Hospices Seek Special Focus CONs to Reach Underserved Populations

Some states with certificate of need (CON) regulations have special focus policies that allow hospice providers to expand services among underserved communities. But navigating these CON processes can be a challenge.

State medical facilities plans (SMFPs) are programs built into CON processes that focus on expanding health care services among populations with specific unmet needs. Though not widely used among states, these can be a route for some hospices seeking to improve disparities among individuals lacking diverse, equitable and inclusive end-of-life care.

Hospice CON applicants taking the SMFP route can petition to launch services within an area or at an institution where patients and families with special attributions lack resources or require care that differs from services provided by standard methodologies and policies. This can include end-of-life and serious illness care among minority groups with various physical, socio-economic, spiritual and cultural needs.


A difficulty in seeking these types of special focus CONs is proving an unmet need among specific populations, according to André Lee, co-founder and administrator of Nashville-based Heart’n Soul Hospice.

“It’s hard to convince and describe to regulatory committees and existing providers in a certain area that you hope to accomplish a change in tenor of the environment for those in the minority presence of their communities,” Lee told Hospice News. “They may not understand or see that they do not have a penetration in the minority population. It’s not overcrowding a market; it’s bringing in a new era of representation to hospice care. You need data on the population to prove that.”

Heart’n Soul Hospice provides home-based hospice services in Tennessee and Washington. Lee, along with co-founders Bishop Sandy McClain and CEO David Turner, applied for a license to establish the hospice in 2020 during the pandemic.

Sandy McClain, David Turner, André Lee Heart’n Soul Hospice
Heart’n Soul Hospice Founders Sandy McCain, David Turner and André Lee. Photo courtesy of Heart’n Soul Hospice.

The hospice has since expanded to three counties in middle Tennessee and has considered expansion in Alabama, among other neighboring eastern states, Lee stated.

A common thread of many CON processes is they lack the ability to determine health equity gaps, something special focus programs can help address, according to Lee.

Including methodologies in CON applications that assess disparities in a community could aid in breaking down barriers among underserved populations and also reduce overall health care spending at the end of life, he added.

“Each state has its own steps along a CON process, and most of them have a formula they use to indicate whether or not you’ll be allowed to start a hospice based on need,” Lee said. “But these formulas don’t often have a breakdown in terms of the details of minority constituents within a region. You don’t often have a window into how many minorities in Black, Hispanic, Middle Eastern or other backgrounds are transitioning into a hospice. So, the degree that you can examine that data down to that degree of unmet hospice need among underserved populations, that’s one step toward reaching them, building trust and having monetary savings when these patients are kept out of expensive hospitals and other care settings.”

Virginia and North Carolina are among the states with SFMP certificate of need programs in place that apply to a range of health care facility types. 

A major objective of SFMPs is to provide policies and projections of need that guide specific health care facilities and services, including hospice, according to the North Carolina Department of Health and Human Services (NCDHHS).

“Development of the SMFP is a continuous and open process,” NCDHHS representatives told Hospice News in an email. “Projections of need for the various facilities and services are used in conjunction with other statutes and rules in reviewing CON applications for establishment, expansion or conversion of health care facilities and services.”

In addition to seeking out public commentary from community members and health care organizations, SMFP CON processes can be very “data-driven,” according to Matt Wolfe, office manager shareholder, Baker Donelson, Bearman, Caldwell & Berkowitz, PC. The advisory firm represents clients across the United States, including the Association for Home Care & Hospice of North Carolina (AHHC-NC).

Hospices considering a CON with an SMFP focus should back their application with demographic information of the particular region, taking into account whether there’s a true need for an additional provider for residents that may not be fully served.

“The opportunity to petition for an adjusted need or special needs determination comes with data around things that may not be addressed in a particular county,” Wolfe told Hospice News. “There’s limitation on the certificate of need law as to whether an application can be approved to serve only a particular subpopulation or certain groups of socioeconomic or ethnic status. The methodology to determine a need for an additional service is applied every year based upon data that’s submitted by existing hospices’ demographic information, and that varies depending on what type of services they provide.”

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