This article is sponsored by CareXM. This article is based on a virtual discussion with Kathleen Benton, President and CEO of Hospice Savannah. This discussion took place on October 3rd, 2024.

Hospice News: I’m now pleased to introduce our speaker. Dr. Kathleen Benton is the CEO at Hospice Savannah. She is heavily involved in the region through volunteer advisory board roles and professorships at Armstrong State University and the Mercer University Medical School.

Dr. Benton has a master’s degree in medical ethics and a doctorate in public health. She has offered and reviewed many publications relevant to the topics of palliative care, ethics, hospice, and communication. Her first publication, a children’s book entitled Daniel’s World: A Book About Children with Disabilities, is the closest to her heart. She lives her vocation passionate about helping families through ethical decision-making processes. She resides in Savannah, Georgia with her husband, Rex, and her three children, Julia, Grace, Jack, and Andrew. Dr. Benton, thank you for being here.

Dr. Kathleen Benton: Thank you for having me, Jim. I’m excited to be with everyone today.

HSPN: Perfect. I’ll let you take it away.

Dr. Benton: I just want to begin by telling everyone hello. If you’re in any part of the country that’s experienced this terrible storm aftermath, I hope you are much more fortunate and have power and are able to survive the devastation. I know a lot of people are in bad places right now. Many of us, those of us who lead healthcare communities and organizations, are in trouble trying to make sure our patients have their needs met.

Today, we’re going to talk a lot about a different kind of need, a need that stems from learning and understanding communication. We’re going to explore some innovative techniques that I have used with my organization. I welcome questions. I welcome discussion. Hopefully, this will be a very interactive session. A little bit about where I come from. Savannah, Georgia, is apparently now a bucket list town, so we get lots of tourists down here.

I lead a hospice with about 260 ADC patients, including an inpatient unit with 16 beds, and 1,700 patients in palliative care ranging from clinic, inpatient units, and in the home. We also run a caregiver institute and a Full Circle grief and loss center. I’m like many of the other nonprofit hospices across the country, doing a lot of very purpose-driven work. I, myself, from my professional background, I have to always tell my story because I feel patients pretty much teach you everything.

The first time I ever told a patient what my profession was, I walked into the room working at the hospital system at the time, and I said, “My name is Kathleen. I am the ethicist for the hospital.” The family of the patient pretty much put hands on either side of the door, looked at me, and said, “Ma’am, thank you but no thank you. We do not need an exorcist in this room.” Right away, I was taught the quick lesson that no one knows, at least 20, 22 years ago, what an ethicist is. Just a short education on that.

I was schooled in clinical ethics and really mediating ethical dilemmas in health care. Looking at, is this in the best interest of the patient? Are we truly following the patient’s wishes? Many of the dilemmas, I would say a good 90%, occur at the end of life. That right away got me very involved in not just health care but end-of-life rights in health care. It taught me so much after 12 to 13 years of doing that, really trending cases that seemed so different, but at the root of all of those cases was one missing element.

That element was the lacking area of communication. What do I mean by that? I believe that health care does the worst job of probably all other areas of communicating with folks. We have really taken what it is to be human out of what it is to treat a patient and a person. This has severe consequences. When we look for a diagnosis based on symptoms, but we’re not really listening to the patient and their history and their background, then we may miss huge parts of the diagnosis.

The same holds true in prognostication and in delivery of end-of-life information that if we don’t really take the time to listen and understand the culture and the background, the diversity, and just the personality of the people that we are talking with, the families and the patients, then we really aren’t doing good service to end-of-life care. We aren’t learning their needs. We aren’t learning their understanding of what’s going on.

Put simply, what I found was at the root of all, most all of my ethical dilemmas, there was always an element of missing communication. Frankly, the majority of the time, it was on the side of the healthcare delivery team, not that patient and family, that we weren’t listening. We weren’t saying the right things. We weren’t using the right semantics. There began really my longtime study of many cases, looking at what we could do better and what tools we could find in our healthcare world and beyond to communicate better with very vulnerable patients.

