STATE AGENCY ACTION REPORT ON APPLICATION FOR CERTIFICATE OF NEED

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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 # Landinex Plaza, Suite 2101 Parsippany, New Jersey Authorized Representative: Judith Grey (973) Service Area/Subdistrict District 8, Hospice Service Area 8C, Glades, Hendry and Lee Counties B. PUBLIC HEARING A public hearing was not held or requested regarding the proposal to establish a hospice program in Service Area 8C. However, letters of support were submitted, as discussed below. Letters of Support Compassionate Care Hospice of Florida, Inc. has 79 letters in support of its application. Fifty-eight were submitted with the application and 21 were mailed to the Agency on the applicant s behalf. Six letters were from hospitals and physicians practicing outside of Service Area 8C. The majority of the letters were form letters. These generally state Compassionate Care is a committed and competent provider of quality hospice services. They have some strengths that can meet unmet needs in the subdistrict, such as a Jewish hospice program accredited by the

2 National Institute for Jewish Hospice, bilingual teams that speak Spanish and Creole, and their specialized Cardiac Connections and Promise Renal programs By allowing Compassionate Care to operate in our community, choice will be provided and quality will be enhanced. Compassionate Care has 28 letters of support from Service Area 8C physicians. A sample of these include Dr. Vladimir Ilic, M.D. Cardiologist with Advanced Heart Center of Fort Myers, who states Compassionate s Cardiac Connection program would provide a level of service not currently available here. Dr. Jorge L. Serra, M.D., Internist states interest in the applicant s service to underserved populations with unique programs and service, i.e. National Certification of Jewish Hospice and their strong education and outreach to Hispanic populations. Dr. Mark Moskowitz, M.D., Oncologist indicates support for Compassionate and states that the medical community, health care providers, and the patients and families they serve would benefit from another choice in hospice providers. He states that he would definitely use Compassionate Care as another choice for his patients. Dr. Guillermo Bohm, M.D., Endocrinologist states that as a physician in the area, he can attest to the great need for an additional hospice provider. He states that Compassionate Care s Promise specialized renal program, Cardiac Connection program, Jewish Hospice program, and bilingual teams that speak Spanish and Creole are needed in 8C. Letters of support also discuss perceived issues with the current Service Area 8C provider. Jordan Scardigno, Senior Executive Director of Emeritus at Bonita Springs and Emeritus Fort Myers, Megan Deavers, Administrator Emeritus at Fort Myers, Frances Gray RN, Administrator of Springwood Court assisted living facility and seven other administrators, executive directors, etc. of assisted living facilities (ALFs) located in Lee County within Service Area 8C, submitted letters of support stating for those patients requiring an acute hospice intervention, rather than that patient receiving continuous care services in their facilities, with the current hospice provider they are often relocated to the hospice s hospice house, resulting in a disruption to patient care, removal of the patient from their home, and impacts on the quality of life in their communities. However, it is unclear as to whether or not the removal of the patient from their home is a temporary condition in which the patient is returned to their home after hospice intervention. The hospice provider must determine the appropriate venue for treatment of their patients. They further state their support for Compassionate Care Hospice because of its commitment to provide continuous care in the patient s home (their facility) and will not be developing hospice houses to which community patients will be relocated. 2

