state agency action report on application for certificate of need a. project

STATE AGENCY ACTION REPORT

ON APPLICATION FOR CERTIFICATE OF NEED

A. PROJECT IDENTIFICATION

1. Applicant/CON Action Number

Compassionate Care Hospice of Miami-Dade, Inc. d/b/a Compassionate Care Hospice/CON #10036

18 Aquamarine Avenue Naples, Florida 34114 Authorized Representative: Mr. Geoffrey Smith (201) 919-4905 Memorial Hospital-Flagler, Inc. d/b/a Florida Hospital HospiceCare/CON #10037 770 West Granada Boulevard, Suite 304 Ormond Beach, Florida 32174 Authorized Representative: Mr. David Ottati/Ms. Diane Godfrey

(386) 671-2138 Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida, Inc./CON #10038

717 North Harwood, Suite 1500 Dallas, Texas 75201 Authorized Representative: Mr. R. Dirk Allison (214) 922-9711

2. Service Area/Subdistrict

Hospice Service Area 6B (Hardee, Highlands and Polk Counties) B. PUBLIC HEARING

A public hearing was not held or requested regarding the proposals to establish a hospice program in Hospice Service Area 6B. Letters of support are detailed below for each applicant:

CON Action Numbers: 10036-10038

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Compassionate Care Hospice (CON #10036) submits seven unduplicated letters of support and the Agency received one support letter via the mail. All letters are current, signed and have an address within Polk County, Florida. These include letters from: Lance Anastasio, President/CEO, Winter Haven Hospital; Mike Kosor, CEO, Bartow Regional Medical Center; Angela Smith, NHA, Administrator, Winter Haven Health & Rehabilitative Center; Ken Perry, Administrator, Bartow Center Nursing and Rehabilitation Center; Kenna Parsons, Administrator, The Meadows at Cypress Gardens; Christine Clark, Administrator, Amonet Healthcare International, Inc.; Suze Possible (operator of an adult living facility [ALF] and Ann Barnhart, Sr. Vice President for Operations, Health Management Associates, Inc. Four of these (Winter Haven Health and Rehabilitation Center, The Meadows at Cypress Gardens, Amonet Healthcare International, Inc. and Suze Possible of an ALF in Winter Haven) register some measure of dissatisfaction with the existing Service Area 6B hospice providers. The dissatisfaction is reported as generally either singly or a combination of the following: a lack of massage, music, aroma, pet and related therapies; slowness in responding to continuous care needs; a lack of the provision of medications not directly tied to the primary terminal diagnosis and/or patient overmedication in some instances. No specific existing Service Area 6B hospice provider is named. The applicant includes a 15-page sample hospice general inpatient scatter-bed contract shell1. The following three acute care hospital providers state in their support letters a willingness to contract with the applicant regarding the provision of inpatient hospice services, should the project be approved: Winter Haven Hospital; Bartow Regional Medical Center and Health Management Associates, Inc. [the latter operates Heart of Florida Regional Medical Center, Bartow Regional Medical Center and Highlands Regional Medical Center, with all three located in Service Area 6B]. Two skilled nursing facilities in Service Area 6B (Winter Haven Health & Rehabilitation Center and Bartow Center) make similar commitments to contractual agreements with this applicant. Therefore, in total, six facilities in the service area that would be authorized to contract for inpatient hospice services (hospitals and skilled nursing facilities) indicate a commitment to do so, if the applicant receives CON approval. Florida Hospital HospiceCare (CON #10037) submits one unduplicated letter of support and the Agency received nine support letters independently regarding the project from senior hospital executives,

1 CON Application #10036, Tab 7 – Sample Inpatient Agreement

CON Action Number: 10036-10038

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doctors and nursing home executives, nine are current, with the oldest dated December 12, 2008; one of the 10 is not dated. All 10 are signed, with nine having a Service Area 6B address (Hardee, Highlands or Polk County). The one exception is addressed from Orlando (Orange County, Florida). Below is a list of the 10 hospital, doctor or nursing home executive support letters: Lance Anastasio, President/CEO, Winter Haven Hospital; Robert Mahaffey, CEO, Highlands Regional Medical Center; Hanford Brace, MD, Integrity HealthCare; Mark Niemeyer, Administrator, Adventist Care Center (a SNF in Orlando, Florida); Catherine Exendine, MSN, RN, Nurse Manager, Florida Hospital-Wauchula; Timothy Cook, CEO, Donna Snyder, VP/CNO, Kathy Lee, MD, FACP, Medical Director of Hospital Medicine, Donald Geldart, MD and Nilda Dunstall, Director, Case Management Team, Florida Hospital-Heartland Division. Seven of these 10 letters have an affiliation with the applicant (through Adventist Health System/Sunbelt, Inc. [Florida Hospital]). None of the letters register dissatisfaction with the existing Service Area 6B hospice providers, they generally express concern with a disproportionately growing elderly population in the area and the applicant’s particular sensitivity to medical, social, end-of-life and spiritual needs of hospice patients in a faith-based context. Only one letter of support (Timothy Cook, CEO, Florida Hospital-Heartland Division) agrees in his letter to partner with the applicant to provide inpatient services, should the applicant’s proposal be CON approved. However, Florida Hospital has three affiliated hospitals in the service area and the applicant indicates that it will be able to enter into contracts with one or more of these facilities. The applicant also includes 17 unduplicated letters of appreciation for past services from patients and family members2. Most are hand written and generally express gratitude and appreciation for exceptional and considerate hospice services to family and friends. The applicant’s Attachment L includes 25 additional unduplicated letters of support mostly from Florida Hospital facilities. All are signed and most are dated in December 2008. Thirteen have a Service Area 6B address.

Odyssey HealthCare of Central Florida, Inc. (CON #10038) submits nine unduplicated letters of support3 for its proposed hospice program in Service Area 6B and the Agency received one support letter independently regarding the project. All letters of support are current, with the oldest dated November 5, 2008. Nine of the 10 are signed and

2 CON Application #10037, Attachment H – Patient and Family Testimonials 3 CON Application #10038, Appendix N – Letters of Support from Subdistrict 6B


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have an address within Service Area 6B (Hardee, Highlands and Polk Counties). Below is a list of the 10 letters: Jack Stephens, President/CEO, Lakeland Regional Medical Center; Julie Travis, Director, Case Management, Lake Wales Medical Center; David Queener, Executive Director and Traci Whisman, Regional Director of Sales and Marketing, Summerville at Lakeland; David Smith, Administrator, Lake Placid Health Care Center; Tom Glass, Administrator, Haines City Health Care; Jason Canlas, Administrator and Art Hutchins, RN, Director of Nursing, Spring Lake Rehabilitation Center; Dennis Curley, Executive Director, Lake Howard Heights and Louise McCann (unsigned), Health and Wellness Director, Sterling House/Clare Bridge Cottage. A recurring theme is recognition of the applicant’s 14 service standards and a belief there is need for more choices in selecting hospice care in the area, beyond that of the existing local hospice providers. The applicant includes a signed “Memorandum(s) of Understanding” with one hospital and three nursing homes located in Service Area 6B (Lakeland Regional Medical Center, Haines City Health Care Center, Lake Placid Health Care Center and Spring Lake Rehabilitation Center) to enter into contractual agreements for the provision of inpatient hospice services, should the applicant’s project be approved. The applicant also includes 26 unduplicated letters of appreciation for past services from patients and family members4. Most of the notes of appreciation are hand written, few are dated and few have an address. These notes generally express gratitude and appreciation for exceptional and considerate hospice services to family and friends. Letters of Opposition The Agency timely received two letters of opposition regarding CON #’s 10036-10038. Each letter of opposition is briefly described below. Seann Frazier of Greenberg Traurig, PA, on behalf of an existing Hospice Service Area 6B hospice provider – Good Shepherd Hospice, Inc. (Good Shepherd) focuses on five primary reasons to deny the project, with the overriding contention being that need, as promulgated by the Agency, is derived through outdated and faulty data, according to Good Shepherd. The five reasons are summarized below.

4CON Application #10038, Appendix K – Letters of Support & Family Letters of Thanks/Commendation for Odyssey-Daytona and Odyssey-Miami


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Good Shepherd indicates that the most recently published need for one additional hospice program (for the October 2008 Batching Cycle) is derived from the Agency’s estimated 535 admissions. This is above the 350 admissions threshold necessary to trigger published need and hence need for one additional hospice program in the area was published. The Agency’s need methodology is challenged as using outdated death statistics through unpublished/invalid reports5. Mr. Frazier states that the fixed need pool calculation for Service Area 6B constitutes the use of an unadopted rule and invalidates the fixed need pool conclusion. He also contends that there is still a developing hospice market in the area, with the most recently licensed hospice provider in the area (Hope Hospice and Community Services, Inc.) having recently achieved just 346 admissions and not the threshold 350 admissions. According to Mr. Frazier, hospice use rates among African-American and Hispanic populations of the area are similar to the overall state average and much higher than the national average6. He also cites Good Shepherd’s charity care, quality care and programs. Good Shepherd provided $2.1 million of charity care (uncompensated care) in 2007, based on its data. In summary, Greenberg Traurig, PA, states that no “true” need exists regarding hospice services in Service Area 6B and that Good Shepherd is a high-quality and cost-efficient provider that is fully accessible and available to all applicable residents. A second opposition letter is a three-page letter of opposition, with six exhibits (A through F), presented by W. David Watkins, Esq. of Watkins & Associates, PA, Attorneys and Counselors at Law, on behalf of two existing Service Area 6B hospice providers – Hope Hospice and Community Services, Inc. (Hope) and Cornerstone Hospice (Cornerstone). Mr. Watkins states that in the current batching cycle, the hospice penetration rate is 59.9 percent in Service Area 6B, compared to the state’s overall 60.0 percent hospice penetration rate. In summary, Mr. Watkins alleges that based on this hospice use rate, the addition of another provider would result in …”diminished quality, and unnecessary duplication of services and new competition for very limited health care and human resources”7. Again, the validity and credibility of the fixed need pool is challenged, similarly to how it was by Greenberg Traurig, PA. Many of the same references stated in what Mr. Watkins lists as “The First Error” and “The Second Error” were also stated by the Greenberg Traurig, PA, opposition.

5 Greenberg Traurig, PA, Letter of Opposition, page #4 6 Ibid, page #7 7 Watkins & Associates, PA, Letter of Opposition, page #1


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C. PROJECT SUMMARY

Compassionate Care Hospice (CON #10036) (Compassionate Care) proposes the establishment of a new hospice program in Hospice Service Area 6B, consisting of Hardee, Highlands and Polk Counties. Compassionate Care states origination in 1993 and operation in the following 12 states: Delaware, Georgia, Illinois, Massachusetts, Michigan, Minnesota, Missouri, New Jersey, New York, Pennsylvania, South Dakota and Texas. The applicant indicates 29 office locations spread among the 12 states. Compassionate Care does not currently offer services in Florida. The applicant indicates intentions of establishing three office locations upon operations to be effective January 2010. The main office is planned for Northeast Polk County (Haines City), with satellite offices in Bartow (Polk County) and Sebring (Highlands County). The applicant is proposing total project costs of $292,459 for building, equipment, project development and start-up costs. The project does not involve any construction costs. In its Schedule C, the applicant includes the following general statement conditions and proposes seven specific conditions: Compassionate Care Hospice’s General Statement on Willingness to Accept Conditions in Service Area 6B In recent CON applications, many hospice organizations have offered to provide the various required components of hospice services through lengthy listing of numerous specific conditions for award of the CON. As required by law, Compassionate Care Hospice is willing to accept any such conditions on its CON-based on any representations made through this CON application. Compassionate Care will provide all the required components of hospice care, and meet all Medicare Conditions of Participation, and Florida hospice licensure requirements, including the provision of all levels of service (routine home care, continuous care, general inpatient, respite) to all types of patients (cancer, non-cancer, Alzheimer’s, COPD, elderly, young adult, pediatric) without regard to race, ethnicity, gender, age, religious affiliation, diagnosis, financial status, insurance status, or any other discriminating factor.


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Compassionate Care commits to offering excellent quality specialized and individualized programs delivered by a highly qualified interdisciplinary team of professionals, and will implement continuous quality improvement, performance improvement and quality assurance and monitoring programs. The applicant will offer all types of services including physical care and pain management, bereavement counseling and support services (for as long as the bereaved needs such services, without limitation on duration), psycho-social services, spiritual care and counseling, memorial programs and services, palliative radiation and chemotherapy, and message, music, pet and aroma, and other alternative therapy programs. The applicant will implement a volunteer program and offer a wide array of services through its volunteers. Compassionate Care is finally committed to the continuous and ongoing training, orientation and education of its staff, and will implement specific programs such as tuition reimbursement, ongoing in-services and training programs, library resources, and payment of certification for staff. The applicant will ensure that its staff has the resources, equipment (such as lap tops, PDAs, or other IT equipment) to perform effectively in the delivery of care to their patients and families. Compassionate Care will conduct extensive community education and outreach programs in all communities, including all racial, ethnic or religious minority communities, veterans groups and organizations, and will initiate specialized programs and services to meet the individual needs of such communities in terms of language needs or specialized cultural or religious needs. Examples include such programs as Compassionate Care’s Jewish Hospice Certification; use of a culturally diverse staff; use of bilingual staff; and production of education materials and service forms in Spanish language, Creole language or other languages as needed in the community; and sensitivity and training for the special needs of veterans. Compassionate Care will contribute to the community organizations including universities, community colleges or other organizations involved in the training or health care professionals, or in the delivery of social services to the community. Compassionate Care will provide services beyond those mandated and reimbursed by Medicare and Medicaid, including specific financial assistance to meet the specialized financial assistance to meet the special individualized needs of patients through its charitable foundation, including special “last wishes” of a patient or family, need for specialized


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equipment not reimbursement, travel for a special family member to visit with a dying patient, or simply need for assistance with mortgage payments, rent, utilities, groceries, or other necessities. Compassionate Care believes that all of the above types of programs, services, policies and protocols should be provided by any hospice provider, and therefore would accept as a condition to its CON application any or all of these general conditions. However, in order to assist the Agency in distinguishing Compassionate Care Hospice from other applicants, the applicant hereby offers the following specific conditions, that are aimed at specific measurable actions that will increase access and quality of care for hospice patients. Specific Conditions: • Office Locations – In order to increase awareness and visibility of

hospice services, and to provide for convenient meeting places for interdisciplinary care teams, bereavement support groups, family counseling meetings and sessions, and other types of local activities, the applicant commits to opening three office locations upon commencement of services including one in Polk County in the Haines City area, one in Highlands County in the Sebring area, and one in Polk County in the Bartow area. Compliance with this condition will be measured by providing to the Agency the location addresses for each office upon commencement of services.

• Pain Reduction – Compassionate Care Hospice will effectively reduce

severe pain in its hospice patients within 48 hours of admission to hospice. Compliance may be demonstrated based upon an annual report of the applicant’s initial pain scores for patients, and recorded pain scores after 48 hours. The applicant will achieve a reduction for at least 75 percent of patients with severe pain (score of seven to 10) to a pain score of five or less within 48 hours of admission. This exceeds the Florida requirement in Section 400.60501, Florida Statutes.

• Program Accreditation – As a demonstration of commitment to quality,

the applicant will become accredited by the Community Health Accreditation Program (CHAP) within 24 months of its initial licensure. Compliance will be demonstrated by forwarding a copy of the Accreditation to the Agency.

• Medical Directors – Medical directors will assess every patient upon

admission to hospice, and will provide patient visits in the home or


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place of residence. Medical directors will either be board-certified in Hospice and Palliative Care Medicine, or will apply for board-certification within five years of employment as a medical director. Compliance will be demonstrated through an Annual Report to the Agency.

• Other Staff Qualifications – To ensure high quality the applicant will

adopt the following standards and qualifications for staff: RNs will be encouraged to become certified in Hospice and Palliative Care Nursing, and by the third year of operation, 50 percent of all supervisory nurses shall attain such certification, with 100 percent of all supervisory nurses attaining such certification by the fifth year of operation; Chaplains shall be Masters of Divinity, with demonstrated completion of an accredited Clinical Pastoral Education (CPE) program; social workers shall be Masters Level and licensed clinical social workers. Compliance with these qualifications shall be demonstrated in an annual report to the Agency.

• Continuous Care – To address concerns expressed within Service Area

6B by skilled nursing and ALF providers about lack of timely availability of continuous care services, the applicant commits that it will provide at least 1.5 percent of total patient days as continuous care days, and will have continuous care staff at the bedside within two hours of receipt of a request for such services, and will maintain such service until no longer needed. Compliance will be measured and demonstrated by maintaining records of requests for continuous care, and providing an annual report to AHCA on response times and total patient days.

• Patient Visits – Compassionate Care will commit that every patient

shall be contacted on a daily basis to determine their needs for the day, and all patients shall receive in-person visits from Compassionate Care staff at least five times per week for at least two hours per day. Compliance will be monitored by submitting an annual report to the Agency on patient visits.

Florida Hospital HospiceCare (CON #10037) (HospiceCare) proposes the establishment of a new hospice program in Hospice Service Area 6B, consisting of Hardee, Highlands and Polk Counties. HospiceCare indicates state licensure since June 1997 and operation in Service Area 4B (Flagler and Volusia Counties). The applicant indicates it is the only not-for-profit and hospital-based hospice applicant in this batching cycle for Service Area 6B.


