STATE AGENCY ACTION REPORT ON APPLICATION FOR CERTIFICATE OF NEED A. PROJECT IDENTIFICATION 1. Applicant/CON Action Number Odyssey HealthCare of Northwest Florida, Inc./CON #9954 717 North Harwood Street, Suite 1500 Dallas, Texas 75201 Authorized Representative: W. Bradley Bickham, Vice President and General Counsel (214) 245-3176 United Hospice of West Florida, Inc./CON #9955 1626 Jeurgens Court Norcross, Georgia 30093 Authorized Representative: Scott Shull, Vice President (770) 925-4788 Regency Hospice of Northwest Florida, Inc./CON #9971 2145 Highland Avenue Birmingham, Alabama 35205 Authorized Representative: John E. Morris, President and Chief Executive Officer (CEO) (205) 939-8711 2. Service District/Subdistrict Hospice Service Area 1 (Escambia, Santa Rosa, Okaloosa and Walton Counties)
B. PUBLIC HEARING A public hearing was not held or requested regarding the three proposals to establish a hospice program in Hospice Service Area (HSA) 1. However, letters of support and opposition were submitted to the Agency for Health Care Administration (the Agency). Five letters that were not specific to any one applicant were submitted in support of a new hospice. None of these five letters were dated; all were from Pensacola and the surrounding area, none identified themselves as acute hospital or skilled nursing facility affiliated. Two of the five identify themselves as medical doctors (one being retired) and the remaining three do not identify any profession or affiliation. These five letters are of a form letter style. Letters of support are detailed for each applicant: Odyssey HealthCare of Northwest Florida, Inc. (CON #9954) (Odyssey) submits nine letters of support in its application (Volume 2, Attachment J). Of the nine letters submitted by the applicant that support Odyssey by name, five are current, all having been dated in mid-december 2006, the remaining four are not dated and reference favorable experiences at the Odyssey HeatlhCare, Hospice of the Palm Coast. A letter dated December 19, 2006 by the executive director (D. Peoples) of the Northwest Florida Area Agency on Aging, Inc. supports the applicant s plan to provide community education on hospice issues; however, the letter does not discuss support beyond an educational context. None of the support letters committed to or suggested they would commit to a contractual relationship with the applicant, should it become operational. United Hospice of West Florida, Inc. (CON #9955) (UHWF) submits 161 letters of support for the project. The majority of the letters are form letters, 48 have no signature or date, 23 letters are signed but have no employer or association affiliation and no address, making their connection with the community or the applicant impossible for the Agency to determine. Support letters from executives of the following providers indicate a contractual and/or continuity of care commitment, should the applicant become operational: The Heritage of Santa Rosa (a skilled nursing facility in Santa Rosa County), United Pharmacy Services, United Medical, United Nutritional Services and United. In general, support letters state a need for an alternative choice in hospice care. Regency Hospice of Northwest Florida, Inc. (CON #9971) (Regency) submits three letters of support. 2
One letter is from the President and CEO (R. Mason) of Sea Crest Health Care Management, LLC [Sea Crest] states an intent to enter into a contractual relationship with the applicant for routine, general inpatient and respite inpatient service, should the applicant become operational. The contractual relation would relate to Sea Crest s three skilled nursing facilities located in HSA 1: Destin Healthcare and Rehabilitation Center in Destin; Shoal Creek Rehabilitation in Crestview and University Hills Health and Rehabilitation in Pensacola. Another letter was from Healthmark Regional Medical Center Defuniak Springs, a Walton County acute care hospital offering support of the project. There was no commitment to contract for inpatient beds. Letters were also submitted opposing the establishment of a new hospice program in HSA 1. The letters are from the City of Milton City Manager (D. Adams), President and CEO of Walton County Chamber of Commerce (D. Moliterno), President of Drug Free Workplace, Inc. (C. Law, Ph.D.), Baptist Manor Administrator (D. Rappa), Care Staff Director of Operations (J. Navarro), former Medical Director for Blue Cross Blue Shield of Florida (P. Baroco, M.D.), President of Gulf Medical Services, Inc. (K. Steber) and CEO of North Okaloosa Medical Center (D. Sills). It should be noted this last opposer states he is a Covenant Hospice, Inc. board member. In summary, these letters warn against over-saturation or duplication of services in what the opposition letters state as satisfaction with the existing hospice providers in the area (Hospice of the Emerald Coast and Covenant Hospice, Inc.). The City of Milton letter suggests caution against fragmentation, the Baptist Manor letter cautions against creating three struggling hospice providers as opposed to two prospering ones, the care staff letter fears increased prices due to excessive providers and the Gulf Medical Services letter warns that any additional hospices would be detrimental to the existing ones. A letter of opposition was also submitted by Parker, Hudson, Rainer & Dobbs LLP, representing Covenant Hospice, Inc. The law firm indicates that this December 27, 2006 letter, among other things, represents a challenge to the Agency s Fixed Need Pool that appeared in the October 6, 2006 edition of the Florida Administrative Weekly. Agency regulations regarding challenges to fixed need pools state that any person who identifies an error in the fixed need pool numbers must advise the Agency of the error within 10 days of the date the fixed need pool was published in the Florida Administrative Weekly. 3