3 Although the applicant has letters of support from many Service Area 8C health care providers, none provided an indication of their willingness to contract for inpatient hospice beds within their facilities. Letters of Opposition There were 10 letters in opposition to Compassionate Care Hospice of Florida, Inc. establishing a new hospice program in Service Area 8C. J. Robert Griffin, Chief Legal Counsel of Hope Hospice and Community Services, Inc., asserts there is no need for an additional hospice provider in Service Area 8C because: The Agency s fixed need pool calculation demonstrates that there is no need for an additional hospice program to serve Hospice Service Area 8C. Hospice Service Area 8C has consistently achieved hospice penetration, the established measure of access to hospice care in Florida, which exceeds the state average and ranks among the highest penetration rates of any Florida hospice service area. No special circumstances exist which would warrant the approval of the application for another hospice program in Service Area 8C. Tammara A. Hall, District 4 County Commissioner, Lee County, states that Lee County is fortunate to be served by a wonderful, not-for-profit, community based hospice. She states that through her personal experience with Hope Hospice and its services, she is grateful to Hope for the professional and compassionate way they assisted her family in dealing with the death of a loved one. She states that Hope Hospice consistently reaches out to the community to make sure all persons are able to access excellent hospice care and therefore, there is no need for an additional provider in the area. James R. Nathan, President of Lee Memorial Health Systems states that with patient safety, quality compassionate care, end-of-life planning and palliative care increasingly vital care delivery services, it is essential that care coordination and communication be responsive, timely, and consistent for patients, family, and staff. Mr. Nathan contends that adding another hospice into the equation will only increase communication gaps. Dr. Thomas E. Teufel, hematologist/oncologist with Florida Cancer Specialists, is concerned that quality of hospice care will diminish if an out-of-state hospice, or any other hospice, is allowed to come in. Dr. Teufel expresses concern that another hospice, especially 3

4 one that operates for profit, will not be committed to the same quality and access that has become the standard in Fort Myers and the surrounding counties. The six letters from the representatives of two continuing life care retirement communities, one nursing home and two assisted living facilities indicate that Hope is a quality service provider that understands the needs of the community and that Hope provides the kind of truly comprehensive compassionate care that only a deeply committed not-for-profit, community focused heath care organization can provide. Many express concern that the addition of a new hospice provider would create duplication of services and may be detrimental to patients. C. PROJECT SUMMARY Compassionate Care Hospice of Florida, Inc. (CON #10082) proposes to establish a new hospice program in Hospice Service Area 8C, Glades, Hendry, and Lee 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, 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, Hardy, and Highlands Counties. The applicant is proposing total project costs of $141,950 with year one operating costs of $1,160,865 and year two costs of $3,120,923. 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 Hospice 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. 4

5 1. The applicant will implement its Promises (Renal) Program in Subdistrict 8C within year one of operation. This will be measured by a signed declaration statement submitted by Compassionate Care to the Agency. 2. 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 Subdistrict 8C residents. This will be measured by a signed declaratory statement submitted by Compassionate Care to the Agency. 3. At least 20 percent of all interdisciplinary team members in Subdistrict 8C consisting of physicians, registered nurses, home health aides, social workers, chaplains and volunteers, will be bilingual (English and Spanish and/or Creole). This will be measured by a signed declaratory statement submitted by Compassionate Care to The Agency. 4. The applicant has conditioned approval of this application on the provision it will make available all of its marketing and informational material as well as its website in the Spanish language, immediately upon licensure. This will be measured by a signed declaratory statement submitted by Compassionate Care to the Agency. 5. The applicant has conditioned approval of this application on the provision that its main office will be located in western Fort Myers, Lee County, the most densely populated County in Subdistrict 8C. This will be measured by a signed declaratory statement submitted by Compassionate Care to the Agency. 6. The applicant has conditioned approval of this application on the provision it will open a satellite office in Lehigh Acres, eastern Lee County during its first year of operation. This will be measured by a signed declaratory statement submitted by Compassionate Care to the Agency. 7. The applicant has conditioned approval of this application on the provision it will provide one FTE homemaker. This will be measured by a signed declaratory statement by Compassionate Care to the Agency. 5

6 8. The applicant has conditioned approval of this application on the provision it will become accredited by CHAP upon certification. This will be measured by a declaratory statement by Compassionate Care to the Agency. 9. Compassionate Care Hospice of Florida, Inc. will provide a home health aide ratio above NHPCO guidelines at an average of 10 hours per patient per week. This will be measured by a signed declaratory statement submitted by Compassionate Care to the Agency. 10. The applicant has conditioned approval of this application on the provision it will not build freestanding hospice houses in Glades, Hendry or Lee Counties. This will be measured by a signed declaratory statement submitted to the Agency. 11. The applicant has conditioned approval of this application on the provision it will not actively fundraise in Subdistrict 8C market. This 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 stated above. 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. 6

7 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 (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 project 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) 7

