HSPN ELEVATE: Hospice Clinical Innovation Trends

This article is sponsored by Axxess. This article is based on a Hospice News discussion with Faith Protsman, regional medical director at VITAS Healthcare, Raianne Melton, senior clinical manager of professional service at Axxess, and Cheryl Hamilton Fried, president & CEO at Blue Ridge Hospice. This discussion took place on September 7, 2023 during the Hospice News ELEVATE Conference. The article below has been edited for length and clarity.

Hospice News: I wanted to start by asking where the greatest opportunities for clinical innovation is in hospice care?

Cheryl Hamilton Fried: I think there’s an incredible amount of opportunity for innovation right now. In particular, we’re looking at how we engage our staff to create a better patient experience, and for us being in a suburban and more rural area, we are doing a lot of things to make sure that our retention is where it needs to be. We know that satisfied staff make satisfied patients. We’re very pleased to be a four-star quality hospice provider. We’ve experienced 25% growth year over year the last three years. Last year we had less than 20% turnover. If that gives an indication of how important your staff are and how much that equals quality care at the bedside, I’m not sure what else does. That’s really a significant investment that we’ve made and innovation in how we care for staff with personal days, recognition, we have a fleet car program, all the things that we can do to make this the most desirable place to work in our communities.


HSPN: Thank you. Faith, would you proceed?

Dr. Faith Protsman: I think telehealth has really revolutionized the way we provide patient care. It provides a quick and easy connection between patients and clinicians where they can get their questions answered, maybe get medical advice. What we also know, though, is that patients and families want a deep connection at the end of life particularly, and we need to be able to balance that because sometimes patients and families are calling with questions, sometimes they’re calling out of fear, but sometimes patients are calling out of loneliness. They really don’t have anyone that they can talk to and connect with, and that’s something telehealth has really made a difference in.

Raianne Melton: I just have to tell you, I have like two pages of stuff because there’s so much opportunity, and when we look at staffing in particular, in 2025, the majority, 75% of our employees are going to be millennials. What they care about is professional development. I was just speaking to a fellow who’s a millennial and talking about this subject. He says, “I’m only going to give any company five years.” So focusing on staffing and anything that we can do to streamline their processes and provide a work-life balance is going to be the most important thing that we face in the future.


HSPN: I’m wondering what are some of the current drivers of innovation in this space? What’s creating the need for change?

Fried: I come from a 30-year background in hospice care in the nation, primarily in Florida. What I’m seeing in Florida is alarming to me, given what I’ve even seen since I’ve been here in Virginia, working and developing our regional program. We’ve seen double in growth, not the 80% penetration that MA has in the Florida markets, but just in the last three years I’ve been here, we’ve seen double the growth, and we’re seeing what everybody is seeing, reduced payment, longer time to receive reimbursement, more cash flow issues. So we’re keeping a really close eye on that, and how do we survive in our increasingly changing reimbursement environment?

Protsman: I think that the COVID pandemic has really demonstrated the gaps and deficiencies in healthcare, particularly around access to care and barriers to care. It’s also helped us with innovation, though, right? It led us to wrap our arms around telehealth a little bit more, but one of the things, as I said earlier, that we found is that patients and families want that personal connection, and they want more time together. So one of the ways that we address that is by bringing many of the hospital modalities into the home.

By providing that, we give time to patients and families. We give the patients a place of comfort where they can enjoy friends and family and pets and children and really not have to worry about visiting hours at the hospital or rules and regulations around pets, and they’re in a place of comfort. I think that those hospital modalities at VITAS were able to bring high-flow oxygen and other breathing modalities into the home. We’re able to provide IV treatments, and we’re even able to do home extubations with ventilator support. This, again, provides families and patients a much more comfortable and connected experience at the end of life, and that’s what hospice is all about.

Melton: I agree with what both of you have said, but I think we would be remiss if we forgot the regulatory component. We have the staffing issues that are driving innovation. We have a fraud issue, unfortunately, that is tainting the reputation of all of us who are motivated to do a really excellent job for our patients. Looking with a focus on what’s best for our patients and families and really looking to be able to provide that care to the maximum number of patients that we can, should be driving our innovation.

HSPN: Of course, most hospices these days provide more than just hospice. They offer home health, they offer palliative care, and so forth. Does the addition of these other business lines propel any kind of innovation? Cheryl, I know you’ve done some work in this area. How would you respond to that?

Fried: I think end-of-life care truly needs to be reimagined. I think to be conveners with other providers, to be collaborative, provides disruption and innovation, and I believe very strongly that in order to preserve the hospice benefits and to preserve the field and the movement in which it was created, we have to fill the gap between very end-of-life care and acute episodic care. We have to serve those individuals that are in between.