If the Agency concurs in the error, the fixed need pool number will be adjusted and re-published in the first available edition of the Florida Administrative Weekly. Failure to notify the agency of the error during this time period will result in no adjustment to the fixed need pool number for that batching cycle 1. Although the law firm suggests that the fixed need pool is in error, it is noted that the firm did not file a challenge. Had the firm actually filed a challenge, the Agency would have had an opportunity to respond. That response would have triggered a series of events that may have been resolved prior to December 27, 2007, which was the date applications for this batching cycle were required by Agency rule to be complete or withdrawn for further review and the last day for comments on this project. The firm also provided information regarding its client s response to two hurricanes and articles related to the differences between not-for-profit hospice programs and for-profit hospice programs. It is noted that in 2006 hospice licensing law changed to allow for-profit hospice programs to obtain a license in Florida. Included in the information submitted by Parker, Hudson, Rainer & Dobbs, LLP were 105 letters opposing a new hospice program in HSA 1. The letters are well categorized in the following sequential order: local hospital executives/staff and other physicians (25 opposition letters); local nursing homes and adult living facilities [ALFs] (11 opposition letters); volunteers and caregivers (31 opposition letters); Covenant board of directors and staff (12 opposition letters); area non-profit agencies, government entities and area businesses (23 opposition letters) and other Florida hospices (three opposition letters). Of the net 105 letters, most are current, having been dated either in November or December 2006. There are 15 undated letters and three have no signature. C. PROJECT SUMMARY Odyssey HealthCare of Northwest Florida, Inc. (CON #9954) proposes the establishment of a new hospice program in Hospice Service Area 1 (Escambia, Okaloosa, Santa Rosa and Walton Counties). The headquarters office is planned for Escambia County with the first satellite office in Okaloosa County within its first year of operation and the second satellite in Walton County within its third year of operation and six months later, a satellite in Santa Rosa County. This would create a presence in every county in the service area. The applicant states that it has no plan for an inpatient facility, but intents to contract 1 Section 59C-1.008(2), Florida Administrative Code. 4
for inpatient services with area health care providers 2. Odyssey currently operates a hospice program in Florida in Hospice Service Area 4B and 11. Of the three applicants, only Odyssey Healthcare, Inc. currently has hospice operations in Florida. 3 The applicant is proposing total project costs of $464,720; covered are equipment, development and pre-operational start-up costs. There are no land or building costs proposed. Odyssey requests the CON be predicated on the following conditions: establish a new hospice program in Escambia County, with three satellite locations in Okaloosa, Santa Rosa and Walton Counties; provision of non-covered services, such as but not limited to palliative radiation therapy and chemotherapy (related to terminal diagnosis) as well as other therapies (music, massage, aroma, etc.); expenditure of at least $25,000 in the first two years of operation to finance public education programs dealing with end-of-life planning and annual reporting to the Department of Elder Affairs and the Agency. It is noted that core services include those required for patient care and that palliative radiation and chemotherapy may be considered core. Because hospice programs are required to provide core services to anyone seeking them, CON conditions are not necessary to ensure such care is provided. The agreement of a minimum expenditure of $25,000 in the first two years of operation to finance public education programs dealing with end-of-life planning will become a CON condition should this project be approved. United Hospice of West Florida, Inc. (CON #9955) (UHWF) proposes the establishment of a new hospice program in Hospice Service Area 1 (Escambia, Okaloosa, Santa Rosa and Walton Counties). UHWF indicates that it operates hospice programs in Georgia, South Carolina and North Carolina. UHWF plans to establish a headquarters in Santa Rosa County, with a satellite in Walton County. The applicant is proposing total project costs of $336,467; covered are building (renovation), equipment, development and pre-operational startup costs. There are no land costs proposed with the renovation being tele/data wiring costs. UHWF requests the CON be predicated on the following conditions: headquarters in Santa Rosa; acceptance of all those who seek care 2 It is noted that hospice programs can provide the inpatient component of care in either a freestanding inpatient hospice facility, a nursing home or an acute care hospital. 3 Florida Need Projections for Hospice Programs, October 2006 Batching Cycle/January 2008 Hospice Planning Horizon. 5
regardless of ability to pay, including charity and self-pay, Medicare and Medicaid patients and also the acceptance of patients without caregivers and acceptance of homeless patients. Because hospice programs are required to provide services to anyone seeking them, CON conditions are not necessary to ensure such care is provided. Regency Hospice of Northwest Florida, Inc. (CON #9971) proposes the establishment of a new hospice program in Hospice Service Area 1 (Escambia, Okaloosa, Santa Rosa and Walton Counties). Regency indicates that it currently operates hospice programs in Alabama, Georgia and South Carolina. The applicant is proposing total project costs of $195,745; covered are equipment, development and pre-operational start-up costs. There are no land or building costs proposed. Regency requests the CON be predicated on the following condition: at least 2.5 percent of total patient days to patients who are medically indigent. Because hospice programs are required to provide services to anyone seeking them, CON conditions are not necessary to ensure such care is provided. All programs with CON conditions are required under Section 408.040, Florida Statutes, to report compliance with CON conditions annually to the Agency. D. REVIEW PROCEDURE The evaluation process is structured by the Certificate of Need review criteria found in Section 408.035, 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. 6
