2017 REPORT. Hospice Demographics and Outcome Measures

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1 2017 REPORT Hospice Demographics and Outcome Measures

2 i 2017 Hospice Demographic and Outcome Measures Report October 2017

3 Table of Contents Executive Summary... 1 Data Collected... 2 Outcome Measure 1 (OM1)... 3 Accreditation... 5 Individual Hospice Information... 6 Hospice Geographical Coverage... 9 Inpatient Facilities and Residential Units Primary Diagnosis at Time of Admission Patient Race and Ethnicity...16 Patient Age Discharges by Disposition Type Patient Days by Location...18 Reimbursement Additional Hospice Data Centers for Medicare & Medicaid Services (CMS) Quality Measures for Hospice Quality Reporting Program and Data Submission Requirements Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey Conclusion Appendix A ii 2017 Hospice Demographic and Outcome Measures Report October 2017

4 iii 2017 Hospice Demographic and Outcome Measures Report October 2017

5 Executive Summary As mandated in Section of the Florida Statutes, together with Rule 58A-2.005, Florida Administrative Code, the Department of Elder Affairs (DOEA) must develop an annual report that analyzes and evaluates the quality and effectiveness of hospice care for hospices licensed in the state. This report contains an analysis of data submitted by all 45 of Florida s licensed hospices for The sources are data submitted directly to DOEA of demographic and outcome measures and data submitted to the Centers for Medicare & Medicaid Services (CMS) of nationally endorsed quality measures. These quality measures are endorsed by the National Quality Forum (NQF) and the results were made public in August of All 45 Florida hospices met the standard set for the outcome measure developed by the Department: 50 percent or more patients who reported severe pain on a 0-10 scale reported a reduction to five or less by the end of the fourth day of care in the hospice program (OM1). 1 Individual hospices varied on the results of their nationally endorsed quality measures, though Florida followed similar trends as national averages. Beginning in 2015, the National Hospice and Palliative Care Organization (NHPCO) replaced the Family Evaluation of Hospice Care (FEHC) survey with the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. The CAHPS survey asks consumers and patients to evaluate their experiences with hospice, but does not include two outcome measures DOEA had been previously tracking: the percentage of patients/families who indicated the patient received the right amount of medicine for their pain (OM2), and the percentage of patients/families who stated they would recommend the hospice facility to others based on the care the patient received (OM2A). Calendar year 2014 was the sixth and final year for which results for these two outcome measures are available for each hospice. With the adoption of the CAHPS survey in 2015, these measures have become optional for each reporting year, with 11 hospices voluntarily submitting data on OM2 and OM2A for In all, hospice demographic and outcome measure results for 2016 were similar to previous reporting years. In 2016, Florida hospices individually operated as many as seven independent facilities or residential units, 2 and more than half of all Florida hospices were accredited organizations (60%). The typical hospice patient is a Caucasian individual (72%) who is 65 years or older in age (86%), two characteristics that remain constant across each year of reporting. The majority of hospice services were provided in private residences (55% of all patient days), and Medicare remains the primary source of payment (87% of all hospice reimbursements) during the reporting year. The average length of admission was nine days. 1 Outcome Measure 1 was previously mandated for hospices to report annually. The submittal of this data has become optional during the transition to the DOEA s adoption of national hospice outcome measures and survey data. 2 The Vitas Healthcare Corporation of Florida is registered under three different license numbers. Throughout this report, we will be reporting on these three licensed entities as separate hospices and will not be aggregating their submitted data Hospice Demographic and Outcome Measures Report October 2017

6 A notable trend is the four percent increase in the number of facility admissions from 2015 (47,901) to 2016 (49,776), a partial recovery of the nearly six percent decreased admissions between 2014 and 2015 (50,920 to 47,901). Previously, from 2009 to 2014, facilities experienced a steady increase in admissions (34,719 to 50,920, respectively). Despite increasing admissions from last year, Florida hospice organizations operated 106 inpatient facilities and residential units in 2016, one fewer than in Data Collected Section of the Florida Statutes requires the Department of Elder Affairs (DOEA), in conjunction with the Agency for Health Care Administration (AHCA), to develop outcome measures to determine the quality and effectiveness of hospice care for hospices licensed in Florida. This statute, along with Rule 58A-2.005, Florida Administrative Code, defines the outcome measures, as well as the demographic and diagnostic information hospices are required to submit annually to DOEA. A secure online form was made accessible January 1, 2010, to all hospices for the purpose of data collection. For a copy of the form, please refer to Appendix A. The information provided by each hospice organization includes the following: Hospice contact information; Counties served; Facility and residential unit information (including the number of beds, facility admissions, and facility patient days); Outcome Measure 1: Proportion of patients reporting a reduction of pain (optional for 2016 reporting year); Outcome Measure 2: Proportion of patients receiving the right amount of pain medicine (optional for 2016 reporting year); Outcome Measure 2A: Proportion of patients who would recommend hospice services to others (optional for 2016 reporting year); Diagnosis, age, race, and reimbursement information for patients admitted; Number of patient days by location; and Number of patient discharges by death/non-death Hospice Demographic and Outcome Measures Report October 2017

