STATE AGENCY ACTION REPORT ON APPLICATION FOR CERTIFICATE OF NEED (813) (386) Hospice Service Area 7B (Orange and Osceola Counties)

Transcription

1 STATE AGENCY ACTION REPORT ON APPLICATION FOR CERTIFICATE OF NEED A. PROJECT IDENTIFICATION 1. Applicant/CON Action Number Greystone Hospice of District 7B LLC/CON # Park Oak Boulevard, Suite 300 Tampa, Florida Authorized Representative: Bruce G. Schroeder (813) Halifax Hospice, Inc./CON # Woodbriar Trail Port Orange, Florida Authorized Representative: Fran Davis (386) Service District/Subdistrict Hospice Service Area 7B (Orange and Osceola Counties) B. PUBLIC HEARING A public hearing was not held or requested regarding the proposed projects. Letters of Support Greystone Hospice of District 7B LLC (CON application #10209): Six unduplicated letters of support were included in the application s Volume I, Tab 3. All letters were signed; five were dated between December 3 and December 16, Dr. Clark s support letter was not dated. Two support letters originated from Hospice Service Area 7B (Orange County). The support letters are summarized below. Stuart Beebe, President & CEO, Sonata Health Care LLC (Orlando) indicates his organization owns, operates and develops assisted living facilities and memory care communities in the central Florida area. He

2 and Julie Fernandez, Executive Director, Serenades by Sonata (Longwood, Florida in Hospice Service Area 7C) state that if given the opportunity, I would refer our residents and their families to Greystone for their hospice program. Brooke Ellis, Executive Director, Serenates by Sonata (Winter Garden, Florida - Hospice Service Area 7B), states her facility would be willing to discuss contractual agreements with the applicant to make beds available in the community for general hospice care for her facility s residents so they can age-in-place. Lowell F. Clark, MD, President and Owner, The Clark Clinic, Inc., states he currently presides over two rural health clinics (located in Bushnell and Howey-In-The-Hills) and 17 nursing home/(assisted living) ALF facilities throughout Central Florida. The reviewer notes that Dr. Clark is board-certified in internal medicine and is on the hospital staff at Leesburg Regional Medical Center, The Villages Regional Medical Center and Florida Hospital Waterman. Dr. Clark is also the certified medical director at several nursing and rehabilitation facilities in Lake and Sumter Counties. 1 The Clark Clinic s rural health clinics, the three hospitals, and nursing homes/alfs are all located in Hospice Service Area 3E. However, Dr. Clark states his 15 providers see patients in Alachua, Orange, Lake, Sumter, Marion and Volusia Counties. He states that he has worked with Greystone Health Management (GHM) operators for over 14 years and they are by far the most organized, ethical and 100 percent committed to patient care group in the healthcare industry in our community. He further states I have not seen another corporate model that works any better than theirs (GHM) and none can hold a candle to their administrative team. Peter Winn, Senior Vice President, Post Acute Care Physicians (Miramar, Florida) states having worked with Greystone for seven years and continues to be impressed with their professionalism and corporate culture which focuses on being patient driven and a good community partner. He states his organization has over 170 physicians and that many continue to provide patient center care in Greystone facilities. The applicant also included a letter from Amy Tucci, President & CEO of Hospice Foundation of America (HFA), who states that If Greystone Hospice s application for a CON is approved, HFA is prepared to continue its work on behalf of the hospice care philosophy with Greystone Hospice. 1 Source: The Clark Clinic s website at 2

3 Two hand-written testimonial letters are included in Volume 2, Tab 9. These testimonials cite the quality care provided by Greystone Home Healthcare. Halifax Hospice, Inc. (CON application #10210): Twenty-five unduplicated letters of support were included in the application s Volume 2, Attachment I. All letters were signed; 15 were dated between November 4 and December 16, Ten letters were not dated. Fourteen support letters originated from Hospice Service Area 7B Orange County (12 letters) and Osceola County (two letters). Many of the support letters were complimentary of Halifax Health Hospice of Volusia/Flagler (Halifax Health Hospice) and state that high quality hospice services would be provided by the applicant, if the application is approved. These letters are summarized below. Teresa Jacobs, Orange County Mayor, and Fred Hawkins, Jr., Vice- Chairman, County Commissioner, District 5, Osceola County Board of County Commissioners, state that the applicant can significantly improve hospice access for Orlando-area residents and their families and is in the best position to assist the most financially disadvantaged, hospice eligible patients in the area. They also state they are aware that the applicant has already held a number of discussions with Orlando Health to begin developing an effective working relationship. Hasib Ibne-Rasa, MD, President, East Coast Hospital Inpatient Specialists, (ECHIS), states having had the opportunity to work with the Halifax team over the last few years with patients that have received care in Orlando but live in the Volusia and Flagler County service area. The reviewer notes that ECHIS s office is in Seminole County and that it is a group of 10 physicians, two advanced registered nurse practitioners (ARNPs) and one physician assistant (PA), serving: Central Florida Regional Hospital (Seminole County) and two Volusia County hospitals Florida Hospital Fish Memorial and Florida Hospital Deland. 2 Dr. Ibne-Rasa states our community needs a hospice that has your commitment to service, responsiveness and professionalism. He also states ECHIS has been impressed by the fast response time to our admission requests, your support in transporting patients safely to their destination whether home, or to one of your high quality inpatient units. A similarly supportive comment was made by staff at the Lake Bennett Health and Rehabilitation Center (Ocoee, Florida). 2 Source: ECHIS website at 3

