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STATE AGENCY ACTION REPORT

ON APPLICATION FOR CERTIFICATE OF NEED

A. PROJECT IDENTIFICATION

1. Applicant/CON Action Number

Catholic Hospice of Central Florida, Inc./CON #10069

14875 N. W. 77 Avenue, Suite 100 Miami Lakes, Florida 33014

Authorized Representative: Ms. Julie E. Smith (850) 425-2444

Memorial Hospital-Flagler, Inc. d/b/a Florida Hospital HospiceCare/CON #10070

770 West Grenada Boulevard, Suite 304 Ormond Beach, Florida 32147

Authorized Representatives Mr. David Ottati Ms. Diane Godfrey

(386) 671-2138 (407) 303-9659

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida/CON #10071 717 North Harwood, Suite 1500

Dallas, Texas 75201

Authorized Representative Mr. Jason S. Howard (214) 922-9711

United Hospice of Florida, Inc./CON #10072 1626 Jeurgens Court

Norcross, Georgia 30093 Authorized Representative Mr. Neil L. Pruitt, Jr.

(770) 925-4788

CON Action Numbers: 10069, 10070, 10071, & 10072

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2. Service Area/Subdistrict

Hospice Service Area 7B, Orange and Osceola Counties

B. PUBLIC HEARING

A public hearing was not held or requested regarding the proposals to establish a hospice program in Hospice Service Area (SA) 7B. However, letters of support were submitted, as discussed below.

Catholic Hospice of Central Florida, Inc. (CON #10069) submitted

approximately 248 letters of support with its application. The letters of support were from physicians, businesses, commissioners, educators, faith-based organizations, government leaders, community organizations

and other members of the community at large. One hundred and forty seven letters had Orange or Osceola County (SA 7B) addresses. These

include letters from 70 residents, 33 churches and faith based organizations, 27 community organizations and businesses, 10 physicians, five local government officers, and five local health care

facilities. The applicant‟s support letters generally indicate that: Catholic Hospice has excellent educational and outreach services; project approval would increase access to faith-based services, the community

would benefit from a faith based approach to hospice care, Catholic Hospice will have bilingual staff ideally suited to meet the needs of the

diverse community, and that Catholic Hospice provides quality compassionate care to its patients.

Mildred Fernandez, Orange County Commissioner, John “Q” Quinones, Osceola County Commissioner, Orlando City Commissioner Tony Ortiz, Osceola County Sheriff Robert E. “Bob” Hansell, and Captain Miguel A.

Pagan of the Orange County Sheriff‟s Department provided letters which contained one or more of the above statements. The applicant‟s letters

from local health care facilities include Shannon Elswick, President, Orlando Regional Medical Center, Orlando Health; Clarence H. Brown III, M.D., President and CEO of MD Anderson Cancer Center – Orlando,

John S. Lord, Chairman, Nemours Board of Directors (Nemours has an Orlando outpatient clinic and CON approval to construct a children‟s

hospital in Orange County), Diane Boodram, NHA, Executive Director of Rio Pinar Health Care (a 180-bed nursing home in Orlando), and Kevin Johnson, Executive Director of Bishop Grady Villas (an ALF in St. Cloud

- Osceola County). The applicant‟s support letters from local physicians, churches and faith-based organizations, and community organizations and businesses all essentially contain one of more of the above

statements.


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The remaining 101 letters of support were from physicians, businesses, organizations and residents of Seminole, Miami-Dade and Monroe

Counties.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) submitted 53 letters of support with its application. The letters of support were from clergy, community leaders and

organizations, assisted living facilities, volunteers, skilled nursing facilities, and Seventh Day Adventist Church/Sunbelt, Inc. Florida Hospital affiliates. Twenty-two of the letters of support were from Florida

Hospital or one of its affiliates such as Florida Hospital Orlando Palliative Care Program, Florida Hospital Cancer Institute, or Florida Hospital

Memorial Home Health. These letters emphasized that the addition of a hospice program would be a complimentary extension of the continuum of care that already exists as a part of the Florida Hospital network.

Thirteen letters of support were submitted by community leaders and organizations. The applicant‟s letters generally indicated that: Florida

Hospital is a multi-faceted health care system that has the infrastructure to support a hospice organization; Florida Hospital provides quality care and has “a deep understanding of the medical, social and end of life

needs of the residents in our service area”, and various training and educational opportunities would be available should the applicant be awarded the CON.

John “Q” Quinones, Osceola County Commissioner and Rick Daigneault,

LMHC, Health Services Administrator for Orange County Government Health Services Division, provide letters which contained one or more of the above statements. The letters from representatives of local

organizations also cite several of the above statements. The Rev. Lizette M. Acosta, Director of the Latino/Latina Studies Program (LLSP) at Asbury Theological Seminary indicates that LLSP students are provided

supervised ministry experience at Florida Hospital East Orlando and that the addition of hospice would be of great service to the (Latino)

community. Marinella Castroman RN, CEO and Marketing Director of Select Specialty

Hospital – Orlando and Rose O‟Neil CEO of Select Specialty Hospital – Orlando North provided general letters of support. Ms. Castroman stated

that she sees the need based on their (Select‟s) patient population and fully supports Florida Hospital‟s application. Ms. O‟Neil cites her facility‟s partnership with Florida Hospital and the need for hospice care

for patients discharged from Select. Representatives of nursing homes providing general letters of support include: Diane Boodram, NHA, Executive Director of Rio Pinar Health Care (a 180 bed nursing home in

Orlando), Abigail Ashe, NHA Rosewood Health & Rehabilitation Center (120 beds - Orlando), Tristan S. Mohadeo, Executive Director of Colonial

Lakes Health Care (180 beds -Winter Garden) and Mindy Wright, MHSA,


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Regional Sales Consultant for Sea Crest Healthcare Management, which manages several Orange and Osceola County facilities. Texus Wallace,

representing Almark Health Services, Inc. indicates his company‟s three small ALFs have worked with Florida Hospital for over 16 years and that

the addition of hospice care for Florida Hospital would effectively improve continuity of care for the ALF population.

The majority of the applicant‟s letters are from representatives of facilities that are part of the Seventh Day Adventist Church/Sunbelt, Inc. health care chain. Some of these are summarized below.

Joseph D. Portoghese, MD, Chief Academic Officer and General Surgery

Residency Program Director at Florida Hospital, indicates that the hospice program will open the possibility of establishing an accredited training program in Palliative Care Medicine. Dr. Portoghese concludes

that the project has the potential for multiplying the positive effect for the community by alignment with a hospital big enough to support medical

education. Gregory K. Ellis, M. Div., B.C.C., Administrative Director for Pastoral

Care at Florida Hospital indicates that through the hospice program, Florida Hospital would be able to serve the community in terms of training opportunities for pastors in its Clinical Pastoral Education (CPE)

program. CPE provides training for pastors in the specialized ministry of spiritual care within the clinical context and Mr. Ellis indicates that the

hospice environment is a “very fertile ground for such learning and training to take place”. He indicates that his CPE training included both traditional hospital and hospice and that the hospice portion “was

transformational and life changing”. Kenneth Zill, Executive Director of Volunteer Services at Florida Hospital

states his program presently has over 3,000 volunteers who provide nearly 300,000 hours annually. They serve in all Florida Hospitals,

urgent care centers, community clinics and numerous administrative roles across the system. Mr. Zill indicates that this network will yield a much faster ramp-up of dedicated hospice volunteers than would

otherwise be possible.