7 PERCENTAGE OF PATIENTS Outcome Measure 1 (OM1) All 45 hospices submitted data for Outcome Measure 1. Outcome Measure 1 compares the percentage of patients who had severe pain (seven or higher on a 0-10 scale) at time of admission and whose pain was reduced to a level of five or lower by the end of the fourth day of care in the hospice program. 3 The standard for OM1 is to have at least 50 percent of patients who experienced severe pain at admission have their pain reduced by the end of the fourth day of care. In 2016, all hospices met or exceeded the 50 percent standard for decreasing pain to a level of five or lower by the end of the fourth day, with the exception of Heartland Home Health Care and Hospice, which did not report any patients who reported severe pain at admission and could not participate in this measure. 4 As shown in Exhibit 1 below, 11 hospices reported they reduced the pain level to five or lower by the end of the fourth day for 96 to 100 percent of their patients (compared to 19 hospices in 2015), and 19 hospices reported they reduced the pain level to five or lower by the end of the fourth day for 81 to 95 percent of their patients (compared to 16 hospices in 2015). Exhibit 1: Number of Hospices Whose Percentage of Patients with Severe Pain Was Reduced to Level Five or Lower by the End of the Fourth Day % % % % % STANDARD Data provided by individual hospice organizations, n = 44; This analysis includes hospices that treated patients who reported severe symptoms upon admission. One hospice was excluded from the analysis because none of the patients reported severe symptoms upon admission. 3 Outcome Measure 1 was previously mandated for hospices to report annually under Section of the Florida Statues, but the submittal of this data has become optional during the transition to the DOEA s adoption of national hospice outcome measures and survey data Hospice Demographic and Outcome Measures Report October 2017

8 Historically, the number of hospices that did not meet the standard for minimum pain reduction by the fourth day ranged from one hospice in 2009 to two hospices in Between 2011 and 2014, all but one hospice met the standard. In 2015 and 2016, all hospices met the standard (see Exhibit 5 on pages 6-8 for a list of the hospices and the percentage of their patients who met this outcome measure). Statewide in 2016, hospices reported pain level data for 65,200 patients at the time of admission. As illustrated in Exhibit 2 below, 16.1 percent of patients (10,492) reported having severe pain at admission. Of those reporting severe pain at the time of admission, 64.4 percent reported a reduction in pain to a level of five or lower by the end of the fourth day of care, 8.6 percent reported their pain level was a six or higher by the end of the fourth day of care, and 27 percent were unable to report their pain level by the fourth day. These totals include patients who chose not to receive pain medicine. Exhibit 2: Florida Hospice Patients Pain Level at Time of Admission and Pain Level at End of Fourth Day of Care for Those Who Had Severe Pain at Admission DAY 1 ALL PATIENTS PATIENTS WITH NO, MILD, OR MODERATE PAIN PATIENTS WITH SEVERE PAIN DAY 4 PATIENTS WITH SEVERE PAIN ON DAY % 83.9% REDUCED PAIN, LEVEL 5 OR LOWER 64.4% PATIENT UNABLE TO REPORT 27.0% CONTINUED PAIN, LEVEL 6 OR HIGHER 8.6% Data provided by individual hospice organizations, n=65,200 (Day 1) and n=10,492 (Day 4); This analysis includes hospices that treated patients who reported severe symptoms upon admission. One hospice was excluded from the analysis because none of the patients reported severe pain upon admission. Inconsistencies in the data collection for this outcome measure were identified. Namely, the first day on which pain measures are collected varies by hospice, as some start reporting pain on the day of The inconsistencies in data admission while others start on the first day of care collection for the pain received. Additionally, when multiple pain scores were management outcome measure reported on the fourth day, the score selected varies; were similar to those some hospices use the first score reported, some use the recognized by CMS as an lowest score reported, and others use the highest pain industry-wide challenge in the score reported. The Centers for Medicare & Medicaid National Quality Forum Hospice Demographic and Outcome Measures Report October 2017

9 Services (CMS) reported similar challenges in the reporting of the National Quality Forum (NQF) pain measure as a barrier to using this measure nationwide and proposed revisions to these measures to more accurately capture pain measure reporting. 5 Accreditation While all hospices in the state of Florida must be licensed (Section , Florida Statutes), accreditation is a voluntary process that requires a hospice organization to submit to an extensive on-site evaluation that covers several areas of patient care and patient safety. Many see accreditation as a tool for measuring the quality of an organization. As illustrated in Exhibit 3 below, although the percentage of accredited hospices has been inconsistent from 2009 to 2015, the overall trend indicates a rise in the percentage of accredited hospices over time. In 2016, 60 percent of Florida hospices were accredited, an all-time high since 2009 (44%). Information regarding individual hospice accreditation can be found in the following section. Exhibit 3: Number and Percentage of Accredited Hospices, Number of Accredited Hospices Number of Hospices Percentage of Accredited Hospices 44% 42% 51% 44% 49% 57% 56% 60% Data provided by individual hospice organizations and confirmed by the Agency for Health Care Administration, n=45; RTI International, Supporting Analyses for Updates to the HIS V2.00.0: Findings from a Pilot Study and Technical Expert Panel. Retrieved from: Reporting/Downloads/Supporting-Analyses-for-HIS-V2000-Updates_Final.pdf Hospice Demographic and Outcome Measures Report October 2017