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The applicant is not specific on an exact location or number of office locations to promote the project. However, HospiceCare states intentions of partnering with Adventist Health System/Sunbelt, Inc. (Florida Hospital) and states plans to contract for inpatient services with one or more of the Florida Hospital facilities in the service area – Heartland (in Highlands County), Lake Placid (in Highlands County) and Wauchula (in Hardee County). The applicant also states intentions of considering other hospitals in the area for like contracting. The applicant is proposing total project costs of $306,380 for equipment, project development and start-up costs. The project does not involve any construction costs. In its Schedule C, the applicant proposes the following conditions: 1. Commitment for the provision of programs and services for

residents of Service Area 6B that are outside the Medicare hospice benefit which will include community hospice education, palliative care education, and community bereavement. This would also include the development of Project StoryKeeper as a means of providing training for hospice staff and volunteers that can be put to use in establishing a patient’s family history/legacy. Project StoryKeeper allows patients to record their life stories as part of their legacy to their loved ones, so that their stories can be told and shared long after they have passed away.

2. HospiceCare will enter into agreements with one or more of the

Florida Hospital Heartland Division hospitals (Heartland, Lake Placid and Wauchula) to provide inpatient hospice services to residents of Polk, Hardee, and Highlands Counties.

3. The commitment for the provision of volunteer services to hospice

patients that substantially exceeds the five percent requirement mandated under the Medicare program. Based on the success of its Flagler and Volusia program, Florida Hospital HospiceCare commits to a minimum of 10 percent of its hours of care being provided by hospice volunteers. The additional commitment of volunteer hours will begin with the second year of operation.

4. Provision of programs for the Hispanic population which will

include support from or involvement of bilingual staff and volunteers, translated literature, training on cultural differences and competencies, and flexible programming to meet their unique needs. Bereavement services will include special outreach to the Hispanic population of Service Area 6B.


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5. The development in year one of a community resource information

web site. This educational site will include various lay and professional education pieces related to chronic illness, death, dying and bereavement.

6. The development of a Community Advisory Board to be composed

of residents inclusive of the Highlands, Hardee and Polk communities. The purpose of the Community Advisory Board is to provide input and feedback about service area needs and provide recommendations for consideration in future program development.

7. A minimum annual funding of $10,000 towards a “Special Wish

Fund” designated for the end-of-life wishes for HospiceCare patients and their families. This commitment would begin with year two of operations.

Odyssey HealthCare of Central Florida, Inc. (CON #10038) (Odyssey] proposes the establishment of a new hospice program in Hospice Service Area 6B, consisting of Hardee, Highlands and Polk Counties. The applicant states its sole shareholder and parent is Odyssey HealthCare Operating B, LP, founded in 1995. The parent is stated to have 100 licensed hospice programs spread among 30 states8, with hospice care being its only line of business. The applicant also states affiliation with two existing Florida hospices owned and operated by the parent – Odyssey Healthcare/ Daytona (Hospice Service Area 4B) and Odyssey Healthcare/Miami (Hospice Service Area 11). Florida hospice licensure by the parent’s two Florida hospices occurred in 2005 and 2006, respectively. The applicant expresses intent to address three patient populations it contends are underserved – cancer patients aged 65 years and older, non-cancer patients aged 65 years and older and patients in need of continuous care. The applicant proposes to condition CON approval to have satellite offices in Highlands County (in year two of operation) and Hardee County (in year three of operation)9. The applicant further states in its condition that with the two satellite offices, Odyssey will have a presence in each of the three counties in the subdistrict. However, on page 107 the applicant restates the conditions and adds that it will develop the main office in Polk County.

8 CON Application #10038, page #24 9 Ibid, page #162


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The applicant is proposing total project costs of $619,264 for equipment, project development and start-up costs. The project does not involve any construction costs. In its Schedule C, the applicant proposes the following conditions: 1. The applicant will provide supportive hospice services, such as but

not limited to: palliative radiation therapy and palliative chemotherapy related to the patient’s terminal diagnosis. This will be measured via a signed declaratory statement by the applicant, which may be supported via a review of patient medical records.

2. The applicant will provide continuous care to two percent of

patient days. This will be measured via a signed declaratory statement by the applicant, which may be supported via a review of patient medical records.

3. The applicant will implement the “Care Beyond” Program. This will

be measured via a signed declaratory statement by the applicant. 4. 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. This will be measured via a signed declaratory statement by the applicant, which may be supported via a review of patient medical records.

5. The applicant will admit all eligible patients without regard to their

ability to pay. This will be measured by the applicant’s Medicare certification which requires this standard.

6. The applicant commits to having every patient being assessed by a

physician upon admission to the hospice. This will be measured via a signed declaratory statement by the applicant which may be supported via a review of patient medical records.

7. The applicant will immediately implement its Performance

Improvement (PT) plan including the following assessments: Pain management, family satisfaction, employee satisfaction, and referral source satisfaction. This will be measured via a signed declaratory statement by the applicant, which may be supported via a review of patient medical records.


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8. 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. This will be measured via a signed declaratory statement by the applicant, which may be supported via a review of patient medical records.

9. The applicant will implement Odyssey’s triage and on-call

programs upon licensure. These programs provide for uninterrupted 24-hour care seven days a week. Further explanation of the program is offered in the application narrative. This will be measured via publication of the relevant collateral materials for the provider and patient community.

10. The applicant will establish a local ethics committee within the

first year of operation. This will be measured via submissions of the names and other relevant information of the Ethics Committee members and the related schedule of meetings to the Agency.

11. The applicant will establish a local medical advisory committee

within the first year of operation. This will be measured via submissions of the names and other relevant information of the Ethics Committee members and the related schedule of meetings to the Agency.

12. The applicant will provide educational programs, including but not

limited to, in-service training (components of Odyssey University) resources to the community, including nursing homes, assisted living facilities, Council on Aging and staff of the existing provider. In-service training would be offered to registered nurses, social workers, administrators and other staff that would benefit from an increased knowledge of hospice care and services. The applicant will host at least one seminar annually during the first two years of operation for clergy and community faith leaders (The Clergy End of Life Education Program), to enhance spiritual support for Hospice patients in the district. This will be measured via a signed declaratory statement by the applicant.

13. The applicant will provide patients, family members and referral

sources with information of services provided by the Dream Foundation. The Dream Foundation is the first national group of its kind that exists for terminally ill applicants over the age of 18. Through its Day Dreams (a program for terminally ill adults over the age of 65), Emergency Dreams and Quality of Life Dreams, the Dream Foundation provides patients and families with a sense of


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completion and fulfillment. Odyssey has formally partnered with the Dream Foundation to improve care for our patients and to advance our mutual interests in the field of hospice. This will be measured by the applicant’s inclusion of Dream Foundation information in Odyssey’s collateral materials.

14. The applicant, through Odyssey HealthCare, Inc. or the Odyssey

VistaCare Hospice Foundation, will make a $25,000 contribution to an appropriate not-for-profit entity in the community to fund education for end-of-life issues. Upon approval, Odyssey will meet with the Area Council on Aging or similar organization to identify and determine the most appropriate entity within the community related to education for end-of-life issues. This will be measured via a signed declaratory statement by the applicant and evidence of funds provided to the not-for-profit entity.

15. The applicant will commit to 0.5 FTE the first year of operation for

the development efforts of a children’s hospice program in the Subdistrict 6B community. The children’s program will offer an expanded hospice benefit for patients up to age 21. This program will focus on longer term services for patients who may not otherwise qualify for hospice such as those with developmental conditions, cancers, chronic illnesses or brain injury that shorten lives and place special demands on families. After one year and as the census of pediatric and PlC patients increases, dedicated staff will be increased to constitute a CSFP (Child and Family Support Program) interdisciplinary team. This will be measured via a signed declaratory statement by the applicant.

16. The applicant will commit to 0.5 FTE the first year of operation for

the development efforts for community bereavement programs in Subdistrict 6B community. The bereavement program will be broadly based to extend beyond the families of patients admitted to Odyssey HealthCare. These programs will be an extension of the programs currently offered in Subdistrict 6B. 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. This will be measured via a signed declaratory statement by the applicant.


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17. The applicant will commit to the provision of programs for the

Hispanic populations which will include support from or involvement of bilingual staff, translated literature, training on cultural differences and competencies and flexible programming to meet their unique needs. Bereavement services will include Hispanic children. This will be measured via a signed declaratory statement by the applicant.

18. The applicant will develop a community resource library during the

first year of the proposed hospice’s operation. The library will include various lay and professional education pieces related to chronic illness, death, dying and bereavement. This will be measured via a signed declaratory statement by the applicant.

19. The applicant commits that the Odyssey VistaCare Hospice

Foundation will establish a Children’s Bereavement Camp in Florida by the end of the first year of operation, replicating what currently exists in Odyssey’s SkyCamp. This will be measured via a signed declaratory statement by the applicant.

20. The applicant will have a minimum of three community education

representatives’ staff members, expanding community awareness of hospice services and educating local medical staff, community leaders and potential hospice patients as to the benefits of and availability of hospice care. Compliance with this condition will be measured via submission of an annual report confirming that at least three CER staff members are employed at the proposed new service and active in the local community. Additionally, if approved, Odyssey will provide education, training and assistance in development of respite care policies, procedures and protocols to nursing homes.

21. The applicant will develop satellite offices to ensure enhanced

access to hospice services in each of the three counties of Service Area 6B. The applicant will develop the main office of Odyssey Central Florida in Polk County. Odyssey Central Florida commits to the development of two satellite offices; Highlands County in year two of operation and Hardee County in year three of operation.

22. Finally, as evidenced by conditions defined above and by Odyssey’s

broad array of proven hospice services, programs and resources discussed in detail throughout this application, the applicant will model the proposed new hospice program as a Comprehensive


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Hospice Center as defined in The Florida Model of Hospice Care, A Report for Florida Hospices and Palliative Care, Inc., prepared February, 2004 by the Center for Gerontology & Health Care Research, Brown University School of Medicine. This study is presented in Appendix R. Examples of the research/academic endeavors and community advocacy activities beyond community hospice model activities that support the applicant’s Comprehensive Hospice Center condition include:

• Providing Odyssey University on-line training and educational

resources to the community, • Participating with and promoting Dream Foundation activities

and fund raising, • Providing $25,000 to the local market to support enhanced

education for end-of-life care, • Providing dedicated staff for children’s hospice initiatives and

for community bereavement activities, • Establishing a Florida Children’s Bereavement Camp, and, • Sponsoring and participating in national hospice care

educational activities including but not limited to support of and participation in the National Palliative and Hospice Care Organization, the Symptom Control and Palliative Care Fellowship Program at the University of Texas’s M.D. Anderson Cancer Center, the Palliative Care Fellowship program at the University of Alabama at Birmingham Fellowship through the Greater Birmingham Palliative Care Fellowship Program and the Clergy End-of Life-Education Program at Baylor University.

This will be measured via a signed declaratory statement by the applicant.

NOTE: 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. Rule 59C-1.013(4) Florida Administrative Code contains condition compliance reporting criteria that the Agency uses for an approved CON that has conditions.


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D. REVIEW PROCEDURE

The evaluation process is structured by the certificate of need review criteria found in Section 408.035, Florida Statutes, rules of the State of Florida, and Chapters 59C-1 and 59C-2, Florida Administrative Code. These criteria form the basis for the goals of the review process. The goals represent desirable outcomes to be attained by successful applicants who demonstrate an overall compliance with the criteria. Analysis of an applicant's capability to undertake the proposed project successfully is conducted by evaluating the responses provided in the application, and independent information gathered by the reviewer. Applications are analyzed to identify various strengths and weaknesses in each proposal. If more than one application is submitted for the same type of project in the same district (subdistrict or service planning area), applications are comparatively reviewed to determine which applicant best meets the review criteria. Section 59C-1.010(2) b, Florida Administrative Code, prohibits any amendments once an application has been deemed complete. The burden of proof to entitlement of a certificate rests with the applicant. As such, the applicant is responsible for the representations in the application. This is attested to as part of the application in the certification of the applicant. As part of the fact-finding, the consultant, Steve Love, analyzed the application in its entirety with consultation from financial analyst, Derron Hillman, who evaluated the financial data.

E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA

The following indicates the level of conformity of the proposed 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.


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In Volume 34, Number 40 of the Florida Administrative Weekly, dated October 3, 2008, the Agency for Health Care Administration published a need for one hospice program in AHCA Hospice Service Area 6B for the January 2010 Hospice Planning Horizon. Hospice Service Area 6B is currently served by the following three licensed hospice providers: Cornerstone Hospice and Palliative Care; Good Shepherd Hospice, Inc. and Hope Hospice and Community Services, Inc. Each co-batched applicant is applying in response to published need for a hospice program in Hospice Service Area 6B (Hardee, Highlands and Polk Counties). However, all applicants provide additional arguments in support of need for their projects as discussed below. Compassionate Care Hospice (CON #10036) states that in addition to its reliance upon the published fixed need pool determination of need, it has undertaken its own needs assessment related to specific conditions in Service Area 6B associated with population demographics and dynamics; availability, utilization and quality of like services in the service area; hospice treatment trends; and market conditions. Compassionate Care's assessment of these conditions included both quantitative data analysis and interviews with health care providers in the service area whose clients/patients utilize hospice services. The applicant states that the results of its need assessment affirm the Agency's determination that an additional hospice program is needed in Service Area 6B. The applicant next discusses specific characteristics of the service area and the manner in which these characteristics impact hospice needs. The factors considered in this assessment include: hospice use rates and trends, population size and composition, mortality rates and other factors, and unmet service area needs which are discussed below. Compassionate Care Hospice cites Florida hospice programs admissions totaling 98,619 terminally ill patients during calendar year 2007, which represents 58.8 percent of all Florida resident deaths (167,708)10 during CY 2007. However, the hospice service area with the largest number of deaths (District 11) had only a 43.6 percent admission rate, substantially lower than that of any of the other 26 service areas. Compassionate Care contends that there are clearly factors, such as its high percentage of Hispanic residents, at work in District 11 (Dade and Monroe Counties) which contribute to its lower admission rate. The applicant contends that the inclusion of Dade and Monroe Counties (hospice service area 11) in the calculation skews the statewide average downward, which can be

10 Office of Vital Statistics 2007 deaths include 167 deaths where county of residence is not known.


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seen by comparing the statewide average with District 11 (58.8 percent) to the statewide average excluding District 11 - 60.8 percent, or to the statewide median of 60.0 percent. The calendar year 2007 admission rate in Service Area 6B (56.9 percent) fell 3.1 percentage points below the state median and 3.9 percentage points below the state average (excluding District 11). Compassionate Care states that state averages and medians merely reflect "typical" performance. Alternatively, the applicant contends that need might better be gauged by comparisons to those areas of the state with the highest admission rates. The applicant included a table on page 15 of its application comparing admissions rate among service areas. This table shows that Service Area 3C had an admission rate of 75.2 percent (18.2 percentage points higher than the Service Area 6B rate). Nine service areas had admission rates of 64.5 percent or above (7.6 percentage points higher than 6B) placing them in the top third of all service areas. Service Area 6B ranked 20th out of 27 service areas in admission rate during calendar 2007, placing it in the bottom third of all hospice service areas. The applicant contends that a ranking this low can only be justified if there are pronounced market characteristics which work against higher admission rates. The applicant next provides a table showing the Service Area 6B hospice admission trends from CY 2001 – 2007.

Service Area 6B Hospice Admission Trends CY 2001-2007

Year Admits Deaths Admit Rate 2001 1,962 6,662 29.5% 2002 2,267 6,821 33.2% 2003 3,003 6,865 43.7% 2004 3,353 7,130 47.0% 2005 3,179 7,219 44.0% 2006 3,688 7,091 52.0% 2007 4,061 7,136 56.9%

Source: Agency for Health Care Administration Fixed Need Pool Publications for the appropriate years.

The table demonstrates that the admission rate grew from 29.5 percent to 56.9 percent in Service Area 6B during this period. The applicant contends that continuation of this historic growth trend would result in 5,069 hospice admissions in the calendar year 2010 horizon year and an admission rate of 64.9 percent. This rate falls between the 69th and 73rd percentile of year 2007 admission rates among the 27 hospice service areas. The applicant uses this trend model to project 5,069


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hospice admissions for 2010 planning horizon or an increase of 816 admissions. Compassionate Care contends that because eight service areas currently exceed the projected 2010 admission rate for 6B, and admission rates statewide continue to increase, the projected level of admissions is reasonable, assuming there are no demographic or other factors limiting continued hospice admission growth. A discussion of Hospice Area 6B’s population size and composition with projections to July 2010 is provided. Mortality rates and other factors potentially impacting hospice use are also address with separate discussion for age 85 and over11, cancer deaths, race and ethnicity, hospice appropriate death, and personal income. The applicant concludes that assessment of these factors impacting hospice use rates support its conclusion that admission/penetration rates in Service Area 6B should exceed the state average. Per capita income is the only factor that might suggest below average use hospice but the applicant contends it has the experience and expertise to mitigate any access problems that might exist for low income persons. The applicant contends that 6B has unmet service needs based on “extensive field work” in which Compassionate Care corporate representatives contacted each of the service area’s 10 hospitals, 31 nursing homes and 49 assisted living facilities by telephone. Compassionate Care representatives subsequently visited 20 (actually 17 per the list in tab 5) of area’s hospitals, nursing homes, assisted living facilities, and other medical and residential care providers in the three counties and interviewed administrative and clinical staffs of these organizations. The applicant contends that 10 factors from inadequate provision of continuous care services to inadequate communication between hospice staff and facility personnel concerning changes in patient care patients exist. The applicant commits that it will provide at least 1.5 percent of total patient days as continuous care days and notes to Schedule 7A support this. The applicant’s complete list of unmet needs in Service Area 6A are in its response to Agency preferences in Item 2 a 1 below. While some of these are mentioned in the applicant’s support letters, they are anecdotal. The three existing 6B hospices have a total of one confirmed compliant for inappropriate discharge and two confirmed complaints without deficiency during the previous 36 months ending January 27, 2009. Therefore, quality of care does not appear to be an issue in Service Area 6B.

