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STATE AGENCY ACTION REPORT
ON APPLICATION FOR CERTIFICATE OF NEED
A. PROJECT IDENTIFICATION
1. Applicant/CON Action Number
Compassionate Care Hospice of Lake and Sumter, Inc./CON #10140
200 Lanidex Plaza, Suite 2101
Parsippany, New Jersey 07054
Authorized Representative: Judith Grey
(973) 402-4712
Harbor Light Hospice of Florida, Inc./CON #10141
800 Roosevelt Road #C206
Glen Ellyn, Illinois 60137
Authorized Representative: Freeman Smith
(630) 942-0100
Hospice of Marion County, Inc./CON #10142
3231 SW 34th Avenue
Ocala, Florida 34474
Authorized Representative: Mary Ellen Poe
(352) 873-7434
VITAS Healthcare Corporation of Florida/CON #10144
100 South Biscayne Boulevard, Suite 1300
Miami, Florida 33131
Authorized Representative: Dr. Ronald T. Luke
(512) 371-8166
2. Service Area/Subdistrict
Hospice Service Area 3E, Lake and Sumter Counties
CON Action Numbers: 10140, 10141, 10142 and 10144
2
B. PUBLIC HEARING
A public hearing was not held or requested regarding the proposals to
establish a hospice program in Hospice Service Area 3E. However, letters
of support were submitted, as discussed below.
General Letters of Support
Sue Cordova, President and CEO of the United Way of Lake & Sumter
Counties, Inc. submitted an email which states that while (her
organization) does, “not have a specific Hospice Care organization to
support, we do encourage you to give preference to a non-profit Hospice.”
She cites that the majority of individuals in the service area live below
the poverty level and that, “a non-profit provider is better equipped to
handle our population and become a partner to other service providers
that can assist during a time of crisis.”
Compassionate Care Hospice of Lake and Sumter, Inc. (CON #10140)
had 25 letters of support from Hospice Service Area 3E dated from May
10, 2012 - June 15, 2012. They included cardiologists, other physicians,
a long-term care hospital, a nursing home, three assisted living facilities,
two home health agencies, a Florida State Senator and a veteran’s
organization. In general, these letters maintained the need for a hospice
choice in the service area as well as advocating for Compassionate Care
based upon its reputation for quality services.
State Senator D. Alan Hays of the 20th District emphasizes “the need for
patient choice and enhancement of hospice services in the
community…competitive environments lead to quality enhancement and
improvements as opposed to the potential for complacency.” Senator
Hays goes on to say, “Compassionate Care is known for providing quality
services in the communities in which it operates. It also matches its
unique abilities to the local and needs of the communities in which it
serves.”
Eight cardiologists submitted letters of support. Six of these letters
stated the community’s need for Compassionate Care’s Cardiac
Connections program, with three cardiologists citing that 20-30 of their
patients “are neither candidates for surgery or transplant…and as such
their only option at this time is admission to the hospital when they
become symptomatic.” These cardiologists include Dr. Prabhakara B.
Kunamneni, Central Florida Cardiology & Vascular Center, LLC; Dr.
Ronnie Sabbah, Florida Heart and Vascular Center; Dr. Patrick K.
CON Action Numbers: 10140, 10141, 10142 and 10144
3
Williams, Florida Heart and Vascular Center; Dr. John R. Hurt, Florida
Heart and Vascular Center; Dr. Osama Al Suleiman, Heart and Vascular;
Dr. Jose R. Rosado, Florida Heart and Vascular Center; Dr. Steven J.
Nerad; Dr. Thomas F. Perente, Heart Care & Vascular Medicine. Seven
additional physicians sent in letters of support including: Dr. Robert
Meade, Florida Heart and Vascular Center; Dr. Jose Carrau, South Lake
Neurology; Dr. Cheryl Durstein-Decker, the Doc’s IN; Dr. Annil Chet
Sawh, Orlando Medical Group; Dr. Mary Rose Boehm; Dr. Khalid
Maqsood, South Lake Gastroenterology; Dr. Rajab Abu Khadrah, South
Lake Gastroenterology. The office manager of White House Medical
Center, a physician’s office in Clermont, also submitted a letter of
support.
Other letter writers include Commander Johnny Gibbons of the
American Legion Veterans Memorial Post 347, Karen Blakely,
Administrator of Ruleme Center, a 138-bed Lake County SNF and
Steven M. Klein, CEO of Promise Hospital of Florida at the Villages.1
Three assisted living facilities submitted letters, including: Jim
Jennings, Executive Director of Superior Residences of Clermont; Gerard
Zamanski, Administrator of Leisure Manor Assisted Living Facility;
Debbie Flaherty, Executive Director of Sterling House, Brookdale Senior
Living.2 The two home health agency letters were from representatives of
Phoenix Home Care and Angels Care Home Health. Promise Hospital of
Florida at the Villages and Superior Residences of Clermont stated their
intent “to enter into appropriate arrangements to incorporate
Compassionate Care into our resident choices for hospice care.”
Harbor Light Hospice of Florida, Inc. (CON #10141) had 53 letters and
one memo of support for its services. Six letters and the memo are from
Hospice Service Area 3E. Two letters are from Steven W. Sell
representing Osprey Point Nursing Center, a 60-bed SNF located in
Sumter County. One letter states, “Nursing home facilities are required
to offer choice in physicians, food and every aspect of care, yet, there is
only one hospice provider in our county.” Mr. Sell’s second letter
indicates that Osprey Point would be “interested in and agreeable to
developing a contract with Harbor Light Hospice for the provision of
inpatient hospice services.”
Three assisted living facilities submitted letters of support, Waterman
Cove, TLC Family Care Home and Mission Oaks. Two home health
agencies provided letters. Christine Magnifico, Vice President of
Advanced Nursing Concepts, Inc. stated “I feel it crucial to provide a
1 Mr. Klein also sent a letter of support for VITAS Healthcare Corporation of America. 2 Ms. Flaherty also sent a letter of support for Hospice of Marion County.
CON Action Numbers: 10140, 10141, 10142 and 10144
4
choice when presenting any type of medical care.” Ben Miccichi,
Administrative Officer of Maxim Healthcare Services, sent in a letter and
a memo of support for the proposed program.
The remaining 47 letters of recommendation/reference are from out of
state from providers working with current Harbor Light Hospice
locations. Thirty-seven of these letters are not dated; the remaining eight
letters are dated June 6, 2012-June 18, 2012. These letters include one
doctor, two long-term care hospitals and 43 from nursing
homes/assisted living facilities. The letters speak of the organization’s
service, knowledge and dedication. Several facilities maintain that even
though this is a small organization, Harbor Light adapts quickly and
tailors programs to fit resident’s needs.
Hospice of Marion County, Inc. (CON #10142) had 231 letters of
support and one email for its project, 146 are from or serve residents
within Hospice Service Area 3E. Three of these letters were unsigned.
Forty-one of these letters were not dated, 190 were dated February 24,
2012 through June 14, 2012. These include three members of the
Marion County government, six members of the Marion County Chamber
of Commerce Hispanic Business Council, a representative of a college, 23
members of religious organizations, one outpatient clinic, 57 physicians,
10 service organizations, two physical therapists, 19 assisted living or
skilled nursing facilities, 14 care management/home care service
providers, 30 residents from Lake/Sumter County, 27 residents from
outside the service area (the majority from Marion County), 11 health
care facilities/medical practices, 15 businesses, 10 family members of
patients and two volunteers.
Letters from physicians serving residents within Hospice Service Area 3E
include: Four members of the Ocala Neurosurgical Center; one member
of the Villages Lung & Sleep Ctr.; Dr. William Rodriguez, Dr. Anish K.
Khanna, Dr. Asm Rahman, Dr. Darin S. Brown, Dr. Syed Umair,
Dr. Abminav Khanna, Dr. David Stephenson and one other doctor from
the Ocala Hospitalist Group; Dr. Srinivas Reddy; Dr. Clarissa R.
Abrantes, Institute of Medical Excellence; Dr. Sandeep K. Thaper,
Central Florida Hematology and Oncology; Dr. Fariborz Delbakhsh;
Dr. Michele Hornstein, Central Florida Medical Care; Dr. Sheri Hamnik,
Neurology Center of Excellence; Dr. Uzoma Nwaubani, Female
Continence & Pelvic Surgery Center; Dr. Tuan K.I. Dean, Villa Medical
Group; Dr. Larry Foster, Leesburg Family Medicine; Dr. Jay Shaktawat,
Health First Internal Medicine Associates; Dr. Sundeep Shah, Dr. Eldar
Baigabatov, Dr. James S. Miller and Dr. Hazem El-Arousy of Premier
Medical Associates; Dr. Stephanie Walker, Rivers Family Medicine;
Dr. Frederick M. Yutani, Solanki Cardiology, LLC; Dr. Joyce Smolarski,
CON Action Numbers: 10140, 10141, 10142 and 10144
5
Southeastern Integrated Medical; Dr. Winston E. Evalle; Dr. Donald T.
Eagle, Florida Physicians Medical Group; Dr. Pedro J. Arroyo; Dr. Kevin
Brown, New Beginning, TCM; Dr. Stacy John Berckes, Florida Pain
Management Center, Inc.; Dr. Sergio Balingit; Dr. Ravi P. Gupta and
Dr. Norman Novis of Mid-Florida Primary Care; Dr. Abu Azizullah,
Internal Medicine Practices; Dr. Catherine B. Horner of Family Doctors of
Belleview; Dr. Stanimir Stantchev, Florida Medical Associates; Dr. Robert
Boissoneault, Oncology Institute; Dr. Khai Chang, Dr. Shahbaz Cheema,
Dr. Page Smith and Dr. Ma Thuzar Aung of Lakeview Internal Medicine,
P.A.; Dr. Rakesh Rohatgi, Tri-County Hematology & Oncology;
Dr. Lourdes M. Mathew, Lake Cancer Medical Center; Dr. Thomas
Cartwright of Ocala Oncology.
Ten representatives of health care organizations/medical groups that
support the service area sent in letters of support, including: Carolyn
Porter, Director of Case Management and Dr. Lon H. McPherson, Senior
Vice President of Medical Affairs/Chief Quality Officer at Munroe
Regional Medical Center; Dr. Anette V. Nieves of Munroe Regional
Medical Center’s clinic, The Oaks at 138th; Raymond J. McNeal, Practice
Administrator and Nancy Spano, Clinical Services Supervisor of Ocala
Oncology; Timothy I. Sullivan, member of the Board of Directors at
Central Florida Health Alliance; Dolly McCranie, Director of Case
Management at Central Florida Health Alliance and at The Villages
Health System; Steven Marc Capps of Thomas E. Langley Medical Center;
and Maen Hussein of Florida Cancer Specialists. Kenneth R. Mattison,
President and CEO of Florida Hospital Waterman stated Waterman is
willing to consider contracting with Hospice of Marion County (HMC) to
provide short-term inpatient care.
Dr. K. Todd Donahoe of the Department of Veterans Affairs, The Villages
Outpatient Clinic, sent in a letter of support. Two physical therapists
voiced their support—Cindy Mill, Clinic Manager of Fit for Life Physical
Therapy and Ed Yuiska, Rehab Golf Specialist at Lake Centre for Rehab.
Ten assisted living facilities/skilled nursing facilities that support the
service area sent in letters of support, including: Pat Manco,
Administrator at The Bridgewater at Waterman Village; Dori Beard,
Executive Director and Allison Metcalf, Marketing Director at Mission
Oaks Assisted Living and Memory Care; Lois Pattison of The Springs of
Lady Lake; Vincent A Zaun, Nursing Home Administrator of Lady Lake
Specialty Care;3 Debbie Flaherty, Executive Director of Sterling House; a
representative of Savannah Manor; Diana Saxton of Lexington Park; Bill
Reyes, Caregiver at Pleasantvillle Assisted Living Facility; Bonnie Varnell
at Lake Ridge Village.
3 Mr. Zaun also sent in a letter of support for VITAS Healthcare Corporation of Florida.
CON Action Numbers: 10140, 10141, 10142 and 10144
6
Twenty-two members of the religious community that serve the hospice
service area were represented, including: Ronald W. Mansdoerfer; the
Very Reverend John C. Giel, Pastor at the Catholic Community of St.
Paul; Billy Ray, Pastor of Evangelism, FBC Bushnell; an assistant pastor
at Celebration of Praise Church; Dr. M. McCoy Gibbs, Minister of
Visitation at Morrison United Methodist Church; Eitan Zur, President of
Temple Shalom; Father Peter Sagorski, Pastor of St. Vincent de Paul
Catholic Church; Deborah West, Administrative Assistant of Union
Congregational Church; Bruce W. Stewart, Senior Pastor at Open Door
Baptist Church; Reverend Pedro Zapata, Pastor of St. Lawrence Catholic
Church; Father Hugh Bromiley, Rector at St. George Episcopal Church;
Reverend Jeffrey Thomas, First United Methodist Church; Michael
Wayne Hood, Pastor of Bushnell Presbyterian Church; Deborah Marsich
the Faith Community Nurse Coordinator, Judith Woletz a Faith
Community Nurse and Joy Nutter at Hope Lutheran Church; Dr. Chris
Hardeman, Pastor at Faith Presbyterian Church; 14 members of the
United Church of Christ at The Villages; Richard Fountain, Pastor at
First Baptist Church; William A. Kamp, Pastor at First Presbyterian
Church of Wildwood; Donald H. Garms Sr., Pastor at Lighthouse Worship
Center Church of God; Andrea Cauthen, Children’s Pastor at First United
Methodist Church; a representative of Providence Baptist Church. Two
representatives of organizations within the service area sent in letters of
support—the Vice Chair of the Early Learning Coalition and Nick Jones,
President of The Village Airheads (COPD support group).
Seven care management/home care/home health agencies that serve
Subdistrict 3E support the proposed program, including: Beulah Scott,
Owner and President of All Coast Home Health Services; Summer Minor,
Administrative Assistant at Preferred Home Health; Deborah Stiles,
Assistant Director at McCoy Adult Day Care Center; Jan Marino, Account
Manager at infinity Homecare; Don Johnson at Heidi’s Haven; Robbi D.
Funderburk, Patient Care Coordinator at Greystone Home Healthcare;
Jamie Reardon, Director of Operations at Amedisys Home Health Care;
Rhonda L Combs, Administrator at Daycare HomeCare; Connie Michalik,
Administrator at Waterman Village Home Care; the Director of Health
and Wellness at Lake Harris Health Systems, LLC. Ten representatives
of business that serve Subdistrict 3E sent in letters of support,
including: Sheila Endicott, Manager of All Faiths Cremation Society;
Patricia De Roe, Manager of The Lost Parrot; Bob Bachelor, owner of The
Paint Shoppe; Amy Reed Pittman, Attorney at the Millhorn Law Firm;
Rodney J. Len, General Manager at Danny Len Buick-Pontiac & GMC
Trucks; Greg A. Beliveau, President of LPG Urban & Regional Planners,
Inc.; Annette Varner and Patty Schiefer at CenturyLink; Amanda
Wettstein at That Company; Judy Owens at Cupcake Delights.
CON Action Numbers: 10140, 10141, 10142 and 10144
7
In general these letters stated that Hospice of Marion County provides
excellent care and service, is dedicated to ensuring the well-being of
patients/families/friends during enrollment to the program and is a
leader in providing end-of-life education to the general community as
well as health care professionals. The remaining 85 out-of-the-service-
area letters reiterate the above as well as speaking to the Hospice of
Marion County’s reputation within Marion County as an involved
member of the community.
VITAS Healthcare Corporation of Florida (CON #10144) had 59 letters
of support, 29 are from Hospice Service Area 3E or serve residents within
Hospice Service Area 3E. Two of these letters are not dated. The
remaining letters are dated May 8, 2012-June 18, 2012. These include
representatives from three hospitals, a county official, three case
managers, three physicians, four members of the religious community,
four representatives of organizations, one higher education director, five
skilled nursing homes/assisted living facilities, two residents and three
care management/home care service providers.
Letters from or serving residents from Hospice Service Area 3E were
received from: Fred Harrop, USAF, Manager of Veteran Services at the
Sumter County Board of County Commissioners; Faye Rose, Director of
Pastoral Care, Florida Hospital Waterman; Steven M. Klein, CEO of
Promise Hospital of Florida at the Villages; Sita Price, Coordinator of the
Heart Failure Program at ORMC Orlando Health Heart Institute;
Kimberly Hogan, Director of Case Management at Health Central
Hospital; Courtney Lemming, Case Manager for the Cardiovascular ICU
at Health Central Hospital; Tara L. Curry, Case Manager at Health
Central Hospital; Dr. Kerlan Peter Wolsley, South Lake Hospital
Intensivist; Dr. Charles Morgan; Dr. Jeffrey Cohen, Nephrology
Associates of Central Florida; Reverend John W. Harrington, Senior
Pastor at Morrison United Methodist Church; Reverend Annette Stiles
Pendergrass, North Central District Superintendent of the United
Methodist Church; Timothy Whitaker, Resident Bishop of the United
Methodist Church; Reverend Todd Bardin, Montverde United Methodist
Church; Sharon Melton, Director of Programs for the Alzheimer’s
Association of Central and North Florida Chapter; Candace Huber of
Transformation Communities; April Carpenter, Campaign Manager for
the Leukemia & Lymphoma Society of Northern & Central Florida
Chapter Light the Night; Bonnie Cruz, President of the Florida
Association Directors of Nursing Administration, LTC; Margaret S.
Wacker, Director of the Nursing Program at Lake Sumter Community
College; Vincent A. Zaun at Lady Lake Specialty Care Center; Teresa
Mena, Director of Nursing at The Edgewater at Waterman Village; Dana
CON Action Numbers: 10140, 10141, 10142 and 10144
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Weaver, Administrator of Sutton Homes; Kelley Keoppen, owner and
Administrator at The Gardens at Lakeview; Terry Haehnel, Executive
Director at Emeritus at Oak Park; Robert Lowe, President and owner of
BrightStar of Lake County; Deborah Snow, Community Liaison at
Phoenix Home Care; John Lazo, Area Director of CSI—Caregiver Services,
Inc. These letters speak to VITAS’ experience, quality and ability to
provide services and education to Lake and Sumter County residents.
Many mentioned VITAS’s commitment to charity care patients. Of
particular note, two letters mentioned the current limited resources for
hospice in Lake County. Sita Price of ORMC’s Orlando Health Heart
Institute mentions that, “The one provider in Lake County has not been
able to manage the needs of my advanced heart failure patients.”
Dr. Jeffrey Cohen states, “Since there is only one hospice provider in
Lake County, I have had to redirect patients to Orange County in-patient
units as VITAS is willing to care for these more complicated patients.”
Two of the nursing homes, Lady Lake Specialty Care Center and The
Edgewater at Waterman Village, stated that they would consider
contractual arrangements with VITAS upon approval.
The remaining 30 letters are from out of the service area but within the
State of Florida—these letters attest to VITAS’ success in other parts of
the state. A relatively common theme is that VITAS is supportive to
patients and families, provides outreach and educational tools as well as
highly professional. Several letters speak of VITAS’ commitment to the
community through several financial contributions and participating in
charitable events. Many letters mentioned VITAS’ commitment and
willingness to care for charity care patients.
In addition to the above letters, the applicant also included a letter from
R. Terry Rigsby, Attorney at Law, with Pennington, Moore, Wilkinson,
Bell & Dunbar. Mr. Rigsby cites an orchestrated letter-writing campaign
by the existing hospice in Service Area 3E, Cornerstone Hospice &
Palliative Care, “to convince the Agency that in spite of the unchallenged
published need, no additional hospice should be approved to serve Lake
and Sumter Counties.” Mr. Rigsby responds to this campaign by stating,
“Choice and regulated competition in the provision of hospice care are in
the public’s best interest. The Agency’s hospice need projection should
outweigh the desires of an existing provider that seeks to maintain its
monopoly, as there is no demonstrated reason not to approve an
additional program for the 3E service area.”
CON Action Numbers: 10140, 10141, 10142 and 10144
9
Letters of Opposition
Mr. Karl David Acuff wrote on behalf of Cornerstone Hospice, Inc., the
existing provider in Hospice Service Area 3E, stating that it accepts that
the fixed need methodology projects a need for one new program in this
batch cycle. However, Cornerstone does object to the trend of applicants
arguing that a second hospice could be approved in addition to an
approval under the fixed need pool. Mr. Acuff states, “Hospice Service
Area 3E is one of the least populous service area and would not benefit
from the addition of multiple providers, the confusion amongst the public
and splintering of health care resources, including personnel, would
diminish the cohesiveness, continuity and potentially even the quality of
hospice care in the community. Mr. Acuff’s letter included 37
unduplicated letters of opposition, described below.
Seven of these letters were not dated; the remaining 30 were dated
June 4, 2012 through June 19, 2012. The letters cited Cornerstone
Hospice’s high quality care, knowledge and experience to the residents of
Lake and Sumter Counties. The majority of these letters stated that they
did “not see an unmet need for hospice services in our local community.”
These letters arrived from a variety of sources. One pastor, the Reverend
Ed Waters of St. Timothy Catholic Church submitted a letter. Four
health care administrators sent in letters: Rebecca Grohler, Manager of
Operations at InterCommunity Cancer Centers; Debra Trovato,
Administrator of Moffitt Cancer Center at the Villages Health System;
Nancy Moreland, Manager of Leesburg Regional Medical Center
Medical/Oncology; Barbara Jean Lane, Clinical Coordinator at Florida
Hospital Waterman Cancer Institute. Four Chambers of Commerce
submitted letters, including: Andrew Cripps, Executive Director of the
Sumter County Chamber of Commerce, Inc.; Cathy Hoechst, President of
the Mount Dora Area Chamber of Commerce; Ray San Fratello, President
of the South Lake Chamber of Commerce; Colleen McGinely, Executive
Director of the Tavares Chamber of Commerce. Evadne Tsolo, an
oncology social worker from the Cancer Institute at Florida Hospital
Waterman, sent in a letter of opposition. Three funeral homes were
represented: John Roemmelt, Funeral Director of Steverson, Hamlin &
Hilbish; Terry L. Hensley, Manager of Beyers Funeral Home, Lady Lake;
Roger A. Beyers, President and Owner of Beyers Funeral Homes and
Crematory of Lake and Sumter Counties. Charlotte Wigle, ARNP-C,
submitted a letter. One nursing home--Bill Mobley, Administrator at
Leesburg Health & Rehab, LLC—was represented.
CON Action Numbers: 10140, 10141, 10142 and 10144
10
Seven businesses sent in letters, including: Lucille M. Espey-Francis,
Attorney at Law; Catherine G. Kyle, Kyle Promotions; H. Scott Smith,
MBA Business Solutions; Gregory A. Yager, General Manager of Plaza
Cadillac; Thomas J. Popieski, Area President of BankFIRST; David L,
Weiss, CPA at Weiss Retirement Strategies; Vann Gannaway of Vann
Gannaway Chevrolet, Inc. Ten doctors submitted letters: Dr. William H.
Weaver, Carefirst Family Practice; Dr. William Finlayson III; Dr. Bruce M.
Weaver, Carefirst Family Practice; Dr. Peter Amos Ankoh; Dr. Herman M.
Flink, Radiation Oncologist at InterCommunity Cancer Centers; Dr.
Frank Pellegrino; Dr. Christopher T. Soprenuk; Dr. Ahmed Al-Hazzouri of
Florida Cancer Specialists & Research Institute; Dr. Bobby E. Harrison,
Radiation Oncologist at InterCommunity Cancer Centers; Dr. Maria
Bello. Two non-profit organizations sent in letters Linda H. Krupski,
President of LovExtension, Inc. and H. Scott Smith, Treasurer of Golden
Triangle Kiwanis Foundation. One Senior Home Care sent in a letter,
Robert Lowe, President and Owner of BrightStar of Lake County.
C. PROJECT SUMMARY
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140), a development stage corporation, proposes the
establishment of a new hospice program in Hospice Service Area 3E. The
applicant is a wholly owned subsidiary of Compassionate Care Group,
Ltd. which was founded in 1993 and operates 32 programs in 21 states.
Compassionate Care Hospice is licensed to serve patients in Hospice
Services Area 6B (Polk, Highlands and Hardee Counties).
The applicant is proposing total project costs of $142,965 with year one
operating costs of $1,348,681 and year two costs of $3,102,696.
Schedule C includes the following conditions:
1. The applicant will implement its Cardiac Connections program
immediately upon licensure. It will be made available to all eligible
residents with a qualifying cardiovascular disease. As part of this
implementation the applicant will ensure:
(a) The medical director of Compassionate Care’s Cardiac
Connections Program will be a cardiologist.
(b) The Cardiac Connections Program will have a licensed nurse
practitioner.
CON Action Numbers: 10140, 10141, 10142 and 10144
11
(c) At a minimum, Compassionate Care will hold quarterly
meetings for area cardiologists to maintain open
communications with the community cardiologists to
continue to educate them about options in end of life care for
their patients.
(d) At a minimum, Compassionate Care will coordinate with
local hospitals’ staff and/or physicians on a monthly basis to
review the Cardiac Connections Program and how it may be
benefiting both the hospital and the patient in terms of
reduction in readmission rates, program success and other
measure to be determined.
(e) Cardiac Connection Program patients will receive daily
communication from Compassionate Care staff either via an
in-person visit, or by telephone if an in-person visit is not
scheduled on a particular day.
(f) All Cardiac Connections Program patients will have a
Cardiac Comfort Kit with them in their home.
(g) Compassionate Care will prepare an annual report for the
Agency for Health Care Administration addressing how
hospital readmissions for heart failure have decreased in the
subdistrict relative to the Compassionate Care cardiac
admissions.
2. Compassionate Care Hospice Group, Ltd. will implement its
Pathways to Compassion Program immediately upon licensure of
Compassionate Care, which will be made available to all eligible
Lake and Sumter County residents.
3. Compassionate Care will implement its Veterans Outreach
Program immediately upon licensure as detailed within CON
application #10140.
4. The applicant has conditioned approval of this application on the
provision that it will become accredited by CHAP upon
certification.4
5. Compassionate Care will provide a home health aide ratio above
NHPCO (National Hospice and Palliative Care Organization)
guidelines at an average of 10 hours per patient per week.
6. Compassionate Care will not participate in fundraising activities in
Subdistrict 3E.
7. Compassionate Care will not build or operate freestanding hospice
facilities in Subdistrict 3E.
4 Per http://www.healthfinder.gov/orgs/HR3805.htm, The Community Health Accreditation Program, Inc. (CHAP) is an independent, not for profit accrediting body for community-based health organizations. Benefits of accreditation by CHAP include management consultation of the highest quality, access to a broad network of professional resources, and guidance critical to building intra and inter-organizational collaboration and strength.
CON Action Numbers: 10140, 10141, 10142 and 10144
12
Harbor Light Hospice of Florida, Inc. (CON #10141), a recently
created, private corporation is seeking to establish a new hospice
program in Hospice Service Area 3E. Harbor Light states that while it is
a new corporate entity in Florida, it is an experienced and well-qualified
hospice provider with five separate entities providing hospice services
from 19 locations in eight states. The applicant notes that 16 of these
hospice programs were start-ups.
Harbor Light is proposing total project costs of $176,460 with year one
operating costs of $805,148 and year two costs of $2,134,559.
Schedule C includes the following conditions:
The applicant will provide supportive hospice services, such as, but
not limited to, palliative radiation therapy and palliative
chemotherapy and other supportive therapies related to the patient’s
terminal diagnosis.
The applicant will provide continuous care.
The applicant will provide hospice services 24 hours a day, seven days
a week including weekend care as indicated by the patient’s medical
condition.
The applicant will immediately implement its Quality
Assurance/Performance Improvement plan including the following
assessments: pain management, family satisfaction, employee
satisfaction and referral source satisfaction.
The applicant will make available a range of non-covered
supplementary therapies such as, but not limited to: pet, music,
massage, aroma and other holistic treatments.
The applicant will establish a local ethics committee within the first
year of operation.
The applicant will commit to at least 0.5 FTE of staff manpower for
development efforts regarding community bereavement programs in
the local market. The bereavement programs will be broadly based to
extend beyond the families of patients admitted to Harbor Light.
These programs will be an extension of the programs currently offered
in the hospice service area. The applicant will provide bilingual staff
to provide bereavement services to the Hispanic population, including
Hispanic children. At a minimum, one bereavement group consisting
of approximately eight sessions will be offered by the end of the first
year of operation. As the bereavement client census increases after
one year, full time staff will be employed.