Cary Smith, NHA, Vice President of Regional Operations of Adventist Care Centers which operates four nursing homes in the Orlando area indicates that his “facilities would greatly welcome an opportunity to

effectively collaborate with a Florida Hospital HospiceCare program by providing support for their long-term care patients (and that) having this type of program with Florida Hospital would improve the continuity of

care for these residents of our community”. The applicant states it


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intends to enter into contracts with one or more Florida Hospital facilities, Adventist Care Center skilled nursing facilities and other

providers in the service area.

Eight of the letters were from either volunteers of Florida Hospital HospiceCare or families that were served by the hospice in Ormond Beach and Palm Coast, Florida.

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida (CON #10071) submitted 50 letters of

support with its application. These were from assisted living facilities, nursing homes, retirement communities, and families that received

services through Odyssey‟s other hospice programs. The 15 letters provided by nursing homes, assisted living facilities and retirement communities stated that having an additional hospice provider in the

area could only cause all other area hospices to provide better care and services to its patients. The letters also expressed a need for better

hospice education and a belief that the applicant can adequately provide such education. The remaining 35 letters of support were from families that received services from Odyssey-Daytona and Odyssey-Miami. These

letters expressed gratitude to Odyssey for its caring and compassionate attitude when providing comfort and a sense of dignity for its patients and their families. Although the applicant provided letters of support

from area ALFs and nursing homes, none provided agreements to contract for inpatient services.

United Hospice of Florida, Inc. (CON #10072) provided 58 letters of support with its application. These were from hospitals, nursing homes,

assisted living communities, local businesses and physicians. The applicant also provided letters of support from UHS-Pruitt Subsidiaries and patients and families who have received services from United Health

Services in the past. Thirteen letters were from the local service area. A social worker from Florida Hospital Cancer Institute offers her support of

United Hospice to provide additional hospice services. A letter from the CEO, Rebecca Brewer, of St. Cloud Regional Medical Center states they are willing to work cooperatively with this hospice provider, and will

enter into appropriate contractual relationships to ensure that hospice patients in need of inpatient care receive it at their hospital. The other

letters of support emphasized the importance of allowing families to choose the provider that best fits their needs and that adding a new hospice program to the local service area will raise the standard through

competition with existing hospice providers. United Hospice‟s subsidiaries provided five letters of support. United Medical stated its interest in coordinating to provide medical equipment services for

patients in the service area. United Pharmacy Services stated its willingness to supply pharmaceuticals and medical supplies to United

Hospice. UHS Pruitt-Corporations states its interest in working with


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United Hospice in coordinating and providing assessment and dietary counseling to the residents of Orange and Osceola Counties. United

Rehab stated it is prepared to provide physical, occupational, speech and respiratory therapy services under a contracted agreement with United

Hospice. The remaining 40 letters of support were from families previously served by UHS. The letters expressed thanks and gratitude for superior hospice services.

C. PROJECT SUMMARY

Catholic Hospice of Central Florida, Inc. (CON #10069) proposes to

establish a new hospice program in Hospice Service Area 7B, Orange and Osceola counties. Catholic Hospice of Central Florida, Inc. is a newly formed entity whose sole member is Catholic Hospice, Inc. and as such

has no operational history. Catholic Hospice, Inc., a faith-based organization, has a history of providing hospice services in Miami-Dade,

Monroe and Broward Counties. The proposed total project cost is $334,800 with year one total operating

costs of $2,207,564 and year two costs of $5,065,314. The applicant agrees to condition award of the CON as follows:

1. Catholic Hospice will respond to patient referrals within two hours of receipt of the referral.

2. Catholic Hospice staff will contact all patients admitted within 48

hours after admission and then again after seven days to ensure

patient/family needs are being met. 3. After hours phone calls to Catholic Hospice by patients and

families will be answered by hospice staff

4. Catholic Hospice RN case managers, social workers and chaplains will use laptop computers in the field to collect and input clinical information into the patient database system in order to maximize

available clinical information and responses to patient and family needs.

5. Catholic Hospice will assess the quality of care via meetings with

all contracted hospitals and long term facilities to review services

provided to patient and families as well as service and responsiveness to the needs of these providers.


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6. Catholic Hospice will provide an emergency pharmaceutical kit (E-Kit) to all hospice patients admitted in their home, as appropriate

and ordered by a hospice physician, in order to provide emergent access to palliative medications in the event of a medical crisis by

the patient at night or on weekends, when the patient‟s access to palliative medications may be limited or not timely. The E-Kit will be provided in accordance with all applicable state and federal

dispensing laws and is intended to be responsive to patient and family needs as well as enhanced patient care after regular business hours at night and on weekends.

7. Catholic Hospice will contract with OnePoint Patient Care

Pharmacy, a hospice pharmacy, for hospice related drugs, pharmaceuticals and biologicals in accordance with state and federal dispensing requirements and statutes. OnePoint Patient

Care Pharmacy will dispense the hospice related drugs, pharmaceuticals and biological for Catholic Hospice patients. The

dispensing will include home delivery of medications at no cost to Catholic Hospice patients and families in order to improve hospice services and reduce the caregiver burden of the family caregivers

while promoting patient satisfaction. 8. Catholic Hospice will contract for durable medical equipment

(DME)/home medical equipment (HME) from a specialty hospice medical equipment provider who understands and is responsive to

the unique needs of hospice patients and families. 9. Catholic Hospice will offer individual and group grief counseling

services to any resident of the service area in need of such services regardless of any prior relationships with Catholic Hospice.

10. Catholic Hospice will conduct annual memorial services for those primary caregivers and families served Catholic Hospice as well as

any other resident of the service area. 11. At initiation of service, Catholic Hospice will become an

organizational member of Florida Hospice and Palliative Care (FHPC) as well as the National Hospice and Palliative Care

Organization (NHPCO). 12. At initiation of service, Catholic Hospice will become a member of

the Tri-County Volunteer Organizations Active in Disasters (Tri-VOAD) in order to collaborate with the Community Emergency Response team (CERT) on disaster preparedness.


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13. Catholic Hospice will provide community support groups for those primary caregivers and families served by Catholic Hospice as well

as any other resident of the service area.

14. Catholic Hospice will provide a children‟s annual grief camp, Camp Hope, for those families and caregivers who have children served by Catholic Hospice as well and any other resident of the service

area. 15. Catholic Hospice will target diversity and cultural outreach

activities to Hispanics. Catholic Hospice will advertise in Hispanic language papers, and provide culturally relevant material in

Spanish. 16. Catholic Hospice will provide cultural diversity and sensitivity

training to all staff members, including but not limited to Hispanic culture.

17. Bereavement services will include special outreach to Hispanic

children, including introduction to hospice at school counselor

level, offering grief counseling through school administration to grief-stricken children throughout the school year, and identifying children who would benefit from Camp Hope.

18. Catholic Hospice will target the recruitment and retention of

bilingual (English/Spanish) staff. Catholic Hospice will commit that at least 20 percent of its staff in Orange and Osceola Counties will be bilingual.

19. Catholic Hospice will provide community education seminars on

the following topics: Bridging the Gap at End of Life, Care at the

Time of Dying, Care of the Actively Dying, Advanced Directives, Alzheimer‟s and Related Disorders, Domestic Violence, End of Life

Communication, Fall Prevention, Florida Assisted Living, and Hospice 101.