10 Individual Hospice Information Hospice organizations are organized into three tax-status categories: (1) not-for-profit hospice organizations, which are subject to 501(c)3 tax-exempt provisions; (2) for-profit hospice organizations, which can be privately owned or publicly held entities; and (3) not-for-profit government hospices, which are owned and operated by federal, state, or local municipalities. Both not-for-profit private and government hospices are categorized in this report as nonprofit. As illustrated in Exhibit 4 below, the majority of hospices in 2016 (31 or 68.9%) had nonprofit status. The number of for-profit hospices increased from 2014 to 2015 (13 and 14, respectively), but has remained the same from 2015 to 2016 (14 or 31.1%). Overall, the percentage of for-profit hospices in Florida has nearly doubled over the past eight reporting years, from 17.1 percent in 2009 to 31.1 percent in Exhibit 4: Number and Percentage of For-Profit Hospices, Number of For-Profit Hospices Percentage of For-Profit Hospices Data from the Agency for Health Care Administration, Exhibit 5 below lists the city in which each hospice organization is located, Outcome Measure 1 (OM1) results, the accreditation entity (if any), the profit status, and the number of patients admitted for each of the 45 hospices licensed in Florida. The majority of hospices were accredited by The Joint Commission (TJC; 15), followed by the Community Health Accreditation Program (CHAP; 8), and the American Commission for Healthcare (ACHC; 3). Exhibit 5: Measure (OM) Results, Accrediting Entity, Profit Status, and Number of Patients by Hospice Hospice Name City OM1 Accreditation Profit Number of Entity Status Patients Avow Hospice, Inc. Naples 80% TJC Non-Profit 1,869 Big Bend Hospice, Inc. Tallahassee 67% CHAP Non-Profit 1,502 Catholic Hospice, Inc. Miami Lakes 98% TJC Non-Profit 2,594 Community Hospice of Northeast Florida, Inc. Jacksonville 95% N/A Non-Profit 5,817 Compassionate Care Hospice of Central Florida, Inc. Lakeland 100% CHAP For-Profit 222 Compassionate Care Hospice of Lake and Sumter, Inc. Minneola 86% CHAPS For-Profit 262 Compassionate Care Hospice of Miami Dade and the Florida Keys, Hialeah 67% CHAPS For-Profit 248 Inc. Cornerstone Hospice & Palliative Care Tavares 92% N/A Non-Profit 8,603 Covenant Hospice, Inc. Pensacola 100% TJC Non-Profit 3,945 Florida Hospital HospiceCare Ormond Brach 100% TJC Non-Profit 1,417 Good Shepherd Hospice Temple Terrace 84% TJC Non-Profit 3, Hospice Demographic and Outcome Measures Report October 2017

11 Exhibit 5: Measure (OM) Results, Accrediting Entity, Profit Status, and Number of Patients by Hospice (Continued) Hospice Name City OM1 Accreditation Entity Profit Status Number of Patients Gulfside Hospice & Pasco Palliative Care Land O Lakes 98% TJC Non-Profit 2,297 Halifax Hospice, Inc. Port Orange 93% N/A Non-Profit 2,874 Haven Hospice Gainesville 98% ACHA Non-Profit 4,232 Heartland Home Health Care and Hospice Jacksonville N/A* ACHA For-Profit 214 Heartland Hospice Services Plantation 100% ACHC For-Profit 1,076 Hope Hospice and Community Services, Inc. Fort Myers 81% CHAP Non-Profit 5,162 Hospice by the Sea Boca Raton 86% TJC Non-Profit 3,346 Hospice of Citrus and the Nature Coast Beverly Hills 87% TJC Non-Profit 930 Hospice of Gold Coast Home Health Services Fort Lauderdale 80% CHAPS Non-Profit 343 Hospice of Health First, Inc. West Melbourne 78% TJC Non-Profit 1,468 Hospice of Marion County, Inc. Ocala 96% TJC Non-Profit 3,199 Hospice of Okeechobee, Inc. Okeechobee 57% N/A Non-Profit 206 Hospice of Palm Beach County Inc. West Palm Beach 86% TJC Non-Profit 6,867 Hospice of St. Francis, Inc. Titusville 73% CHAPS Non-Profit 1,320 Hospice of the Comforter Inc. Altmonte Springs 80% N/A Non-Profit 2,553 Hospice of the Emerald Coast, Inc. Panama City 84% N/A Non-Profit 2,226 Hospice of the Florida Keys, Inc. Key West 100% N/A Non-Profit 240 Hospice of the Treasure Coast, Inc. Stuart 67% N/A Non-Profit 1,154 HPH Hospice Temple Terrace 81% N/A Non-Profit 3,464 LifePath Hospice Temple Terrace 87% TJC Non-Profit 6,123 Odyssey Healthcare of Marion County, LLC Overland Park 78% N/A For-Profit 1,652 OpusCare of South Florida Miami 100% N/A Non-Profit 858 Regency Hospice of Northwest Florida, Inc. Pensacola 84% N/A For-Profit 520 Samaritan Care Hospice of Florida Overland Park KS 71% N/A For-Profit 240 Seasons Hospice & Palliative Care of Broward Florida, LLC Dania Beach 61% N/A For-Profit 756 Seasons Hospice and Palliative Care of Southern Florida Miami 86% TJC For-Profit 1,884 Suncoast Hospice Clearwater 96% TJC Non-Profit 6,831 The Hospice of Martin and St. Lucie, Inc. Stuart 70% N/A Non-Profit 2,656 Tidewell Hospice, Inc. Sarasota 85% CHAP Non-Profit 7, Hospice Demographic and Outcome Measures Report October 2017

12 Exhibit 5: Measure (OM) Results, Accrediting Entity, Profit Status, and Number of Patients by Hospice (Continued) Hospice Name City OM1 Accreditation Profit Number of Entity Status Patients Vitas Healthcare Corporation of Florida Boynton Beach 89% N/A For-Profit 7,878 Vitas Healthcare Corporation of Florida Melbourne 80% N/A For-Profit 9,328 Vitas Healthcare Corporation of North Miami Florida Beach 87% N/A For-Profit 7,070 VNA Hospice of Indian River County, Inc. Vero Beach 88% TJC Non-Profit 1,336 Wuesthoff Brevard Hospice and Palliative Care Viera 89% N/A For-Profit 646 Totals and averages 39 Unique 31 Non- 88% 27 Accredited Cities Profit 65,200 Data provided by individual hospice organizations, n=45; ACHC = American Commission for Healthcare, CHAP = Community Health Accreditation Program, TJC = The Joint Commission *Note: Heartland Home Health Care and Hospice did not have any patients report severe pain on the day of admission and could not participate in the OM1 calculation Hospice Demographic and Outcome Measures Report October 2017