Section 59C-1.010(2)(b), Florida Administrative Code, prohibits any amendments once an application has been deemed complete. The burden of proof to entitlement of a certificate rests with the applicant. As such, the applicant is responsible for the representations in the application. This is attested to as part of the application in the certification of the applicant. As part of the fact-finding, consultant Steve Love analyzed the application in its entirety with consultation from financial analyst John Williamson, who evaluated the financial data. 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 408.035, and 408.037, and applicable rules of the State of Florida, Chapters 59C-1 and 59C-2, Florida Administrative Code. 1. Fixed Need Pool Does the project proposed respond to need as published by a fixed need pool? Chapter 59C-1.008, Florida Administrative Code and Chapter 59C-1.0355, Florida Administrative Code. In Volume 32, Number 40 of the Florida Administrative Weekly dated October 6, 2006, a hospice program net need of one (1) was published for Hospice Service Area 1 for the January 2008 Hospice Planning Horizon. Hospice Service Area 1 is currently served by Covenant Hospice, Inc. and Hospice of the Emerald Coast. 4 Each co-batched applicant is applying in response to published need for a hospice program in Hospice Service Area 1. The following describes the area(s) in which each applicant believes unmet need or underserved populations exist in the applicable Hospice Service Area 1 county or counties, with each applicant indicating that it will address those area(s) where it sees the greatest need: Odyssey HealthCare of Northwest Florida, Inc. (CON #9954) responds to Agency fixed need pool calculations and points out that the addition of a third hospice in HSA 1 will not have a negative impact on patient volume at the existing hospices, just as the prior addition of a second 4 Covenant operates in Hospice Service Area 1, 2A and 2B, while Hospice of the Emerald Coast operates only in HSA 1. 7
hospice in HSA 1 did not cause the patient volume at the existing hospice to decline. 5 Odyssey states the Agency assumes that the percentage of deaths in each of four categories (cancer patients under age 65, cancer patients age 65 and older, non-cancer patients under age 65 and non-cancer patients age 65 and older) is constant on a statewide basis. The applicant appears to be referring to the projected values of the number of deaths used in the Agency s hospice program need methodology, often referred to as P factors by Florida hospice providers and CON applicants for hospice services and also appears to be suggesting that methodology is inadequate in some way thereby challenging that need methodology in its discussion. The need methodology is adopted in Section 59C-1.0355, Florida Administrative Code, and was used to determine need for the additional program this applicant seeks to develop. The methodology also looks at projected deaths by calculating a three-year average resident death rate, which is the sum of the service area (not the state as a whole) resident deaths for the three most recent calendar years. It is noted that CON applications are not the venue for rule challenges. As noted in the Project Summary above, if approved, the applicant intends to establish offices in all four HSA 1 counties and has provided a time schedule for establishment of these offices that ends 3.5 years from initial licensing. Need beyond that published by the Agency was not demonstrated. United Hospice of West Florida, Inc. (CON #9955) discusses where it believes a concentration of services is most needed offering discussion on access based on population growth within the planning area, particularly growth in the Hispanic population and states that it will target this population to make sure the needs of this growing Hispanic community are met 6. The applicant goes on to state that hospice penetration in HSA 1 is poorest among non-cancer patients (all ages) relative to cancer patients in the district and also that penetration among non-cancer patients (all ages) is poorer than statewide penetration. However, the 5 CON#9954, AHCA Form CON-1, page#50 6 CON#9955, AHCA Form CON-1, page#48 8
applicant does not demonstrate that Hispanic patients choosing hospice are unable to access services or provide any other evidence of an unmet need. It is interesting that although specifically noting that it would condition the CON to providing care to the homeless and other populations, the applicant did not agree to provide a certain percentage of its services to the Hispanic population. The applicant s presentation here supports Agency published need, but does not identify a specific geographic, financial, or cultural assess issue. Specifically, this does not demonstrate that Hispanic patients in the planning area are unable to access hospice services. The applicant indicates it believes other underserved populations include: The residents of Santa Rosa, Okaloosa and Walton Counties with an emphasis on Santa Rosa County Non-cancer patients Patients without caregivers Its reasons for noting these areas are all data driven showing little or no local contact beyond obtaining letters of support. There is no evidence that these areas are currently underserved. As noted earlier, the applicant plans to locate in Santa Rosa County with a satellite office in Walton County. The applicant has also secured letters of support from three area nursing homes, one each in Santa Rosa, Okaloosa and Walton County. Need beyond that published by the Agency was not demonstrated. Regency Hospice of Northwest Florida, Inc. (CON #9971) responds to Agency fixed need pool calculations and states it will sponsor community education programs in churches, social clubs, community health centers, ALFs and local medical practices 7. It may be material that no letters of support were included in the application or received independently by the Agency, from local churches, social clubs or ALFs, though a letter stating intent to contract with three nursing homes in the district was included in the application. The three nursing homes are Destin Healthcare and Rehabilitation Center in Destin, Shoal Creek Rehabilitation Center in Crestview, and University Hills Health and Rehabilitation in Pensacola. The applicant indicates it will also support education at community health centers 8. According to the Florida Association of Community Health Centers (FACHC), there are currently no member community health centers (federally qualified health centers) 7 CON #9971, AHCA Form CON-1, page#16 8 Ibid 9