20. Catholic Hospice will initiate the “Wishes Granted” program in Service Area 7B.

21. Catholic Hospice commits to opening its main office in the

Kissimmee area to best serve all the people of Service Area 7B.

Memorial Hospital-Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) proposes to establish a new hospice program in Hospice

Service Area 7B, Orange and Osceola Counties. Memorial Hospital-Flagler, Inc. is one of the 17 acute care facilities in Florida owned by

Adventist Health System. Florida Hospital and Florida Hospital


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HospiceCare are a part of the Adventist Health System. Six Florida Hospital facilities are located in Service Area 7B: Florida Hospital

Apopka, Florida Hospital Celebration, Florida Hospital East Orlando, Florida Hospital Kissimmee, Florida Hospital Orlando and Winter Park

Memorial Hospital. The proposed total project cost is $306,380 with year one operating costs

of $2,323,888 and year two costs of $3,261,895. The applicant agrees to condition award of the CON as follows:

1. Florida Hospital HospiceCare will provide programs and services for residents of Service Area 7B that are outside the Medicare

hospice benefit which will include community hospice 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. Also included is the development of a

pet therapy program for hospice patients. Pet therapy offers psychological benefits in terms of emotional connection, stress reduction, and reduced feelings of loneliness or isolation.

2. Florida Hospital HospiceCare will provide an ongoing education

program on hospice care to provide easily accessible information for medical staff members of the Florida Hospitals in Orange and Osceola Counties and resident physicians and fellows in Florida

Hospital's teaching program.

3. Florida Hospital HospiceCare commits to develop and offer a

structured curriculum for Florida Hospital's Chaplaincy Residents. At a minimum the program will include hospice overview,

admission requirements, patient and family satisfaction results, and spiritual considerations in end-of-life care.

4. Florida Hospital HospiceCare commits to the following initiatives to improve the quality of hospice care offered:

Pain assessment on admission and by the second day of

admission (within 48 hours);

Provide palliative care modalities including radiation therapy;

Encourage additional staff credentialing for physicians, nurses, chaplains, and social workers through a certification

reimbursement program;


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Maintain accreditation by The Joint Commission (formerly

known as the Joint Commission on Accreditation of Health Care Organizations)

5. Florida Hospital HospiceCare commits to enter into agreements with one or more of the six Florida Hospital hospitals (Apopka,

Celebration Health, East Orlando, Kissimmee, Orlando and Winter Park Memorial) and one or more Adventist Care Centers (skilled nursing facilities) in Service Area 7B to provide inpatient hospice

services to residents of Orange and Osceola Counties. 6. Florida Hospital HospiceCare commits to provide volunteer services

to hospice patients that substantially exceeds the five percent requirement mandated under the Medicare Conditions of

Participation. 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.

7. Florida Hospital HospiceCare commits to provide 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 identified needs. Bereavement services will

include outreach to the Hispanic population of Service Area 7B.

8. Florida Hospital HospiceCare commits to develop a community resource information website in the first year of operation. This educational site will include various lay and professional education

pieces related to chronic illness, death, dying, and bereavement.

9. Florida Hospital HospiceCare commits to develop a community advisory board composed of residents inclusive of both the Orange and Osceola communities. The purpose of the community advisory

board is to provide input and feedback about service area needs and recommendations for consideration in future program development.

10. Florida Hospital HospiceCare commits to minimum annual funding

of $10,000 towards a "Special Wish Fund" designated for the end-of-life wishes for Florida Hospital HospiceCare patients and their families. This commitment would begin in the second year of

operations.


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11. Florida Hospital HospiceCare commits to open two offices in the

first year of operation. One office will be opened in Osceola County on the campus or in proximity to Florida Hospital Kissimmee. The

Orange County office will be located on the campus or in close proximity of an Orange County facility to best suit the needs of the Clinical Pastoral Education, Medical Education, and Palliative Care

programs. Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey

HealthCare of Central Florida (CON #10071) proposes to establish a new hospice program in Hospice Service Area 7B, Orange and Osceola

Counties. The applicant states that its sole shareholder and parent is Odyssey HealthCare Operating B, LP. The parent is stated to have 92 Medicare-certified hospice programs in 29 states. Odyssey is licensed in

Florida as Odyssey HealthCare of Marion County, Inc. and serves three hospice service areas (SA): SA 11 (Miami-Dade and Monroe Counties),

SA 4B (Volusia and Flagler Counties) and as of January 1, 2010 SA 3B (Marion County).1

The proposed total project cost is $635,608 with year one operating costs of $1,945,888 and year two costs of $3,490,434. The applicant agrees to condition award of the CON as follows:

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 applicant which

may be supported via a review of patient medical records.

2. The applicant will provide continuous care. This will be measured

via a signed declaratory statement by 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 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 applicant, which may be supported via a review of

patient medical records.

1 Odyssey HealthCare of Marion County, Inc. became licensee for hospice Service Areas 4B & 11

effective November 1, 2009 and added Marion County to its license effective January 1, 2010. Odyssey had previously operated as Odyssey HealthCare.


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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 (PI) 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.

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 a signed declaratory statement by the

applicant.

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

Medical Advisory 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, and the Council on Aging. In-service training would be offered to registered nurses, social workers,

administrators and other staff that would benefit from an


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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 completion and fulfillment. Odyssey has 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 via

a signed declaratory statement by the applicant.

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 organizations 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 to

evaluate the need, if any, for an expanded children's hospice

program in the community including, but not limited to, the need for a children's program that offers an expanded hospice benefit for

patients up to age 21. The program would 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. If during the first year of operation it is

determined that existing children's hospice services in the community are available to meet local needs, the applicant will donate $25,000 to support existing local children's hospice

programs. If after this first year there is found to be a need for additional children's hospice services, a child and family support program interdisciplinary team will be established to support the

needs of this target population. This will be measured via a signed declaratory statement by the applicant.


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16. The applicant will commit to 0.5 FTE the first year of operation for development efforts regarding community bereavement programs

in the community. The bereavement programs 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 the hospice service area. The applicant will provide bilingual staff to provide bereavement

services to the Hispanic population, including Hispanic children. At a minimum, one bereavement group consisting of approximately eight sessions will be offered by the end of the first year of

operation. As the bereavement client census increases after one year, full-time staff will be employed. This will be measured via a

signed declaratory statement by the applicant. 17. The applicant will commit to the provision of programs for the

Hispanic and other minority 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. Hospice staffing will reflect the racial and ethnic mix of the local community served.

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 facilitate the provision of a children's bereavement

camp in Florida by the end of the first year of operation, similar to what Odyssey currently provides via Odyssey's SkyCamp, Camp

Healing Tree and Camp Odyssey. This will be measured via a signed declaratory statement by the applicant.

20. The applicant will have a minimum staff of at least three community education representatives, 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 community education representative 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.


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21. Hospice Service Area 7B includes two counties: Orange and

Osceola. Odyssey commits to the immediate development of its main office in Orange County and a satellite office in Osceola

County by the end of year one of operation. The applicant commits to become accredited by the Joint Commission and the National Institute for Jewish Hospice by the end of its second year of

operation.

22. The applicant commits to medical directors assessing every patient

on admission and providing visits in home or place of residence. The medical director is to be board-certified in hospice and

palliative care medicine or will apply for board-certification within five years of employment.

23. The applicant commits that every patient will be contacted on a daily basis. The applicant commits to sponsoring two to four

education seminars per year for physicians, long-term care facilities and assisted living facilities (ALFs). The focus of these seminars is to educate the local health care community on the

provision of hospice services within ALFs and other long-term care facilities: a coordinated plan of care for the patient, increased support for patient, family and facility staff, and the provision of

equipment, medication and supplies.