4 Below is a list of other support letters the applicant provided and referenced in Volume 1, Part C of the application: Brian Ouellette, Nursing Home Administrator (NHA), Kris Linden, Registered Nurse (RN), Director of Nursing (DON) and Young Kirkby (Business Office Manager), The Health Center of Windermere Milana Jeftic, Administrator, Assurance Home Health Traci Jones, RN, General Manager, Nurse On Call-Home Healthcare Karen Northover, NHA, MSSL, Executive Director, Avante at Orlando Skilled Nursing & Rehabilitation Center Eloise Abrahams, RN, NHA, Guardian Care Nursing and Rehabilitation Center Matt File, Administrator, Conway Lakes Health & Rehabilitation Center Elaine Gavin-Zoske, Administrator, Quality Professionals, Inc. Marc Gutierrez, Practice Administrator, ECHIS W. Daniel Hale, Ph.D., President and Executive Director, The O Neil Foundation for Community Health Donald R. Smith, Chairman/CEO, Veterans Tribute and Museum of Osceola County, Inc./Museum of Military History, Inc. Mike Kirby, Winter Park, Florida Sharlene Barron, Resource Development/Community Development, Good Samaritan Society Brian Culbreth, Orange County, Florida and The Childrey family. Below is a list of other support letters the applicant provided in Volume 2, Attachment I of the application. Cathy Henderson, NHA, Orlando Lutheran Towers Reverend Jim Spencer, Rector, St. Peter the Fisherman Episcopal Church Steve Griswack, Orlando Resident Marion Foo, Deland, Florida and Susan Miller, Owner/President, Home Instead Senior Care. The formerly mentioned writers provided the following comments: 4

5 Hospice Service Area 7B (HSA 7B) would benefit from Halifax Health s o Breathe Easy program (addressing lung issues such as chronic obstructive pulmonary disease or COPD) o Rest Easy program (for patients with heart disease) o a successful pediatric hospice program, with intent to open a Partners In Care program for children o a strong history of service and a strong financial commitment to the area it serves and o a history of extensive community bereavement support, innovative chaplaincy and an extensive network of hospice care centers (Ouellette, Linden, Kirkby, Jeftic, Northover, Abrahams and Henderson). Halifax Health Hospice is a leader in working with our patients as well as providing many innovative community programs that support various areas of the community (Jones) Halifax Health s strong and reputable history of a palliative care program the professionalism, expertise and compassion provided by Halifax Health Hospice over the past few years (Gavin-Zoske) Halifax Health Hospice s proactive breaking down of barriers that often prevent people from receiving hospice care (Hale) Halifax Health Hospice s support for underserved areas, including pediatrics, minorities, Spanish-speaking communities and extensive Veteran s programs (Smith) Halifax Health Hospice s reputation in the Volusia County area is top of the line, Halifax Health Hospice has found and addressed areas of concern that home health agencies had not noticed and to extend such services through the applicant is simply a way to offer more care to those in need in a wonderful way (Barron) and during the last 10 years many patients have had their end-of-life journeys improved by the expertise of Halifax Health Hospice (Rev. Spencer). C. PROJECT SUMMARY Greystone Hospice of District 7B LLC (CON application #10209), also referenced as Greystone, is a newly formed development stage Florida for-profit corporation and proposes to establish a new hospice program in Hospice Service Area 7B. Greystone expects issuance of licensure in 5

6 December 2014 and initiation of service in January The applicant s sister corporation, Greystone Healthcare Management (GHM) operates 18 skilled nursing facilities (SNFs) in Florida. The applicant is proposing total project costs of $337,831 with year one operating costs of $2,417,447 and year two operating costs of $4,605,814. Per the applicant, based on its research, it has concluded that there are no populations within Hospice Service Area 7B whose needs are being completely unmet. However, Greystone contends that while it intends to serve the entirety of the hospice population in the area, there are ongoing needs that will increase over time as the population of the service area increases and ages and as the composition of the population changes. Greystone further contends that there is an ongoing need for a hospice program committed to meeting the cultural, language and religious needs of the area s large and rapidly growing Hispanic community. Schedule C includes the following conditions: Financial Support Greystone Hospice of District 7B LLC commits to establishment of a new nonprofit charitable foundation to assist in meeting the needs of the residents of Orange and Osceola Counties. The new foundation will be funded through $1 million in contributions from Greystone & Co., Inc. during the initial five-year period of hospice program licensure, with at least $200,000 contributed within 90 days of initial licensure of the proposed hospice program. The foundation will be designed to distribute funds based on local needs as demonstrated through a registered not-for-profit organizations current or planned work in the community. An example of such programs and organization include, but are not limited to: United Way Local colleges and nursing scholarships Programs to raise awareness of hospice services Provision of education and training to clinical and volunteer staff who are involved in hospice care Provision of support or establishment of programs that benefit hospice patients and/or their families that are not otherwise covered as a reimbursed service Provision of education and training to clinicians within the community 6