in HSA 1, with the nearest in Florida being in Bay County 9. Regarding local medical practices, one medical site support letter was provided in direct support of this applicant from Healthmark Regional Medical Center Defuniak Springs, an acute care hospital in Walton County. As noted earlier, the applicant intends to establish a headquarters in Defuniak Springs (Walton County), Florida. Though it does not exclude any county in the district per se, it states it will direct its focus on rural, underserved areas, particularly Walton County, in addition to the more traditional population centers 10. The applicant states it will conduct outreach among racial minorities in HSA 1. It references a significant African-American population in Escambia County, but offers no ethnicity. Need beyond that published by the Agency was not demonstrated. 2. Agency Rule Criteria and Preferences a. Rule 59C-1.0355(4)(e) Preferences for a New Hospice Program. The Agency shall give preference to an applicant meeting one or more of the criteria specified in the below listed subparagraphs: (1) Preference shall be given to an applicant who has a commitment to serve populations with unmet needs. None of the co-batched applicant meet this preference. Odyssey HealthCare of Northwest Florida, Inc. (CON #9954) states it is committed to serving all eligible hospice patients, regardless of diagnosis and regardless of gender, national origin, race, creed, sexual orientation, disability, age, place of residence or ability to pay 11. The applicant contends that utilization is currently low for cancer patients age 65 and older, patients of all ages with non-cancer diagnosis, inadequate services to nursing home and ALFs and in the African-American Community. However, this was not demonstrated. United Hospice of West Florida, Inc. (CON #9955) states its commitment to serving populations in HSA 1, specifically outside of Escambia County, the Hispanic Population, residents in need of hospice care with non-cancer diagnoses, and patients without primary caregivers 12. The applicant contends that residents of 9 http://www.fachc.org/map_member_locations.htm 10 CON #9971, AHCA Form CON-1, page#24 11 CON#9954, AHCA Form CON-1, page#14 12 CON#9955, AHCA Form CON-1, page#74 10
Santa Rosa, Okaloosa and Walton Counties are ill-served with two exisiting hospices with office locations in Escambia County and none in the non-escambia portion of HSA 1. It is noted that the hospice program not being physically located in a county is not evidence that the county is underserved. Additionally, the applicant did not provide evidence that there were any unserved areas. Regency Hospice of Northwest Florida, Inc. (CON #9971) states its intention to serve all eligible patients and believes unmet need in the district is primarily a result of geographic issues. While it states it will provide outreach to racial minorities, like co-batched applicant Odyssey, it grants priority to the African-American population in Escambia County and does not reference Hispanics, as UHWF does. Regency indicates that the Hispanic population in HSA1 is low relative to Florida and the United States as a whole. The applicant believes there are potentially unmet needs in Walton County. Although the applicant has said potentially, its discussion suggests that it believes there are currently unmet needs in Walton County. However, nothing was presented to provide evidence of an unmet need. It is noted that based on that belief, Regency will open an office in Walton County if awarded the CON. (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. None of the co-batched applicant are proposing a more costefficient alternative than contracting for services. There are two types of inpatient facilities with which a hospice program can contract for inpatient services. Those two facility types are: acute care hospitals and skilled nursing facilities. Although all three applicants indicate that they intend to contract for services, only Regency has given evidence of its ability to contract for inpatient services. Odyssey HealthCare of Northwest Florida, Inc. (CON #9954) claims it will not construct an inpatient hospice facility but will rather contract with acute care providers in all four HSA 1 counties. However, support letters in the application and those received independently by the Agency do not confirm that any 11
facility or inpatient service provider has committed to such agreement with Odyssey. United Hospice of West Florida, Inc. (CON #9955) does not propose a freestanding inpatient facility but rather contractual agreements to meet inpatient needs, as they may develop. As noted above, the applicant has provided support for its project from three skilled nursing facilities, which is evidence of its ability to contract for inpatient care: Heritage of Santa Rosa (Santa Rosa County) Crestview Manor (Okaloosa County) Chautauqua Nursing and Rehabilitation Center (Walton County) One of the three, Crestview Manor suggests that it will contract with the applicant. It is noted that the applicant did not provide any letters of support or other evidence of its ability to contract for acute inpatient care at local hospitals. Regency Hospice of Northwest Florida, Inc. (CON #9971) does not propose a freestanding inpatient facility but rather contractual agreements with existing nursing homes and hospitals. One support letter attests to a commitment to enter into contractual relationships for inpatient and respite services spread among three nursing facilities one in Pensacola, one in Destin and one in Crestview. Regency also recevied one letter of support from Healthmark Regional Medical Center Defuniak Springs, an acute care hospital in Walton County. Healthmark offered general support, which shows that a local contact for acute inpatient services has been made by the applicant, but unlike the nursing home provider, it did not indicate that it would contract for inpatient beds. 12
