VNA to add competing Island hospice service
By Nelson Sigelman
Published: February 19, 2009
The Vineyard Nursing Association (VNA) will add Medicare certified hospice care to its list of home healthcare services. In a press release issued last Thursday, the VNA said it was establishing the program to provide Hospice patients with access to insurance benefits not now available on the Island.
"We have been in the home care business for 25 years now, and we have looked at it repeatedly," said Robert Tonti, VNA chief executive officer, said in a telephone interview with The Martha's Vineyard Times. "We feel now is a reasonable time to move forward."
Photo by Lynn Christoffers
In his press release, Mr. Tonti said VNA decided to make an announcement because the formal Medicare certification process will take 8 to 11 months to complete. "In the interim," said the press release, "we want to avoid any confusion as to our plans. We expect to become a state licensed and fully operating hospice this spring, which is required to do before the Medicare certification process can be completed."
"We are, of course, mindful of the admirable work that the Hospice of Martha's Vineyard has provided to end of life patients for years," Mr. Tonti went on. "We have opened up a frank dialogue with them to see if we can come together as one organization to better serve the community. We also understand, however, that Hospice of Martha's Vineyard has elected not to directly pursue Medicare certification at this time."
The VNA announcement presents a challenge for Hospice of Martha's Vineyard, the volunteer-based nonprofit that now provides emotional, spiritual, physical, and medical support for people with life-ending illnesses. Hospice Martha's Vineyard was established in 1981, to provide care free of charge and without many of the encumbrances associated with Medicare or other insurers' rules and regulations.
Representatives of both organizations met on January 21 to discuss a consolidation, but Hospice Martha's Vineyard leaders said VNA's only proposal was that it would absorb their organization, a plan Hospice Martha's Vineyard rejected.
At least for the near term, it appears that the Island will have two competing Hospices. Future discussions are planned.
This week representatives of both organizations picked their words carefully. But the delicate nature of the relationship and concern over last week's announcement and the confusion it may create was apparent.
Insurance access is key
The Vineyard Nursing Association is a 25-year-old nonprofit provider of home healthcare services for patients and families in need of care for short-term, long-term, and chronic illnesses.
For almost 24 years, the Island hosted two competing community-based nursing organizations, the independent VNA and Martha's Vineyard Community Services' Visiting Nurse Service (VNS). That ended last March when the Community Services board announced that patients would be served best by one home healthcare service and ended the VNS.
In a telephone conversation Tuesday, Mr. Tonti and Sandie Carr-Dolby, VNA clinical director, stressed that VNA had great respect for Hospice Martha's Vineyard, but had concluded the community would be better served if there were access to Hospice insurance benefits.
Ms. Dolby said that as an agency certified for hospice care, VNA would be responsible for arranging all medications related to care for terminal illnesses and any needed equipment, the cost of which would be covered by insurance.
Patients who receive VNA services over a period of time for an illness that then proceeds to an end-of-life phase would also be provided with continuity of care, Ms. Dolby explained. The familiarity that develops between patients and members of the VNA care team is invaluable, she said.
"And that's the point," said Ms. Dolby. "That's why we are doing this. Because there are benefits to having all of that within one organization; of not having two separate organizations show up at the door."
Ms. Dolby said that, as good as Hospice Martha's Vineyard is, it does not offer a full array of Hospice services. "They do wonderful work. They are very caring people, and they try very hard, but they cannot offer continuity of care," she said. "They cannot offer home health aid services; they cannot offer physical therapy services."
Mr. Tonti said that while Hospice of Martha's Vineyard does provide care outside of the six-month end of life diagnosis requirement, Hospices around the country have not found the time limit to be challenge or a problem. "In fact, you will find that the average time that people are spending as a Hospice patient is less than 60 days," he said. "Because there is a reticence by the doctor to make the diagnosis until he is more sure perhaps, and there is a reticence on the side of the patient to accept that."
