of a licensed program are not being served. 3. That there are persons referred to hospice programs who are not being admitted within 48 hours (excluding cases when a later admission date has been requested). The applicant shall indicate the number of such persons. Compassionate Care Hospice of Florida, Inc. does not directly respond to the above criteria but indicates the not normal and special circumstances it describes in its need discussion below support approval of the project. c. Other Special Circumstances. The applicant presents an overview of the special and not normal circumstances that it states exist in Service Area 11. The applicant states that the gap in hospice admissions in Service Area 11 is so vast that it would be sufficient to warrant almost nine new hospice providers based on the Agency s traditional 350 threshold (3,013/350= 8.6). However, because Service Area 11 has one approved hospice program any additional need is negated for two years from the date of the new program s licensure. 7

8 District 11 Hospice Utilization Current Utilization and Projected Need July 2011 Batching Cycle District 11 Providers U65C 65C U65NC 65NC Total Projected Hospice Patients 1,188 2, ,320 12,309 Catholic Hospice Inc ,823 Douglas Gardens Hospice, Inc HospiceCare of Southeast Florida, Inc Hospice of South Florida Hospice of the Florida Keys, Inc VITAS Healthcare Corporation of Florida 603 1, ,231 5,661 Odyssey Healthcare Current District 11 Utilization 863 2, ,478 9,296 Projected Minus Current ,842 3,013 Need Projected Minus Current Hospice Patients >350 1 Approved Hospice Providers for District 11 1 Net Need 0 Source: CON Application #10091, page 10. The applicant states that the most significant numeric gap in services is within non-cancer patients age 65 and older. The applicant states that this gap in services is enough to warrant a need for more than five hospice programs (1,842/350= 5.3). The under 65 non-cancer cohort represents the second largest gap in service reflecting a 451 projected gap in admissions. The applicant states that each of these population and disease categories individually warrant approval of an additional hospice provider; but together they are represent a gap in admissions of 720, which is sufficient to trigger a need for two hospices (720/350=2.1). The following table illustrates hospice penetration rates for Service Area 11 compared to statewide hospice penetration rates for each of the age/diagnosis cohorts. District 11 Hospice Penetration Rate Current Utilization and 2007 Deaths District 11 U65C 65C U65NC 65NC Total Hospice Admissions 863 2, ,478 9, Resident Deaths 1,188 2,836 3,946 10,363 18,606 District 11 Hospice Penetration Rates 72.7% 87.9% 11.7% 51.5% 50.0% Statewide Hospice Admission 10,494 27,513 7,107 61, , Resident Deaths 11,132 28,634 32,595 95, ,530 Statewide Hospice Penetration rate 94.3% 96.1% 21.8% 64.9% 63.8% District 11 Short Fall 21.9% 8.2% 10.1% 13.4% 13.8% Source: CON Application #10091, page 11. The applicant s table above demonstrates that Service Area 11 has lower penetration rates compared to the statewide penetration rates in each of the four age/disease categories. Compassionate Care states that based on its needs analysis, it has identified specific terminally ill populations which are in need of hospice services and significantly underserved, each 8