(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. Each of the co-batched applicants provided information to suggest that it had developed policies to enable it to meet this preference. Further demonstration can be used to show that the applicant should receive preference includes local contacts to illustrate the ability of the applicant to place hospice homeless patients in an appropriate setting. UHWF and Regency provided some documentation to indicate that they would be able to place patients, without a home, in appropriate settings. Odyssey HealthCare of Northwest Florida, Inc. (CON #9954) states that it serves all eligible patients and their families without regard to primary caregiver status, homelessness or HIV status, and states its commitment to extend these practices to HSA 1. This is documented primarily in the applicant s non-discrimination policy 13. Procedures to account for contingencies are described. The applicant meets this preference. United Hospice of West Florida, Inc. (CON #9955) states that it maintains its commitment in corporate policy to serving patients who do not have primary caregivers at home, the homeless and patients with AIDS. The applicant states there are procedures for each applicable circumstance and refers to applicable portions of the application 14. Policies include non-discrimination, patient and family rights, general admission and others. Procedures to account for contingencies are described. UHCWF is the only cobatched applicant that predicates on conditions 15 that it will accept patients without caregivers and the homeless. The applicant meets this preference. Regency Hospice of Northwest Florida, Inc. (CON #9971) does not specifically reference an attachment 16 as the other co-batched applicants. However, Regency narratively describes its history and protocol regarding patients who lack a primary caregiver at home, the homeless and those with HIV/AIDS. The applicant does not indicate any of these characteristics would be a barrier to admission or services. The applicant meets this preference. 13 CON #9954, Volume 2, Attachment M - Access to Care 14 CON #9955, Volume 2, Attachment P - Polices 15 CON #9955 AHCA Form 1 Schedule C/Part C.4 16 CON #9971, AHCA Form CON-1, page#24 and 25 13
(4) In the case of proposals for a hospice service area comprised of three or more counties, preference shall be given to an applicant who has a commitment to establish a physical presence in an underserved county or counties. Hospice Service Area 1 is composed of four counties (Escambia, Santa Rosa, Okaloosa and Walton). The area currently has exisiting hospice physical presence in all four counties. Although none of the co-batched applicants demonstrated that any county or counties were underserved and thereby do not meet this preference, each committed to a physical presence in more than one county. Odyssey was the only applicant committing to a physical presence in all four counties, with its main office in Escambia County. Regency commits to a physical presence in three of the four counties and UHWF commits to a physical presence in two of the four counties. Odyssey HealthCare of Northwest Florida, Inc. (CON #9954) commits to first establishing a main office in Escambia County. Subsequently, it plans to establish satellites in Okaloosa, Walton and Santa Rosa Counties (in that order). The satellite in Santa Rosa County should be operational within 42 months of the creation of the main office in Escambia County. This will create Odyssey s presence in each of the district s four counties. United Hospice of West Florida, Inc. (CON #9955) commits to a headquarters office in Santa Rosa County. UHCWF proposes a satellite in Walton County. The applicant states that it has chosen Santa Rosa County as its headquarters for a number of reasons including the fact that there is already hospice headquarters presence in Escambia. Regency Hospice of Northwest Florida, Inc. (CON #9971) states it intends to have a greater rural presence, but does not commit to locating an office in Santa Rosa County. The applicant commits to establishing offices in Pensacola (Escambia County), Fort Walton Beach (Okaloosa County) and in Defuniak Springs (Walton County). 14
(5) Preference shall be given to an applicant who proposes to provide services that are not specifically covered by private insurance, Medicaid or Medicare. Each applicant committed to providing services not covered by private insurance, Medicaid or Medicare. None of the commitments for services to patients offered by the co-batched applicants were proposed in a measurable CON condition. It is noted that Odyssey s agreement to provide a minimum expenditure of $25,000 in the first two years of operation to finance public education programs dealing with end-of-life planning is not a hospice service and cannot be considered under the preference. Odyssey HealthCare of Northwest Florida, Inc. (CON #9954) considers itself a community hospice pursuant to the Brown Study 17. Briefly, the Brown Study describes a Community Hospice as a hospice that relies upon Medicare hospice revenues but in addition, provides services that reach a wider net of patients. This wider net of non-medicare compliant and consequently unreimbursable patients could include, among others, those lacking a projected six-month or less life expectancy. Under these conditions, a hospice may absorb patients earlier in the progression of a terminal or life-limiting illness and afford the patient a greater or higher quality of life. Generally, hospices that embrace successfully this Community Hospice model are hospices that are not solely dependent upon Medicare reimbursement to cover all of their costs and have other sources