What we have seen over the years, because I can tell you, starting out 30 years ago or somewhere around there, as even going out to calling on physicians and nursing homes and saying, “Please give us early referrals, please give us early referrals,” just hasn’t happened in 30 years. We have to be responsible for what it is that we do as hospice providers to care for that gap so that we can redefine end-of-life care to not two weeks, to a year, to two years, to three years, and how do we get into those areas and provide those social determinants of care and all of the things that you spoke about that are so important for us to keep individuals safe and at home and preserve their dignity at the end of life.

HSPN: Faith, would you answer that question?

Protsman: Absolutely. Partnerships, we have a number of different business lines. I think the most exciting things that are happening at VITAS are the way we provide round the clock care, we have a 24/7 telehealth service that connects clinicians and patients to answer questions, to give medical advice, to connect with a physician, or even dispatch a member to the bedside.

We’ve also partnered with AT&T Business to provide a virtual reality experience to patients. One of the things we’ve found, we’ve done some research with them, is that that can actually help reduce symptoms of patients, such as anxiety and loneliness, but also physical symptoms such as pain and shortness of breath. It’s a wonderful tool that enables patients and family members to have a new experience together. They can travel to a remote destination together. They can revisit a childhood home, something they wouldn’t be able to do in the physical sense. Then recently we’ve launched our My Supplies app and that allows us to customize medical equipment and medical supplies to the specification of the patient and their treatment objectives, and it really streamlines our whole process and allows our clinicians to have more time at the bedside.

We’re able to track orders in real time, and that allows us to collaborate with things like transportation. Then they have instant messaging, which allows our team members to collaborate and coordinate with the HME folks. It’s really been able to reduce down the amount of time our clinicians spend on administrative tasks, as we’ve heard, down to minutes rather than hours.

Melton: I think the one good thing about VBID is it’s requiring palliative care to be involved. It also has a very large focus on how we communicate between entities, and that interoperability of having everybody connected in a real way from the primary care provider to the hospital, to the skilled nursing facility through palliative care, and back again into hospice is going to be a very important focus that is being brought to attention by VBID. What I’m really hoping is we move into the future, that we really move out of our hospice silo, which you all know that we’re in, and really focus on being very innovative in the way that we communicate with all of the entities that are involved with the patient.

HSPN: I wanted to ask if each of you could talk about the innovations you’re pursuing within your own organizations.

Protsman: What’s exciting in VITAS is we actually encourage our employees to identify areas of their workflows and processes that can be improved, and we use low-code technology platforms to create applications that can be used in the day-to-day work that our care team members do. What’s incredible is that it takes these thoughts and ideas and maybe even complaints, right, and it enables our team members to create tangible tools that can actually make their lives easier and help us provide better care, because really, our clinicians want to be at the bedside. They want to be with the patients. That’s the place they love the most. We’re trying to make that happen.

HSPN: If I could ask a follow-up to that. How do the staff communicate those ideas to their leadership?

Protsman: Absolutely. Depending on the level that they’re at, they can talk to their general manager who will then share it with the regional team, and then it goes up to the national team. There’s a project we call VITAS Builds. Within there, different teams are put together to work on a specific problem or issue or place to improve. I was fortunate enough to be involved in one of those and the application idea that we had was reviewed by our C-suite leadership and happened to be one of the apps that they went for. So we’ve spent the last year piloting and testing and we’ll probably roll it out at the beginning of next year.

Melton: Well, I come with a little bit of a different focus. Axxess is an innovative technology company that builds electronic medical records. We’re right in the ring there, really looking at what we can do to improve the end-user’s experience. I will tell you, as a recovering hospice admission nurse, and my husband’s also a recovering hospice admission nurse, if we had a dollar for every hour that we documented after hours in order to get our documentation in, we’d have an island in the South Pacific. So really looking at creating a solution that works for the end-user instead of the end-user working for the solution has been our goal.

One of the things I’m most excited about, having written hundreds of admission narratives, is that we currently have an option, well, it’s not an option, it’s embedded, an admission template that as they document the physical assessment, it pulls in all that information that you’ve entered into the EMR into the template. So, you don’t have to rewrite that they are a DNR in the admission template, you don’t have to enter their allergies, and you don’t have to review the LCDs, because you’ve already entered them into your documentation, so it automatically pulls that. For me, that’s a huge win.

We also have a mobile app that, as you have your visit scheduled for the day, [it] does your mileage [and] your geographic route. It’s like having a Garmin built in, which that’s another thing that I really love. Let me see. Like I said, I brought a lot of stuff. Our patient portal is just really pulling out information for our patients that makes it very easy for the patient to see when their visits are, what to expect, who’s going to be coming.