9 individually supporting the need for an additional hospice provider. The applicant identifies special circumstances as people residing in small assisted living facilities that are largely ignored and overlooked by existing hospice providers, Hispanic terminally-ill individuals, terminallyill cancer individuals of all ages and terminally-ill with non-cancer diagnoses of all ages as significantly underserved populations. The applicant asserts there is more than sufficient need in Service Area 11 to support two new successful programs (HCR Manor Care and Compassionate Care Hospice of Florida). The applicant states that for more than the past 15 years the Agency has consistently published a projected gap in hospice admissions in Service Area 11 that exceeds the 350 admission threshold. In the past eight batching cycles, this projected gap in admissions has exceeded 3,000. Yet, a need for one additional hospice provider can only be published after an approved program has been licensed for at least two years. The applicant states that in CON Application #10043, HCR projects it will serve 321 patients in its first year, 437 in its second year and 502 patients in year three based on what it refers to as the Florida experience and the experience of the existing providers in Service Area 11. Compassionate Care Hospice states that assuming HCR attains its projected year three admissions, there will still be a tremendous gap in projected admissions of 2,511 remaining (3, =2,511); at the point when this new provider has been licensed for two years, need will be published once again. This will further feed into the Service Area 11 cyclical pattern of enormous need and very short supply rather than a more balanced approach to supply and demand. The applicant states that the not normal circumstance is a programmatic and cultural access problem and is evident in the exorbitant gap in projected hospice admissions in Service Area 11. Compassionate Care contends that this situation is persistent and irreparable unless a second new provider is awarded a CON to develop a program in Miami-Dade and Monroe Counties. Compassionate Care Hospice states this not normal circumstance is the result of the Hispanic terminally-ill population that is not being fully served by existing providers. Compassionate Care Hospice asserts it is fully committed to ameliorating this not normal circumstance and addressing the special circumstances. Terminally-Ill Residing in Small Assisted Living Facilities The applicant states that Miami-Dade and Monroe Counties have 981 assisted living facilities (ALFs) with 10,379 licensed beds. Of the 981 ALFs, 937 of them have 30 licensed beds or fewer and 835 of them are licensed for 10 or less beds. The 835 ALFs with 10 or less beds have an 9

10 aggregate 5,071 licensed beds; these represent 49 percent of all ALF beds. According to the applicant these smaller ALFs are a main driver of the lower hospice penetration rate. There appears to be a lack of education and outreach in the small individual ALFs. The applicant states that existing providers appear not to be focusing on reaching out to these small facilities largely due to the number of potential residents contacted in an educational and support visit is disproportionately low compared to larger facilities (85 percent of the facilities represent 49 percent of the beds). Therefore, the applicant states the existing providers are focusing on the larger institutions (15 percent of the facilities with 51 percent of the beds) where it is easier and more economical to conduct education, outreach, and to provide care. The applicant states that based on interviews and community feedback, many of the small ALFs have a fundamental misunderstanding about hospice. They generally do not understand that the resident does not lose other funding sources by choosing hospice and that opting for hospice service does not result in the resident s relocation to another facility. The applicant has conditioned its application on the provision it will implement a concentrated outreach program for assisted living facilities and will visit all licensed ALF providers, regardless of size, in the first year of operation. It will also will provide educational information to such ALFs in the language suitable for the facility staff and residents. The applicant states that many of these smaller ALFs are located in Hialeah and as such it will locate its main office in Hialeah. The applicant has 10 letters of support from Service Area 11 ALFs with 12 or fewer beds: The Haven (six beds), Home for the Angels (six beds), A Loving Place (12 beds), Seraphim Care, Inc. (eight beds), All USA Homes, Inc. (six beds), Ady s Family Home (six beds), Carely Home Care (six beds), Abuelitas Home (six beds), A Home Away from Home (six beds), and Casita Amor Care (six beds). These letters do not document that hospice services in Service Area 11 are not available or accessible to residents of small ALFs. Hispanic Terminally-Ill Population The applicant states Hispanics are the largest ethnic population in Service Area 11 yet they are the least likely cohort to utilize hospice services. A recent study by Karen Andersen, et. al. in The Journal of Pain titled, Racial and Ethnic Disparities in Pain: Causes and Consequences of Unequal Care, found persistence of racial and ethnic disparities in acute, chronic, cancer, and palliative pain across the lifespan and treatment settings, with minorities receiving lesser quality pain care then non-hispanic whites. The applicant states that racial and ethnic disparities in acute pain, chronic cancer pain and palliative 10