13 Hospice Geographical Coverage As with the prior years of reporting, each of Florida s 67 counties was served by at least one hospice organization in The number of hospice organizations serving each county is listed in Exhibit 6 below. Exhibit 6: Geographical Coverage of Florida Hospices, 2016 County Number of Hospice Organizations County Number of Hospice Organizations County Alachua 2 Hardee 4 Okeechobee 3 Baker 4 Hendry 1 Orange 5 Bay 2 Hernando 1 Osceola 5 Bradford 2 Highlands 4 Palm Beach 3 Brevard 4 Hillsborough 1 Pasco 2 Broward 7 Holmes 2 Pinellas 1 Calhoun 2 Indian River 1 Polk 4 Charlotte 1 Jackson 2 Putnam 2 Citrus 2 Jefferson 2 Saint Johns 4 Clay 4 Lafayette 2 Saint Lucie 3 Collier 2 Lake 2 Santa Rosa 3 Columbia 2 Lee 1 Sarasota 1 Desoto 1 Leon 2 Seminole 2 Dixie 2 Levy 2 Sumter 2 Duval 4 Liberty 2 Suwannee 2 Escambia 3 Madison 2 Taylor 2 Flagler 5 Manatee 1 Union 2 Franklin 2 Marion 2 Volusia 5 Gadsden 2 Martin 3 Wakulla 2 Gilchrist 2 Miami-Dade 7 Walton 3 Glades 1 Monroe 6 Washington 2 Gulf 2 Nassau 4 Hamilton 2 Okaloosa 3 Data provided by individual hospice organizations, n=45; 2016 Number of Hospice Organizations Hospice Demographic and Outcome Measures Report October 2017

14 Inpatient Facilities and Residential Units During 2016, Florida hospice organizations operated 106 inpatient facilities and residential units, increasing from 87 in The number of operating inpatient facilities and residential units decreased by one from 2015 to These include inpatient wings or rooms within a hospital or skilled nursing facility that were operated by the hospice as well as freestanding hospice inpatient facilities and residential units that appear on the hospice license. Each facility/unit must meet the following criteria: (1) Consist of one or more beds that are owned or leased by the hospice, (2) Be staffed by the hospice organization, and (3) Have policies and procedures set by the hospice. In 2016, Florida hospice organizations individually operated as many as seven independent facilities or residential units. The 10 hospice organizations that did not have facilities in 2016 provided inpatient care and services to individuals in private residences. The number of hospices with one or two facilities/residential units increased from 14 in 2015 to 17 in The number of hospices with three to eight facilities/residential units decreased to 18 hospices (compared to 19 hospices in 2015). There were 49,776 patient admissions to Florida hospices in 2016, and hospices provided 1,526 beds in their facilities and residential units. The increasing trend in Exhibit 7 below depicts that the number of admissions to hospice facilities and residential units steadily increased from 34,719 in 2009 to the high point of 50,920 in 2014, with a six percent decrease in 2015 (47,901). Exhibit 7: Patient Admissions to Florida Hospices, ,938 50,920 47,901 49,776 38,469 39,799 41,878 34, Data provided by individual hospice organizations, n=49,776; Hospice Demographic and Outcome Measures Report October 2017

15 As shown in Exhibit 8 below, the number of beds provided by Florida hospices has increased 15 percent from 2009 (1,329) to 2016 (1,526). There was an average of 32.6 admissions per bed and an average of patient days per bed in From 2009 to 2016, the average rate of admissions increased by about seven admissions per bed (25%) while the average number of patient days spent per bed decreased by about 13 days (-5%). Although the length of stay per hospice admission increased from the low of in 2014 to in 2015, the length of stay has decreased from days in 2015 to in Exhibit 8: Admissions, Hospice Beds, and Facility Patient Days, 2009 through 2016 Difference to 2016 Admissions 34,719 38,469 39,799 41,878 47,938 50,920 47,901 49,776 15,057 (43%) Number of Beds 1,329 1,445 1,545 1,520 1,550 1,551 1,556 1, (15%) Total Days 340, , , , , , , ,346 31,266 (9%) Average Admissions per Bed (25%) Average Patient Days Spent per Bed (-5%) Data provided by individual hospice organizations, n=45; As shown in Exhibit 9 below, the overall average length of stay per hospice admission decreased to 7.5 days (eight days if rounded) in 2016 (compared to 8.0 days in 2015). Likewise, the median length of stay per hospice admission was 7.1 days in 2016 (compared to 7.8 days in 2015). 6 Exhibit 9: Average and Median Days per Hospice Admission, AVERAGE MEDIAN Data provided by individual hospice organization, n=45; 2016, average calculations performed by DOEA 6 The length of stay (number of days) per hospice admission can be reported as both an average and a median. The median, however, is considered a more meaningful measure for understanding the experience of the typical patient since it is not influenced by outliers (extreme values) Hospice Demographic and Outcome Measures Report October 2017