8 indicated a hospice program net need of zero in Hospice Service Area 8C for the July 2011 Hospice Planning Horizon. Hospice Service Area 8C is currently served by Hope Hospice and Community Services. 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 subdistrict s hospice admissions, resident deaths and resulting penetration rate for each age/diagnosis category compared to the statewide average. The applicant examines Service Area 8C s reported CY 2009 admissions for cancer patients and concludes that Hope Hospice s penetration rate in the under age 65 cancer cohort and the 65 and older cancer cohort exceed 100 percent; essentially Hope admitted 1,548 cancer patients but there were only 1,520 cancer related deaths in the three counties 1. Compassionate Care s table below contains the complete analysis. 1 Subdistrict 8C Hope Hospice CY 2009 admissions with adjustment of approximately 10.3 percent in the U65C, 65C, U65NC and 65NC categories to Hope s 524 admissions in Subdistrict 6B, CON Application #10082, page 7. 8

9 Subdistrict 8C Hospice Penetration Rate Current Utilization and 2007 Deaths Subdistrict 8C U65C 65C U65NC 65NC Total Hospice Admissions 428 1, ,728 4, Resident Deaths 427 1,093 1,143 3,548 6,211 Subdistrict 8C Hospice Penetration Rates 100.2% 102.5% 23.3% 76.9% 73.1% 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% Source: CON Application #10082, page 7. The applicant also provides this analysis using CY 2008 resident deaths which show 1,120 resident deaths in the cancer age 65 and over cohort and as Hope reported 1,120 admissions, the result is a 100 percent penetration rate. The under age 65 cancer cohort had 362 deaths and Hope reported 428 admissions (approximately 118 percent penetration rate) in this group. The remaining CY 2008 comparison yields results similar to the table above. Compassionate Care states that either some or all of the following is occurring in Subdistrict 8C: 1. Hope has a significant number of readmissions to hospice and therefore terminal patients are being double counted beyond what might be expected; and/or, 2. Hope is admitting patients from other hospice service areas and counting them as 8C admissions; and/or, 3. Hope is admitting patients who may not want to forego curative treatment but enroll without full understanding of hospice, disenroll and then re-enroll at a later date; and/or, 4. Hope s admitted patients still in active treatment for cancer (chemotherapy and radiation), show an improvement in status because of their receiving curative treatment, and so are discharged and later re-admitted. The applicant states that all of these activities are unacceptable. Compassionate Care contends this raises the question - Does the reported number of Hope s patients being served include patients that may not have elected the hospice benefit? Hope Hospice provided end of life care to 75.1 percent of Subdistrict 8C s terminally ill patients (4,542/6,050) in CY 2008 compared to the state average of 62.7 percent (106,898 hospice admits/170,452 deaths). Compassionate Care contends that this about 12.5 point difference is so high it raises the 9

10 question as to the validity of the reported information. The applicant s data appears to support this contention. Compassionate Care asserts that the following not normal circumstances that exist in Service Area 8C further demonstrate need for an additional hospice service provider. First, Compassionate Care Hospice states that Service Area 8C is a monopolistic market with only a single hospice provider serving the three-county area. Subdistrict 8C has the second highest volume of resident deaths per hospice program within the State of Florida 2. The applicant states that other hospice service areas with similar death counts have three or four hospice providers; Subdistrict 4B (Volusia County) has nearly 1,000 more deaths than Subdistrict 8C but had five hospice programs 3. The applicant continues its argument stating subdistricts with half the death count as 8C such as 6C (Manatee), 2B (Leon and others) and 2A (Bay and others) each have two hospice providers. Compassionate Care Hospice states that the entire continuum of health care in Service Area 8C lacks diversity and choice. The applicant notes that four of the six acute care hospitals in Lee and Hendry Counties are owned by Lee Memorial Health System. Compassionate Care states that while Lee Memorial Heath System is nearly a monopolistic hospital provider in the area, particularly in Lee County, residents can opt to leave the county for their acute care needs. However, there is no outmigration for hospice services because Florida hospice law requires the hospice to be licensed to serve residents of the subdistrict which a hospice is licensed. Therefore, hospice services must be provided locally. The applicant asserts that having only one provider to serve nearly 700,000 people (3.6 percent of the state s population) or assume end of life care for more than 6,000 persons who die annually is a not normal circumstance. The applicant notes that relative to monopolistic hospice environments, is that complacency of an existing provider leads to hampered access to hospice services. Some of the applicant s support letters indicate some discontent with Hope Hospice practices. The second not normal circumstance identified by the applicant is the abnormally high percent of patients discharged live. The applicant states that according to Section 1861 (dd) of the Public Health Services Act, to be eligible for the Medicare Hospice Benefit, the patient must be certified by a physician to be terminally-ill with a life expectancy of six months or 2 Hospice Programs per Resident Deaths by Subdistrict Calendar Year 2008 Deaths and 2009 Hospice Admissions, CON Application #10082, page Per the Florida Vital Statistics Annual report for Calendar Year 2008 Deaths in Subdistrict 4B (Volusia County) were 7,012 and Subdistrict 8C (Glades, Hendry and Lee Counties) were 6,

