hospice care in southeast michigan: comparative analysis

C O M M U N I T Y C O N S U L T I N G C L U B

R e a l P r o j e c t s , R e a l S e r v i c e

C O M M U N I T Y C O N S U L T I N G C L U B

R e a l P r o j e c t s , R e a l S e r v i c e

Hospice Care in Southeast Michigan:

Comparative Analysis

Agenda

Agenda

Overview of Competitors

Overview of Hospice Care in Michigan

Customer Needs

Summary

I

II

III

IV

V

AppendixVI

Agenda

Agenda

Overview of Key Competitors(Hospice of Michigan, Hospice of Washtenaw, Angela Hospice, Henry Ford Hospice)


Customer Needs

- Consolidated Service Area

- Service Area by Competitor

- Summary by Identified Characteristic- Promises Made- Response Time- Patient Processing- Visit Frequency

Summary

I

II

III

IV

V

AppendixVI

- All Service Providers in 7 County Area

Consolidated - Service Area

Arbor Hospice, Hospice of Michigan, Hospice of Washtenaw, Henry Ford Hospice, Angela Hospice

Hospice of Michigan

Arbor Hospice, Hospice of Michigan, Hospice of Washtenaw, Henry Ford Hospice

Arbor Hospice, Hospice of Michigan, Hospice of Washtenaw

Hospice of Michigan, Hospice of Washtenaw

Hospice of Michigan, Henry Ford Hospice

Hospice of Michigan, Henry Ford Hospice, Angela Hospice

Source: Michigan Hospice & Palliative Care Organization

Hospice of Michigan - Service Area


Hospice of Washtenaw - Service Area


Angela Hospice - Service Area


Henry Ford Hospice - Service Area


Arbor Hospice - Service Area


Competition within Service Area

Jackson Lenawee Livingston Monroe Oakland Washtenaw WayneArbor HospiceAngela HospiceBeaumont HospiceCommunity Home Health & HospiceCommunity Hospice & Home Health Care ServicesDivision of Trinity Continuing Care - Cranbrook HospiceFriends of Hospice of Shiawassee, Inc.Good Samaritan Hospice Care – Barry Community HospiceHeartland HospiceHospice of Henry Ford Health SystemHospice of Integrated ServicesHospice of Jackson and OaklawnHospice of LenaweeHospice of MichiganHospice of Northwest OhioHospice of WashtenawHurley Medical Center HospiceKarmanos Cancer Institute HospiceLighthouse HospiceLivingston Community HospiceMcLaren Hospice ServicesMercy Memorial Hospice of MonroeSimon HouseSt. John Health System Home Services HospiceVNA Hospice

Arbor Hospice Service Area

Competitor


Hospiceof

Michigan

Service Summary – Hospice of Michigan

Mission• Hospice of Michigan's mission is to ensure quality of life and a comfortable, peaceful death for all patients receiving care, and to provide support for their loved ones. Will serve everyone in communities who needs and seeks care, and strive to improve the state of end-of-life care.

Vision• Hospice of Michigan will be the premier provider of expert, compassionate care for people who are experiencing life-threatening illnesses. Partnerships with patients, families, customers, employees and communities will enhance ability to provide care to all those who need it. Excel at service, innovation and research which will improve the quality of care for those served.

Approach / Goals• Behave as a true interdisciplinary team.• Plan for the future.• Continually seek to eliminate barriers and improve access to services.• Set and exceed best practice standards for end-of-life care.• Measure everything in order to improve.• Provide opportunities for staff development and reward staff for their contributions to vision, mission and goals.

Services• Physical support: pain management, symptom control, personal care • Emotional and spiritual support: helping patients and families cope • Grief support: helping families, friends for 13 months after the loved one’s death • Volunteer services: providing respite care, doing chores, listening • Financial assistance: helping all terminally ill patients, regardless of ability to pay

Source: http://www.hom.org/; Hospice of Michigan Public Relations

Service Summary – Hospice of Michigan (con’t)

Differentiating Factors

•Statewide. Hospice of Michigan was the first statewide hospice program in the country when it was founded in

1994 in a merger of 10 hospices across Michigan. Serves 45 counties throughout Michigan's Lower Peninsula.