16 Exhibit 10 below presents information about the number of beds, patient admissions, and days patients spent at a facility by county, in addition to providing the averages by county. Exhibit 10: Inpatient facilities/residential Units Operated by Florida Hospices by County, 2016 County Total Beds Total Facility Admissions Total Facility Days Average Admissions per Bed Average Days per Bed Average Occupancy Rate Average Facility Days per Admission Alachua , % 5.5 Bay , % 7.4 Brevard 57 1,611 14, % 8.8 Broward 118 3,394 36, % 10.7 Charlotte , % 7.5 Citrus , % 7.3 Clay , % 7.2 Collier , % 6.0 Columbia , % 7.2 Desoto , % 9.5 Duval 96 2,438 19, % 8.2 Escambia 34 1,126 8, % 7.5 Flagler , % 4.9 Hernando , % 4.1 Highlands , % 4.7 Hillsborough 48 2,472 13, % 5.4 Indian River , % 6.6 Lake , % 5.5 Lee 100 3,501 34, % 9.8 Leon , % 5.5 Levy , % 5.3 Manatee 20 1,036 6, % 6.4 Marion 56 1,337 16, % 12.3 Martin 16 1,143 6, % 5.6 Miami-Dade 99 2,363 26, % 11.3 Nassau , % 6.6 Okeechobee , % Hospice Demographic and Outcome Measures Report October 2017

17 Exhibit 10: Inpatient facilities/residential Units Operated by Florida Hospices by County, 2016 (Continued) County Total Beds Total Facility Admissions Total Facility Days Average Admissions per Bed Average Days per Bed Average Occupancy Rate Average Facility Days per Admission Orange 54 1,643 11, % 7.1 Palm Beach 139 4,306 34, % 8.1 Pasco 102 1,752 8, % 4.9 Pinellas 92 2,626 19, % 7.4 Polk 28 1,232 6, % 5.0 Putnam , % 5.9 Saint Johns , % 5.8 Sarasota 18 1,042 6, % 6.1 Seminole , % 7.2 St. Lucie , % 5.6 Sumter 20 1,077 5, % 5.4 Volusia 72 2,736 15, % 5.7 Total/Average 1,526 49, , % 7.5 Data provided by individual hospice organization, n=49,776; The number of admissions may not equal the number of patients since a patient can be admitted more than once during the calendar year and a person may be a patient during the calendar year, but admitted prior to the start of the calendar year Hospice Demographic and Outcome Measures Report October 2017

18 Primary Diagnosis at Time of Admission Hospices reported on the primary diagnosis of 128,480 patients at the time of admission. This total includes admissions to facilities and residential units. The following diagnosis categories were used: cancer, Acquired Immune Deficiency Syndrome (AIDS), pulmonary disease, renal disease, cardiovascular disease, and other. In 2016, 35.0 percent of patients admitted to Florida hospices had a primary diagnosis included in the other category, as shown in Exhibit 11 below. Approximately 31.8 percent responded that cancer was their primary diagnosis, followed by 19.2 percent for cardiovascular disease, and 11.4 percent for pulmonary disease. AIDS and renal failure represented less than three percent of patient primary diagnoses (0.3% and 2.3% respectively). The proportions of patients primary diagnoses at the time of admission to hospices in 2016 are similar to those in recent years. Exhibit 11: Primary Diagnosis at Time of Admission to a Florida Hospice OTHER 35.0% CANCER 31.8% CARDIOVASCULAR DISEASE 19.2% PULMONARY DISEASE 11.4% RENAL DISEASE 2.2% AIDS 0.3% Data provided by individual hospice organizations, n=128,480; 2016 In 2017, reporting on 2016 data, the National Hospice and Palliative Care Organization (NHPCO) reported that the cancer diagnosis constituted 28 percent of primary diagnoses for national hospice admissions, followed by 19 percent cardiac and circulatory, 17 percent dementia, 11 percent respiratory, 9 percent stroke, and 17 percent other. 7 Florida hospices are not instructed to report information on diagnosis related to dementia; however, this diagnosis may be contained in the relatively large proportion of other diagnoses (35.0%). Overall, the proportions of primary diagnoses at time of admission to Florida hospices closely resemble the national rates reported by the NHPCO. 7 National Hospice and Palliative Care Organization. (2017) Facts and Figures: Hospice Care in America; 2016 Edition. Alexandria, VA: National Hospice and Palliative Care Organization, September Hospice Demographic and Outcome Measures Report October 2017

19 In 2011, a study in the Journal of American Medical Associations reported lower proportions of cancer patients and higher proportions of patients with dementia in for-profit hospices compared to non-profit hospices. 8 Similarly, Florida experienced a significant (p<.05) pattern of a lower percentage of patients with a cancer diagnosis in for-profit hospices compared to non-profit hospices (28% and 33%, respectively) in Exhibit 12: 2016 Patient Primary Diagnosis at Time of Admission to Florida Hospices, by Profit Status Cancer Heart Pulmonary Renal AIDS "Other" Total Non-Profit 33.3% 19.5% 11.9% 2.5% 0.2% 32.5% 100% For-Profit 27.5% 18.2% 9.9% 1.4% 0.4% 42.6% 100% Data provided by individual hospice organizations, n = 128,480; 2016 * Significant at the p<0.05 level Unfortunately, the proportion of patients with dementia could not be directly replicated with available data because hospices are not currently required to report the diagnoses of Alzheimer s diseases, dementia, or a related disorder. However, as shown in Exhibit 12 above, the higher occurrence of patients diagnosed with other in for-profit hospices compared to non-profit hospices (43% and 33%, respectively) may include a considerable number of patients with Alzheimer s disease or a related form of dementia. 8 Wachterman, M.W., Marcantonio, E.R., Davis, R.B., and McCarthy, E.P. (2011) Association of the Hospice Agency Profit Status With Patient Diagnosis, Location of Care, and Length of Stay. Journal of the American Medical Association, 305(5), Hospice Demographic and Outcome Measures Report October 2017