"And to stop seeking any level of curative care," interjected Ms. Dolby.
Asked if the VNA and Hospice of Martha's Vineyard are both able to offer services under the auspices of the VNA umbrella but follow separate models, Mr. Tonti said, "Technically, the answer to that is no.
We cannot work with them unless they are a certified Hospice."
Mr. Tonti said he could not predict what a future model may look like. "Our hope, and the reason we approached them, very openly and aboveboard, was to try and work out a way for them to join with us," he said. "And I don't have the answer as to how that could happen."
With reference to the January meeting, Mr. Tonti said first meetings are always a challenge. "I thought it went okay. We introduced what we were trying to accomplish going forward," he said.
Mr. Tonti said that VNA did make an offer, and Hospice of Martha's Vineyard "did not think it was enough." Given the length of time the approval process will take, VNA will move forward, he said.
Mr. Tonti added, "I do not know where it is going to end up. I am hopeful we will figure out a way to do it together."
We will not disappear
Hospice operates from a trailer parked on the Martha's Vineyard Hospital grounds. It does not charge for its services and relies entirely on fundraising.
Terre Young, Hospice Martha's Vineyard executive director, said in 1981 the original founders wanted Hospice to be a community supported program, so that all community members could take advantage of the support it provides. She said Medicare reimbursement carries certain restrictions, most notably an agreement on a diagnosis of six months to live by the patient's physician and the Hospice medical director.
"Our program eliminates that requirement," said Ms. Young.
The patient or the family must pay for medication. In many cases, that cost will be limited to an insurance co-pay. Ms. Young said Hospice is able to help support families in need of financial assistance.
Medicare-certified Hospice programs take on all the responsibilities for the needs of the patient, including medication, physical therapy and equipment, said Ms. Young, but only for those diagnosed with six months to live.
While acknowledging the benefits of Hospice insurance coverage, Ms. Young noted that over a 27-year span, Hospice Martha's Vineyard has taken care of 1,220 terminally ill patients and their families, all of whom have managed the financial part, some with assistance. "You don't have to have a Medicare benefit in order to have your end-of-life care needs met, financially, emotionally or spiritually," she said.
In 2008, Ms. Young explained that Hospice cared for 71 patients and their families. She noted that 44 of those patients died in 2008, and 21 of those deaths were cases shared with VNA, and seven were shared with VNS, before that MVCS unit closed in March.
Ms. Young said her first notice of VNA's plan to become a competing organization came in December, when a community member she described as reliable told her that VNA planned to establish a Hospice and absorb her agency. The plan was outlined at the January meeting.
Asked to describe the outcome of that meeting, Ms. Young said, "We, Hospice of Martha's Vineyard, were not able to accept the proposal that they offered." She said the proposal would have meant the end of Hospice of Martha's Vineyard.
Ms. Young said that while the VNA would provide access to insurance, it would take time to provide what is now provided. "We have an institutional memory that comes with the work, and our culture is wholeheartedly and completely philosophically Hospice care," she said. "They need to change quite a bit of their culture to get it. They can do it. They can learn, but it is going to take them a while."
In the meantime, she said she worries that the creation of a new Hospice service will create confusion within the community.
For now, Ms. Young explained, "We are not going to go away."
Nancy Whipple of Edgartown, newly elected Hospice Martha's Vineyard chairman, said she could not say with any certainty why the VNA had decided to create a Hospice, beyond a possible financial benefit. "That is a very good question - why?" she said.
Asked if would be possible to have one organization that could provide insurance benefits and also do what Hospice Martha's Vineyard now does, Ms. Whipple laughed and said, "I think there is indeed a way, but we do not just want to be swallowed up by VNA."
Hospice Martha's Vineyard plans to meet with the VNA to discuss what it regards as possibilities for a collaborative effort so that the two organizations can work hand-in-hand, she said. "But, I don't have high hopes," she added. "I think they would just like us to see things their way."