7 Reduction of the overall healthcare cost in the community Provision of services that might not be otherwise funded or provided Other general purposes, with an emphasis on healthcare, that benefit Service Area 7B. The foundation will be prohibited from making contributions that directly benefit Greystone Hospice of District 7B LLC or any Greystone affiliate. Compliance with this condition will be measured by submission to AHCA of evidence of the legal organization of the foundation entity, the restrictions on use of foundation funds, and an annual itemization of recipients and amounts of distributed funds, including a description of the specific programs and services funded to benefit area residents in need. Office Locations Hospice Service Area 7B includes two counties: Orange and Osceola. Greystone Hospice of 7B LLC commits to the development of its main office in Orlando, Orange County, and commits to open a satellite office in Poinciana, Osceola County, by the end of year three of operation. Compliance will be demonstrated by furnishing AHCA with copies of relevant portions of signed lease agreements. Fundraising Greystone Hospice of 7B LLC commits that it will not engage in fundraising activities in the service area. Persons wishing to make donations will be encouraged to donate instead to the newly established foundation (described in Condition #1 3 ) or to one of the area s existing nonprofit hospice foundations. Compliance with this condition will be demonstrated by submission to AHCA of an annual statement verifying this had occurred. Reporting Greystone Hospice of District 7B LLC commits to voluntarily report to AHCA s Family Evaluation of Hospice Care (FEHC) Satisfaction Survey found at the FloridaHealthFinder.gov website. Compliance with this condition will be measured by submission of the required information. Veterans Greystone Hospice of District 7B LLC commits to partner with the We Honor Veterans program, which recognizes the unique needs of terminally-ill veterans and their families. Compliance with this condition will be measured by submission of written acknowledgement from the We Honor Veterans program of the hospice s involvement. 3 The reviewer notes that the applicant bolds but does not specifically number its proposed conditions. 7

8 Halifax Hospice, Inc. (CON application #10210), a Florida not-forprofit, 501(c)(3) corporation, proposes to establish a new hospice program in Hospice Service Area 7B. Halifax Hospice, Inc. expects issuance of licensure on June 1, 2014 and initiation of service on July 1, The applicant has been licensed since 1979 as Halifax Health Hospice of Volusia/Flagler to operate a hospice program in Hospice Service Area 4B and seeks to expand its hospice services into adjoining Hospice Service Area 7B. The applicant is proposing total project costs of $389,204 with year one incremental operating costs of $2,901,905 and year two incremental operating costs of $7,186,603. Per the applicant, the Hispanic population in Hospice Service Area 7B is large and growing particularly in Osceola County and Halifax will specifically reach out to the Hispanic community. Halifax also states plans to pursue the same efforts for veterans care in Orange and Osceola Counties that it has pursued in Subdistrict 4B. Schedule C includes the following conditions: 1. Halifax conditions this application on seeking CON approval for the development of a freestanding hospice house in Subdistrict 7B when the average census of patients in Orange and Osceola Counties reaches 200 patients. This condition will be measured initially by the submission of the CON application, and when approved, by licensure and annual reporting of hospice house utilization. 2. Halifax conditions this application on the development of a physical presence in Osceola County whether it be a main or branch office. This condition will be measured by an annual report to AHCA of the location of Halifax s presence in Osceola County. 3. Halifax conditions this application on the implementation of a Hispanic education and outreach program. This condition will be measured by an annual report to AHCA providing a summary of the Hispanic education and outreach program. 8

9 4. Halifax conditions the application on the development of a program for veterans that achieves the Level 4 designation of the NHPCA (National Hospice and Palliative Care Association) within two years of initiation of the hospice program in Subdistrict 7B. This condition will be measured by a report to AHCA documenting achievement of the Level 4 designation within two years of operation. 5. Halifax conditions this application on the participation in the PIC:TFK (Partners in Care: Together for Kids) program 4 in Orange and Osceola Counties within two years of initiation of the hospice program in Subdistrict 7B. This condition will be measured by a report to AHCA documenting the participation of Halifax in the PIC:TFK program within two years of initiation of operation. 6. Halifax conditions this application on the development of a children s grief program within two years of initiation of the hospice program in Subdistrict 7B. This condition will be measured by an annual report to AHCA summarizing the children s grief program starting within two years of operation. 7. Halifax conditions this application on the development of a traumatic loss program for families of victims of homicide, suicide and other traumatic loss within two years of initiation of the hospice program in Subdistrict 7B. This condition will be measured by an annual report to AHCA summarizing the traumatic loss program starting within two years of operation. Should a 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. The applicants proposed conditions are as they 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 Also, several of these conditions are required hospice services and as such would not require condition compliance reports. 4 Per CON application #10210, page 27, PIC:TFK is a 1915(b) Medicaid waiver program operated under the authority of Children s Medical Services (CMS) and is a demonstration program of the Children s Hospice International Program of All Inclusive Care for Children (CHI PACC) model. Per the website at PIC-TFK is a program that offers specialized palliative care support services for children and adolescents up to the age of 21. 9

