Virginia-based Blue Ridge Hospice, and its CEO Cheryl Hamilton Fried, are mobilizing for value-based care with geographic expansion and a new suite of services.
Fried took the helm at Blue Ridge Hospice in January 2021 and moved quickly to reinforce the non-profit’s marketing and business development operations. Within 18 months of her arrival, Blue Ridge saw its patient census take a 40% leap. Last week, the hospice launched a new palliative care service and a PACE program.
The organization serves a 2,200-square-mile region that includes urban, suburban, and rural communities with an average daily census of roughly 300 patients.
But Hamilton Fried seeks to make a difference beyond the Blue Ridge service region. She is currently spearheading the development of a new regional collaborative with other providers in the Mid-Atlantic states.
Hospice News spoke with Hamilton Fried about the hospice provider’s recent growth and the opportunities she sees within value-based care.
Can you provide some color around how Blue Ridge has achieved its recent growth?
When I arrived there was very little investment in marketing and outreach programs.
We have an incredible quality program. That was one of the things that attracted me to the organization. We actually have the highest quality scores in the Commonwealth of Virginia, so it was a shame that our services were not being offered as much or as frequently as they could have been. So we’ve made significant investments where other hospices are scaling back.
We were able to invest in communications — direct-to-consumer, as well as our business-to-business and referral sources.
What led you to decide that this was the right time to move into palliative care and PACE?
We are really focused on value-based transformation. We understand that hospice length of stay continues to shrink year over year, and we’re in the end-of-life business.
Community-based palliative care is something that was absent in our community, and we believe that we are the right organization to provide those services. And it’s the right time as payment models are shifting to more value-based reimbursement. We really believe that this is the future.
We’re future makers, and we want to be able to see the [Medicare] hospice benefit preserved and to be the program that is covering and meeting the community’s needs.
We have a serious gap in our communities right now, and those are people that don’t qualify or don’t want hospice — but the traditional health care system was not meeting their needs. So PACE is a natural fit for us.
Hospice has always been about an interdisciplinary team model, and PACE allows us to provide that type of care. It is a full-risk reimbursement situation, but that didn’t make us shy away. We have a very engaged and visionary board, and we believe that we are the right people to manage that risk and keep people out of institutions and at home.
We were in a competitive scenario in [Virginia]. I actually asked the state to open up the Request for Proposals, and I knew that anyone could apply for that. We were competing with for-profit and private equity-backed organizations. The Commonwealth of Virginia ultimately decided that we would be awarded the program.
Can you share some more details on the palliative care pilot and how you’re approaching that service?
We want to be cautious but ambitious, because we know there’s a need in the community. So far half of the palliative care consults that we’ve been asked to provide have converted to hospice care. We have started in skilled nursing facilities and assisted living facilities, and we have done some home-based palliative care.
We’ve just hired an additional full-time nurse practitioner to assist us with growing our program. We believe that we will be able to take on as much as the community needs in our existing service areas.
Is that pilot taking place throughout your entire service region, or is it limited to certain markets?
Right now, we are primarily serving Winchester City and Frederick [Virginia]. But we have provided some consults in Shenandoah County and Paige [County]. We intend to provide consults in all of our service areas.
I noted that when you were with a previous organization, one of the things you worked on was the Medicare Care Choices Model demonstration. I know that demo just finished and all the data are being analyzed. But I wondered if there was anything you learned or experienced while doing that work that informed your approach to palliative care at Blue Ridge?
As an organization, and personally, I’m very excited about the programs that the Center for Medicare & Medicaid Innovation (CMMI) is creating. Unfortunately, there hasn’t been a really successful model yet. We’ll see what the data show.
With that particular model, I found it very difficult to meet the requirements. I think it ended up excluding a population that needed that service, because it was very restrictive. So what I learned is that community-based palliative care is a better model.
I very much support acute-based palliative care as well. Our local hospital system has its own palliative care program. We work very closely with them to provide guidance in the hospital, and they provide us with referrals outside of the hospital so those patients can continue to receive palliative care.
I would like to see models that are really embracing the value-based transformation like we are in our organization.