11 pain care continue to persist. The study states that non-minority patients are more likely to enroll in hospice than minority patients. Specifically, six percent of patients in the United States enrolled in hospice care are Hispanic. The applicant states that most patients receiving Medicare hospice benefits are non-hispanic whites. One contributing factor to such low utilization is that Hispanic patients and providers have limited knowledge of hospice programs and goals. Compassionate Care notes that cultural attitudes and beliefs surrounding end-of-life care may adversely affect hospice enrollment. The word hospice in Spanish translates into hospicio which refers to a place such as an asylum related to poverty and abandonment. The applicant states that the word hospicio has a negative connotation that makes many Hispanic individuals reject the concept before they have invested any time or effort into learning about it. The cultural disparities between Hispanics and non-hispanics are apparent in the tendency for the terminally-ill to not utilize end-of-life care. Compassionate Care states that the percentage of deaths among Hispanics in both Miami-Dade and Monroe Counties is on the rise, while the percentage of non-hispanic deaths is slowly declining. During CY 2008, Hispanic deaths were 58 percent (10,728) of the (18,635) deaths in the district. District 11 Resident Deaths Hispanic versus Non-Hispanic Deaths 1999 and 2008 Hispanic Deaths CY 1999 Deaths CY 2008 Deaths 10-Year Change Ages 0 to 64 2,079 2, % Ages 65+ 7,139 8, % Total 9,218 10, % Non-Hispanic Deaths Ages 0 to 64 3,144 2, % Ages 65+ 7,477 5, % Total 10,621 7, % Total Deaths Ages 0 to 64 5,223 4, % Ages ,616 13, % Total 19,839 18, % Hispanic as % of Total 46.5% 57.6% -- Source: CON Application #10091, page 31. Compassionate Care states that 48.7 (2,226 discharges/4,570 discharges) percent of all hospital discharges to hospice were Hispanic even though Hispanic deaths accounted for 59.2 percent of Miami-Dade 11

12 County s total deaths. Hispanic hospice discharges are 48.5 percent (2,228 discharges/4,594 total discharges) and Hispanic deaths 57.6 percent (10,728/18,635) of the service area total. Compassionate states the shortfall in Hispanic discharges to hospice represents a significant volume of underserved patients. District 11 Hispanic Deaths and Admissions to Hospice Calendar Year 2009 Hispanic Cohort District 11 Total Miami-Dade County Monroe County Hispanic Percent of Total Deaths (A) 57.6% 59.2% 11.4% Total Discharges from Hospital to Hospice (B) 4,594 4, Hispanic Discharges from Hospital to Hospice (C) 2,228 2,226 2 Hispanic % of Discharges to Hospice From Hospital (B C = D) 48.5% 48.7% 8.3% Hospice Shortfall (A D = E) % 3.1% Additional Volume (E * B = F) Restated Hispanic Discharges to Hospice with Shortfall (C + F) 2,709 2,706 3 Source: CON Application #10091, page 33. The chart above indicates that the applicant s shortfall is the 10.5 percent less Hispanic hospital discharges to hospice compared to non- Hispanic hospital discharges to hospice in Miami-Dade. Applying the non-hispanic (10.5 percent difference) discharge rate to the Hispanic discharges results in an additional 481 Hispanic hospital discharges to hospice. District 11 Hispanic Deaths and Admissions to Hospice Calendar Year 2009 Hispanic Cohort District 11 Total Total Hospice Admissions 9,296 Less Discharges from Hospital to Hospice 4,594 Remaining Hospice Admissions (G) 4,702 Percent Hispanic (D) 48.5% Shortfall (E) 10.5% Additional Volume (G * E = I) 494 Total Additional Hispanic Hospice Admission (F + I) 975 Source: CON Application #10091, page 33. Compassionate states that in 2009 there were 9,296 total hospice admissions; of those, 4,702 were admitted from either home or from another non-hospital location. The applicant applies the 10.5 percent shortfall above and concludes there would have been 494 additional Hispanic hospice admissions from home, skilled nursing facilities, assisted living facilities and any other non-hospital setting. Compassionate Care concludes that there would have been 975 additional Hispanic admissions to hospice for all settings. 12