10 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. 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, consultant Steve Love, analyzed the application in its entirety with consultation from financial analyst Eric West of the Bureau of Central Services, who evaluated the financial data. 10

11 E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA The following indicate the level of conformity of the proposed project with the review criteria and application content requirements found in Sections and , and applicable rules of the State of Florida, Chapters 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? Or does the project proposed seek beds or services in excess of the fixed need pool? Rule 59C-1.008(2), Florida Administrative Code. In Volume 39, Number 189, of the Florida Administrative Register, dated September 27, 2013, a hospice program need of one was published for Service Area 7B for the January 2015 Hospice Planning Horizon. Therefore, the applicants are applying in response to published need. Service Area 7B is currently served by the following hospice providers: Cornerstone Hospice and Palliative Care, Inc. Florida Hospital HospiceCare Hospice of the Comforter, Inc. Samaritan Care Hospice of Florida, and VITAS Healthcare Corporation of Florida. Hospice admissions in Hospice Service Area 7B are listed below by provider: Hospice Admissions in Hospice Service Area 7B for the 12-Month Period ending June 30, 2013 *Cornerstone Hospice and Palliative Care, Inc. 819 *Florida Hospital HospiceCare 126 *Hospice of the Comforter, Inc. 1,350 Samaritan Care Hospice of Florida 360 *VITAS Healthcare Corporation of Florida. 2,693 Total 5,348 Source: Agency for Health Care Administration s Florida Need Projections for the January 2015 Hospice Planning Horizon, published September 27, NOTE: *The applicant serves an adjacent service area(s). As previously stated, the applicants are applying in response to published need for a hospice program in Hospice Service Area 7B, Orange and Osceola Counties. However, the applicants provide additional arguments in support of need for their projects as discussed later in this section. 11

12 Greystone Hospice of District 7B LLC (CON application #10209) indicates having undertaken its own needs assessment related to specific conditions in Hospice Service Area 7B, including extensive research into hospice utilization by patient race/ethnicity, age and diagnosis, as well as county and age-specific mortality rates and trends. Greystone also discusses its need assessment based on what the applicant considers the following characteristics of the service area that impact hospice needs: Population size and composition Mortality rates and other factors potentially impacting hospice use and Local community support. Population Characteristics Impacting Hospice Program Needs in Service Area 7B Greystone indicates that the total population growth of the service area from 2010 to 2015 is estimated to increase by 131,279 residents (9.3 percent) compared to a statewide total population growth rate of 5.0 percent. Similarly, Greystone indicates that the total Hispanic population growth of the service area for the same period is estimated to increase by 78,345 residents (18.2 percent) compared to a statewide total Hispanic population growth rate of 12.1 percent. Greystone emphasizes that over this same period the Hispanic population of the service area is almost double that of the overall population (18.2 percent versus 9.3 percent). The applicant asserts that by 2015, a third of the service area s 1.55 million residents are expected to be Hispanic, with this population cohort accounting for 49 percent of Osceola County residents, by the same period. Greystone also indicates that during calendar year 2012, Hispanics accounted for 18 percent of all deaths in Hospice Service Area 7B and 29 percent of deaths in Osceola County. The reviewer notes that Greystone provides descriptive population characteristics but does not document access or quality of care problems with any subgroups. Mortality and Other Factors Impacting Resident Hospice Needs Greystone states that historically, higher rates of hospice utilization have been found among higher income populations. Per the applicant, in 2011, there were lower Osceola County per capita income and lower Osceola County median household income when compared to Orange County and the state overall. See the table below. 12

13 Estimated Income All Ages Hospice Service Area 7B in 2011 Income County Per Capita Median Household Percent of Poverty Orange $35,990 $49, % Osceola $27,171 $46, % Florida $39,636 $47, % Source: CON application #10209, page 15, Table 3. Based on the above table, Greystone suggests that income characteristics of the area may exert downward pressure on hospice utilization within some lower income portions of Service Area 7B. Community Perceptions and Support for Greystone Greytone s letters of support were summarized in Item B of this report. Proposed Office Locations Greystone states development plans to establish an initial care team office in Orlando upon initiation of operations in January 2015 and a second location in Poinciana (Osceola County) prior to the end of The reviewer confirms that per CON application #10209, Schedule 7A, operating year two ends December 31, Per Greystone, in 2010, Hispanic or Latino persons of any race comprised 51.2 percent of the Poinciana population, with Poinciana being the Little Puerto Rico of Florida. Utilization Forecast Greystone cites the Hospice Service Area 7B net need of 561 admissions for the January 2015 planning horizon and projects that its program will have 300 admissions in year one (CY 2015) and 353 admissions in year two (CY 2016). See the table below. Admissions Patient Days Number Percent Number Percent Payer Year 1 Year 2 Year 1 Year 2 Year 1 Year 2 Year 1 Year 2 Medicare % 88% 13,990 20,976 93% 93% Medicaid % 7% % 4% Commercial % 3% % 2% Self-Pay 0 0 0% 0% 0 0 0% 0% Indigent/Charity % 3% % 2% Total % 100%* 15,110 22, %* 100%* Source: CON application #10209, page 22. Note: *The reviewer notes these arithmetic totals are 101 percent. The difference is probably due to rounding. 13