CON Action Numbers: 10140, 10141, 10142 and 10144
13
The applicant will provide bilingual or multilingual staff resources to
ensure that hospice services and hospice education or support
programs are available to all segments of the service area population
regardless of language/ethnic heritage.
The applicant will commit to at least 0.5 FTE of staff manpower for a
community education specialist, expanding community awareness of
hospice services and educating medical staff, community leaders and
potential hospice patients as to the benefits of and availability of
hospice care.
The applicant will commit to the development of a satellite office by
the 18th month of operation.
The applicant commits to become accredited by the Joint Commission
within its first year of operation.
The applicant commits to sponsoring four education seminars per
year for physicians, long-term care facilities and assisted living
facilities. The focus of these seminars is to educate the local health
care community on the provision of hospice services within assisted
living facilities and other long-term care facilities: a coordinated plan
of care for the patient, increase support for the patient/family/facility
staff and the provision of equipment, medication and supplies.
The applicant commits that it will not establish any new hospice
housing facilities during the first five years of its operation.
The applicant commits that it will not solicit community funds in
support of its hospice operations. Any unsolicited donations received
will be dedicated directly to the enhancement of Harbor Light Florida
programs in Lake/Sumter.
The applicant will commit to the provision of the following programs
focused on special needs populations:
o Alzheimer’s/Dementia program will be offered
o Hispanic/Latino program will be provided as well as Spanish
translations of its patient handbook, website and brochure
o Palliative Care program will be offered
o Cardiac program will be offered
o Deaf and Hearing Impaired Program will commit to having a
Sorenson VRS device and TTY device available at each one of its
locations. In addition, the applicant will employ bilingual ASL and
ESL-speaking staff in the event Harbor Light staff are unavailable.
CON Action Numbers: 10140, 10141, 10142 and 10144
14
The applicant will utilize appropriately educated and trained
interpreters and commits to provide specialized training and
resource tools for staff working with individuals with hearing
impairment to enhance the provision of hospice care to such
individuals. Harbor Light commits to spend $10,000 plus the cost
of a community educator to work with the medical community on
deaf and hearing impaired issues
o Military Veteran’s Program including participation in We Honor
Veterans as well as a commitment to hiring veterans
Hospice of Marion County, Inc. (CON #10142), a not-for-profit
corporation, proposes the establishment of new hospice program in
Hospice Service Area 3E. The applicant has been a hospice provider in
Marion County for 29 years.
HMC is proposing total project costs of $292,179 with year one operating
costs of $1,746,402 and year two costs of $3,100,487.
Schedule C includes the following conditions:
1. Commitment to extend the Partners in Care/Together for Kids
program to Subdistrict 3E.
2. Commitment to extend specialized chronic disease certification to
Subdistrict 3E and to have completed at least five workshop series
by the end of the second year of operations.
3. Commitment to establish a dedicated hospice inpatient unit in a
hospital or skilled nursing facility, or freestanding hospice house in
Subdistrict 3E once an average daily census level of 150 has been
attained for a six-month period. Fulfillment of this condition will be
dependent upon: (a) successfully negotiating a lease with a willing
facility partner or (b) obtaining certificate of need approval for a free
standing facility and subsequent licensure from the Agency for
Health Care Administration.
4. Commitment to use the profits of the Thrift Store, located in The
Villages, to support non-reimbursed programs and charity care in
Subdistrict 3E.
5. Commitment to make available palliative care consultation services
(on an inpatient and/or outpatient basis) to patients in Subdistrict
3E within the first two years of operation.
CON Action Numbers: 10140, 10141, 10142 and 10144
15
6. Commitment to offer a separate children’s bereavement camp to the
Lake and Sumter community. This meaningful day camp provides
enhancements to traditional bereavement services, especially for
those children experiencing problematic grief. The children’s
bereavement day camp will coordinate with the Partners in
Care/Together for Kids program to ensure siblings of these patients
are also served.
7. Commitment to actively participate in community activities,
including education sponsorship, in the amount of $10,000 the first
year of operations and $15,000 by the end of the second year of
operation.
8. In collaboration with the Community Health IT Strategic Partners,
commitment to work with other health care providers in Subdistrict
3E to establish a health information exchange.
9. Commitment to extend the We Honor Veterans program into
Subdistrict 3E.
10. Commitment to extend HMC’s existing special disease programs for
heart failure, pulmonary disease, Alzheimer’s/dementia, including
the telemonitoring program into Subdistrict 3E.
VITAS Healthcare Corporation of Florida (CON #10144), a for-profit
entity, proposes the establishment of a new hospice program in Hospice
Service Area 3E, Lake and Sumter County. The proposed hospice
program will operate as an extension of the VITAS Healthcare
Corporation of Florida (VHCF) hospice program that has been operating
in Florida for the past 30 years. The applicant is currently licensed to
operate hospice programs in 16 Florida counties. VITAS Healthcare
Corporation, the applicant’s parent organization, operates 52 hospice
programs in 18 states and the District of Columbia.
VHCF is proposing total project costs of $881,036 with year one
operating costs of $2,223,926 and year two costs of $4,708,316.
Schedule C includes the following conditions:
1. VHCF will provide at least five percent of its total patient days as
continuous care by year two.
VHCF will guarantee that at least 65 percent of patients admitted
have non-cancer diagnoses.
CON Action Numbers: 10140, 10141, 10142 and 10144
16
2. VHCF will meet exceed the statutory requirement in 400.60501,
Florida Statutes. Seventy percent or more of patients who report
severe pain (seven to 10 on the World Health Organization pain
scale) will report a reduction to five or less on the pain scale within
48 hours after admission.
3. A VHCF staff member or volunteer will attend at least 90 percent of
all deaths to ensure patients do not die alone.
4. VHCF will achieve an overall patient satisfaction score of 90
percent or above on the patient’s family’s evaluation of care while
under the care of VITAS.
5. VHCF will achieve an overall registered nurse satisfaction score of
90 percent or above on patient’s family satisfaction with the nurse
while under the care of VITAS.
6. VHCF will implement a pet therapy program to begin immediately.
PetPals is a program where screened dogs visit shut-ins, nursing
homes, assisted living facilities, adult day care center and
Alzheimer patients.
7. VHCF will establish a satellite hospice office in Sumter County
during the first year of operation.
8. VHCF will implement a TeleCare Program consisting of 24/7 nurse
availability to begin immediately.
9. VHCF will establish a Local Ethics Committee to begin upon
certification.
10. VHCF will implement CarePlanIT, a handheld bedside information
system, by the end of the second year of operation.
11. VHCF will implement VITAS Palliative Care Solutions in Subdistrict
3E by the end of the first year of operations.
12. VHCF will provide palliative radiation, chemotherapy and
transfusions as appropriate for treating symptoms.
13. VHCF will commit to having every patient being assessed by a
physician within 24 hours of admission to the hospice. Medical
directors provide patient visits in their residence.
14. The medical director will be board-certified in hospice or palliative
care medicine, or apply for board certification within five years of
employment.
15. By the second year of operation, 50 percent of all supervisory
nurses will attain certification in hospice and palliative care
nursing. RNs will be encouraged to become certified in Hospice
and palliative care nursing.
16. A Master’s of Divinity or equivalent graduate degree from an
accredited seminary or theological school will be required for
chaplains.
CON Action Numbers: 10140, 10141, 10142 and 10144
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17. Social workers will be licensed clinical social workers or Master’s
level.
18. Bereavement services will be available to the family beyond one
year after the death of a patient if needed.
19. VHCF agrees that it will not engage in any fundraising events or
campaigns to obtain charitable contributions from residents of the
subdistrict. VHCF will respond to inquiries from persons seeking
to make charitable contributions for hospice services with
information on relevant 501(c)(3) organizations that benefit Florida
residents.
20. VHCF will establish a Clinical Pastoral Education program to begin
immediately.
21. VITAS will make a charitable contribution in the amount of
$190,000 to Lake and Sumter Community College to fund an
endowed teaching chair, scholarships and ongoing education and
training for nursing students. This funding will be provided during
the first five years of licensure.
22. VITAS will make a charitable contribution to the United Way of
Lake and Sumter in the amount of up to $225,000 during the first
two years of licensure. Up to $25,000 will be used to fund a
survey assessment of senior needs. Additionally, based on the
community projects geared toward seniors that are identified by
the assessment, VITAS will fund up to $100,000 per year for two
years to offset the expected costs of such programs.
Hospice programs are required by federal and state law to provide services
to everyone requesting them and therefore the Agency would not place
conditions on a program to provide legally required services such as
palliative radiation and chemotherapy and care to the indigent and charity
patients. The applicants’ proposed conditions are as they stated.
However, Section 408.043 (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. 408.031-408.045.” Also,
many of these conditions are required hospice services and as such would
not require condition compliance reports.
CON Action Numbers: 10140, 10141, 10142 and 10144
18
Should a project be approved, the applicant’s proposed conditions would be
reported in the annual condition compliance report as required by Rule
59C-1.013 (3) Florida Administrative Code. Section 408.606 (5) Florida
Statutes states that “The agency may deny a license to an applicant that
fails to meet any condition for the provision of hospice care or services
imposed by the agency on a certificate of need by final agency action,
unless the applicant can demonstrate that good cause exists for the
applicant’s failure to meet such condition”.
D. REVIEW PROCEDURE
The evaluation process is structured by the certificate of need review
criteria found in Section 408.035, Florida Statutes; and applicable rules
of the State of Florida, and Chapters 59C-1 and 59C-2, Florida
Administrative Code. These criteria form the basis for the goals of the
review process. The goals represent desirable outcomes to be attained by
successful applicants who demonstrate an overall compliance with the
criteria. Analysis of an applicant's capability to undertake the proposed
project successfully is conducted by evaluating the responses provided in
the application and independent information gathered by the reviewer.
Applications are analyzed to identify various strengths and weaknesses
in each proposal. If more than one application is submitted for the same
type of project in the same district (subdistrict or service planning area),
applications are comparatively reviewed to determine which applicant
best meets the review criteria.
Section 59C-1.010 (3) (b), Florida Administrative Code, prohibits any
amendments once an application has been deemed complete. The
burden of proof to entitlement of a certificate rests with the applicant.
As such, the applicant is responsible for the representations in the
application. This is attested to as part of the application in the
Certification of the Applicant.
As part of the fact-finding, the consultant, Marisol Novak, analyzed the
application in its entirety with consultation from financial analysts,
Derron Hillman and Eric West, who evaluated the financial data.
CON Action Numbers: 10140, 10141, 10142 and 10144
19
E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA
The following indicates the level of conformity of the proposed projects
with the criteria found in Florida Statutes, Sections 408.035 and
408.037; 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-1.0355, Florida Administrative Code.
In Volume 38, Number 13 of the Florida Administrative Weekly dated
March 30, 2012, a hospice program need of one was published for
Service Area 3E for the July 2013 Hospice Planning Horizon. Service
Area 3E is currently served by Cornerstone Hospice and Palliative Care.
Each co-batched applicant is applying in response to published need for
a hospice program in Hospice Service Area 3E, Lake and Sumter
Counties. However, all applicants provide additional arguments in
support of need for their projects as discussed below.
Below are population estimates for Lake and Sumter Counties, Hospice
Service Area 3E, from July 2012 to July 2017.
Population Estimates for Lake County, Sumter County and Florida
July 2012 - July 2017 Lake County
Age Group
Year Change
2012 2017 Number Percent
Under 65 231,103 265,164 34,061 14.7%
65+ 73,576 88,378 14,802 20.1%
Lake County Total 304,679 353,542 48,863 16.0%
Sumter County
Age Group
Year Change
2012 2017 Number Percent
Under 65 54,568 58,817 4,249 7.8%
65+ 46,180 61,087 14,907 32.3%
Sumter County Total 100,748 119,904 19,156 19.0%
Service Area Subdistrict 3E
Age Group
Year Change
2012 2017 Number Percent
Under 65 285,671 323,981 38,310 13.4%
65+ 119,756 149,465 29,709 24.8%
Service Area Total 405,427 473,446 68,019 16.8%
State of Florida
Under 65 15,703,051 16,609,626 906,575 5.8%
65+ 3,425,139 4,009,870 584,731 17.1%
State Total 19,128,190 20,619,496 1,491,306 7.8% Source: AHCA Florida Population Estimates 2010-2025, published February 2012.
CON Action Numbers: 10140, 10141, 10142 and 10144
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Compassionate Care Hospice of Lake and Sumter, Inc. (CON #10140)
indicates that despite the increasing resident deaths in Hospice Service
Area 3E, admissions to the existing hospice have declined between 2009
and 2011, by 5.8 percent (162 admissions). Applying the fixed need
formula to Hospice Service Area 3E results in the following computation
and outcome:
Subdistrict 3E Hospice Utilization
Current Utilization and Projected Need July 2013 Batching Cycle
Subdistrict 3E Provider
Under 65 with
Cancer
65+ with Cancer
Under 65 Non-
Cancer
65+ Non-Cancer
Total
Projected Hospice Patients 293 872 163 1,913 3,241
Cornerstone Hospice and Palliative Care 286 801 150 1,581 2,817
Unserved Hospice Patients 7 71 13 332 424
Net Need (if Unserved Hospice Patients > 350) 1 Source: CON application #10140, page 11.
The applicant notes that more than 81 percent of the projected unserved
hospice patients are in the non-cancer category, with 332 incremental
non-cancer related hospice admissions age 65+ that will not be admitted
by the existing provider.
Compassionate Care uses the 2010 Medicare claims data released by the
Centers for Medicare and Medicaid Services (CMS) to isolate
Cornerstone’s Lake and Sumter demographic and patient information.5
The applicant notes that this is not 100 percent of subdistrict patients
but it cites that 88 percent of Cornerstone’s CY 2011 admissions were
Medicare patients. Therefore, Compassionate Care maintains that this
data provides an accurate portrayal of Cornerstone’s overall utilization
and is used as the proxy for the organization’s operation in Subdistrict
3E.
The applicant indicates that according to Medicare data, Cornerstone
had 2,119 admissions with 1,834 deaths and 285 patients discharged
alive in calendar year 2010. Compassionate Care provides a comparison
between Cornerstone’s Medicare deaths and Lake and Sumter County
65+ deaths by disease category. The applicant notes that 1,860 elderly
persons in Hospice Service Area 3E died while not involved in hospice
service and 54 percent of those deaths were cardiac patients. See the
table below.
5 The applicant notes that the 2011 Hospice Annual Report published by the Department of Elder Affairs is reported on an aggregated basis. Cornerstone reports with its other programs in Hospice Service Areas 6B and 7B.
CON Action Numbers: 10140, 10141, 10142 and 10144
21
Hospice Service Area 3E Resident Deaths by Disease Category
Ages 65+ for Calendar Year 2010
Disease Category
3E Resident
Deaths Ages 65+
Cornerstone
Medicare Deaths
Deaths Not on Hospice
Percent of Deaths Not on
Hospice
Cardiac 1,219 214 1,005 54.0%
Respiratory 319 103 216 11.6%
Cancer 949 616 273 14.7%
Neurological 203 156 47 2.5%
Alzheimer’s 202 188 14 0.8%
Other/Diabetes/ Renal 802 497 305 16.4%
Total Deaths 3,694 1,834 1,860 100.0% Source: CON application #10140, page 13.
Compassionate Care contends that Cornerstone provides a
disproportionately low level of hospice care to cardiac patients compared
to all other disease cohorts. The applicant states that only 17.6 percent
of all of the subdistrict’s 65+ residents who died of cardiac disease in
calendar year 2010 were provided hospice care compared to 50 percent
of the total resident deaths 65+ who received hospice care.
Compassionate Care indicates that when cardiac cases are omitted from
the calculation, 66 percent of non-cardiac related 65+ deaths in Hospice
Service Area 3E were admitted to Cornerstone reflecting a 48 point
disparity between non-cardiac penetration and cardiac penetration rates.
See the table below.
Hospice Service Area 3E Resident Deaths and Hospice Penetration Rates by Disease
Category Ages 65+ for Calendar Year 2010
Disease Category
3E Resident Deaths
Ages 65+
Cornerstone
Medicare Deaths
Percent of Deaths Served by
Cornerstone Hospice
Cardiac 1,219 214 17.6%
Respiratory 319 103 32.3%
Cancer 949 676 71.2%
Neurological 203 156 76.8%
Alzheimer’s 202 188 93.1%
Other/Diabetes/ Renal 802 497 62.0%
Total Deaths 3,694 1,834 49.6%
Total Deaths Less Cardiac 2,475 1,620 65.5% Source: CON application #10140, page 13.
The applicant maintains that, had the 1,219 age 65+ residents who died
from cardiac disease accessed hospice at the overall non-cardiac
subdistrict penetration rate of 65.5 percent—there would have been 584
additional cardiac admissions to Cornerstone Hospice in calendar year
2010. See the table below.
CON Action Numbers: 10140, 10141, 10142 and 10144
22
Estimate of Cardiac Patients to be Served by Hospice
Based on the Non-Cardiac Penetration Rate Subdistrict 3E for Calendar Year 2010
Subdistrict 3E Cardiac Deaths, Age 65+ 1,219
Overall Non-Cardiac Subdistrict 3E Percent of Deaths Serviced by Hospice 65.5%
Number of Cardiac Death to be Served by Hospice if at 65.5% penetration 798
Actual Cardiac Deaths Served by Hospice 214
Incremental Cardiac Deaths that could be Served by Hospice 584 Source: CON application #10140, page 14.
Compassionate Care states that in terms of total cardiac deaths, Sumter
County’s cardiovascular deaths have increased nearly 20 percent and
Lake County’s nearly five percent between 2008 and 2010—an 8.2
percent increase for Hospice Service Area 3E. The applicant notes that
this is in contrast to the State of Florida for the same period of time
whose cardiovascular deaths declined 1.4 percent. See the table below.
Major Cardiovascular Related Deaths
Calendar Years 2008-2010 Service Area 2008 2009 2010
Lake County 1,016 1,045 1,064
Sumter County 306 317 366
Subdistrict 3E 1,322 1,362 1,430
State of Florida 54,107 53,351 53,330 Source: CON application #10140, pages 15-16.
The applicant cites 2009 joint recommendations from the American
Heart Association and the American College of Cardiology for patients
with refractory end stage heart failure that identifies “options for end-of-
life should be discussed with patient and family” as one of the guidelines
for the proper management of end stage heart disease. Based upon this
guideline, Compassionate Care Hospice developed its Cardiac
Connections Program to provide an option for end stage cardiac patients
and their families.
Compassionate Care asserts that end-stage heart disease patients
require hospice as urgently as patients with the most serious types of
cancer. A subset of cardio vascular disease is congestive heart failure
affecting 5.7 million people annually in the U.S. of which, between 75
and 80 percent are 65+. The applicant notes that heart failure is the #1
cause of hospitalizations for people 65+ accounting for 6.5 million
hospital days and $27.9 billion in total direct and indirect Medicare costs
each year.
CON Action Numbers: 10140, 10141, 10142 and 10144
23
The applicant cites a study that finds that cardiovascular disease
prevalence is projected to increase substantially between 2010 and
2030—by 25 percent.6 See the table below.
Projections of Crude Cardiovascular Diseases Prevalence by Percent
2010-2030 in the U.S. Year
All Cardiovascular
Disease
Hypertension
Coronary
Heart Disease
Heart
Failure
Stroke
2010 36.9 33.9 8 2.8 3.2
2015 37.8 34.8 8.3 3.0 3.4
2020 38.7 35.7 8.6 3.1 3.6
2025 39.7 36.5 8.9 3.3 3.8
2030 40.5 37.3 9.3 3.5 4.0
% Change 9.9% 9.9% 16.6% 25.0% 24.9% Source: CON application #10140, page 19.
Compassionate Care indicates that the mortality rate, at year one, is
higher for heart failure than other illnesses—approaching that of
pancreatic cancer. In addition, an estimated 65 percent of all hospital
admissions of patients age 65+ are diagnosed with heart failure
nationally with a 30-day rate of readmission of 24.8 percent for Medicare
patients. The applicant asserts that heart failure is the number one
reason for readmission in the Country with Lake/Sumter Counties being
no different.
The applicant states that between July 1, 2007 and June 30, 2010, the
four Lake and Sumter acute care hospitals had a weighted average
Medicare readmission rate for heart failure of 25.1 percent.
Compassionate Care presents each specific Medicare heart failure
readmission rate:
Leesburg Regional Medical Center: 26.6%
The Villages Regional Hospital: 25.5%
Florida Hospital Waterman: 21.5%
South Lake Hospital: 27.2%
Compassionate Care indicates that heart failure is the leading cause for
hospital readmissions and therefore the costliest to CMS. Currently CMS
penalizes all hospitals for any heart failure Medicare readmission within
30 days of discharge through claims denial or consolidating with primary
admission. Thomson Reuters estimates that the cost of each hospital
readmission is $5,000 to a hospital—a cost savings to CMS but a strain
to the hospital provider.
6 Forecasting the Future of Cardiovascular Disease in the United States: A Policy Statement from the
American Heart Association by Hendenreich; et.al., 2011.
CON Action Numbers: 10140, 10141, 10142 and 10144
24
The applicant states that the four acute care hospitals in Lake and
Sumter Counties readmitted 843 Medicare heart failure patients within
30 days of original discharge resulting in aggregated reimbursement loss
to these hospitals of $4.2 million dollars between July 1, 2007 and
June 30, 2010.7 See the table below.
Heart Failure Readmission Impact Lake and Sumter County Hospitals
Medicare Patients Discharged Between July 1, 2007-June 30, 2010 Heart Failure Patients
Leesburg Regional Medical Center
The Villages
Regional Hospital
Florida Hospital
Waterman
South Lake Hospital
Total Lake and Sumter
County Hospitals
Medicare Admissions 1,338 708 919 400 3,365
Rate of Readmission 26.6% 25.5% 21.5% 27.2% 25.1%
Readmissions 356 181 198 109 843
CMS Estimate per
Readmission
$5,000
Fiscal Implication $1,779,540 $902,700 $987,925 $544,000 $4,214,165 Source: CON application #10140, page 22.
Compassionate Care indicates that the Patient Protection and Affordable
Care Act will penalize up to one percent of all inpatient Medicare
payments starting in Federal Fiscal Year 2013 for all hospitals with
readmission rates exceeding the national average for heart failure, acute
myocardial infarction or pneumonia. The applicant contends that these
penalties could far exceed the current penalty/lost reimbursement of
$5,000 per patient.
The applicant states that CMS has estimated that the Cardiac
Connections Programs have saved $22,000 per patient admitted
resulting in a net saving to CMS of $24.2 million—the current 300
patients enrolled in the program will have a savings of $6.6 million. The
$22,000 savings is due to the fact that these patients are enrolled in end-
of-life care and treated throughout the rest of their days by hospice.
Compassionate Care asserts that this savings is not related to the
hospital claims denial discussed above.
Compassionate Care quantifies the specific savings for Lake and Sumter
Counties by stating that the estimated 165 Cardiac Connections Program
patients for the proposed program would equate to a $3,630,000 annual
savings to CMS as well as a $195,000 annual savings to the area
hospitals.
7 The applicant cites data published by the U.S. Department of Health and Human Services.
CON Action Numbers: 10140, 10141, 10142 and 10144
25
The applicant states that it was rated #1 (out of 53 cardiac hospice
programs) by CMS in November 2011 for its cardiac care and results.
Cardiac Connections is a heart failure home management program
serving patients and the medical community in recognizing the unique
needs of individuals suffering from advanced heart failure. The primary
goals of the Cardiac Connections program are as follows:
Break the cycle of emergency room visits and hospitalizations
Manage anxiety
Comfort the patient’s family
Improve the patient’s functional status
Alleviate dyspnea (shortness of breath)
Alleviate pain
Since inception in November 2009, Compassionate Care indicates that
Cardiac Connections has had (in aggregate) more than 1,100 patients
with 300 currently enrolled. The applicant notes that the readmission
rate of patients enrolled in the Cardiac Connections Program is only one
percent while nationally for heart failure it is 24.8 percent and 25.1 for
the four acute care hospitals in Lake and Sumter County.
Compassionate Care asserts that Cardiac Connections will help Lake and
Sumter County residents by providing clinical leadership team experts,
unmatched solutions and a specialized cardiac formulary. The Cardiac
Connections team are experts in end-stage heart disease and committed
to the proper management of these patients at the end-of-life.
The applicant states that Cardiac Connections program patients have an
average length of stay of 83 days, primarily are not inpatients, half use
continuous care occasionally (two days over the course of enrollment)
and only a small percent reside in nursing homes. Compassionate Care
presents the attributes that the proposed Cardiac Connection program in
Hospice Service Area 3E will have:
Clinical management of the patient will be overseen by an advanced
nurse practitioner who is cardiac certified—this person will visit the
patient one to two times per week and additionally as needed.
Patients will be evaluated by a cardiac nurse practitioner upon
admission.
The hospice physician, a cardiologist, will visit the patient at home
within one week of admission to the hospice program.
The physician appointed as medical director of Cardiac Connections
at Compassionate Care will be a board-certified cardiologist.
Each patient in the Cardiac Connections Program will be seen by a
home health aide for two hours a day, Monday through Friday.
Each patient will have a dietary consult from a registered dietician.
CON Action Numbers: 10140, 10141, 10142 and 10144
26
Each patient will be evaluated by a physical therapist.
Each patient will undergo a nutritional consult.
Holistic therapies to reduce patient’s anxiety and other symptoms
including massage and music therapy will be provided.
Compassionate Care Hospice staff will maintain daily contact to
monitor symptoms—all after-hour symptom calls will receive a
nursing visit.
Patient and family support will be readily available with social services
and pastoral care.
Every Cardiac Connections patient will receive a Cardiac Comfort Kit
to be kept in their place of residence in the case of emergency
containing specific medication. The Cardiac Comfort Kit is distributed
to every patient but has only been used in one percent of all Cardiac
Connections patients.
Compassionate Care notes that eight cardiologists from Lake and Sumter
Counties have indicated support for the proposed program, six explicitly
addressing the need for the Cardiac Connections program to
accommodate their terminally-ill cardiac patients. These cardiologists
are on staff at each of the four short-term acute care hospitals in Lake
and Sumter Counties.
The applicant asserts that in addition to the Cardiac Connections
program, it still will be a full-service hospice serving patients of all
diseases. Compassionate Care maintains that the existing provider in
Hospice Service Area 3E has lost its prior level of focus on reaching
cancer patients, consistent with its overall admission decline. See the
table below.
Cornerstone Hospice in Hospice Service Area 3E Cancer Admissions
Ages 65+ Calendar Year 2009-2011
2009 2010 2011 2009-2011
Cancer Admissions 904 810 801 ---
Percent Change from Prior Year --- (10.4%) (1.1%) (11.4%) Source: CON application #10140, page 30.
Compassionate Care states that it will provide care for all patients,
including cancers of all forms. The applicant states that its’ Pathways to
Compassion Program provides palliative care to both hospice patients
and to non-terminal, non-hospice patients. The goal is to provide
symptom relief and patient comfort during any state of illness with the
intent of improving quality of life for the patients and families.
Compassionate Care indicates that this program increasing hospice
penetration through a non-hospice option acting as a bridge to hospice
care since it can be offered before end-of-life care is absolutely necessary.
CON Action Numbers: 10140, 10141, 10142 and 10144
27
The applicant indicates that it was not able to undertake marketing or
referral development prior to licensure in Subdistrict 6B.8 Therefore, it
presents admissions and patient days for this start-up from July 2011 to
April 2012.9 The applicant notes that during this time it had an average
length of stay of 66 days. Compassionate Care envisions a similar
environment in Subdistrict 3E upon CON application #10140’s approval.
See the table below.
Compassionate Care Hospice Subdistrict 6B Program
Start-Up Utilization by Month Month Admissions Patient Days Average Daily Census
July 2011 12 619 20.0
August 2011 20 814 26.3
September 2011 15 943 31.4
October 2011 11 1,019 32.9
November 2011 16 1,089 36.3
December 2011 12 1,170 37.7
January 2012 13 1,078 34.8
February 2012 19 1,249 43.1
March 2012 14 1,143 36.9
April 2012 24 1,161 38.7
Total 156 10,285 33.7 Source: CON application #10140, page 34.