•Larger. Because of size, Hospice of Michigan can offer many services smaller hospices cannot afford, including

complex and costly comfort care for patients who need it.

•Specialists. Hospice of Michigan has specialists in many areas, including pediatric hospice care, high-tech

palliative care and care for people with AIDS. Have more doctors and nurses who are board certified in hospice

and palliative care.

•Open admissions. Hospice of Michigan has no restrictive admissions criteria. Anyone with any terminal illness

can be admitted to HOM, whether or not they have a caregiver at home.

•Recognized leader. Hospice of Michigan is currently participating in several nationwide research projects to

improve end-of-life care in the United States. President and CEO, Dorothy E. Deremo, is one of 12 members of

Michigan Governor John Engler's Commission on End of Life Care. Executive Medical Director, Dr. John Finn, is

president-elect of the American Academy of Hospice and Palliative Medicine.

•Specialized programs. Hospice of Michigan has programs tailored to meet the needs of diverse cultural and

religious groups.


Promises Made

Response Time

Patient Processing

Visit Frequency

Service Summary – Hospice of Michigan (con’t)

• Hospice of Michigan's makes no promises to admitted patients. The patient is informed as to all the people and services that will be available to them through Hospice of Michigan.

• Depending on the time of day of the referral, a patient can be processed anywhere from 4 – 24 hours.

• Depending on where the patient lives, response time can vary from 15 minutes to 75 minutes.

• Depending on the patient and symptoms, visit frequency can vary from daily to weekly.


Hospiceof

Washtenaw

Mission

Approach / Goals


Service Summary - Hospice of Washtenaw

• Hospice of Washtenaw offers a wide range of services that meet the many physical, emotional and spiritual

needs of patients and their families.

•The goal is to achieve constant control over pain without impairing alertness. Patients are encouraged to remain as

active as possible and stay in close contact with family and friends.

• Home Care and Hospice together offer to patients with a life-limiting illness the option of a "Bridge Program.“

• Staff assist in the management of end-of-life issues while the patient is still receiving treatment for the disease

process.

•Hospice of Washtenaw focuses not on healing and recovery, but on comfort and quality of life. Through

specialized services, help patients and their families manage physical, emotional, social and spiritual needs.

Patients live their final days with peace and dignity in the comfort of their own home or care facility. Work with

family and friends to help them cope with end of life transition and stress of the approaching loss.

Vision

Source: Hospice of Washtenaw Public Relations

Promises Made

Response Time

Patient Processing

Visit Frequency

•Pain control: To provide patient centered care and to assist them to be pain free or at the pain level they desire

•Respect patients’ wish: To be able to die in the place and way that they wish

•Family assistance: To support the patient’s family and to provide follow up care for the family after the patient's death.

•Phone response is within 30-45 minutes; will try and be at their home within 1 hour for an urgent request, such as a pain crisis.

•Hospice of Washtenaw tries and admits all referrals ASAP and within 24 hours of time of referral.

•It is based on their acuity, i.e how sick they are and the intensity of their needs; some patients receive daily visits and some once or twice per week; they are visited by RNs, Social Workers, Spiritual Care Coordinators, Volunteers, home health aides, etc.

Service Summary - Hospice of Washtenaw (con’t)

Source: Hospice of Washtenaw Public Relations

AngelaHospice

Mission

Vision

Approach / Goals


Service Summary - Angela Hospice

•Hospice seeks to empower the patient to carry on an alert and pain free life, to promote dignity

and to maximize quality of life. It focuses on living rather than dying.

•Angela Hospice is the first freestanding hospice care facility built in Michigan (1994). In addition to

in-patient, in-home, and bereavement care, Angela Hospice offers Pediatric Services titled, “Nest is

Best.”

•Hospice is a philosophy rather than a place. Hospice is best when begun early enough that the

patient and family can benefit fully from support and counseling.

•Caring for people with an incurable illness in the warmth and comfort of their own home is the heart of the Angela

Hospice philosophy.

Source: Hospice of Washtenaw Public Relations; http://www.angelahospice.org

Promises Made

Response Time

Patient Processing

Visit Frequency

Service Summary - Angela Hospice (con’t)

•Good quality service care

•Comfort Care

•Pain-free

•Emotional Support

•Spiritual Counseling

•Angela Hospice tries to respond by phone in under one hour, and get to the patient’s home ASAP for urgent crisis requests.