20 Patient Race and Ethnicity Hospices reported on the race and ethnicity of 128,480 patients at the time of admission. The following race and ethnicity categories were used: Caucasian, Black, Asian, Hispanic, and other. Hospices reported that a majority (71.7%) of their patients were Caucasian, 7.6 percent were Black, and 0.5 percent were Asian. In addition, 9.2 percent of hospice patients identified as some other race or combination of races and 11.0 percent of patients identified themselves as Hispanic. A significantly larger percentage of patients served by non-profit hospices in 2016 identified as Caucasian (77.8%), compared to 53.2 percent of patients served by for-profit hospices who identified as Caucasian, as displayed in Exhibit 13 below. 9 In contrast, Hispanic patients were served by for-profit hospices at a much higher rate than non-profit hospices (25.6% and 6.1%, respectively). Exhibit 13: Percent of Caucasian Patients Served by For-Profit and Non-Profit Hospices, 2016 Data provided by individual hospice organizations, n=128,480; 2016 The racial and ethnic composition of patients in hospices by profit status varied slightly from 2015 to 2016, with fewer for-profit patients identifying as Hispanic in 2016 (25.6%) than in 2015 (33.0%). There were also more Caucasian patients in for-profit hospices in 2016 (53.2%) than in 2015 (48.0%). 9 Significant at the p<0.05 level Hospice Demographic and Outcome Measures Report October 2017

21 Patient Age Hospices reported the age of 128,480 patients at the time of admission. Each person admitted was grouped into one of three age categories: 0-18, 19-64, or 65 and older. Approximately 85.7 percent of all hospice patients admitted were 65 and older. About 14.1 percent of hospice patients admitted were between the ages of 19 and 64, and 0.2 percent of hospice patients admitted were younger than 19. Overall, the age distribution of patients admitted to Florida hospices has changed very little in 2016 compared to previous years. Discharges by Disposition Type Hospices reported on the disposition of discharge by patient, whereby each discharge was grouped into one of two categories: deaths and non-deaths. Individuals who died while receiving hospice services are included in the deaths category. For 2016, as illustrated in Exhibit 14 below, discharge dispositions due to death were higher in non-profit (85.3%) than in for-profit hospices (74.6%). In for-profit hospices, the proportion of discharges due to patient death has decreased between 2009 (82.0%) and 2016 (74.6%) by 7.4 percentage points. In contrast, the proportion of discharges due to patient death in non-profit hospices since 2009 has increased by 4.3 percentage points, from 81.0 percent in 2009 to 85.3 percent in Overall, the distribution of discharge dispositions has changed very little since Exhibit 14: Florida Hospice Patient Discharges by Disposition and Profit Status, 2016 DEATHS NON-DEATHS 85.3% 82.6% 74.6% 25.4% 14.7% 17.4% FOR-PROFIT NON-PROFIT TOTAL Data provided by individual hospice organizations, n =124,991; Hospice Demographic and Outcome Measures Report October 2017

22 Patient Days by Location Hospices provide services in many location types. The majority of patient care is provided in the place the patient calls home. In addition to private residences, this may include nursing homes and residential facilities. Hospice organizations are also able to operate dedicated inpatient units on or adjacent to a hospital campus, or provide services in their own freestanding facility. Most of these facilities provide a mix of general inpatient and residential care. Hospices reported the number of location days spent by type of location, as shown in Exhibit 15 below. In 2016, 55.1 percent of hospice patient days were spent in private residences, 21.5 percent of hospice days were spent in an assisted living facility, 18.2 percent were spent in a nursing home with contracted non-inpatient beds, and 5.2 percent of all hospice days were spent in all other types of settings. From 2012 to 2015, the total number of days patients spent at residential facilities dropped by 67.5 percent (from 58,117 to 18,872 days) and continued to decrease to 17,771 days in Although the total number of days in inpatient beds more than doubled from 2012 to 2013 (from 13,480 to 28,989), the number has since decreased from 34,807 in 2014 to 29,147 in Exhibit 15: Percent of Patient Days Spent by Location, 2016 PRIVATE RESIDENCE 55.1% ASSISTED LIVING FACILITY 21.5% NON-INPATIENT BED 18.2% OTHER 5.2% Data provided by hospice organizations, patient days(n)=9,528,342; 2016 Note: Other category includes hospice patient days spent in the following settings: residential facility, family care, inpatient bed, dedicated hospice, facilities other than a dedicated hospice, freestanding facilities, and all other types of settings Hospice Demographic and Outcome Measures Report October 2017

