Hospices are hard at work developing new business lines such as palliative care to reach patients further upstream and capitalize on value-based care opportunities. As beneficial as these services can be both to patients and providers, the importance of effective program design cannot be overstated.

Florida-based Alivia Care is among a growing pool of hospice providers that have pursued new opportunities to extend their care continuum, including palliative care, home health and other services. In the midst of these initiatives, the organization contends with brutal industry-wide headwinds — with the workforce shortage at the top of that list.

From its very inception, Alivia Care has been focused on growth. The nonprofit emerged in 2020 when Florida’s Community Hospice & Palliative Care rebranded into a larger company with a wider range of services. Since then, launching new programs and pursuing affiliations have been priorities.

Alivia President and CEO Susan Ponder-Stansel, of Alivia Care recently spoke with Hospice News about service diversification strategies and cultivating referral growth in a time when staff are scarce.

Many hospice providers have turned their focus to palliative care services, including Alivia Care. What are some of the most important factors driving this trend?

Hospice programs are recognizing that they have to move upstream in order to improve both the overall utilization of hospice and the timely access to hospice care. Falling lengths of stay have been a tail of the pandemic, so reaching patients before the last few days of life is critical.

Many of us have developed either palliative care programs or transitional care programs to help fill the gap in our very fragmented system of care that leaves patients without a clear roadmap between acute or curative care and hospice care.

What are some common pitfalls providers see when building a palliative care program from the ground up? How can providers avoid them?

Among the pitfalls I have seen are not designing the palliative care program correctly, so that it ends up being a place patients stay way too long. Getting the design right so palliative provides the right amount and type of support, but is not ‘hospice lite’ is a challenge. Many hospices actually develop their own ‘substitute competition’ without realizing they are doing so.

The second problem I often see is going into palliative care with the perception that it is a profit center versus a cost center.

With current reimbursement, most of us are either relying on Medicare Part B payment for physician services or a contract rate from a health plan or other payer, which seldom covers the entire cost of the service. Understanding that palliative care is part of care navigation and care transition services, versus something that will be profitable in and of itself, is important at the outset.

Lastly, many hospices develop this service without looking at who is already in this space in their market, and without being able to identify and explain the unique value proposition their particular flavor of the service offers. Many of the competitors in this space utilize telephonic or virtual models of support to deliver the service, giving them cost advantages when negotiating with payers. Most hospice programs I’ve seen use ‘boots on the ground’ to deliver this care, but don’t have the data to make the case that is leads to better outcomes than the virtual programs many private companies are offering.

Regarding the labor pressures, has the strain eased or improved recently?

Staffing constraints have not eased and show no signs of doing so. Difficulty finding and hiring all levels of clinicians, including physicians, has been a constant source of stress for hospices.

We continue to see workers make the decision to exit the workforce or change jobs so that they can work fewer hours or have more work-life balance. This will continue for years to come and represents a demographic shift, not a temporary trend.

Staffing shortages have continued to bear financial weight this year for hospices. How do you see labor pressures impacting bottom lines in 2022?

Labor pressures will be the most difficult drag on the bottom line that hospice programs will face — not only in 2022, but for many years to come. For many providers, not having enough staff has forced them to shut down beds in hospice units, be unable to take patients under their care or to provide services such as continuous home care.

Supply that does not meet demand is pushing up costs for the labor portion of our business in not just direct clinical care, but in some other areas of essential support such as IT and accounting.

The other complicating factor is the exit of the traditional baby boomers and older Generation-X workforce, and the different view of compensation, work-life balance and the role of work that younger millennials and older Generation-Z staff will have. Many of us are ill-prepared to deal with this demographic change of who will make up our workforce.

A lot of hospices have needed to invest more heavily in technology to build efficiency, expand teleheath services and remain competitive. What are some of the most pressing financial points for hospices when it comes to technology?

Technology will enable us to mitigate many of the challenges we will face in the years ahead, including our staffing shortages. Ensuring that our clinical documentation wastes as little of staff time as possible will be key to both recruiting and retention, as will using technology to improve processes and offload things that can be done by someone other than our licensed professionals.

Technology will also be needed for improving patient care and allowing hospices to head off emergency room admissions or care crises.

Additionally, technology will be needed for the level and quality of data each of us will need to support our decisions and to evaluate our outcomes — both for our internal use and for payers and regulators.

If the [U.S. Centers for Medicare & Medicaid Services (CMS)] continues to allow reimbursement for telemedicine and telehealth visits, there will be both strong consumer acceptance of receiving this method of care and a willingness of hospices to use this tool for patient care in appropriate and helpful ways.

Cost will be a challenge for smaller hospice programs. Navigating the complexities of all the new and emerging technical products is a real concern for many.

Investments in new technology can be costly, and we can’t afford to get it wrong. But sorting through all the noise out there to evaluate what will really meet our needs is going to require different skills and knowledge than many providers currently have access to internally.

Where is the needle threading in terms of hospice growth opportunities in coming years? What care settings might offer the most promising referral streams?

Senior living and retirement communities will be among the opportunities of the future. Baby boomers and their families most assuredly want to age in place and have care come to them rather than having to go to a care setting.

Hospice is a unique, person-centered type of care that aligns well with the desires of those who want to remain independent for as long as possible.

And, if palliative or concurrent transitional care becomes a payment under regular Medicare, then patients with end-stage dementia, renal and neurological disorders may be willing and able to come to hospice care in much greater numbers than is the case now.