•During the first, setup visit, an admitting nurse assess the patients needs and determines how many visits nurses, aides, volunteers, etc. will need to make. This varies greatly by patient needs.

•Processing can be completed in less than 24 hours after referral from the physician. Angela Hospice likes to be setup in the patient’s home before the arrival of the patient from the hospital.


Services Offered

Service Summary - Angela Hospice (con’t)

•There are currently 77 patients in in-home care under Angela Hospice.

•Professional Services include:

•Registered Nurses/Nurses Aides

•Hospice Physicians

•Certified Home Health Aides

•Social Work

•Spiritual Staff

•Bereavement Services

•Volunteers

•Other therapies, as needed.


Henry FordHospice

Mission

Vision (Henry Ford Healthcare System)

Service Summary - Hospices of Henry Ford

•Henry Ford Hospice is dedicated to providing compassionate hospice care of the highest quality to serve the needs of terminally ill patients and their families within the community. The hospice services will be comprehensive, efficient, clinically effective and enhanced by education and research programs.

•The primary objective is quality of life, not cure. Hospice care is comfort oriented, and is intended neither to shorten nor to

prolong life -- but to assist patients and their loved ones through the dying process with dignity.

Approach / Goals

•To offer a seamless array of acute, primary, tertiary, quaternary and preventive care backed by excellence in research and education.

Source: www.henryfordhealth.org. Hospices of Henry Ford Office of Public Relations


• A seamless health care system (resources)

• Extensive hospital (feeder) network

• Performance measurement through family and physician satisfaction surveys

• Largest volunteer network, 200 volunteers (37,500 volunteer hours in 2002)

• Variety of settings for care; area nursing homes (50 contracts), assisted-living center (12 beds), adult foster-care homes, homes for the aged, & senior citizen apartments

• Diversification• Community Outreach

• Clinical Improvement • Physician Organization

Response Time

Service Summary - Hospices of Henry Ford (con’t)

• Will travel to patient within 1 hour of call

• Will visit hospital within 24 hours of referral

Patient Processing

• Daily visits or as determined by per care-plan

• For home-care patients evaluations, care-plan and infrastructure are complete within 7 days

Visit Frequency

Promises Made

• Hospices of Henry Ford Health System is dedicated to providing compassionate hospice services of the highest quality to terminally ill patients and their families.

• Team members committed to honoring the wishes of the patient and caregivers during this difficult time of transition

• Care advice and availability around the clock, 365 days a year.

• Hospice services designed to meet the individual needs of patient and family.



Services Offered

• Social work services

• Visits by hospice registered nurses

• Nutritional services

• Durable medical equipment

• Trained volunteers

• Children's hospice

• Spiritual care and counseling

• Medications for pain and symptom control

• 24-hour availability

• Skilled-care facility placement

• Care for the caregiver

• 13-month bereavement support and follow-up

• Legal aid

• Education

Quality Assurance

• Accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

• A 98% satisfaction rate as measured by the Family Satisfaction Survey developed by the National Hospice Organization. The survey assess family satisfaction with care and service in the following areas:

– Symptom Management

– Customer service

– Access to care

– Simplicity of instructional materials

– Support of caregiver



Education

The Hospices of Henry Ford have committed to raising awareness and broadening public understanding of the hospice

philosophy. The Hospice Speakers Bureau serves social, civic, professional, educational and religious groups throughout

southeast Michigan. Speakers are available to address the following topics:

• What is hospice?

• Services provided by hospice

• Pain and symptom management

• The nurse's role in the hospice care plan

• Advance Medical Directives

• DNR (Do-Not-Resuscitate) orders

• Hospice volunteer opportunities

• Hospice home safety

• Patients' Bill of Rights

• How to talk with children about death

• How adults can help grieving children

• Living wills

• The nature of grief

• Pastoral care for hospice patients

• Medicare and hospice benefits



Assisted Living (12 bed facility) Expansion Plans

The assisted-living facility managed by the Hospices of Henry Ford operates on a wait list system. There are

currently no plans for expanding the assisted living facility. Since its launch in 2000 the facility has not been

profitable. The Henry Ford System and its Hospice operation have applied for Acute Symptom Control and Respite

Care Certifications. Upon certification it is their objective to include these additional services to increase profitability.