United Hospice of Florida, Inc. (CON #10072) proposes to establish a new hospice program in Hospice Service Area 7B, Orange and Osceola Counties. United Hospice is a wholly owned subsidiary of United Health

Services of Florida, Inc. The parent company, United Health Services, Inc., is a part of the United Health Services-Pruitt family of companies. United Health Services, Inc. is a holding company which owns and/or

operates, through its subsidiaries, 71 long-term care facilities, 25 hospice programs, 13 home health care agencies, five pharmacies, a

health care management company, a nutritional services company, a clinical services company, and medical supply company and 14 SOURCE offices.2 United Health Services, Inc. (UHS), manages its many

subsidiaries through its corporate office located in Norcross, Georgia.

The proposed total project cost is $247,009 with year one operating costs of $1,841,126 and year two costs of $4,775,746. The applicant agrees to condition award of the CON as follows:

2 The State of Georgia & UHS-Pruitt websites indicate UHS-Pruitt subsidiary UniHealth Solutions oversees UHS participation in SOURCE. SOURCE is an acronym for Service Options Using Resources

in Community Environments and is the State of Georgia‟s Medicaid long-term care diversion program.


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1. UHS Home and Community Based Services Provider: Upon CON approval, United Hospice's ultimate parent, UHS, will develop, in

conjunction with United Hospice, UHS' family of services and companies in Subdistrict 7B and will enhance the hospice services

available to area residents by making such a service available not only to United's hospice patients, but also to any other existing hospice provider who wishes to contract for such services. These

services and companies include United Home Care, United Rehab, United Medical, United Pharmacy Services and United Clinical Services. This will be measured by a signed declaratory statement

submitted by United Hospice to the Agency.

2. Hispanic Outreach: Reflective of its commitment to enhancing access to end-of-life care of Hispanic residents in Subdistrict 7B, the applicant has conditioned approval of its application on the

provision it will implement and maintain an African American outreach program.

• A bilingual (Spanish speaking) staff member will be responsible

for the outreach initiatives. This individual's objective will be to

coordinate staff activities, plan events and serve as a key contact within community leaders.

• By the end of the second full year of operation, 40 percent of the staff serving Osceola County will be bilingual to reflect the

demographic make-up of the community, including Spanish speaking physicians, nurses, home health aides, chaplains and social workers.

• Marketing and family educational materials, as well as all

hospice admissions forms, advance directives, bereavement

materials and any other written materials used in the provision of hospice services to patients and families will be available in

both English and Spanish. • United Hospice will form a planning and outreach team

consisting of staff, volunteers and community members. This team will provide support for the staff person assigned primary

responsibility for outreach effort. • United Hospice will host listening sessions with Hispanic

community leaders, Hispanic clergy and other members of the Hispanic community to develop an understanding of attitudes and beliefs regarding end-of-life care.

• Based on listening sessions, United Hospice will develop a

message, presentation and marketing materials that address


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needs and issues expressed by focus group respondents to ultimately deliver the message that addresses needs and

concerns of the community.

• United Hospice will continually assess existing tools and obtain or develop new resources as needed to provide culturally meaningful and appropriate educational opportunities for the

Hispanic community.

• The applicant will provide ongoing comprehensive training for

staff and volunteers who are actively involved in the outreach program. These individuals will plan quarterly town hall

meetings with members of the community to engage, educate and energize individuals to begin end-of-life conversations in their organizations, congregations and so forth.

• United Hospice will develop and maintain a calendar of events

that address, support and celebrate Hispanic issues, heritage and health care concerns. Staff members will attend various calendar events with the goal of making United Hospice of

Florida the name and face known throughout the community. • The applicant will develop a census tracking tool to routinely

track referrals generated by the outreach program to measure its ongoing success.

• By the time of final CON approval, the United Hospice website

will be available and accessible in the Spanish language.

• The applicant will report its admissions annually by ethnicity to

measure success and increase in percentage of Hispanic

admissions. This condition will be measured by a signed affidavit submitted to the Agency.

3. CHAP Accreditation – United Hospice has conditioned approval of

this application on the provision it will seek and obtain CHAP

accreditation upon certification. This will be measured by submitting United Hospice's accreditation certificate to the Agency

upon receipt.

4. Membership Organizations - Upon licensure, United Hospice will

become a member of the following community organizations: • Florida Hospice and Palliative Care;

• Hispanic Chamber of Commerce of Central Florida; • Orlando Regional Chamber of Commerce; and

• Kissimmee/Osceola Chamber of Commerce;


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This will be measured by a signed affidavit submitted to the

Agency.

5. United Hospice Foundation - United Hospice Foundation will make available to Florida residents, its annual scholarship program targeted at those who are studying nursing, pharmacy or therapy

with an interest in end-of-life care. The scholarship is available each year to four students in the amount of $2,000 for the school year. This will be measured by a signed affidavit submitted to the

Agency.

6. Office Locations – United Hospice will open two office locations immediately upon licensure; at least one location will be in a Hispanic area of Osceola County. A third office location will open

in the third year of operation.

7. Staffing Ratios and Qualification – United Hospice will meet or exceed all NHPCO Guidelines for qualifications and staffing ratios for patient care staff. This will be measured by a signed

declaratory affidavit submitted to the Agency. ALL: None of the applicants proposed to condition to voluntary reporting

of the Agency‟s „Family Evaluation of Hospice Care (FEHC) Satisfaction Survey‟ found at the FloridaHealthFinder.gov website. 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.

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.


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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, Cheslyn Green, analyzed the application in its entirety with consultation from financial analyst,

Everett Broussard, 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.

In Volume 35, Number 39 of the Florida Administrative Weekly, dated October 2, 2009, the Agency for Health Care Administration published a

need for one hospice program in Hospice Service Area 7B for the January 2011 Hospice Planning Horizon. Hospice Service Area 7B is currently served by four licensed hospice providers: VITAS Healthcare Corporation

of Florida, Hospice of the Comforter, Inc., Samaritan Care Hospice, and Cornerstone Hospice and Palliative Care.

Each co-batched applicant is applying in response to published need for a hospice program in Hospice Service Area 7B, Orange and Osceola

Counties. However, all applicants provided additional arguments in support of need for their projects as discussed below.

Catholic Hospice of Central Florida, Inc. (CON #10069) states that Service Area 7B has experienced rapid population growth between April

1, 2000 and April 2009, 32 percent compared to 19 percent in the state


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as a whole. Within Osceola County the population increased by 62 percent. Orange County grew by 27 percent. Growth within service Area

7B‟s Hispanic community was even more dramatic, according to the applicant, increasing by 94 percent since 2000, nearly double the

statewide growth rate of 51 percent. The applicant provides percentages only for the majority of its population discussion, actual population numbers are included when provided. The applicant states that the April

2009 estimated service area population of 1,414,362, includes 425,505 Hispanic residents. Catholic Hospice indicates that Orange County trails only Miami-Dade and Broward Counties in total number of Hispanic

residents. Osceola County, with 43 percent Hispanic residents, ranks third among all Florida counties while Orange County at 27 percent

ranks seventh in percent Hispanic residents. Overall, 30 percent of 7B residents are Hispanic compared to 21 percent statewide. The applicant states that rapid growth is projected to continue over the next five years,

especially among Hispanics. Between April 1, 2009 and 2014, the resident population of the service area is expected to increase by 12

percent as compared to eight percent in the state as a whole with projected growth in Osceola County of 19 percent and 11 percent in Orange County. Hispanic population growth of 23 percent is projected

within the service area as compared to 16 percent statewide. By 2014, the applicant states that Service Area 7B is expected to have 524,316 Hispanic residents, representing one-third (33 percent) of the area‟s total

1.6 million population.3 The applicant concludes that demand for hospice services should increase with population growth.