of revenue that will help off-set non-reimbursable charges. The applicant states the following non-covered services to all patients will be available, whether insured or not or whether or not the patient has the ability to pay: 13 months of bereavement; pet, music, massage and aroma therapies; dialysis; palliative radiation and palliative chemotherapy treatments. As noted earlier, palliative radiation and chemotherapy treatment, if required by the patient to manage pain, would not be considered uncovered services. United Hospice of West Florida, Inc. (CON #9955) states it will provide services including but not limited to the following: pet, music, massage and aroma therapies; dialysis; palliative radiation and palliative chemotherapy not covered by private insurance, Medicaid or Medicare. The applicant specifically mentions up to 17 The Florida Model of Hospice Care: A Report for Florida Hospice and Palliative Care, Inc. February 2004 15
13 months of bereavement care and other services elsewhere in its application 18. As noted earlier, palliative radiation and chemotherapy treatment, if required by the patient to mange pain, would not be considered uncovered services. Regency Hospice of Northwest Florida, Inc. (CON #9971) identifies the following services that it provides in its existing non- Florida locations: bereavement and chaplain services; recruitment, training and supervision of volunteers; community education regarding end-of-life care; care for the medically indigent; flower and music ministries; assistance with utility, food, clothing expenses and other non-specified necessities for needy patients including daily living expenses (utility charges, clothing, etc.). Regency offers no references to explore how it defines a needy patient who is eligible for assistance with these latter expenses or what the maximums may be. b. Chapter 59C-1.0355, Florida Administrative Code contains the following general provisions and review criteria to be considered in reviewing hospice programs. (1) Consistency with Plans (Rule 59C-1.0355(5), Florida Administrative Code). An applicant for a new hospice program shall include evidence in the application that the proposal is consistent with the needs of the community and other criteria contained in the Local Health Council Plans. The application for a new hospice shall include letters from health organizations, social services organizations, and other entities within the proposed service area that endorse the applicant's development of a hospice program. In 2004, CON preferences were removed from the criteria required for review; however, the applicant shall provide evidence that the proposal is consistent with criteria contained in the local health council plans. The Florida Department of Health, Office of Local Health Councils, is custodian of the contract between the state and the HSA 1 local health council - Northwest Florida Health Council, Inc. This organization is no longer required, by contract, to submit a local health plan for state review and consideration. Odyssey HealthCare of Northwest Florida, Inc. (CON #9954): This applicant has identified what it considers need in HSA 1 relative to hospice service deficiencies and references them 18 CON #9955, AHCA Form CON-1, page#8 16
throughout the application, as stated in section E.1 above and E.3 below. United Hospice of West Florida, Inc. (CON #9955): This applicant has identified what it considers need in HSA 1 relative to hospice service deficiencies and references them throughout the application, as stated in section E.1 above and E.3 below. Regency Hospice of Northwest Florida, Inc. (CON #9971): This applicant has identified what it considers need in HSA 1 relative to hospice service deficiencies and references them throughout the application, as stated in section E.1 above and E.3 below. (2) Required Program Description (Rule 59C-1.0355(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 tables illustrate the total full-time equivalents (FTEs) [Schedule 6A of each applicant s submission] and the total projected admissions (Schedule 5 (assumptions)) proposed by each applicant for the first two years of program service: Total Proposed FTEs By Applicant for Years One and Two CON # Applicant Year One (2008) FTEs Year Two (2009) FTEs 9954 Odyssey 16.40 33.80 9955 UHCWF 9.92 13.32 9971 Regency 24.83 42.34 Source: CON Applications 9954, 9955 and 9971 Odyssey proposes a contracted medical director, hence no FTE for this position. UHWF states that physician, ancillary and dietary positions will be contracted, hence no FTEs for these positions. UHWF states that it will contract for dietary counseling in the notes to Schedule 6. Regency states that it will directly provide all core services and generally notes counseling but does not specifically address dietary counseling. It is noted that dietary counseling services cannot be contracted in Florida and must be provided directly by the hospice. With the exception of physician services, all core hospice services must be provided directly 17
by the hospice and cannot be contracted. 19 The hospice care team must directly provide the following core services: nursing services, social work services, pastoral or counseling services, dietary counseling, and bereavement counseling services. A hospice may 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. Total Projected Admissions By Applicant for Years One and Two CON # Applicant Year One (2008) Admissions Year Two (2009) Admissions 9954 Odyssey 270 411 9955 UHCWF 264 454 9971 Regency 20 242 496 Source: CON Applications 9954, 9955 and 9971 The FTE and admissions tables above are presented to illustrate the differences between the number of staff (inhouse) relative to the number of projected admissions. It is noted that Regency expects to admit the most patients by year two and also has appropriately listed the highest number of staff in year two. Odyssey HealthCare of Northwest Florida, Inc. (CON #9954) discusses generalized volunteer functions 21. Volunteers are stated by the applicant to provide both administrative support and patient/family support functions. However, no exact volunteer ratio or volunteer-topatient estimate is offered. Schedule 6A indicates a 0.5 volunteer coordinator FTE but no estimated number of volunteers being coordinated or supervised. It is noted that this applicant, consistent with the other two co-batched applicants, states it will document and maintain a volunteer staff sufficient to provide administrative or direct patient care in an amount of at least five percent of the total patient care hours of all paid hospice employees and contract staff. 