Advertising & Promotion Channels

• Marketing within geographic areas (through local groups) - Church & fraternal organizations, and speaking engagements

• Promotion among doctors (5 primary feeder hospitals) - Hospice nurse on site each day

• Educational Programs - Nursing Student Education Program (500 nurses graduate annually) - Classroom training (affiliations with local area universities)

• Routing of medical care professionals

• Target advertising in community newspapers

• Billboard (7 alternate sites in Detroit area)

• Underwriters of PBS documentary series

• TV commercial produced and launched in 2002

• Public radio service announcements


ArborHospice

Service Summary – Arbor Hospice

Mission

Vision

Approach / Goals

•“To give comfort, assurance and care to families and patients who have life-limiting illness, and to educate and nurture others in this care”

• Continued patient and revenue growth through:• A defined marketing strategy addressing public and physician education, brand differentiation, and defined presence in satellite branches.• Cultivation of new markets• Strengthening of existing referral base• Overcoming cultural issues:

• Misperception that hospice is “the place where one goes to die”• Reluctance to come to terms with the fact that a loved one is going to die

• Streamlined operations• shift in organizational philosophy towards “growth and development” drives adjustments in staff structure• Management of limited resources to vie with larger competitors• Overcoming “historical financial difficulties” through improved project management and accounting

Differentiating Factors•Arbor Hospice Residence, extensive grief counseling services, comprehensive pediatric hospice care, Pathfinders program (grief support for children, adolescents, and adults), extensive home care services

Source: Arbor Hospice

• Establish AHHC as leader in premium end-of-life care and related support services• Build “brand equity”• Create context for AHHC in minds of employees, consumers, and donor prospects• Communicate in a consistent voice

Service Summary – Arbor Hospice (con’t)

Promises Made

Response Time

Patient Processing

• Top quality medical care• Weekend admissions and prompt referrals• Continuity of service• Over 15 years of service• Referring physicians and discharge planners like to work with AHHC

• A phone call back within 15 minutes (weekends, phone answered by pager, returned within 15 minutes)• 800 line gives immediate access - though rarely an emergency call, still makes sense for rapid response

• Residence – average of two weeks to get patient in residence, from time of phone call• 24 hours (average) from time of call to time bed considered a hospice (or home care) bed • Average length of stay 6-8 days • Can admit field patient and then put on waiting list for residence• Can also go from hospital to home care to residence• If in a hospital, patient is discharged from hospital & admitted to AHHC, and no hospital nurses take care of patient any longer – all hospice care at that point.


Service Summary – Arbor Hospice (con’t)

Visit Frequency

• On call 24 hours• Frequency for hospice – determined on a case by case basis• Nurse/nurses aide - on average, 2 times a week (M-F), though towards end of life, increases to 5 times a week. • AHHC social workers - 2-3 times a month if needed, tend not to be needed as much for home care, though toward end of life winds up being m-f • Physical therapists, chaplain, speech therapists used fairly infrequently• Family or volunteers usually goes by 2-3 times a week take care of clothing, food, etc.

Residence • Nurses/aides go in every 2 hours to turn patients, and are on call 24 hours•Social workers range from several times a day to once a week (social worker does admissions, evaluations, understanding end of life issues, legal or financial issues, wills, clergy, etc.; essentially helps the whole family as liaison between patient and the world of hospice care)•Chaplain from several times a day to once a week (non-denominational, hired by hospice, four total, one for each region and one for residence, share weekend and on call). •4 medical directors/physicians (arranged like chaplains), and overall medical director (managing physician, who reviews every case, manages policy, etc.). Though nurses have doctor’s order to sign off on death certificate.

Field


ServiceComparison

Promises Made

Angela Hospice

•Good quality service care

•Comfort Care

•Pain-free

•Emotional Support

•Spiritual Counseling

Hospice of Washtenaw

•Pain control: To provide patient centered care and to assist them to be pain free or at the pain level they desire

•Respect patients’ wish: To be able to die in the place and way that they wish

•Family assistance: To support the patient’s family and to provide follow up care for the family after the patient's death

Hospice of Michigan

* Please see respective organizational slide for source information.