23 Reimbursement Hospice care is covered under a variety of payment sources, including Medicare, Medicaid, and most private insurance plans, and patients receive hospice care regardless of their ability to pay. The Medicare hospice benefit, enacted by Congress in 1982, is the predominate source of payment for hospice care. Florida hospices reported the percentage of reimbursement from the following: Medicare, Medicaid, third party, self-pay, uncompensated, and other methods. The majority (87.2%) of hospice income came from Medicare in Additionally, Medicaid paid 6.0 percent of hospice reimbursement, while 4.6 percent came from third parties, 1.4 percent was uncompensated, and less than 1 percent came from private pay (0.6%) or other (0.2%). 87.2% of reimbursements were paid using Medicare. Non-profit hospices received a smaller percentage of reimbursement from Medicare compared to for-profit hospices (86.0% compared to 89.8%), a larger percentage from Medicaid (6.9% compared to 4.0%), and a slightly higher percentage from third parties (4.9% compared to 3.9%). This differs from the previous year, with for-profit hospices receiving a significantly lower rate of federal and third-party reimbursements (90.0%) than non-profit hospices (97.0%) in In 2016, however, non-profit hospices (97.8%) and for-profit hospices (97.6%) received similar rates of federal and third-party reimbursements. Relatedly, in 2015, for-profit hospices were not compensated (8.4%) more often than non-profit hospices (1.2%), while in 2016, both for-profit hospices (1.4%) and non-profit hospices (1.3%) had similar percentages of uncompensated expenditures Hospice Demographic and Outcome Measures Report October 2017

24 Additional Hospice Data AHCA issued 48 instances of Top Ten State and Federal Health Deficiency Citations to hospices across the state from January 1, 2016, through December 31, The majority of these deficiencies related to deficiencies in plans of care (10). 10 Four citations regarded staff training requirements for Alzheimer s disease. 11 Three citations were each issued for exercise of rights/respect for property/person, coordination of services, and minimum licensure requirement (client notice). Two citations were issued for two separate aspects of plan of care and two separate aspects of staff training requirements for Alzheimer s disease. 12 Two citations were each issued for coordination of services, prevention, nursing services, clinical records, administration and management of a hospice, nursing services, and unlicensed activity. 13 Information about legal orders and statements of deficiencies for Florida hospices can be found on AHCA s website The statute ( (5-6)) this deficiency refers to concerns the required content of a patient s care plan, such as identification of primary caregiver, patient diagnosis, and assessment of patient and family needs. For a full description of each deficiency, please refer to 11 The statute ( (1)(C-1) outlines the timeline and amount of training required by each type of employee. 12 One deficiency in plan of care (statute (B) refers to caregiver and patient being provided a paper copy of the plan of care. The other deficiency in plan of care (statue (2)) refers to the required employ of a full-time registered nurse who is responsible for coordinating the implementation of the plan of care for each patient. One deficiency in staff training (statute (1)(A)) requires staff employed at the agency to receive written information about interacting with person with Alzheimer s disease. The other deficiency in staff training (statute (1)(b)) is the requirement of employees who directly work with patients with Alzheimer s disease to have at least one hour of training Hospice Demographic and Outcome Measures Report October 2017

25 Centers for Medicare & Medicaid Services (CMS) Quality Measures for Hospice Quality Reporting Program and Data Submission Requirements In April 2014, the Centers for Medicare & Medicaid Services (CMS) met the requirements of the Privacy Act of 1974 by establishing a new System of Records, titled the Hospice Item Set (HIS) System. This system supports the collection of data required for the Hospice Quality Reporting Program (HQRP). The Affordable Care Act (ACA) requires that the CMS use nationally endorsed quality measures in the HQRP. Hospices are required to use and submit patient-level data for the following seven measures endorsed by the National Quality Forum (NQF): NQF #1617 Percentage of patient stays treated with an opioid that are offered/prescribed a bowel regimen or documentation why this was not needed (Opioid/Bowel); NQF #1634 Percentage of patient stays during which the patient was screened for pain during the initial nursing assessment (Pain Screening); NQF #1637 Percentage of patient stays during which the patient screened positive for pain and received a comprehensive assessment of pain within one day of the screening (Pain Assessment); NQF #1638 Percentage of patient stays during which the patient screened positive for dyspnea and received treatment within one day of the screening (Dyspnea Treatment); NQF #1639 Percentage of patient stays during which the patient was screened for dyspnea during the initial nursing assessment (Dyspnea Screening); NQF #1641 Percentage of patient stays with chart documentation that the hospice discussed (or attempted to discuss) preferences for life sustaining treatments (Treatment Preferences); and NQF #1647 Percentage of patient stays with documentation of a discussion of spiritual/religious concerns or documentation that the patient and/or caregiver did not want to discuss spiritual/religious concerns (Beliefs and Values Addressed). 15 As illustrated in Exhibit 16 on the following page, Florida hospices show similar trends to those reflected in national averages. For six out of the seven measures, both in Florida and nationally, 85 percent or more survey respondents responded positively, with the exception of the pain assessment measures, with 78 percent nationally and 73 percent in Florida responding positively. Florida rated above the national average for every measure, except for the pain assessment and beliefs and values addressed (89% in Florida; 94% nationally) measures Centers for Medicare & Medicaid Services. (2016) Current Measures. 16 Access to the NQF data can be found at the following website: Hospice Demographic and Outcome Measures Report October 2017