19 S. 400.6085, Florida Statutes: Contractual services.--a hospice may contract out for some elements of its services. However, the core services, as set forth in s. 400.609(1), with the exception of physician services, shall be provided directly by the hospice. Any contract entered into between a hospice and a health care facility or service provider must specify that the hospice retains the responsibility for planning, coordinating, and prescribing hospice care and services for the hospice patient and family. A hospice that contracts for any hospice service is prohibited from charging fees for services provided directly by the hospice care team that duplicate contractual services provided to the patient and family. 20 This applicant states the estimated first and second year admissions in CON #9971, AHCA Form CON-1, page#30, not in the Schedule 5 assumptions. 21 CON #9954, AHCA Form CON-1, page#58 and 59 18
This applicant offered no specific attachment to further detail volunteerism. United Hospice of West Florida, Inc. (CON #9955) describes volunteer activities 22 in which services may be professional (in the event the volunteer is applicably licensed), administrative or direct patient care/family support (in a non-licensed capacity). This applicant referenced to an attachment with a table of contents of a volunteer training manual and an introduction to hospice volunteerism. However, no exact volunteer ratio or volunteer-to-patient estimate is offered. Schedule 6A does not reflect a volunteer coordinator FTE and offers no estimated number of volunteers being coordinated or supervised. It is noted that this applicant, consistent with the other two co-batched applicants, states it will document and maintain a volunteer staff sufficient to provide administrative or direct patient care in an amount of at least five percent of the total patient care hours of all paid hospice employees and contract staff. Regency Hospice of Northwest Florida, Inc. (CON #9971) describes volunteer services and an applicable attachment in the application 23. Stated functions are administrative and patient/family support as well as special projects. The attachment includes nine distinctive policies on volunteerism in the hospice setting, ranging from service, recruitment, guidelines and training to medical emergency and death-ofpatient protocols. This is not an exhaustive list of the policies. However, no exact volunteer ratio or volunteer-topatient estimate is offered. Schedule 6A indicates a 1.5 volunteer coordinator FTE by the second year of operation but no estimated number of volunteers being coordinated or supervised. This is the greatest FTE of volunteer coordinators of the three co-batched applicants which suggests the applicant either intends to have a higher volume of volunteers or plans to more closely oversee volunteers. This may be consistent with the fact that Regency anticipates the greatest volume of employees and admissions of the three co-batched applicants, by the second year of operation. It is noted that this applicant, consistent with the other two co-batched applicants, states it will 22 CON #9955 AHCA Form CON-1, page#15, 69, 87 and 90 and Volume 2, Attachment H Volunteer Program 23 CON #9971 AHCA Form CON-1, page#17 and Volume 3, Attachment S-1/Volunteer Services 19
document and maintain a volunteer staff sufficient to provide administrative or direct patient care in an amount of at least five percent of the total patient care hours of all paid hospice employees and contract staff. (b) Expected sources of patient referrals. Odyssey HealthCare of Northwest Florida, Inc. (CON #9954) lists its anticipated sources of referral in its application 24 including but not limited to patient selfreferral, case managers, continuing care retirement communities, elder housing and places of religious worship. The narrative in the application heavily focuses on nursing homes and ALFs as likely referral sources. The applicant states it utilizes community education representatives to search out relationships with potential referral opportunities. United Hospice of West Florida, Inc. (CON #9955) lists its expected sources of referral in its application 25. The expected referral sources identified by the applicant are primarily as follows: hospitals, physician groups; and longterm care facilities (SNFs and ALFs). SNFs state support specifically, but no hospitals are shown to. This applicant states a community education plan is drawn up to address applicable aspects of this need. Regency Hospice of Northwest Florida, Inc. (CON #9971) does not respond to this inquiry directly. However, it does refer to Attachment H-7 of Volume 2 of its application. Potential referral sources are documented for this application in letters of support submitted by a hospital in Walton County and a nursing home. 24 CON #9954 AHCA Form CON-1, page#59 and 60 25 CON #9955 AHCA Form CON-1, page#91 20