11 The applicant cites the NHPCO Facts and Figures on Hospice Care released October 2008 which indicates that 36.6 percent of hospice patients were age 85 and over during 2007.


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Compassionate Care concludes that its analysis of the above factors demonstrate the need for an additional hospice program in Service Area 6B and are the underpinning key aspects of it's development plan including the selection of initial office locations; Haines City, Bartow and Sebring. The analysis culminates in a utilization forecast for the proposed program which it then states is based on the aggregate experience of hospice programs initiating operations in Florida beginning in CY 2002 (market shares provided in page 30 table), size of the 6B market and Compassionate Care’s market plan. The applicant concludes that it will have 275 admits in CY 2010 (year one) admits, 415 in year two, 520 in year three and 625 in year four, with its market share starting at 5.7 percent increasing to 12.4 in year four. Year four market share would place with a higher fourth year market share than four of the six hospices licensed since 2002 that have been in operation for four years. Florida Hospital HospiceCare (CON #10037) identifies the following additional factors which it contends document the need for a new hospice program in Service Area 6B: The applicant states that the elderly population (age 65 and over) is increasing at a faster rate than any other age group. Based on the application of the Agency's hospice need methodology to Service Area 6B, elderly residents (age 65 and over) who do not have cancer are projected to have an unmet need of 471 hospice admissions in 2010. The applicant indicates that Service Area 6B had an estimated population of 694,643 residents in 2006 and is projected to grow rapidly to a projected population of 779,535 residents by 2012, representing an increase of 12.2 percent. While the proportion of elderly residents (age 65 and over) is projected to remain at approximately 20 percent of the total population in Service Area 6B during the period, the number of elderly residents will increase by 14.0 percent from 137,682 in 2006 to 156,987 in 2012. Highlands County has a significantly higher proportion of elderly residents, 32.1 percent in 2006, than Hardee and Polk Counties. Florida HospiceCare indicates that since the elderly are the primary users of hospice care and as the elderly population continues to grow rapidly, more residents in Service Area 6B will require the services of a complete hospice care program. The applicant contends that there is a significant increase in the Hispanic population which supports the need for bilingual programs which HospiceCare can offer. Service Area 6B’s historical Hispanic population growth data from 2000 to 2007 is provided which shows this group accounted for 3,137 persons aged 65 and over in 2000 increasing to 6,437 in 2007 or 5.3 percent of the service area’s age 65 and over total


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population. Florida Hospital HospiceCare indicates it will provide bilingual programs and culturally sensitive programming to meet the need of the Hispanic population. The applicant does not provide projected Hispanic population growth. The applicant also contends that it will service to HIV/AIDS patients but the service area had only 34 deaths from this cause in CY 2007. Alzheimer’s patient care is also discussed but 6B deaths from this disease total 133 in 2002, peaking to 138 in 2004 and decreasing to 79 in 2007. These numbers do not indicate a substantial unmet need for hospice services to these patients. The applicant also cites hospice penetration rates which have increased six percent since 2006, meaning more people are seeking hospice services when it comes to end-of-life decisions. Approximately 90 percent of elderly patients with cancer are utilizing hospice care and contends that HospiceCare will improve the awareness and availability of hospice care and services by providing a program with a higher degree of integration into the continuum of care. Florida Hospital’s presence in the service area is cited as a basis for the preceding assertion. The applicant’s need discussion concluded with citing the fixed need pool projections. Florida Hospital HospiceCare projects 250 admissions in year one, 350 in year two and 375 admissions in year three. This results in a five percent market share in year one, seven percent year two and an eight percent year three market share. Odyssey HealthCare of Central Florida, Inc. (CON #10038) contends that in addition to the Agency-defined need for an additional hospice program in Service Area 6B, there are special and not normal circumstances that warrant the approval of another hospice program. The applicant states the following are those circumstances. (a) The consistently underserved patient group: cancer patients aged

65 years and older, (b) The consistently underserved patient group: non-cancer patients

aged 65 years and older, and, (c) The consistently underserved patient group: patients in need of

continuous care. The applicant’s discussion of special and not normal circumstances that support and confirm the need for an additional hospice program in 6B includes data from the Agency for Health Care Administration and information obtained via interviews with local providers.


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(a) The consistently underserved patient group: cancer patients aged

65 years and older. The applicant contends that data from the Agency for Health Care Administration clearly demonstrates that in 6B, cancer patients over the age of 65 years have been consistently underserved by the existing hospice providers. The applicant provides a table on page 119 showing that 6B providers have with the exception of October 2007 been consistently below the state average percent for all batching cycles since April 2004. This is in contrast to the statewide experience; where hospice served 91.7 percent of the patients age 65 years and older dying of cancer compared to Service Area 6B’s 89.5 percent during the October 2008 batching cycle. In 2006, there were 1,139 Service Area 6B resident cancer deaths (age 65 years and older); at the statewide utilization rate of 91.7 percent, 1,044 of these residents would have been served by hospice. However, the lower Service Area 6B utilization rate was 89.5 percent or only 1,020 residents that were actually served by hospice; leaving 119 Service Area 6B residents that could have benefited from hospice that did not receive those services. The applicant states that in most markets, Odyssey serves a lower percentage of cancer patients than might be expected based on the national U.S. hospice market, since the non-cancer patients are frequently the under-served hospice patients. That is not the case in Service Area 6B, where there is a long standing trend of a lower percentage cancer deaths (over the age of 65 years) served by the current hospice providers than is the experience statewide in Florida.

(b) The consistently underserved patient group: non-cancer patients

aged 65 years and older. The applicant presents data which shows the statewide experience; where hospice served 60.1 percent of the patients age 65 years and older dying of causes other than cancer compared to Service Area 6B’s 56.7 percent during the October 2008 batching cycle. While Service Area 6B hospices are not at the state average penetration rate as documented by CON #10036, the problem with these assumptions is that Odyssey does not explain how it arrives at the 6B percentages of care to patients over age 65 cancer and non-cancer that were served by the existing hospices. Two of the 6B hospices serve other service areas and Agency data does not have a specific service area breakout for these categories. The data


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allows these hospices to provide a roll up of all service areas for its service to cancer and non-cancer patients by age 0-64 and then 65 and over. The applicant needed to explain its process for reaching the 6B percentages to support these contentions.

(c) The consistently underserved patient group: patients in need of

continuous care. The applicant states its preliminary needs assessment indicated that there is a need for continuous care to be more available for hospice patients in Service Area 6B. Further, this identified need in Service Area 6B is consistent with a national trend observed by Odyssey: the admission of patients into hospice service with higher acuity levels from the hospital, in some cases directly from the intensive care unit. These "higher acuity" patients have many diagnoses, including cancer, pulmonary disease and heart disease. As a result, these patients, while appropriate for hospice care, have a higher cost of care than the "typical" hospice patient often with higher levels of continuous care than traditional patients. The applicant next provides a description of the four types of continuous care authorized by the Medicare benefit (the other types of care being routine, inpatient and respite). Continuous care is similar to inpatient care services, but the care is provided in the patient's home, rather than in a hospital setting or a hospice house setting. This level of care helps patients and families during times of crisis. The continuous/crisis care patient must have a skilled need that requires a minimum of eight hours of care per day on an ongoing basis. Skilled nursing care must be provided for at least 51 percent of the hours. There are three major reasons for commencing with continuous care for a patient: • Symptoms out of control, • Uncontrolled pain, and, • Caregiver breakdown. In most communities, including Service Area 6B, hospice providers choose to have the patient admitted for inpatient services instead of providing continuous care because of the difficulty and strict regulations associated with providing this care. As previously stated, to receive reimbursement for continuous care, a patient must receive a minimum of eight hours of care in a given calendar day and receive at least 51 percent skilled nursing care of the total care received. Therefore, if a person is clinically determined to need continuous/crisis care and begins receiving said care at 5:00 P.M. on a given day, the hospice receives no reimbursement as there are only seven hours remaining in that day and the eight


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hour minimum threshold cannot be met. Similarly, if a patient dies before 8:00 A.M., the eight-hour minimum threshold cannot be met and the hospice will not be reimbursed.

The applicant indicates that Odyssey currently provides and will provide continuous/crisis care in Service Area 6B. When Odyssey entered the Daytona market, continuous care was barely utilized by the existing hospice providers. Odyssey provided continuous care from the start. The competitive response to Odyssey's continuous care initiative saw the other hospices in Daytona stepping up to the plate and initiating the development of and hiring for continuous care in their programs. Even with this competitive response, referral sources in the Daytona market preferred Odyssey for this level of care because, unlike other local hospice providers, Odyssey - Daytona uses its own staff of nurses to provide continuous care, rather than using agency staffing to provide the service. Odyssey representatives who met with Service Area 6B providers cited that the existing hospice providers were inconsistent with their provision of crisis care, also known as continuous care, in nursing homes. Odyssey will ensure that this level of care is provided in Service Area 6B. The applicant concludes that its commitment is evidenced by Odyssey's proposed condition to provide continuous care as two percent of its total patient days. The applicant’s notes to Schedule 7A do not support this contention. Regardless, continuous care is the most expensive level of hospice care and the applicants do not document that patients in need of this care are not receiving it. The applicant also provides a discussion of the Agency’s need as published, a modified Agency need methodology and a historic growth rate projection methodology. A discussion of the modified need projection and historic growth rate project method follows. For the modified Agency need methodology, the applicant states that the actual Service Area 6B penetration rates for non-cancer patients under age 65 is 26.1 percent (26.1 percent of non-cancer residents under age 65 dying utilized hospice care) compared to a state-wide penetration rate of 20.7 percent. Similarly, the actual Service Area 6B penetration rates for cancer patients under the age of 65 years is 111.4 percent (111.4 percent of cancer residents age 65+ dying utilized hospice care) compared to a statewide penetration rate of 88.8 percent. As a result, in order to establish a realistic forecast of Service Area 6B hospice market size a modified Agency approach has been developed to reflect actual nature of the local market in the two under age 65 resident


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subgroups shown in the Table below, when actual Service Area 6B hospice penetration rates (capping cancer under age 65 penetration at 100 percent) are applied to the non-cancer under age 65 and cancer under age projected deaths and the state average hospice penetration rates are applied to the cancer 65+ and non-cancer 65+ projected deaths, the market forecast hospice admissions for Service Area 6B is 4,928 hospice admissions for the 12 months ending 12/2010 - 140 more admission than forecast when using the state’s methodology. However, it appears that the applicant is including patients (the 111.4 percent patient number certainly supports this) that are not residents of Service Area 6B in its 6B analysis.

The historic growth rate market forecast considers hospice admissions from the 12-month periods ending 2004 thorough 2008. This shows that Service Area 6B has increased from 3,162 hospice admissions in 2004 to 4,253 in 2008 or by 7.69 percent. The applicant projects annual growth at half of the 7.69 percent historical growth or by 3.84 percent from 2008 through 2011. The chart below contains these projections.

Service Area 6B

Projected Hospice Admissions CY 2008-2011

Based on 3.84 Percent Annual Growth

2008

2009

2010

2011 2008-2011 Growth

Admissions 4,253 4,416 4,586 4,762 509 Source: CON Application #10038, page 145.

The applicant contends that its projections are conservative based on the use of the 3.84 percent annual growth rate, and that the substantial pool of new incremental hospice patients, along with the existing providers performance at current levels supports need for its project.

2. Agency Rule Criteria and Preferences a. Rule 59C-1.0355(4)(e) Florida Administrative Code. Preferences for

a New Hospice Program. The Agency shall give preference to an applicant meeting one or more of the criteria specified in the below listed subparagraphs:


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(1) Preference shall be given to an applicant who has a

commitment to serve populations with unmet needs.

Compassionate Care Hospice (CON #10036) states that responsiveness, breadth of service and quality of care could be improved upon in the service area. The applicant states the current Service Area 6B hospice population is experiencing unmet need in the following areas: • Inadequate provision of continuous care services to actively

dying patients. • Inadequate provision of homemaker services. • Unavailability of social work services. • Over medication of hospice patients. • Inadequate provision of medical supplies needed by hospice

patients. • Two of the three hospices do not provide music or massage

therapy. • Inadequate level of CNA care provided to ALF patients. • Existing hospices do not routinely pay for all medications

needed by hospice patients in nursing homes. • Inadequate pre-admission screening results in an excessive

proportion of patients being disenrolled from hospice. • Inadequate communication between hospice staff and facility

personnel concerning changes in patient care plans. At least some of these stated inadequacies are borne out by support letters from health care providers that promote this applicant. Tab 5 of the application includes a letter from Dee Brock, RN, the Compassionate Care representative, that summarizes her Service Area 6B telephone survey with the conclusions stated above. She also describes her field visit during the week of November 18-21 and listed the four hospitals, three nursing homes and 10 assisted living facilities visited. The applicant conditions that continuous care will be at 1.5 percent of patient days. Nationally, continuous care was 0.9 percent of total hospice patient days in 2007 and 0.4 percent in 200612.

12 NHPCO Facts & Figures on Hospice Care released October 2008, page 12.


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The applicant states that historic Agency forecasts consistently under-predict actual horizon year admissions due largely to the steady increase in hospice admission rates. The applicant estimates 275, 415 and 520 admissions for first, second and third year operations, respectively.

Florida Hospital HospiceCare (CON #10037) states intentions to serve the unmet needs of the population eligible for hospice through a variety of approaches, each of which the applicant states will seek to improve awareness and understanding of the benefits of hospice within the community. HospiceCare attests commitment to offering ongoing staff and medical community education and training programs designed to provide information, enhance services, and expand understanding of hospice needs. Some examples (and target audiences) of HospiceCare’ s educational offerings in Service Area 4B are stated to be as follows: • End-of-Life Issues (nurses) • Pain management in-service • Cancer and the Caregiver • Therapeutic Communication: Dementia and Aphasia • Therapeutic Communication: Nutrition — Modified Diets • The Patient with Decreased Mobility • How to Talk to Patients and Their Families about Hospice

(nursing home in-service) • Spiritual Care Education (hospital nurse interns) • Appropriate Times to Call Hospice (nursing home) • Advanced Directives Seminars provided quarterly • Hospice Care: What is it all about? (cremation society) HospiceCare’s commitment to serving the unmet hospice needs of the community are to be expanded to Hospice Service Area 6B, with project approval. Odyssey HealthCare of Central Florida, Inc. (CON #10038) states three particular populations in Service Area 6B with what the applicant calls “special and not normal circumstances”. These populations are as follows: cancer patients aged 65 years and older; non-cancer patients aged 65 years and older and patients in need of continuous care. The applicant warrants that cancer patients aged 65 years and older in Service Area 6B are having unmet need by stating that in 2006, there were 1,139 cancer deaths (patients 65 years and older) in the service area and that with a statewide cancer death rate of


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91.7 percent for this age group, 1,044 of these cancer patients in this age range in the service area should have received hospice care. However, the applicant states this age group with a cancer diagnosis, in this service area, totaled only 1,020 admissions. Odyssey states this lower admission rate for this population in this service area has trended below expectations for several years. Regarding the non-cancer patients aged 65 years and older in the service area, there were 4,154 non-cancer deaths and that with a statewide non-cancer death rate of 60.1 percent for this age group, 2,497 of these non-cancer patients in this age range in the service area should have received hospice care. However, the applicant states this age group with a non-cancer diagnosis, in this service area, totaled only 2,357. Odyssey states that this too has trended in this direction for several years. Finally, the applicant states that continuous care is needed to a greater extent than is currently utilized by existing hospice providers in Service Area 6B. The applicant conditions that continuous care will be at two percent of patient days. Nationally, continuous care was 0.9 percent of total hospice patient days in 2007 and 0.4 percent in 2006.13

(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 (CON #10036) states it will contract with existing hospitals and skilled nursing facilities in Subdistrict 6B to provide inpatient beds. The applicant reports letters from senior executives of the following health care entities in which contractual relationship commitments are made: Health Management Associates on behalf of its three hospitals in the service area; Winter Haven Hospital; and Winter Haven Health & Rehabilitative Center (an area SNF). Among the co-batched applicants, Compassionate Care reports the greatest number of entities (total of six) that commit to a contractual relationship for inpatient hospice beds, should the application be approved. If approved, the applicant states that in summary, it will continue to contact existing health care facilities to obtain a balance of locations to provide the hospice patients with the most convenient options.