14 Greystone estimates that in its first year of operation, it projects a market share of 5.1 percent of the total Hospice Service Area 7B admissions of 5,909 by 2015 (300/5,909=5.08 percent). Per Greystone, 5.1 percent is easily achievable and still allowing for utilization growth among the existing providers. Impact on Existing Service Area 7B Providers Greystone anticipates that in 2015, Greystone s 300 admissions will leave the existing providers with their current utilization of 5,348 collective admissions, plus 261 additional (the difference between the net need, or projected minus current, of 561 and the 300 anticipated by Greystone). The applicant expects the growth in hospice admissions within the service area is sufficient to allow Greystone to achieve its goal of building a viable new program while allowing existing hospice programs to continue growing their admissions. The CON reviewer notes that there is published need for an additional program in Hospice Service Area 7B; therefore, the impact on existing providers is of minimal concern. Halifax Hospice, Inc. (CON application #10210) states plans to bring a robust outreach program and a commitment to serve all patients rather than selectively market to the more profitable Medicare patient population. Halifax contends it will bring a different approach and a different range of services than are currently available to the area, and states that it has resources and the commitment to overcome barriers to hospice utilization than are currently present in Subdistrict 7B. Existing Providers Halifax expects to afford patients in the service area other options for care, as it plans to seek CON approval to open a freestanding inpatient facility once its census in Subdistrict 7B reaches 200. The applicant compares current average patient caseloads in Hospice Service Areas 7B and 4B, citing its higher freestanding facility patient case load compared to the current average situation in both Hospice Service Area 7B and 4B. See the table below. 14

15 Average Patient Case Load Percentages Provided in Hospice Service Area 7B and 4B Hospice Residential Unit Freestanding Inpatient Hospice Facility Hospice Service Area/Provider Private Home Nursing Home ALF Hospital 7B 58.0% 21.4% 15.1% 0.5% 2.4% 2.6% 4B 52.8% 21.3% 18.4% 0.0% 4.1% 3.4% Halifax Health Hospice 49.0% 25.1% 18.2% 0.0% 7.2% 0.5% Source: CON application #10210, pages 47 and 48, Exhibits 2 and 3, respectively. Halifax s Quality Outcomes and Enhancement of Care to Service Area The applicant discusses participation by Halifax Health Hospice of Volusia/Flagler in the Agency s Hospice Provider Family Satisfaction Survey. The most recent results of this survey range from January 2013 through March Per the Agency website at Halifax Health Hospice of Volusia/Flagler attained a five-star rating on each of the five questions in the survey. Respondents ranged from a low of 141 to a high of 176. The five-star rating is the highest attainable and indicates respondents were 90 to 100 percent satisfied with the hospice s performance. Halifax Hospice participates in a statewide patient/family satisfaction survey, complied by the Department of Elder Affairs (DOEA). The survey results are indicated as percentages for three Outcome Measures 1, 2 and 2A. Outcome Measure 1 measures the percentage of patients who had severe pain (seven or higher on the 0-to-10 scale) at admission and whose pain was reduced to a level of five or less by the end of the fourth day of care in the hospice program. Outcome Measure 2 includes the following question: Did the patient receive the right amount of medicine for his or her pain? Outcome Measure 2A includes the following question: Based on the care the patient received, would the patient and/or responsible party recommend hospice services to others? 15

16 Per the DOEA s 2013 Report on Hospice Demographic and Outcomes Measures, issued October 2013 (for calendar year 2012), family and patient satisfaction survey results on Halifax Hospice s performance, existing Hospice Service Areas 4B, 7B and the state average are shown below. Halifax Hospice, Inc. (CON application #10210) 2012 Outcome Measure Results Outcome Measure Number of Hospice 1 2 2A Patients Halifax Hospice, Inc. 91% 95% 98% 3,214 Cornerstone Hospice & Palliative Care 84% 95% 92% 4,481 Florida Hospital HospiceCare 57% 93% 90% 931 Gentiva Hospice a/k/a Odyssey 91% 93% 92% 1,333 Haven Hospice 82% 96% 93% 3,084 Hospice of the Comforter, Inc. 80% 94% 97% 2,515 Samaritan Care Hospice of Florida 89% 91% 89% 518 Vitas Healthcare Corp. (Melbourne) 80% 94% 98% 6,454 State 84% 95% 97% 116,242 Source: DOEA, 2013 Report on Hospice Demographics and Outcomes Measures, issued October 2013 for calendar year 2012, pages Note: Florida hospices reported pain level data for 53,097 patients at the time of admission and 8,966 patients reported severe pain on admission. There were 18,958 survey responses to Outcome Measure 2 and 25,489 responses to Outcome Measure 2A. Number of responses by hospice was not provided. As shown in the table above, Halifax Hospice s patient/family satisfaction is at 91.0 percent for Outcome Measure 1, 95.0 percent for Outcome Measure 2 and 98.0 percent for Outcome Measure 2A. This is higher than the state average with the exception of Outcome Measure 2, where Halifax meets the state average. Halifax exceeds all HSA 4B and 7B providers in all outcome measures with the exception of Haven Hospice s 96 percent in Outcome Measure 2 (Halifax has 95 percent) and Outcome Measure 1 where it is tied with Gentiva Hospice (91 percent) and Outcome Measure 2A where it is tied with Vitas Healthcare (98 percent). The above table is consistent with CON application #10210, page 50, Exhibit 4, with the exception that the applicant does not include Gentiva Hospice which has Miami-Dade and Monroe (HSA 11), Flagler and Volusia Counties (HSA 4B) and Marion County (HSA 3B), on its license. Demographic Profile of Subdistrict 7B Population Halifax presents population estimates for Service Area 7B (Orange and Osceola Counties combined) and Florida population estimates for the five-year period from January 2013 to January