11 less. The applicant states that in 2009 Hope Hospice discharged 1,082 live patients, representing 22 percent (1,082 live discharges/4,917 total discharges) of its total discharges bringing into question the true prognosis of its patients. The Florida average for all hospice programs is 18 percent (18,706 live discharges/103,827 total discharges) 4. The applicant states that Hope Hospice had the fourth greatest number of live discharges of any provider in the state 5. The applicant states that Hope Hospice s 1,082 live discharges account for nearly six percent (1,082 live discharges/18,706 total live discharges) of all live discharges from hospices within the entire state, whereas its total hospice discharges of 4,917 accounted for 4.7 percent (4,917 total hospice discharges/103,827 total state hospice discharges) of all Florida hospice cases 6. Although, Compassionate Care has 103,827 admissions compared to the 104,207 in the Department of Elder Affairs CY 2009 Hospice Report, the applicant s conclusions are supported by the data in the report. The applicant asserts that this high volume of discharges in Subdistrict 8C might be some of the reason why the hospice penetration rate is so much greater than the rest of the state; and it is not that all terminally ill patients are being served. Rather, patients are being admitted to Hope Hospice, discharged live, and then readmitted at a later date. The applicant states that it is questionable whether Hope actually admits hospice appropriate patients who are no longer seeking curative treatment, or if hospice, in this market, is improperly utilized and/or reported. The third not normal circumstance identified by the applicant is Hope Hospice s (the current Service Area 8C hospice provider) reporting or misreporting of admissions by age and diagnosis. The applicant asserts that the excessively high penetration rate, including exceeding 100 percent or greater for persons with cancer, suggests a different process to count its admissions than practiced among its peers, or a different admissions practice, thereby partially explaining the high number of live discharges. The applicant states that it is impossible to gauge the true gap in hospice admissions (those who died without ever receiving hospice care) because Hope Hospice is not reporting true admissions. The 4 The Florida Department of Elder Affairs CY 2009 Hospice Annual Report data confirms Hope s figures. Live hospice discharges were 18,818 of the 104,207 in the DOEA report or percent of the state total. 5 Florida Hospice Providers Live Discharges and Deaths Calendar Year 2009, CON Application #10082, page 19. As noted above the DOEA report has slightly more discharges 104,207 than the 103,827 reported by the applicant. 6 Florida Hospice Providers Live Discharges and Deaths Calendar Year 2009, CON Application #10082, page

