Changemakers: Susan Ponder Stansel, CEO Alivia Care

Alivia Care CEO Susan Ponder Stansel came to the hospice field in 1985 as a volunteer clinical social worker at the Hospice of Northeast Florida, which was later rebranded as Community Hospice & Palliative Care. Six years later in 1991, she was the nonprofit’s CEO, putting the organization on a growth trajectory that saw the hospice’s daily census rise from about 60 to 1,200.

Last year, Ponder Stansel spearheaded the establishment of Alivia Care, a larger post-acute organization that maintains Community Hospice & Palliative Care as a wholly-owned subsidiary. In addition to hospice and palliative care, Alivia subsidiaries will provide home health, private duty nursing services, personal care, PACE programs and advanced care management. Alivia serves nearly 8,000 hospice patients and 9,000 palliative care patients annually in addition to its other service lines.

In this Changemakers interview, Ponder Stansel speaks with Hospice News about the impetus behind Alivia Care, the ways an evolving payment environment may transform hospice and serious illness care and how looming workforce shortages may change care delivery in the long term.

Would you introduce Alivia Care and talk about your rebranding experience and the impetus for that?

Alivia Care is the parent company for not only Community Hospice & Palliative Care, but our A Better Life home care brand. We operate a Medicare-certified private duty service, our PACE program, our physician enterprise, and now Alivia Care of Georgia. We have a sort of family now, which is why we rebranded.

The purpose of Alivia Care is really to be a framework. It’s not necessarily consumer facing. Rather, it is that ‘50,000-foot view’ of how we as a provider of care in the home can really be prepared for the changes that are coming, and also make sure that that we are well aligned with where both consumer preferences and reimbursement is going.

A lot of change is happening in the health care system right now. Can you speak to some of the most significant changes that you’ve seen impact end-of-life and serious illness care in recent years?

One of the things that I see is just the demographics. When you look at how many of us are living longer — and with chronic illnesses that will eventually become advanced. That’s been a huge shift, particularly in hospice.

When you look at when I got started with hospice in 1985, almost 90% of our patient census had advanced cancer. Today for my program and for most hospices it’s 30% to 40%. The other patients’ tend to have diagnoses that tend to have a less predictable trajectory. It’s sometimes difficult to get that end-of-life prognosis for conditions like dementia and congestive heart failure. And then you look at who isn’t receiving hospice care, like those who have end-stage renal disease.

I think that the reason that hospice is having some of these diagnoses that we didn’t really have years ago is that there’s really no place else in the system for patients who are trying to live well with these illnesses to go to get anything other than fragmented care. Sadly, I think that the response from [the U.S. Centers for Medicare & Medicaid Services (CMS)] has been to double down on regulatory oversight, with hospices who care for these patients. It’s made some of us afraid to admit them. It’s a symptom of a real gap in our system.

COVID was like steroids for demand for care at home and for consumer-directed care. It was already coming, but I see a real shift. My parents’ generation was very willing to just let the system move them along in whatever way made sense for the system, and a lot of that was payment based care. I’m a Baby Boomer, and many of us really don’t want to do that. We’re looking for things that give us more control and more involvement in our care.

Hospice is a good alignment for that particularly sensitive, patient-centered care and always has been.

I would be remiss if I didn’t also talk about the pilot under the [value-based insurance design (VBID)] — the Medicare hospice carve-in. I think that’s probably going to be the biggest disrupting force in hospice care since Medicare began paying for hospice in 1983. I think that will change everything, some things for the better and some things that I’m not so fond of.

The stated goal of that was to make sure more patients had access to care in a more timely manner. I see a major disrupter coming.

Would you elaborate on the aspects that you’re not fond of pertaining to VBID?

The program designed for VBID includes transitional services that help patients get support who are navigating an advanced illness and help them make better decisions. The theory was that more of them will choose hospice, and more of them will choose it in a more timely manner.