17 Hospice Service Area 7B and Florida Population Estimates January 2013 January 2018 District 7B Florida Age Group Percent Change Percent Change Under 65 1,322,099 1,455, % 15,754,190 16,500, % Over , , % 3,462,588 4,021, % Total 1,477,256 1,645, % 19,216,778 20,522, % Source: CON application #10210, page 51, Exhibit 5, from AHCA Florida Population Estimates , Sept release. The applicant cites that the percentage growth rate for the age 65 and over population in Subdistrict 7B from 2013 to 2018, exceeds the state average and notes the 65 and over population is the primary consumers of hospice care. Halifax next addresses population estimates for Orange and Osceola Counties (see table below). Population Estimates for Orange and Osceola Counties January 2013 January 2018 Orange County Osceola County Age Group Percent Change Percent Change Under 65 1,068,631 1,163, % 253, , % Over , , % 33,152 42, % Total 1,190,636 1,311, % 286, , % Source: CON application #10210, page 52, Exhibit 6, from AHCA Florida Population Estimates , Sept release. Halifax Hospice, Inc. s Exhibit 6 indicates and the Agency confirms higher population growth percentages for Osceola County than for Orange County. The applicant states that there is tremendous growth in both counties with significant growth in Osceola County, so it plans to address and target Osceola County for hospice services. Pediatric Population Similar to its pediatric hospice services in Hospice Service Area 4B, Halifax Hospice, Inc. states plans to bring these programs to Hospice Service Area 7B, whether it be the Partners in Care Program, the Palliative Care Consult Services or the PedsPal offering. Halifax Hospice, Inc. misstates its pediatric population estimates indicating they are pediatric patient totals for 2013 to However, these estimates are for the age 17 and under populations for Orange and Osceola Counties, HSA 7B and the state. See the table below. 17

18 Orange & Osceola Counties, Hospice Service Area 7B and Florida Population Age 17 & Under Estimates January 2013 January Percent Change Orange County 281, , % Osceola County 73,247 82, % Subdistrict 7B Total 354, , % Florida 4,032,133 4,207, % Source: CON application #10210, page 52, Exhibit 7, from AHCA Florida Population Estimates , Sept release. Halifax Hospice notes the 9.47 percent increase in the age 17 and under population and contends this will be a population that will require hospices to be available and its established pediatric programs will be needed. The applicant also provided a discussion of the deaths of between 2003 and 2012 of the Subdistrict 7B population under age 18. However, these patients are not a significant volume of the service area s deaths (208 of the service area s 8,811 (0.26 percent) in CY 2012). See the table below. Historic Pediatric Deaths Percent Change All Deaths % Cancer % Cardiovascular Disease % Respiratory Disease % Source: CON application #10210, page 57, from Florida Department of Health CHARTS. Race and Ethnicity Per Halifax Hospice, Inc., race and ethnic growth patterns in the proposed area indicate a new hospice must be prepared to develop programs that address increasing diversity and that diversity programs are of particular interest to the applicant. Halifax Hospice, Inc. states its intent to offer those of African descent and Spanish-speaking communities hospice education, care and materials specific to both their culture and language (CON application #10210, Volume 2, Attachment Q). A brief review of this attachment indicates multiple materials provided in Spanish. The applicant also states its plan to conduct outreach with Spanish-speaking staff and into Hispanic churches, including churches in the Orlando and Kissimmee communities. Halifax Hospice, Inc. plans to approach and work with the following various Hispanic organizations: The Hispanic Chamber of Commerce of Central Florida The Hispanic American Professional & Business Women s Association The Hispanic Young Professionals & Entrepreneurs of Orlando 18