We are positioning ourselves to be an organization that applies for new types of programs that are being made available through CMMI. We have launched a diversity, equity, and inclusion program, which I know is the big focus for CMMI. We do serve suburban, urban, and rural areas, so we believe that’s something that is important for us, and we have a keen eye on the needs of each particular community.
We have created a “Do-Not-Wait” strategy, which has increased our same-day referral-to-admission conversion. We have made a significant investment in talking about our services to physicians so that we are getting those patients pre-hospitalization versus post-hospitalization.
The average length of stay for patients that we receive out of the hospital is about 11 days. If they come from somewhere else, it’s about 45 days. We’re trying to cut out that last [hospital] stay that individual have, and palliative care is a way for us to do that, as is the PACE program.
Have you expanded geographically in addition to launching the new services?
We’ve served part of Loudoun County for many years, but we’re growing our footprint farther into that area, which is where our second PACE site will be located. That’s another initiative that hasn’t quite come to realization yet, but we’re staffing up and making sure that we can meet the needs of that community right now.
That is one of America’s fastest-growing counties. It’s an area where we see enormous opportunities to serve more. We serve western Loudoun currently, and we’re carving a big portion of eastern Loudoun County into our service area. This moves us further into northern Virginia, which is one of our strategic goals for hospice.
And then we are sort of becoming a convener of cooperation among like-minded, not-for-profit end-of-life and serious illness providers in the mid-Atlantic region. We have an appreciation of the affiliated groups that are scattered around the country, and the models that are being created. We are pursuing a similar path and forming that strategy here in this area.
I think that that’s going to occur organically with the partners that we’re speaking with right now, but we’re really excited. We would be contiguous in this mid-Atlantic area.
Can you share some more details on your PACE model?
Our PACE site is an adult day center and medical clinic, as well as an outpatient rehab center.
We provide transportation to and from the facility, and we have a network of specialists and primary care physicians that will oversee the care of the PACE participants.
For PACE, we employ a team of 11 interdisciplinary members that coordinate care. We also provide meal services and health services, and about half of our participant population will be in the day center at any given time.
There’s no overnight stay. Some of the care is provided in the home, but a significant amount is provided in the facility as well.
How are you securing reimbursement for these services or making them sustainable?
Medicare Advantage, traditional Medicare, and PACE reimburse us, but not for startup expenses. It’s a heavy lift to start, but [Blue Ridge] has a healthy balance sheet and believes that this is where the future of health care is moving.
We are reimbursed from Medicare on a risk-adjusted scale, and we are reimbursed on a contracted rate through Medicaid. We don’t establish that contracted rate. They do that through an actuary.
Can you talk about some of the challenges that you had to overcome the launch of these services? The first thing that comes to mind for me would be staffing. Was that an issue, and did you encounter others?
We have not had the significant retention or recruitment issues that a lot of organizations have had. Blue Ridge Hospice has an excellent reputation and our communities. We invest heavily in our employees. That’s recognized inside and outside the organization. We do have a growing workforce.
We are in the fastest-growing city in the Commonwealth of Virginia. So it’s exciting to have a pool of individuals and actually provide new types of jobs for the community — transportation drivers, recreational therapists, and additional aides for the center.
We actually were able to do a market analysis to make sure that as we grew that we would have the workforce available to us in this community.
What can you share about your future plans, next steps for Blue Ridge, or for these new programs in particular?
We are undergoing this value-based transformation at the organization. It’s a really exciting time for us. We do plan to open up our second PACE site in Loudoun County and to expand palliative care throughout our entire service area.
I just have one more question. A lot of times when I talk to hospice leaders around the country about this movement toward value-based care, they seem very apprehensive about it. They recognize that’s where we’re going, but they seem more worried than excited. You seem very optimistic about it, and I wonder if you could add some color around that. Am I reading that right? And if so, what has you excited about this?
You’re reading it absolutely 100% correctly. I think it opens up opportunities for organizations like hospices to truly care for end-of-life patients — and if you think about end-of-life as the person’s last year or the last two years, those are the programs that we are creating to fill the gap.
I believe that CMMI is headed in the right direction. It creates opportunities for programs like ours to move earlier into the continuum of that dying process and provide the best care in the right place at the right time. We want to be able to meet those needs and make sure that we’re preserving the hospice benefit at the same time. And if it’s not us, then who is going to do it?
We feel like these are great opportunities for us.