The applicant states that its organization has extensive experience in
providing hospice services in markets with specific needs whether the
need stems from a gap in disease specific care or a specific
demographic/environment. The parent believes that patients are entitled
to live as fully and as comfortably as possible and the hospice will
provide the special care and services that makes those choices possible.
Compassionate Care states that the parent provides a comprehensive
program, designed to support the patient and their family during a most
difficult time. It provides four levels of care: respite, general inpatient,
routine and continuous care. Care is provided based on the patient’s
individual needs by a highly skilled interdisciplinary team consisting of:
physicians, nurses, social worker, counselors, chaplains,
physical/occupational therapists, pharmacists, dieticians, home health
aides and volunteers.
The applicant indicates that it takes care of patients primarily in their
home—an individual’s home or apartment, a long-term care facility or
assisted living. Compassionate Care presents a list of programs it
provides including:
8 Compassionate Care states this was a stipulated condition to its settlement agreement with an existing provider. 9 This hospice program was licensed February 22, 2011.
CON Action Numbers: 10140, 10141, 10142 and 10144
28
First Night at Home
Cardiac Connections
Promise Program (end-stage renal disease program)
Pulmonary Connections Program
Veterans Outreach
Compassionate Care 4 Kids
Volunteer Services
Bereavement Services
Rainbows (bereavement support program for children)
Pathways to Compassion (palliative care program)
Transitions (community service program)
Massage Therapy
Music Therapy
Energetic Care
Sacred Spaces
Comfort Corners
Guided Imagery
Reminiscence Therapy
Pet Therapy
Aromatherapy
Reflexology
Hypnotherapy
The applicant notes that it will consider implementing a program to
provide palliative comfort and care to terminally-ill patients housed at
the Lake County Correction Facility in Clermont should there be a
proven gap in service for hospice care.
Compassionate Care states that Cornerstone, the sole existing provider,
has experienced a 3.4 percent decline in admissions in the past two
years in its three hospice service areas. See the table below.
Cornerstone Hospice Admissions Trend by Subdistrict
Calendar Years 2009-2011 Cornerstone Hospice
CY 2009
CY 2010
CY 2011
Percent Change
2010-2011
Percent Change
2009-2011
Subdistrict 3E 2,979 2,958 2,817 (4.8%) (5.4%)
Subdistrict 6B 697 806 771 (4.3%) 10.6%
Subdistrict 7B 689 638 663 3.9% (3.8%)
Total 4,365 4,402 4,251 (3.4%) (2.6%) Source: CON application #10140, page 55.
The applicant states that Cornerstone is a not-for-profit community
hospice that relies on charitable donations from the community to
supplement its services. In addition, Cornerstone owns and operates
four hospice houses in Hospice Service Area 3E. Compassionate Care
CON Action Numbers: 10140, 10141, 10142 and 10144
29
states that it is a for-profit corporation that has conditioned approval of
CON #10140 on the provisions that it will not participate in fundraising
activities in Subdistrict 3E and will not build or operate freestanding
hospice facilities.
Compassionate Care asserts that it is not seeking to compete with
Cornerstone for admissions; rather it is seeking to work collaboratively
with Cornerstone to ensure enhanced access to hospice care and reduce
the 424 person gap in admissions that exists in the planning horizon.
Compassionate Care’s organization has worked collaboratively with
Cornerstone in the past in Hospice Service Area 6B—the only subdistrict
where Cornerstone has demonstrated an increase in the past two years.
The applicant forecasts that it will have a positive impact on Lake and
Sumter Counties through increased market penetration, increased
consumer/facility education and expanding hospice opportunities for the
underserved population that have compromised access. The applicant
states that it will offer a choice in hospice providers to terminally-ill
residents of Hospice Service Area 3E while targeting the underserved
cardiac patients, cancer patients and others whom have been identified
as having barriers to hospice care.
Compassionate Care forecasts 157 admissions in year one and 366
admissions in year two. The applicant notes that its year two volumes
only represent 7.7 percent of the 4,753 subdistrict deaths forecasted for
the 12 months ending June 30, 2014. Compassionate Care maintains
that this will enable Cornerstone to grow and the applicant to meet the
defined needs of unserved patients.
The applicant indicates that as a small to midsize privately held for-profit
company it has the benefits of achieving economies of scale, but unlike
larger corporate chains it has extremely low overhead and is able to
respond quickly to community needs. The parent company of
Compassionate Care takes a decentralized approach to allow hospices to
act more autonomously unlike larger national chains, such as VITAS,
that are highly centralized.
Compassionate Care notes that it has a sister program in Hospice
Service Area 6B that is contiguous to the south of Hospice Service Area
3E. The applicant indicates that certain economies of scale can achieve
a seamless entry with these existing operations to the south.
CON Action Numbers: 10140, 10141, 10142 and 10144
30
Compassionate Care notes that two of the co-batched applicants are
without existing operations in the State of Florida, or even in the
southeast.10 The applicant provides the following summaries of each of
the competing co-batched applicants:11
Hospice of Marion County: a local not-for profit that has hospice
operations to the north of Lake and Sumter Counties. Its operating
model is strikingly similar to the existing Cornerstone. It relies on
local fundraising activity for its livelihood. Like Cornerstone, it
operates hospice houses and has freestanding inpatient hospice
facilities. If approved, it would directly compete with Cornerstone for
charitable contributions from within Lake and Sumter Counties and
would have comparable operations in terms of community and
strategy, therefore, not providing a different approach and unique
programs to reach the unserved patients.
Harbor Light Hospice of Florida: a subsidiary of Harbor Light
Hospice based out of Illinois.12 It has no existing or approved
operations in the State of Florida. Based on its website, Harbor Light
appears to be a for-profit company with operations in Illinois, Indiana,
Oregon and Virginia.13
VITAS Healthcare Corporation of Florida: is the country’s largest
hospice provider as well as Florida’s largest hospice provider, serving
16 Florida counties. VITAS is a significantly large company with
program manuals, corporate approach to meeting needs and national
standards. This is evidenced by VITAS’ Hospice Annual Reports
published by DOEA. In each market where it operates in the State of
Florida, VITAS consistently provides only 12-13 percent of its
admissions to patients with end stage heart disease. Compassionate
Care contends that its local community based approach to
programming differentiates it from VITAS and demonstrates that
Compassionate is the more appropriate applicant to meet the defined
need.
Harbor Light Hospice of Florida, Inc. (CON #10141) presents the
following information to document the system limitations and the
rationale that exists to support the proposed hospice program, including:
10 The reviewer notes that Passages Hospice of Central Florida, Inc. was administratively withdrawn on June 21, 2012. The reviewer also notes that Harbor Light Hospice does provide hospice services in Ellijay, Georgia; Dalton, Georgia; and Scottsboro, Alabama. 11 The reviewer did not include the summary regarding Passages Hospice of Central Florida, Inc. 12 Compassionate Care incorrectly identifies this entity as Harbor Lights Hospice of Florida. 13 Harbor Light Hospice has five separate entities providing hospice services in eight states: Virginia, Ohio, Georgia, Alabama, Indiana, Illinois, Nebraska and Oregon.
CON Action Numbers: 10140, 10141, 10142 and 10144
31
Population, Total and By Age Cohort
The applicant states that the 2012-2015 percentage increase in total
population in Hospice Service Area 3E (10.4 percent or 42,271) is well
above the growth rate projected for District 3 (7.5 percent or 122,576)
and more than double the growth rate projected for the State of Florida
(4.8 percent or 923,614). See the table below.
District 3 Projected Total Population Growth
By Hospice Service Area 2012-2015
Service Area
2012
2015
Absolute Change
Percent Change 2012-2015
3A 579,511 606,714 27,203 4.7%
3B 337,281 365,290 28,009 8.3%
3C 142,481 151,630 9,149 6.4%
3D 176,144 192,088 15,944 9.1%
3E 405,427 447,698 42,271 10.4%
District 3 Total 1,640,844 1,763,420 122,576 7.5%
State of Florida 19,128,190 20,015,804 923,614 4.8% Source: CON application #10141, page 31.
Harbor Light maintains that the 65+ population for Hospice Service Area
3E is projected to grow 13.8 percent (16,476), well above the growth rates
for District 3 at 11.7 percent (45,349) and the State of Florida at 9.5
percent (323,695). See the table below.
District 3 Projected 65+ Population Growth
By Hospice Service Area 2012-2015
Service Area
2012
2015
Absolute Change
Percent Change 2012-2015
3A 87,108 97,716 10,608 12.2%
3B 88,396 98,217 9,821 11.1%
3C 46,077 50,048 3,971 8.6%
3D 45,555 50,028 4,473 9.8%
3E 119,756 136,232 16,476 13.8%
District 3 Total 386,892 432,241 45,349 11.7%
State of Florida 3,425,139 3,748,834 323,695 9.5% Source: CON application #10141, page 33.
The applicant contends that when the population age 75 years and older
is considered, the greatest growth is also projected to occur within
Hospice Service Area 3E (15.5 percent or 7,739)—significantly above
District 3 (11.8 percent or 19,873) and more than double the rate
projected for the State of Florida (7.1 percent or 112,120). See the table
below.
CON Action Numbers: 10140, 10141, 10142 and 10144
32
District 3 Projected 75+ Population Growth
By Hospice Service Area 2012-2015
Service Area
2012
2015
Absolute Change
Percent Change 2012-2015
3A 36,634 40,214 3,580 9.8%
3B 39,628 44,098 4,470 11.3%
3C 21,168 23,322 2,154 10.2%
3D 21,650 23,580 1,930 8.9%
3E 49,912 57,651 7,739 15.5%
District 3 Total 168,992 188,865 19,873 11.8%
State of Florida 1,582,212 1,694,332 112,120 7.1% Source: CON application #10141, page 34.
Underserved Population: Hispanic Population
Harbor Light maintains that Lake and Sumter Counties are home to a
significant number of Hispanic persons, 11 percent of Lake and Sumter
County’s population were of Hispanic or Latino origin in calendar year
2010. See the table below.
Hispanic Population
Lake County, Sumter County and Florida 2010
Sumter Lake 3E Florida
Population, 2010 as per the US Census 93,420 297,052 390,472 18,801,310
Percent of Persons of Hispanic or Latino origin
as per the US Census
6.0%
12.1%
11%
22.5%
Number of Persons of Hispanic or Latino origin
as calculated by the applicant
5,605
35,943
41,548
4,230,295 Source: CON application #10141, page 35
The applicant cites 2010 Department of Elder Affairs data that indicates
that six percent of the hospice patients in Hospice Service Area 3E were
of Hispanic of Latino origin. Harbor Light states that this is far below the
11 percent of residents who are of Hispanic or Latino origin. Therefore,
the applicant concludes that it is clear that the Hispanic population
remains an underserved group for hospice services.
Harbor Light indicates that it has a specialized team that is currently
developing a program tailored to meet the needs of the Hispanic/Latino
community. The team is headed by Nicole Rosenbaum who holds a
Bachelor Degree in International Studies and Spanish and a Master’s of
Science Degree in Elementary ESL Education, both from the University of
Miami.
The reviewer notes that according to the Department of Health Office of
Vital Statistics Annual Report 2010, Deaths, there were 134 total resident
deaths of Hispanic origin in Lake and Sumter County in calendar year
2010. This represented 2.92 percent of deaths in all age groups in these
counties.
CON Action Numbers: 10140, 10141, 10142 and 10144
33
Underserved Population: Non-Cancer Patients
Harbor Light asserts that while it is committed to serving the entire
population of Hospice Service Area 3E, it specifically commits to serve
the underserved population of non-cancer patients in both the under 65
and 65+ age cohort. The applicant notes that despite the percent
utilization for non-cancer patients under the age of 65 equaling the state
average, Hospice Service Area 3E ranks 18th out of the 27 hospice service
areas. Harbor Light maintains that there is a clear indication that
improvement in hospice utilization for non-cancer patients under the age
of 65 is needed and achievable.
The applicant contends that there is a greater opportunity to serve the
needs of non-cancer patients over the age of 65 years. Hospice Service
Area 3E ranks 23rd out of the 27 hospice service areas—with only 61.9
percent of patients served, well below the state average of 69.2 percent.
Harbor Light indicates that it will have specialized programs to meet the
needs of specific patient groups, including:
Harbor Light’s Alzheimer’s Disease/Dementia Program
Harbor Light’s Cardiac Program
Harbor Light’s Skin Integrity/Wound Care Program
Special Needs Populations
The applicant states that it is dedicated to meeting the special needs of
Hospice Service Area 3E and has conditioned CON #10141 to that effect.
Harbor Light notes that there are an estimated 61,000 deaf and hearing
impaired individuals who live and work in Lake and Sumter County.14
The applicant commits to the development and implementation of
programs focused on improving access to hospice service by hearing
impaired and deaf persons in Hospice Service Area 3E. The program will
include training on communication differences, competencies and flexible
programming to meet the needs of the deaf and hearing impaired. In
addition, special community outreach efforts, clinical care protocols and
bereavement services for families will be implemented to increase deaf
and hearing impaired participation in hospice.
14 As estimated by the Deaf and Hearing Services of Lake and Sumter Counties, Inc.
CON Action Numbers: 10140, 10141, 10142 and 10144
34
Harbor Light also identifies veterans as a special needs population as
veterans comprise 29 percent of the Hospice Service Area 3E population
age 65+. See the table below.
Veterans Aged 65+
Hospice Service Area 3E By Gender
2010 Lake Sumter 3E
Men
Veterans, Age 65+ 20,158 11,676 31,834
Total 65+ Population 33,234 20,262 53,496
Percentage of Veterans 61% 58% 60%
Women
Veterans, Age 65+ 672 325 997
Total 65+ Population 38,805 20,344 59,149
Percentage of Veterans 2% 2% 2%
Total Men and Women
Veterans, Age 65+ 20,830 12,001 32,831
Total 65+ Population 72,039 40,606 112,645
Percentage of Veterans 29% 30% 29% Source: CON application #10141, page 28.
The applicant commits to participate in the We Honor Veterans program
and also commits to the hiring of veterans.15
Deaths Served by Hospice
Harbor Light indicates that while there was an increase in the number of
deaths in Hospice Service Area 3E, the number of deaths served by the
sole hospice provider has grown at a lower than expected rate when
compared to District 3 and the State of Florida hospice patient volumes.
The applicant states that Hospice Service Area 3E experienced the
greatest percent increase in the number of resident deaths (11.3 percent)
but with the lowest percentage increase in the number of patients served
by hospice (14.6 percent). See the table below.
15 We Honor Veterans is a program of the National Hospice and Palliative Care Organization in collaboration with the Department of Veterans Affairs inviting hospices, state hospice organizations, Hospice-Veteran partnerships and VA facilities to focus on respectful inquiry, compassionate listening and grateful acknowledgement.
CON Action Numbers: 10140, 10141, 10142 and 10144
35
Resident Deaths, Hospice Patients and Percentage of Patients Served by Hospice
Hospice Service Area 3E, District 3 and Florida 2006-2010
2006 2010 Absolute Change Percent Change
Hospice Service Area 3E
Deaths 4,120 4,585 465 11.3%
Hospice Patients 2,582 2,958 376 14.6%
% of Deaths Served by Hospice 63% 65%
District 3
Deaths 17,808 18,958 1,150 6.5%
Hospice Patients 10,170 12,800 2,630 25.9%
% of Deaths Served by Hospice 57% 68%
Florida
Deaths 169,365 172,509 3,144 1.9%
Hospice Patients 93,764 110,377 16,613 17.7%
% of Deaths Served by Hospice 55% 64%
Source: CON application #10141, page 54.
Hospice of Marion County, Inc. (CON #10142) identifies several key
factors that demonstrate that it is the best applicant to meet the needs of
Hospice Service Area 3E, including:
Not-for-profit status
Regional presence
Vision and commitment
Commitment to quality
Community support
Cost Savings
HMC asserts that it is committed to integrity, compassion,
communication, teamwork and stewardships to those it serves on a daily
basis. The applicant maintains that Hospice Service Area 3E will benefit
from quality initiatives and clinical protocols already established in
Subdistrict 3B to ensure that the highest quality of service will be
delivered.
The applicant notes the wide spectrum of letters of support, over 240,
from community residents and health care professionals. The reviewer
notes that the applicant had 231 unduplicated letters of support and one
unsigned email for its project, 146 are from or serve residents within
Hospice Service Area 3E. HMC states that the proposed program will
implement community education efforts, clinical care protocols and
bereavement services for families to increase participation in hospice for
groups traditionally underserved including Hispanics and Veterans.
The applicant states that it is a not-for-profit organization that has
provided high quality, efficient, patient-centered hospice services in
Marion County for nearly 30 years. HMC notes that Hospice Service
Area 3E shares many demographic characteristics with Marion County,
CON Action Numbers: 10140, 10141, 10142 and 10144
36
therefore many of the HMC’s current operations can be utilized as a
basis for the programs that will be offered to Lake and Sumter residents.
The applicant maintains that it has existing relationships in the market
and proposes to share its existing resources to maximize economies of
scale.
HMC indicates that there is growing concern among federal regulators
regarding the rapid increase in Medicare hospice expenditures. The
Medicare Payment Advisory Commission (MedPAC) made several findings
regarding this issue, including:16
Medicare spending for hospice care has increased dramatically in
recent years. This spending increase was driven by greater numbers
of beneficiaries electing hospice and by longer stays among hospice
patients with the longest stays.
The structure of Medicare’s hospice payment system makes very long
stays in hospice more profitable for providers than shorter stays.
The Office of Inspector General (OIG) recently completed a study on
hospices that rely heavily on nursing home patients finding that these
hospices are more likely to be for profit and to treat patients with
conditions with longer stays requiring less complex care. The OIG
recommended that CMS both monitor hospices that rely heavily on
nursing home patients and reduce payment rates for hospice services
provided in nursing homes.
The markedly longer stays among assisted living facility residents
(constituting about eight percent of hospice patients) compared with
nursing facility residents is not understood and bears further
monitoring and examination.
The applicant states that its proposed program best addresses the
concerns raised regarding unnecessary utilization of hospice services by
very long-stay patients. HMC is committed to serve all types of patients
requiring hospice care, not just those who are most profitable. The
applicant compares its caseload of hospice patients by setting for
calendar year 2011 with VITAS’ caseload by setting. The applicant
contends that VITAS has a greater focus on serving long-stay patients in
an institutional setting.
16 Medicare and the Health Care Delivery System Report to the Congress, MedPAC, June 2012.
CON Action Numbers: 10140, 10141, 10142 and 10144
37
Caseload of Hospice Patients by Setting
Hospice Marion County and VITAS Calendar Year 2011
Hospice
Home
Hospital
Hospice Res. Unit
FS IP Hospice Facility
Nursing Home
ACLF
Total
January to June 2011 (number of patients)
Hospice of
Marion County
233
0
0
35
55
61
384
VITAS 2,188 273 0 0 972 1,331 4,764
January to June 2011 (percent of patients)
Hospice of
Marion County
60.7%
0.0%
0.0%
9.1%
14.3%
15.9%
100.0%
VITAS 45.9% 5.7% 0.0% 0.0% 20.4% 27.9% 100.0%
July to December 2011 (number of patients)
Hospice of
Marion County
205
0
0
42
72
61
380
VITAS 2,556 273 0 0 1,023 1,331 5,183
July to December 2011 (percent of patients)
Hospice of
Marion County
53.9%
0.0%
0.0%
11.1%
18.9%
16.1%
100.0%
VITAS 49.3% 5.3% 0.0% 0.0% 19.7% 25.7% 100.0%
Source: CON application #10142, pages 77-78.
The applicant cites a 2011 Department of Elder Affairs Report that stated
that 41 percent of Florida hospice patients were located in nursing
homes or assisted living facilities. HMC indicates that it was below this
percentage while VITAS exceeded the statewide average in all semi-
annual periods in 2010 and 2011. The applicant asserts that the
implications of long-stay Medicare expenditures hold true for Florida’s
Medicaid program. Therefore, HMC concludes that the Medicaid budget
is negatively impacted by inappropriately admitting long-stay Medicaid
patients. However, the applicant’s tables are based on the Agency’s
semi-annual reports, which include one day snap shots, January 1 and
July 1 of calendar years 2010 and 2011. The Department of Elder
Affairs data is based on annual totals which would be more definitive.
HMC states that freestanding inpatient hospice facilities provide a
specialized and compassionate setting for end-of-life care and requires
expenditures over and above the expense of contracting an inpatient bed
in a nursing home or hospital. The applicant notes that while it
currently operates four freestanding hospice facilities, VITAS does not
offer freestanding inpatient hospice facilities in any of the subdistricts it
serves.
The applicant indicates that it will structure services geographically to
address the specific needs in each area of the two counties. HMC
presents demographic trends for Hospice Services Area 3E, including:
CON Action Numbers: 10140, 10141, 10142 and 10144
38
The total population of Subdistrict 3E is projected to increase by 16.7
percent between 2012 and 2017. The population age 65+ will
increase substantially faster (24.7 percent) over that period. The
applicant’s table below indicates that total population growth is 12.9
percent from 409,790 in 2012 to 462,736 in 2017. The age 65+
population is projected to increase from 114,358 in 2012 to 138,461
residents in 2017 or by 21.1 percent.
The percentage of 65+ residents in Subdistrict 3E is greater than
Florida overall, and this percentage is increasing.
The pediatric population is not increasing as rapidly as the elderly,
but they still represent an important component of the population
whose hospice needs must be addressed.
The percentage growth in Sumter County’s population between 2012
and 2017 is projected to be greater than that of Lake County,
although Lake County will experience higher absolute growth.
The greatest rates of growth will occur in southern Lake and northern
Sumter Counties.
Minorities are growing more rapidly than white residents of each
county. Hispanic residents, in particular, will represent a larger
percentage of the total population by 2017.
HMC indicates that the population of Hospice Service Area 3E is
projected to be 462,736 residents in 2017, a growth of 12.9 percent. The
applicant notes the 65+ population is growing significantly, leading to
greater demand for health care services including hospice. The applicant
maintains that the population growth anticipated in pediatric population
is of particular significance as well. See the table below.
Population by Age Cohort Hospice Service Area 3E
2012-2017 2012 2017 Percent Change
Under 21 85,389 97,479 14.2%
21-64 210,043 226,796 8.0%
65+ 114,358 138,461 21.1%
Total 409,790 462,736 12.9% Source: CON application #10142, page 82 based on ‘Claritas Marketplace’.
The applicant presents the sectional population of Lake and Sumter
Counties by race. HMC especially notes the growing African-American
and Asian populations in Lake County and the growing Asian population
in Sumter County. See the tables below.
CON Action Numbers: 10140, 10141, 10142 and 10144
39
Population by Race for Lake County
2012-2017 Ethnicity Southern Lake County Central Lake County Northern Lake County
2012
2017
% Change
2012
2017
% Change
2012
2017
% Change
African-American 20,205 26,105 29.2% 18,332 19,457 6.1% 4,968 5,270 6.1%
Native Americans 774 967 24.9% 730 875 19.9% 416 494 18.8%
Asians 6,404 9,489 48.2% 2,480 3,138 26.5% 647 807 24.7%
White Alone 117,339 129,657 10.5% 157,792 168,342 6.7% 49,463 51,285 24.7%
Native Hawaiian
Pacific Islander
178
259
45.5%
125
168
34.4%
18
18
0.0%
Some Other Race 10,236 14,260 39.3% 4,711 6,274 33.2% 2,200 2,740 24.5%
Two or More Races 5,653 7,853 38.9% 3,300 4,134 25.3% 1,220 1,468 20.3%
Total 160,789 188,590 17.3% 187,470 202,388 8.0% 58,932 62,082 5.3%
Source: CON application #10142, page 85.
Population by Race for Sumter County 2012-2017
Ethnicity Southern Sumter County Central Sumter County Northern Sumter County
2012
2017
% Change
2012
2017
% Change
2012
2017
% Change
African-American 622 459 -26.2% 1,772 1,812 2.3% 6,772 6,423 -5.2%
Native Americans 71 67 -5.6% 92 90 -2.2% 216 217 0.5%
Asians 36 46 27.8% 90 109 21.1% 636 916 40.6%
White Alone 7,324 8,356 14.1% 12,900 14,516 12.5% 70,683 87,925 24.4%
Native Hawaiian
Pacific Islander
7
7
0.0%
8
7
-12.5%
24
25
4.2%
Some Other Race 354 421 18.9% 596 754 26.5% 701 802 14.4%
Two or More Races 205 242 18.0% 317 382 20.5% 650 709 9.1%
Total 8,619 9,598 11.4% 15,775 17,670 12.0% 79,682 97,017 21.8%
Source: CON application #10142, page 87.
HMC defined the Hispanic population in Hospice Service Area 3E as an
underserved group because they traditionally use hospice care at a lower
rate than the general population. The reviewer notes that according to
the Department of Health Office of Vital Statistics Annual Report 2010,
Deaths, there were 134 total resident deaths of Hispanic origin in Lake
and Sumter County in calendar year 2010. This represented 2.92
percent of deaths in all age groups in these counties.
The applicant states that Lake County has a significant Hispanic
population of 57,007 (14.0 percent) in 2012 and projected to grow to
75,755 (16.9 percent) in 2017. HMC indicates that a majority of the
Hispanic population lives in southern Lake County. The applicant notes
that the Hispanic population accounts for a lower percentage of the total
population in Sumter County than Lake, with the majority residing in
northern Sumter. See the tables below.
CON Action Numbers: 10140, 10141, 10142 and 10144
40
Lake County Hispanic Population
2012-2017 Southern Lake Central Lake Northern Lake Total
2012 2017 2012 2017 2012 2017 2012 2017
Non-Hispanic 126,053 140,237 171,877 182,240 52,254 53,828 350,184 376,305
Hispanic 34,736 48,353 15,593 20,148 6,678 8,254 57,007 76,755
Total 160,789 188,590 187,470 20,388 58,932 62,082 407,191 453,060
Percent Hispanic 21.6% 25.6% 8.3% 10.0% 11.3% 13.3% 14.0% 16.9%
Source: CON application #10142, page 88.
Sumter County Hispanic Population 2012-2017
Southern Sumter Central Sumter Northern Sumter Total
2012 2017 2012 2017 2012 2017 2012 2017
Non-Hispanic 7,677 8,480 14,176 15,708 75,884 92,649 97,737 116,837
Hispanic 942 1,118 1,599 1,962 3,798 4,368 6,339 7,448
Total 8,619 9,598 15,775 17,670 79,682 97,017 104,076 124,285
Percent Hispanic 10.9% 11.6% 10.1% 11.1% 4.8% 4.5% 6.1% 6.0%
Source: CON application #10142, page 89.
HMC indicates that the Hispanic population is expected to grow over 33
percent in the Clermont area (southwest Lake County) an over 30
percent in the Leesburg area—where the applicant’s office will be located.
HMC contends that its proposed office location will be poised to serve
this growing demographic group. The applicant states that it will
increase utilization of hospice services among the Hispanic population by
addressing the unique language and cultural needs as well as expand its
existing Marion County programs to Hospice Service Area 3E.
Furthermore, HMC will develop community partnering programs to
ensure education on Hispanic beliefs and traditions along with education
and service to families. The applicant will employ bilingual, Spanish-
speaking staff and provide translated forms and literature.
The applicant states that the number of deaths in Subdistrict 3E has
grown over the past several years, but the increase has not been
consistent across all age groups. Subdistrict 3E total deaths increased
by 12.5 percent from 4,077 in 2005 to 4,585 in 2010. The total number
of deaths from all causes in the age 75 and over cohort grew from 2,434
in 2005 to 2,763 in 2010 (13.5 percent increase). HMC identifies an
increase in particular causes of death during this time period, including:
Chronic lower respiratory disease (increase of 24.3 percent), malignant
neoplasms (increase of 19.1 percent) and Alzheimer’s disease (increase of
15.1 percent). See the table below.