• Hospice of Michigan's makes no promises to admitted patients. The patient is informed as to all the people and services that will be available to them through Hospice of Michigan.

Promises Made (con’t)

Henry Ford Hospice

• Hospices of Henry Ford Health System is dedicated to providing compassionate hospice services of the highest quality to terminally ill patients and their families.

• Team members committed to honoring the wishes of the patient and caregivers during this difficult time of transition

• Care advice and availability around the clock, 365 days a year.

• Hospice services designed to meet the individual needs of patient and family.


Arbor Hospice

• Top quality medical care• Weekend admissions and prompt referrals• Continuity of service• Over 15 years of service• Referring physicians and discharge planners like to work with AHHC• Arbor Hospice Residence• Committed to staff education• Specialized care for children• Grief support services for adults and children

Response Time

• Angela Hospice tries to respond by phone in under one hour, and get to the patient’s home ASAP for urgent crisis requests.

Angela Hospice

• Hospice of Washtenaw: Phone response is within 30-45 minutes and we can try and be at their home within 1 hour for an urgent request, such as a pain crisis.


Arbor Hospice

• Will travel to patient within 1 hour of call

• Will visit hospital within 24 hours of referral

Henry Ford Hospice


Hospice of Michigan

• A phone call back within 15 minutes (weekends, phone answered by pager, returned within 15 minutes)

• 800 line gives immediate access - though rarely an emergency call, still makes sense for rapid response

• Depending on where the patient lives, response time can vary from 15 minutes to 75 minutes.

Patient Processing

Angela Hospice

Processing can be completed in less than 24 hours after referral from the physician. Angela Hospice likes to be setup in the patient’s home before the arrival of the patient from the hospital.


• Hospice of Washtenaw tries and admits all referrals ASAP and within 24 hours of time of referral.

Henry Ford Hospice

• For home-care patients evaluations, care-plan and infrastructure are complete within 7 days

Arbor Hospice

• Residence – average of two weeks to get patient in residence, from time of phone call• 24 hours (average) from time of call to time bed considered a hospice (or home care) bed • Average length of stay 6-8 days • Can admit field patient and then put on waiting list for residence• Can also go from hospital to home care to residence• If in a hospital, patient is discharged from hospital & admitted to AHHC, and no hospital nurses take care of patient any longer – all hospice care at that point.


Hospice of Michigan

• Depending on the time of day of the referral, a patient can be processed anywhere from 4 – 24 hours.

Visit Frequency

Angela Hospice

• During the first, setup visit, an admitting nurse assess the patients needs and determines how many visits nurses, aides, volunteers, etc. will need to make. This varies greatly by patient needs.

• It is based on their acuity, i.e how sick they are and the intensity of their needs; some patients receive daily visits and some once or twice per week; they are visited by RNs, Social Workers, Spiritual Care Coordinators, Volunteers, home health aides, etc.


Henry Ford Hospice

• Daily visits or as determined by per care-plan


Hospice of Michigan

• Depending on the patient and symptoms, visit frequency can vary from daily to weekly.

Visit Frequency (con’t)

• On call 24 hours

• Frequency for hospice – determined on a case by case basis

• Nurse/nurses aide - on average, 2 times a week (M-F), though towards end of life, increases to 5 times a week.

• AHHC social workers - 2-3 times a month if needed, tend not to be needed as much for home care, though toward

end of life winds up being m-f

• Physical therapists, chaplain, speech therapists used fairly infrequently

• Family or volunteers usually goes by 2-3 times a week take care of clothing, food, etc.

Arbor Hospice

Residence

• Nurses/aides go in every 2 hours to turn patients, and are on call 24 hours

•Social workers range from several times a day to once a week (social worker does admissions,

evaluations, understanding end of life issues, legal or financial issues, wills, clergy, etc.; essentially helps

the whole family as liaison between patient and the world of hospice care)

•Chaplain from several times a day to once a week (non-denominational, hired by hospice, four total, one

for each region and one for residence, share weekend and on call).

•4 medical directors/physicians (arranged like chaplains), and overall medical director (managing

physician, who reviews every case, manages policy, etc.). Though nurses have doctor’s order to sign off

on death certificate.