Most of us are dealing with median lengths of stay of 8, 10 or 12 days. Timely access is a huge problem, and COVID only made it worse. The thought was that health plans would work with hospice providers and other types of providers to do the advanced care planning, the palliative care, transitional care, and community-based hospice. But what has ended up beginning to emerge already is the tendency for health plans to want to own all the means of production and using service lines that they have, or acquiring service lines, in order to do the palliative care, and in some cases acquiring hospice programs as well.

For those that want to be in network, we’re already seeing some requesting for discounts for volume. ‘If we send you a lot of patients, can you give us a 10% discount on the rate?’

I’m not taking any of this personally, but for nonprofit, community-based programs like mine who don’t have a 10% margin, we can give a 10% discount but we’ll lose money. One of the trends that I see that could really change the way consumers receive hospice care is that community-based programs will have to find ways to reduce costs so that they can give those kinds of discounts, or they really will be sort of marginalized in the market as Medicare Advantage spreads.

This is assuming that the carve-in works and Medicare Advantage continues to grow. I do believe that CMS wants to get out of the fee-for-service business, particularly with these high-need and high-cost populations. So I’m assuming Medicare Advantage will continue to grow. I think that will have some impact on the organizational structure of some of the hospice providers that exist right now.

How do you feel that some of the work that you’ve been doing with Alivia helps to drive change?

I often sit back and think about what can we do in our little neck of the woods when a lot of this is happening at a macro level with big companies that are merging and consolidating and rolling out new businesses. But I think you have to think globally and act locally. So for us, it’s our region.

We’re really looking at Alivia Care as a way for us to better leverage our resources and avoid duplicate spend. In doing so,you have a parent company, and a lot of the services that you develop that any company will need, like [human resources], [information technology], compliance marketing, you can spread those over a broader base so that you can be more efficient. You’re putting more of your dollars toward care versus administrative overhead. So that was part of what we were wanting to do, knowing that there’ll continue to be downward pressure on reimbursement and more costs associated with finding and keeping good staff. We’re already seeing some of those staffing shortages and competition for clinicians.

The other reason that we wanted to do Alivia Care is that we really see opportunities among physician practices in our region, bringing PACE to this community where it didn’t exist before. We looked at where we had both interest, resources and opportunity to fill in gaps in our local care market. We really did it with an eye toward where we could be a good partner with those that are caring for patients, either further upstream, or at particular points in their illness where they could use somebody to fill in their gaps.

We tried to take a system approach. Our focus is on care in the home. We definitely see more care being pushed into the community for really those high-need, high-cost patients. We wanted to include those who wanted to age independently in the community and try to avoid institutional care for as long as possible.

All of these things really focus on care for people who want to live better with advanced illness. More of us will be living longer with advanced illnesses. We saw this as a way to really develop some capacity and expertise that could be valuable to consumers, payers and to other health care partners.

How do you think the staffing shortage issue might affect change in the industry, for better or worse?

Yeah, that’s going to be fascinating. There’s going to have to be a lot of things that we all consider doing to deal with some of the shortages we’re already seeing. I think the use of technology where it makes sense to make your clinicians more efficient is definitely going to have to be in the mix. I think a lot of us had to use it during COVID, and now we’re evaluating where it works well and where it doesn’t.

I also think that the ability to make sure that your internal structure and workflows allow everyone to practice at the very top of their license is really going to be important. It’s not just compensation. You have to look at things like your electronic health records, such that your clinicians are having to spend an inordinate amount of time using it. It’s not user friendly. That’s a factor in losing staff sometimes or in their feeling just burned out because they’re seeing patients and then having to spend hours documenting. It’s all of these things together. It’s not just about better marketing and better salaries. There are also some other considerations about what you can do to really make sure you’re using the talent that you do get as efficiently and effectively as you can.

I know there are some national initiatives to really open the pipeline for nursing schools and for palliative-certified physicians and geriatrics, but that’ll take years. In the short term, I think most of us are having to increase salaries, and then we’re really looking at keeping the people once we get them by making sure we’re we’re not making their lives harder. We also have to use them effectively inside, because they are scarce resources. This includes people like the tech folks who backup our clinicians. There’s a lot of demand for them.