13 Ibid.


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Florida Hospital HospiceCare (CON #10037) states intentions to contract with one or more Florida Hospital facilities (Heartland, Lake Placid or Wauchula), all located in Service Area 6B, to provide inpatient beds. A letter attesting to this commitment, from Florida Hospital Heartland, is included in the application. Among the co-batched applicants, HospiceCare has the fewest number of entities (one facility) that commit to a contractual relationship for inpatient hospice beds. Odyssey HealthCare of Central Florida, Inc. (CON #10038) proposes to provide the inpatient care component of its hospice program through contractual arrangements with existing health care facilities in the area. The applicant includes a signed “Memorandum(s) of Understanding” with one hospital and three nursing homes located in Service Area 6B (Lakeland Regional Medical Center, Haines City Health Center, Lake Placid Health Care Center and Spring Lake Rehabilitation Center) to enter into contractual agreements for the provision of inpatient hospice services, should the applicant’s project be approved.

(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.

Of the co-batched applicants, Compassionate Care is most specific regarding a percent of its parent’s patients recently served (in 2006) that lived alone. All co-batched applicants state they will serve patients and have mechanisms in place to meet the admission plans for patients who do not have a primary care giver, are homeless and/or are patients with AIDS. Compassionate Care Hospice (CON #10036) states that they are committed to serving patients who do not have primary caregivers at home, the homeless, and patients with AIDS. The applicant states that in 2006, of its 6,322 hospice patients, 549 (or approximately 8.7 percent) lived alone14. Another 140 patients (or about 2.2 percent) are stated to be living with “compromised caregivers”. In total, this is near 11 percent of patients in 2006 that the applicant states lived alone or with a compromised caregiver, according to the parent’s records. In addition, Compassionate Care states it has provided care to individuals in boarding homes, homeless shelters, psychiatric

14 CON Application #10036, page #38


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centers, and correctional facilities. Compassionate Care states that it serves all patients and, in addition to those who live alone, this includes transients, and those who have AIDS, or are homeless. The applicant states that if a homeless patient desiring Compassionate Care Hospice care is discharged from a hospital and has nowhere to go, Compassionate Care will place them in an inpatient unit and apply for Medicaid. Once the patient qualifies and receives Medicaid, they will be placed into a long-term care environment in which hospice care can still be provided as long as the patient requires such care. Florida Hospital HospiceCare (CON #10037) states it does not discriminate against anyone seeking its services and has been committed to serve patients who do not have primary caregivers at home, are homeless, and/or have AIDS/HIV. The Florida Hospital facilities in Service Area 6B, including Florida Hospital Wauchula, a critical access hospital, and through its Heartland Division, home care and other outpatient services have a history of providing care to residents of Hardee County, which the applicant reports to have a relatively large Hispanic population (over 40 percent of total population) and a significant number of migrant farm workers. Of the co-batched applicants, HospiceCare narrows its attention to Hardee County in this criterion. Odyssey HealthCare of Central Florida, Inc. (CON #10038) states that it accepts all patients who meet admission criteria, including patients who do not have a primary care giver at home, the homeless and patients with AIDS. The applicant explains that an Odyssey nurse will coordinate appropriate action and placement with the rest of the interdisciplinary team and hospice physician or attending physician. Odyssey describes numerous mechanisms to address admissions and placement in Appendix H (Policies & Procedures Manual) of its application.

(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 6B consists of three counties (Hardee, Highlands and Polk) and therefore; this criterion is applicable to this review.


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In the current service area hospice arrangement, two of the three existing hospice service providers (Good Shepherd Hospice and Hope Hospice and Community Services) maintain at least one office location in each of the three Service Area 6B counties. Cornerstone Hospice and Palliative Care, maintains office location in Highlands and Polk Counties, but not in Hardee County. The chart below indicates the number of operational hospice locations in the service area, by county.

Hospice Service Area 6B Operational Hospice Office Locations

By Provider and By County as of January 28, 2009 County/Provider Cornerstone Good Shepherd Hope Hospice Total

Hardee 0 1 1 2

Highlands 1 1 1 3

Polk 1 4 1 6 Total 2 6 3 11 Source: Agency for Health Care Administration Home Care Unit Licensure Records.

Compassionate Care Hospice (CON #10036) states that it will open three offices within its first year of operation. The main office location will be in northeast Polk County (Haines City) with satellite offices in the Bartow and Sebring areas. This initial slate of Compassionate Care office locations does not include an office in Hardee County. This is justified by the applicant in that Hardee County has a relatively small elderly population which is not growing rapidly, and a relatively small proportion of service area deaths. Further, Hardee County already has offices of two existing hospice providers, per Compassionate Care and confirmed by Agency records. The applicant states that Hardee County is not currently underserved, relative to other counties in the service area, nor do medical or demographic trends suggest that it is likely to be underserved in the near future. Compassionate Care will serve all of the counties in the service area from its three initial office locations and will continue to monitor service delivery needs throughout the entire service area. Compassionate Care states it will expand its physical presence as needed so as to meet area needs in a comprehensive and efficient manner. Florida Hospital HospiceCare (CON #10037) states it will lease an administrative office in Service Area 6B but is not specific about where or when. The applicant states that it already have a physical presence by virtue of Florida Hospital’s three existing hospitals in the service area (facilities in Hardee and Highlands Counties). It is noted that of the three counties in Service Area 6B,


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Polk has the largest population and will continue to have the largest population, including the most residents age 65 and over, by the January 2010 Planning Horizon and for years beyond. Odyssey HealthCare of Central Florida, Inc. (CON #10038) states that in year two of operations (ending December 31, 2011) it will maintain a satellite office in Highlands County and in year three (ending December 31, 2012) it will maintain a satellite office in Hardee County. Polk County, the most populous county in the service area, is not mentioned as an office site. The applicant further states in its condition that will develop its main office in Polk County.

(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 (CON #10036) states it currently provides services that are not covered by private insurance, Medicaid, or Medicare, and will continue to do so in the program proposed for Service Area 6B. Compassionate Care states it provides services needed to all patients regardless of payer status, and in many instances regardless of legal status. Each of the existing Compassionate Care programs is stated to provide a substantial portion of services that are not specifically covered by private insurance, Medicaid or Medicare. Compassionate Care states that in 2006 the proportion of care delivered to patients who were unable to pay was 2.8 percent. Compassionate Care estimates about a two percent hospice population being unable to pay in Service Area 6B. In addition to providing its full range of services to patients not covered by private insurance, Medicaid or Medicare, Compassionate Care states it offers services that are not included in the range of services typically reimbursed by these programs. These services include: • Bereavement – Compassionate Care alleges it exceeds the

Medicare Conditions of Participation for provision of bereavement services. Supporting families, friends, and loved ones through an effective bereavement program is stated to be an essential component of Compassionate Care’s program. Bereavement counselors assist grieving families in finding health paths to healing. These counselors are said to be available to family members for a minimum of 15 months


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following the death of the hospice patient and volunteers are said to be trained to understand healthy bereavement care, to recognize abnormal patterns of grief, and to provide appropriate support and encouragement through the grieving process. Compassionate Care also proposes that it will provide age-specific grief group counseling, through programs such as the Rainbow Program, a pediatric bereavement program, as well as individualized one-on-one counseling.

• Compassionate Care Hospice Foundation Activities –

Compassionate Care Hospice Foundation, Inc. is stated to be a non-profit fundraising organization affiliated with Compassionate Care Hospice which provides financial assistance to terminally ill patients and families in need. It also is stated to support public programs that provide the general public with information regarding end-of-life choices allowing individuals to determine and communicate their wishes and help their families prepare for the future. The following are stated recent examples of instances in which the Compassionate Care Hospice Foundation provided assistance to patients and families:

o Paying rent, mortgage and utility payments on behalf of

struggling families. In the current economic crisis, more families are anticipated to be in need of such support.

o Providing summer camp tuition for an 11 year-old child whose single mother was terminally ill.

o Providing a special therapeutic pillow to help ease pain for a terminally ill child.

o Covering the cost of dinner and a babysitter for parents who were caring for a terminally ill child.

o Funding special projects, volunteer efforts, and educational programs in various communities designed to raise public awareness about hospice care and its benefits.

o Providing an annual $10,000 grant toward funding Compassionate Courage, a program for school-aged children with a family member undergoing cancer treatments, terminal illness, or children who have experienced a loss due to death or changes in family structure.


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• Compassionate Courage – A program offering a safe place for

children to express their feelings and share with others who have experienced similar loss. Compassionate Courage programs provide bereavement support groups for elementary and middle school children who are dealing with a significant loss.

• Complementary Therapies – Complementary therapies are

stated to be offered at no charge to hospice patients to ease pain and discomfort. Sample therapies include the following:

o Songs for the Soul – Music therapists provide unique,

relaxing music to alleviate stress, pain and discomfort, and to promote peace, tranquility, and relaxation.

o Looking Great – A licensed beautician provides haircuts, hairstyling, and beauty tips, helping patients look and feel their best.

o Therapeutic Touch – A licensed massage therapist provides a variety of massage techniques to reduce stress, relieve cramps, and improve circulation promoting comfort and an increased sense of well being.

o Pet Visitor Program – Physical contact with pets has been shown to have a number of benefits, reducing stress and increasing joy and well being. To date, Compassionate Care has incorporated dogs, cats and rabbits in its program, to the delight of many patients.

o Good Scents – An aroma therapy program. o Art Therapy – A program assisting patient and family

members in creating arts and crafts projects. Using ones hands to create a product helps alleviate depression and provides a sense of connectedness and accomplishment.

Florida Hospital HospiceCare (CON #10037) states that it and Florida Hospital have a long history of providing services to all patients without regard to ability to pay. In 2007, the applicant reports Florida Hospital provided $16.2 million dollars of charitable care at its three hospitals in Service Area 6B. HospiceCare attests that uninsured or indigent patients receive care with the same quality and dignity as those patients with insurance. Moreover, HospiceCare has developed a number of services that fall outside any insurance coverage when developing their hospice program for other counties in Florida, such as bereavement services, per the application. HospiceCare goes on to state community services that will be provided at no charge to recipients may include education,


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resource library, teen volunteers, caregiver support, HIV programs, palliative care consults, and caregiver services for patients without caregivers. Bereavement services such as community bereavement groups and counseling for non-hospice bereaved, community education on grief and loss, and holiday grief groups will also be offered in Service Area 6B, per the applicant. The proposed HospiceCare program projects a total of 2.0 percent of its patient revenues will be charity patients and 3.0 percent will be uncompensated care (including charity care). Odyssey HealthCare of Central Florida, Inc. (CON #10038) states that services not specifically covered by Medicaid or Medicare include the following: pet, music, massage and aroma therapies; dialysis and palliative radiation and palliative chemotherapy. With the exception of dialysis, these non-covered services are conditioned by the applicant. It is further stated the hospice services will be provided to all patients regardless of their ability to pay and this too is conditioned. As stated previously, 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 those lacking the ability to pay.

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 (CON #10036) states it will provide staff to equal or exceed the staff recommendations of the National Hospice and Palliative Care Organizations (NHPCO). It also states it has consistently met or exceeded the Medicare Conditions of Participation requirement that hospices provide a minimum of five percent of direct patient care or administrative staff hours through volunteers. Compassionate Care’s Schedule 6A indicates 34.4 FTEs in year one (ending December 31, 2010) and 52.6 FTEs in year


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two (ending December 31, 2011). Compassionate Care states it will utilize an interdisciplinary team model. The applicant states that by including a wide range of personnel skills and experience and input from the family, Compassionate Care believes that the patient and the family are the primary unit of care. Other members of the care team include: patient’s primary hospice physician, hospice medical director, registered nurse (RN), social worker, certified home health aides/nursing assistants, therapists (to be utilized on a contractual basis), dieticians, bereavement counselors, chaplains, and trained volunteers. Additional staff will be added as needed. Florida Hospital HospiceCare (CON #10037) states that trained members of an interdisciplinary team will be comprised of nurses, physicians, social workers, chaplains, home health aides and volunteers. The applicant’s Schedule 6A accounts for a total of 17.6 FTE’s dedicated to serving the program in year one and 25.6 FTE’s in year two. However, it is noted home health aides are not listed in the schedule or in the schedule notes. The schedule indicates 1.0 FTEs for volunteer services for year one and 1.5 FTEs for year two. The applicant states that Dr. John Steely will be the medical director and includes Dr. Steely’s Curriculum Vitae in the application’s attachment M. It is stated the administrative director will oversee the proposed hospice program. HospiceCare states volunteers will be trained to provide respite, companionship, transportation, supportive visiting, homemaking, sharing of special talents, and bereavement support. Some volunteers and groups of volunteers may participate in fundraising activities and volunteers will be supervised by a designated staff member. The applicant commits to a minimum of 10 percent of its hours of care will be provided by hospice volunteers in its second year of operations. This is twice the five percent requirement mandated under the Medicare program and the 10 percent commitment is conditioned by the applicant. Odyssey HealthCare of Central Florida, Inc. (CON

#10038) states it will provide each patient and family with a “Circle of Care”; an interdisciplinary team of its employees and the patient’s physician dedicated to providing a high-level of care and assistance to patients and their families as designed and in use by the applicant. The interdisciplinary


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team is stated to be specialized in end-of-life care and in pain and symptom management. The manager of the interdisciplinary team is the nurse who assesses the needs of the patient and family. The applicant states that in addition to the nurse case manager, the patient’s attending physician and the medical director, the interdisciplinary team also includes the following: a home health care aide (for direct patient care); a chaplain (addressing concerns of a spiritual nature); a social worker (addressing psycho-social needs of patients and family members); trained volunteers (for companionship and supportive non-medical services); a bereavement counselor (to manage support groups, newsletters and referrals) and an on-call nursing team. The applicant’s Schedule 6A indicates a total of 15.7 FTE’s dedicated to serving the program in year one and 30.6 FTE’s in year two.

(b) Expected sources of patient referrals.

Compassionate Care Hospice (CON #10036) states that patient referrals are expected to come from numerous sources, including physicians, hospital social workers and case managers, long-term care facilities, other community-based agencies, and family members and others. The applicant states it has made contacts with major health care providers in Service Area 6B and will continue to develop these relationships once approved. The applicant intends to educate the existing providers about the types of services it can provide to their patients.

Florida Hospital HospiceCare (CON #10037) states an expectation that referrals will be received from the following sources: hospitals; physicians; nursing homes; assisted living facilities; home health agencies; patient self-referrals; families and friends; managed care companies and faith communities. Odyssey HealthCare of Central Florida, Inc. (CON

#10038) states an expectation of referrals through the following sources: physicians; long-term care facilities (including nursing homes and assisted living facilities/adult day care centers); hospitals and managed care and insurance companies. The applicant expresses an interest in patients “aging in place”.


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(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.

The table below is provided, to illustrate projected admissions for years one and two for each of the co-batched applicants.

Total Projected Admissions By Applicant for Years One and Two

CON # Applicant Year One Year Two Both Years

10036 Compassionate Care 275 415 690

10037 FL Hospice “HospiceCare” 250 350 600

10038 Odyssey 285 405 690 Source: CON Application #’s 10036-10038.

As indicated in the table above, two co-batched applicants both anticipate serving a total of 690 patients in the first two combined years Compassionate Care Hospice (CON #10036) and Odyssey HealthCare of Central Florida, Inc. (CON #10038) while Florida Hospital HospiceCare (CON #10037) anticipates serving the fewest in the first two combined years (600 patients). As described in the tables for each co-batched applicant below, CON #10038 anticipates serving the highest percentage of Medicare patients in the first two years of operation and CON #10037 anticipates serving the lowest percentage of Medicare patients in the same period. Also, in the same period, CON #10036 projects serving the most indigent/self-pay patients (51 patients), followed by CON #10037 (24 patients) and last, CON #10038 (14 patients). It is noted that hospice programs are required by federal and state law to provide services to everyone requesting them, regardless of ability to pay. Compassionate Care Hospice (CON #10036) provides estimates as shown below regarding payer types for the first two years of operation.


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Expected Admissions by Payer Type

For Compassionate Care Hospice of Miami-Dade, Inc. d/b/a Compassionate Care Hospice - CON #10036

Service Area 6B Payer Type Year One Year Two

Medicare 205 348

Medicaid 8 14

Private Insurance 25 39

Indigent/Self-Pay 37 14 Total 275 415 Source: CON Application #10036, page #44.

As shown in the table above, the applicant intends to serve 275 and 415 patients in its first and second year of operation, respectively. It is noted that the applicant’s provision of Medicare will comprise 74.55 percent of admissions during the first year and 83.86 percent of admissions during the second year of operations. Also indigent/self-pay is expected to comprise 13.45 percent in year one and 3.37 percent in year two.

Florida Hospital HospiceCare (CON #10037) provides estimates as shown below regarding payer types for the first two years of operation.

Projected HospiceCare Admissions by Payer CON #10037 Years One and Two of Operation


Medicare 167 234

Medicaid 70 98

Private Insurance 3 4

Indigent/Self-Pay 10 14 Total 250 350 Source: CON Application #10037, page #43.