(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. As stated previously, the table below is duplicated, for convenience, it illustrates projected admissions for years one and two for each applicant. Total Projected Admissions By Applicant for Years One and Two CON # Applicant Year One (2008) Admissions Year Two (2009) Admissions 9954 Odyssey 270 411 9955 UHCWF 264 454 9971 Regency 26 242 496 Source: CON Applications 9954, 9955 and 9971 Odyssey HealthCare of Northwest Florida, Inc. (CON #9954) provides the following admissions by payer group: Odyssey Expected Admissions by Payer Type Payer Type Year One Year Two Medicare 253 386 Medicaid 8 12 Self-Pay or Uncompensated/Charity 5 8 Commercial Insurance 3 5 Total 269 27 411 Source: CON application 9954 United Hospice of West Florida, Inc. (CON #9955) provides the following admissions by payer group: UHCWF Expected Admissions by Payer Type Payer Type Year One Year Two Medicare 219 377 Medicaid 23 39 Self-Pay or Uncompensated/Charity 5 8 Commercial Insurance 17 30 Total 264 454 Source: CON application 9955 Regency Hospice of Northwest Florida, Inc. (CON #9971) provides the following admissions by payer group: Regency Expected Admissions by Payer Type Payer Type Year One Year Two 26 This applicant states the estimated first and second year admissions in CON #9971, AHCA Form CON-1, page#30, not in the Schedule 5 assumptions. 27 CON #9954 AHCA Form CON-1, page#61 shows 270 but arithmetically the categories as presented total 269. 21
Medicare 213 436 Medicaid 11 22 Self-Pay or Uncompensated/Charity 6 12 Commercial Insurance 12 26 Total 242 496 Source: CON application 9971 (d) Projected number of admissions, by type of terminal illness, for the first two years of operation. Odyssey HealthCare of Northwest Florida, Inc. (CON #9954) provides the following projected number of admissions by diagnosis: Projected Admissions by Diagnosis Diagnosis Year One Year Two Cancer 89 135 Non-Cancer/Other 182 276 Total 271 28 411 Source: CON Application 9954 United Hospice of West Florida, Inc. (CON #9955) provides the following projected number of admissions by age and diagnosis: Projected Admissions by Diagnosis Diagnosis Year One Year Two Cancer 95 163 Non-Cancer/Other 169 291 Total 264 454 Source: CON Application 9955 Regency Hospice of Northwest Florida, Inc. (CON #9971) provides the following projected number of admissions by diagnosis: Projected Admissions by Diagnosis Diagnosis Year One Year Two Cancer 95 195 Non-Cancer/Other 147 301 Total 242 496 Source: CON Application 9971 (e) Projected number of admissions, by two age groups, under 65 and 65 or older, for the first two years of operation. 28 CON #9954 AHCA Form CON-1, page#61 shows 270 but arithmetically the categories as presented total 271. 22
Odyssey HealthCare of Northwest Florida, Inc. (CON #9954) provided the following projected number of admissions by age group 29 : Projected Admissions by Age Group Age Group Year One Year Two Under 65 56 89 65 and Older 214 326 Total 270 411 Source: CON Application 9954 United Hospice of West Florida, Inc. (CON #9955) provides the following projected number of admissions by age group: Projected Admissions by Age Group Age Group Year One Year Two Under 65 56 95 65 and Older 208 359 Total 264 454 Source: CON Application 9955 Regency Hospice of Northwest Florida, Inc. (CON #9971) provides the following projected number of admissions by age group: Projected Admissions by Age Group Age Group Year One Year Two Under 65 50 101 65 and Older 192 395 Total 242 496 Source: CON Application 9971 (f) Identification of the services that will be provided directly by hospice staff and volunteers and those that will be provided through contractual arrangements. Odyssey HealthCare of Northwest Florida, Inc. (CON #9954) reports all services are provided directly by staff and volunteers except for those contracted which are listed as follows: physicians; nutritionists; physical, speech and occupational therapists. Nutritionist and therapist services are provided on an individual basis, in consultation with the interdisciplinary team, patient, family members and the attending physician. Regarding the applicant s comment that it will contract with a nutritionist for services, as noted earlier, dietary counseling is a core hospice service and cannot be contracted. Odyssey does show dietary counseling 29 CON #9954 AHCA Form CON-1, page#61 and 62. Of the three co-batch applicants, Odyssey does not offer a breakdown of total cancer and non-cancer/other diagnoses by age group. 23
as a direct service. The applicant provides no other detail in this section. United Hospice of West Florida, Inc. (CON #9955) states that the majority of services will be provided by its hospice care team, listed as a nurse case manager, home health care aide, chaplain, medical social worker, volunteer coordinator and bereavement coordinator. Nutritionist and therapist services are provided on an individual basis, in consultation with the interdisciplinary team, patient, family members and the attending physician. As noted earlier, the applicant has stated that it will contract for dietary counseling. This cannot be a contracted service in Florida. UHWF stats that a minimal level of contractual care will be provided by a medical director and United Rehab. This applicant indicates the most contracting of staff and the fewest number of inhouse employees of the three co-batched applicants. The applicant provides no other detail in this section. Regency Hospice of Northwest Florida, Inc. (CON #9971) reports its staff will provide the following services: nursing, home health aide, social work, chaplain, counseling and bereavement services. Volunteers will support hospice success through helping families and loved ones care for patients, raising funds and performing administrative support functions 30. As noted earlier, dietary counseling is not specifically addressed and cannot be contracted by hospice providers. (g) Proposed arrangements for providing inpatient care. Odyssey HealthCare of Northwest Florida, Inc. (CON #9954) states it currently has no plans to construct a freestanding facility for inpatient services but has done so in other market and could consider doing so in HSA 1, provided that a need exists in the future. The current plan is to seek inpatient services through contractual relationships with existing hospitals and nursing homes. None of this applicant s support letters are from nursing homes or hospitals and therefore no evidence was presented supporting the applicant s claims that it will be able to make arrangements for inpatient care. 30 It is noted this is the only co-batched applicant that does not state affirmatively in this section that an interdisciplinary team, the patient, family member(s) and the attending physician will take an active part in discussion and determination of the contractual process. 24