Forming partnerships outside the system
Forming partnerships outside the system
Hospice intertwines with local systems
Can independent hospices achieve the close working relationships with larger health care systems that will enable them to retain their terminal care business and impact on end-of-life care more broadly? Many independents have chosen to be acquired by larger systems. (See Hospice Management Advisor, September 1997, pp. 99-100.) But the cost of giving up independence may include losing a mission focused exclusively on care of the dying, as well as the community-based agency’s special relationship with its community. (See related story, p. 116.)
The need to influence the functional integration of health systems and the care and referral processes of the larger system is becoming ever clearer. But can hospices achieve this influence as partners, instead of as acquisitions, of the leading health systems in their communities? Answers will be different in different environments, depending on such issues as the level of competition in the market, the numbers and relative strength of health systems, managed care penetration, and historical patterns of relationships and collaborations.
In some communities, independent hospices are demonstrating creative ways to intertwine their destinies with local health systems, without giving up their independence. Of course, any meaningful relationship alters both participants, and the ties that independent hospices develop with health systems inevitably place limits on their ability to operate unilaterally.
"We are fortunate. We have a long-standing relationship with what was once a hospital and is now a health system," says Pamela Barrett, ACSW, CEO of community-based Hospice at Greensboro (NC). The hospice began as a grass-roots enterprise in the late 1970s. In 1984, the local hospital, Moses Cone Health Care System, made an equity investment in the hospice and settled into a role as part owner and institutional member, with six seats on the hospice’s 12-seat board of directors.
"We don’t own them. As far as we’re concerned, they can be freestanding, and operate independently and do all the right things," says Tim Rice, Moses Cone’s executive vice president for health services. "If the hospice was a department of the hospital, it just wouldn’t be the same kind of organization," he observes. "I do think the days of the freestanding, totally nonaffiliated hospice are short-lived. But we have no reason to have this hospice for breakfast. Our economic interests are not directly linked with theirs. But our philosophy is that the hospice is part of this organization, and we have a responsibility to them. We have a lot of joint ventures in this community," including a recent partnership with a local urban ministry to establish a health clinic for indigent patients, Rice says.
"In an environment like this, hospice thrives," Barrett says. "We are at the table; we can be part of the solution. There’s a recognition that there are legitimate issues and that we can find ways to address them. I view the whole move to end-of-life care as an interesting, exciting opportunity not a threat." Working on improving end-of-life care in the hospital is just beginning.
Moses Cone and its affiliated home health agency are participating with Hospice at Greensboro in the Boston-based Institute for Healthcare Improvement’s Breakthrough Collaborative on Improving Care at the End of Life. (See HMA, September 1997, pp. 100-102.) In February, they jointly formed a 15-member planning committee called Circle of Caring, to begin talking about end-of-life care issues and the systemic problems identified by SUPPORT (the Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment).
The hospice has also adapted Arlington, VA-based National Hospice Organization guidelines on non-cancer admissions, in the form of user-friendly algorithms which ask a series of questions that can guide referral decisions across the care continuum. The collaborative will be using the algorithms to study whether appropriate hospice patients can be identified in a more timely manner. "We want to make sure, not just that the dying patients are getting to hospice, but that they are where they need to be all along the way, seamlessly," Barrett says.
"Because of our historical relationship, when opportunity comes along, we don’t have to start creating trust, we just start calling the right people. In some ways, the situation is almost too good to be true. This community is not so highly competitive. But other hospices can find themselves in cooperative, collaborative relationships that advance the ultimate goal of improving quality of life for patients at the end of life. Ultimately, the hospice may have to make some choices. But it is possible to bring competing hospital systems to the table and use hospice as a meeting ground," Barrett says.
"The most important thing boils down to relationships, building trust and commonality looking for natural partnerships. If we’re really committed to our mission, we won’t be much of a threat. We are not the only ones who can do good work, but we have a tremendous amount of experience and expertise. In our system everybody acknowledges that," she adds.
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