CON Action Numbers: 10140, 10141, 10142 and 10144
41
Trends in Deaths for Hospice Service Area 3E
2005-2010
Age Group
Cause of Death
2005
2006
2007
2008
2009
2010
Percent Change
2005-2010
Under
19
Cardiovascular Diseases 1 1 0 2 1 2 100.0%
Chronic Lower Respiratory Diseases 1 0 1 0 0 0 -100.0%
Human Immunodeficiency Virus 0 0 0 0 0 0 0.0%
Malignant Neoplasms 1 1 1 0 2 3 200.0%
Alzheimer’s Disease 0 0 0 0 0 0 0.0%
All Causes 55 43 68 50 48 43 -21.8%
20-44 Cardiovascular Diseases 25 18 19 19 28 21 -16.0%
Chronic Lower Respiratory Diseases 0 1 1 1 1 0 0.0%
Human Immunodeficiency Virus 5 4 5 8 8 2 -60.0%
Malignant Neoplasms 22 18 22 19 20 19 -13.6%
Alzheimer’s Disease 0 0 0 0 0 0 0.0%
All Causes 174 161 156 171 167 150 -13.8%
45-64 Cardiovascular Diseases 183 175 150 172 155 188 2.7%
Chronic Lower Respiratory Diseases 29 14 30 29 18 27 -6.9%
Human Immunodeficiency Virus 7 4 3 6 6 8 14.3%
Malignant Neoplasms 221 207 204 266 277 231 4.5%
Alzheimer’s Disease 2 0 1 3 0 0 -100.0%
All Causes 628 607 584 719 731 698 11.1%
65-74 Cardiovascular Diseases 244 225 217 196 235 239 -2.0%
Chronic Lower Respiratory Diseases 46 47 52 68 59 66 43.5%
Human Immunodeficiency Virus 0 0 1 0 2 0 0.0%
Malignant Neoplasms 289 333 339 312 369 400 38.4%
Alzheimer’s Disease 6 8 5 14 11 16 166.7%
All Causes 786 799 806 817 892 931 18.4%
75+ Cardiovascular Diseases 1,042 1,000 909 933 943 980 -6.0%
Chronic Lower Respiratory Diseases 134 127 140 174 176 168 25.4%
Human Immunodeficiency Virus 0 0 1 0 0 0 0.0%
Malignant Neoplasms 461 518 468 513 567 549 19.1%
Alzheimer’s Disease 161 180 159 166 159 186 15.5%
All Causes 2,434 2,510 2,406 2,561 2,625 2,763 13.5%
All
Ages
Cardiovascular Diseases 1,495 1,419 1,295 1,322 1,362 1,430 -4.3%
Chronic Lower Respiratory Diseases 210 189 224 272 254 261 24.3%
Human Immunodeficiency Virus 12 8 10 14 16 10 -16.7%
Malignant Neoplasms 994 1,077 1,034 1,110 1,235 1,202 20.9%
Alzheimer’s Disease 169 188 165 183 170 202 19.5%
All Causes 4,077 4,120 4,020 4,318 4,463 4,585 12.5%
Source: CON application #10142, page 94.
HMC contends that it is uniquely qualified to serve patients suffering
from chronic lower respiratory diseases as it offers the Inspirations
program specifically designed to care for patients suffering from chronic
lower respiratory diseases through all stages of the disease process. This
program offers specialized services, such as a specialized plan of care,
specially trained nursing teams, nurses on call 24 hours a day,
Telehealth, nutrition consultants, patient and caregiver education and
psycho-social support among other services. The applicant states that it
also has a specialized program to serve Alzheimer’s disease patients
called the Reflections program that offers services such as a specialized
plan of care coordinated with patient’s physician, nursing teams specially
trained in dementia care, nurses on call 24 hours a day, medications and
medical equipment specific for dementia patients, patient and caregiver
education and psycho-social support among other services.
CON Action Numbers: 10140, 10141, 10142 and 10144
42
The applicant notes that while parts of Lake and Sumter Counties are
experiencing rapid population growth, it will reach out to the more rural
areas of the district as these populations often lack knowledge of the
benefits of hospice care. HMC indicates that it will ensure the rural
portions of Hospice Service Area 3E are addressed through outreach and
education efforts.
HMC states that in 2010, 45.8 percent of white Medicare decedents
utilized hospice services while only 37 percent of Hispanic and 34
percent of African-American Medicare decedents utilized services during
that time. Asian Americans Medicare decedents have the lowest
utilization at 28.1 percent. The applicant states that such utilization
trends suggest that the cultural, religious and philosophical differences
are prevalent and may impact the rate of hospice use. The reviewer
notes that the Department of Health Office of Vital Statistics Annual Report
2010, Deaths, indicates there were 134 total resident deaths of Hispanic
origin in Lake and Sumter Counties in calendar year 2010. This
represented 2.92 percent of deaths in all age groups in these counties.
African-Americans accounted for 245 total resident deaths, or 5.32
percent of deaths in all age groups in these counties.
The applicant states that Hospice Service Area 3E ranks 17th lowest
among the 27 subdistricts in the number of hospice admissions to
reported deaths (a/k/a the hospice penetration rate). HMC notes that
the penetration rate dropped from 66.73 percent in CY 2009 to 64.51
percent in CY 2010. The applicant maintains that there is clearly
potential in Hospice Service Area 3E to increase hospice penetration
rates through greater patient education, outreach to referral sources and
enhancing availability to underserved groups. HMC asserts that
approval of the proposed program will facilitate an increase in hospice
penetration rate with a focus on patients who are appropriate for such
care rather than those who will generate the greatest profitability.
HMC states that it currently serves all age categories and is well suited to
serve the age 65+ population. The applicant indicates that it has a track
record of serving all ethnic groups and cultures and that this sensitivity
to cultural differences will be brought to the residents of Hospice Service
Area 3E. The applicant provides its 2010 admission by age and
race/ethnicity. See the table below.
CON Action Numbers: 10140, 10141, 10142 and 10144
43
HMC Admissions by Age and Race/Ethnicity
CY 2010
Age Group # of
Patients Percent of Admissions
Race/ Ethnicity
# of Patients
Percent of Admissions
Under 19 2 0.07% White 2,629 91.28%
19-64 336 11.67% Black 173 6.01%
65+ 2,542 88.26% Hispanic 64 2.22%
Total
2,880 Admissions
Other 11 0.38%
Asian 3 0.10%
Total 2,880 Source: CON application #10142, page 103.
The applicant maintains that its admissions grew 6.9 percent between
2009 and 2011—despite Odyssey’s new hospice program in the district.
HMC states that this historical trend indicates that it is able to compete
with new providers and can positively affect future hospice utilization.
See the table below.
Historical Admissions by Provider in Marion County
Year Hospice of Marion County Odyssey Hospice Total
2009 2,535 Not yet operational 2,535
2010 2,731 185 2,916
2011 2,709 208 2,917 Source: CON application #10142, page 104.
HMC states that it has consistently demonstrated its ability to grow
hospice penetration rates in Marion County. In 2004, Marion County’s
penetration rate was 50.5 percent; by 2010 it had grown to 67.9 percent.
The applicant asserts that this increase was directly due to its efforts to
increase community awareness of hospice and to offer innovative
programs to address the diverse needs of the county’s residents. HMC
notes that Hospice Service Area 3E only grew 7.3 percent during this
same time period. However, Marion County did not reach 62 percent of
deaths to hospice admits until 2009 when a new provider entered the
market, while Service Area 3E has consistently averaged over 62 percent
since 2006. See the table below.
Hospice Penetration Rates in Marion, Lake and Sumter Counties
2004-2004 Service
Area
2004
2005
2006
2007
2008
2009
2010 Percent Change
3B Resident Deaths 3,832 3,897 3,990 3,923 4,147 4,077 4,292 --
Hospice Admissions 1,937 1,970 2,233 2,236 2,485 2,535 2,916 --
Percent of Deaths
Served
50.5%
50.6%
56.0%
57.0%
59.9%
62.2%
67.9%
17.4%
3E Resident Deaths 3,783 4,077 4,120 4,020 4,318 4,464 4,585 --
Hospice Admissions 2,164 2,387 2,582 2,673 2,875 2,979 2,958 --
Percent of Deaths
Served
57.2%
58.5%
62.7%
66.5%
66.6%
66.7%
64.5%
7.3%
Source: CON application #10142, page 105.
CON Action Numbers: 10140, 10141, 10142 and 10144
44
HMC provides projected utilization of the proposed program based on the
following assumptions:
The actual 2010 death rates by age and disease category for
Subdistrict 3E were applied to the estimated population for 2011 and
projected population for 2013, 2014 and 2015 to project deaths. This
rate was held constant throughout the projection period.
These projected deaths were used to determine the estimated and
projected penetration rates. The estimated 2011 penetration rate
showed a significant drop from 2010.
The projected penetration rates are applied to projected deaths to
yield the total projected hospice admissions from 2013-2015.
The projected penetration rates were based on the actual penetration
rates, by age and disease category for the State of Florida and Marion
County. Rates were projected to increase to a similar level to that
achieved by Marion County and the State of Florida in 2010.
Subdistrict 3E’s penetration rate is projected to reach the state’s 2010
rate in 2015.
Projected market shares were applied to the projected total hospice
admissions to calculate the number of admissions by category and
age that HMC would serve. Rates are generally based on the
experience of other hospices in Florida and Odyssey Hospice in
Subdistrict 3B. These market shares reflect the applicant’s ramp up
period and year two’s market share is reflective of the impact the
provider will make in the Subdistrict 3E market. HMC’s market share
projections are very reasonable for a hospice provider with the depth
of experience, community education and outreach programs, quality
services and existing relationship HMC has in the proposed service
area.
The assumed average lengths of stay were multiplied by the projected
admissions to determine the projected patient days. The average
lengths of stay are expected to be 40 days in year one and 52 days in
year two. The lengths of stay assumptions give effect to the start-up
of operations in year one and year two.
CON Action Numbers: 10140, 10141, 10142 and 10144
45
Projected Utilization for HMC
Subdistrict 3E Year One and Year Two
Projected
2,013 2,014
Hospice Admissions Year One Year Two
Cancer Under 65 209 229
Cancer 65+ 528 577
Non-Cancer Under 65 573 627
Non-Cancer 65+ 1,800 1,969
Total 3,111 3,403
Incremental Growth
Hospice Admissions 2011 to Year One 2011 to Year Two
Total 294 586
Projected
Market Shares 5.75% 9.00%
Admissions by HMC in Subdistrict 3E
Cancer Under 65 12 21
Cancer 65+ 30 52
Non-Cancer Under 65 33 56
Non-Cancer 65+ 104 177
Total 179 306
Average Length of Stay 40 52.1
Projected Patient Days 7,160 15,943
Average Daily Census 19.62 43.68
Source: CON application #10142, page 108.
The applicant presents the expected distribution of projected patient
days by level of care provided reflecting HMC’s commitment to maintain
patients in their homes to the greatest extent possible. See the table
below.
Projection of Patient Days by Level of Care
Year One Year Two
Routine Home Care 6,630 14,763
Continuous Home Care 379 845
Inpatient Respite Care 129 287
General Inpatient Care 22 49
Total 7,160 15,943 Source: CON application #10142, page 109.
HMC states that it will be able to achieve its projected utilization without
any material impact on the existing hospice provider because it will serve
a number of hospice patients that will reduce the incremental need
shown in the Agency for Health Care Administration’s need methodology.
The applicant provides additional factors that support the conclusion
that the existing provider will not be adversely affected, including:
HMC intends to enter Subdistrict 3E with the same dedication to
meeting the broad needs of the community as it currently has in
Subdistrict 3B, which will result in an increasing the hospice
penetration rate. To the extent that the penetration rates are higher
than projected, there will be an even greater number of hospice
patients to be shared by the existing provider and HMC.
CON Action Numbers: 10140, 10141, 10142 and 10144
46
HMC will bring new programs and approaches to meeting the hospice
needs of Subdistrict 3E. The special needs populations the applicant
has targeted may choose hospice care in larger numbers, contributing
to the higher penetration rate.
HMC will provide services that are not currently adequately provided
by the existing Subdistrict 3E hospice provider. By doing this, HMC
services will offer local residents an alternative by increasing the
awareness and participation in the hospice programs.
VITAS Healthcare Corporation of Florida (CON #10144) provides a
summary of the Agency need calculation for Subdistrict 3E. The
applicant maintains that the Agency need for an additional hospice does
not indicate any current patients are not being served, but that the
planning area can support an additional provider with a number of
admissions sufficient to provide a high quality program without reducing
current admissions to existing hospices as a group. See the table below.
Agency for Health Care Administration Need Calculation
Subdistrict 3E Under 65
(Cancer diagnosis)
65+ (Cancer diagnosis)
Under 65 (non-cancer diagnosis)
65+ (non-cancer
diagnosis)
Total
Cornerstone Hospice Total** 431 1,208 226 2,386 4,251
Percentage Mix 10.1% 28.4% 5.3% 56.1% 100.0%
Cornerstone Hospice 3E Estimate 286 800 150 1,581 2,817
Projected Deaths 7/13-6/14 314 908 721 2,810 4,753
Statewide Use Rate 2011 0.934 0.960 0.226 0.681 0.658
Projected Need 7/13-6/14 293 872 163 1,913 3,241
Current Utilization 2011 286 800 150 1,581 2,817
Projected Hospice Need 7/13-6/14 293 872 163 1,913 3,241
Net Need 7 72 13 332 424 ** Also serves an adjacent service area. Therefore, Cornerstone Hospice admissions have been interpolated solely for
Subdistrict 3E by applying percent mix of admissions by age and disease status to total subdistrict admissions for
this hospice.
Source: CON application #10144, page 13.
The applicant contends that there is a need for a second hospice in
Subdistrict 3E as residents currently do not have a choice of hospice
providers. Approval of the proposed program, VHCF asserts, will result
in choice for patients and healthy competition between VHCF and
Cornerstone.
VHCF indicates that Cornerstone Hospice & Palliative Care is well
established with deep roots and well-established referral relationships.
The applicant states that not every new hospice is successful against
entrenched existing providers citing disappointing start-ups including:
Odyssey in Subdistrict 3B, Regency in District 1, Compassionate Care in
Subdistrict 6B, Heartland in Subdistrict 4A and Catholic in District 10.
VHCF states that these hospice programs are not effective competitors.
CON Action Numbers: 10140, 10141, 10142 and 10144
47
The applicant indicates that an approved applicant must have the
resources and demonstrated ability to create a successful new hospice.
VHCF contends that there have only been two effective competitors with
admission volumes that meet or exceed the projections in the
applications—VITAS in Subdistrict 8B (licensed May 2008) and VITAS in
Subdistrict 4A (licensed May 2011). See the table below.
Projected and Actual Admissions in First Two Years of Operation
Florida Hospice Programs Hospice
Subdistrict
Projected Actual Difference
Yr 1 Yr 2 Q1-Q4* Q5-Q8 Yr 1 Yr 2
Hospice of Citrus County 3A 234 544 85 258 (149) (286)
Heartland 4A 156 276 106 95 (50) (181)
Catholic Hospice 10 457 495 119 318 (338) (177)
VHCF 8B 186 354 183 406 (3) 52
Haven/N. Central Florida
Hospice
4B
140
250
108
108
(32)
(142)
Regency 1 242 496 78 184 (164) (312)
Odyssey 3B 285 405 185 208 (100) (197)
Compassionate Care
Hospice
6B
275
415
148
NA
(127)
--
HCR Manor/Heartland 11 321 437 99 NA (222) --
VHCF 4A 162 297 302 NA 140 --
Hospice of Palm Beach
County
10
250
570
NA
NA
--
--
Memorial Flagler
Hospital/Florida Hospital
Hospice Care
7B
280
410
NA
NA
--
-- *It should be noted that the applicant began with the quarter after a hospice was licensed to estimate the
number of admissions for the first two years of operation.
Source: CON application #10144, page 15.
VHCF contends that it is significant to know how quickly the approved
applicant will be licensed and in operation—the Agency should be
mindful how quickly the applicant it approves will actually offer services.
The applicant states that the average time from CON approval to
licensure for the two VHCF hospices was 34 days while Compassionate
Care Hospice delayed licensing for over 15 months in 6B. VHCF has
scheduled licensure in the month after it receives final approval—actual
experience shows that this goal can be achieved.
The applicant analyzed the unmet needs in Subdistrict 3E using the
Hospice Standard Analytical File (SAF) and the Denominator File, making
the necessary adjustments to restrict the analysis to the 65+ population
(constituting over 95 percent of the unmet need in the subdistrict).17
Based on this data, VHCF made the following findings on need:
17 The SAF and the Denominator File are both published annually by the Centers for Medicare and Medicaid Services. The full analysis is provided by the applicant in Tab 13 of CON application #10144.
CON Action Numbers: 10140, 10141, 10142 and 10144
48
Patients with non-cancer diagnoses in the subdistrict have a lower
Medicare hospice admission rate (49.93 percent) than the state
average (57.47 percent). This confirms the Agency data showing the
largest need is in the 65+ non-cancer subgroup.
Only 49.8 percent of Sumter County’s 2010 Medicare beneficiaries’
deaths were admitted to hospice care in 2010. This number is below
the subdistrict’s admission rate and far below Florida’s Medicare
hospice admission rate of 64.6 percent. While both counties are
underserved, the population is greater in Sumter County.
African-American patients in the subdistrict have a lower hospice
admission rate than the state average, with African-American
experiencing a 48.3 percent admission rate in 3E and a 52.5 percent
admission rate statewide.
Hispanic patients in the subdistrict have a hospice admission rate
very close to the state average for Hispanics. Hispanics do not appear
to be an underserved group in the subdistrict.
According to July 1, 2011 census data collected by AHCA, the existing
hospice in Subdistrict 3E served 30 percent of its total patients in
nursing homes or assisted living facilities. This percentage is lower
than the average Florida percentage of 42 percent, and illustrates the
need for a hospice experienced in providing care to patients in nursing
homes or assisted living facilities. On the same date VHCF hospices,
combined, were serving 46 percent of their patients in nursing homes
or assisted living facilities, demonstrating VHCF’s ability to serve
these patients.
VHCF states that for several decades there has been no competitive
pressure on Cornerstone to improve its outreach to underserved groups
or to increase its responsiveness to its patients. The applicant maintains
that approval of proposed program will create both choice and
competitive pressure—benefitting the residents of the subdistrict.
The applicant indicates that it will bring new resources for community
education and benefit the residents of Subdistrict 3E by raising the
admission rate. VHCF and VITAS state that it has developed programs
to better reach African-Americans and patients with non-cancer
diagnoses. The applicant also maintains that it has proven its ability to
reach patients in nursing homes—creating programs and training to
meet the needs of patients in these facilities. These underserved sub-
population groups fit within the specialized programs offered by VHCF
and will be served by the proposed program.
CON Action Numbers: 10140, 10141, 10142 and 10144
49
VHCF states that the initial office of the proposed program will be located
in the Leesburg, Florida area. The applicant chose this location based on
the functions of the office and on an analysis of population distribution,
the road network and the location of long-term care facilities. This office
will be able to efficiently serve the large number of deaths in Lake County
while also reaching underserved patients in Sumter County. The
applicant will open and staff an office in Sumter County by the end of the
first year of operations.
The applicant indicates that 55 percent of the subdistrict’s Medicare
patient deaths in calendar year 2010 received hospice services, well
below the state average of 64.6 percent for patients 65+. VHCF
maintains that not serving as many terminally ill elderly residents in a
hospice program increases the costs borne by the health care system.
The applicant asserts that it will reach out to underserved population
groups and increase market penetration as it has in other Florida
markets. VHCF contends that its contribution to increasing admission
rates in the subdistricts it currently serves illustrates its ability to
increase awareness of hospice and provide hospice care to the
community. See the table below.
Hospice Admission Rates in VHCF Subdistricts
Calendar Year 2005-2010 Subdistrict CY 2005 CY 2006 CY 2007 CY 2008 CY 2009 CY 2010
4A VITAS Opened in 2011
4B 53% 57% 61% 66% 70% 70%
7A 55% 58% 60% 63% 64% 67%
7B 51% 55% 60% 60% 63% 61%
7C 46% 52% 56% 58% 58% 58%
8B VITAS Opened in 2008 56% 62% 70%
9C 62% 67% 67% 70% 70% 72%
10 55% 55% 57% 56% 58% 58%
11 40% 41% 44% 46% 50% 53%
Total 51% 53% 56% 57% 60% 61% Source: CON application #10144, page 20.
VHCF maintains that statistics document a shortcoming of the existing
hospice to effectively reach the African-American community in the
subdistrict. One explanation for this may be the relatively small size of
this community in the subdistrict—the African-American age 65+
population in the subdistrict in 2010 was 3,550. VHCF asserts that it is
willing to make the special commitment to reach a small community
within the total elderly population.
VITAS works with many African-American professionals, religious and
civic organizations to increase African-American access to hospice care—
including working with Bethune-Cookman University’s nursing program
to support opportunities for end of life care education for advanced
CON Action Numbers: 10140, 10141, 10142 and 10144
50
nursing students. VITAS also created a community liaison position to
serve as a community educator and hospice advocate to promote
relationships with key members of their respective communities. The
applicant indicates that these positions are essential in furthering
VITAS’s commitment to bring quality hospice care to diverse and
underserved communities.
The applicant maintains that it does a better job of working with the
African-American community than Cornerstone Hospice and Hospice of
Marion County. VHCF supplied a summary of the percentage of
admissions it, Cornerstone Hospice and Hospice of Marion County
provided to African-American patients in 2010 and the percentage of
areas residents ages 65+ that were African-American. See the table
below.
Percent of African-American Residents and Hospice Patients by Provider
Calendar Year 2010 Hospice Hospice % Resident % Percent Difference
Cornerstone 4.60% 7.70% -40.3%
VHCF 10.06% 8.66% 16.1%
Hospice of Marion County 5.86% 5.64% 4.1% Source: CON application #10144, page 23.
Upon approval of this application, VHCF will develop an aggressive and
effective outreach program to the African-American community in both of
Subdistrict 3E’s counties. The outreach program will utilize the written
materials, community liaison positions and other techniques that have
proven effective in areas VHCF currently serves.
VHCF and VITAS have specialized programs, that have proved effective
elsewhere, for specific disease categories which will be implemented in
Subdistrict 3E including18:
Chronic Obstructive Pulmonary Disease (COPD)
Alzheimer’s
Heart Disease
Diabetes
Admission rates for non-cancer patients of all ages, especially non-cancer
patients 65+ are far below expectations. According to the applicant,
Agency for Health Care Administration data shows 78.3 percent of the
growth in demand in Subdistrict 3E is generated by non-cancer patients
65+. VHCF states that it has proven success with non-cancer patients.
18 The applicant provides sample educational material for specific disease categories in TAB 19.
CON Action Numbers: 10140, 10141, 10142 and 10144
51
The applicant maintains that it is programmatically superior in
educating the community and generating referrals of terminally ill non-
cancer patients with a long history of operational experience in serving
this group. See the table below.
Hospice Experience with Non-Cancer Patients
2009 2010 2011
Existing Subdistrict 3E providers 58.9% 63.3% 61.4%
VHCF Florida Hospices 67.9% 68.9% 69.4%
State of Florida 64.5% 65.3% 65.6% Source: CON application #10144, page 24.
The applicant analyzed the causes of death by studying the subdistrict
death rate with a focus on terminal rather than sudden causes and has
identified several disease categories that have need and are underserved.
See the table below.
Office of Vital Statistics--Death by Cause
Calendar Year 2008-2010 Subdistrict 3E
Cause
2008
Percent of Total
2009
Percent of Total
2010
Percent of Total
Cancer 838 19.4% 940 21.1% 897 19.6%
Diabetes 142 3.3% 120 2.7% 146 3.2%
Cardiovascular 1,086 25.2% 1,116 25.0% 1,161 25.3%
COPD/Respiratory 214 5.0% 200 4.5% 200 4.4%
Alzheimer 343 7.9% 324 7.3% 398 8.7%
Chronic Liver 42 1.0% 50 1.1% 47 1.0%
Pneumonia & Influenza 45 1.0% 41 0.9% 39 0.9%
Stroke 186 4.3% 191 4.3% 193 4.2%
Renal Failure 50 1.2% 59 1.3% 44 1.0%
HIV/AIDS 22 0.5% 15 0.3% 17 0.4%
Other 1,350 31.2% 1,408 31.5% 1,443 31.4%
Total 4,318 100.0% 4,464 100.0% 4,585 100.0% Source: CON application #10144, page 25.
VHCF cites that cardiovascular disease represents 25 percent of all
deaths in Subdistrict 3E—more than cancer’s 20 percent. The applicant
maintains that it has a proven history of providing quality care to
patients with cardiovascular disease and heart failure. VHCF states that
patients with cardiovascular disease require special hospice care that is
not being provided by Cornerstone, as attested in the excerpted letter
below:
“The resources for hospice in Lake County are currently very limited. The
one provider in Lake County has not been able to manage the needs of my
advanced heart failure patients…”
--Sita Price, Heart Failure Program Coordinator, ORMC,
Orlando Heart Institute.
CON Action Numbers: 10140, 10141, 10142 and 10144
52
The applicant states that it will develop programs identifying those with
heart disease, Alzheimer’s disease, stroke and pulmonary conditions. In
addition, VHCF will accept as a condition on CON application #10144
that at least 65 percent of patients admitted will have non-cancer
diagnoses.
VHCF notes that patients 65+ with non-cancer diagnoses are sometimes
in nursing homes when hospice services commence and that it has
successfully worked with nursing homes throughout Florida to provide
hospice services to its patients. According to July 1, 2011, census data
collected by the Agency for Health Care Administration, the existing
hospice in Subdistrict 3E served 30 percent of its total patients in
nursing homes or assisted living facilities, well below the state average of
42 percent. However, the applicant’s data is based on the Agency’s semi-
annual reports, which include one day snap shots, January 1 and July 1
of calendar years 2010 and 2011. The Department of Elder Affairs data
is based on annual totals which would be more definitive.
The applicant states that this shortfall in nursing home patients may
reflect a lack of outreach or it may reflect a perceived competitor to
nursing homes in the form of Cornerstone’s four hospice residences.
VHCF indicates that it can work effectively with nursing homes in the
Subdistrict.19
VHCF maintains that it is the best able applicant to establish a
successful hospice program in Subdistrict 3E. The applicant asserts that
it is committed to serving all patients, providing 19,900 days of charity
care in 2011. The applicant states that it has the experience,
management resources and financial resources to assure a rapid and
successful start-up in Subdistrict 3E.
VHCF provides the highest percentage of continuous care days of any
applicant, ensuring that patients are able to be treated where they
reside. See the table below.
Continuous Care Days Calendar Year 2010
Provider
Total Days
Continuous Care Days
Percent Continuous Care
Compassionate Care (Nationwide) 907,850 3,492 0.4%
Hospice of Marion County 147,293 1,706 1.2%
Harbor Light Hospice (Nationwide) 294,626 9 0.0%
VHCF (Statewide) 1,767,091 108,301 6.1% Source: CON application #10144, page 31.
19 The applicant includes examples of training documentation in Tab 20 of CON application #10144.
CON Action Numbers: 10140, 10141, 10142 and 10144
53
The applicant contends that of the competing applicants, only it has a
track record of successfully expanding its services to additional Florida
counties. VHCF gives several reasons why it is the applicant best
equipped to quickly establish a successful hospice program in
Subdistrict 3E, these include:
Compassionate Care Hospice waited 476 days to become licensed
after receiving final AHCA approval.
Compassionate Care Hospice’s admissions are running below
projections.
Hospice of Marion County is very similar to Cornerstone in its
approach to hospice services, thereby not much of an alternative.
Both Cornerstone and Hospice of Marion County provide little
continuous care and develop an extensive network of hospice houses.
Hospice of Marion County already markets its hospice residences to
residents in Lake and Sumter County.
Hospice of Marion County does not offer any community hospice
services or palliative care services that VHCF does not currently
provide.
Harbor Light Hospice has no experience in Florida or adjacent
states.20 As the focus of its organization is in the Midwest,
establishing a hospice in Florida is a major geographic and cultural
leap.
VHCF provides several factors why it has been more successful in
creating new hospice programs in Florida, including:
VHCF began providing hospice services in Florida more than 30 years
ago. It has well-known referral sources throughout the state with an
excellent reputation. VHCF’s quality and patient satisfaction is the
reason for its reputation.
Since it has a long history in Florida, VHCF understands the states
many ethnic, cultural and religious communities, how to connect with
these communities and how to adapt hospice service to their specific
needs and desires.
VHCF knows how to work closely with local community groups,
government agencies, colleges and charities and to quickly be
recognized as a contributing member of the local community.
20 Harbor Light Hospice does provide hospice services in Ellijay, Georgia; Dalton, Georgia; and Scottsboro, Alabama.
CON Action Numbers: 10140, 10141, 10142 and 10144
54
VITAS has created 26 new hospices since 2001—with the human,
financial and organizational resources as well as the experience to
quickly establish new programs to make them successful.