26 Exhibit 16: National and Florida Averages on National Quality Forum Measures Opioid/Bowel Pain Screening Pain Assessment Dyspnea Assessment Dyspnea Treatment Beliefs and Values Addressed Treatment Preferences 78% 73% 93% 93% 94% 95% 97% 99% 95% 98% 94% 89% 98% 98% 0% 20% 40% 60% 80% 100% National Average Florida Average Data provided by CMS; collected between 10/01/ /30/2016. Number of hospices nationally, n=4,489. Number of respondents, n=1,340,419 Florida hospices, n=43. Number of Florida respondents, n= 120,480. Note: CMS collected data from Vitas Healthcare Corporation of Florida as one entity, while in this report each location was counted individually. Hospice of Health First, Inc., did not provide national hospice reporting data. To compare the results of the NQF measures for individual hospices in Florida, please refer to Exhibit 17. Thirty-seven of the 42 hospices rated 50 percent or higher on all measures and 22 of the 42 hospices rated 75 percent or higher on all measures. The lowest ratings were for beliefs and values (30%, Compassionate Care Hospice of Central Florida, Inc.) and for pain assessment (11%, Good Shepherd Hospice). Out of the other five measures, the lowest rating was 64 percent (Opioid/Bowel regimen, LifePath Hospice). Exhibit 17: National Quality Forum Measure Results by Hospice Beliefs Treatment Pain Pain Facility Name and Preferences Screening Assessment Values Dyspnea Screening Dyspnea Treatment Opioid/Bowel Regimen Avow Hospice, Inc Big Bend Hospice, Inc Catholic Hospice, Inc Community Hospice of Northeast Florida, Inc Compassionate Care Hospice of Central N/A Florida, Inc. Compassionate Care Hospice of Lake and Sumter, Inc N/A Hospice Demographic and Outcome Measures Report October 2017

27 Exhibit 17: National Quality Forum Measure Results by Hospice (Continued) Facility Name Treatment Preferences Beliefs and Values Pain Screening Pain Assessment Dyspnea Screening Dyspnea Treatment Opioid/Bowel Regimen Compassionate Care Hospice of Miami Dade N/A and the Florida Keys, Inc. Cornerstone Hospice & Palliative Care Covenant Hospice, Inc Florida Hospital HospiceCare Good Shepherd Hospice Gulfside Hospice & Pasco Palliative Care Halifax Hospice, Inc Haven Hospice Heartland Home Health Care and Hospice Heartland Hospice Services Hope Hospice and Community Services, Inc Hospice by the Sea Hospice of Citrus and the Nature Coast Hospice of Gold Coast Home Health Services Hospice of Marion County, Inc Hospice of Okeechobee, Inc Hospice of Palm Beach County Inc Hospice of St. Francis, Inc Hospice of the Comforter Inc Hospice of the Emerald Coast, Inc Hospice of the Florida Keys, Inc Hospice of the Treasure Coast, Inc HPH Hospice LifePath Hospice Hospice Demographic and Outcome Measures Report October 2017

28 Exhibit 17: National Quality Forum Measure Results by Hospice (Continued) Facility Name Treatment Preferences Beliefs and Values Pain Screening Pain Assessment Dyspnea Screening Dyspnea Treatment Opioid/Bowel Regimen Odyssey Healthcare of Marion County, LLC OpusCare of South Florida Regency Hospice of Northwest Florida, Inc Samaritan Care Hospice of Florida Seasons Hospice & Palliative Care of Broward Florida, LLC Seasons Hospice and Palliative Care of Southern Florida Suncoast Hospice The Hospice of Martin and St. Lucie, Inc Tidewell Hospice, Inc Vitas Healthcare Corporation of Florida VNA Hospice of Indian River County, Inc Wuesthoff Brevard Hospice and Palliative Care Data provided by CMS; collected between 10/01/ /30/2016. n= 42. Note: The name used for Odyssey Healthcare of Marion County, LLC in NQF reporting was Kindred Hospice (CMS Certification #101548). The name used for Samaritan Care Hospice of Florida in NQF reporting was Kindred Hospice (CMS Certification #101540). In NQF reporting, Vitas Healthcare Corporation of Florida was treated as one entity while in this report the three locations were treated as unique entities. Hospice of Health First, Inc., did not provide national hospice reporting data. When comparing the national results by profit status, non-profit and for-profit hospices received similar average results, as illustrated in Exhibit 18 on the following page. The largest differences in average was for pain assessment, with 79% of for-profit respondants reporting positively compared to 70% of non-profit respondents, and beliefs and values, with 81% of forprofit respondents reporting positively compared to 92% of non-profit respondents. For all other measures, non-profit and for-profit averages were within four percentage points of one another Hospice Demographic and Outcome Measures Report October 2017

29 Exhibit 18: Non-Profit and For-Profit Averages on National Quality Forum Measures Opioid/Bowel Regimen Dyspnea Treatment Dyspnea Screening Pain Assessment Pain Screening Beliefs and Values Treatment Preferences 70% 79% 81% 93% 94% 98% 95% 99% 98% 96% 92% 92% 98% 97% 0% 20% 40% 60% 80% 100% Non-Profit For-Profit Data provided by CMS; collected between 10/01/ /30/2016. Florida hospices, n=42. Non-Profit, n=30. For-Profit, n=12. Note: CMS collected data from Vitas Healthcare Corporation of Florida as one entity, while in this report each location was counted individually. Hospice of Health First, Inc., did not provide national hospice reporting data Hospice Demographic and Outcome Measures Report October 2017

30 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey In 2015, hospices began contracting with approved survey vendors to administer the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey. The standardized 47 question CAHPS Hospice Survey includes the following measures: hospice team communication, getting timely care, treating family members with respect, providing emotional support, support for religious and spiritual beliefs, getting help for symptoms, information continuity, understanding the side effects of pain medication, and getting hospice care training. 17 This survey allows the informal caregiver (family member or friend) to provide an overall rating of the hospice care their patient received and ask if they would recommend this hospice to others in the future. The CAHPS Hospice Survey gives emphasis to additional in-depth aspects of hospice care experiences and focuses on the patient s perspective of the experience of care, rather than on patient satisfaction. For these reasons, the Department is interested in using CAHPS data to either replace or complement current hospice quality reporting requirements in future hospice outcome measure analyses, though this data is not expected to be available until December of Hospice Demographic and Outcome Measures Report October 2017