Field


# Bed

s

# Phy

sician

s

# Em

ploye

es

# Pat

ients

Serve

d

Arbor Hospice

Hospice of Michigan

Angela Hospice

Henry Ford Hospice


42 7,000 18 500

19651,400+30

10016 1 145

12 1,850 5 150

0 4503 part-time 30


Basic Comparative Statistics

Grief S

uppo

rt

Home

Care

In N

ursin

g Hom

e

& Hos

pital

Spiritu

al Car

e

Clinica

l Res

ourc

es

Arbor Hospice

Hospice of Michigan

Angela Hospice

Henry Ford Hospice


Hospic

e Hom

e

X X X X X X

X X X X X X

X X X X X X

X X X X X X

X X X X X


Overview of Service Summary

• Due to the broad characterization of hospice benefits combined with the hospice requirements set forth by the state of Michigan, hospice organizations look similar to the customer upon initial inspection.

Agenda

Agenda



Summary

- Basic Care Requirements

- Medical Training and Hospice Care

- Issues with Financing

- Michigan End of Life Care

- Demographics

Customer Needs

I

II

III

IV

V

AppendixVI

Basic Care Requirements

• General Services Offered– Medical Care– Nursing Care– Social Work– Spiritual Care

• Quality Assurance Program– Using an interdisciplinary committee to identify problems

• Patient Rights and Responsibilities– Develop and post in public place the rights of patients

• Governing Board– An organized governing body to conduct operations– Administrator who ensure implementation of all

procedures

Source: Michigan Commission on End of Life Care

Hospice-Related Educational Environment in Michigan

Availability of education in medical residency and fellowship programs in Michigan

• A recent survey of residency and fellowship programs in Michigan reflects that “physicians are not well educated in end-of-life care.”

• The table above reiterates the continuing struggle hospice organizations will have as they try to grow and gain legitimacy with patients and doctors.

Source: Open Society Institute, “Project on Death in American”

Hospice-Related Educational Environment in Michigan (con’t)

Adequacy of education in medical residency and fellowship programs in Michigan

• There seems to be room for improvement when it comes to physician training relative to end of life care in general and specifically hospice care.

• Only 20% of the respondent's reported any required formal training in hospice care.

• Less than one-third of the doctors responded to having any formal training in hospice care.

Discrepancy in Hospice Training by Type of Care

Primary Care

Non-primary Care

• Due to the broad characterization of hospice benefits combined with the hospice requirements set forth by the state of Michigan, hospice organizations look similar to the customer upon initial inspection.

Challenges in Financing Hospice Care (for the patient)

Michigan End of Life Care

• Great variation exists in how services are provided and funded within various settings:

- Uncoordinated mix of Medicare, Medicaid, private insurance and out of pocket funds

• Small proportion of Medicare and Medicaid patients enroll in hospice benefit, < 20%

• Arbitrary hospice care eligibility criteria:

- Rule that states patient must have life expectancy of six months or less

- Medicare reimbursement requires that 80% of hospice services be provided in the home

• Hospice reimbursement not based on actual costs of delivering care

• Cultural attitudes delay decision to move from curative therapies to end-of-life care options

• Generally patients preferences for treatment at end of life are unknown, few standardized policies to communicate these preferences to health care providers

Source: Michigan Commission on End of Life Care, Report to the Governor July 2002

Michigan End of Life Care (con’t)

Demographics: An aging population

• There are 1.8 million people age 65 and older in Michigan, expected to grow significantly

• Nationally, 70% of annual deaths occur among people age 65 and over;

- of the 84,906 people who died in Michigan in 1998, 75% were over 65

• Michigan trends likely to parallel Census Bureau projections, which highlight an increase in the total U.S. population as well as in the median and mean ages over the next 30 years.

Source: U.S. Census Bureau, Population Projections Program, Population Division. January 13, 2000

40.239.237.936.5Median Age

38.938.137.435.8Median Age

351.0324.9299.9275.4Population (in millions)

2030202020102000

Age 2000 2010 2020 2030

Millions % of Pop. Millions % of Pop. Millions % of Pop. Millions % of Pop.

