Since being named President and CEO of Florida-based Interim HealthCare in January, Jennifer Sheets has spent a lot of time on the road, visiting the franchise owners who comprise Interim’s network of 325 hospice, home health care, and other home-based health service locations.

Interim’s franchise business model is unique in health care. Franchise owners in the network range from large private equity investors to mom-and-pop startups, some of which have been in the owners’ families for two or three generations. The company recently ranked 24th in Franchise Direct’s Top 100 Global Franchises.

“The fact that you have owners who are truly in it to improve the quality of life in the communities that they serve is a beautiful thing,” Sheets said. “It builds a kind of automatic engagement and desire to see the company grow.”

In a conversation with Hospice News, Sheets shared her insights on how the hospice industry is evolving and the ways organizations need to adapt to their changing environment.

“The industry is going to have to look at how we think through things like strategic partnerships. How do we navigate inefficient processes across the continuum?” she said. “How do we deal with the fact that there are very real workforce shortages? And how can we make sure we are at the table for conversations about collaborative community-based partnerships?”

How might changing demographics in the United States affect the hospice industry?

Looking to the future, the thing that many people haven’t realized is that there will be a changing of the guard in terms of family decision makers.

Right now, the children of baby boomers are making decisions about our parents, but when we look forward it is going to be the millennials that are going to be informing their parents’ end-of-life decisions. That will require us to think in a new way about health care.

This is a generation that is more focused on the consumer experience. Many of these consumers are going to take out their phones and search for the best hospice provider in their area. They want more transparency. They are going to want information at their fingertips about service and quality at their fingertips. Right now, the industry doesn’t think that way.

A shift coming in health care, and we as an industry need to think about how we are going to impact that consumer experience.

As an executive in an organization that provides hospice care, what keeps you up at night?

The fact that there are so many people in the most vulnerable moments of their lives who are unaware of the relief and support that hospice care provides.

There is a real deficit in understanding and a lot of misconceptions about hospice care. People tend to think of it as a place to die—a time when nothing else can be done, when in actuality hospice is the thing that can be done. It’s about quality of life and being with the people that you care about rather than being in a hospital on life support all by yourself. It’s about support for the patient’s family.

What are some common misconceptions about hospice care?

There are so many misconceptions about everything having to do with hospice. There is a lack of understanding regarding eligibility for the Medicare benefit and what is covered. There are misconceptions about how we provide medications and supplies.

Many people also don’t understand the level of support that we provide to caregivers and families, support that continues after the patient’s death through bereavement services. This is the one area of health care where you have the opportunity to let the family caregiver breathe, so they don’t have to be a full-time caregiver and a part-time spouse or son or daughter. Hospice is so needed, and so many people are unaware of what it is.

What do you see as the key messages that hospice providers need to get across during community outreach?

The two things I have heard consistently from patients and families in my career is that they wish they had known about the benefit sooner. I do think it is so important that we let people in the community know that they are not alone in their most vulnerable moments. Help is out there.

When the goal of care shifts to a desire to be home and be comfortable, hospice services when delivered with quality and integrity is the answer. We need to get that message out there.

In what ways do you see the hospice industry changing? How might hospice care and hospice business operations be different five years from now?

As our population continues to change, I think we are going to see more and more people who are going to have to transition to a home-based program such as hospice care. I think we are going to see more specialized programs to respond to multiple diagnoses and chronic conditions that people are coping with.

Also with changing regulations and rising demand we will see the need for more coordinated care. Some small hospice and other health care organizations will be unable to survive on their own. They are going to have to look for more strategic partnerships in their communities to respond to the changes.

How should hospices be preparing for a large influx of patients as the population ages?

We need to focus on early intervention and patient education about the service that hospice provides. We need to focus on community awareness and work to develop more disease-specific programs and strategies that not only address health care needs, but social determinants and the patient and family’s non-medical needs—the other factors that affect the person’s well being.

Hospice needs to screen someone’s ability to prepare or obtain nutritious meals and connect them to community services like Meals on Wheels if there is a need there. We need to screen for depression, and overall recognize the other factors that can affect a person’s quality of life.

The person’s most important needs may not be related to their medical condition. This realization will change the way health care is delivered in the future. Being able to address that full continuum of care will be critical going forward, either through offering the service or by partnering with people in your community.

Hospices are coming under increasing regulatory scrutiny, how should organizations respond to this?

One advantage that hospice organizations have is that hospice was an early leader in quality improvement programs. We continuously invest in the development, education, and competency of the clinical and operational leadership. I think that is a must.

Continually examining processes and conducting self-audits is crucial to helping us highlight and respond to areas that need additional focus. For us it’s always about that: How do we continue to improve?

One of the major issues in health care today is the opioid epidemic. How do hospice providers balance patients’ needs with regulatory compliance?

The need for opioid medication for end of life care is not going away anytime soon. Organizations really need to get ahead of this. We need to consider alternate therapies of course, but also provide the needed therapy if it is opioid therapy in a safe and controlled environment without limiting patients access to care.

Pain is the No. 1 symptom in hospice care, and we need to be able to address that. I think we need to educate families and patients about the risks and benefits of opioids. Some organizations have stated to use accountability agreements, educating families about opioid use, and putting tools in place to identify and prevent diversion by families or others who come into the home. We also need staff education and training to ensure we have as many safety guardrails in place not only to address the pain but to make sure that we are doing so in a safe and controlled environment.

What is your reaction to the forthcoming demonstration of a Medicare Advantage carve-in for hospice?

Overall I think it’s a great thing. It’s putting hospice out there in the middle of the health care continuum where it should be. It boils down to relationships, and providers need to be having conversations now about how to work with Medicare Advantage plans.

But this is new. Traditionally hospice services have been kind of siloed, so I think organizations are going to have to figure out how they are going to respond to things like shared and coordinated record information.

For example, the screening process: How do we flag when hospice patients may need to go back to a different level of care if they are no longer continuing to decline? On the flip side of that, we need to screen for patients that are currently in hospice care that for whom we may be able to supplement with something additional to keep them home in the lower acuity care setting, where they want to be.

What concerns do you have regarding the carve-in?

One of the highest costs in hospice care is medication. So I have to say that I am concerned, knowing that Medicare has a focus on reducing their Part D expenses.

Hospices have to be ready to respond with education and training for physicians and clinicians related to a true medication reconciliation, where we screen for medications that are no longer beneficial at the end of life. Because if the idea is to shift that spending away from Part D, then on the hospice side we need to remain diligent in providing the therapy that most impacts quality of life.