13 Compassionate Care states this deficiency suggests that there is a disproportionately low utilization by Hispanics, and increasing them to the same level as non-hispanics accounts for approximately one third of the published numeric shortfall of 3,013. The applicant states that Compassionate Care Hospice has the skill set to meet the needs of Service Area 11 s Hispanic population, including the specific programming for each of the identified terminal illnesses that are prevalent in this Hispanic community. The applicant provides excerpts from local Hispanic support letters, out of state Hispanic support letters, a description of its success in other states and a detailed description of its proposed Hispanic out-reach program. These letters support Compassionate Care s ability to outreach to the Hispanic community. They do not document that hospice services in Service Area 11 are not available or accessible to the Hispanic community. Compassionate Care Hospice concludes that its skill set to admit, manage and treat Hispanic patients in a most culturally sensitive way will enhance overall hospice penetration for Hispanic terminally-ill residents. Terminally-Ill Non-Cancer Patients The applicant states that the greatest numeric gap in Service Area 11 hospice admissions falls within the non-cancer patient population. Of the 3,013 total projected gap in hospice admissions, 76 percent will be non-cancer. Compared to the State of Florida, the Service Area 11 noncancer hospice penetration rate is 10.1 percent lower in the under 65 years of age cohort, and 13.4 percent lower than the state in the 65 and older cohort. 13

14 District 11 Non-Cancer Penetration Rate 2009 Hospice Admissions and 2007 Resident Deaths 1 District 11 Under 65 Non- Cancer 65 and Older Non-Cancer Total Non- Cancer District 11 Hospice Admissions 461 5,478 5, Resident Deaths 3,946 10,636 14,582 Hospice Penetration Rate 11.7% 51.5% 40.7% Florida Hospice Admissions 7,107 61,784 68, Resident Deaths 32,595 95, ,764 Hospice Penetration Rate 21.8% 64.9% 53.9% District 11 Shortfall 10.1% 13.4% 13.2% Source: CON Application #10091, page 42 from Florida Need Projections, April 2, 2010 and NHA Analysis. Note: The applicant s table included District X Hospice Admissions in District 11 and in the Florida Hospice admissions on pages 42 and 46, which we have corrected and deleted. District 11 Projected Non-Cancer Hospice Admissions July 2011 Planning Horizon District 11 Under 65 Non-Cancer 65 and Older Non-Cancer Total Non- Cancer Projected Hospice Patients 912 7,320 8,232 Current District 11 Utilization 461 5,478 5,939 Projected Minus Current 451 1,842 2,293 Source: CON Application #10091, page 43. The applicant states that the 2,293 gap in projected non-cancer hospice admissions noted above suggest that with just non-cancer patients, there is a need for at least six additional hospices (2,293/350= 6.6). The noncancer gap in service alone is a much greater gap in admissions that any other hospice service area has statewide. Compassionate Care does not document that hospice services are not available or accessible to this Service Area 11 population. Hispanic Non-Cancer Terminally-Ill While cancer accounts for 2,337 annual deaths in Service Area 11 which is the second most common disease, it is heart disease that is the most common cause of death amongst Hispanic residents of Service Area 11. Heart disease accounts for 29.2 percent of total Hispanic deaths in Miami-Dade and Monroe Counties. Compassionate Care Hospice states this significantly increases among the 65 and older cohort, representing 32.3 percent of all Hispanic deaths. Chronic lower respiratory disease is the third most significant cause of death, accounting for 4.6 percent of 1 The applicant notes that its hospice admissions numbers are based AHCA publication and on NHA analysis. The Agency does not require hospices that serve multiple service areas to provide the breakout of the under age 65/age 65 and over/cancer/non-cancer admissions for individual service areas they serve. Therefore, the applicant apparently assigns certain percentages to SA 11 residents served by three of the seven hospices as these three hospices serve more than one service area. 14