As shown in the table above, the applicant intends to serve 250 and 350 patients in its first and second year of operation, respectively. It is noted that the applicant’s provision of Medicare will comprise 66.80 percent of admissions during the first year and 66.86 percent of admissions during the second year of operations. Also indigent/self-pay is expected to comprise 4.0 percent in both year one and year two. Odyssey HealthCare of Central Florida, Inc. (CON

#10038) provides estimates as shown below regarding payer types for the first two years of operation.


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Projected Odyssey HealthCare of Central Florida, Inc. Admissions by Payer CON #10038 Years One and Two of Operation


Medicare 265 377

Medicaid 11 16

Insurance 3 4

Self-Pay 6 8

Other 0 0 Total 285 405 Source: CON Application #10038, page #177.

As shown in the table above, the applicant intends to serve 285 and 405 patients in its first and second year of operation, respectively. It is noted that the applicant’s provision of Medicare will comprise 92.98 percent of admissions during the first year and 93.09 percent of admissions during the second year of operations. Also self-pay is expected to comprise 2.12 percent in year one and 1.98 percent in year two.

(d) Projected number of admissions, by type of terminal illness, for the first two years of operation.

Compassionate Care Hospice (CON #10036) provides the following table illustrating the projected number of admissions by type of terminal illness for the first two years of operation.

Projected number of Admissions by Diagnosis For Compassionate Care

Years One and Two of Operation Hospice Service Area 6B

Disease Year One Year Two

Cancer 96 144

Non-cancer 179 271 Total 275 415 Source: CON Application #10036, page #44.

The applicant projects to serve 275 patients in year one and 415 patients in year two and of the co-batched applicants does not specify any one or combination of expected non-cancer diagnoses.

Florida Hospital HospiceCare (CON #10037), also referenced as HospiceCare, provides the following table illustrating the projected number of admissions by type of terminal illness for the first two years of operation.


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Projected number of Admissions by Diagnosis For HospiceCare

Years One and Two of Operation Hospice Service Area 6B

Disease Year One Year Two

Cancer 84 117

AIDS 2 3

COPD 16 22

End Stage Renal Disease 7 9

Congestive Heart Failure 24 34

Other 117 165 Total 250 350 Source: CON #10037, page #44.

The applicant projects to serve 250 patients in year one and 350 patients in year two. Odyssey HealthCare of Central Florida, Inc. (CON

#10038) provides the following table illustrating the projected number of admissions by type of terminal illness for the first two years of operation.

Projected Admissions by Diagnosis for Odyssey Years One and Two of Operation

Hospice Service Area 6B Disease Year One Year Two

Cancer 88 126

Alzheimer’s/Dementia 48 69

Congestive Heart Failure 51 73

COPD 23 32

Debility 26 36

Renal 9 12

Liver/Other 40 57 Total 285 405 Source: CON Application #10038, page #177.

The applicant projects to serve 285 patients in year one and 405 patients in year two.

(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 (CON #10036) projects 275 admissions in its first year of operations and 415 in the second year. The projected number of admissions by age groups under 65 and 65 or older appears in the following table.


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Projected Number of Admissions by Age Group

for Compassionate Care Years One and Two of Operation

Service Area 6B Under 65 Over 65 Total

Year One 46 229 275

Year Two 68 347 415

Source: CON Application #10036, page #44. Florida Hospital HospiceCare (CON #10037) projects 250 admissions in its first year of operations and 350 in the second year. The projected number of admissions by age groups under 65 and 65 or older appears in the following table.

Projected Number of Admissions by Age Group for HospiceCare Years One and Two of Operation

Hospice Service Area 6B Under 65 Over 65 Total

Year One 40 210 250

Year Two 56 294 350

Source: CON Application #10037, page #45. Odyssey HealthCare of Central Florida, Inc. (CON

#10038) projects 285 admissions in its first year of operations and 405 in the second year. The projected number of admissions by age groups under 65 and 65 or older appears in the following table.

Projected Number of Admissions by Age Group for Odyssey Years One and Two of Operation

Hospice Service Area 6B Under 65 Over 65 Total

Year One 29 256 285

Year Two 41 364 405

Source: CON Application #10038, page #178.

(f) Identification of the services that will be provided directly by hospice staff and volunteers and those that will be provided through contractual arrangements.

The hospice care team shall directly provide the following core services: nursing services, social work services, pastoral or counseling services, dietary counseling, and bereavement counseling services. Physician services may be provided by the hospice directly or through contract. A hospice may also


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use contracted staff if necessary to supplement hospice employees in order to meet the needs of patients during periods of peak patient loads or under extraordinary circumstances. Memorial Hospital-Flagler, Inc. (CON #10037) does not include any FTEs for dietician or for dietary consulting; this is a core requirement and must be provided by hospice staff. With that exception, all co-batched applicants provide FTEs for mandatory in-house services. Compassionate Care Hospice (CON #10036) asserts that it will provide what it lists as core services – physician, nursing, social work, pastoral and counseling, bereavement counseling, home health aide, pharmacy, supplies and durable medical equipment, homemaker and chore, and dietician/nutritionist – all directly through hospice staff and volunteers. Compassionate Care states intention to contract for the following services: physical, occupational and speech therapy; massage; music; inpatient and respite; patient transportation and infusion. Florida Hospital HospiceCare (CON #10037) asserts that it will provide directly by hospice staff or volunteers the following: routine home care; respite care; continuous care; physician services; bereavement services; homes health aide services; medical social services; volunteer services; spiritual counseling services; patient and family education support and palliative care (e.g. massage, music therapy and pet therapy). The applicant’s Schedule 7B does not include respite care or continuous care, which are required hospice services. The following services are stated by the applicant as available on a contractual basis as needed: therapy services (physical, occupational and speech); dietary counseling, clinical pharmacist and inpatient services. The applicant’s Schedule 6A includes FTEs for all mandatory in-house services with the exception of dietary counseling, which the applicant states will be available on a contractual basis, as needed. It is noted that dietary counseling is a mandatory core service that must be provided directly and cannot be contracted.


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Odyssey HealthCare of Central Florida, Inc. (CON

#10038) asserts that with the exception of physicians and a minimal level of contract services by physical, speech and occupational therapists, the majority of services will be provided by the hospice care team and volunteers. The applicant indicates in-house services are as follows: home health care aides; chaplain; social worker; volunteers; bereavement coordinator and a 24/7 on-call nursing team.

(g) Proposed arrangements for providing inpatient care.

All of the applicants include support letters or other documents that attest to hospital and/or skilled nursing facilities in Service Area 6B that are willing to contract with the applicant for inpatient hospice services. Compassionate Care Hospice (CON #10036) anticipates contractual arrangements with existing hospitals and nursing homes in the area. The applicant has secured letters of support from Ann Barnhart, Regional Vice President of Health Management Associates, on behalf of its three licensed hospitals in the service area; Lance Anastasio, President of Winter Haven Hospital and Angela Smith, Administrator, at Winter Haven Health & Rehabilitative Center (a SNF), stating their willingness to enter into agreements with Compassionate Care to provide inpatient care for Compassionate Care patients.

Florida Hospital HospiceCare (CON #10037) states intentions to contract with existing hospitals and skilled nursing facilities in Hardee, Highlands and Polk Counties. The applicant states that inpatient care needed by its hospice patients will be provided by one or more of the three Florida Hospital facilities in the service area (Heartland, Lake Placid or Wauchula), all located in Service Area 6B. A letter attesting to this commitment, from Florida Hospital Heartland, is included in the application. The applicant states it may contract with an existing hospice facility in the service area to meet inpatient hospice needs. Among the co-batched applicants, HospiceCare has the fewest number of entities that commit to a contractual relationship for inpatient hospice beds.


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#10038) states plans for contractual arrangements with acute care hospitals and skilled nursing facilities throughout Service Area 6B. The applicant has current, signed agreements with the following four providers: Lakeland Regional Medical Center; Haines City Health Center; Lake Placid Health Care Center and Spring Lake Rehabilitation Center. The applicant indicates it will seek to establish arrangements with nursing homes and assisted living facilities in the applicable service area to ensure that patients in these facilities can remain in their “home” and receive the appropriate level of hospice services the care setting allows. The applicant states that this is similar to the arrangements it presently has with these types of facilities through Odyssey HealthCare-Daytona and Odyssey HealthCare-Miami/Dade. It is noted that assisted living facilities do not meet mandated licensure requirements, sufficient to satisfy inpatient hospice service requirements. Currently, only hospitals and skilled nursing facilities meet these required licensure mandates.

(h) Proposed number of inpatient beds that will be located in a freestanding inpatient facility, in hospitals, and in nursing homes.

Compassionate Care Hospice (CON #10036) proposes an estimate of less than one average daily census (ADC) in year one and just over one ADC inpatient bed in year two.

The applicant states this will be achieved through contractual agreements with nursing homes and hospitals in Service Area 6B. There will be no dedicated or reserved beds for Compassionate Care patients but rather, beds will be acquired on an “as needed” basis under the terms of its agreements.

Florida Hospital HospiceCare (CON #10037) does not offer a number of expected inpatient beds that will be needed, neither on an annualized, nor on an ADC basis. Odyssey HealthCare of Central Florida, Inc. (CON

#10038) does not offer a number of expected inpatient beds that will be needed, neither on an annualized, nor on an ADC basis.


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(i) Circumstances under which a patient would be admitted to an inpatient bed.

All co-batched applicants express an interest in admitting patients to an inpatient bed when less intensive methods of care are impractical, unfeasible, ineffective or otherwise inappropriate, given patient desires, symptoms and caregiver or family dynamics. Compassionate Care Hospice (CON #10036) states that its patients are admitted to an inpatient bed according to the guidelines set forth in the Federal Medicare Guidelines for hospice inpatient care. Inpatient care is stated to be a short term adjunct to hospice home care and the decision to implement inpatient care will be on a case-by-case basis, with input from the interdisciplinary team and the attending physician. In order to qualify for inpatient care, the applicant indicates that in addition to meetings the federal Medicare guidelines for hospice inpatient care, the patient must also meet one or more of the following criteria: pain; other prominent symptoms (such as imminent death, infeasible or impractical home care and related higher intensity or higher acuity care not reasonably available in a home setting); psychosocial pathology (disturbed mental status) such as depression or anxiety in the extreme; acutely unsafe home environment; breakdown or disruption in family dynamics and related issues. Compassionate Care states that it will also provide respite care for when the patient’s family/caregiver needs a short period of relief. This will be offered on an “as needed” basis for a maximum of five days per respite admission for a Medicare/Medicaid patient. For patients covered by other insurers, the duration may be approved for a longer period of time.

Florida Hospital HospiceCare (CON #10037) states the HospiceCare interdisciplinary team evaluates patients to determine the need for inpatient care, based on the patient’s condition and family circumstances. Per the applicant, some circumstances that would warrant inpatient admission would include the following: acute pain or other symptoms that cannot be adequately addressed at home and those who are imminently dying and have complex care needs. It is also stated that inpatient care is appropriate for temporary


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emergency situations in which the caregiver is unable to provide the patient with skilled care at home (for instance, sudden illness/impairment/death of primary caregiver). To meet the need for inpatient care, HospiceCare states intentions to contract with hospitals and nursing homes in Service Area 6B. If CON approved and after HospiceCare is established in Service Area 6B, the applicant proposes to develop inpatient options for patients similar to what it provides currently in Service Area 4B (Flagler and Volusia Counties). HospiceCare states inpatient hospice care is provided in Service Area 4B in numerous locations, including the Stuart F. Meyer freestanding hospice inpatient facility. Odyssey HealthCare of Central Florida, Inc. (CON

#10038) states admission to an inpatient bed is dictated by a patient’s medical need and if possible, symptoms are addressed and care is provided in the “home” setting wherever that may be. However, per the applicant, inpatient care applies when care cannot be effectively managed in the home setting, and when continuous care is not an option due to the level of caregiver support available, or patient or family wishes call for this care. The applicant states that patients are encouraged to seek the level of care with which they are most comfortable, including inpatient hospice care. To meet this need, the applicant states intentions to secure inpatient contracts with hospitals and nursing homes in Service Area 6B. However, the applicant stresses a focus on allowing the patient to remain in their home setting at all times and is committed to providing continuous care, to which the applicant conditions to two percent of patient days, the highest percentage of this commitment of any of the co-batched applicants.

(j) Provisions for serving persons without primary caregivers at home.

All co-batched applicants state that they have mechanisms and procedures in place to address patient needs for serving persons without primary caregivers at home.


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Compassionate Care Hospice (CON #10036) states that they are committed to serving patients who do not have primary caregivers at home, the homeless, and patients with AIDS. The applicant states that in 2006, of its 6,322 hospice patients, 549 (or approximately 8.7 percent) lived alone. Another 140 patients (or about 2.2 percent) are stated to be living with “compromised caregivers”. In total, this is near 11 percent of patients in 2006 that the applicant states lived alone or with a compromised caregiver. In addition, Compassionate Care states it has provided care to individuals in boarding homes, homeless shelters, psychiatric centers, and correctional facilities. Compassionate Care reports it serves all patients and, in addition to those who live alone, this includes transients, and those who have AIDS, or are homeless. The applicant states that if a homeless patient desiring Compassionate Care Hospice care is discharged from a hospital and has nowhere to go, Compassionate Care will place them in an inpatient unit and apply for Medicaid. Once the patient qualifies and receives Medicaid, they will be placed into a long-term care environment in which hospice care can still be provided as long as the patient requires such care. Florida Hospital HospiceCare (CON #10037) states an objective for every patient to be able to remain in the least restrictive and most emotionally supportive environment possible. It is also stated that patients who have no support at home will receive increased support from the hospice staff and volunteers whenever possible. The HospiceCare team will help each patient without a caregiver develop a plan of care that may include the patient’s network of friends, family, neighbors, and other members of the community to help assist them and remain in their home. For those hospice patients that are unable to develop a caregiver network and are not physically or mentally able to remain at home, HospiceCare states it may recommend that the patient enter an assisted living facility, nursing home, or inpatient hospice facility and hospice care will continue in these settings, per the applicant.


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#10038) states that it will provide hospice care to those patients who do not have a primary care giver at home, the homeless and patients with AIDS. This is supported by the applicant’s non-discrimination policy (included in the application). An Odyssey nurse is stated to evaluate patient circumstances to see if inpatient care is appropriate. It is further stated an Odyssey nurse (registered nurse) will coordinate the admission with the attending physician or hospice physician and the interdisciplinary team. In the applicant’s Appendix H, Odyssey Policy and Procedure Manuals-Tables of Contents, including General Inpatient Care, and Access to Care Policies, such procedures are explained.

(k) Arrangements for the provision of bereavement services.

Compassionate Care Hospice (CON #10036) offers a measurable time frame (at least 15 months) for the provision of bereavement services after the patient’s death and that a sympathy card will be sent out within two weeks after the patient’s death. Both Compassionate Care and Odyssey (CON #10038) specifically offer specialized bereavement programs designed for children, with the latter offering the most descriptive and in-depth. It is noted that Odyssey does not state its children’s program is based in Florida but conditions its application on establishing one here, similar to its “SKY Camp” program, by the end of its first year of operation. Memorial Hospital-Flagler, Inc. (CON #10037) conditions for special bereavement programs for the Hispanic population and Odyssey (CON #10038) conditions for bereavement services for Hispanic children. Compassionate Care Hospice (CON #10036) states that it will provide bereavement services to the surviving family members for at least 15 months after the patient’s death. Bereavement services will begin with an initial bereavement risk assessment to be completed by the social worker, bereavement coordinator or designee within three days of admission or at the earliest convenience of the patient/ family/caregiver. The applicant states that the bereavement coordinator may also provide supportive counseling prior to the death of the patient but within two weeks after the death of the patient a sympathy card will be sent to the bereaved.


