This article is brought to you by SilverStone Hospice. The article is based on an interview that took place during a virtual panel discussion with Alfonso Montiel of SilverStone Hospice at the Hospice News Staffing Summit. The panel took place virtually on March 23, 2022. This is an excerpt from the session, which has been edited for length and clarity.
Hospice News: Hi, everyone, good afternoon. My name is Jim Parker. I’ll be moderating this session and we’re talking with Alfonso Montiel. He is the CEO of SilverStone Hospice in Texas. I just wanted to start by talking a little bit about SilverStone Hospice, your scale, and some details about the communities you serve.
Montiel: I bought SilverStone two and a half years ago. Two weeks later, the pandemic started, and it’s been challenging for the industry as a whole in terms of staffing. SilverStone was a 10-year-old company that happened to serve all of Dallas Fort Worth, five counties. The census then was in the 20s and 40s. I’m happy to report right now, this week we’ll hit 80, next week 100. We have been growing very steadily in our average daily census despite the pandemic.
We provide hospice care as we all know, and now very recently, we have launched palliative care, which we like to call true palliative care because when I first joined what I consider to be a sacred industry and a work that you can only do if you have a true calling, everybody talks about the word palliative, left and right, saying everybody was doing it. After a lot of research, a lot of money and lawyers, and putting together the right structures, I have to say very few people have it, very few people do it.
For us, the idea is if you spend nine months preparing to have a baby, why shouldn’t you spend at least nine months preparing somebody for the last chapter of their lives?
Hospice News: Thank you. As you mentioned, with these longstanding labor pressures that worsened during the pandemic that’s certainly no secret to anyone. Could you give an overview of how SilverStone fared during the last two years in terms of staffing?
Montiel: The past two years were awful. It was very, very hard and I’ll tell you why.
When COVID started, the first thing I witnessed for us was that our nurses back then were afraid to go and see patients. That was the first challenge. Nobody knew what was happening. I remember specifically, the first call saying, “OK, we have the protective equipment. This is what we’re going to do,” and two or three nurses saying, “We’re not doing it.” I said, “What do you mean? You made an oath to serve patients.” They’re like, “Yes, but we have children. I made an oath to be a mother.” It was an emotionally difficult time for everyone.
Then as the need for more nurses to serve the pandemic happened, I saw borderline absurd levels of compensation. I would get nurses telling me they were making $5,000 a week. How do you retain a hospice nurse when she’s getting an offer in California, with expenses paid, to do Covid-19 related visits for $5K a week? Suddenly, it became very, very difficult to retain and attract good nurses. It took us two years to have the quality of nurses that we have.
Hospice News: Thank you. You mentioned, of course, nurses but just maybe a little more color, was nursing the biggest issue when it came to staffing? What disciplines or occupations were you seeing?
Montiel: For us, it was. We have one thing that is different, I think, from most hospices, which is we have a full-time medical director. We have others to support our efforts but our doctors are here, so we never had a problem with that. We never had an issue with aides, we have just aides that are angels and hardworking, and they organize themselves in terms of how to cover for each other, but it was RNs, it was case managers that were the challenge for us.
Hospice News: You had some challenges even recently that we discussed earlier that were pretty dramatic, if you’ll forgive the term. You mentioned that due to the demand for new hires and the very limited supply you had brought on some people that you later felt you shouldn’t have. Could you tell us about that?
Montiel: Yes. I’ll find an elegant way to do it. By the way, I misspoke earlier, nurses, and DONs were another big challenge. At that level, DONs and administrators I suppose are a big challenge. We were in a rush to hire because I was afraid we were going to have service failures. At several levels of the organization, for case managers, at the operations level also, the chaplain role, we ended up hiring people that we should have never hired. Under normal circumstances, I would’ve been able to read and react quickly and determine that person wasn’t right, but we didn’t, and we paid the consequences. We paid the consequences in losing a number of patients. It did happen to us. I like to say that in the culture of SilverStone, we never claim to be perfect, but we do claim to be very quick at correcting our mistakes, so that’s what happened.
The pandemic seems to have resulted in the people that will stay feeling a sense of ownership of the company, and those people were the ones who became guardians and started bringing their friends. Anecdotally, as I was driving from the facility here for this session, I [received] 14 text messages of people wanting to join us; medical resources, social workers that are coming word of mouth from the people that were here today. To get one of those six months ago, I had to spend my weekend on Indeed actively looking.
The issue with hospice and also with palliative care is the way we provide service is quite decentralized. Sometimes it takes a while to confirm whether you made a good decision in hiring somebody or not. You can make a thousand background checks and a thousand reference calls but you don’t know until you work with that person, you don’t know until you talk to the family and hear what happened and how it happened.
I became really good at screening resumes and to this day I do it every day and I do it proactively. My DON and I sit down and we look at the trend or referrals, things that are happening in a particular week, and I say, “Well, if we don’t start looking for that new case manager today, we won’t be ready in two or three weeks.” I like to believe because things are stabilizing, I also like to believe that we grew a brand that people respect and a place where people like to work.
Hospice News: Thank you. Of course, we’re going to come back to the workforce shortage. I think it’s the biggest issue. It’s on everyone’s mind. I wanted to digress a moment and talk about some of the other considerations that go along with labor and staffing, like vetting those right people, or oversight of employees, or spreading out visiting patient homes that you don’t really see during the day. What are some of the other big concerns or challenges that exist in addition to that shrinking labor pool?
Montiel: Today I focus on how I ensure that we have a 360-degree view of that patient and their family. We have put together processes here where traditionally, what I had seen is the case manager takes over. That’s the definition of a case manager and so that runs the medical, the nurse runs the care for that family. For those listening, they don’t understand yet what hospice is. Every two weeks, we call it IDG, and the whole team and all the discipline get together to evaluate patients, certify, recertify, look at plans of care of the clients, and all that.
That is technically required by the law, but I have recently created a process, where even the care consultant, which is a name we gave to our marketers, business development people, even the care consultant that brought a patient has to have a touch base with that family moving forward. I thought about it for two reasons, one is to get the 360 degree where the care consultant, the psychosocial team, the medical team, everybody is looking at our patient and the family from their angle. I also felt that it didn’t feel right that family or patient trust business development person with joining a hospice, signing a DNR, and doing everything you do and then that person disappears. It felt to me that there was a disconnect. Now I require constant communication with them.
I call families randomly myself as well. I’m going to narrow this to tell you what my concern is. My concern is that people, and most families, at the end of life, are very vulnerable. I wish I could tell you that everybody knows what to do. No, they don’t know what to do. They don’t understand the process. They don’t understand their rights. They don’t understand what to expect. We were very, very proactive to make sure that they know that they’re not a hostage to one nurse or to the aid or two. They have a whole team of people taking care of them. That was my concern a few months ago, especially how decentralized everything is.
My concern in coming to this industry is that I’m not your traditional hospice CEO. My happiness is that I’m not a traditional hospice CEO. As you know, I was a lawyer. Then I was in finance. Then I was working with refugees in Iraq and Syria and all that. I tend to look at a lot of the situations for the first time, having had the management and experiences in building businesses that I had before, and I care. I care deeply about our patients.
When a concern shows off, I look at it from the angle and the eyes of an outsider that now a few years later has become dangerous enough to know what to do.
This excerpt has been edited for length and clarity. To watch the full discussion on video, please visit:
SilverStone embraces the opportunity to offer alternative healing therapies, modalities and practices. To learn more, visit: https://silverstonehospice.com/.
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