15 2008 Hispanic deaths. Diabetes and Alzheimer s disease are both quite prevalent in the Hispanic community representing 3.8 and 3.2 percent of total Hispanic deaths, respectively. District 11 Hispanic Deaths and Percent of Total 2008 Deaths Hispanic Deaths by Disease Ages 0-64 Ages 65+ Total Cancer 622 1,715 2,337 Heart Disease 404 2,731 3,135 Diabetes Alzheimer s Disease Chronic Lower Respiratory All Other 1,123 3,885 4,008 Total 2,283 8,445 10,728 Percent of Total Cancer 27.2% 20.3% 21.8% Heart Disease 17.7% 32.3% 29.2% Diabetes 3.9% 3.8% 3.8% Alzheimer s Disease 0.1% 4.1% 3.2% Chronic Lower Respiratory 1.9% 5.4% 4.6% All Other 49.2% 34.2% 37.4% Total 100.0% 100.0% 100.0% Source: CON Application #10091, page 44. The applicant states that though Hispanics represent nearly 58 percent of Service Area 11 s total deaths, they account for a disproportionate share of Service Area 11 deaths in several non-cancer specific disease categories. The table below shows Hispanic deaths as the percent of the District s total deaths. District 11 Hispanic Deaths as Percent of the District s Total 2008 Deaths Disease Ages 0-64 Ages 65+ Total Cancer 52.1% 59.2% 57.1% Heart Disease 44.9% 62.6% 59.6% Diabetes 47.8% 66.4% 61.2% Alzheimer s Disease 66.7% 67.0% 67.0% Chronic Lower Respiratory 49.4% 63.3% 61.8% All Other 46.0% 60.6% 55.7% Total 45.9% 61.8% 57.6% Source: CON Application #10091, page 44. As shown above, Hispanics account for 67 percent of all Service Area 11 deaths caused by Alzheimer s Disease. Compassionate Care states the next greatest disparity is among chronic lower respiratory related deaths; Hispanics account for nearly 62 percent of Service Area 11 s deaths 2. While Compassionate Care contends there are cultural access problems, it does not document that hospice services are not available or accessible to Service Area 11 s Hispanic population. 2 CON Application #10091, page

16 Terminally-Ill Cancer Patients Compassionate Care states Service Area 11 has more than 4,000 cancer (4,024 in CY 2007) related deaths; of those 3,358 actually received hospice care representing an 83.4 percent hospice penetration rate 3. The State of Florida average hospice penetration rate for cancer patients is 95.6 percent (38,007 admissions/39,766 deaths) representing a 12.2 percent difference based on 2007 deaths applied to 2009 hospice admissions. The applicant states the under 65 age cohort in Service Area 11 has a hospice penetration rate shortfall of nearly 22 percent and the 65 and older cohort has a shortfall of eight percent; essentially 666 terminally-ill patients in Service Area 11 go without end-of-life care, according the applicant 4. District 11 Cancer Hospice Penetration Rate 2009 Hospice Admissions and 2007 Resident Deaths District 11 Under 65 Cancer 65 and Older Cancer Total Cancer District 11 Hospice Admissions 863 2,494 3, Resident Deaths 1,188 2,836 4,024 Hospice Penetration Rate 72.7% 87.9% 83.4% Florida Hospice Admissions 10,494 27,513 38, Resident Deaths 11,132 28,634 39,766 Hospice Penetration Rate 94.3% 96.1% 95.6% District 11 Shortfall 21.6% 8.2% 12.2% Source: CON Application #10091, page 46. The applicant used total oncology discharges from hospitals to assess the percentage of patients that were discharged/transferred to hospice for Service Area 11 and found that the service area had the greatest number of oncology related hospital discharges (8,193) of any other hospice service area. Service Area 11 also had the greatest number of oncology discharges to hospice (900). However the applicant states Service Area 11 is lowest statewide in the percent of total oncology patients discharged to hospice, 11 percent 5 (900/8,193). Compassionate Care does not document that hospice services are not available or accessible to this Service Area 11 population. 3 The applicant s hospice admissions numbers are based AHCA publication and on NHA analysis. The Agency does not require hospices that serve multiple service areas to provide the breakout of the under age 65/age 65 and over/cancer/non-cancer admissions for individual service areas they serve. Therefore, the applicant apparently assigned a certain percentage to SA 11 residents served by three of the seven hospices as these three hospices serve more than one area. 4 District 11 Cancer Hospice Penetration Rate 2009 Hospice Admission and 2007 Resident Deaths, CON Application #10091, page Statewide Oncology Discharges and Percent Discharged to Hospice Calendar Year 2009, CON Application #10091, page