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Bereavement counselors work with patients and families to assist with coping, grief work, and bereavement care and teach grieving families how to find healthy paths to healing. Trained volunteer counselors may be assigned to make regular contacts. Compassionate Care further states that a pediatric-oriented program called Compassionate Courage will be made available. In summary, this program (Compassionate Courage) is designed to address age-specific concerns and healing mechanism for bereaved children. Florida Hospital HospiceCare (CON #10037) states it provides bereavement services both to the families of its patients and the families in the community. HospiceCare states intentions to reach out to the community and offer families the opportunity to work through the grief process by providing them with the necessary tools, resources, and support for healing. HospiceCare states it makes one-on-one counseling available for those that need extra help with the grief process. This counseling is short-term and specific to the bereavement need. As part of the continuum of care provided by HospiceCare, these programs not only enhance the life of the community, but also provide points of access to other hospice services, per the application. Per HospiceCare, many persons served by these programs have no relationship to a hospice patient, but have been affected by caregiver or loss issues. HospiceCare also indicates that it provides counseling for staff at any agency (schools, businesses, hospitals) that requests help with bereavement issues. Bereavement support is also provided to HospiceCare staff and volunteers, who face their own grieving process following the deaths of their patient or if one of their own family members dies. If approved to provide hospice services in Hardee, Highlands and Polk Counties (Hospice Service Area 6B), HospiceCare states intentions to work with the local community to identify needs and offer a range of programs based on community input, particularly with outreach to Hispanic residents (special attention to the bereavement needs of the


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Hispanic population is conditioned by the applicant). These services will be modeled after the bereavement programs HospiceCare currently offers in Flagler and Volusia Counties (Hospice Service Area 4B). This applicant is not specific about how often, or in what sequence it will offer bereavement service (such as up to a certain number of months after the applicable patient’s death, upon or before admission or in advance of imminent death). Odyssey HealthCare of Central Florida, Inc. (CON

#10038) states bereavement services begin with an initial assessment by an Odyssey nurse during patient admission and continue after the patent’s death. The bereavement coordinator is a part of the psychosocial/interdisciplinary team. The applicant states it offers the following bereavement activities and services: condolence correspondence; written materials, articles, and resources; one-on-one counseling; bereavement letters; grief support groups; memorial services and a holiday bereavement program. Odyssey states it has been contacted by local hospitals for assistance with the families of dying patients not on hospice service and though not reimbursable for Odyssey, the staff has provided bereavement services to provide support to the non-hospice as well as hospital staff. Through the Odyssey HealthCare Foundation (the Foundation), the applicant states it offers “SKY Camp” – a free weekend camp for children ages seven to 17 grieving the death of a loved one. Children attend the camp as guests of the Foundation. This is at no charge. Stated activities at the camp are: swimming; basketball; volleyball; ping-pong and the challenge course - physical challenges designed for the various age groups (such as climbing, balancing and teamwork). In essence, this program is designed to reduce feelings of isolation and fear, and then to move on. Per the applicant, SKY Camp, initiated in 1997, also includes family support groups and individual grief counseling. The applicant states intentions to establish a Florida-based children’s bereavement camp, similar to SKY Camp.


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(l) Proposed community education activities concerning

hospice programs.

In summary, all co-batched applicants have educational activities to expand public awareness of hospice program objectives and services. Memorial Hospital-Flagler, Inc. (CON #10037) conditions for developing a community resource information web site targeted at hospice education. Odyssey (CON #10038) conditions for a minimum of three community education representatives to address hospice topics are areas of interest in hospice activities, programs and services. Compassionate Care Hospice (CON #10036) states that it tailors its services and program offerings to the unique needs of the communities in which it serves. Compassionate Care asserts that it is committed to providing community education activities concerning hospice programs to residents of Service Area 6B. The applicant states that through hospital, nursing home and related visits in the area, it was realized there is a need for general hospice programs. Compassionate Care plans to provide quarterly in-service training sessions at each hospital and nursing home. Representatives will meet individually with the administration of each licensed facility at least once a month. Community education activities will include: • Community education programs on overview of hospice,

pediatric hospice, how to cope with dying, and other outreach programs to the underserved.

• Educational seminars presented to long-term care facilities on the care of hospice patients.

• Support groups for caregivers and family member of terminally ill patients.

Florida Hospital HospiceCare (CON #10037) estimates that in 2008 alone, HospiceCare likely “touched” almost 800,000 residents in Service Area 4B with the message of hospice, through various modalities such as health fairs, small group lectures, and educational presentations at local colleges, newspaper coverage, and radio interviews. The applicant also states it partners with other hospice agencies in the


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area to provide superior educational presentations on care giving, grief, and bereavement. Networking with these agencies is stated to create a strong presence and promotes education and awareness. HospiceCare states it provides community, consumer and professional education services as a part of its mission to serve everyone in the community affected by life-limiting illness, care giving and bereavement. Educational programs are stated to be a way of supporting all people anticipating and experiencing illness, care giving, or bereavement. Several educational topics available to patients and their families include booklets, readings, journals, etc. on home health care, HIV/AIDs, cancer and caregivers, and therapeutic communication for patients suffering from dementia and aphasia, per the applicant. As part of its proposed plan for community education, the applicant states intentions to develop medical education programs for medical staff members who maintain privileges at Florida Hospital facilities, within Service Area 6B. Hospice organizations have made concerted efforts to improve physician education on hospice benefits to patients and their families. However, HospiceCare states that medical schools have been slow to develop clinical education in end-of-life care, requiring physicians to gain insight and knowledge about hospice once they begin their medical practices. To educate physicians, HospiceCare will work with their Florida Hospital partners to provide training both within Florida Hospital facilities and at medical staff meetings. Several intended goals of this training and education are stated to be as follows: • Increasing the physician’s comfort level in discussing

hospice referrals with patients and families. • Understanding the characteristics of hospice care – with

hospice care being an alternative to inpatient hospital or home health services for providing care to terminally-ill patients.

• Reviewing the interdisciplinary approach of hospice – that the interdisciplinary approach and role will address physical, spiritual, and emotional needs of patients and their families.


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• Understanding the cost and benefit of hospice care – physicians learn the cost model of terminal care that is provided in the hospice and how these costs compare to care provided by hospitals, home health, and other services.

• Dealing with cultural “objections” to hospice care – physicians learn and understand how to address concerns that may be voiced by minorities or other ethnic groups regarding the use of hospice care.

HospiceCare states it has found that providing education about hospice to employed physician groups, emergency room physicians and hospitalists, as well as discharge planners, case managers, and other clinical staff, is a particularly effective way to identify non-cancer patients who are medically eligible for hospice services. The applicant further states it is developing a community resource information web site targeted at hospice education. This educational site is stated to include various lay and professional education pieces related to chronic illness, death, dying, and bereavement. Patients and their families will be able to access this site and educate themselves in regards to hospice care and the options available for end-of-life care, per the applicant. Odyssey HealthCare of Central Florida, Inc. (CON

#10038) states intentions of providing three or more community education representatives15 to develop relationships with patient referral sources and related partners (such a physicians, social workers, nurses, hospital discharge planners, ALF personnel and nursing home staff) all in an effort to provide applicable community education on hospice topics. The applicant indicates frequently requested hospice topics include: hospice and Medicare regulations; pain management; advance directives; personal perspectives; grief and loss; symptom management; Alzheimer’s disease and hospice; Is my patient appropriate for hospice? and stress management. If CON approved, the applicant states an interest in hosting a seminar for clergy and community faith leaders.

15 CON Application #10038, Schedule 6A does not specifically itemize education representatives, per se and this is not referenced in the schedule’s notes. However, the applicant conditions for a minimum of three community education representatives.


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(m) Fundraising activities.

Compassionate Care Hospice (CON #10036) states that it does not intend to engage to a great extent in fundraising to support its ongoing operations. Nonetheless, it does state that it participates in limited fundraising activities, primarily through bequests and family gifts, and makes use of such funding when appropriate, through the efforts and actions of its related Compassionate Care Hospice Foundation, Inc. (the Foundation), a non-profit organization stated to be based in Newark, Delaware. Compassionate Care states the Foundation is designed to provide financial assistance to terminally ill patients and families in need. Additionally, it supports public programs to provide the general public with information about the end-of-life choice so that individuals can determine and communicate their wishes and help their families prepare for the future. Compassionate Care Hospice Foundation is stated to be active in many of the communities in which Compassionate Care has operations and if the application is CON approved, would have similar activities in Service Area 6B. None of its funds are used for provision of direct hospice care; rather it is available to assist when financial difficulty overwhelms families and places them under untenable stress. Compassionate Care Hospice Foundation provides services in instances that are typically not covered or reimbursed by insurance, according to the applicant. Compassionate Care indicates that it will contribute to community organizations including universities, community colleges or other organizations involved in training health care professionals, or in the delivery of social services to the community in its general willingness condition statements but does not provide an amount.

Florida Hospital HospiceCare (CON #10037) states that HospiceCare’s existing foundation will be utilized and will build upon the fundraising programs utilized in Flagler and Volusia Counties (Hospice Service Area 4B). HospiceCare’s current foundation is stated to have been established to raise and manage charitable contributions in support of its faith-based mission and various patient and family care services. The applicant states that most of fundraising proceeds are reinvested in the local community through


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palliative care and residential hospice services, caregiver education and support, community education, family support, and bereavement services. HospiceCare states that in 2007 donors helped to subsidize hospice care for those unable to pay and that community support for HospiceCare also resulted in donations for the majority of funds needed to build the Stuart F. Meyer Hospice House in Palm Coast (Hospice Service Area 4B), per the applicant. HospiceCare has also conditioned this application to provide a minimum annual funding of $10,000 towards a “Special Wish Fund” designated for the end-of-life wishes for HospiceCare patients and their families. Odyssey HealthCare of Central Florida, Inc. (CON

#10038) states it will not perform any fundraising activities in direct support of its programs but will support existing community-based fundraising efforts such as those of local health care support groups and the existing hospice provider (singular), as well as the fundraising of the parent’s “Dream Foundation”. Per the applicant, through the parent (Odyssey), the Odyssey VistaCare Hospice Foundation contributed nearly $680,000 to worth organization in 2006 and more than $878,000 in 2007.

The applicant conditions that through the parent (Odyssey HealthCare) or the Odyssey VistaCare Hospice Foundation a $25,000 contribution will be made to an appropriate not-for-profit entity in the community to fund education for end-of-life issues. This is the greatest conditioned contribution by any of the co-batched applicants.

The applicant offers numerous instances of non-reimbursable events and services it states were provided by Odyssey HealthCare-Daytona. The applicant is non-specific on when the stated non-reimbursable events took place and does not offer an estimate of these cumulative or individual costs of the services described.


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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 Service Area 6B.

The following chart illustrates the increase in hospice admissions for the past five years. As shown below, admissions have increased from 2,650 in the year ending June 30, 2003 to 4,253 in the year ending June 30, 2008.

Hospice Admissions for Service Area 6B Fiscal Years 2003 – 2008

Fiscal Year Admissions

07/07 – 06/08 07/06 – 06/07 07/05 – 06/06 07/04 – 06/05 07/03 – 06/04 07/02 – 06/03

4,253 3,807 3,516 3,305 3,163 2,650

Source: AHCA Florida Need Projections for Hospice Programs, 2003-2008

Compassionate Care Hospice (CON #10036) notes that three licensed hospice providers offer services in the service area. This applicant also notes continued hospice admission growth over the past five years (for the 12-month period ending June 30, 2008) notwithstanding CON approval and licensure of additional providers. The applicant proposes that a main office in Haines City (Polk County), with satellites in Bartow (Polk County) and Sebring (Highlands County), will address hospice needs based on population concentrations and growth and particularly the elderly. Letters of support corroborate the applicant’s conclusions that need is based, at least in part, on a lack of prompt continuous care, instances of overmedication of patients and a lack of ancillary services (such as music, massage and/or aromatherapy). The applicant asserts that it is committed to providing the highest quality care possible to terminally ill patients and their families. The applicant has provided evidence that it can obtain local support needed to provide the hospice services it proposes in this hospice service area.


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Florida Hospital HospiceCare (CON #10037) states it will increase access to hospice service in the area, by virtue of its planned hospice program, upon CON approval. Services are stated to be offered without regard to diagnosis, ability to pay or ethnicity. HospiceCare states it is a Medicare-certified and Joint Commission accredited member of the National Hospice Palliative Care Organization and Florida Hospice Palliative Care, Inc. The applicant also includes a 12-point performance improvement plan in attachment O of the application. HospiceCare includes 19 sample training topics it attests it applies to community education and in-service training, some of which include the following: preventing medical efforts; HIV update; SARS; cancer and the caregiver; care of the diabetic patient, and others. HospiceCare states efficiency by centralizing certain services, some of these include the following: 24/7 phone coverage; IT services; billing and collection and others. Nursing, pastoral and physician oversight would be managed locally, per the applicant. Use of existing providers is stated to be well utilized, particularly in light of the fact the Agency has published a need for an additional program in the Service Area 6B for the January 2010 Planning Horizon. Odyssey HealthCare of Central Florida, Inc. (CON #10038) is clear in identifying three groups in need of hospice care, by age group and by diagnosis, that are in the service area. Those in need are identified by the applicant as follows: cancer patients over the age of 65, non-cancer patients over the age of 65 and patients in need of continuous care. No other co-batched applicant identifies need in terms of age groups and diagnosis. The applicant asserts that the availability and access will be improved by admission within three hours after receiving a physician’s order for hospice care; however, this three-hour window is not conditioned by the applicant. The applicant does condition for hospice services specifically designed for the Hispanic population and conditions for bereavement tailored for Hispanic children. The applicant believes efficiency will be improved by the overall weight of the parent’s experience and size, including a new electronic clinical system to fully integrate billing and clinical system. Comprehensive compliance and a continuous improvement program are also stated as an increased efficiency feature. Odyssey indicates that based on Agency determination of need, existing hospice providers will not be negatively impacted by the addition of an additional hospice program in the area.


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b. Does the applicant have a history of providing quality of care? Has the applicant demonstrated the ability to provide quality care? Is the applicant a Gold Seal Program nursing facility that is proposing to add beds to an existing nursing home? ss. 408.035(1)(c) and (j), Florida Statutes.

Compassionate Care Hospice (CON #10036) states it is a newly formed entity and therefore has no operational history. However, Compassionate Care states origination in 1993 and operation in the following 12 states: Delaware, Georgia, Illinois, Massachusetts, Michigan, Minnesota, Missouri, New Jersey, New York, Pennsylvania, South Dakota and Texas. The applicant indicates 29 office locations spread among the 12 states. The applicant includes as tab 9 – Compassionate Care Hospice Sample Policies and Procedures that address a wide range of hospice practices. Some of these policies and procedures include: incident reporting; clinical record review; summary satisfaction surveys; condition of participation forms; annual evaluation; orientation; continuous care services; interdisciplinary team plan; complaint/grievance procedures; initial/comprehensive assessment and others. Compassionate Care states its performance improvement plan is incorporated within Medicare conditions of participation, as required by Florida licensure rules. Compassionate Care states it has extensive benchmarking and also attests to close monitoring and collection of measurable data on 15 separate events; some of these include the following: medication errors; adverse drug reactions; patient falls; 911 calls; infection control; pain assessment and control review; satisfaction surveys; comfort within 48 hours of admission and performance improvement. The applicant indicates that every hospice patient is seen at home by the medical director. Compassionate Care states if CON approved, it will seek membership in the Florida Hospice and Palliative Care Organization.

Florida Hospital HospiceCare (CON #10037) states it has full accreditation by the Joint Commission and references recent positive feedback on Agency surveying16. The applicant highlights performance improvement mechanisms that are in place. For the three-year period ending January 12, 2009, the applicant has one confirmed and zero confirmed without deficiency complaints, per Agency records. The sole confirmed complaint concerns patient care.

16 CON Application #10037, Attachment I – HospiceCare Awards and Certifications


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Odyssey HealthCare of Central Florida, Inc. (CON #10038) is the sole shareholder is Odyssey HealthCare Operating B, LP, a wholly owned subsidiary of Odyssey. The parent is stated to have 100 licensed hospice programs spread among 30 states. The parent’s existing Florida hospice programs (Odyssey HealthCare-Daytona and Odyssey HealthCare-Miami/Dade) are stated to have an ADC of 122 and 253 patients, respectively. It is also stated they (Odyssey HealthCare-Daytona and Odyssey HealthCare-Miami/Dade) have over 37,000 and 70,000 patient days, respectively. The parent attests to the Pioneer Award and the GM Circle of Excellence Award17. If CON approved, the applicant anticipates establishing and operating a hospice program in Service Area 6B, similarly with the speed and efficiency that it did when approved to operate hospice programs in Service Areas 4B and 11. The applicant goes on to attest that Odyssey hospice programs enjoy membership in the National Hospice and Palliative Care Organization, and are Medicare and Medicaid certified (or are pursuing said certification). The applicant says it will adopt and practice the same standards of quality and efficiency that are promoted by the parent. For the three-year period ending January 12, 2009, the parent’s Odyssey HealthCare-Daytona (licensed as Hospice of the Palm Coast) and Odyssey HealthCare-Miami/Dade, jointly, have one confirmed and zero confirmed without deficiency complaints, per Agency records. The confirmed complaint is administrative.

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 (CON #10036) is applying to develop a hospice program in Service Area 6B, proposes a project cost of $292,459 and incremental operating costs in year two of $4,367,420. Compassionate Care is a Florida for-profit corporation and a development stage company that was formed on October 20, 2008 for the purpose of operating a hospice in Florida, with net assets of $0 and $70 in liabilities for the period ended November 30, 2008. At 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.

17 CON Application #10038 does not include these awards for Agency review.


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Capital Requirements: Schedule 2 indicates total capital projects of $805,928 which consist of the CON subject to this review, CON #10042 for a hospice in District 11 and $150,000 in other capitalization. In addition, the Applicant will have to fund the projected year one operating loss of $280,706. Available Capital: The applicant states that its parent corporation, Compassionate Care Hospice Group, Ltd. (Parent), will provide funding for the project through a line of credit provided by JP Morgan. In support of this statement, the applicant provided a letter from JP Morgan showing a $2,000,000 line of credit, and indicates that the entire line of credit is available. It should be noted that the applicant included operating results of its affiliate. Because the affiliate’s operating results were unaudited the Agency did not consider them in this review. Staffing:

Schedule 6A indicates for year one ending December 31, 2010, the applicant forecasts 34.4 FTEs as follows: administration, 5.0 FTE’s; physicians, 0.3 FTEs; nursing, 24.6 FTEs; ancillary, 1.0 FTEs; dietary 0.5 FTEs and social services, 3.0 FTEs. In the second year ending December 31, 2011 the applicant forecasts 52.6 FTE’s as follows: administration, 7.0 FTE’s; physicians, 0.6 FTEs; nursing, 39.0 FTEs; ancillary, 1.0 FTEs; dietary 0.5 FTEs and social services, 4.5 FTEs. The applicant states it does not anticipate any inordinate difficulties with recruitment of the required staff, due largely to its stated nationally recognized reputation. Conclusion:

Funding for this project should be available as needed. Florida Hospital HospiceCare (CON #10037) is applying to develop a hospice program in Service Area 6B, proposes a project cost of $306,380 and incremental operating costs in year two of $2,956,036. The applicant is a Florida non-profit corporation that was licensed in June of 1997. The audited financial statements of the applicant, for the periods ending December 31, 2006 and 2007 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 3.7 indicates current assets are more than three and a half times the current obligations, a strong position.