VITAS is widely recognized for its hospice leadership at the state and
national levels. Director level positions are held by VITAS
professionals at the Florida Hospice and Palliative Care Association
and the National Hospice and Palliative Care Organization.
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.
Each applicant is responding to published need for an additional
hospice program for the July 2011 planning horizon.
Each applicant discusses serving populations they believe to be
underserved.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140) states that it is committed to meeting the needs of
all patients and their families in need of end-of-life care in Lake
and Sumter Counties. The applicant maintains that based upon
the Agency for Health Care Administration’s Florida Need
Projections for Hospice Programs, all age groups and all diagnoses
for hospice service in Hospice Service Area 3E are underserved. In
addition, Compassionate Care identified terminally-ill resident with
end stage cardiovascular disease as an underserved patient
population. The applicant indicates that its strategy and initial
plan for enhancing accessibility to hospice amongst all these
groups is provided in response to Question 1.
Harbor Light Hospice of Florida, Inc. (CON #10141) maintains
that it is committed to serving the entire population of Hospice
Service Area 3E, but specifically commits to serve the populations
with unmet needs. The applicant identified the following
populations as underserved:
CON Action Numbers: 10140, 10141, 10142 and 10144
55
Non-cancer patients under the age of 65 years
Non-cancer patients 65+
Hispanic/Latino community
The applicant notes that despite an increase in the number of
deaths in Hospice Service Area 3E, the number of deaths served by
the sole hospice provider has grown at a lower than expected rate
when compared to District 3 and the State of Florida. Harbor Light
contends that while the district and the State of Florida have made
significant strides in increasing the percentage of resident deaths
served by hospice, Hospice Service Area 3E has not. The applicant
concludes that this provides further evidence for the need for an
additional hospice provider in Hospice Service Area 3E.
Hospice of Marion County, Inc. (CON #10142) states that there
are significant unmet needs in Hospice Service Area 3E with
particular need demonstrated for: Hispanics, veterans, individuals
with chronic disease and pediatric patients (under age 21).
HMC indicates that through its proposed marketing and public
outreach efforts, access will improve throughout Hospice Service
Area 3E. The applicant will meet the unmet needs by providing
special programs that cater to the specified populations with
programs that include: special community education efforts,
clinical care protocols and bereavement services. The applicant
contends that hospice penetration rates can be raised to surpass
the state’s current penetration rate based upon its operational
history, experience and educational/outreach methods.
The applicant states that it will address the specific needs of
patients who are Hispanic by including bilingual patient and
educational materials. HMC will establish an office in the
Leesburg area initially, near a large and growing Hispanic
population.
HMC indicates that it has specialized qualifications to address the
needs of patients with chronic disease through it Chronic Disease
Self-Management Program that targets adults with long-term
health conditions such as arthritis, diabetes, cancer, chronic pain,
depression and others. The applicant will serve the lead facilitator
to initiate support workshops that focus on self-help for those with
these chronic diseases. HMC states that it also offers specialized
care for pediatric patients.
CON Action Numbers: 10140, 10141, 10142 and 10144
56
VITAS Healthcare Corporation of Florida (CON #10144) states
that it deserves this preference. The applicant indicates that it will
offer services to people of all ages, all disease groups and all
racial/ethnic groups. VHCF will serve patients regardless of where
in the subdistrict they reside, and in whatever place they call
home—nursing facility, hospital or private residence.
In addition, the applicant states that it has identified underserved
groups in Subdistrict 3E and has committed to serve those
populations. VHCF undertook detailed market research including
meetings with local providers and community leaders as well as
analysis of available data from the Agency and Medicare’s Hospice
Standard Analytical File to determine underserved groups and
areas. VHCF identified the following groups which are in need of
additional hospice services, all of these groups are predominately
in the 65+ population:
African-American patients
Non-cancer patients needing hospice services
Patients in nursing homes
Sumter County residents
VHCF states that the existing hospice has not adequately reached
out to these groups. The applicant maintains that it has
successfully increased hospice admissions from elderly black and
non-cancer groups in other Florida markets and understands what
is necessary in Subdistrict 3E. VHCF will commit to, and has
proven it is able to meet the current need. The applicant asserts
that given the opportunity, it will be successful in reaching and
meeting the needs of the underserved persons. However, VCHF
does not provide evidence from the local area that the statistical
appearance of lower utilization is an indicator of an underserved
group.
(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 cost-efficient alternative.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140) intends to have contractual agreements with
nursing homes and hospitals, as well as other health care
providers to provide hospice inpatient care. The applicant states
CON Action Numbers: 10140, 10141, 10142 and 10144
57
that by partnering with hospitals and nursing homes to provide
hospice inpatient care that it will fulfill its goal to expand
awareness and utilization of hospice.
The applicant notes that it has obtained letters of support from a
handful of assisted living facilities and nursing homes in the
Hospice Service Area. Compassionate Care states that it received
letters of support of CON application #10140 from several
cardiologists and neurologists who are on staff at the four local
acute care hospitals—Leesburg Regional Medical Center, The
Villages Regional Hospital, South Lake Hospital and Florida
Hospital Waterman. Compassionate Care also received a letter
from Steven Klein, CEO of Promises Hospital of Florida at The
Villages indicating his intent to enter into patient care
arrangements with the applicant upon CON approval. Superior
Residences of Clermont, an assisted living facility, expressed a
similar intent.
Compassionate Care contends that because existing hospitals in
the service area currently have contracts with the existing
provider, some were reluctant to provide letters of support to a new
provider until a CON is issued. The applicant is confident that it
will be able to enter into other contractual agreement to have
inpatient beds available at hospitals well-distributed in the service
area. Compassionate Care states that it will work cooperatively
with each hospital’s discharge planning department as a resource
for patients in need of hospice care.
Harbor Light Hospice of Florida, Inc. (CON #10141) proposes to
provide the inpatient care component of the hospice program
through contractual arrangements with existing health care
facilities. The applicant had one letter of interest included in CON
application #10141 from Osprey Point, a skilled nursing facility.
Hospice of Marion County, Inc. (CON #10142) proposes to
provide the inpatient care component of the proposed program
through contractual arrangements with existing health care
facilities, including acute care hospitals and skilled nursing
facilities. The applicant maintains that negotiations for additional
contracts with hospitals and nursing homes are ongoing to ensure
the widest network.
CON Action Numbers: 10140, 10141, 10142 and 10144
58
The applicant states that it has been established in adjoining
Hospice Service Area 3B, Marion County, and has four hospice
houses there—Lake and Sumter residents will also be able to
choose from one of HMC’s already established hospice houses.
The applicant indicates that Tuscany House is already utilized by
some Subdistrict 3E residents.
HMC cites a letter of intent to contract for inpatient beds provided
by Florida Hospital Waterman once implementation of the
proposed program begins. The letter in included in CON
application #10142.
The reviewer notes that the applicant states the following condition
upon approval of CON application #10142, “to establish a
dedicated hospice inpatient unit in a hospital, skilled nursing
facility or freestanding hospice house once an average daily census
level of 150 has been attained for a six month period.”
VITAS Healthcare Corporation of Florida (CON #10144) states
that it deserves this preference. The applicant indicates that it
prefers to have contractual agreements with nursing homes and
hospitals to meet patient needs in Subdistrict 3E. VHCF
maintains that by partnering with hospitals and nursing homes to
provide hospice inpatient care, it will fulfill its goal to expand
awareness of and utilization of hospice. VITAS partners with both
non-profit and for-profit facilities in bringing hospices services to
the local communities it serves. VITAS operates 34 hospice
inpatient units across the country.
The applicant indicates that its agreements are not limited to just
inpatient facilities such as skilled nursing facilities and hospitals.
Some examples of the different types of contractual agreements
include:
Ambulance
Durable medical equipment
Inpatient respite care
Radiological
Therapy
Home health
Infusion therapy
Laboratory
CON Action Numbers: 10140, 10141, 10142 and 10144
59
VHCF is seeking to establish a new hospice program with no plans
to establish its own inpatient unit in 3E in the foreseeable future.
Upon CON approval, the applicant states that it will establish
inpatient agreements within the subdistrict. VHCF indicates that
preliminary discussions with Edgewater at Waterman Village and
Lady Lake Specialty Care Center have shown a willingness to enter
into contractual agreements with the applicant pending CON
approval and upon licensure. Letters of interest from these
facilities were included in CON application #10144.
(3) Preference shall be given to an applicant who has a commitment to serve patients who do not have primary caregivers at home; the homeless; and patients with AIDS.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140) maintains that it is committed to serving all
patients including those who do not have primary caregivers at
home, the homeless and patients with AIDS in Subdistrict 3E as
evidenced by its history of serving these patient populations in its
existing markets.
In the case that a patient is not able to care for him/herself and
has no caregiver support group, Compassionate Care may
recommend placement in an assisted living facility or nursing
home in which it will be able to provide residential care.
Compassionate Care social workers will assist patients without
financial resources to obtain residential care in a hospice unit
within an assisted living facility or nursing home, as determined by
their medical condition. The applicant proposes to establish
relationships with area nursing homes and assisted living facilities
as the need arises.
In addition to its commitment to serving patients either without
caregivers at home, with compromised caregivers and AIDS
patients, Compassionate Care will service homeless individuals. If
a patient in need of hospice care is homeless, the applicant will
place the patient in an inpatient unit and assist him/her with
applying for Medicaid. Once the patient qualifies, he/she will be
placed in a long-term care environment where the patient can
begin or continue hospice care.
CON Action Numbers: 10140, 10141, 10142 and 10144
60
Harbor Light Hospice of Florida, Inc. (CON #10141) states that
it will serve patients who do not have primary caregivers at home,
the homeless and patients with AIDS. At admission, patients are
given an initial assessment from a team of professionals with
factors such as the current clinical condition of the patient, safety
of the environment, educational needs and current state of
finances.
The applicant maintains that when a primary caregiver is not
continually present with a patient, the patient’s environment is
always discussed with contingency plans for when/if the patients
becomes compromised at a bi-weekly conference meeting with the
professional team. The Harbor Light Team is proactive in helping
patients through all transition, including moving to or developing a
safe environment when caregiver breakdown is detected.
Harbor Light indicates that if a patient does not have a caregiver, a
social worker immediately develops a plan of care to provide for
care and present options to the patient, including providing
assistance in securing a bed in a facility. Upon assessment, the
social worker assists family in accessing appropriate community
resources.
Hospice of Marion County, Inc. (CON #10142) provides service
to everyone who makes an inquiry, beginning with information,
education, referral and counseling. The applicant states that it will
admit all patients who qualify for hospice care within its licensed
service area, including homeless persons, persons without primary
caregivers and persons with HIV/AIDS.
VITAS Healthcare Corporation of Florida (CON #10144) states
that it deserves this preference. The applicant asserts that it is
committed to serving all residents, including the homeless,
utilizing all community and VITAS resources as necessary to
assure a safe and comfortable environment. VHCF maintains that
terminally ill patients with no at home support will receive
increased attention from the hospice staff. The applicant states
that every effort will be made to develop a caregiver network from
among neighbors, nearby relatives and friends, church members
and hospice volunteers who will be capable of providing the
necessary amount of supervision, assistance and companionship
to the patient within the patient’s or caregiver’s home.
CON Action Numbers: 10140, 10141, 10142 and 10144
61
Patients living alone with the ability to care for him or herself for
the most part, will be assisted by the applicant in developing a
network of caregivers to assist the patient or recommend that
qualified adult sitter services be obtained should that not pose a
financial hardship. VHCF may provide patients or family members
with cell phones for 24-access and communication to those who
may have none available. Where appropriate, the applicant will
provide continuous care to allow the patient to remain at home.
VHCF notes the WellFlorida Councils’ identification of an
increasing population of homeless residents in the southern part of
Lake County. The applicant states that it is committed to serving
the growing homeless population in Lake County. In cases where
the patient is homeless, VHCF may assist patients to find
placement in an assisted living facility or nursing home—
caseworkers will assist patients in applying for available funding
for room and board. The applicant proposes to establish
relationships with area nursing homes and assisted living facilities
to serve patients in this situation as the need arises.21
The applicant notes that HIV and AIDS deaths do not account for a
significant portion of deaths in Subdistrict 3E—15 AIDS related
deaths in 2009 and 17 in 2010. VHCF does maintain that it is
aware of the unique need of patients with this diagnosis. The
applicant is committed to ensuring terminally-ill individuals with
HIV have access to hospice services—including specialized training
for staff and volunteers.
(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 3E consists of only two counties, Lake and
Sumter. This criterion is not applicable to this review.
(5) Preference shall be given to an applicant who proposes to provide services that are not specifically covered by private insurance, Medicaid, or Medicare.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140) states that it offers a host of special programs and
services that are not specifically covered by private insurance,
21 A copy of sample contracts to be used with nursing homes and assisted living facilities for this purpose are included in TAB 17 of CON application #10144.
CON Action Numbers: 10140, 10141, 10142 and 10144
62
Medicare or Medicaid. The applicant presents a list of ‘Non-Core
Services’ it will provide as a condition of approval of CON
application #10140, including:
Pathways to Compassion, a palliative care program
Cardiac Connections
Promise Program, to meet the requirements of the needy
population
Veterans Outreach
Complementary Care Program which includes: massage
therapy, music therapy, energetic care, sacred spaces, guided
imagery, reminiscence therapy, pet therapy, aromatherapy,
reflexology and hypnotherapy
Transitions, a community service program
Jewish Hospice Program
Hispanic Hospice Program
Compassionate Care 4 Kids
Life Enhancement Specialists, provides recreational activities
for socially isolated patients
First Night at Home
Community Outreach
Volunteer Services
Bereavement Services
Rainbows, a bereavement support program for children
Comfort Corners, decorates designated areas in long-term care
facilities
Harbor Light Hospice of Florida, Inc. (CON #10141) maintains
that it currently provides required patient care services not
specifically reimbursed by private insurance, Medicaid or Medicare
in its existing hospice operations and will provide similar
supportive services as needed in this proposed hospice program.
These services will include, but are not limited to, pet therapy,
massage therapy, aroma therapies, dialysis, palliative radiation
and palliative chemotherapy. The applicant indicates that these
services will be provided through the trained employees/volunteers
and through contractual agreements for services requiring a
hospital environment setting.
Hospice of Marion County, Inc. (CON #10142) states that it
currently and will continue to provide a broad range of services
that are not covered by private insurance, Medicaid or Medicare.
Specific non-covered services provided include:
CON Action Numbers: 10140, 10141, 10142 and 10144
63
Bereavement and grief support programs
Integrative/expressive therapies such as massage therapy, pet
therapy, music appreciation and Reiki.22
Supportive counseling
Volunteers to provide respite for caregivers at home, assistance
with errands and light homemaking tasks
Services to persons who have exhausted their insurance benefit
Recruitment, training and use of volunteers to augment HMC’s
capabilities
Veteran recognition events
Community education
Employee programs
VITAS Healthcare Corporation of Florida (CON #10144) states
that it deserves this preference. The applicant asserts that VITAS
has made a strong commitment in this regard from its beginning
days when all patients were care for solely depending on donations
and volunteers. VITAS states that it provides at least one percent
of revenues in charity care. For fiscal year 2011, this amount
exceeded $9.9 million while charity care amount for Florida
hospices exceeded $4.5 million.
VHCF indicates that it will provide the following non-core services
as a condition of approval of CON application #10144:
VHCF will meet exceed the statutory requirement in 400.60501,
Florida Statutes. Seventy percent or more of patients who
report severe pain (seven to 10 on the World Health
Organization pain scale) will report a reduction to five or less on
the pain scale within 48 hours after admission.
A VHCF staff member or volunteer will attend at least 90
percent of all deaths to ensure patients do not die alone.
VHCF will achieve an overall patient satisfaction score of 90
percent or above on the patient’s family’s evaluation of care
while under the care of VITAS.
VHCF will achieve an overall Registered Nurse satisfaction score
of 90 percent or above on patient’s family satisfaction with the
VHCF nurse while under the care of VITAS.
22 According to Reiki.org, Reiki is a Japanese technique for stress reduction and relaxation that also promotes healing. “It is administered by ‘laying on hands’ and is based on the idea that an unseen ‘life force energy’ flows through us and is what causes us to be alive.”
CON Action Numbers: 10140, 10141, 10142 and 10144
64
VHCF will implement a Pet Therapy program to begin
immediately. PetPals is a program where screened dogs visit
shut-ins, nursing homes, assisted living facilities, adult day
care center and Alzheimer patients.
b. Chapter 59C-1.0355, Florida Administrative Code contains the
following general provisions and review criteria to be considered in reviewing hospice programs. (1) 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.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140): As reflected in Schedule 6A of the
application, the following is the proposed Subdistrict 3E
staffing for each of the first two years of operation.
Compassionate Care Proposed Staffing for Subdistrict 3E
April 2013-March 2015 First Two Years of Operation
Position
Average Number of FTEs Year One
Average Number of FTEs Year Two
Administrator 1.0 1.0
Professional Relations Coordinator 1.0 1.0
Secretary 1.0 2.0
Community Liaison 0.5 1.0
Clinical Coordinator 1.0 1.0
Medical Director 0.2 0.5
Registered Nurses 2.0 4.5
Per Diem Registered Nurses 0.3 1.0
LPN 0.0 1.0
Per Diem LPN 0.0 0.5
Nurses’ Aides 6.0 14.0
Nurse Practitioner 1.0 1.0
Per Diem Nurses’ Aides 0.4 1.6
Continuous Care Per Diem LPN 0.6 1.81
Continuous Care Per Diem Aide 0.6 1.81
Life Enhancement Specialist 0.2 1.0
Music Therapist 0.2 0.5
Massage Therapist 0.2 0.5
Dietary Services 0.2 0.5
Social Worker 1.0 2.0
Volunteer Coordinator 0.5 1.0
Chaplain 0.5 1.0
Total 18.4 40.22 Source: CON application #10140, page 87.
CON Action Numbers: 10140, 10141, 10142 and 10144
65
The applicant indicates that staffing is based upon the
anticipated direct nursing and care staff to be utilized in the
delivery of hospice services and the direct support staff
required. Compassionate Care states that clinical staff
includes one clinical coordinator and one nurse practitioner
who will be dedicated to the Cardiac Connections Program as
well as specially designated continuous care LPNs and
nurses’ aides. Compassionate Care maintains that
volunteers will also be recruited enthusiastically consistent
with the volunteer services program.
Harbor Light Hospice of Florida, Inc. (CON #10141): As
reflected in Schedule 6A of the application, the following is
the proposed Subdistrict 3E staffing for each of the first two
years of operation.
Harbor Light Proposed Staffing for Subdistrict 3E
Calendar Years 2013 and 2014 First Two Years of Operation
Position
Average Number of FTEs Year One
Average Number of FTEs Year Two
Marketing 1.2 2.0
Executive Director 1.0 1.0
Supervisor 0.3 1.2
Office 0.7 1.0
Patient Care Coordinator 0.7 1.0
Medical Director 0.02 0.1
R.N.’s 1.1 4.7
L.P.N.’s 0.4 1.7
HHAs 1.1 4.7
Bereavement Coordinator/Chaplain 0.3 1.2
MSW/Volunteer Coordinator 0.6 2.4
Total 7.4* 20.9* *These numbers should be 7.42 and 21.0, respectively.
Source: CON application #10141, Schedule 6A, page 130.
Harbor Light states that it will routinely provide
substantially all core services directly by hospice employees.
The applicant indicates that its interdisciplinary team
consists of a nurse, certified nursing assistant, volunteer,
chaplain, social worker and medical director. The reviewer
notes that there were no FTE allocations for a social worker
or certified nursing assistant on the applicant’s Schedule 6A.
The applicant indicates that extra attention from the entire
team promotes quality of life and dignity throughout the last
moments of life. In addition, Harbor Light states that it will
call in, as needed, specialists such as a dietician or a
therapist to meet the specialized needs of a dying person.
CON Action Numbers: 10140, 10141, 10142 and 10144
66
Harbor Light maintains that it provides all hospice
diagnosis-related medications, including all pain control and
symptom control measures. It will provide medical
equipment and supplies helpful to controlling symptoms,
including equipment that would prevent skin breakdowns.
The applicant contends that without hospice services, this
would have to be paid for by the family.
Hospice of Marion County, Inc. (CON #10142): As
reflected in Schedule 6A of the application, the following is
the proposed Subdistrict 3E staffing for each of the first two
years of operation:
Hospice of Marion County Proposed Staffing
Subdistrict 3E Calendar Years 2013 and 2014 First Two Years of Operation
Position
Average Number of FTEs Year One
Average Number of FTEs Year Two
Medical Records Clerk 0.5 1.0
Volunteer Services ---- 0.5
All Other Administration 2.75 3.5
Physicians 0.25 0.35
Clinical Coordinator 1.0 1.0
R.N.’s 4.5 6.0
L.P.N.’s 1.5 1.5
Hospice Aides 1.5 3.0
Pharmacy ---- 0.5
Dietician 0.2 0.2
Social Worker 0.75 1.5
Chaplain 0.5 1.0
Bereavement Counselors 0.25 0.5
Total 13.7 20.55 Source: CON application #10142, Schedule 6A.
The applicant maintains that the proposed staffing has been
developed based on its operational experience. HMC states
that it will provide certain support and billing services for the
proposed program from its Ocala offices.
HMC states that volunteers do not appear in the above
schedule but that it anticipates recruiting, training and
using volunteer staff at approximately the same proportion
as it does in its Marion operation relative to admissions.
Currently, the applicant utilizes 600 individual volunteers
including 25 whom already reside in Lake/Sumter County.
The volunteer’s services range from patient support activities
to administrative/clerical activities to outreach activities.
CON Action Numbers: 10140, 10141, 10142 and 10144
67
VITAS Healthcare Corporation of Florida (CON #10144):
As reflected in Schedule 6A of the application, the following
is the proposed Subdistrict 3E staffing for each of the first
two years of operation:
VHCF Proposed Staffing for Subdistrict 3E
October 2012-September 2014 First Two Years of Operation
Position
Average Number of FTEs Year One
Average Number of FTEs Year Two
General Manager/Administrator 1.00 1.00
Admissions/Hospice
Reps/Community Liaison
3.46
4.50
Bereavement Manager 0.71 1.00
Business Manager 0.83 1.00
PC Secretary 1.00 1.50
Receptionist 0.75 2.00
Medical Director/Physician 0.45 0.93
Team Director (RN) 1.25 2.25
Continuous Care Manager 0.00 0.75
RNs 3.06 6.74
LPN/Aides 7.65 24.15
On-Call Representatives 1.58 2.00
Social Worker 1.21 1.83
Chaplain 1.00 1.13
Total 23.96* 50.78 *This number should be 23.95.
Source: CON application #10144, page 76.
The applicant indicates that some staffing positions and
support functions will be provided via overhead allocation
from existing VHCF operations. Volunteer staff hours are
expected to equate to a minimum of five percent employee
time. Additionally, dietary counseling will be a key part of
VHCF’s service.23
(b) Expected sources of patient referrals.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140) believes due to the area’s tremendous need
for hospice services and the highest quality of care provided
by the applicant, attracting patients will not be difficult.
Referrals will come from area physicians, hospitals, nursing
homes, health care providers, family members and the
patients themselves. The applicant notes the many letters of
support for the proposed program from area physicians,
assisted living facilities, nursing homes, hospitals, other
community organizations and residents. Compassionate
23 Dietary services expense are included under the “homecare ancillary” line item on Schedule 8a of the financial schedules within TAB 2 of CON application #10144.
CON Action Numbers: 10140, 10141, 10142 and 10144
68
Care contends that these letters both constitute groups likely
to provide referrals as well as showing the eagerness of the
community for the applicant to initiate services.
Harbor Light Hospice of Florida, Inc. (CON #10141)
indicates that in a hospice, a client base is built through
providing superior levels of service which results in earning
the trust of those who are in a position to recommend
hospice service to patients and families. Harbor Light will
develop a reputation for excellence in care thereby gaining
the trust and admiration of professionals who refer patients
to the program.
The applicant states that it currently operates 19 programs
in eight states and has successfully developed and
maintained strong relationships with referral source in
support of each of these programs. In preparation for CON
application #10141, Harbor Light has been engaged in
extensive ground work to enhance its understanding of the
local area and introduce itself to the Lake/Sumter medical
community and the spectrum of potential referral sources.
The applicant states it has had a positive reception. Harbor
Light is fully confident in its ability to integrate into the area
and succeed by devoting all necessary resources to
establishing contacts and effectively conveying its history,
experience and commitment to quality.
In addition, Harbor Light Chairman Frank Rosenbaum
included a letter of intent to purchase an existing, well-
established home health agency whose operations
encompass Lake and Sumter Counties and serve a large
volume of patients in these counties. The applicant
contends that while no direct affiliation will exist between the
home health agency and Harbor Light, Mr. Rosenbaum’s
ownership position in the home health entity will bring with
it the immediate substantial benefit of established
relationships with physicians groups, hospitals, long-term
care and rehabilitation interests in Service Area 3E.
Hospice of Marion County, Inc. (CON #10142) provides a
list of sources it will target for hospice referrals, including:
Physicians
Hospital discharge planners
Social workers
CON Action Numbers: 10140, 10141, 10142 and 10144
69
Nursing facilities
Assisted living facilities
Home health agencies
Group homes
Community social service agencies
Churches
Veterans groups
The applicant notes that the health care providers and
organizations that wrote letters of support for CON
application #10142 are indicative of the potential to gain
referrals from a variety of sources.
HMC indicates that it will conduct a variety of marketing
activities to let the community know of its presence as a
hospice provider in the district and has reserved a
considerable portion of the funding for the proposed project
for community outreach initiatives. In addition, the
applicant asserts that it recognizes the significant Hispanic
and Veterans communities within Hospice Service Area 3E
and will provide special programs that cater to the
populations. These programs will include special community
education efforts, clinical care protocols and bereavement
services for families in order to increase participation for
groups traditionally underrepresented.
VITAS Healthcare Corporation of Florida (CON #10144)
maintains that it knows how to enter a community with
established hospices and develop referral services based on
VITAS’ 26 successful hospice start-ups since 2001.
Referrals will come from area physicians, hospitals, clergy,
social service agencies, disease advocacy groups, nursing
homes, other health care providers, family members and
patients themselves. The applicant points to the letters of
support gathered for CON application #10144 in Subdistrict
3E and areas VHCF already serves. VHCF expects that its
reputation with groups and individuals in other service areas
will open doors with their counterparts in Subdistrict 3E.
In addition, the applicant will develop outreach programs
and services geared toward Subdistrict 3E referral sources.
CON Action Numbers: 10140, 10141, 10142 and 10144
70
The programs will enhance education about hospice services
and VHCF’s mission. The program also has budgeted
positions for community liaison personnel to work with the
African-American community and with groups working with
patients with non-cancer diagnoses.
VHCF points to its success in Subdistricts 4A and 8B and
expects referrals to the proposed program to be in addition to
referrals to the existing hospice in the subdistrict.
(c) Projected number of admissions, by payer type,
including Medicare, Medicaid, private insurance, self-pay, and indigent care patients for the first two years of operation.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140): The following table shows the projected
payer source for admissions by year for the proposed
program.
Expected Admissions by Payer Type
For Compassionate Care Hospice of Lake and Sumter, Inc. Service Area 3E
Payer Source Year One Year Two
Medicare 147 344
Medicaid 5 11
Charity 2 5
Insurance 3 6
Total 157 366
Source: CON application #10140, page 89.
The applicant indicates that it does not expect to collect any
funds on the patients it treats during the first three months
of operation (representing 370 days of care), between
licensure and certification dates.
Harbor Light Hospice of Florida, Inc. (CON #10141): The
following table shows the projected payer source for
admissions by year for the proposed program.
Harbor Light Hospice of Florida, Inc. Projected Admissions by Payer Type Year One and Year Two of Operation
Medicaid
Medicare
Commercial/ Charity/ Other
Total
Year One 3 67 3 73
Year Two 8 188 8 204 Source: CON application #10141, page 69.
CON Action Numbers: 10140, 10141, 10142 and 10144
71
Hospice of Marion County, Inc. (CON #10142): The
following table shows the projected payer source for patient
days by year for the proposed program.
Hospice of Marion County, Inc.