17 Compassionate Care anticipates it will serve 219 hospice patients in year one, and 606 in year two. Projected market shares were applied to the projected total hospice admissions to calculate the number of admissions by category and age that Compassionate Care would serve. Rates are generally based on the experience of other hospices in Florida. The applicant states that the average lengths of stay are expected to be 35 days and 65 days in years one and two respectively. 2. Agency Rule Criteria and Preferences a. Rule 59C (4)(e) Florida Administrative Code - 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. Although the applicant did not receive preference for this criterion because it has not clearly demonstrated there are populations of unmet need, the applicant discussed populations it believes to be underserved. Compassionate Care Hospice of Florida states it is committed to meeting the needs of all its patients and their families in need of end-of-life in Miami-Dade and Monroe Counties. The applicant states that it is going to admit patients of all ages and diagnoses. According to the applicant specific underserved patient populations include terminally ill residents in small ALFs, the four age/diagnosis cohorts and terminally-ill Hispanic residents. (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. Compassionate Care Hospice of Florida intends to have contractual agreements with nursing homes and hospitals, as well as other healthcare providers designed to meet patient needs in Miami- Dade and Monroe Counties. The applicant states that by partnering with hospitals and nursing homes to provide hospice patient care, it will fulfill its goal to expand awareness and utilization of hospice. The applicant received letters of support and 17

18 agreements for contractual inpatient hospice services from the following Service Area 11 hospitals and SNFs: Palmetto General Hospital; Lower Keys Medical Center, Fishermen s Hospital; Kindred Hospital South Florida Coral Gables; Larkin Community Hospital; The Nursing Center at Mercy; Harmony Health Center; Fair Havens Center; Oceanside Extended Care Center; Claridge House Nursing & Rehabilitation Center; North Beach Rehabilitation Center; Hampton Court Nursing & Rehabilitation Center and Homestead Manor. (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. Compassionate Care Hospice of Florida is committed to serving all patients including those who do not have primary caregivers at home, the homeless and patients with AIDS in Service Area 11. The applicant states that its commitment is evidenced by its history of serving these patients in other markets. The applicant states that in 2009, 8.5 percent of all Compassionate Care Hospice patients lived alone without a caregiver and 3.3 percent lived with a compromised caregiver. In the case that the patient is not able to care for him/herself and has no caregiver support group, Compassionate Care may recommend placement in an assisted living facility or nursing home, in which the hospice program will be able to provide residential care. The applicant states that its social workers will assist patients without financial resources to obtain residential care in a hospice unit within an ALF or nursing home, as determined by their medical condition. The applicant states that typically if a patient in need of hospice care is homeless, Compassionate Care will place the patient in an inpatient unit and assist in applying for Medicaid; once the patient qualifies, he/she is placed in a long-term care environment where the patient can begin or continue hospice care. However, the process of qualifying the homeless for Medicaid can be difficult. One way in which the homeless can receive Medicaid is by qualifying for Supplemental Security Income (SSI) benefits through social security. Once becoming eligible for SSI, Medicaid coverage is a benefit of the program. In most cases, the hospital will initiate the process of applying for SSI and Medicaid in order to receive payment for services. The homeless can receive SSI for six months out of every nine months they stay in a public (government run) emergency shelter. There is no time limit on getting SSI in a private shelter. 18