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The working capital of $47.7 million is a measure of excess liquidity that could be used to fund capital projects. The ratio of cash flow to current liabilities of 1.9 indicates that cash flow is almost twice current obligations. This is well above average and a strong position. Overall, the applicant has a strong short-term position. (See Table below). Long-Term Position:

The ratio of long-term debt to net assets of 1.3 indicates the applicant is highly leveraged and may have difficulty obtaining future debt as necessary. The ratio of cash flow to assets of 21.1 percent is well above average and a good position. The most recent year had $17.6 million in operating income, which resulted in an operating margin of 19.6 percent. Overall, the applicant has an acceptable long-term position. (See Table below).

CON #10037

Memorial Hospital - Flagler, Inc.

12/31/2007 12/31/2006

Current Assets (CA) $65,312,770 $121,952,875

Cash and Current Investment $54,888,200 $108,034,291

Total Assets (TA) $157,793,309 $207,612,524

Current Liabilities (CL) $17,536,500 $17,307,102

Total Liabilities (TL) $95,488,075 $100,649,790

Net Assets (NA) $62,305,234 $106,962,734

Total Revenues (TR) $89,739,632 $84,273,364

Interest Expense (IE) $3,809,357 $4,269,348

Operating Income (OI) $17,560,769 $17,053,863

Cash Flow from Operations (CFO) $33,230,936 $30,451,977

Working Capital $47,776,270 $104,645,773

FINANCIAL RATIOS

12/31/2007 12/31/2006

Current Ratio (CA/CL) 3.7 7.0

Cash Flow to Current Liabilities (CFO/CL) 1.9 1.8

Long-Term Debt to Net Assets (TL-CL/NA) 1.3 0.8

Times Interest Earned (OI+IE/IE) 5.6 5.0

Net Assets to Total Assets (NA/TA) 39.5% 51.5%

Operating Margin (OI/TR) 19.6% 20.2%

Return on Assets (OI/TA) 11.1% 8.2%

Operating Cash Flow to Assets (CFO/TA) 21.1% 14.7%


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It should be noted that the applicant had a significant decrease in net assets over the prior year ($44.7 million or a 41.8 percent decrease). A review of the audit indicates that this was primarily the result of a transfer in cash to affiliated entities of approximately $74.4 million for capital needs.

Capital Requirements:

Schedule 2 indicates total capital projects of $39,662,672 which consist of the CON subject to this review, CON #10040 for a hospice in Hospice Service Area 7B, $1,291,835 in maturities on long-term debt, $17,225,000 in funds approved but not yet expended in the capital budget and $20,533,077 in capital projects as proposed in the five year capital budget. It should be noted that the applicant is projecting a year one operating loss of $22,844; however, the applicant is projecting to fund this loss through charitable contributions. Available Capital:

The applicant states that it will provide funding for the project through cash reserves and cash from operations. Funding from the entire capital budget will be proceeded through cash reserves, cash from operations, proceeds from bond issues designated for capital expenditures, and/or other financing methods commonly employed in the health care industry. Operating cash flows for the most recent year was $33.2 million with working capital of $47.8 million. Staffing:

Schedule 6A indicates for year one, the applicant forecasts 17.6 FTEs as follows: administration, 4.0 FTE’s; physicians, 0.1 FTEs; nursing, 10.0 FTEs; social services, 2.0 FTEs; spiritual care, 0.5 FTEs and other (volunteer services), 1.0 FTEs. In the second year, the applicant forecasts 23.6 FTEs as follows: administration, 4.5 FTE’s; physicians, 0.1 FTEs; nursing, 14.0 FTEs; social services, 3.0 FTEs; spiritual care, 0.5 FTEs and other (volunteer services), 1.5 FTEs. The applicant does not provide FTE staff for dietary counseling, which is mandatory according to statute18. Per the applicant, the staffing pattern was developed by the Hospice Department of Memorial Hospital HospiceCare. It is stated also that some support and billing will be provided by offices in Ormond Beach, Florida.

18 Section 400.609(1)(a), Florida Statutes


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Conclusion:

Funding for this project should be available as needed.

Odyssey HealthCare of Central Florida, Inc. (CON #10038) is applying to develop a hospice program in Service Area 6B, proposes a project cost of $619,264 and incremental operating costs in year two of $3,130,616. The applicant is a Florida for-profit corporation, incorporated on October 18, 2006. As of September 30, 2008, the applicant had no assets and $165,700 in liabilities, with $165,700 operating loss. This amount is an inter-company payable. The applicant provided audited financial statements of its ultimate parent company and subsidiaries, Odyssey Healthcare, Inc. (Parent), a for-profit corporation, for the periods ending December 31, 2007 and 2006. These statements were analyzed for the purpose of evaluating the parent’s ability to provide the capital and operational funding necessary to implement the project.

Short-Term Position:

The parent’s current ratio of 2.0 indicates current assets are two times the current obligations, an adequate position. The working capital of $72.5 million is a measure of excess liquidity that could be used to fund capital projects. The ratio of cash flow to current liabilities of 0.2 is well below average and a week position. Overall, the applicant’s parent has an adequate short-term position. (See Table below). Long-Term Position:

The ratio of long-term debt to net assets of 0.1 indicates the applicant has sufficient equity to have access to capital. The ratio of cash flow to assets of 6.1 percent is slightly below average and an adequate position. The most recent year had $20.5 million in operating income, which resulted in a 5.1 percent operating margin. Overall, the applicant’s parent has a good long-term position. (See Table below).


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CON #10038

Odyssey HealthCare, Inc. & Subsidiaries

12/31/2007 12/31/2006

Current Assets (CA) $148,673,000 $146,686,000

Cash and Current Investment $62,179,000 $69,962,000

Total Assets (TA) $275,209,000 $269,986,000

Current Liabilities (CL) $76,180,000 $76,131,000

Total Liabilities (TL) $92,372,000 $90,390,000

Net Assets (NA) $182,837,000 $179,596,000

Total Revenues (TR) $404,872,000 $384,981,000

Interest Expense (IE) $208,000 $187,000

Operating Income (OI) $20,488,000 $33,031,000

Cash Flow from Operations (CFO) $16,881,000 $34,684,000

Working Capital $72,493,000 $70,555,000

FINANCIAL RATIOS

12/31/2007 12/31/2006

Current Ratio (CA/CL) 2.0 1.9

Cash Flow to Current Liabilities (CFO/CL) 0.2 0.5

Long-Term Debt to Net Assets (TL-CL/NA) 0.1 0.1

Times Interest Earned (OI+IE/IE) 99.5 177.6

Net Assets to Total Assets (NA/TA) 66.4% 66.5%

Operating Margin (OI/TR) 5.1% 8.6%

Return on Assets (OI/TA) 7.4% 12.2%

Operating Cash Flow to Assets (CFO/TA) 6.1% 12.8%

Capital Requirements:

Schedule 2 indicates total capital projects of $619,264 which is the CON subject to this review. The applicant is projecting a year one operating loss of $492,324. The applicant will have to fund the year one operating loss until profitability can be reached. Available Capital:

Funding for this project will be provided by the parent. The parent has working capital of $72.5 million and $20.5 million in operating income. In addition, cash flow from operations was $16.9 million. The project would represent 0.85 percent of the parent’s working capital and 3.67 percent of operating cash flows. Staffing:

Schedule 6A indicates for year one ending December 31, 2010, the applicant forecasts 15.7 FTEs as follows: administration, 8.0 FTE’s; physicians, 0.1 FTEs; nursing, 5.2 FTEs; ancillary, 1.5 FTEs; dietary 0.3


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FTEs and social services, 0.6 FTEs In the second year ending December 31, 2011, the applicant forecasts 30.6 FTE’s as follows: administration, 9.5 FTE’s; physicians, 0.1 FTEs; nursing, 15.2 FTEs; ancillary, 3.9 FTEs; dietary 0.3 FTEs and social services, 1.6 FTEs. The applicant states that the parent, Odyssey HealthCare, has effective recruitment and retention policies in place and successfully currently staffs 100 Medicare-certified hospice programs, spread among 30 states. The applicant further states that the parent has an inter-company transfer policy whereby existing employees may transfer to other Odyssey hospice locations and that job opportunity postings are sent by internal e-mail and on the company’s intranet site: www.odyinfo.com. The applicant’s Appendix J-Odyssey Employee Handbook, includes an extensive table of contents. 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. Compassionate Care Hospice (CON #10036): For year two of operations, the applicant projected the following percentage of total patient days by group: Medicare at 89.8 percent, Medicaid at 3.1 percent, self-pay/charity at 2.1 percent, and commercial insurance at 5.0 percent. The applicant indicated on Schedule 7 that the service it intends to provide is routine home care, continuous home care, inpatient respite, and general inpatient care, and for which the Department of Health and Human Services sets rates. The Federal rates were calculated for the Polk County, Florida Wage Index for Medicare Hospice payments of 0.9091 and inflated through December 2011. The average price adjustment factor used was three percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2008 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 below.


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The applicant’s projected gross revenue was 4.59 percent, or $233,989, more than the calculated gross revenue. Approximately half of the difference is the result of Medicare contractual adjustments. The remaining difference is not considered material. Operating profits from this project are expected to increase from a loss of $280,706 for year one to a profit of $406,891 for year two. Conclusion:

This project appears to be financially feasible.

HOSPICE REVENUE

CON #10036 Compassionate Care Hospice of Miami-Dade, Inc.

Wage Index for Polk County(.9091)

Wage

Component Wage Index

Adjusted Wage Amount

Unadjusted Component

Payment Rate

Routine Home Care $96.17 0.9091 $87.43 $43.80 $131.23

Continuous Home Care $561.32 0.9091 $510.30 $255.62 $765.92

Inpatient Respite $78.37 0.9091 $71.25 $66.42 $137.67

General Inpatient $398.56 0.9091 $362.33 $224.10 $586.43

Payment Rate

Inflation Factor Year

Two

Inflation Adjusted Amount

Patient Days Year 2,

December 31-2011

Calculated Gross Revenue

Routine Home Care $131.23 1.067 $140.07 31,152 $4,363,355

Continuous Home Care $765.92 1.067 $817.50 500 $408,751

Inpatient Respite $137.67 1.067 $146.94 417 $61,273

General Inpatient $586.43 1.067 $625.93 43 $26,915

Total 32,112 $4,860,294

From Schedule 7 $5,094,283

Difference $233,989

Percentage difference 4.59%

Florida Hospital HospiceCare (CON #10037): For year two of operations, the applicant projected the following percentage of total patient days by group: Medicare at 67.0 percent, Medicaid at 28.0 percent, self-pay/charity at 4.0 percent, and commercial insurance at 1.0 percent. The applicant indicated on Schedule 7 that the service it intends to provide is routine home care, and general inpatient care, for which the Department of Health and Human Services sets rates. The Federal rates were calculated for the Polk County, Florida Wage Index for Medicare


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Hospice payments of 0.9091 and inflated through December 2011. The average price adjustment factor used was three percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2008 Health Care Cost Review. The applicant did not provide a table with patient days by level of care (routine home, continuous home, inpatient respite, and general inpatient care). Therefore, estimated revenues for each level of service from Schedule 7, year two were divided by the calculated reimbursement rate for that service in order to estimate the total patient days that would be generated by that level of revenue. Schedule 7 appears to include a 10 percent contractual adjustment to Medicare revenues, so the Agency reduced gross Medicare revenues by 10 percent for each level of care. The Agency did not include the revenue associated with skilled nursing facility inpatient, since the notes to Schedule 7 indicate that this is pass-through room and board revenue. The results were then compared to the applicant’s estimated number of patient days. The results of the calculations are summarized in the Table below. The applicant’s projected patient days were 2.8 percent or 436 days less than the calculated patient days. The applicant’s projected revenues appear to be slightly overstated; however, the difference is not considered material. Operating profits from this project are expected to increase from an operating loss of $22,844 for year one to an operating profit of $128,359 for year two. Conclusion:



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HOSPICE REVENUE

CON #10037 Memorial Hospital - Flagler, Inc.


Wage




Payment Rate





Payment Rate


Two


Gross Revenue Year 2, Dec-2011*

Calculated Medicare Patient Days

Routine Home Care $131.23 1.067 $140.07 $2,251,081 16,072

Continuous Home Care $765.92 1.067 $817.50 $0 0

Inpatient Respite $137.67 1.067 $146.94 $0 0

General Inpatient $586.43 1.067 $625.93 $71,802 115

Total $2,322,883 16,186

From Schedule 7 15,750

Difference -436

Percentage difference -2.77%

*note Medicare Revenue includes a 10% contractual adjustment

Odyssey HealthCare of Central Florida, Inc. (CON #10038): For year two of operations, the applicant projected the following percentage of total patient days by group: Medicare at 93.0 percent, Medicaid at 4.0 percent, self-pay/charity at 2.0 percent, and managed care/commercial insurance at 1.0 percent. The applicant indicated on Schedule 7 that the service it intends to provide is routine home care, continuous home care, general inpatient care, and inpatient respite, for which the Department of Health and Human Services sets rates. The Federal rates were calculated for the Polk County, Florida Wage Index for Medicare Hospice payments of 0.9091 and inflated through December 2011. The average price adjustment factor used was three percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2008 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


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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 below. The applicant offered 22 conditions to its proposed hospice program. Several of these conditions would likely have a financial impact on the applicant. Based on the notes accompanying the projections, it appears that the applicant has taken into consideration the costs associated with the proposed conditions in the financial projections. The applicant’s projected gross revenue was 3.73 percent, or $122,867, less than the calculated gross revenue. Projected revenues appear to be understated. Understating revenue is a conservative assumption and therefore, considered reasonable. Operating profits from this project are expected to increase from a loss of $492,324 for year one to a profit of $57,820 for year two. Conclusion:


HOSPICE REVENUE

CON #10038 Odyssey HealthCare of Collier County, Inc.


Wage




Payment Rate





Payment Rate


Two


Patient Days Year 2,

December 31-2011

Calculated Gross Revenue

Routine Home Care $131.23 1.067 $140.07 19,110 $2,676,673

Continuous Home Care $765.92 1.067 $817.50 406 $331,906

Inpatient Respite $137.67 1.067 $146.94 203 $29,828

General Inpatient $586.43 1.067 $625.93 609 $381,190

Total 20,328 $3,419,597

From Schedule 7 $3,296,730

Difference -$122,867

Percentage difference -3.73%


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e. Will the proposed project foster competition to promote quality and

cost-effectiveness? ss. 408.035(1)(g), Florida Statutes.

Each co-batched applicant is applying for a new hospice program to be located in Hospice Service Area 6B that currently has three existing hospice program. Therefore, each co-batched applicant is offering a new choice of provider in the hospice service area. Compassionate Care Hospice (CON #10036) is projecting 5.0 percent of its patient days from managed care/commercial insurance payers with 92.9 percent of patient days expected to come from fixed-price government payer sources (Medicare and Medicaid), with the remaining 2.1 percent as self-pay/charity. Florida Hospital HospiceCare (CON #10037) is projecting 1.0 percent of its patient days from managed care/commercial insurance payers with 95.0 percent of patient days expected to come from fixed-price government payer sources (Medicare and Medicaid). Odyssey HealthCare of Central Florida, Inc. (CON #10038) is projecting 1.0 percent of its patient days from managed care/commercial insurance payers with 97.0 percent of patient days expected to come from fixed-price government payer sources (Medicare and Medicaid). 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. With the large majority of patient care being provided from fixed-price government payer sources, these projects are not likely to have any discernable 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.


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Conclusion:

The applicants’ projects are not likely to result in price-based competition.

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 and Ch. 59A-3 or 59A-4, Florida Administrative Code.

There are no construction costs or 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.

Medicaid paid 4.5 percent of total hospice patient days nation-wide in 2007 and 4.8 percent in 2006. In 2007, total hospice admissions paid by Medicaid was 5.0 percent and 5.3 percent in 2006.19 In Florida, Medicaid paid 4.6 percent of CY 2007’s total patient days and 5.6 percent of CY 2006’s.

