Rural hospices develop new strategies for surviving in a competitive world

The key is collaboration, flexibility

One of the biggest problems for rural hospices is that payments and regulations are calibrated toward urban hospices, and they largely overlook the challenges rural and small hospices face, a rural hospice expert says.

"It's hard in today's environment for a very small hospice to make it," says Beth Virnig, PhD, an associate professor at the University of Minnesota in Minneapolis. Virnig spoke about rural hospice survival strategies at Hospice Minnesota's 2006 End-of-Life Conference, held April 18-19, 2006, in St. Cloud, MN.

"We have some that choose not to be Medicare-certified because they're not capable of pulling it off," Virnig says. "Things are very fragile and vulnerable right now, and we do hear from a lot of rural hospices that they're caught between their need and an immense compassion to help others."

Some rural hospices believe that if they don't provide the services, nobody will, so they find themselves stretched further and further, she adds.

The Medicare regulations and financial reimbursement system makes it even more difficult for these hospices.

For example, all hospices are required to employ a social worker, but social workers tend to live in urban areas, and some small hospices do not have a large enough caseload to afford a full-time social worker, Virnig says.

If hospices were allowed some flexibility in how they cover the services social workers typically provide, then they might find a nurse who is trained in counseling or a counselor who could take on the social worker role, Virnig says.

"But the regulations say you have to have a social worker," she says. "So if you're a really small hospice with a daily census of eight, you don't need a full-time social worker, but if you were lucky enough to find a social worker, you'd have to pay 100 percent of the person's salary because it would be difficult to convince someone to move to the area to pay only part-time."

This is just one example where the regulations do not match the rural hospice's reality, Virnig explains.

"Hospices have to pay disproportionately for a social worker in rural areas because they need to pay for more than what they need," Virnig says.

Rural and small hospices face other problems, as well.

For example, it's harder for these hospices to provide evening and weekend nursing care, Virnig says.

"The cost of care is higher in rural areas because you need to have someone on call 24/7/365, but if you only have eight patients, you don't need that many nurses," Virnig explains. "A hospice that has two nurses on staff will need them to be on call nearly all of the time, and this leads to burnout."

This is where the Medicare payment structure does not make sense for rural hospices, since they are paid the same per diem rate as larger hospices that may not have as many staffing difficulties, she says.

"What can hospices do to make it easier to live in this context?" Virnig says. "We can all say we want more money from Medicare, but you better have a back-up plan, so the one thing we want is to encourage hospices to think creatively."

Virnig offers these suggestions for how rural and small hospices can find solutions to regulatory, payment, and other problems:

* Change the "territorial" mindset:

"Rural hospices tend to be very territorial," Virnig says. "They have their own identify, like a small town."

Hospices work well in small towns because they have community buy-in and hospice workers know everyone, she notes.

"You might be taking care of the mother of your friend or the woman who sold you candy at the corner store when you were growing up," Virnig says. "And that's a caring environment with inter-relationships, and that's the positive aspect of it all."

On the downside, rural hospices can become territorial, fearing they will lose their identity if they make any changes, Virnig says.

The solution is for rural hospices to change the territorial mindset and figure out ways to cooperate with neighboring hospices, without losing their own identities, she says.

For instance, rural hospices across a state could band together to form a cooperative for buying medication, since hospices typically have a 98 percent overlap in their medication formularies, Virnig suggests.

"My guess is they would negotiate hugely lower drug prices than they have right now," Virnig says. "But that would involve having a huge amount of trust."

* Form a float pool:

Maybe individual rural hospices cannot afford to hire enough staff to cover vacations, but a number of hospices together could provide fill-in staff for vacations or other types of staff time off, Virnig says.

"Imagine if 20 or 30 hospices were to band together and develop a float pool for social workers," Virnig says. "If there was a pool of social workers that everyone could tap into, then when their own social worker needs a vacation, they can go to the float pool to find someone to fill in."

Likewise, a number of rural and small hospices could share a special nursing on-call center that would triage evening and weekend calls and then send a nurse to the community from which the call arrived, Virnig says.

"Rather than have every hospice hire their own private service for on-call nursing, they could each take one week of on-call duty," Virnig says. "So two weeks out of the year, your hospice would cover this, but the rest of the time, somebody else would cover it."

This would work similarly to how large hospices with satellite offices handle on-call duties, Virnig says.

"They will share on-call on weekends and share calls if a nurse goes on vacation because they have a pool of nurses within the larger organization," Virnig says. "We're seeing this happen within consolidations of single organizations into satellite offices for a larger organization."

But it would be possible for small rural hospices to do the same thing and still maintain their own identity, she adds.

"It would allow hospices to remain more financially stable, which may help them avoid having to go the route of becoming incorporated," Virnig says.

* Use technology to increase efficiency:

If hospices do band together, it's very easy with today's technology to have an individual hospice's telephone number transferred to a shared service center or to another hospice for a period of time, Virnig says.

The hospice staff could give patients and families instructions that contain simple codes, such as, "If you need help on weekends, then ask for Mary or Carol," Virnig says.

These would be the code names for that particular hospice, so when the call comes in, the person handling the off-hours calls will know that the patient is served by Hospice AAA and not Hospice CCC, she explains.

Even simpler, the caller ID services available will let the call receptionist know the call was routed through Hospice AAA, so the person could answer the phone, "Hello, this is Hospice AAA, how can I help you?" Virnig adds.

"So patients wouldn't necessarily know that the call transfer is going on," Virnig says.

"Imagine what this type of call-forwarding service would do for staff morale?" Virnig says. "Staff burnout is hard; you are taking care of your third grade teacher or friends or aunt, and that means your hospice work is a much more personal thing, which is both positive and negative."

Another technological possibility is tele-nursing, which has been used successfully in recent years by home care agencies, Virnig says.