19 (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. The applicant has conditioned approval of this application on the provision its main office will be located in Hialeah, Miami-Dade County. The applicant states that its second office location will be in Marathon, Monroe County and will open during the first year of operation. (5) Preference shall be given to an applicant who proposes to provide services that are not specifically covered by private insurance, Medicaid, or Medicare. The applicant states it offers a host of special programs and services that are not specifically covered by private insurance, Medicaid or Medicare. The applicant commits to provide the following non-core services: Pathways to Compassion - a palliative care program whose mission is to prevent and relieve suffering and to support the highest quality of life for patients and families. The program is not the same as hospice care nor is its patients counted as hospice patients in either state or federal reports. Palliative care may be provided at any time during a person s illness or debilitating condition. Complementary Care Program - services offered in this program are massage therapy, music therapy, energetic care, sacred spaces, guided imagery, reminiscence therapy, and pet therapy. Transitions - a community service program, designed to enhance the quality of life for individuals and their families facing life-limiting illnesses. Services include emotional support, education, and practical assistance such as running errands, performing house chores and food preparation. Transitions is a free service provided to eligible residents/patients and is funded by Compassionate Care Hospice and community donations. 19

20 Jewish Hospice Program Compassionate Care provides and coordinates resources and services that meet the needs of the Jewish Community surrounding loss, life s changes, terminal illness, dying and grief. Hispanic Hospice Program Compassionate Care develops all Hispanic/Spanish speaking interdisciplinary teams to serve the needs of these patients. All patient informational brochures are available in Spanish and all team members are bilingual, including chaplains, nurses, social workers and others. Staff is trained on cultural sensitivities and recognizes important Hispanic related dates and events. Compassionate Care 4 Kids services are provided in a team approach to patient care strengthened for Compassionate Care partnerships with local children s hospitals. Life Enhancement Specialists are paid employees at Compassionate Care who provide recreational activities for socially isolated patients. The life enhancement specialist focuses on enhancing the patient s quality of life by carrying out various activities such as painting the patient s nails, playing music, conversing with the patient and keeping this person company. Schedule 6 provides for one FTE life enhancement specialist. Homemaker full-time paid employees whose role is to carry out day to day tasks on behalf of the patient and/or patient s family to maintain the home. Homemakers are not licensed professionals and therefore they cannot do all activities of daily living such as bathing the patient. Schedule 6A includes one homemaker FTE in year one and two homemaker FTEs in year two. Cardiac Connections - a care model developed to meet the unique needs of patients with advanced cardiac disease and congestive heart failure. Treatment will greatly reduce or eliminate visits to the emergency room and hospitalization. Promise Program meets the requirements of needy populations. Compassionate Care provides a supportive network of medical, nursing, and psychosocial interventions for patients who may be considering stopping dialysis treatments. 20

21 First Night at Home program is designed to ensure new hospice patients receive a little extra support the first few days on service. Hospice aides are staffed for evening or off hour shifts. Weekend personal care support is readily available to all patients. Veterans Outreach will be implemented to meet the end-of-life needs of this patient population by assisting veterans in accessing available services and supports offered to veterans. Community Outreach reaches out to local schools and supports children experiencing the death of a loved one. Compassionate Care hospice teams will participate and sponsor community toy and food drives around the holidays. Compassionate Care will also partner with local hospitals and healthcare organizations to reach beyond hospice and focus on wellness and patient education; and attend and/or host community health and wellness fairs and other events. Volunteer Services trained volunteers will be used to provide administrative support and direct patient care. Volunteer services will be based on patient need and requests as assessed by the volunteer coordinator Bereavement Services after a patient has died, the team will keep in contact with the family on a regular basis for at least 13 months after the death of a love done. The team may provide memorial services in long-term care facilities and assisted living facilities. Rainbows is a bereavement support program for children who are experiencing grief through a death or divorce in the family. Comfort Corners is a program in which Compassionate Care sponsors designated areas within a long-term care facility and decorates the area to resemble a warm, home-like environment for hospice patients and their families. 21