Compassionate Care Hospice (CON #10036) states that it is both Medicare and Medicaid certified in all its 29 office locations in its 12 different states. The applicant states that it has a history of providing health services to Medicaid patients and the medically indigent. According to the applicant and what the applicant calls “recent data” (the exact time frame is not specified), its programs collectively provided 17,377 Medicaid days representing 5.0 percent of total patient days. Additionally the applicant states that Compassionate Care provided 7.0 percent of total patient days to self-pay/charity/other patients. Schedule 7A shows $223,300 for charity/self-pay (uncompensated) care in year one, and $105,452 for charity care year two. Self-pay (uncompensated) care will account for 8.7 percent of total patient days for year one and 2.1 percent of total patient days for year two. Compassionate Care’s patient day Medicaid percentage is projected to be 2.9 percent for year one and 3.1 percent for year two, per notes to Schedule 7A.

19 NHPCO Facts & Figures released October 2008 from http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-figures_2008.pdf


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Florida Hospital HospiceCare (CON #10037) states that the applicant’s parent, Florida Hospital, in 2007, provided over $16.2 million in charity care, among the three Florida Hospital hospitals (Heartland, Lake Placid and Wauchula) in Hospice Service Area 6B. The applicant commits that it will provide hospice care regardless of ability to pay.

Schedule 7A shows $48,028 for charity/self-pay care in year one, and $69,258 for charity care year two. This applicant separately categorizes bad debt for year one at $24,014 and at year two, $34,628. However, 28 percent of the applicant’s year one and two patient days are projected as Medicaid patients which is atypical of hospice care and results in $937,636 revenue in year two from Florida Medicaid. As stated above, Florida Hospice’s Medicaid patient days were 4.6 percent of CY 2007’s total and 5.6 percent of CY 2006’s. Medicaid accounted for 4.5 percent of the nation’s total hospice patient days in 2007 and 5.6 percent in 2006.

Odyssey HealthCare of Central Florida, Inc. (CON #10038) states that in fiscal year 2007, approximately 60 percent of the parent’s (Odyssey HealthCare’s) non-Medicare net revenue is Medicaid and also that approximately 1.2 percent of services are provided to indigent/charity patients. The applicant stresses that it conditions that it will provide care to all eligible patients without regard to their ability to pay. As stated previously in this report, hospice programs are required by federal and state law to provide hospice services to everyone requesting them regardless of their ability to pay and therefore the Agency would not place conditions on a program to provide legally required services. Schedule 7A shows $31,635 for charity/self-pay care in year one, and $92,165 for charity care year two. According to the schedule notes, charity care is reflected in the self-pay column and is forecasted at 2.0 percent of patient days for both year one and year two.

F. SUMMARY

In Volume 34, Number 40 of the Florida Administrative Weekly, dated October 3, 2008, the Agency for Health Care Administration published need for a new hospice program in AHCA Hospice Service Area 6B (Hardee, Highlands and Polk Counties) for the January 2010 Hospice Planning Horizon.


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Compassionate Care Hospice (CON #10036) proposes to establish a new hospice program in Hospice Service Area 6B (Hardee, Highlands and Polk Counties). The proposed total project cost is $292,459 with year one operating costs of $2,545,491 and year two costs of $4,367,420. Compassionate Care proposes eight general and seven specific conditions (see pages 6-9). Florida Hospital HospiceCare (CON #10037) proposes to establish a new hospice program in Hospice Service Area 6B (Hardee, Highlands and Polk Counties). The proposed total project cost is $306,380 with year one operating costs of $2,167,796 and year two costs of $2,956,036. However, the applicant appears to overstate the amount of Medicaid patients it will serve as it is way over the national average and does not include the provision of continuous home care (the highest per diem reimbursement category) and respite care in its financial projections. HospiceCare proposes seven conditions (see pages 10-11). Odyssey HealthCare of Central Florida, Inc. (CON #10038) proposes to establish a new hospice program in Hospice Service Area 6B (Hardee, Highlands and Polk Counties). The proposed total project cost is $619,264 with year one operating costs of $1,593,526 and year two costs of $3,130,616. Odyssey proposes 22 conditions (see pages 11-16). Need/Access:

Each co-batched applicant is responding to published need for an additional hospice program for the January 2010 Planning Horizon and each applicant discusses populations it believes to be experiencing unmet need. Compassionate Care Hospice (CON #10036) provided a needs assessment related to specific conditions in Service Area 6B associated with population demographics and dynamics; availability, utilization and quality of like services in the service area; hospice treatment trends; and market conditions. The factors considered in this assessment include: hospice use rates and trends, population size and composition, mortality rates and other factors, and unmet service area needs which are discussed below. The applicant presented extensive data comparing


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Hospice Area 6B with the state average penetration rate and an alternative need methodology including mortality rates and other factors potentially impacting hospice use and also addresses with separate discussion for age 85 and over, cancer deaths, race and ethnicity, hospice appropriate death, and personal income.

Florida Hospital HospiceCare (CON #10037) contends that the elderly population (age 65 and over) is increasing at a faster rate than any other age group. Based on the application of the Agency’s hospice need methodology to Service Area 6B, elderly residents (age 65 and over) who do not have cancer are projected to have an unmet need of 471 hospice admissions in 2010. The applicant indicates that service Area 6B had an estimated population of 694,643 residents in 2006 and is projected to grow rapidly to a projected population of 779,535 residents by 2012, representing an increase of 12.2 percent. Florida HospiceCare indicates that since the elderly are the primary users of hospice care and as the elderly population continues to grow rapidly, more residents in Service Area 6B will require the services of a complete hospice care program. Florida HospiceCare contends that the significant increase in the Hispanic population supports the need for bilingual programs, which HospiceCare can offer (and proposes as a condition to approval). Service Area 6B’s historical Hispanic population growth data from 2000 to 2007 is provided which shows this group accounted for 3,137 persons aged 65 and over in 2000 increasing to 6,437 in 2007 or 5.3 percent of the service area’s age 65 and over total population. Florida Hospital HospiceCare indicates it will provide bilingual programs and culturally sensitive programming to meet the need of the Hispanic population. However, the applicant does not provide projected Hispanic population growth and is the least specific regarding a given population in need.

Odyssey HealthCare of Central Florida, Inc. (CON #10038) presents an analysis based on unmet need population in terms of age group (over 65 years of age) and diagnosis (cancer or non-cancer) in Service Area 6B. However, the applicant does not explain how it arrived at conclusions about the number of patients served in these categories as it stated their numbers were based on Agency data. With two of the three existing 6B providers serving one and two other service areas respectively, the exact numbers of 6B residents in these categories as stated by the applicant could not be determined. The applicant also provides an analysis based on the higher of the local market rate or the Florida penetration rate and one based on continuation of historic growth rates of Service Area 6B admissions over the last five years.


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All three of the co-batched applicants provide evidence that they have local support for their proposals to enter the service area. Local letters of support, highest to lowest volume, are as follows: CON #10037 (52 [35 support letters and 17 appreciation letters of past service]; CON #10038 (36 [10 support letters and 26 appreciation letters of past service] and CON #10036 (eight support letters). Regarding CON #10037, the applicant with the most support letters, most of those are from Florida Hospital facilities and affiliates. In broad summary these letters essentially state interest in working with the applicant, if approved. The Agency’s need methodology that resulted in published need for a new program in Service Area 6B showed the projected number of admissions minus the current number of admissions for the January 2010 Planning Horizon as 537. Both CON #10036 and CON #10038 proposed equally the greatest expected admission totals to address this published need:

Total Projected Admissions By Applicant for Years One and Two

CON # Applicant Year One Year Two Both Years

10036 Compassionate Care 275 415 690

10037 FL Hospice HospiceCare 250 350 600

10038 Odyssey 285 405 690 Source: CON Application #’s 10036-10038.

Quality of Care:

Each co-batched applicant offered evidence of its ability to provide quality care. Financial Feasibility/Availability of Funds:

Compassionate Care Hospice (CON #10036): Funding for this project should be available as needed based on the parent’s $2 million dollar line of credit letter for JP Morgan. The project appears to be financially feasible and will not likely result in price-based competition. Short-term and long-term strength of the applicant could not be determined as the applicant is a start up company with no results from operations. Florida Hospital HospiceCare (CON #10037): Funding for this project will be through the applicant’s cash reserves and cash from operations should be available as needed. The project appears to be financially feasible and will not likely result in price-based competition. The applicant has a strong short-term position and acceptable long-term position.


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Odyssey HealthCare of Central Florida, Inc. (CON #10038): Funding for this project will be provided by the applicant’s parent and should be available as needed. The project appears to be financially feasible and will not likely result in price-based competition. The parent has an adequate short-term position and a good long-term position. Medicaid/Charity Care:

Medicaid paid 4.5 percent of total hospice patient days nation-wide in 2007 and 4.8 percent in 2006. In 2007, total hospice admissions/patients paid by Medicaid was 5.0 percent and 5.3 percent in 2006.20 In Florida, Medicaid paid 4.6 percent of CY 2007’s total patient days and 5.6 percent of CY 2006’s. During FY 07-08 Medicaid patients accounted for 5.0 percent of total Florida hospice admissions and 4.4 percent of hospice patient days. During FY 07-08, Florida hospices reported 4.3 percent of total admissions and 2.8 percent of total hospice patient days were uncompensated care.21

Hospice Service Area 6B Projected Medicaid and Charity Care by Admissions

Year One and Year Two

CON

Year one Medicaid Admissions

Year one Indigent/ Self Pay Admissions

Year one Total

Admissions

Year two Medicaid Admissions

Year two Indigent/ Self Pay Admissions

Year two Total

Admissions

10036 8 37 275 14 14 415 10037* 70 10 250 98 14 350

10038 11 6 285 16 8 405 Note: Obtained from applicant’s responses to Rule 59C-1.0335(6) (c) F.A.C.

Compassionate Care Hospice (CON #10036): Schedule 7A shows $223,300 for charity/self-pay (uncompensated) care in year one, and $105,452 for charity care year two. Self-pay (uncompensated) care will account for 8.7 percent of total patient days for year one (13.45 percent of admissions) and 2.1 percent of total patient days (3.37 percent of admissions) for year two. The applicant indicates that Medicaid will account for 2.93 percent of its patient days and 2.90 percent of admissions in year one and 3.14 percent patient days (3.37 percent of admissions) in year two of the project. The applicant projects Medicaid revenue at $72,674 in year one and $155,867 in year two. Year two’s 415 admissions are projected to yield 32,112 patient days.

20 NHPCO Facts & Figures released October 2008 from http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-figures_2008.pdf 21 Florida specific information from A White Paper: Will Elimination of the Optional Medicaid Hospice Benefit Save the State of Florida Money? Prepared for: Florida Hospice & Palliative Care in December 2008. FY 07-08 data based on reports from 32 of 42 reporting Florida Hospices.


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Florida Hospital HospiceCare (CON #10037): Schedule 7A shows $48,028 for charity/self-pay care in year one, and $69,258 for charity care year two. This applicant separately categorizes bad debt for year one at $24,014 and at year two, $34,628. The applicant indicates that Medicaid will account for 28 percent of its patient days and admissions in both years one and two of the project. Medicaid revenue is projected at $653,405 in year one and $937,636 in year two. The applicant’s Medicaid projection is atypical and if realized costly to the State Medicaid budget. Year two’s 350 admissions are projected to yield 15,750 patient days. Odyssey HealthCare of Central Florida, Inc. (CON #10038): Schedule 7A shows $31,635 for self-pay care in year one, and $92,165 for year two. According to the schedule notes, charity care is reflected in the self-pay column and is forecasted at 2.0 percent of patient days for both year one and year two. Charity admissions account for 2.10 percent in year one’s total and 1.97 percent in year two. The applicant indicates that Medicaid will account for four percent of its patient days in both years one and two of the project. Medicaid is projected to be 3.85 percent of total admissions in year one and 3.95 percent in year two. Medicaid revenue is projected at $44,986 in year one and $130,247 in year two. Year two’s 405 admissions are projected to yield 20,328 patient days.

G. RECOMMENDATION

Approve CON #10036 to establish a new hospice program in Hospice Service Area 6B. The project involves a total project cost of $292,459. The project does not involve any construction costs. CONDITIONS: As required by law, Compassionate Care Hospice is willing to accept any such conditions on its CON-based on any representations made through this CON application. Compassionate Care will provide all the required components of hospice care, and meet all Medicare Conditions of Participation, and Florida hospice licensure requirements, including the provision of all levels of service (routine home care, continuous care, general inpatient, respite) to all types of patients (cancer, non-cancer, Alzheimer’s, COPD, elderly, young adult, pediatric) without regard to race, ethnicity, gender, age, religious affiliation, diagnosis, financial status, insurance status, or any other discriminating factor.


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Compassionate Care commits to offering excellent quality specialized and individualized programs delivered by a highly qualified interdisciplinary team of professionals, and will implement continuous quality improvement, performance improvement and quality assurance and monitoring programs. The applicant will offer all types of services including physical care and pain management, bereavement counseling and support services (for as long as the bereaved needs such services, without limitation on duration), psycho-social services, spiritual care and counseling, memorial programs and services, palliative radiation and chemotherapy, and message, music, pet and aroma, and other alternative therapy programs. The applicant will implement a volunteer program and offer a wide array of services through its volunteers. Compassionate Care is finally committed to the continuous and ongoing training, orientation and education of its staff, and will implement specific programs such as tuition reimbursement, ongoing in-services and training programs, library resources, and payment of certification for staff. The applicant will ensure that its staff has the resources, equipment (such as lap tops, PDAs, or other IT equipment) to perform effectively in the delivery of care to their patients and families. Compassionate Care will conduct extensive community education and outreach programs in all communities, including all racial, ethnic or religious minority communities, veterans groups and organizations, and will initiate specialized programs and services to meet the individual needs of such communities in terms of language needs or specialized cultural or religious needs. Examples include such programs as Compassionate Care’s Jewish Hospice Certification; use of a culturally diverse staff; use of bilingual staff; and production of education materials and service forms in Spanish language, Creole language or other languages as needed in the community; and sensitivity and training for the special needs of veterans. Compassionate Care will contribute to the community organizations including universities, community colleges or other organizations involved in the training or health care professionals, or in the delivery of social services to the community.


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Compassionate Care will provide services beyond those mandated and reimbursed by Medicare and Medicaid, including specific financial assistance to meet the specialized financial assistance to meet the special individualized needs of patients through its charitable foundation, including special “last wishes” of a patient or family, need for specialized equipment not reimbursement, travel for a special family member to visit with a dying patient, or simply need for assistance with mortgage payments, rent, utilities, groceries, or other necessities. Compassionate Care believes that all of the above types of programs, services, policies and protocols should be provided by any hospice provider, and therefore would accept as a condition to its CON application any or all of these general conditions. Specific Conditions: • Office Locations – In order to increase awareness and visibility of

hospice services, and to provide for convenient meeting places for interdisciplinary care teams, bereavement support groups, family counseling meetings and sessions, and other types of local activities, the applicant commits to opening three office locations upon commencement of services including one in Polk County in the Haines City area, one in Highlands County in the Sebring area, and one in Polk County in the Bartow area. Compliance with this condition will be measured by providing to the Agency the location addresses for each office upon commencement of services.

• Pain Reduction – Compassionate Care Hospice will effectively reduce

severe pain in its hospice patients within 48 hours of admission to hospice. Compliance may be demonstrated based upon an annual report of the applicant’s initial pain scores for patients, and recorded pain scores after 48 hours. The applicant will achieve a reduction for at least 75 percent of patients with severe pain (score of seven to 10) to a pain score of five or less within 48 hours of admission. This exceeds the Florida requirement in Section 400.60501, Florida Statutes.

• Program Accreditation – As a demonstration of commitment to quality,

the applicant will become accredited by the Community Health Accreditation Program (CHAP) within 24 months of its initial licensure. Compliance will be demonstrated by forwarding a copy of the Accreditation to the Agency.


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• Medical Directors – Medical directors will assess every patient upon admission to hospice, and will provide patient visits in the home or place of residence. Medical directors will either be board-certified in Hospice and Palliative Care Medicine, or will apply for board-certification within five years of employment as a medical director. Compliance will be demonstrated through an Annual Report to the Agency.

• Other Staff Qualifications – To ensure high quality the applicant will

adopt the following standards and qualifications for staff: RNs will be encouraged to become certified in Hospice and Palliative Care Nursing, and by the third year of operation, 50 percent of all supervisory nurses shall attain such certification, with 100 percent of all supervisory nurses attaining such certification by the fifth year of operation; Chaplains shall be Masters of Divinity, with demonstrated completion of an accredited Clinical Pastoral Education (CPE) program; social workers shall be Masters Level and licensed clinical social workers. Compliance with these qualifications shall be demonstrated in an annual report to the Agency.

• Continuous Care – To address concerns expressed within Service Area

6B by skilled nursing and ALF providers about lack of timely availability of continuous care services, the applicant commits that it will provide at least 1.5 percent of total patient days as continuous care days, and will have continuous care staff at the bedside within two hours of receipt of a request for such services, and will maintain such service until no longer needed. Compliance will be measured and demonstrated by maintaining records of requests for continuous care, and providing an annual report to AHCA on response times and total patient days.

• Patient Visits – Compassionate Care will commit that every patient

shall be contacted on a daily basis to determine their needs for the day, and all patients shall receive in-person visits from Compassionate Care staff at least five times per week for at least two hours per day. Compliance will be monitored by submitting an annual report to the Agency on patient visits.

Deny CON #10037 and CON #10038.


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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

Chief, Bureau of Health Facility Regulation

state agency action report on application for certificate of need a. project

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