Catholic Hospice next discusses the Pew Foundation‟s Forum on Religion and Public Life, U.S. Religious Landscape Survey of February 2008 and

states that based on its research, the foundation estimates that between 65 and 68 percent (roughly two-thirds) of the Hispanic/Latino population is affiliated with the Catholic Church. The applicant states it is

committed to providing hospice care oriented to the language, cultural and religious beliefs of the Hispanic/Latino community. The applicant

states that its sister organization Catholic Hospice, Inc., currently provides hospice care in Service Areas 10 and 11 which along with Service Area 7B have the highest concentration of Hispanic/Latino

residents in the state of Florida.

Catholic Hospice states that during calendar year 2008 Hispanics accounted for 10 percent of all deaths in Service Area 10 and 58 percent of deaths in Service Area 11. By comparison, Hispanics constituted 31

percent of the patients serviced by Catholic Hospice Inc, in Service Area 10 and 78 percent of those served in Service Area 11. The applicant states that it has a long standing commitment and record of serving the

3 Catholic Hospice indicates that the population estimates are based on the Florida Office of Economic

and Demographic Research (EDR) data.


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Hispanic Community and is ideally suited to addressing the documented need for a new hospice program in Service Area 7B.

The applicant states that consistent with the low percentage of elderly

residents within the service area, the proportion of deaths accounted for by persons age 65 or older (65.9 percent) lags behind the statewide average (74.1 percent). Persons age 85 and older use hospice care

services at a higher rate than all other age groups. Within Service Area 7B, persons in this advanced age category made up 25.3 percent of all deaths as compared to 31.0 percent of deaths among all Florida

residents. The applicant contends that the low percentage of deaths accounted for by elderly and extremely elderly residents within Service

Area 7B implies hospice penetration rates below the statewide rate. Catholic Hospice states that historically, non-Hispanic whites have used

hospice services at a higher rate than other ethnic and racial groups, including Hispanics, Black/African Americans, and persons of

Asian/Pacific Island descent. During calendar year 2008, there were 1,343 deaths among Hispanic residents of Service Area 7B representing 16.3 percent of all service area deaths. By comparison, Hispanics

accounted for 11.1 percent of all Florida resident deaths. The same year there were 1,322 deaths to Black/African American residents of the service area. These deaths make up 16.0 percent of all resident deaths.

By comparison, African Americans accounted for 10.7 percent of all Florida resident deaths.

Catholic Hospice contends that the high percentage of both Hispanic and Black/African American deaths in the service area leads to the

expectation of a hospice penetration rate below the statewide rate. The applicant states that the hospice admissions and admission rates may be depressed due to a high proportion of sudden/unexpected deaths by

suicide, homicide, perinatal conditions, unintentional injury (accidents) or other external causes. Catholic Hospice contends that within the

service area, hospice appropriate deaths accounted for a somewhat lower percentage of all resident deaths as compared to the state as a whole (89.3 percent versus 91.7 percent). While the use of hospice services had

grown among persons with non-cancer diagnoses, cancer patients continue to make up a disproportionate share of all hospice users.

Cancer patients accounted for 23.2 percent of service area deaths in 2008 compared to 23.9 of all Florida resident deaths.

The applicant states that historically, higher rates of hospice utilization have been found among higher income populations. Orange County ($31,589) ranked above the Florida median county per capita income of

$26,072 in 2005. However, the per capita income fell below the 2005 statewide average per capita income level $34,001. Per-capita income in

Osceola County ($22,008) fell 35 percent below the statewide average.


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The applicant states that per capita income may exert downward pressure on hospice utilization within some lower-income portions of

Service Area 7B.

According to the applicant, between 2001 and 2008 hospice admissions in Florida grew by 51 percent despite just a two percent increase in resident deaths over that same period. Hospice admissions in Service

Area 7B grew somewhat slower (46 percent) despite a much greater increase in resident deaths (seven percent). As a result, Service Area 7B‟s hospice admissions rate for calendar year 2008 (59.6 percent)

lagged behind the state median rate of 62.3 percent. The applicant asserts that this lag in hospice admissions within 7B is consistent with

the presence of various factors impeding hospice use, as discussed above. Catholic Hospice concludes that these factors must be addressed and overcome in order for hospice use rates to grow to a level more

consistent with the true needs of the service area.

The applicant states that after sending out several members of its staff to speak to members of the community, several concerns were identified within the Osceola County area. The applicant states that a local

hospital administrator identified a poor response time to patients and families in need of immediate end-of-life care within the Osceola County area, which the applicant states leads to the perception of insensitivity to

patients and families as well as an inability to meet their needs. The next concern as identified by area residents was a need to have an

additional choice of hospice. The third area of concern voiced by many residents was the need for a faith-based, not-for-profit provider that would offer those patients and families that needed to access hospice

care an alternative to the current providers. Catholic Hospice states that its staff visited all skilled nursing facilities in

Kissimmee and it was very apparent there was a desperate need for a hospice experienced in hospice services that meet the needs of the

Hispanic population. The need for a hospice with bilingual staff that speak Spanish in addition to English was also identified. According to the applicant, concerns were also raised as to the number of field staff

who are unable to communicate with the clients, residents and patients for whom they are caring. The applicant also identified a need for

children‟s grief counseling and bereavement services within the service area. Catholic Hospice states that this should be in a therapeutic environment such as a camp and amongst peers in order to resolve grief

issues as well as to have grief issues identified by bereavement professionals. The applicant states this is why the development of the camp is a condition to this application.

The applicant cites Catholic Hospices‟ service to the Hispanic

community, states that it has a mission of service to the indigent and low


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income population and that it will make a concerted effort to reach out to all segments of the service area‟s population. Catholic concludes that its

market assessment affirms the Agency‟s finding of need for an additional hospice program to serve Area 7B and hospice admissions in the 2011

horizon year should equal or exceed the level forecast by the Agency.

Catholic Hospice contends that its strengths will spur utilization

throughout all segments of the population, particularly among lower income and ethnic residents.

The applicant states that it will place its main office in Kissimmee because the location addresses a variety of considerations including: an

emphasis on service to the Hispanic community, the location of existing hospice programs, access to the transportation network serving the area and population size and projected growth within the service area.

Catholic Hospice also states that three of the four have branch offices in the Kissimmee area. The city of Kissimmee is centered in zip code area

34741 which has the largest number of Hispanic residents (28,164 of 48,629 total or 58 percent) of any zip code within the service area. Zip code area 34743 which includes the eastern terminus of the city has

nearly as many total Hispanics (26,125) and the highest percentage of Hispanic residents (26,125 of 38,079 total or 69 percent) within the service area. The second largest concentration of Hispanics is in the

Union Park area of Orange County, east of downtown Orlando.