12 applicant states that having between 100 and 118 percent of cancer patients being admitted to hospice is not a reliable statistic and therefore raises the question as to the validity of the underlying data which is reported. The applicant states that the non-cancer reported admissions are likely to be over stated as well as Hope Hospice exceeds the state average in percentage of admissions in these categories (see the applicant s Subdistrict 8C Penetration Rate chart on page 9 of this report). The applicant concludes that with such high live discharge data, combined with hospice penetration rates exceeding 100 percent in two of the four categories and the unusually high non-cancer rates, raises the question as to whether there is suppressed need due to reporting procedures employed by Hope Hospice. The applicant states that in meeting with members throughout the Service Area 8C community there was an overall agreement that there is need for a new hospice, not only to provide choice, but to have a more timely response when hospice is called. Hope Hospice s provision of continuous care is stated as a concern by several assisted living facility (ALF) operators. Jordan Scardigno, Senior Executive Director, Emeritus Bonita Springs and Emeritus Fort Myers states, while we have maintained a good relationship with Hope Hospice, we have found the relationship to be tumultuous throughout the years. Reaction times to emergencies have been slow, there s reluctance to provide continuous care, high turnover had been consistent, and as a result quality of care has been lacking. 7 Jordan Scardigno s letter of support did not further explain the reaction times to emergencies comment. Megan Deavers, Administrator, Emeritus at Fort Myers (a 116-bed ALF) states, for those patients requiring an acute hospice intervention, rather than that patient receiving continuous care services in our facility, with the current hospice they are often relocated to the hospice s hospice house. This results in a disruption to patient care, removal of the patient from their home and impacts on the quality of life in our community. Frances Gray, Administrator, Springwood Court Assisted Living Facility (a 110-bed ALF) states that rather than the patient receiving continuous care in our facility, with the current hospice they are often relocate to the hospice s hospice house which results in disruption of patient care. Dolores Jean Festa, Owner and Administrator, Villa Palms Assisted Living (a 19-bed ALF), states that removal of the patient from the home impacts on the quality of life in our community. Four other ALF operators also cite the continuous care concern. The applicant states that for the last three years, Hope Hospice has provided between 0.1 and 0.4 percent of its total patient days to 7 Excerpts of support letters for CON Application #10082, page 22 and Appendix 5. 12

13 continuous care 8. Compassionate Care Hospice states that by year two of operations it will reach two percent of its patient days to be continuous care and as it expands its volume, it will offer more continuous care as dictated by the subdistrict s needs. The applicant has conditioned not to construct freestanding hospice houses in Glades, Hendry or Lee Counties. The applicant states that with the approval of its hospice program in Service Area 6B, Hardee, Highlands, and Polk Counties, Subdistrict 8C is a natural transition both programmatically and geographically. Compassionate Care Hospice projects it will have a positive impact on Service Area 8C through increased market penetration, increased consumer and facility education and expanding hospice opportunities to minority patient population groups that have compromised access. The applicant states that non-price competition will raise quality of care, responsiveness levels and availability of unique programming for patients, families and constituent population groups. Compassionate Care Hospice states that its entry into the Service Area 8C market will not negatively impact the existing provider but rather benefit the community at large. The applicant anticipates it will serve 138 hospice patients in year one, and 372 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 Hospice would serve. Rates are generally based on the experience of other hospices in Florida. The applicant states that these market shares are expected to range from 1.9 percent in 2012 to 5.2 percent in 2013, which it considers reasonable. 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: 8 Hope Hospice Percent Continuous Care of Total Patient Days Medicare Cost Reports Fiscal Years 2007 through 2009, CON Application #10082, page

14 (1) Preference shall be given to an applicant who has a commitment to serve populations with unmet needs. The applicant does not clearly demonstrate that any population in the service area has unmet needs. Compassionate Care Hospice states it is committed to meeting the needs of all its patients and their families in need of end-of-life care in Glades, Hendry, and Lee Counties. The applicant states that it is going to admit patients of all ages and diagnoses. According to the applicant populations with unmet needs are those persons who do not seek services from Hope Hospice and those residents, family members, and patients of the facilities, physicians and others identified in its support letters including assisted living residents and persons in specific disease categories such as renal and cardiac patients. (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 intends to have contractual agreements with nursing homes and hospitals, as well as other health care providers designed to meet patient needs in Glades, Hendry and Lee 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. Although the applicant anticipates developing relationships with existing healthcare providers for the inpatient component of care based on its letters of support, it does not have any documented commitments or letters of interest for inpatient services in Service Area 8C at this time. (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 is committed to serving all patients, including those who do not have primary caregivers at home, the homeless and patients with AIDS in Subdistrict 8C. 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 14

15 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 Hospice 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 Hospice 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. (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 western Fort Myers, Lee County, the most densely populated county in Service Area 8C. The applicant states that its second office location will be in Lehigh Acres, eastern Lee County, where it will be easily accessible to both Hendry and Glade Counties. (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. 15