Our telehealth visits. I just love them. Imagine a world where you’re a triage nurse, can do a telehealth visit maybe using FaceTime, using our dedicated platform, and do a complete visit documentation, rather than going out to do a visit. Now, you can’t avoid all visits, but you can do a lot of good with a telehealth visit. Well, I could go on and on. I’ll stop there, but this is the stuff that really makes me excited.

HSPN: Excellent. Cheryl, will you tell us about the work you’re doing at Blue Ridge?

Fried: Yes. I do come at it from a different perspective. I’ve been in charge of 2,500 census not-for-profit hospices and joined 185 not-for-profit census regional hospice providers. As I said, we’ve grown considerably over the last three years, which has been a privilege, but I think it’s because we really are very community-focused. We aren’t just interested in being a larger hospice. We do lean process improvement. We do all the things to make the visit and the experience the best we can make it. As I said, going back to my early years, it’s not enough that we’re trying to educate about hospice care and about the value and need of that.

I’m thrilled about President Carter and thrilled about the examples that are becoming more public. I truly wish that the stigma would be removed and that a larger hospice would be the solution. The solution really is to redefine end-of-life care, and I really believe that if we don’t own the continuum of that serious and frail population, we will never be able to provide them with a hospice experience. I look at it as being a veteran legacy provider, I suppose, which I never thought I’d call myself, but I do look at it from a different lens and have seen it from the for-profit side and the not-for-profit side, and I feel like it’s not about profits. It’s about the survival of being able to provide the right care at end-of-life.

HSPN: As a community-based provider, how do you remain true to the values and organizing principles of a legacy hospice and build an innovative future?

Fried: Let’s see if I can recap the last three years of my life. It is really about culture. I joined an organization that was celebrating their 40th anniversary as a legacy provider in the area, had been very stagnant in their census growth and not looking at things that are related to death service ratios, or where are we at and who can we provide services that we aren’t providing services to, and I feel like being true to our community is giving back to our staff, is reinvesting in our community.

A PACE program doesn’t happen overnight, just like most of you may not know that an inpatient hospice building doesn’t happen overnight, but these are the things that we want to continue to invest in that we know will help us preserve the hospice model of care in the future, and so it’s important for us to be the well-respected provider known as the provider of choice in our community for hospice to say we are the ones to bring these additional services, we are the ones to partner with, we are the ones to convene with, we care about what matters, that’s our staff and that’s the employees and the patients that we’re caring for.

HSPN: Faith, of course, you’re representing the largest hospice provider by market share in the nation according to our most recent data, but how does an organization like VITAS remain true to the values and organizing principles?

Protsman: We are a large organization, however, the care that we provide is local, the care that we provide is community-based. Yes, that’s the short answer. VITAS really has a culture of giving back to the community, being involved in the community, and it’s not about for-profit or not-for-profit. I’ve worked for nonprofit organizations and they care about profit as much as the for-profit ones do.

Fried: Yes, we do. I am an alumni of VITAS, by the way.

Protsman: I could tell. What I love about working for this organization is that there’s so much support, and really caring about the patients and their families, that is the focus. When I first joined the organization, I attended a conference where the IT vice president was talking about something, talking numbers and all of this stuff, but he brought it down to the patient level. I was amazed that this incredibly intelligent mathematical person can bring it down to the person level, to that patient level, to that family level, and that’s really what our focus is.

I want to add on to one of the things I mentioned a little bit ago about our team members making a difference. One of our team members helped us develop our patient care coordination app. This app allows real-time updates of visit completion and schedule changes. It’s named after our very first patient that we cared for at VITAS.

That app allows us to communicate virtually, locate documentation, make changes, and really narrow down the time that we’ve spent in administrative burdens from hours down to minutes. It allows VITAS team members to be able to complete 60,000 patient visits per week. That is all about the patient. That’s where our focus is.

HSPN: Thank you. Raianne, of course, Axxess isn’t a provider, but say, how would you advise a provider on this question?

Melton: I’ve been in hospice for 20 years, and I’ve had the privilege to work at large national hospices, mom-and-pop hospices, and everything in between. I would say that those businesses who are the most successful are the ones who care about the patients and care about the outcomes. Any company that cares about their patients and their family experience and what they’re doing, is going to grow, because you’re in it for the right reason. I think that the majority of us here, you come to hospice to work, and you either stay or you leave pretty quick, right? I describe myself as the geeky hospice nurse, but I truly am invested and care about my patient outcomes. I think that’s how you do it.

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