Projected Patient Days by Payer Type Year One and Year Two of Operation
Medicare
Medicaid
3rd Party Insurance
Self-Pay/ Other
Total
Year 1 6,437 408 215 100 7,160
Year 2 14,332 909 478 223 15,943
% of Total 89.9% 5.7% 3.0% 1.4% 100% Source: CON application #10142, page 130.
The applicant did not provide the projected number of
admissions by payer type.
VITAS Healthcare Corporation of Florida (CON #10144):
The following table shows the projected payer source for
admissions by year for the proposed program.
Projected Admissions by Payer
VITAS Healthcare Corporation of Florida Subdistrict 3E
Payer Type Year One Year Two
Medicare 197 391
Medicaid 10 19
Indigent 3 5
Private Insurance/Self-pay/ Other 4 8
Total 214 423
Source: CON application #10144, page 78.
The applicant notes that the forecasted admissions were not
done by payer. However, patient days were projected by
payer and using patient day’s percentage of total provided a
reasonable forecast of admissions by payer.
(d) Projected number of admissions, by type of terminal
illness, for the first two years of operation.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140) provides the following summary table of
expected admissions by type.
CON Action Numbers: 10140, 10141, 10142 and 10144
72
Projected number of Admissions by Diagnosis
For Compassionate Care Hospice of Lake and Sumter, Inc. Service Area 3E
Diagnosis Year One Year Two
Cancer 50 92
Cardiac 55 165
Respiratory 20 35
Renal Failure 10 20
HIV/AIDS 2 4
Other 20 50
Total 157 366 Source: CON application #10140, page 89.
Harbor Light Hospice of Florida, Inc. (CON #10141)
indicates that it expects that the patients of the proposed
program will be similar to that of its national experience.
See the table below.
Harbor Light Hospice of Florida, Inc.
Projected Admissions by Type of Terminal Illness Years One and Year Two of Operation
Cancer CHF COPD Renal Other Total
Year 1 22 9 7 1 34 73
Year 2 61 27 18 4 94 204 Source: CON application #10141, page 69.
Hospice of Marion County, Inc. (CON #10142) provides
the following summary table of expected admissions by type.
Hospice of Marion County, Inc. Projected Admissions by Type
Years One and Two of Operation Year One
Hospice Admissions Year Two
Hospice Admissions
Under 65 65+ Total Under 65 65+ Total
Cancer 12 30 42 21 52 73
Other 33 104 137 56 177 233
Total 45 134 179 77 229 306 Source: CON application #10142, page 130.
VITAS Healthcare Corporation of Florida (CON #10144)
provides the projected number of admissions by terminal
illness for the first two years of operation of the proposed
program. The applicant notes that one of its conditions
upon approval is that at least 65 percent of admissions will
be patients with non-cancer diagnoses. See the table below.
CON Action Numbers: 10140, 10141, 10142 and 10144
73
Projected Number of Admissions by Diagnosis
VITAS Healthcare Corporation of Florida Service Area 3E
Disease Year One Year Two
Cancer 66 131
HIV/AIDS 2 4
Respiratory 17 34
Cardiac 27 54
Alzheimer/Cerebral
Degeneration
45 88
Cerebrovascular/Stroke 12 24
Other 45 88
Total 214 423 Source: CON application #10144, page 79.
(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 Lake and Sumter, Inc.
(CON #10140) provides the following table for the projected
number of admissions by age cohort.
Projected Admissions by Age Group
Compassionate Care Hospice of Lake and Sumter, Inc. Subdistrict 3E
Age Group Year One Admissions Year Two Admissions
Under 65 16 37
Over 65 141 329 Source: CON application #10140, page 90.
Harbor Light Hospice of Florida, Inc. (CON #10141)
provides the following table for the projected number of
admissions by age cohort.
Harbor Light Hospice of Florida, Inc. Projected Admissions by Age Groups Years One and Year Two of Operation
Under 65 Over 65 Total
Year One 7 66 73
Year Two 20 184 204 Source: CON application #10141, page 70.
Hospice of Marion County, Inc. (CON #10142) provides
the following table for the projected number of admissions by
age cohort.
CON Action Numbers: 10140, 10141, 10142 and 10144
74
Hospice of Marion County, Inc. Projected Admissions by Type
Years One and Two of Operation Year One
Hospice Admissions Year Two
Hospice Admissions
Under 65 65+ Total Under 65 65+ Total
Cancer 12 30 42 21 52 73
Other 33 104 137 56 177 233
Total 45 134 179 77 229 306 Source: CON application #10142, page 130.
VITAS Healthcare Corporation of Florida (CON #10144)
provides the following table for the projected number of
admissions by age cohort.
Projected Admissions by Age Group
VITAS Healthcare Corporation of Florida Subdistrict 3E
Age Group Year One Admissions Year Two Admissions
Under 65 30 60
Over 65 184 363 Source: CON application #10144, page 79.
The applicant states that the reliability of its volume
projections in CON application #10144 is supported by
actual experience elsewhere in Florida. VHCF asserts that
its projections are conservative and represent minimum
expectations allowing for continued growth in admissions by
the existing hospice.
VHCF maintains that it would be unfortunate for the Agency
to reward applicants that project the largest number of
admissions. The applicant notes that most new hospice
program applicants fall well short of its application
projections. VHCF states that it is glad to serve as many
patients as it can, preferring to under promise and over
deliver in utilization projections. The applicant hopes it will
not be penalized for taking this approach.
(f) Identification of the services that will be provided directly by hospice staff and volunteers and those that will be provided through contractual arrangements.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140) states that core services, including physician
services, nursing services, social work services,
pastoral/counseling and dietary counseling will be provided
for by its staff and volunteers. The applicant indicates that
CON Action Numbers: 10140, 10141, 10142 and 10144
75
it will contract for certain services as needed by the patients
including: 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,
aromatherapy, reflexology, hypnotherapy, life enhancement
services and homemaker services.
Harbor Light Hospice of Florida, Inc. (CON #10141) states
that it will routinely provide substantially all core services
directly by hospice employees including Medicare-covered
hospice services and bereavement counseling. The applicant
provides a definition of duties for each member of its
interdisciplinary team:
The registered nurse focuses much expertise on pain
control and symptom management with the dying process
The medical director collaborates with the
interdisciplinary team to ensure that medical admission
prognostic criteria are met as well as the overall
responsibility for the interdisciplinary group ensuring
that all areas consistently meet patient and family needs
The social worker performs the role of a counselor with
the dying process of the resident, the residents’ family
and extended family
The Chaplain’s role is to establish or reconnect the
resident with his or her own religious roots.
The certified nursing assistant can spend extra time
assisting the patient with the activities of daily living,
writing notes to friends and escorting residents on walks
The volunteer can be a special friend, taking time to talk
to or to read to the resident
The applicant indicates that extra attention from the entire
team promotes quality of life and dignity throughout the last
moments of life. In addition, Harbor Light states that it will
call in, as needed, specialists such as a dietician or a
therapist to meet the specialized needs of a dying person.
CON Action Numbers: 10140, 10141, 10142 and 10144
76
Harbor Light maintains that it provides all hospice
diagnosis-related medications, including all pain control and
symptom control measures. It will provide medical
equipment and supplies helpful to controlling symptoms,
including equipment that would prevent skin breakdowns.
The applicant contends that without hospice services, this
would have to be paid for by the family.
Hospice of Marion County, Inc. (CON #10142) states that
it will provide all of its core services directly by hospice staff
and volunteers, including:
Nursing services
Social work services
Spiritual services
Dietary counseling
Bereavement counseling services
Home health aides
Pharmacy services
Supplies and durable medical equipment
Homemaker and chore services
Physician services
Infusion therapy
Additional services may be provided through contractual
arrangement, including:
Physical, occupational and speech therapy
Patient transportation services
Additional physician services
The applicant indicates that other services that are needed
on an occasional basis, such as daycare, handyman services,
alternative therapies or funeral ceremonies may be provided
directly—if the requisite skill are available among the
staff/volunteers—or may be purchased on an as needed
basis from reputable providers.
VITAS Healthcare Corporation of Florida (CON #10144)
states that core services, including physician services,
nursing services, social work services, pastoral counseling
and dietary counseling will be provided by the applicant’s
staff and volunteers. VHCF will contract for other services
as needed by the patients.
CON Action Numbers: 10140, 10141, 10142 and 10144
77
The applicant anticipates having employees provide all
services with the exception of durable medical
equipment/supplies and pharmacy services. VHCF does
note that from time to time, there may be a need for
supplemental staff engaged in certain functions such as
physical therapy, speech-language, pathology, massage
therapy and occupational therapy. The applicant maintains
that establishment of managed care contracts, development
of per diem contracts and use of the Vx information
technology system within Subdistrict 3E will be easily
accomplished due to VHCF’s already licensed programs in
Florida.
(g) Proposed arrangements for providing inpatient care.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140) states that its intent is to have contractual
arrangements with nursing homes and hospitals designed to
meet patient needs in Hospice Service Area 3E. The
applicant maintains that this is the most cost-efficient
alternative as the inpatient and respite need of the patients
can be easily met by existing hospital and nursing home
facilities. Compassionate Care anticipates 69 inpatient
hospice days for year one of operation and 210 in year two.
The applicant cites the letter of support by Promise Hospital
of Florida at The Villages indicating its intent to enter into
patient care arrangements with Compassionate Care upon
approval. Harbor Light Hospice of Florida, Inc. (CON #10141)
proposes to provide the inpatient care component of the
hospice program through contractual arrangements with
existing health care facilities. The applicant states that
Osprey Point Nursing Center is interested in and agreeable
to developing a contract with Harbor Light upon approval.
The letter was included in CON application #10141.
Hospice of Marion County, Inc. (CON #10142) proposes to
provide the inpatient care component of the proposed
program through contractual arrangements with existing
health care facilities, including acute care hospitals and
skilled nursing facilities. The applicant maintains that
negotiations for additional contracts with hospitals and
nursing homes are ongoing to ensure the widest network.
CON Action Numbers: 10140, 10141, 10142 and 10144
78
A sample agreement is provided in Attachment AC in CON
application #10142.
HMC cites a letter of intent to contract for inpatient beds
provided by Florida Hospital Waterman once implementation
of the proposed program begins. The letter is included in
CON application #10142.
The applicant states that it does not propose to construct a
freestanding inpatient hospice facility in Subdistrict 3E at
this time. However, HMC contends that residents will have
access to Tuscany house, as they do now, which borders
Sumter County and is proximal to Lake County.
The reviewer notes that the applicant states the following
condition upon approval of CON application #10142, “to
establish a dedicated hospice inpatient unit in a hospital,
skilled nursing facility or freestanding hospice house once an
average daily census level of 150 has been attained for a six
month period.”
VITAS Healthcare Corporation of Florida (CON #10144)
states that it has no plans to establish its own inpatient unit
in 3E in the foreseeable future. The inpatient and respite
need of these patients will be met by existing hospital and
nursing home facilities. The applicant states it will establish
inpatient agreements within the subdistrict upon CON
approval of application #10144. VHCF points to its
numerous inpatient agreements throughout Florida. The
applicant states that it is experienced in identifying the
appropriate facilities to help deliver hospice services
effectively and efficiently to patients and families. VHCF
indicates that The Edgewater at Waterman Village and Lady
Lake Specialty Care have shown a willingness to enter into
contractual agreements.
(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 Lake and Sumter, Inc.
(CON #10140) indicates that it will not construct beds and
will be contracting for existing beds on an as needed basis.
CON Action Numbers: 10140, 10141, 10142 and 10144
79
The applicant asserts that it will develop relationships with
existing providers to utilize existing infrastructure to provide
the residential and inpatient component of hospice care.
The applicant anticipates 69 inpatient hospice days for year
one of operation and 210 in year two.
Harbor Light Hospice of Florida, Inc. (CON #10141) states
that it will arrange for the provision of inpatient care through
contractual arrangements with hospitals, nursing homes
and other setting throughout Hospice Service Area 3E.
Hospice of Marion County, Inc. (CON #10142) indicates
that this is not applicable as it will contract for inpatient
beds with existing providers in Subdistrict 3. The reviewer
notes that the applicant states the following condition upon
approval of CON application #10142, “to establish a
dedicated hospice inpatient unit in a hospital, skilled
nursing facility or freestanding hospice house once an
average daily census level of 150 has been attained for a six
month period.”
VITAS Healthcare Corporation of Florida (CON #10144)
states that the total number of inpatient days projected in
year two of the proposed program is 821. The applicant
indicates that it will contract for more beds than projected to
provide services conveniently for patients and to handle
census fluctuations.
(i) Circumstances under which a patient would be admitted to an inpatient bed.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140) maintains that one or more of the following
clinical criteria should be present for a patient to be
considered appropriate for admission to general inpatient
care:
CON Action Numbers: 10140, 10141, 10142 and 10144
80
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
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.
CON Action Numbers: 10140, 10141, 10142 and 10144
81
The applicant indicates that similar criteria are employed for
continued inpatient care. Compassionate Care employs
admission criteria relative to respite care consistent with
that modality of treatment.
To assure continuity of care between home and the inpatient
setting, the applicant states that a specific policy focused on
communication among team members, hospital staff,
physicians and others are used. Compassionate Care states
that this policy assures that there are no gaps in services,
treatment or patient needs.
Harbor Light Hospice of Florida, Inc. (CON #10141)
indicates that it will admit patients to an inpatient bed for
the following reasons:
Short-term inpatient care for pain control
Symptom management
Respite services
The applicant states that these services will be provided in a
participating Medicare or Medicaid facility that offers a
home-like atmosphere and ensures that patient areas are
designed to preserve the dignity, comfort and privacy of
patients.
Hospice of Marion County, Inc. (CON #10142) states that
inpatient care is dictated by a patient’s medical need and
that if possible, symptoms are addressed in the patient’s
home environment. Admission to a HMC general inpatient
bed is based on one or more of the following acute care
admission criteria:
Pain control
Symptom control
Imminent death with symptoms necessitating frequent
physician and nursing intervention
Medical-surgical procedures or therapies aimed at
palliation of symptoms
Family education needs necessary in order to follow the
established plan of care at home
CON Action Numbers: 10140, 10141, 10142 and 10144
82
Provision of a safe and supportive environment to the
terminally ill individual during periods of acute
psychosocial and/or spiritual breakdown of the primary
caregivers
Primary caregiver incapable of continuing daily care in
the home setting
VITAS Healthcare Corporation of Florida (CON #10144)
states that circumstances under which a patient will be
admitted to an inpatient bed depend upon the patient’s
physical condition and the home care situation. The
applicant maintains that it has the ability to deliver
continuous care services at home to its patients, enabling
the ability to avoid admission to inpatient units.
VHCF has written guidelines defining patient and facility
eligibility for facility-based care. Any facility with which
VHCF contracts for hospice care must meet appropriate
licensing, regulatory and certification requirements.
Facilities must have an environment that ensures the
comfort and safety of each patient, accommodates
personalized patient-directed treatment and promotes family
involvement in care giving.
(j) Provisions for serving persons without primary
caregivers at home.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140) maintains that it is committed to serving all
patients including those who do not have primary caregivers
at home as evidenced by its history of serving these patient
populations in its existing markets.
In the case that a patient is not able to care for him/herself
and has no caregiver support group, Compassionate Care
may recommend placement in an assisted living facility or
nursing home in which it will be able to provide residential
care. Compassionate Care social workers will assist patients
without financial resources to obtain residential care in a
hospice unit within an assisted living facility or nursing
home, as determined by their medical condition. The
applicant proposes to establish relationships with area
nursing homes and assisted living facilities as the need
arises.
CON Action Numbers: 10140, 10141, 10142 and 10144
83
The applicant asserts that it is intimately familiar with
appropriate methods and techniques for provision of care to
special needs populations including those without
caregivers. Compassionate Care states that it will be able
and willing to meet similar needs in Hospice Service Area 3E. Harbor Light Hospice of Florida, Inc. (CON #10141)
indicates that if a patient does not have a caregiver, a social
worker will immediately develop a plan of care to provide for
care and present options to the patient, including providing
assistance in securing a bed in an appropriate facility. The
applicant states that upon assessment, the social worker will
assist family in accessing appropriate community resources.
Hospice of Marion County, Inc. (CON #10142) states that
it serves patients without caregivers by working to develop a
plan to them the care they need when they can no longer
care for themselves. The applicant states that in such cases,
it would be able to provide residential care services as
routine as home care to any hospice patient in a nursing
home or assisted living setting. HMC maintains that its
Tuscany House may serve as an alternative for persons
without primary caregivers at home.
VITAS Healthcare Corporation of Florida (CON #10144)
maintains that terminally ill patients with no at home
support will receive increased attention from the hospice
staff. The applicant states that every effort will be made to
develop a caregiver network from among neighbors, nearby
relatives and friends, church members and hospice
volunteers who will be capable of providing the necessary
amount of supervision, assistance and companionship
within the patient’s or caregiver’s home.
Patients living alone with the ability to care for him or herself
for the most part, will be assisted by the applicant in
developing a network of caregivers to assist the patient or
recommend that qualified adult sitter services be obtained
should that not pose a financial hardship. VHCF may
provide patients or family members with cell phones for 24-
access and communication to those who may have none
available. Where appropriate, the applicant will provide
continuous care to allow the patient to remain at home.
CON Action Numbers: 10140, 10141, 10142 and 10144
84
(k) Arrangements for the provision of bereavement services.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140) states that its policy is to provide appropriate
and coordinated bereavement services/counseling to families
and caregivers as well as residents/staff of skilled nursing
facilities, assisted living and other medical facilities for at
least 13 months following the death of the patient.
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. Compassionate Care 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 maintains that
persons deemed to be experiencing moderate or severe grief
will receive increased services.
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.
Harbor Light Hospice of Florida, Inc. (CON #10141) states
that while patients are receiving hospice services, a
bereavement plan of care is developed to recognize
anticipatory grief and identify any additional bereavement
support that families may require for a minimum of 13
months following the death of a loved one. Bereavement
support can take a variety of forms including: telephone
calls, visits, written materials about grieving and support
groups.
The applicant will provide support groups for bereaved
families who have experienced the death of a loved one. This
service will be offered to any member of the community who
has experienced the death of a loved one. Bereavement
services to be provided include:
CON Action Numbers: 10140, 10141, 10142 and 10144
85
Contacts from the interdisciplinary team
Grief support programs for families by social workers and
spiritual care
Memorial services
Individual grief support
Educational programs on grief and bereavement to the
community
Holiday grief programs
Resource information on grief
Hospice of Marion County, Inc. (CON #10142) indicates
that it has extensive policies and procedures in place for the
provision of bereavement services. The applicant states that
the patient, caregiver(s) and family are assessed for coping
skills and bereavement risk factors periodically. Interested
families are referred to the bereavement department while
high-risk referrals are called into the bereavement
department immediately. Community patients may be self-
referred or referred by appropriate individuals/professionals.
The applicant states that services provided through the
bereavement center include:
Individual and family grief support
Grief support for children
Grief support groups
Camp Mariposa
School support groups
Memorial services
Community outreach
Resource materials
Referrals
VITAS Healthcare Corporation of Florida (CON #10144)
states that staff and volunteers will provide bereavement
services. The applicant states that bereavement services are
appropriate from the time of the nursing assessment until
the primary tasks of mourning are accomplished and the
survivor can emotionally reinvest into life and other
relationships.
CON Action Numbers: 10140, 10141, 10142 and 10144
86
VHCF indicates that bereavement support will be available
24 hours a day, seven days a week. A psychosocial staff
person who has been trained in providing bereavement
support will be listed on the on-call schedule and be
accessible through a toll-free number. Core grief services to
be offered to families include:
Grief supportive counseling
Home visits
Bereavement group activities
Volunteer support
Patient/family grief education materials
Quarterly follow-up/correspondence
Memorial gatherings
Resources and referrals
Staff bereavement support
Community grief education and events
The applicant states that the bereavement program will be
under the direction of the volunteer/bereavement manager
who will be responsible for establishing bereavement services
and running the day-to-day bereavement program. The
goals and objectives of the bereavement team at the of a
patient’s death are as follows:
Facilitating the experience of sadness, loss and grief
following the death of a loved one.
Validating the many experiences that are felt by those
who grieve.
Offering support and guidance to family members and
friends who have experienced a loss.
Identifying complicated/abnormal mourning and initiate
resources to assist the family.
VHCF cites that it institutes staff bereavement support as
well. The general manager is responsible for assuring that
grief support is provided to staff and volunteers through
private consultation and regularly scheduled meetings. In
addition, direct patient care staff are given the opportunity
for closure with the family by making a closure visit or phone
call after the death of the patient.
CON Action Numbers: 10140, 10141, 10142 and 10144
87
(l) Proposed community education activities concerning
hospice programs.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140) indicates that it will provide extensive
community education activities surrounding the benefits of
hospice to increase hospice awareness and utilization. The
applicant states that it has forecasted one FTE for a
professional relations coordinator in year one and year two of
operation as well as 0.5 FTE in year one and 1.0 FTE in year
two for a clinical liaison.24 These individuals will be
responsible for leading the outreach for specific disease
focused programming, veterans outreach, further developing
relationships through the community, coordinating
educational sessions, presentations and other outreach
activities.
The applicant indicates that it will host hospice educational
events at senior organizations, religious affiliated groups,
veterans’ organizations, health fairs, skilled nursing homes
and assisted living facilities to educate the residents of Lake
and Sumter Counties on the benefits of holistic end-of-life
care through hospice.
Harbor Light Hospice of Florida, Inc. (CON #10141) states
that it has a strong history of offering educational
opportunities to the communities that it serves. The
applicant indicates that the educational opportunities focus
on hospice and the issues surrounding hospice care and will
be offered to the general public in community centers,
Alzheimer Association meetings, health fairs, churches,
senior organizations and other local groups. Harbor Light
offers educational programs in skilled nursing facilities,
retirement communities, assisted living facilities and other
health care facilities/organizations. The applicant provided
a list of sample topics for these educational programs on
page 73 of CON application #10141.
24 Compassionate Care does not have a clinical liaison listed on Schedule 6 (staffing) but does have a community liaison listed for 0.5 FTE (year one) and 1.0 FTE (year two).
CON Action Numbers: 10140, 10141, 10142 and 10144
88
The applicant indicates that it offers educational programs
specifically to meet the needs of clinicians in the community.
Harbor Light provides a list of social work board approved
programs on page 73 of CON application #10141.
Harbor Light commits to sponsoring four education seminars
per year for physicians, long-term care facilities and assisted
living facilities. The applicant commits to at least 0.5 FTE of
staff manpower for community education specialist,
expanding community awareness of hospice services.
Hospice of Marion County, Inc. (CON #10142) indicates
that it currently has an active and effective community
outreach and education program in Marion County, adjacent
to Hospice Service Area 3E. The applicant maintains that it
is adept at operating this program, hosting and sponsoring
numerous community events. Staff members have
performed outreach to the following types of
groups/organizations:
Senior centers
Businesses
Health fairs
Churches/synagogues
Schools
Chamber of Commerce
Community centers
Libraries
Hospitals
Town halls
Neighborhood groups
Skilled nursing facilities and assisted living facilities
Non-profit organizations
The applicant states that special community education
efforts, clinical care protocols and bereavement services will
be implemented to increase participation in hospice for
groups traditionally underrepresented in the service area,
especially those of Hispanic heritage. HMC asserts that it
will employ bilingual, Spanish-speaking staff to assist in
these efforts.
CON Action Numbers: 10140, 10141, 10142 and 10144
89
HMC plans a considerable marketing campaign to launch
the proposed program into the services area and foster
community support through regular and frequent
educational seminars. The applicant contends that by
educating the public about the benefits of hospice care,
utilization is expected to increase for all hospice providers in
the area.
VITAS Healthcare Corporation of Florida (CON #10144)
proposes to educate the Subdistrict 3E community through
public forums such as seminars and community education
at churches, schools and other social organizations. The
applicant states that it will offer in-house training to keep
subdistrict health care facilities informed of hospice issues.
VHCF identified numerous groups to which it will provide
education, attend meetings and develop protocols, including:
Florida Health Care Association
Florida Assisted Living Association
Florida Association Directors of Nursing Administration
American Legion
Veterans of Foreign Wars Chapter
Local nursing homes
Local assisted living facilities
United Way
The applicant indicates that it offers many area schools
internship positions and educational opportunities for their
students as a community service. Student LPNs and RNs
participate by doing rotation with the VITAS Hospice
program. In addition, VHCF has condition approval of this
application upon a charitable contribution to United Way of
Lake and Sumter in the amount of up to $225,000 during
the first two years of licensure.
VHCF states that education activities that will be implement
in Subdistrict 3E, upon approval, will include:
Hospice overview
Coping with loss
Pain management
Advance directives
CON Action Numbers: 10140, 10141, 10142 and 10144
90
Children and death
Psychological reaction to terminal illness
Psychological reaction to death
Stress management
Coping with sorrow
Care techniques
The applicant provided a list of projects within communities
where it has chosen to participate both financially and
through employee volunteerism within the following areas of
interest: education, health, civic and culture/arts. VITAS
states that it has made a real commitment to the
communities it serves and provides some benefits it has
supplied. The applicant asserts that it will encourage
involvement in community activities and provide financial
contributions as it can.
(m) Fundraising activities. Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140) indicates that it has a relationship with
Compassionate Care Hospice Foundation, an unrelated not-
for-profit 501(c)3 organization. The foundation’s mission is
to provide the resources necessary to support the
extraordinary needs of hospice patients and their families.
The applicant states that it will not actively raise funds from
the community but if an individual wants to make a
charitable donation, they will be directed to Compassionate
Care Hospice Foundation’s website. Compassionate Care
conditioned approval of CON #10140 on the provision it will
not participate in fundraising activities in Subdistrict 3E. Harbor Light Hospice of Florida, Inc. (CON #10141)
asserts that it will not perform any local fundraising
activities in direct support of its operations. All program
services and activities will be funded by the hospice’s
operations. The applicant indicates that any unsolicited
donations received will be dedicated directly to the
enhancement of its programs in Lake and Sumter Counties.
Harbor Light maintains that the proposed program will have
no impact on the fundraising activities of the existing local
provider.
CON Action Numbers: 10140, 10141, 10142 and 10144
91
Hospice of Marion County, Inc. (CON #10142) indicates
that it regularly receives reimbursement from third-party
payers—increasingly relying on donations to more fully carry
out its mission and vision. The applicant contends that
several factors contribute to this increasing reliance:
The current economic downturn has created increasing
unemployment and less cash for personal spending on
self-pay and for donations.
The amount of charity care provided in 2011 was
$924,279 and through March 2012, it was $161,223.
Hospice reimbursement increases do not meet increasing
inflation of operating expenses, and it is anticipated that
reimbursement will be cut in upcoming years.
Length of stays are very short with 36 percent of patient
on service for 0-7 days.
The organization’s hospice houses are of an age that
requires increased maintenance.
Direct competition has created a need to spend more
dollars in non-patient care expense.
Technology costs will likely increase over the next several
months.
The applicant states that like most hospice programs, it will
rely upon alternative sources of funds to help subsidize its
operations. HMC commits to use the profits of the Thrift
Store, located in The Villages, to provide support for non-
reimbursed programs and charity care for Subdistrict 3E
residents.
HMC indicates that it undertakes a wide variety of
fundraising activities as well as various levels of memorials
and named gifts. Families, friends and other who have been
positively impacted by the applicant’s services can also give:
Lead trusts
Stocks, bonds, annuities
Real estate
Charitable remainder trusts
Bequests and wills
Life insurance gifts
CON Action Numbers: 10140, 10141, 10142 and 10144
92
The applicant notes that it sponsors, participates in or
otherwise supports a wide array of community benefit events
such as horse events, golf tournaments galas, etc. HMC
states that it has four thrift stores as well; the items are
donated by supporters and are sold with proceeds going
directly to patient care.
VITAS Healthcare Corporation of Florida (CON #10144)
agrees that it will not engage in any fundraising events or
campaigns to obtain charitable contributions from residents
of the subdistrict. VHCF will respond to inquiries from
persons seeking to make charitable contributions for hospice
services with information on relevant 501(c)(3) organizations
that benefit Florida residents. Therefore, the applicant
contends, it will not dilute the potential contributions
available in the community or adversely impact existing
hospice programs and their fundraising efforts.
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. 408.035(1)(a) and (b), Florida Statutes.
Need for an additional hospice program is evidenced by the availability,
accessibility and extent to utilization of existing health care facilities and
health services in this service area. The co-batched applicants are
responding to published need of one hospice program in Hospice Service
Area 3E.