Hispanic Population by Zip Code Area: 2009 Within 10-mile radius of Kissimmee

Area County Hispanic Total % Hispanic

32824 Orange 18,378 33,025 56%

32837 Orange 16,200 48,098 34%

32831 Orange 2,261 13,678 17%

34741 Osceola 28,164 48,629 58%

34743 Osceola 26,125 38,079 69%

34744 Osceola 17,008 42,162 40%

34746 Osceola 11,827 33,317 35%

34758 Osceola 14,631 30,910 47%

34769 Osceola 3,995 23,120 17%

138,589 311,018 45%

7B 397,649 1,419,409 28% Source: CON Application #10069, page 19.


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Hispanic Population by Zip Code Area: 2009

Union Park Area of Orange County Area County Hispanic Total % Hispanic

32792 Orange 9,981 45,729 22%

32807 Orange 15,818 32,193 49%

32817 Orange 10,069 38,289 26%

32822 Orange 27,117 56,464 48%

32825 Orange 22,834 55,696 41%

32826 Orange 5,621 21,989 26%

32828 Orange 15,662 52,297 30%

107,102 302,657 35%

7B 397,649 1,419,409 28% Source: CON Application #10069, page 19.

Hispanics make up 40 percent of Kissimmee and Union Park residents while only 19 percent of the service area population outside these two areas is Hispanic. The applicant states that while three of the four

existing 7B hospice programs maintain a satellite office in Osceola County, all within the Kissimmee area, it would be the only hospice program to establish Kissimmee as its primary office location. The

applicant states that a primary office location in Kissimmee will afford lower income residents a high level of access to the full range of

community outreach and family support services it offers. Agency records indicate that the three existing providers with branch offices in Kissimmee are Hospice of the Comforter and VITAS in zip code 34741

and Cornerstone in zip code 34744. The applicant does not demonstrate that having a primary office in the same area that has three branch offices within a 10-mile radius of Kissimmee would have any impact on

the provision of hospice care.

Over the next five years, Kissimmee and the surrounding area is projected to continue its rapid growth. The nine zip code area (as previously defined) is expected to realize a 19.5 percent increase in

population from January 2009 to January 2014. By comparison, the previously defined Union Park area (which has the area‟s second highest

concentration of Hispanic residents) is expected to grow by 11.5 percent. The remainder of the service area is projected to grow by 12.4 percent.

Projected Population Growth within 7B

January 2009 to January 2014 Difference

Area 2009 2014 # %

Kissimmee 311,018 371,803 60,785 19.5%

Union Park 302,657 337,603 34,946 11.5%

Other 7B 805,734 905,580 99,846 12.4%

7B 1,419,409 1,614,986 195,577 13.8% Source: CON Application #10069, page 22.


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The applicant states that the continuing trend of rapid population growth in and around the city of Kissimmee lends added support to its selection

of Kissimmee as its primary office location. As program needs become established and patient census grows, a satellite office will be developed.

The applicant states its first, second and third year admissions are estimated at 161, 413, and 508 respectively. The first year‟s market

share will be three percent, the second year share will be 7.5 percent and the third year share will be 9.0 percent. The following is an illustration of projected admissions for the applicant in Service Area 7B.

Projected Admissions for CHI in Service Area 7B

Based on the Hospice Rule Mortality Methodology and Inputs

Year 1 Year 2 Year 3 Year 4 CY 2011 CY 2012 CY 2013 CY 2014

July 1 Population 1,485,528 1,523,278 1,560,902 1,598,043

Under 65 1,337,443 1,368,055 1,398,382 1,428,110

65 and over 148,085 155,223 162,520 169,933

Estimated Deaths

Cancer Under 65 769 789 808 827

Cancer 65+ 1,370 1,405 1,440 1,474

Non-Cancer Under 65 2,370 2,430 2,490 2,549

Non-Cancer 65+ 4,512 4,626 4,741 4,853

All Diagnoses, All Ages 9,021 9,250 9,479 9,704

Penetration Rates

Cancer under 65 92.0% 92.0% 92.0% 92.0%

Cancer 65+ 93.7% 93.7% 93.7% 93.7%

Non-Cancer under 65 21.3% 21.3% 21.3% 21.3%

Non-Cancer 65+ 63.8% 63.8% 63.8% 63.8%

All Diagnoses, All Ages 59.6% 59.6% 59.6% 59.6%

Hospice Admissions

Cancer under 65 708 726 744 761

Cancer 65+ 1,284 1,317 1,349 1,381

Non-Cancer under 65 505 518 530 543

Non-Cancer 65+ 2,878 2,952 3,024 3,096

All Diagnoses, All Ages 5,537 5,513 5,647 5,781

Market Share

Catholic Hospice 3.0% 7.5% 9.0% 11.0%

Others 97.0% 92.5% 91.0% 89.0%

Total 100% 100% 100% 100%

Admissions by Program

Catholic Hospice 161 413 508 636

Others 5,214 5,100 5,139 5,145

Total 5,375 5,513 5,647 5,781

Source: CON Application #10069, page 23.

The applicant states that the annual patient admissions for its proposed

program is based primarily on: the aggregate experience of hospice programs initiating operations in Florida since the beginning of calendar year 2002 and the size of the Service Area 7B market.

The applicant asserts that projected growth in hospice admissions within

the service area is sufficient to achieve its goal of building a viable new program within the area, while also allowing existing hospice programs to continue growing their admissions.


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Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) proposes to establish a hospice program in Service Area

7B and to open two offices in the first year of operations. One office will be in Osceola County on the campus or in proximity to Florida Hospital

Kissimmee. The applicant states that the other office will be located in Orange County on the campus or in proximity of an Orange County facility to best suit the needs of the (Florida Hospital) Clinical Pastoral

Education, Medical Education and Palliative Care programs. Florida Hospital HospiceCare indicates that there are several

characteristics that distinguish it from existing providers and other applicants, which makes it the best applicant to meet the published need

and serve as a complement to existing hospice providers. These include its mission, chaplaincy and pastoral care, integration and continuum of care, and medical education for physicians, residents and other health

professionals.

In discussion of its mission, the applicant indicates that there are six principles that Adventist Health System draw motivation and direction to guide how employees and patients are treated. These are:

Christian Mission - We serve the needs of our communities in

harmony with Christ‟s healing ministry and incorporate Christian values at every level of service.

Quality and Service Excellence - We meet or exceed both the service

standards of the health care industry and the expectations of the patients we serve and measure through continuous surveying of

patient satisfaction.

Compassion – We are sensitive to the needs of the individuals and

families we serve and meet their needs with kindness and empathy.

Focus on Community Wellness – We commit time, talent and financial

support to educate our neighbors in the principles of illness prevention and healthful living.

High Ethical Standards – We conduct business with integrity, honesty and fairness. As responsible stewards, we use our financial resources

wisely by choosing business practices which are cost-effective, productive and result in a fair return on investment.

Cultural Diversity – We value the diversity of our patients, employees,

business colleagues and visitors and treat them with kindness and respect regardless of their background, race, religion or culture.

The applicant indicates that Florida Hospital HospiceCare provides

hospice services consistent with its mission statement and this program will complement other services through education concerning hospice within the organization and promote timely referral of patients.