20–54 yrs 138.1 50.2% 143.5 47.8% 143.3 44.1% 150.8 43.0%

> 54 yrs 58.8 21.4% 75.1 35.0% 95.8 29.5% 107.6 30.6%

> 64 yrs 34.8 12.6% 39.7 13.2% 53.7 16.5% 70.3 20.0%

> 84 yrs 4.3 1.6% 5.7 15.0% 6.8 2.1% 8.9 2.5%

$42,864

$64,705

$50,505

$62,538

$54,326

$37,525

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

Le

na

we

e

Liv

ing

sto

n

Mo

nro

e

Oa

kla

nd

Wa

sh

ten

aw

Wa

yn

e

0

500

1,000

1,500

2,000

2,500

Jackson Lenawee Livingston Monroe Oakland Washtenaw Wayne

5%

10%

15%

20%

Total Population Over 65

Income distribution by household

Population Distribution

Source: http://quickfacts.census.gov/qfd/states/26000.html



Most Frequent Causes of Death (Michigan, 1998)

• Diseases of the heart (27,851)

• Cancer (19,442)

• Stroke (5,760)

• Chronic obstructive pulmonary disease, COPD and allied conditions (3,807)

• Unintentional injuries (3,096)

• Pneumonia and influenza (3,090)

• Diabetes mellitus (2,449)

• Alzheimer’s (644)

Source: Michigan Resident Death Files, 1990-1998.

The top 5 disproportionately affect the elder populationMedical treatments make it possible to live with these diseases but care is intensive, prolonged, and often costly. It is

difficult to determine when patients with such illness can be diagnosed as terminal.

Heat Disease Cancer Stroke COPD and allied diseases

Pneumonia and flu

Total 27,851 19,442 5,760 3,804 3,096

People 65 and older

23,209

(83%)

13,703

(70%)

5,602

(88%)

3,271

(86%)

2,756

(89%)


Where Death Occurs

In general, people in Michigan and in the nation die in one of three locations:

• Many advocates consider it a positive trend that an increasing number of people dies in the home

• Increase reflects an acceptance of the preference to die at home

• Improvements in technology, increased outpatient services and more access to home heath care are all likely contributors to upward trend.

• A challenge to be considered, is that those dying at home present an additional burden to the informal caregivers and the household for services previous rendered by health care providers.

• Data shows a decreasing reliance on hospitals for end-of-life care

• Nursing homes are often the setting of last resource for most people who are elderly and disables,m with complex diagnoses and health care needs, data indicates the nursing facility residents must be included in any targeted end-of-life care quality improvement efforts.

Source: Michigan Resident Death Files, 1990-1998

Hospitals Nursing Homes Home Other

1990 (78,501 deaths) 59.5% 15.5% 20.0% 6.0%

1996 (83,469 deaths) 48.5% 21.8% 25.9% 3.8%

1998 (84,906 deaths) 47.0% 25.9% 26.0% 4.0%

Source: Michigan Commission on End of Life Care, Report to Governor July 2002

Average number of days in hospitals during last six

months of life

Average Medicare reimbursements for

inpatient care during the last six months of life

Percent of Medicare deaths that occurred in hospitals, rather than

elsewhere

National Range: 3.3 – 17.6

National Range: $3,767 - $21,282

National Range: 10.9% - 48.8%

Source: Dartmouth World Atlas Report;www.dartmouthatlas.org/endoflife/end_of_life.php


Agenda

Agenda



Customer Needs- Needs- Barriers- Volunteer Issues

Summary

I

II

III

IV

V

AppendixVI

Customer Needs

Freedom - Do not want to reach the end of their lives “hooked up to a machine”

- Lack of control over own end-of-life process

Trust - Uncomfortable with the topic

- "sad," "depressing," "bad luck," "too far in the future," “too busy living to focus on dying.”

Compassion - Prefer a natural death in familiar surroundings with loved ones.

- Fear dying in pain – dying well means dying free of pain

Spirituality - Respect cultural and religious differences

- Ensure important values and practices surrounding death and dying are honored; respect norms during the difficult time of death.