I think the most that I learned and that I have to offer in life did not actually come from that training or that professional experience but instead came at the early age of five when my youngest brother was born with the same disease as the Elephant Man. Daniel was born with a disease called Proteus syndrome. Throughout his life, he had 110 surgeries and thousands and thousands of hospitalizations all over the country and even various places around the globe.

I can’t imagine learning more from being the sister, being the caregiver of Daniel, just to see all the gaps in chronic care management, to see all the gaps in care of the seriously ill. For example, when he was first placed on a trach, it’s like it happened at the blink of an eye without any real discussion. We just moved on to the next thing without a serious discussion about wishes.

Daniel eventually passed away about eight years ago, but not before he was placed on that trach and peritoneal dialysis and feeding tube and many other interventions and, all the while, not really focusing on what he wanted as a good quality of life. I feel that it has privileged me to live alongside him and to have watched him die, to be able to share that journey in understanding what we can do better for our patients, again, who are the most vulnerable, who are the absolute sickest.

To start all of that off, I think I’d just like to share that in my own organization, I sit down with the staff once a month at orientation, new staff, and I remind them who we are taking care of. We all know we’re taking care of dying patients and that’s a given, but what we don’t often realize is that these dying patients are oftentimes, they may say, or their families may say, “This is the worst day of my life.”

When you are in a role that is your job or your vocation, dependent upon how you view it, and you are serving people who say that they are in the worst day of their life and you have the opportunity to rescue them from that or to support them during that, that is both a burden and a privilege. It’s something that right away, being in hospice, I think we all have to realize because it means that the chips on our shoulders that we might carry from day to day have to disappear.

We need to know that one thing. That one thing is good communication. That one thing is about listening. What does that mean? That certainly does not mean knowing a medical record number or even a disease, even the symptoms your patient is having. Rather, the more important thing is, do you know the name of that person, that family member, and then what they like to be called? Do you know that they love to garden and that the family member has a tomato garden in the backside of the house?

Do you know that they have very, very little control over what is going on in their lives at that moment? We’re there to help them through that time. We are there to be the team that surrounds them and make sure that they can be lifted up in a vulnerable time. I’ll oftentimes give an example of challenging communication that needs to occur. If a CNA is traveling to a house and the patient prior has made him or her late, not only does that call need to happen to say, “I’m so sorry. I’m running late,” the call needs to be with knowledge of what you’re doing.

You’re running late and the only control that family members had all day long to help to get that good bath. The nurse is going to be here and help make you feel a whole lot better.” If that control is lost because the CNA or the nurse or the chaplain is late, then we’re taking that control away from the family member and they already have very, very little.

The families have very little control to help the patient, and the patients have very little control over their life in general. It’s so important that we remember the one thing – a listening ear. The one thing is the overt communication that has to be focused on with that family. We have to know that this is Mrs. Smith, who gardens when you’re there to give a bath, that this is Mr. Jones, who just went to the wedding that he always wanted to go to. Wedding cake is one of his favorite things in the world.

These are the points of communication, the humanization that we can bring back into health care, but they only can come back if we have tools and mechanisms to allow us to listen. Right now, it’s important to note the reality of our culture and that’s many things. That is, we work in healthcare during the perfect storm. The perfect storm includes what we should have anticipated 10 years ago, but not everyone’s eye was on the ball, that we would be in a population of people who are extremely robust, age 65 and older.

We are in an imbalance in the United States of the aging and the youth. What does that mean? That means that those who are aging and who are getting ill because that is a huge part of aging dramatically outnumber the young caregivers who are coming up to take care of them in many, many different ways, whether it’s to deliver their drugs by driving the FedEx or UPS truck or whether it’s to be their nurse or whether it’s to be their sitter or whether it’s to answer the phone.