19 The National Association of Hispanic Journalists and The Hispanic Office for Local Assistance, among others. Using Claritas Marketplace, CON application #10210, Exhibit 8 indicates that the age 65 and over population growth for Subdistrict 7B s racial mix will go from 159,930 (in 2013) to 198,107 (in 2018), an increase of percent, with an annualized growth rate of 4.37 percent. Using the same source, CON application #10210, Exhibit 9 indicates that the total population growth for Subdistrict 7B s racial mix will go from 1,480,485 (in 2013) to 1,584,594 (in 2018), an increase of 7.03 percent, with an annualized growth rate of 1.37 percent. These two exhibits indicate a higher percentage population growth and a higher annualized rate of population growth for the age 65 and over population in the area, compared to Subdistrict 7B overall. Again using Claritas Marketplace, CON application #10210, Exhibit 10 indicates the Subdistrict 7B total Hispanic population of 486,447 ( in 2013) will increase to 579,870 (in 2018), an increase of percent. Per the exhibit, the Hispanic population statewide, over the same period, will grow by percent. Per the exhibit, the not Hispanic population over the same period will grow by 1.08 percent in Subdistrict 7B and by 1.71 percent statewide. CON application #10210, Exhibit 11 indicates that from 2013 to 2018, the total Hispanic population in Orange County will grow by 60,756 residents (a percent increase) and in Osceola County by 32,667 residents (a percent increase). Halifax Hospice, Inc. indicates that it is a culturally sensitive and diverse organization that understands that culture shapes choices for life support and care. The applicant further states that it extends an invitation to all cultural groups, races, ethnicities and religions to contact Halifax to host community events or receive more information. Veterans Per Halifax Hospice, Inc., using VetPop by the Veterans Administration, as of 2013, there were 86,998 veterans in Subdistrict 7B and by 2018, this population will be 80,986. See the table below. Veteran Population for Subdistrict 7B Veterans 65 and Under 57,770 56,259 55,114 54,203 53,148 52,265 Veterans ,228 29,493 29,471 29,247 29,068 28,721 Total Subdistrict 7B 86,998 85,752 84,585 83,450 82,215 80,986 Source: CON application #10210, page 56, Exhibit

20 Halifax Hospice, Inc. states the elderly veteran population is at the highest risk for the conditions that require hospice care such as cancer, cardiac disease, pulmonary disease and Alzheimer s dementia. The reviewer notes that Halifax Hospice, Inc. does not specifically address a lack of access or quality of care for this population, in the current situation. Deaths in Subdistrict 7B by Age, Race, Ethnicity Per the applicant, using Florida Department of Health, Florida CHARTS, (CON application #10210, Exhibit 13) indicates that from 2003 to 2012, the Subdistrict 7B incremental death count for residents under age 65 rose by 271 deaths (10.70 percent), for residents age 65 and over by 493 deaths (8.94 percent) and for all ages, the cumulated death count rose by 764 deaths (9.49 percent). CON application #10210, Exhibit 15 indicates Subdistrict 7B s total Hispanic population death count rose by 634 deaths (65.09 percent) compared to a total non-hispanic population death count rise of 112 deaths (1.59 percent). CON application #10210, Exhibit 16 indicates the Black population age 65 and over incremental death count rose by 143 deaths (23.87 percent) and for all races, the incremental death count rose by 751 deaths (9.33 percent). Causes of Death in Subdistrict 7B Again per the applicant, using Florida Department of Health, Florida CHARTS, (CON application #10210, Exhibit 17) indicates that from 2003 to 2012 the Subdistrict 7B incremental death count due to Alzheimer s Disease rose by 31 deaths (16.23 percent), cancer by 304 deaths (16.58 percent), diabetes by 67 deaths (29.52 percent) and due to Parkinson s Disease by 21 deaths (34.43 percent). Historical Utilization of Hospice Services in Subdistrict 7B and Florida Halifax Hospice, Inc. discusses acute care discharges to hospice, hospice penetration rates and rates by category (cancer vs. non-cancer, under age 65 and age 65 and over) and related penetration issues from 2009 through 2012, in CON application #10210, pages 60 through 69. The applicant offers projected utilization based on the following 20 bulleted points: Population data for the historical years 2009 through 2012 was obtained from Florida CHARTS. Projected population data for 2013 through 2018 was based on Agency projections. Historic death rates for Subdistrict 7B for the years 2009 through 2012 was obtained from Florida CHARTS. 20

21 Death rates by 10,000 residents for 2009 through 2012 was then calculated utilizing the historical death rates and the population figures from Florida CHARTS. The compound annual growth rate (CAGR) for deaths between 2009 and 2012 was then calculated for the diagnosis and age demographics in the exhibit(s). These CAGRs were utilized to obtain the projected death rates for 2013 through With these death rates and the projected population figures the projected deaths by diagnosis and age for 2013 through 2018 was calculated. Historic hospice admissions for 2009 through 2012 were obtained from the Agency s Hospice Need Projections. Utilizing the historic hospice admissions and the deaths by category and age, the penetration rates for 2009 through 2012 were calculated. The penetration rate of percent for the population with cancer under age 65 remains constant in 2013, but begins to increase to approach the State of Florida s penetration rate in 2012 of percent. The penetration rate of the population with cancer age 65 and over will remain constant as it is near or above the Florida penetration rate. The penetration rate of the population with all other diagnoses who are under age 65 will remain the same for 2013, but thereafter increase to approach the Florida penetration rate of over 22 percent. The penetration rate of the population with all other diagnoses who are age 65 and over will remain constant as the rate is close to the Florida penetration rate. With the projected penetration rates, along with projected deaths from 2013 to 2018, the projected hospice admission for these five projected years was calculated. Fiscal year hospice patients in the subdistrict were then calculated based on the assumed July 1, 2015 start date for Halifax to serve the area. The incremental patients between 2013 and 2015 of 428, as well as the increase in patients between 2013 and 2016 of 528 provide a significant level of demand for a new hospice without any impact on existing providers. It was presumed that in the first year of operations, 2015, Halifax would capture half of the incremental volume between 2013 and In the second year of operations, it was assumed that Halifax would serve less than 80 percent of the incremental volume of patients. Based on the projected utilization levels, Halifax projects market share from the first two years of operation of 3.7 and 7.8 percent. 21