Family Consideration - Family consideration is primary concern in making end-of-life decisions

- Do not want their dying to burden their families financially, emotionally, or physically

Responsible Planning - Resist taking action

- Lack of common and comfortable language to talk about dying is a significant barrier to planning

- Lack of understanding of processes

- Misperception of expense, difficulty of documentation

- Question whether written document is necessary; argue that loved ones already know what they would want

Societal Responsibility - To create a public dialogue around the subject of death and dying

Source: American Health Decisions

Perceived Barriers

Patients Do not believe current health care system supports ideal concept of dying

- Current planning options do not support the way these Americans want to manage the

death and dying experience

- A health care system designed to cure illness and sustain life, not necessarily to help

patients die the way they wish

- Treatments that prolong life “unnaturally,” and cause unnecessary suffering

- Cost, rather than what is best for the patient, determines the treatments they receive

Shortcomings in Doctor-Patient relationship

- Loss of established relationships with changing health care plans, time crunch of medical

practices

- Results in a loss of trust in doctors for end-of-life advice

- Want dialogue in context of long-standing and trusting relationship, when doctor is willing to

spend the necessary time

Source: American Health Decisions

Volunteer Issues

Over 90% of volunteers and professionals agree or strongly agree that volunteers are essential to the mission of hospice

- provide companionship, support, and respite for patients and families in times of crisis

Volunteer Demographics- 80% female- Median age – 55 (30% are 65 or older)- Half are employed full or part time

Primary criticisms of volunteers- Get too emotionally involved with patients and families- Exceed boundaries of the volunteer role - Fail to do what they promise- give inappropriate medical advice to patients and families (19%).

Future of Hospice Volunteerism

- Structural pressures as hospice expands, enters medical mainstream

- In rising cost environment of health care, increased concerns about maintaining strong volunteer programs

- Need to “quantify” effectiveness of volunteers in order to justify continued expenditures

- Concerns about scarcity of traditional hospice volunteers (middle-aged, educated white women) and difficulty of recruiting nontraditional populations (minority and male volunteers)

Source: The Robert Wood Johnson Foundation

Agenda

Agenda



Customer Needs

Summary

I

II

III

IV

V

AppendixVI

• Trends in the Hospice Care Landscape

•An increasingly aging population will heighten demand for end of life services

•Demand for superior care will drive need for adequate, hospice-specific education of health care professionals

•Medicare’s “80% rule” will continue to increase demand for home care services

•An increasing number of people are already dying in their homes

•Competitive Environment for Hospice Care in the State of Michigan

•Increasing overlap of service areas as established organizations vie for market share

•Increasingly similar service capabilities offered by established hospice organizations

Summary

• Challenges for Arbor Hospice– Differentiate services in an increasingly homogenized competitive environment– Expand geographic presence to compete with larger hospice organizations,

through innovative growth strategies– Lack of affiliation with larger health network

• Opportunities for Arbor Hospice – Increase presence in community at large

• Competitors currently sitting at points of influence (e.g., Hospice of Michigan on the board of the state of Michigan’s commission on End of Life care)

• Build referral base though extended community and health care provider relationships

• Continued educational outreach to the public and health care providers– Continued emphasis on differentiation from competitors

• Arbor Residence• Extensive Grief Counseling• Other unique services

Summary (con’t)

Agenda

Agenda



Customer Needs

Summary

I

II

III

IV

V

AppendixVI

Additional Websites Referenced

1. Quest for Life - national survey that documents results on end of life care.http://www.ahd.org/ahd/library/statements/quest.html#anchor283545

2. State of Michigan report on current condition of Hospice and Palliative care as well as future goals the state hopes to accomplish.http://www.michigan.gov/mdch/0,1607,7-132-2940_3183_4895-19878--,00.html

3. State of Michigan website for the state sponsored Hospice and Palliative Care organization to monitor state hospice organizations and provide consumers with information.http://www.mihospice.org/

4. Foundation that develops study’s and grants to look at hospice and end of life issues.http://www.rwjf.org/index.jsp

5. An organization that was given a grant to develop national standards on all aspects surrounding Hospice care and support.http://www.hospicefed.org/

6. Census demographics by state and county.http://quickfacts.census.gov/qfd/states/26000.html

7. Report on end of life statistics for the state of Michigan (days in bed, types of illness, etc)http://www.dartmouthatlas.org/endoflife/end_of_life.php

A Report on Dying in America

Michigan Commission on End of Life Care

Dartmouth Quick World Atlas

Report on the State of Michigan

hospice care in southeast michigan: comparative analysis

Documents

hospice of michigan

vision hospice of michigan

angela hospice source

southeast michigan

life care

quality of care

respite care

compassionate care