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In reference to chaplaincy and clinical pastoral education, the applicant indicates that Florida Hospital is one of 13 Clinical Pastoral Education

(CPE) programs in Florida and one of two in SA 7B that is accredited by the Association for Clinical Pastoral Education (ACPE). ACPE is a 2,600

member group that includes 350 ACPE accredited CPE Centers and 600 ACPE-certified faculty members (called CPE supervisors). There are 113 Theological Schools Members and 23 Faith Groups and Agencies who

partner with ACPE in seeking to provide excellence in theological education. Asbury Theological Seminary is the ACPE accredited theological school in SA 7B and is described as an institution in the

Wesleyan tradition that collaborates with the Florida Hospital CPE

Center. The Florida Hospital CPE Center is stated to provide several programs including:

Full-time, one-year ACPE-accredited residency (currently eight full-time residents),

Part-time, six-month ACPE-accredited residency (35 residents per semester, 70 per year),

ACPE-accredited training for CPE supervisors,

An intensive 11-week unit of CPE during the summer months which

is open to clergy, laity, religious workers, and students for the ministry; designed to integrate personal, interpersonal and

professional learning in ministry formation,

A summer program offered at Florida Hospital East Orlando in

conjunction with the Asbury Seminary Latino/Latina Studies Program (LLSP); the entire program is conducted in Spanish language,

Programs and resources to community organizations - Association of Professional Chaplains, Andrews University (Adventist university and

seminary in Orlando), and many others,

Continuing education for ministry and training for institutional

chaplains. FloridaHospice Care indicates that hospice care represents a natural

extension of the pastoral care provided by Florida Hospital chaplains.

In reference to the integration and continuum of care as an existing provider the applicant indicates that:

As a hospital-based applicant for a hospice program, FloridaHospice Care will be an integrated part of Adventist/Sunbelt and Florida Hospital. Florida Hospital has provided health care to residents of central Florida

for over 100 years, earning a reputation of excellence and the trust of patients and physicians. As a trusted provider of care across the entire

service continuum, Florida Hospital is well-positioned to inform and raise


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awareness of the benefits of hospice care. Six Florida Hospital acute care and two Adventist Care Center skilled nursing facilities provide

geographic coverage to residents of Orange and Osceola Counties:

Florida Hospital Orlando, a state-of-the-art 1,080-bed facility located in Orlando in Orange County, is the largest of the six Florida Hospital

facilities in Service Area 7B.

Florida Hospital Orlando is an accredited Community Comprehensive

Cancer Center, provides organ transplant services, open heart and other state-of-the-art cardiovascular surgery, behavioral health,

orthopedic, and rehabilitation services, comprehensive services and education in a Diabetes Center, and other inpatient and outpatient services along the continuum of care.

The applicant‟s integration and continuum of care discussion included

Table 1 on page nine of the application which documented individual Florida Hospital facilities discharge volume. Florida Hospital facilities discharged 66,238 Service Area 7B residents (excluding normal

newborns) during the 12 months ending June 2009. The applicant contends that a hospice program affiliated with a hospital is more likely

to increase awareness of hospice as an option and to maximize the resources available within the health care system, particularly with residents who do not have cancer. The applicant cites a 2001 National

Hospice & Palliative Care Organization and the Center for Palliative Care, study entitled “Hospital-Hospice Partnerships in Palliative Care: Creating a Continuum of Service” as support for its project. Page 11 of the

application includes the following summary of the benefits of integration Florida Hospital HospiceCare contends apply to this project.

Benefits of Collaboration for Hospital and Hospice Partners For the Hospital: Improve the quality of care for hospitalized seriously and terminally ill

patients and their families.

Learn more about the nature and value of hospice services, including psychosocial, spiritual, and bereavement components and the functioning of the hospice interdisciplinary team.

Launch palliative care and end-of-life services in collaboration with an experienced provider.

Improve continuity of care with post-hospital settings.

Utilize training opportunities for staff.

Affiliate with hospice's positive community image and philanthropic success.

Draw upon a new avenue of reimbursement (the Medicare Hospice Benefit) for terminally ill hospitalized patients.

Improve resource utilization for seriously ill patients and reduce the costs of their care, according to recent research.


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For the Hospice: Access more patients who will benefit from hospice care earlier in the course

of a terminal illness.

Learn more about the challenges and practice of end-of-life care in the acute care setting.

Gain access to the organizational resources of the hospital.

Learn more about inpatient palliative care treatments.

Establish new or improved organizational linkages to larger health systems.

Participate in palliative care expansion by applying knowledge and expertise to a setting where many patients with life-threatening illnesses receive their care.

Integrate hospice services within a broader continuum of palliative care.

Achieve more appropriate and timely referrals through participation in the

broader continuum.

Clinical Benefits of a Hospital-based Palliative Care Program For the Patient:

Reduction in symptom burden.

Care concordant with patient-family preferences.

Patient-family-professional consensus on the goals of medical care.

Improved patient and family satisfaction.

The applicant states that approval of Florida Hospital HospiceCare will

benefit the overall health care system in several ways:

Heightened awareness of hospice as an option for care for patients

throughout the continuum of care, including with patients with partnering community organizations and other health care providers;

Potentially earlier placements in hospice care; and

Increased educational opportunities for physicians, medical residents,

and other health care providers.

However, many of these benefits could be obtained by hospice and hospital collaboration regardless of the licensure relationship between the two entities.

In reference to medical education for physicians, residents and other

health professionals, the applicant notes that Florida Hospital is a statutory family practice teaching hospital with residencies in family practice and surgery and fellowships in geriatric medicine and

gynecological oncology. The applicant indicates that Florida Hospital is uniquely qualified to provide ongoing education and communication

about this important service (hospice) to these physicians in training. Florida Hospital‟s teaching program is described and the applicant indicates that it will initiate a comprehensive and ongoing physician

education program targeted to providing information and ease of access to the physicians in Orange County and specifically those on staff at


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Florida Hospital‟s Orange and Osceola hospitals. Education topics will include „Death, Dying and Bereavement‟, „Hospice 101‟, „Hospice

Eligibility Requirements‟ and „Spiritual Considerations at the End of Life‟. The applicant indicates that these programs will be expanded to meet the

educational and training needs of health care professional students. The applicant also contends that there are additional Florida Hospital

HospiceCare attributes and qualifications that distinguish its application. These include the following:

Florida Hospital HospiceCare has a history of providing excellent

services for patients and their families, including proven practices and policies and a compassionate understanding of the nature of hospice

care.

Florida Hospital HospiceCare will provide a volunteer service that is

integrated with the community, leveraging the success of Florida Hospital and Florida Hospital HospiceCare in recruiting and utilizing

community volunteer resources.

Florida Hospital HospiceCare will develop a Community Advisory

Board once the application is approved to appropriately guide program and service development.

Florida Hospital HospiceCare and related entities have in-place the

resources and infrastructure needed to successfully implement the hospice service in Service Area 7B.

Referral relationships with area physicians, post-acute providers, community organizations, and charities;

Agreements for inpatient care needed by hospice patients will be entered into with one or more Florida Hospital facilities in Service

Area 7B (Florida Hospital Apopka, Florida Hospital Celebration Health, Florida Hospital East Orlando, Florida Hospital Kissimmee, Florida Hospital Orlando, and Winter Park Memorial Hospital), the

Adventist Care Center skilled nursing facilities, as well as other area providers; and

Support and billing cycle services, recruiting, and staff training, and other administrative services will be provided by the existing offices of

Florida Hospital HospiceCare. Florida Hospital HospiceCare will provide services that go beyond the Medicare Hospice Benefit.

Florida Hospital HospiceCare concludes that it provides excellent and compassionate hospices services in Service Area 4B and is the best

applicant to meet the identified need in Service Area 7B. The applicant next provides a discussion of Service Area 7B.