22 b. Chapter 59C , Florida Administrative Code contains the following general provisions and review criteria to be considered in reviewing hospice programs. (1) Required Program Description (Rule 59C (6), Florida Administrative Code): An applicant for a new hospice program shall provide a detailed program description in its certificate of need application, including: (a) Proposed staffing, including use of volunteers. The following is the proposed staffing for years one and two of operation: Position Average Number of FTE Year One Average Number of FTE Year Two Administrator Professional Relations Coordinator Secretary Community Liaison Clerk for Monroe Office Medical Director Registered Nurse Per Diem Registered Nurses Licensed Nurse Practitioners Per Diem Lic d Nurse Practitioners Nurses Aides Per Diem Nurses Aides Homemaker Life Enhancement Specialist Continuous Care Per Diem LPN Continuous Care Per Diem Aide Music Therapist Massage Therapist Dietary Services Social Worker Volunteer Coordinator Chaplain Total Source: CON Application #10091, Schedule 6A. 22

23 (b) Expected sources of patient referrals. The applicant states that referrals will come from area physicians, hospitals, nursing homes and other healthcare providers, family members and patients themselves. Compassionate Care states it will develop programs and services geared toward Service Area 11 referral sources. The applicant has letters of support from Service Area 11 hospitals, skilled nursing homes, assisted living facilities, physicians and community organizations. (c) Projected number of admissions, by payer type, including Medicare, Medicaid, private insurance, selfpay, and indigent care patients for the first two years of operation. The applicant provided the following table illustrating its projected number of admissions by payer type for the first two years of operation. Projected Number of Admissions by Payer Type Compassionate Care Hospice of Florida, Inc. Service Area 11 Payer Type Year One Year Two Medicare Medicaid 7 18 Insurance Self-Pay 0 0 Charity 3 8 Total 219* 606 Source: CON Application #10091, page 116. *Year One admissions calculate to 226. The applicant projects Medicare will comprise 94.1 percent of admissions, Medicaid 3.2 percent and charity 1.3 (1.36) percent during the first two years of operations. (d) Projected number of admissions, by type of terminal illness, for the first two years of operation. Compassionate Care provided the following table illustrating the projected number of admissions by type of terminal illness for the first two years of operation. 23

24 Projected number of Admissions by Diagnosis For Compassionate Care Hospice of Florida, Inc. Service Area 11 Diagnosis Year One Year Two Cancer Cardiac Respiratory Renal Failure HIV/AIDS 7 18 Other Total Source: CON Application #10091, page 117. (e) Projected number of admissions, by two age groups, under 65 and 65 or older, for the first two years of operation. Compassionate Care provides the following table for the projected number of admissions by age cohort. Projected Admissions by Age Group for Compassionate Care Hospice of Florida, Inc. Service Area 11 Under 65 Over 65 Total Year One Year Two Source: CON Application #10082, page 80. (f) Identification of the services that will be provided directly by hospice staff and volunteers and those that will be provided through contractual arrangements. The hospice care team shall directly provide the following core services: nursing services, social work services, pastoral or counseling services, dietary counseling, and bereavement counseling services. Physician services may be provided by the hospice directly or through contract. A hospice may also use contracted staff if necessary to supplement hospice employees in order to meet the needs of patients during periods of peak patient loads or under extraordinary circumstances. The applicant states that core services will be provided by its staff and volunteers. Compassionate Care will contract for certain services as needed by the patients: durable medical equipment, medical supplies, pharmaceuticals, physical therapy, speech therapy, and occupational therapy. Noncore services to be provided by Compassionate Care staff 24