The following chart illustrates hospice admissions for the past five years.
As shown below, admissions increased from 2,673 in CY 2007 to 2,817
in 2011. However, the CY 2011 total was greater than only CY 2007’s
during the five years.
Hospice Admissions for Service Area 3E
Calendar Years 2007-2011 Calendar Year Admissions
2011
2010
2009
2008
2007
2,817
2,958
2,979
2,875
2,673 Source: Agency for Health Care Administration Florida Need Projections for
Hospice Programs, 2008-2012.
CON Action Numbers: 10140, 10141, 10142 and 10144
93
Compassionate Care Hospice of Lake and Sumter, Inc. (CON #10140)
states that the Hospice Service Area 3E provider has demonstrated an
increasing failure at serving the market, particularly non-cancer patients
age 65+, resulting in the published need for one additional hospice
provider.
The applicant determined that those diagnosed with end-stage
cardiovascular disease are the leading cause for the gap in those
underserved by hospice. There was a 48 point disparity between non-
cardiac penetration (65.5) and cardiac penetration rates in Hospice
Service Area 3E in calendar year 2010. Compassionate Care contends
that had resident 65+ who died from cardiac disease accessed hospice at
the non-cardiac rate there would have been 584 additional cardiac
admissions to Cornerstone Hospice in calendar year 2010.
In addition to the terminally-ill end stage cardiovascular disease
residents, Compassionate Care asserts it will be a general hospice in
order to meet the needs of all other terminally diagnosed patients,
including cancer patients, in Hospice Service Area 3E.
The applicant indicates that its parent company is in compliance with
the conditions of participation for hospice providers of services under the
Health Insurance for the Aged and Disabled Program as well as the
Medicaid Program. Compassionate Care notes that it has never had
Medicare cap issues, other investigations or focused reviews unlike the
competing applicants in the current batching cycle.
Compassionate Care maintains that it is willing to accept any conditions
on its certificate of need based on any representations made in CON
application #10140. The applicant states that it will provide all required
core components of hospice care set forth by Medicare conditions of
participation as well as Florida hospice licensure requirements.
Compassionate Care asserts that it is a quality focused provider which
invests in the successful training, education, treatment and resources for
staff, physicians, patients and families.
The applicant states that it is a subsidiary of a much larger organization
that has 19 years of experience and has developed several quality
hospice programs throughout the nation. The parent company has a
comprehensive policies and procedure manual that covers a myriad of
topics. Compassionate Care indicates the familiarity with hospice and
the advantage of having the tried and true policies of its parent company
will enable it to provide care in Hospice Service Area 3E in the most
efficient manner.
CON Action Numbers: 10140, 10141, 10142 and 10144
94
Compassionate Care indicates that it will contract for certain services
through the most appropriate and efficient contracts—whether that be
through existing national contracts, extending contracts it has in other
Florida markets or through local contracts. The applicant states it will
ensure staff is educated in the provision of appropriate, high quality
effective and efficient services enabling patients to receive the most
appropriate pain and symptom management to meet the needs.
The applicant contends that hospice services in Lake and Sumter
Counties are currently inaccessible to many qualified patients/families
as evidenced by decreasing penetration rates and the resulting gap in
hospice admissions. Compassionate Care maintains that by approving a
different type of provider, a medium-sized for-profit provider, the Agency
can be assured that access will be enhanced.
The applicant asserts that there is an overwhelming need for end-stage
heart disease patients in Hospice Service Area 3E to have enhanced
access to hospice. Compassionate Care notes that eight cardiologists
offered support for CON application #10140, with three of these
cardiologists quantifying the number of hospice eligible cardiac patients
they currently treat—between 60 and 90. The applicant states that this
supports the need for its Cardiac Connections Program and its forecasted
cardiac volume of 55 in year one and 165 in year two.
Compassionate Care will also provide Veterans programming, specialized
bereavement groups and other disease specific programming such as the
Promise Program for renal disease. In conclusion, the applicant asserts
that it will provide programmatic (clinical) access to appropriate care,
educate the constituent population and provide the highest quality of
patient care possible. Compassionate Care states that its parent
company has history of serving Medicaid recipients and the medically
indigent.
Harbor Light Hospice of Florida, Inc. (CON #10141) states that in
addition to the identified need for one additional hospice program, the
proposed program will expand availability of hospice care throughout the
Lake and Sumter communities as well as enhance access to care for all
components of the local communities.
The applicant indicates that the area is currently served by a single
hospice provider and approval of the proposed program will provide the
incentive for the existing hospice provider to improve and expand the
level of service provided to the residents of Lake and Sumter Counties.
CON Action Numbers: 10140, 10141, 10142 and 10144
95
Harbor Light maintains that the development of the proposed program
will introduce direct competition, resulting in the residents of Lake and
Sumter Counties receiving more and better hospice services.
Harbor Light Hospice of Florida, Inc. is a newly formed corporation part
of a larger organization with a strong reputation for providing quality
hospice for 18 years. The parent company’s on-going commitment to
providing quality hospice services is further demonstrated by its
commitment to seeking accreditation status from The Joint Commission.
Harbor Light indicates that The Joint Commission accredited policies
and procedures in place at Harbor Light’s Nebraska location will be the
basis for the policies and procedures to be reviewed and/or developed for
the proposed program in Hospice Service Area 3E.
The applicant states that it has developed or is in the process of
developing or formalizing existing services into specialty programs to
meet the needs of patients, including: palliative care, Hispanic/Latino
services, wound care, dementia/Alzheimer’s, deaf/hearing impaired,
veteran’s and cardiac services.
The parent company to the applicant has a quality assurance/
performance plan in place at every hospice location and provides an
organization wide “Clinical Practice Council.” The mission of this council
is to ensure quality service delivery and sound performance based on
best clinical practices. The goals of the council include:
Providing quality assurance and safety review
Ensuring compliance with regulatory requirements
Standardizing education and resources for clinical staff and clinical
managers
Reviewing or current clinical policies
Developing new clinical policies and procedures
Implementing of new clinical procedures
Harbor Light states that it has developed a detailed start-up checklist to
utilize for a new business/office development with three major phases:
preparation phase, implementation phase and monitoring phase. The
applicant states that this plan gives it the ability to hire excellent staff
and involve dedicated volunteers, resulting in the provision of excellent
patient care and the development of strong relationships with referral
sources.
CON Action Numbers: 10140, 10141, 10142 and 10144
96
The applicant contends that there is significant hospice market
expansion potential in Hospice Service Area 3E, with a large number of
local residents currently un-served by needed hospice services. Harbor
Light notes that Subdistrict 3E fell just below the Florida average (65.83
percent) with 65.24 percent of all deaths served by hospice, but far below
Hospice Service Area 3C, with the highest hospice utilization rate
observed in State: 89.14 percent. The applicant indicates that an
improvement in hospice utilization for non-cancer patients under age 65
and 65+ is needed and achievable.
Hospice of Marion County, Inc. (CON #10142) asserts that availability,
accessibility, quality of care and extent of utilization in Hospice Service
Area 3E will be improved with the proposed program, primarily as the
result of HMC’s experience, capability and its existing relationships in
the market.
The applicant notes that Hospice Service Area 3E’s penetration rate has
decreased between 2009 and 2011 and states that it is confident that the
extent of utilization of hospice services has substantial room for growth
in Lake and Sumter Counties. HMC states it is well-positioned to
recognize, define and develop strategies to overcome the remaining
barriers and obstacles of access and availability in Hospice Service Area
3E.
HMC indicates that the most significant barrier in the access and
availability of hospice services in the future include:
The continuing ignorance of hospice care among potential consumers
and beneficiaries
Learning of hospice benefits too late to take full advantage of services
Attitudes among potential patients and health care professionals that
resist acknowledgement of death as the likely outcome of a particular
disease process until that process nears its end
The applicant cites its history of strong growth in admissions and the
penetration rate in its adjacent, existing services area as powerful
evidence of its level of understanding the barriers to hospice services that
continue to exist. HMC contends that its staffing plan for Hospice
Service Area 3E, at least 20 FTE positions from the initiation of services,
will be directly involved on a daily basis in communicating with,
educating, and informing the general public and the health care
community.25
25 The reviewer notes that the applicant has a total of 13.70 FTEs of staff added by the proposed project for year one in Schedule 6A.
CON Action Numbers: 10140, 10141, 10142 and 10144
97
HMC asserts that it has created outreach and patient care programs to
address the needs of the Hispanic and veteran communities as utilization
of hospice services varies among different ethnic/racial and population
groups. The applicant contends that when all persons can benefit from
receipt of hospice services at the most effective time in the dying process,
it clearly has a strong and advantageous impact upon quality of care.
The applicant indicates that it currently serves patients in adjacent
Marion County and therefore will be able to initiate high level services
quickly and efficiently upon approval. HMC states that it is prepared to
implement services in Hospice Service Area 3E by January 2013, upon
approval and lack of challenge on the decision. The applicant will
establish a care team office near northern Sumter County is its existing
inpatient hospice facility to implement services and a second care team
office in Leesburg upon initiation of operations.26 HMC asserts that it
will use its vast resources and ability as a regional provider to meet the
growing needs of the district.
HMC expects that its efforts will result in an increase in the current
penetration rate in Hospice Service Area 3E, from the estimated 58.3
percent for 2011 to an anticipated 65.1 percent by calendar year 2015.
The applicant contends that this is consistent with its recent history in
Marion County. HMC asserts that such an increase in the projected level
of hospice care will be a clear enhancement in the existing availability,
accessibility and extent of utilization in Hospice Service Area 3E.
VITAS Healthcare Corporation of Florida (CON #10144) indicates that
it will provide a choice of hospices to residents of Hospice Service Area
3E and increase outreach to underserved population groups as well as
the population as a whole to increase admission rates. The applicant
indicates that state policy dictates the need for the proposed program as
shown by the extent of utilization by the existing hospice service.
VHCF is projecting year one admissions of 214 patients and year two
admissions of 423 patients. The applicant maintains that this is a
reasonable projection based on its recent Florida experience. VHCF
notes that Cornerstone had a total of 4,251 admissions statewide and
2,817 admissions in Hospice Service Area 3E in calendar year 2011.
26 Hospice of Marion County’s existing Tuscany House is located at 17395 SE 109th Terrace Road, Summerfield, Florida—an unincorporated community in Marion County.
CON Action Numbers: 10140, 10141, 10142 and 10144
98
The applicant states that it is compliance with the conditions of
participation for hospice providers of services under the Health
Insurance for the Aged and Disabled Program as well as the Medicaid
program. VHCF maintains that it has many unique features that
enhance quality of care, including:
Providing continuous care to keep patients comfortably at home
which is the most desired location for terminal patients. By year two
VHCF will provide at least five percent of total patient days in
continuous care.
Implementation of procedures to produce a 70 percent reduction in
pain score within 48 hours (a much higher standard than the 50
percent in 96 hours as identified in Florida Statutes).
Culturally sensitive programs developed in conjunction with leading
national agencies to address African-American, Hispanic/Latino and
other cultural and religious ethics, practices and beliefs.
Providing telecommunication resources for patients to maintain
contact with caregivers.
Significant technological investment to enhance patient care.
Twenty-four hour staff availability with patient records at their
fingertips to immediately respond to patient and family inquiries.
Extensive commitment to training programs (WINKS, THINKS, INET
and others).
Having every patient assessed by a physician within 24 hours of
admission to the hospice. Medical directors visit patients in their
residence.
Medical directors must be board-certified in hospice or palliative care
medicine, or apply for board certification within five years of
employment.
RNs are encouraged to become certified in hospice and palliative care
nursing. By the second year of operation, 50 percent of all
supervisory nurses will attain such certification.
Masters of Divinity or equivalent graduate degree from an accredited
seminary or theological school required for chaplains.
Social workers have a Master’s degree or are licensed clinical social
workers.
VHCF maintains that hospice offices increase the visibility of a hospice in
the community. The applicant states that it has conditioned approval of
CON #10144 upon the provision that it will open offices in both counties
during the first year of operation. The initial office will be located in the
Leesburg area. VHCF will rely on conversations with health care
providers, public officials and community leaders in Sumter County as
well as its early operations experience to determine where to locate the
office in Sumter County.
CON Action Numbers: 10140, 10141, 10142 and 10144
99
The applicant asserts that it is well known throughout the communities
where it provides services and welcomes charity care patients. The
applicant indicates that VITAS provides in excess of one percent of
revenues in charity care—amounting to approximately $9.9 million in
2011, and VHCF provided $4.5 million in charity care.
VHCF indicates that it, and its parent, have the scale and experience to
establish and operate extremely efficient hospice programs. The
applicant provides some factors that contribute to this efficiency:
VITAS has successfully started four hospices nationwide since 2010,
including a hospice in Florida. Since 2001, it has had 26 successful
hospice startups. VITAS has the experience and resources to start a
hospice in Subdistrict 3E quickly and inexpensively. The last two new
hospices in Florida granted to VITAS were licensed in an average of 34
days after final CON approval.
VHCF is the highest volume hospice in Florida, licensed to served 16
counties, where over half of Florida’s population resides. Establishing
a hospice in Subdistrict 3E will be an extension of existing services.
All VHCF operations are under a single Medicare provider number
and VHCF services in Subdistrict 3E will not require separate
Medicare certification.
VHCF operations in Subdistrict 3E will not require a separate state
license.
VHCF already has in place the information technology, human
resources, training and managed care contracts needed to support
services in Subdistrict 3E.
For vendors who provide goods and services statewide, VHCF already
has supply contracts in place and will not need to negotiate new
contracts before commencing services in Subdistrict 3E.
The applicant states that VITAS, recognizes it responsibility to admit only
appropriate patients and has taken several important steps in this
regard, including:
VITAS performs patient eligibility review at local and corporate levels
VITAS’ admissions criteria is used to ensure that only individuals
whose condition is appropriate for hospice care are admitted
VITAS created the VITAS Hospice Eligibility Reference Guide App
CON Action Numbers: 10140, 10141, 10142 and 10144
100
VHCF indicates that VITAS’ experience with patients who remain in
hospice over six months is nearly identical to the national average. The
applicant notes that during 2011, less than 11.9 percent of all of VITAS’
admissions had a length of stay longer than six months. Data published
by the NHPCO reported that 11.8 percent of all patients in 2009 and
2010 stayed in hospice care for longer than 180 days nationwide.
The applicant will place a priority of the following components:
Managing customer expectations
Training and expert staff
Making each customer encounter successful
Proactive quality monitoring
Applying research experience to improve patient care
b. Does the applicant have a history of providing quality of care? Has
the applicant demonstrated the ability to provide quality care? ss. 408.035(1), (c), Florida Statutes.
Compassionate Care Hospice of Lake and Sumter, Inc. (CON #10140)
states that it is a shell entity and therefore has no operational history.
However, its parent company has been providing quality hospice care for
19 years and it recently successfully initiated hospice service in Hospice
Service Area 6B (Polk, Highlands and Hardee Counties). The applicant
indicates that it will rely upon the parent’s wealth of knowledge,
expertise, experience and skills in developing and operating within
Hospice Service Area 3E.
The applicant notes that its parent company has 32 hospice programs in
approximately 56 office locations operating in 21 states. In addition to
initiating services in Hospice Service Area 6B, the parent company has a
pending certificate of need application to serve Miami-Dade and Monroe
Counties awaiting a final decision from Florida’s Division of
Administrative Hearings.
Compassionate Care states that the parent’s operations have had no
licensure violations and no Medicare cap issues. All programs are either
already enrolled in both Medicare and Medicaid programs or are actively
awaiting certification. The parent is a member of the National Hospice
and Palliative Care Organization and ascribes to its policies and
procedures.
CON Action Numbers: 10140, 10141, 10142 and 10144
101
The applicant maintains that its parent commitment to quality care
manifest in a variety of ways including:
High levels of planned employee staffing standards that surpass
NHPCO recommended guidelines in positions such as a 1:3 aide to
patient ratio in home health aides
Uniquely tailored programs that go beyond core hospice services
Commitment to provide all four levels of care (routine, inpatient,
respite and continuous care) as needed
Expertise in start-up operations throughout the county, with a focus
on catering to the needs of every local market
Compassionate Care states that the parent has provided the utmost in
quality care to its patients and their families. The applicant provided a
list of activities the parent currently participates in to achieve this
quality, including:
CHAP Accreditation
Surpassing NHPCO staffing standards as well as national
benchmarks
A Quality Assessment and Performance Improvement Plan
Benchmarking
Patient/family satisfaction surveys
Continuing education, in-service training and memberships in quality
associations
Agency records indicate that Compassionate Care had one substantiated
complaint for the period since it initiated service in Hospice Service Area
6B on February 22, 2011. The substantiated complaint was related to
resident/patient/client rights. It is noted that the applicant did not
participate in voluntary reporting between October 2011 and December
2011, on the Florida Health Finder, Hospice Provider Family Satisfaction
Survey.
Harbor Light Hospice of Florida, Inc. (CON #10141) indicates that it is
a newly formed Florida organization with a parent company that has five
separate entities providing hospice services in 19 locations in eight
states. All of the parent company’s hospice locations are licensed by the
states in which they operate and are Medicare and Medicaid certified.
The applicant states it has conditioned the approval of CON application
#10141 that the proposed program will receive Joint Commission
accreditation by the end of the first year of operation.
CON Action Numbers: 10140, 10141, 10142 and 10144
102
Hospice of Marion County, Inc. (CON #10142) states that it has a long
and distinguished history of providing quality of care to its patients. The
applicant notes that it is accredited by the Joint Commission and is
licensed by the Agency for Health Care Administration. HMC is a
provider of Medicare/Medicaid benefits, a member of the National
Hospice and Palliative Care Organization, a member Florida Hospices
and Palliative Care, Inc. and was recently selected as one of nine
hospices in the nation to participate in the Center for Medicare and
Medicaid Services quality reporting initiative.
The applicant provides pertinent dates in the development of its existing
program on page 149 as well as a list of awards it has received in recent
years on page 150 of CON application #10142. HMC states that it
operates in compliance with all federal, state and local statutes,
regulations and ordinances. The applicant indicates that operating
policies, procedures, practices and protocols are in place as well as the
QAPI Plan which will be utilized to initiate services in the proposed
program. HMC asserts that it is fully confident in its ability to extend its
existing high quality hospice care program throughout neighboring
Hospice Service Area 3E.
Agency records indicate that HMC had no substantiated complaints for
the three-year period ending June 26, 2012 in hospice service area 3B.
It is noted that the applicant did participate in voluntary reporting
between October 2011 and December 2011, on the Florida Health
Finder, Hospice Provider Family Satisfaction Survey. HMC had between
68 and 79 survey respondents receiving five star ratings (90 to 100
percent satisfaction) in all categories.
VITAS Healthcare Corporation of Florida (CON #10144) states that it
is an existing licensed hospice and has been in operation for more than
30 years, setting the standard for other hospices as well as extensive
experience in the operation of hospices throughout Florida. VHCF
programs have earned hospice accreditation from the National Institute
for Jewish Hospice as well as The Joint Commission and CHAP. In
addition, the corporate body of VITAS maintains current accreditation by
The Joint Commission and CHAP.
The applicant notes that the proposed program will operate under an
existing Medicare provider number and may not justify the delay and
expense of an external accreditation process. VHCF asserts that
regardless of external accreditation, the proposed program in 3E will
adhere to the same policies, procedures and standards for the VITAS
programs that are externally accredited.
CON Action Numbers: 10140, 10141, 10142 and 10144
103
VHCF provides a timeline of its history and quality of care on pages 98-
99 of CON application #10144—including that it has provided hospice
services since 1978, has an average daily census of over 5,000 patients
and serves more than 24,400 patients annually.
The applicant indicates that it will implement a quality assurance
program consistent with its existing programs in Florida. The objectives
of VHCF’s Quality Improvement Program are as follows:
To identify patient care quality areas for improvement
To ensure the care provided is appropriate to patient needs
To revise procedures as necessary
To attain these objectives, VHCF will establish and implement a system
to:
Continually assess and improve the care and services provided to
patients and their families
Routinely collect and report data on the quality of care
Annually conduct an overall review of the program and all services
provided
Annually complete studies of symptom management, stress,
continuity of care and inpatient care
The applicant states that the information obtained via the quality of
services and quality of outcomes monitoring is reviewed by the joint
practice/utilization review committee. The committee meets at least
quarterly to review audit results, infection and incident tracking,
complaint patterns and resolution, outcomes management reports and
performance improvement activities.
VHCF employs a satisfaction survey to determine how well it is meeting
the needs of patients, families, referral sources and attending physicians.
VITAS will provide access to both the surveys and to software for
analyzing survey results by computer.
Agency records indicate that VHCF has four substantiated complaints for
the three-year period ending June 26, 2012 in hospice Service Areas 4A,
4B, 7A, 7B, 7C, 8B, 9C, 10 and 11. A single complaint can encompass
multiple complaint categories.
CON Action Numbers: 10140, 10141, 10142 and 10144
104
VHCF Substantiated Complaint Categories in the Past 36 Months
Complaint Category Number Substantiated
Administration/Personnel 2
Quality of Care/Treatment 2
Nursing Services 2
Plan of Care 1
Resident/Patient/Client Assessment 1 Source: Agency for Health Care Administration complaint records.
It is noted that the applicant did participate in voluntary reporting
between October 2011 and December 2011, on the Florida Health
Finder, Hospice Provider Family Satisfaction Survey and was listed under
three different headers. VITAS Healthcare Corporation of Florida
22910014, North Miami Beach had between 214 and 275 survey
respondents. VITAS Healthcare Corporation of Florida, 22960083,
Boynton Beach had between 281 and 383 survey respondents. VITAS
Healthcare Corporation of Florida 22960086, Melbourne had between
168 and 201 survey respondents. All three received five-star ratings (90
to 100 percent satisfaction) in all categories.
c. What resources, including health manpower, management
personnel, and funds for capital and operating expenditures, are available for project accomplishment and operation? ss. 408.035(1)(d), Florida Statutes.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140): The audited financial statements of the applicant were
reviewed to assess the financial position as of the balance sheet date and
the financial strength of its operations for the period presented.
The applicant is a Florida for-profit corporation and a development stage
company that was formed on April 6, 2012, for the purpose of operating
a hospice in Florida, with net assets of $150,000 and no liabilities for the
period ended June 5, 2012. As of the date of the audit, no operating
results were available. Without results from operations, an analysis of
the short and long-term strength of the applicant cannot be made.
Capital Requirements:
Schedule 2 indicates total capital projects of $152,965 which is the CON
subject to this review and capital expenditures. In addition, the
applicant will have to fund the projected year one operating loss of
$292,402.
CON Action Numbers: 10140, 10141, 10142 and 10144
105
Available Capital:
The applicant provided a letter from Compassionate Care Group, Ltd
(Parent) which states the parent will provide funding for the project. The
applicant states that the parent’s December 31, 2011 financial
statements show $3.5 million available for taxes and investments.
However, no audited financial statements of the parent were provided,
only an unaudited profit and loss statement. The parent provided a
letter, dated June 27, 2011, from TD Bank indicating the parent has a
$2,000,000 revolving line of credit. The parent did not provide a
statement from the bank indicating the current available balance in the
revolving line of credit. Without a current available balance for the line
of credit and/or current audited financial statements, we cannot rely on
the information presented in the application that would support the
parent’s ability to fund the project. Therefore, funding for this project is
in question. Staffing:
Compassionate Care Proposed Staffing for Subdistrict 3E
April 2013-March 2015 First Two Years of Operation
Position
Average Number of FTEs Year One
Average Number of FTEs Year Two
Administrator 1.0 1.0
Professional Relations Coordinator 1.0 1.0
Secretary 1.0 2.0
Community Liaison 0.5 1.0
Clinical Coordinator 1.0 1.0
Medical Director 0.2 0.5
Registered Nurses 2.0 4.5
Per Diem Registered Nurses 0.3 1.0
LPN 0.0 1.0
Per Diem LPN 0.0 0.5
Nurses’ Aides 6.0 14.0
Nurse Practitioner 1.0 1.0
Per Diem Nurses’ Aides 0.4 1.6
Continuous Care Per Diem LPN 0.6 1.81
Continuous Care Per Diem Aide 0.6 1.81
Life Enhancement Specialist 0.2 1.0
Music Therapist 0.2 0.5
Massage Therapist 0.2 0.5
Dietary Services 0.2 0.5
Social Worker 1.0 2.0
Volunteer Coordinator 0.5 1.0
Chaplain 0.5 1.0
Total 18.4 40.22 Source: CON application #10140, page 87.
Conclusion:
Funding for this project is in question.
CON Action Numbers: 10140, 10141, 10142 and 10144
106
Harbor Light Hospice of Florida, Inc. (CON #10141): The audited
financial statements of the applicant were reviewed to assess the
financial position as of the balance sheet date and the financial strength
of its operations for the period presented.
The applicant is a Florida for-profit corporation and a development stage
company that was formed on April 26, 2012 for the purpose of operating
a hospice in Florida, with net assets of negative $297 and $297 in
liabilities for the period ended May 31, 2012. The audit indicates that
the applicant is economically dependent upon the stockholders and an
affiliate to provide working capital. As of the date of the audit, no
operating results were available. Without results from operations, an
analysis of the short and long-term strength of the applicant cannot be
made. Capital Requirements:
Schedule 2 indicates total capital projects of $176,460 which is the CON
subject to this review. In addition, the applicant will have to fund the
projected year one operating loss of $254,559.
Available Capital:
The applicant provided a letter from its parent corporation, Hospice of
America, Inc. (parent), which states the parent will provide funding for
the project. It should be noted that the applicant included operating
results of its parent. However, the operating results provided by the
parent are unaudited. An audit report gives an independent opinion on
whether or not the financial statements are presented fairly in all
material respects. Without an audit, we cannot rely on the information
presented in the parent’s financial statements. The applicant did provide
a revolving note, signed on 2/24/12, from The Private Bank indicating
the parent has a $2 million revolving line of credit. However, the line of
credit is not guaranteed and subject to disapproval. Therefore, funding
for this project is in question.
CON Action Numbers: 10140, 10141, 10142 and 10144
107
Staffing:
Harbor Light Proposed Staffing for Subdistrict 3E Calendar Year 2013 and 2014 First Two Years of Operation
Position
Average Number of FTEs Year One
Average Number of FTEs Year Two
Marketing 1.2 2.0
Executive Director 1.0 1.0
Supervisor 0.3 1.2
Office 0.7 1.0
Patient Care Coordinator 0.7 1.0
Medical Director 0.02 0.1
R.N.’s 1.1 4.7
L.P.N.’s 0.4 1.7
HHAs 1.1 4.7
Bereavement Coordinator/Chaplain 0.3 1.2
MSW/Volunteer Coordinator 0.6 2.4
Total 7.4* 20.9* *These numbers should be 7.42 and 21, respectively.
Source: CON application #10141, Schedule 6A, page 130.
Conclusion:
Funding for this project is in question.
Hospice of Marion County, Inc. (CON #10142): The applicant, a
Florida not-for-profit corporation, provided audited financial statements
for the periods ending December 31, 2011 and 2010. These statements
were analyzed for the purpose of evaluating the applicant’s ability to
provide the capital and operational funding necessary to implement the
project.
Short-Term Position:
The applicant’s current ratio of 1.9 indicates current assets are greater
than current obligations in the amount $3.6 million, is slightly below
average an adequate position. The ratio of cash flow to current liabilities
of 0.6 is below average and a slightly weak position. Overall, the
applicant has an adequate short-term position. (See Table 1).
Long-Term Position:
The ratio of long-term debt to net assets of 0.6 indicates the applicant
has less equity than long-term debt, a weak position. The ratio of cash
flow to assets of 9.0 percent is slightly below average and an adequate
position. The most recent year had an operating gain of $265,292, which
resulted in a 0.9 percent operating margin. Overall, the applicant has an
adequate long-term position. (See Table 1).
CON Action Numbers: 10140, 10141, 10142 and 10144
108
Capital Requirements:
Schedule 2 indicates total capital projects of $1.19 million which consist
of the CON subject to this review, routine capital equipment and
maturities of long-term debt. In addition, the applicant will have to fund
the projected year one operating loss of $700,784.
Available Capital:
Funding for this project will be provided by the applicant. Based on our
review, the applicant has available working capital of $3.6 million and
cash flow from operations of $2.5 million. The applicant appears to have
sufficient capital to fund this project and the entire capital budget.