16 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. Jewish Hospice Program Compassionate Care Hospice 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 Hospice 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 from Compassionate Care Hospice partnerships with local children s hospitals. 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 provides for one homemaker FTE. Cardiac Connections - is 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. 16

17 Promise Program meets the requirements of needy populations. Compassionate Care Hospice provides a supportive network of medical, nursing, and psychosocial interventions for patients who may be considering stopping dialysis treatments. 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 of Florida s hospice teams will participate and sponsor community toy and food drives around the holidays. Compassionate Care will also partner with local hospitals and health care 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 loved one. 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. 17

18 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: Average Number of FTE Year One Average Number of FTE Year Two Position Administrator Professional Relations Coordinator Secretary Community Liaison Clerk for Second 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 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 #10082, Schedule 6A. (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 Hospice of Florida states it will develop programs and services geared toward Service Area 8C referral sources. The applicant has letters of support from Service Area 8C assisted living facilities, physicians, community leaders, and clinicians. 18

19 (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 8C Payer Type Year One Year Two Medicare Medicaid 4 11 Insurance 2 6 Self-Pay 0 0 Charity 2 5 Total Source: CON Application #10082, page 79. The applicant projects Medicare will comprise 94.1 percent of admissions, Medicaid three percent and charity 1.3 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 Hospice of Florida provided the following table illustrating the projected number of admissions by type of terminal illness for the first two years of operation. Projected number of Admissions by Diagnosis For Compassionate Care Hospice of Florida, Inc. Service Area 8C Diagnosis Year One Year Two Cancer Cardiac Respiratory Renal Failure HIV/AIDS 5 8 Other Total 138* 372 Source: CON Application #10082, page 79. *Actual total 139 The applicant projects to serve 138 patients in year one and 372 patients in year two. 19

20 (e) Projected number of admissions, by two age groups, under 65 and 65 or older, for the first two years of operation. Compassionate Care Hospice of Florida 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 8C 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. Compassionate Care Hospice of Florida 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. Non-core services to be provided by Compassionate Care staff versus contract include: massage therapy, music therapy, energetic care, sacred spaces, guided imagery, reminiscence therapy, pet therapy, aroma therapy, reflexology, hypnotherapy, life enhancement services and homemaker services. (g) Proposed arrangements for providing inpatient care. Compassionate Care Hospice of Florida intends to have contractual agreements with nursing homes and hospitals designed to meet patients needs in Service Area 8C. The 20

21 applicant expects to provide 67 inpatient days in year one and 299 in year two 9. Compassionate Care states that once approved, it will seek to develop inpatient agreements with Service Area 8C hospitals and skilled nursing facilities. (h) Proposed number of inpatient beds that will be located in a freestanding inpatient facility, in hospitals, and in nursing homes. Compassionate Care Hospice of Florida states it will not be constructing beds and will contract for existing beds on an as needed basis; it has no intent on increasing the total number of beds available by facility (both hospital and nursing home). Compassionate Care will use existing licensed beds as patient needs warrant such services, increasing use for hospice services as volumes and resulting needs expand. (i) Circumstances under which a patient would be admitted to an inpatient bed. The applicant states that one or more of the following clinical criteria should be present for the hospice patient to be considered appropriate for admission to general inpatient care: Pain: o Investigation to define appropriate treatment modality o Active treatment to control pain, which may include change in medication and/or the routes of administration o Titration of medications that cannot be done safely at home o Need for advanced technology for analgesic administration, i.e., IV narcotics Other Symptoms: o Death is imminent and care requires ongoing and frequent skilled nursing intervention o Symptoms fail to yield to home management or furnishing the needed care at home is no longer feasible 9 CON Application #10082, Appendix 3, Schedule 5. 21