The applicant states that Service Area 7B had an estimated population of 1,420,611 residents in 2009 and is projected to grow rapidly to a population of 1,598,043 residents by 2014, representing an increase of


31

12.5 percent. Both counties have a relatively young population, with the proportion of elderly residents (age 65 and over) in Orange County

projected to be 10.3 percent of the total population and 11.8 percent in Osceola County in 2014.

The applicant contends that the growth in the Hispanic population in Service Area 7B has been significant. In Orange County, the Hispanic

population grew from 18.8 percent of the total population in 2000 to 26.4 percent in 2008. In Osceola County, the number of Hispanic residents doubled during the period, from 50,727 in 2000 to 121,599 in 2008. The

applicant contends that as a result, Hispanic residents as a percent of total population increased in Osceola County from 29.4 percent in 2000

to 44.5 percent in 2008 and increased in Service Area 7B from 20.5 percent to 29.9 percent during the same time period. The applicant states that although the Hispanic population is younger than the overall

population, the number of Hispanic elderly residents increased in Service Area 7B from 13,762 in 2000 to 27,840 in 2008. HospiceCare contends

that the increase in Hispanic population presents a growing need for a hospice that can accommodate residents of diverse ethnic backgrounds, provide bilingual programs and culturally sensitive programming to serve

this population. The applicant states that the Hispanic population in Service Area 7B meets the definition of a special needs population.

HospiceCare states that mortality in Service Area 7B increased from 2000 to 2008 by a total of 9.8 percent. Although Hispanics make up a

small percentage of total deaths that occur within Service Area 7B (7.2 percent in 2000 and 16.3 percent in 2008), the number of deaths increased by 149.2 percent compared to population growth of 91.0

percent during this period4. The applicant contends that while the number of deaths in Service Area

7B has been relatively stable over the past few years, HIV/AIDS deaths remained fairly consistent except for a brief increase in 2003. The 122

cases of HIV/AIDS deaths in the service area for 2003 were relatively higher than what has been experienced in recent years. HospiceCare states that while the number of deaths caused by HIV/AIDS is not large,

it does represent a segment of the population who are more likely to utilize hospice services. HospiceCare states that another area of focus

has been patients with Alzheimer‟s disease and has therefore, developed their program to include strategies for providing traditional palliative care to patients suffering from the disease.

4 Tables 6 and 7, CON Application #10070, pages 34 and 35: Service Area 7B Deaths by Age and

Ethnicity, 2000 to 2008.


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The applicant provides analysis of historical utilization of hospice services in Florida and Service Area 7B. There are currently four hospice

providers in Service Area 7B, Cornerstone Hospice and Palliative Care, Inc., Hospice of the Comforter, Inc., Samaritan Care Hospice, and VITAS

Healthcare Corporation of Florida. Analysis in this section includes number of admissions by category and age over a two year period for each existing hospice provider. The applicant reports that for the twelve

months ending June 2009 in Service Area 7B Cornerstone had 638 admissions, Hospice of the Comforter 1,882, Samaritan 485, and VITAS had 1,886 admissions.

HospiceCare states that it is confident that it can manage a hospice

program in Service Area 7B that satisfies community needs. HospiceCare states it projected its future hospice utilization using the guidelines and methodology in the hospice rule. An average death rate of

0.006073 was calculated for 2005 through 2007, and then used to project deaths for years 2010 to 2011. The applicant states the result is

a need for 484 additional hospice admissions for the January 2011 Planning Horizon. The applicant states the next step was to apply the three-year death rates to the projected population for 2010 to 2011 to

project deaths by disease category and age. The methodology results in a net need for 484 admissions, which according to the applicant is conservative in projecting need since it assumes constant hospice

penetration rates which have historically increased 5. The applicant contends that based on the Agency‟s hospice need methodology, Service

Area 7B residents who do not have cancer are projected to have an unmet need of 259 hospice admissions in 2011. In addition, residents under 65 without cancer were projected to have an unmet need of 174

admissions in 2011. The applicant‟s need projections are consistent with the Agency‟s publication for this batch as revised on October 13, 2009.

HospiceCare contends it will meet the need identified for residents of Service Area 7B. It will achieve market shares between 5.3 and 7.6

percent, resulting in projected utilization of 280 admissions in 2010 and 410 in 20116. The applicant states it will achieve its utilization without substantial impact on the existing hospice providers in the area.

Odyssey HealthCare of Collier County, Inc., d/b/a Odyssey

HealthCare of Central Florida, (CON #10071) proposes to establish a hospice program in Service Area 7B. The applicant states that based on the market forecast there is adequate hospice volume growth in Hospice

Area 7B to maintain the four existing hospice programs at current

5 Tables 10 and 11, pages 39 and 40, CON Application #10070: Historical Population and Deaths by

Cause/Age 2005-2007 and Projected Utilization for HospiceCare Service Area 7B. 6 Table 14, page 42, CON Application #10070: Projected Market Share for HospiceCare Service Area

7B.


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volume levels while at the same time providing adequate new incremental hospice volume to establish a viable new hospice provider. The applicant

states that in addition to the Agency identified need it will present evidence of the existence of special and not normal circumstances in the

hospice system that also demonstrate the need for the proposed hospice program in Service Area 7B to better serve area residents in need of hospice services.

The applicant states its hospice will be located in Orange County within Service Area 7B and will establish a satellite office in Osceola County by

the end of year one of operation. The 2009 total population of Hospice Service Area 7B accounts for 59 percent of the District 7 total population

(1,420,611/2,418,538). From 2009 to 2012 the hospice service area population is projected to grow from 1,420,611 persons in 2009 to 1,523,278 persons in 2012; an increase of 102,667 persons or 7.2

percent during this three year period.

The percentage increase in total population is well above the growth rates District 7 (6.2 percent) and the State of Florida (4.9 percent). The applicant states that while the projected growth in the total population is

important, a more important consideration is the projected population of the older age cohorts of the service area population which are most likely to use hospice services. The older age cohorts will experience a greater

percent increase in population than the younger age cohorts or the population as a whole. Hospice Service Area 7B is home to a significant

proportion of persons‟ age 65 years and older: 45 percent of District 7‟s 65 and older population live in Hospice Service Area 7B. Hospice Service Area 7B population age 65 and older will increase by 18,414 persons

(+13.5 percent) between 2009 and 2012; a growth rate well above the 7.2 percent growth forecast for the population as a whole. The increase of 18,414 persons represents 50.5 percent of the total increase in the

number of persons‟ age 65 years and older in District 7 (18,414/36,447).

The applicant states that an effective Hospice Service Area 7B hospice provider must be able to support and provide care to a wide array of patients groups with unique needs and service requirements. Cancer

accounted for the largest number of deaths in Hospice Service Area 7B (23.3 percent), closely followed by heart disease accounting for 22.8

percent of deaths. The applicant states it has the ability and experience base to treat all patients in need of hospice care and is prepared to do so in Hospice Service Area 7B. In addition to the gross number of deaths by

cause, providing an estimate of the potential pool of patients for the proposed hospice program, the applicant also profiled chronic disease mortality in the service area comparing the age-adjusted death rates for

the service area versus the State of Florida. The age-adjusted mortality rates provide an estimate of the patients who eventually succumb to

these chronic diseases and therefore, a more accurate estimate not only


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of the potential pool of patients, but also the range of diagnosis of patients eligible for hospice services. The applicant states that its

assessment of chronic disease mortality shows that both Osceola and Orange Counties have rates well above Florida levels for coronary heart

disease,

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