TABLE 1
Hospice of Marion County - CON# 10142
12/31/2011
Current Assets (CA) $7,523,494
Cash and Current Investment $4,655,693
Total Assets (TA) $27,584,782
Current Liabilities (CL) $3,907,470
Total Liabilities (TL) $12,751,049
Net Assets (NA) $14,833,733
Total Revenues (TR) $28,432,889
Interest Expense (IE) $498,449
Operating Income (OI) $265,592
Cash Flow from Operations (CFO) $2,492,924
Working Capital $3,616,024
FINANCIAL RATIOS
12/31/2011
Current Ratio (CA/CL) 1.9
Cash Flow to Current Liabilities (CFO/CL) 0.6
Long-Term Debt to Net Assets (TL-CL/NA) 0.6
Times Interest Earned (OI+IE/IE) 1.5
Net Assets to Total Assets (NA/TA) 53.8%
Operating Margin (OI/TR) 0.9%
Return on Assets (OI/TA) 1.0%
Operating Cash Flow to Assets (CFO/TA) 9.0%
CON Action Numbers: 10140, 10141, 10142 and 10144
109
Staffing:
Hospice of Marion County Proposed Staffing
Subdistrict 3E Calendar Years 2013 and 2014 First Two Years of Operation
Position
Average Number of FTEs Year One
Average Number of FTEs Year Two
Medical Records Clerk 0.5 1.0
Volunteer Services ---- 0.5
All Other Administration 2.75 3.5
Physicians 0.25 0.35
Clinical Coordinator 1.0 1.0
R.N.’s 4.5 6.0
L.P.N.’s 1.5 1.5
Hospice Aides 1.5 3.0
Pharmacy ---- 0.5
Dietician 0.2 0.2
Social Worker 0.75 1.5
Chaplain 0.5 1.0
Bereavement Counselors 0.25 0.5
Total 13.7 20.55 Source: CON application #10142, Schedule 6A.
Conclusion:
Funding for this project should be available as needed.
VITAS Healthcare Corporation of Florida (CON #10144): The
applicant, a Florida for-profit corporation, provided audited financial
statements for the periods ending December 31, 2011 and 2010. These
statements were analyzed for the purpose of evaluating the applicant’s
and parent’s ability to provide the capital and operational funding
necessary to implement the project.
Short-Term Position:
The applicant’s current ratio of 1.1 indicates current assets are slightly
greater than current obligations, but is below average and a slightly weak
position. The ratio of cash flow to current liabilities of 3.1 is well above
average and a strong position. Overall, the applicant has an adequate
short-term position. (See Table 1).
Long-Term Position:
The ratio of long-term debt to net assets of 0 indicates the applicant has
no long-term debt, a strong position. The ratio of cash flow to assets of
24.3 percent is above average and a strong position. The most recent
year had an operating income of $66,317,556, which resulted in a 17.4
percent operating margin. Overall, the applicant has a strong long-term
position. (See Table 1).
CON Action Numbers: 10140, 10141, 10142 and 10144
110
Capital Requirements:
Schedule 2 indicates total capital projects of $6.45 million which consist
of the CON subject to this review, current year capital expenditures for
Florida and non-specified capital expenditures.
Available Capital:
Funding for this project will be provided by the applicant. Based on our
review, the applicant has available working capital of $2,780,607 and
cash flow from operations of $63.5 million. The applicant appears to
have sufficient capital to fund this project and the entire capital budget.
TABLE 1
VITAS Healthcare Corporation of Florida - CON# 10144
12/31/2011
Current Assets (CA) $23,144,885
Cash and Current Investment $0
Total Assets (TA) $260,917,116
Current Liabilities (CL) $20,364,278
Total Liabilities (TL) $20,364,278
Net Assets (NA) $240,552,838
Total Revenues (TR) $382,024,540
Interest Expense (IE) $0
Operating Income (OI) $66,317,556
Cash Flow from Operations (CFO) $63,467,807
Working Capital $2,780,607
FINANCIAL RATIOS
12/31/2011
Current Ratio (CA/CL) 1.1
Cash Flow to Current Liabilities (CFO/CL) 3.1
Long-Term Debt to Net Assets (TL-CL/NA) 0.0
Times Interest Earned (OI+IE/IE) N/A
Net Assets to Total Assets (NA/TA) 92.2%
Operating Margin (OI/TR) 17.4%
Return on Assets (OI/TA) 25.4%
Operating Cash Flow to Assets (CFO/TA) 24.3%
CON Action Numbers: 10140, 10141, 10142 and 10144
111
Staffing:
VHCF Proposed Staffing for Subdistrict 3E
October 2012-September 2014 First Two Years of Operation
Position
Average Number of FTEs Year One
Average Number of FTEs Year Two
General Manager/Administrator 1.00 1.00
Admissions/Hospice
Reps/Community Liaison
3.46
4.50
Bereavement Manager 0.71 1.00
Business Manager 0.83 1.00
PC Secretary 1.00 1.50
Receptionist 0.75 2.00
Medical Director/Physician 0.45 0.93
Team Director (RN) 1.25 2.25
Continuous Care Manager 0.00 0.75
RNs 3.06 6.74
LPN/Aides 7.65 24.15
On-Call Representatives 1.58 2.00
Social Worker 1.21 1.83
Chaplain 1.00 1.13
Total 23.96* 50.78 *This number should be 23.95.
Source: CON application #10144, Schedule 6A.
Conclusion:
Funding for this project should be available as needed.
d. What is the immediate and long-term financial feasibility of the
proposal? ss. 408.035 (1)(f), Florida Statutes.
The following applies to all applicants. Schedule 7 of the application
indicates that the services to be provided are routine home care,
continuous home care, inpatient respite, and general inpatient care.
The Department of Health and Human Services sets rates for routine
home care, continuous home care, inpatient respite care, and general
inpatient care. The Federal rates were calculated for Broward County,
Florida wage index for Medicare Hospice payments of 1.0499 and inflated
through the appropriate period for each applicant. The average price
adjustment factor used was 2.9 percent per year based on the new CMS
Market Basket Price Index as published in the 1st Quarter 2010 Health
Care Cost Review.
Estimated patient days for each level of service from Schedule 7, year two
were multiplied by the calculated reimbursement rate for that service in
order to estimate the total revenue that would be generated by that
number of patient days. The results were then compared to the
applicant’s estimated gross revenue. The results of the calculations are
summarized in the table for each applicant below.
CON Action Numbers: 10140, 10141, 10142 and 10144
112
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140): For year two of operations, the applicant projected the
following percentage of total patient days by group: Medicare at 94.1
percent, Medicaid at 3.0 percent, self-pay/charity at 1.3 percent, and
commercial insurance and other payers at 1.6 percent.
The applicant’s projected gross revenue was 0.8 percent, or $27,362, less
than the calculated gross revenue. Operating profits from this project
are expected to increase from an operating loss of $292,402 for year one
to an operating profit of $287,782 for year two.
The applicant offered several conditions to its proposed hospice program.
None of the conditions appear to have a material financial impact to the
projections. Conclusion:
Assuming the applicant can obtain the necessary financing, this project
appears to be financially feasible.
HOSPICE REVENUE TABLE 1
CON #10140 Compassionate Care Hospice of Lake & Sumter, Inc.
Wage Index for Lake County(0.8705)
Wage Component Wage Index
Adjusted Wage
Amount Unadjusted Component
Payment Rate
Routine Home Care $103.77 0.8705 $90.33 $47.26 $137.59
Continuous Home Care $605.65 0.8705 $527.22 $275.81 $803.03
Inpatient Respite $84.56 0.8705 $73.61 $71.66 $145.27
General Inpatient $430.04 0.8705 $374.35 $241.80 $616.15
Payment Rate
Inflation Factor Year
Two
Inflation Adjusted Amount
Patient Days Year 2,
December 31 -2014
Calculated Gross
Revenue
Routine Home Care $137.59 1.077 $148.24 20,553 $3,046,752
Continuous Home Care $803.03 1.077 $865.17 314 $271,663
Inpatient Respite $145.27 1.077 $156.51 21 $3,287
General Inpatient $616.15 1.077 $663.83 210 $139,404
Total 21,098 $3,461,105
From Schedule 7 $3,433,743
Difference
-$27,362
Percentage difference -0.80%
CON Action Numbers: 10140, 10141, 10142 and 10144
113
Harbor Light Hospice of Florida, Inc. (CON #10141): For year two of
operations, the applicant projected the following percentage of total
patient days by group: Medicare at 92.0 percent, Medicaid at 4.0 percent,
self-pay/charity at 2.0 percent, and commercial insurance and other
payers at 2.0 percent.
The applicant’s projected gross revenue was 0.57 percent, or $13,807,
less than the calculated gross revenue. Operating profits from this
project are expected to increase from an operating loss of $254,559 for
year one to an operating profit of $240,498 for year two.
The applicant offered several conditions to its proposed hospice program.
None of the conditions appear to have a material financial impact to the
projections.
Conclusion:
Assuming the applicant can obtain the necessary financing, this project
appears to be financially feasible.
HOSPICE REVENUE TABLE 2
CON #10141 Harbor Light Hospice of Florida, Inc.
Wage Index for Lake County(0.8705)
Wage Component Wage Index
Adjusted Wage
Amount Unadjusted Component
Payment Rate
Routine Home Care $103.77 0.8705 $90.33 $47.26 $137.59
Continuous Home Care $605.65 0.8705 $527.22 $275.81 $803.03
Inpatient Respite $84.56 0.8705 $73.61 $71.66 $145.27
General Inpatient $430.04 0.8705 $374.35 $241.80 $616.15
Payment Rate
Inflation Factor Year
Two
Inflation Adjusted Amount
Patient Days Year 2,
December 31 -2014
Calculated Gross
Revenue
Routine Home Care $137.59 1.069 $147.06 13,584 $1,997,694
Continuous Home Care $803.03 1.069 $858.30 287 $246,332
Inpatient Respite $145.27 1.069 $155.27 140 $21,738
General Inpatient $616.15 1.069 $658.56 287 $189,007
Total 14,298 $2,454,771
From Schedule 7 $2,440,964
Difference
-$13,807
Percentage difference -0.57%
CON Action Numbers: 10140, 10141, 10142 and 10144
114
Hospice of Marion County, Inc. (CON #10142): For year two of
operations, the applicant projected the following percentage of total
patient days by group: Medicare at 89.9 percent, Medicaid at 5.7 percent,
self-pay/charity at 1.4 percent, and commercial insurance at 3.0
percent.
Based on our calculation, the applicant’s projected gross revenue was
14.5 percent, or $503,910, more than the calculated gross revenue. The
reason for the overstatement is, most likely, an “Other” source of income
which was not identified in the schedules and is not based on patient
days. In any event, overstating revenue is not a conservative assumption
and is potentially unreasonable.
Operating profits from this project are expected to increase from a loss of
$271,773 for year one to a profit of $234,041 for year two. It should be
noted that the $458,577 “Other” revenue has a significant impact on the
profitability of this project. Without such revenue, the project would be
in a loss position for year two.
Conclusion:
This project appears to be financially feasible dependent on the source of
other operating revenue discussed above.
CON Action Numbers: 10140, 10141, 10142 and 10144
115
HOSPICE REVENUE TABLE 2
CON #10142 Hospice of Marion County
Wage Index for Lake County(0.8705)
Wage Component Wage Index
Adjusted Wage
Amount Unadjusted Component
Payment Rate
Routine Home Care $103.77 0.8705 $90.33 $47.26 $137.59
Continuous Home Care $605.65 0.8705 $527.22 $275.81 $803.03
Inpatient Respite $84.56 0.8705 $73.61 $71.66 $145.27
General Inpatient $430.04 0.8705 $374.35 $241.80 $616.15
Payment Rate
Inflation Factor Year
Two
Inflation Adjusted Amount
Patient Days Year 2,
December 31 -2014
Calculated Gross
Revenue
Routine Home Care $137.59 1.069 $147.06 14,763 $2,171,081
Continuous Home Care $803.03 1.069 $858.30 287 $246,332
Inpatient Respite $145.27 1.069 $155.27 49 $7,608
General Inpatient $616.15 1.069 $658.56 845 $556,483
Total 15,944 $2,981,504
From Schedule 7 $3,485,414
Difference
$503,910
Percentage difference 14.46%
VITAS Healthcare Corporation of Florida (CON #10144): For year two
of operations, the applicant projected the following percentage of total
patient days by group: Medicare at 92.4 percent, Medicaid at 4.5 percent,
self-pay/charity at 1.1 percent, and commercial insurance at 2.0
percent.
Based on our calculation, the applicant’s projected gross revenue was
equal to the calculated gross revenue, a conservative position.
Operating profits from this project are expected to increase from a loss of
$651,375 for year one to a profit of $41,399 for year two.
Conclusion:
This project appears to be financially feasible.
CON Action Numbers: 10140, 10141, 10142 and 10144
116
HOSPICE REVENUE TABLE 2
CON #10144 VITAS Healthcare Corporation of Florida
Wage Index for Lake County(0.8705)
Wage Component Wage Index
Adjusted Wage
Amount Unadjusted Component
Payment Rate
Routine Home Care $103.77 0.8705 $90.33 $47.26 $137.59
Continuous Home Care $605.65 0.8705 $527.22 $275.81 $803.03
General Inpatient $430.04 0.8705 $374.35 $241.80 $616.15
Physician Services $0.00 0.8705 $0.00 $0.00 $0.00
Payment Rate
Inflation Factor Year
Two
Inflation Adjusted Amount
Patient Days Year 2,
December 31 -2014
Calculated Gross
Revenue
Routine Home Care $137.59 1.062 $146.11 18,653 $2,725,438
Continuous Home Care $803.03 1.062 $852.76 1,383 $1,179,365
General Inpatient $616.15 1.062 $654.31 821 $537,186
Physician Services $0.00 1.062 $0.00 4,905 $0
Total 25,762 $4,801,135
From Schedule 7 $4,801,135
Difference
$0
Percentage difference 0.00%
e. Will the proposed project foster competition to promote quality and
cost-effectiveness? ss. 408.035(1) (g), Florida Statutes.
The following applies to all applicants. Each co-batched applicant is
offering a new choice of provider in the hospice service area.
This application is for a new hospice program in Hospice Service Area
3E, which currently has one existing hospice program. Therefore, this
project is offering a new choice of provider in the Lake and Sumter
service areas.
The impact of the price of services on consumer choice is limited to the
payer type. Most consumers do not pay directly for hospice services
rather they are covered by a third-party payer. The impact of price
competition would be limited to third-party payers that negotiate price
for services, namely managed care organizations. Therefore, price
competition is limited to the share of patient days that are under
managed care plans.
CON Action Numbers: 10140, 10141, 10142 and 10144
117
With the large majority of patient care being provided from fixed price
government payer sources, this project is not likely to have any
discernible positive impact on price-based competition to promote cost
effectiveness. As providers offer new or enhanced services to patients
and families as a means to compete on quality measures, cost
effectiveness would be impacted since the new or enhanced services
would be offered despite the large percentage of fixed priced government
payers. In other words, the potential exists for new or enhanced services
to be provided for the same federal and state dollars.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140): The applicant is projecting 1.6 percent of its patient
days from managed care/commercial insurance payers with 97.1 percent
of patient days expected to come from fixed price government payer
sources (Medicare and Medicaid), with the remaining 1.3 percent as self-
pay/charity.
Harbor Light Hospice of Florida, Inc. (CON #10141): The applicant is
projecting 2.0 percent of its patient days from managed care/commercial
insurance payers with 96.0 percent of patient days expected to come
from fixed price government payer sources (Medicare and Medicaid), with
the remaining 2.0 percent as self-pay/charity.
Hospice of Marion County, Inc. (CON #10142): The applicant is
projecting 3.0 percent of its patient days from managed care/commercial
insurance payers with 95.6 percent of patient days expected to come
from fixed price government payer sources (Medicare and Medicaid), with
the remaining 1.4 percent as self-pay/charity.
VITAS Healthcare Corporation of Florida (CON #10144): The
applicant is projecting 2.0 percent of its patient days from managed
care/commercial insurance payers with 96.9 percent of patient days
expected to come from fixed price government payer sources (Medicare
and Medicaid), with the remaining 1.1 percent as self-pay/charity.
Conclusion:
These projects are not likely to result in price-based competition.
CON Action Numbers: 10140, 10141, 10142 and 10144
118
f. Are the proposed costs and methods of construction reasonable? Do they comply with statutory and rule requirements? ss. 408.035(1)(h), Florida Statutes.
Each of the co-batched applicants is requesting approval to establish a
new hospice program. There are no construction costs and methods
associated with the proposals.
g. Does the applicant have a history of providing health services to
Medicaid patients and the medically indigent? Does the applicant propose to provide health services to Medicaid patients and the medically indigent? ss. 408.035(1)(i), Florida Statutes.
Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140) states that its parent has an extensive history of
providing services to Medicaid patient and the medically indigent. In
addition, the applicant notes that its Cardiac Connection Program saves
Medicare an average of $22,000 for each person enrolled.
Compassionate Care asserts that it will admit patients to the program,
regardless of their ability to pay. The applicant projects three percent of
total patient days in both years one and two of the proposed program will
be Medicaid payers and 1.3 percent in both years will be provided to
charity care patients.
Harbor Light Hospice of Florida, Inc. (CON #10141) states that its
parent organization’s hospice locations accepts all hospice appropriate
patient referrals and accepts all patients without regard to race, color,
national origin, disability, age or ability to pay for admission, treatment
or participation in its hospice programs, services, activities or
employment. The parent company indicates that it has historically
provided three or four percent of its volume to the Medicaid population.
The applicant notes that the financial schedules in CON application
#10141 provide for 4.0 percent Medicaid and 2.0 percent
charity/indigent.
Hospice of Marion County, Inc. (CON #10142) indicates that it has a
history of providing health services to all patients that require hospice
care without regard to age, sex, race, ethnic group, diagnosis or ability to
pay. The applicant notes that it provided approximately $903,000 in
charity care to its hospice patients in fiscal year 2009. HMC commits to
use the profits of the Thrift Store, located in The Villages, to support non-
reimbursed programs and charity care in Hospice Service Area 3E. The
applicant provides the projected payer mix for the proposed program for
the first two years of operation. See the table below.
CON Action Numbers: 10140, 10141, 10142 and 10144
119
Hospice of Marion County, Inc.
Projected Patient Days by Payer Type Years One and Year Two of Operation
Medicare
Medicaid
3rd Party Insurance
Self-Pay/ Other
Total
Year 1 6,437 408 215 100 7,160
Year 2 14,332 909 478 223 15,943
% of Total 89.9% 5.7% 3.0% 1.4% 100% Source: CON application #10142, page 154.
The applicant maintains that the projected financial forecasts, including
Medicaid and charity care, demonstrates the applicants commitment to
the provision of hospice services to any terminally ill patient, regardless
of ability to pay.
VITAS Healthcare Corporation of Florida (CON #10144) states that it
has a long history of providing services to Medicaid and medically
indigent patients and proposes to provide services to these patients in
Subdistrict 3E. The applicant states that it has a history of meeting
projected commitments to Medicaid and charity care patients, citing its
results from Subdistrict 4A where it projected 4.9 percent to Medicaid
patients but in the first year of operation 7.0 percent of all admissions
were Medicaid patients.
The applicant indicates that it annually provides one percent or more of
revenues in charity care—in FY 2011 this amount exceeded $4.5 million.
VITAS projects Medicaid patients will be 4.5 percent and self-pay/charity
care patients 1.1 percent of total annual patient days in years one and
two, respectively. F. SUMMARY
A fixed need pool was published for a new hospice program in Hospice
Service Area 3E, Lake and Sumter Counties. Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140), a for-profit corporation proposes the establishment of a
new hospice program in Hospice Service Area 3E. The applicant is
proposing total project costs of $142,965 with year one operating costs of
$1,348,681 and year two costs of $3,102,696.
Compassionate Care proposes seven conditions. See pages 10 and 11 for
an in-depth description of the applicant’s proposed conditions.
CON Action Numbers: 10140, 10141, 10142 and 10144
120
Harbor Light Hospice of Florida, Inc. (CON #10141), a for-profit
corporation proposes to establish a new hospice program in Hospice
Service Area 3E. Harbor Light is proposing total project costs of
$176,460 with year one operating costs of $805,148 and year two costs
of $2,134,559.
Harbor Light proposes 15 conditions. See pages 12-14 for an in-depth
description of the applicant’s proposed conditions.
Hospice of Marion County, Inc. (CON #10142), a not-for-profit
corporation, proposes the establishment of new hospice program in
Hospice Service Area 3E. HMC is proposing total project costs of
$292,179 with year one operating costs of $1,746,402 and year two costs
of $3,100,487.
HMC proposes 10 conditions. See pages 14 and 15 for an in-depth
description of the applicant’s proposed conditions.
VITAS Healthcare Corporation of Florida (CON #10144), a for-profit
entity, proposes the establishment of a new hospice program in Hospice
Service Area 3E, Lake and Sumter Counties. VHCF is proposing total
project costs of $881,036 with year one operating costs of $2,223,926
and year two costs of $4,708,316.
VHCF is proposing 23 conditions. See pages 15-17 for an in-depth
description of the applicant’s proposed conditions.
Need/Access:
Each applicant is responding to published need for a new hospice
program. Each applicant states that there is unmet need in Lake and
Sumter Counties, which ranged from access issues for minority
populations including Hispanics and African-Americans, Veterans,
hearing-impaired populations, the pediatric population, cardiac patients,
patients in nursing homes, to cancer patients under the age of 65 years,
cancer patients over the age of 65 years, non-cancer patients under the
age of 65 years and non-cancer patients over the age of 65 years not
having proper access to hospice services.
All applicants provided statistical data of underserved minority
populations in Hospice Service Area 3E; however, none document that
hospice care to minority residents is not available or accessible.
CON Action Numbers: 10140, 10141, 10142 and 10144
121
All co-batched applicants provided evidence that they have local support
for their proposals to enter the service area. All applicants provided
letters of support from hospitals, skilled nursing facilities, continuing
care retirement communities or assisted living facilities within the
hospice service area.
All applicants have agreed to measurable conditions, if awarded the
CON, to ensure that its proposed program offers improved access to
hospice care, improved education regarding available hospice services,
and to address any cultural barriers to hospice care in Lake and Sumter
Counties.
The Agency’s need methodology that resulted in published need for a new
program in Hospice Service Area 3E showed the projected number of
admissions minus the current number of admissions for the July 2013
planning horizon as 423. VHCF proposed the largest program to address
this published need while HMC proposed admission numbers closest to
the projected need:
Total Projected Admissions By Applicant
for Years One and Two CON # Applicant Year One Year Two Both Years
10140 Compassionate Care 157 366 523
10141 Harbor Light 73 204 277
10142 HMC 179 306 485
10144 VHCF 214 423 637
Source: CON application #’s 10140, 10141, 10142 and 10144.
Quality of Care:
Each applicant offered evidence of its ability to provide quality care.
As current providers of hospice services in Florida, HMC and VHCF
participated in the voluntary reporting on the Florida Health Finder,
Hospice Provider Family Satisfaction Survey; Compassionate Care, who
is also a current provider of hospice services in Florida, did not
participate.
Agency records indicate that VHCF has four substantiated complaints for
the three-year period ending June 26, 2012. Compassionate Care had
one substantiated complaint since licensure on February 22, 2011.
Hospice of Marion County, Inc. had no substantiated complaints for the
three-year period ending June 26, 2012.
CON Action Numbers: 10140, 10141, 10142 and 10144
122
Financial Feasibility/Availability of Funds: Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140): Without results from operations, an analysis of the short
and long-term strength of the applicant cannot be made. Compassionate
Care’s ultimate parent provided June 11, 2012 letters stating all $2
million of its line of credit is still available. Funding for this project is in
question. However, assuming the applicant will be able to acquire
funding for start-up and working capital, this project appears to be
financially feasible.
Harbor Light Hospice of Florida, Inc. (CON #10141): Without results
from operations, an analysis of the short and long-term strength of the
applicant cannot be made. Funding for this project is in question.
However, assuming the applicant will be able to acquire funding for
start-up and working capital, this project appears to be financially
feasible.
Hospice of Marion County, Inc. (CON #10142): The applicant has an
adequate short-term and long-term position. Funding for this project
appears to be financially feasible, although this is dependent upon the
source of the “other” operating revenue that was not identified in the
applicant’s financial schedules.
VITAS Healthcare Corporation of Florida (CON #10144): The
applicant has an adequate short-term and strong long-term position.
Funding for this project appears to be financially feasible.
Medicaid/Charity Care: Compassionate Care Hospice of Lake and Sumter, Inc.
(CON #10140): Schedule 7 shows 1.3 percent of total annual patient
days for self-pay/charity care in years one and two of operations.
Compassionate Care’s patient day Medicaid percentage is projected to be
3.0 percent for year one and two of operations.
Harbor Light Hospice of Florida, Inc. (CON #10141): Schedule 7
shows 2.0 percent of total annual patient days for self-pay/charity care
in years one and two of operations. Harbor Light’s patient day Medicaid
percentage is projected to be 4.0 percent for year one and two of
operations.
CON Action Numbers: 10140, 10141, 10142 and 10144
123
Hospice of Marion County, Inc. (CON #10142): Schedule 7 shows 1.4
percent of total annual patient days for self-pay/charity in years one and
two of operations. HMC’s patient day Medicaid percentage is projected to
be 5.7 percent for year one and two of operations.
VITAS Healthcare Corporation of Florida (CON #10144): Schedule 7
shows 1.1 percent of total annual patient days for self-pay/charity in
years one and two of operations. VHCF’s patient day Medicaid
percentage is projected to be 4.5 percent for years one and two of
operations.
G. RECOMMENDATION
Approve CON #10140 to establish a new hospice program in Hospice
Service Area 3E. The total project cost is $142,965 with year one
operating costs of $1,348,681 and year two costs of $3,102,696.
CONDITIONS:
1. The applicant will implement its Cardiac Connections program
immediately upon licensure. It will be made available to all eligible
residents with a qualifying cardiovascular disease. As part of this
implementation the applicant will ensure:
(a) The medical director of Compassionate Care’s Cardiac
Connections Program will be a cardiologist.
(b) The Cardiac Connections Program will have a licensed nurse
practitioner.
(c) At a minimum, Compassionate Care will hold quarterly
meetings for area cardiologists to maintain open
communications with the community cardiologists to
continue to educate them about options in end of life care for
their patients.
(d) At a minimum, Compassionate Care will coordinate with
local hospitals’ staff and/or physicians on a monthly basis to
review the Cardiac Connections Program and how it may be
benefiting both the hospital and the patient in terms of
reduction in readmission rates, program success and other
measure to be determined.
(e) Cardiac Connection Program patients will receive daily
communication from Compassionate Care staff either via an
in-person visit, or by telephone if an in-person visit is not
scheduled on a particular day.
CON Action Numbers: 10140, 10141, 10142 and 10144
124
(f) All Cardiac Connections Program patients will have a
Cardiac Comfort Kit with them in their home.
(g) Compassionate Care will, in its an annual condition
compliance report to the Agency for Health Care
Administration, address how hospital readmissions for heart
failure have decreased in the subdistrict relative to the
Compassionate Care Hospice of Lake and Sumter cardiac
admissions.
2. Compassionate Care Hospice Group, Ltd. will implement its
Pathways to Compassion Program immediately upon licensure of
Compassionate Care Hospice of Lake and Sumter, which will be
made available to all eligible Lake and Sumter County residents.
3. Compassionate Care will implement its Veterans Outreach
Program immediately upon licensure as detailed within CON
application #10140.
4. Compassionate Care will provide a home health aide ratio above
NHPCO guidelines at an average of 10 hours per patient per week.
5. Compassionate Care will not participate in fundraising activities in
Subdistrict 3E.
6. Compassionate Care will not build or operate freestanding hospice
facilities in Subdistrict 3E.
Deny CON Numbers 10141, 10142 and 10144.
CON Action Numbers: 10140, 10141, 10142 and 10144
125
AUTHORIZATION FOR AGENCY ACTION
Authorized representatives of the Agency for Health Care Administration
adopted the recommendation contained herein and released the State Agency
Action Report.
DATE:
James B. McLemore Health Services and Facilities Consultant Supervisor Certificate of Need
Jeffrey N. Gregg Director, Florida Center for Health Information and Policy Analysis