22 o Severe anorexia/and or inability to swallow necessitating alternative nutritional support o Fluctuating/deteriorating mental status necessitating titration of medications, change in environment or consultation and intervention by psychologist or psychiatrist. o Severe shortness of breath or respiratory distress; intractable nausea or vomiting; open lesions requiring frequent professional care; unstable or multiple pathological fractures; other complicated care that cannot be provided in the home setting o Need for continued close monitoring of unstable recurring medical conditions, i.e. hemorrhage, severe anemia, severe hypertension, unstable diabetes, recurrent seizures, etc. Psychosocial Pathology: evaluation of disturbed mental status; depression, anxiety in the extreme; and perception and/or understanding that responds more positively in a comprehensive care setting that is reassuring, safe and/or therapeutic. Compassionate Care states that it will provide respite care when the patient s family/caregiver needs a short period of relief. This will be offered on an as needed basis for a maximum of five days per respite admission for a Medicare/Medicaid patient. For patients covered by other insurers, the duration may be approved for a longer period of time. (j) Provisions for serving persons without primary caregivers at home. Compassionate Care Hospice of Florida states it is committed to serving all patients including those who do not have primary caregivers at home. The applicant states it will admit patients to its hospice service even if the patient does not have a caregiver at home. The applicant states that during CY 2009, 8.5 percent of all its patients lived alone without a caregiver; another 3.3 percent of its patients lived with a compromised caregiver. The applicant states that if a patient does not have a caregiver it may recommend placement in an assisted living facility or nursing home, in which the hospice program would provide residential care. 22

23 The applicant states it will assist patients without financial resources to obtain residential care in a hospice unit within an ALF or nursing home. The applicant also proposes to establish relationships with area nursing homes and assisted living facilities, either entering into per diem contracts or developing hospice units, as the need arises. (k) Arrangements for the provision of bereavement services. Compassionate Care Hospice of Florida states its bereavement services policy is to provide appropriate and coordinated bereavement services and counseling to families and caregivers for at least 13 months following the death of the patient. In addition to providing services to family and caregivers, services may be provided to residents and staff of SNFs, ALFs and other medical facilities as needed, for at least 13 months after the patient s death. Bereavement services will begin with an initial bereavement risk assessment to be completed by the social worker, bereavement coordinator or designee within five days of admission. The applicant states that the bereavement coordinator may also provide supportive counseling prior to the death of the patient. Within three to five weeks after the patient s death, the bereavement follow up assessment is completed by the bereavement counselor following the patient s family/caregiver. The applicant states it also provides bereavement support for children, called Compassionate Courage. The children participate in art, reading, poetry, writing exercises, group discussions, drawings, memory collages, a feeling toss game and books. The applicant s additional material does not describe the feeling toss game but it appears feeling loss would be the appropriate title. (l) Proposed community education activities concerning hospice programs. The applicant states it will provide extensive community education activities to increase hospice awareness and utilization. Compassionate Care Hospice of Florida staffing include 1.5 FTE professional relations coordinators and 1.0 FTE community liaison in both years one and two of operation. According to the applicant, these individuals will be responsible for leading the Hispanic Outreach Program, further developing relationships throughout Glades, Hendry, 23

24 and Lee Counties. They will also educate nursing homes and assisted living facility constituents on the myths and benefits of hospice. The applicant states it will host hospice educational events at senior organizations, religious affiliated groups, veteran s organizations, health fairs and educate minority residents in an effort to educate the community at large on the benefits of holistic end-of-life care through hospice. (m) Fundraising activities. The applicant states that its parent, Compassionate Care Hospice has a relationship with Compassionate Care Hospice Foundation, an unrelated not for profit 501c3 organization, whose mission is to provide the resources necessary to support the extraordinary needs of hospice patients and their families. The applicant states that Compassionate Care does not actively raise funds from the community but if an individual wants to make a charitable donation, the applicant will direct those individuals to Compassionate Care Hospice Foundation s website. Compassionate Care Hospice of Florida has conditioned this application on the provision it will not actively fundraise in Service Area 8C. 3. Statutory Review Criteria a. Is need for the project evidenced by the availability, quality of care, accessibility and extent of utilization of existing health care facilities and health services in the applicant s service area? ss (1)(a) and (b), Florida Statutes. The applicant is applying to establish a hospice program in Hospice Service Area 8C in the absence of published numeric need. The following chart illustrates the increase in hospice admissions for the past five years. As shown below, admissions have increased from 3,389 in 2004 to 4,544 in 2008 with a slight decrease by two admissions in