22 Based on historical data and Halifax s experience, it was assumed that the average length of stay (ALOS) for patients under age 65 was 43 days, with the ALOS for patients age 65 and over was 76 days. Projected ramp up of the Halifax Hospice project based on the above resulted in an average daily census (ADC) of 68.5 by the end of year one and ADC by the end of year two. Halifax s market shares, ALOS and ADC determinations are stated to be very reasonable for a hospice with the depth of experience, community education and outreach programs, quality services and existing relationships Halifax has in the region. The reviewer notes that while the applicant has researched the subdistrict population, the Agency s publication of need accounts for these factors. Halifax Hospice, Inc. expects 214 admissions in year one and 470 in year two. The applicant also expects 214 admissions remaining in year one for other Subdistrict 7B hospice providers and 125 admissions remaining for those same providers, in year two. See the table below. Projected Halifax Patients in Subdistrict 7B Actual Projected Calendar Years Cancer Under Cancer 65 and Over 1,306 1,297 1,367 1,375 1,384 1,393 1,439 Non-Cancer Under Non-Cancer 65 and Over 3,136 3,182 3,426 3,523 3,622 3,724 3,933 Total 5,329 5,389 5,735 5,899 6,069 6,247 6,593 Incremental Market Patients Patients Project Years FY 2015 FY 2016 FY 2015 FY 2016 Cancer Under Cancer 65 and Over 1,371 1, Non-Cancer Under Non-Cancer 65 and Over 3,474 3, Total 5,817 5, Admissions to Halifax in Subdistrict 7B Projected Market Share Projected Admissions Cancer Under % 8.7% Cancer 65 and Over 2.7% 4.8% Non-Cancer Under % 9.2% Non-Cancer 65 and Over 4.2% 8.7% Total Patients 3.7% 7.8% Incremental Patients Remaining for Existing Providers Source: CON application #10210, page 71, Exhibit 30. Halifax Hospice, Inc. expects its ALOS days, by age cohort, ADC days and projected patient days, as shown below. 22

23 ALOS, ADC and Projected Patient Days Year One and Year Two Year One Year Two ALOS Under ALOS 65 and Over Projected Patient Days 13,622 32,257 Average Daily Census Source: CON application #10210, page 72, Exhibit 31. Impact on Existing Providers Halifax Hospice, Inc. restates that it anticipates no material impact on the existing area hospice providers, should the project be approved. The CON reviewer notes that there is published need for an additional program in Hospice Service Area 7B; therefore, the impact on existing providers is of minimal concern. Other Factors Supporting Halifax s Approval Halifax Hospice, Inc. offers the following 10 bulleted characteristics that it contends make it the best candidate to meet the needs of Subdistrict 7B : Halifax s years of experience and expertise providing hospice services to adjacent Subdistrict 4B since 1979 Halifax s skill and experience in innovative, quality hospice program and services that distinguish it from other batched applicants The ability to initiate hospice care and services within days of being approved by the Agency The commitments that Halifax has made with this application to meet the specific needs of the subdistrict Regional reputation of Halifax as an industry leader of hospice services Awards received by Halifax and its staff Demonstrated financial feasibility of the proposed Halifax hospice application Joint Commission Accreditation Halifax s track record for outcome driven hospice care and Halifax is a not-for-profit, mission-driven organization. 23

24 2. 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. Each applicant is responding to published need for an additional hospice program for the January 2015 planning horizon. Each applicant discusses serving populations they believe to be underserved or otherwise in need of target population hospice services. Greystone Hospice of District 7B LLC (CON application #10209) previously stated and contends that it finds there are no populations within Hospice Service Area 7B whose needs are being completely unmet. However, Greystone contends that while it intends to serve the entirety of the hospice population in the area, there are ongoing needs that will increase over time as the population of the service area increases and ages and as the composition of the population changes. Greystone further contends that there is an ongoing need for a hospice program committed to meeting the cultural, language and religious needs of the area s large and rapidly growing Hispanic community. Greystone conditions to open a satellite office in Poinciana, Osceola County, by the end of year three of operation, an area the applicant has described as Little Pueroto Rico. Greystone also conditions to partner with the We Honor Veterans program. Halifax Hospice, Inc. (CON application #10210) previously stated and contends that significant unmet needs in Hospice Service Area 7B are particular among the following groups: Hispanics, Veterans and the population under age 65 that have cancer and other life-limiting illnesses. Halifax Hospice, Inc. previously discussed extensively its plans to reach the area s Hispanic population, a population the applicant has described as having a particularly high growth rate in Osceola County. Halifax Hospice, Inc. conditions to this application the development of a physical presence in Osceola County whether it be a main or branch office. 24