Three agencies join to expand hospice care
Against the backdrop of a national health care debate that has made little progress reaching political consensus, a quiet transformation has taken place on Martha's Vineyard that is reshaping the process of caring for Island residents facing end-of-life decisions.
In December, Hospice & Palliative Care of Cape Cod (HPCCC) began operating on Martha's Vineyard as Island Hospice, in collaboration with Hospice of Martha's Vineyard. About the same time, the Vineyard Nursing Association (VNA) announced that it had signed a staffing agreement with Island Hospice.
In a recent visit to The Times, leaders of the three organizations discussed the ways in which their respective organizations had fitted their services together and what the collaboration will mean for Island residents who need their care.
"This is a unique and complicated relationship in some ways," David Rehm, HPCCC president and chief executive officer (CEO), said, describing how an initial overture had led to a working partnership.
Robert Tonti, VNA chief executive, and Terre Young, Hospice MV executive director, agreed.
A confusing shift
For those not intimately familiar with the Island's health care network, December's closely linked announcements did little to clarify sometimes confusing developments surrounding the provision of hospice care on Martha's Vineyard.
Hospice of Martha's Vineyard (Hospice MV) is a volunteer-based, private nonprofit that provides emotional, spiritual, physical, and medical support for people with life-ending illnesses free of charge and without many of the encumbrances associated with Medicare or other insurers' rules.
More than one year ago, in January 2009, the VNA, a private, nonprofit home health care provider, announced that it planned to add Medicare-certified hospice care to its list of home health care services. The VNA said it was establishing the program to provide Hospice patients with access to insurance benefits not then available on the Island through Hospice MV.
Not long after the VNA announcement, Hospice MV announced it had signed an agreement with HPCCC, the Cape-based Medicare certified Hospice provider, so that the volunteer group could add to its unreimbursed services the provision of hospice care to patients who chose to take advantage of Medicare insurance benefits.
That development set up the prospect of two competing Island programs and three Hospice alternatives. It was, Mr. Tonti told The Times, something he wanted to avoid.
In December the VNA announced it had abandoned its plan to provide certified Hospice service and would provide its range of nursing services to the newly formed Island Hospice.
For Mr. Tonti, a contract with HPCCC meant VNA could continue to provide nursing services to patients and would be relieved of the complex certification process and prospect of competing for hospice patients.
What this end to the behind the scenes organizational jockeying meant for Island families was that a patient faced with a transition from medical to end of life care would be assured seamless care; that the faces of caregivers would not change; and that insurance requirements would not dictate hospice benefits.
Mr. Tonti, VNA's chief executive, explained how the new system might work. For example, a patient diagnosed with cancer and in the last year of life returns from a Boston hospital to his Island home, where VNA provides home health care. Once the decision is made that the patient is eligible for his hospice insurance benefits, which are more comprehensive than home care benefits, the VNA discharges the patient, who is then enrolled in Island Hospice. The caregivers do not change.
Or, in another variant, the patient, without the six-month end of life diagnosis required to take advantage of Medicare benefits, could take advantage of services offered by Hospice MV. If and when it is clear that the patient qualifies for Medicare or private insurance eligibility, the insured hospice option is presented, Ms. Young said.
A patient who makes that choice could be transferred to Island Hospice under the insurance umbrella, or he might choose to remain under the care of Hospice MV.
Either way, Ms. Young said, "The patient, the family, really doesn't see a difference in who is caring for them, or how they are being cared for."
Depending on the situation, Hospice MV may contract for nursing services from Island Hospice, or Island Hospice will contract for nursing services from the VNA. Throughout their discussion, the key elements were always how to make the insurance benefit available while preserving of the continuity of care, according to Mr. Rehm.
"It was relatively easy to figure out the common sense way to make this work best for the patient," Mr. Rehm said. "The complexity was figuring out how to do it in a way that fits within all of the regulatory worlds."
The three organizations differ greatly in the size of their annual budgets. HPCCC's budget is approximately $13.9 million. The VNA's is $3.2 million and Hospice MV's is $324,000.
In part, because Medicare benefits for hospitalized patients are lower than the hospital's customary reimbursements, HPCCC does not have a contract with Martha's Vineyard Hospital, but discussions continue. For now, a patient who needs hospitalization may still receive free Hospice MV care while an in-patient, but the cost of the medical care provided during the hospitalization would be born by the patient or his insurer.
Medicare hospice eligibility is based upon two criteria: physician judgment of a six-month-to-live prognosis should the disease follow its anticipated course, and the patient's desire to receive hospice services.
As with so much in medical care today, reimbursement rates often affect access. Hospice providers receive a flat rate per patient per day to cover all the costs for care. Each hospice sets its own admission criteria, and some mainland hospice organizations admit patients based on an individual's projected cost of care.
Since 1981, Hospice MV has provided end of life care without regard to insurance treatment restrictions or cost or time lines. VNA relies on Medicare reimbursements to provide daily home health care. HPCCC's service philosophy and certification provided the bridge.
Mr. Rehm said that HPCCC admits patients regardless of the complexity or cost of their care, and he said that to his knowledge, his is the only hospice in Southeastern Massachusetts that has what he called "an open door policy." He instituted the policy after taking the helm at the Cape based hospice two years ago.
Previously, Mr. Rehm was the CEO of Washington Home Hospice in Washington D.C., where Vineyard seasonal resident and humor columnist Art Buchwald spent his final days. That is when he learned there was no Medicare- certified hospice on Martha's Vineyard. A sailor, Mr. Rehm was already familiar with Vineyard waters.
A conversation with Terre Young led to a working relationship and mutual respect. "I have been doing this for 25 years," Mr. Rehm said, speaking of his hospice career. "Their [Hospice MV] flexibility is a wonderful thing. The frustration to be in the seat I have been in for 25 years is, we know people need all of this before they are eligible to get it. That is really the issue. So here we had the opportunity, if we did it in the right way, to make sure that the Vineyard still had all of this available."
Mr. Rehm said the Vineyard community will benefit in many ways. He estimated that the new arrangement would provide from $800,000 to $1 million worth of eligible insured services to terminally ill patients on the Vineyard that weren't available last year.
Mr. Rehm said that many people do not take advantage of the hospice benefit because of misconceptions about the Medicare benefits. "The regulations state six months or less if the disease follows a normal course and the patient selects it," he said.
Foregoing treatment is not part of the Medicare regulations, and there is no time limit on benefits should a patient exceed the six-month period, according to Mr. Rehm. "If you are eligible, you are entitled to this benefit, and it is our job to get it to you," he said. "We see that as our obligation and we won't be done until 100 percent of the people are taking advantage of what they are entitled to."