In all different vocations, the working population is much lower than the aging retired population. That storm also includes our time with COVID and the pandemic, which, of course, created one of the greatest resignations. Those who might have stuck out health care for a longer time left just like many other professions. Again, caregivers have dwindled. Likewise, many folks do not know, unless they’re in the collegiate education level, that we are about to embark upon a time where there are lower youth than have ever been in the United States because of the recession that occurred in ’07, ’08, and ’09.

There were fewer children born at that time. The colleges are anticipating less folks will enter. What we should know is that it means less nurses, less CNAs, less younger staff to be able to take care of our patients. That is one important part of our population that we need to face. Why do we need to face that? Well, because if we continue with the language “when I get staffed up, this will happen. When I’m finally staffed up, things won’t be like that.”

That is not likely going to be something that happens, at least consistently, in the future. We are all going to experience very, very short staffing, probably indefinitely because of this population imbalance. I think the important thing to do is to face that. The way that we face that is to understand that we’ve got to find other innovative ways to help our staff and to work with the staff we have instead of just hovering around the thought that we will eventually have everything that we need and all the staff that we need.

The other important part of our population right now is that we are in a time of Amazon. The Amazon population is one of immediate gratification. When you need something, many of us are Prime members, and it is there on your doorstep. When you get used to a culture like that, that’s going to be the expectation for any service, including your hospice team. You may find that in your CAHPS scores or just in the reactions or complaints of your patients and families, we have a really hard time pleasing them and making sure that expectations are met.

Again, we’ve got to find lots of tools. What are those tools? A big piece of this is overcommunication. We can train and we can educate. We can inundate our staff with ways of great communication and listening skills. We also have to pair that with lots and lots of tools to be able to help our staff be short-staffed, help our staff deal with high expectations, and help our staff during the perfect storm of growth in an aging population. Those tools, we’re going to talk about today.

We’re under incredible pressure. Certainly, the pressure is the expectations and the population, the division that comes from political and media sensationalism and all the rest of it. We’re also under huge financial pressures in health care, the cost-cutting, the hospital closures, the partnerships that are lost, the joint ventures, the change in ownership, more change in ownership in healthcare organizations over the last two years than ever before in the history of health care.

All of these things we’re up against, not to mention the incredible audit burden. It used to be in hospice, we didn’t have to have a regulatory agent or a compliance and privacy officer. There are so many more infrastructure needs. Certainly, we’re not trying to victimize ourselves by painting this picture, but we do need to face the reality of the world we live in hospice. Instead of complaining about it, again, find the tools to meet the population where it is at.

As a CEO, we look at different solutions to say, “How do I engage patients differently? How do I foster the relationships that absolutely need to exist when I have maybe 10 PRNs case-managing patients?” Of course, those of us who have been schooled in hospice for many years know that PRNs are wonderful, wonderful staff, but they don’t necessarily have the baseline, the continuity, and the consistency that our patients need to develop that rapport, and to be able to really say, “Mary is not at her baseline because every day when I come, she eats a full bowl of cereal. Today, she’s only half or hasn’t touched her cereal at all.”

We have to address those concerns even if we have the staff to cover. Again, what are the tools? I absolutely believe that we look to technology. I think that technology has been given somewhat of a bad rap at times in the world of health care. Why do I say that? Mostly because I know very well, the dialogue that goes along with discussion around an EMR, EHR, when many clinicians or even leaders will comment that there’s always issues with the EHR, that it dehumanizes health care, that we don’t like to do bedside documentation, that maybe it’s the best way to get everything in and not miss a piece, but it takes away from the personal experience.

We know that technology is certainly a double-edged sword. We really have to find the technology that links with humanization, the technology that ever embraces that touch, that human touch, something like the touch of a masseuse, the masseuse that will never lift a hand off of his or her client when in the middle of a massage. That’s what you’re looking for. You’re looking at chronic touches, many touches to develop that rapport and get to know your patients through a different tool.

When I looked to find that tool, what I was looking for was something similar to what I had seen truly in the hospitality industry. It was one day when I was at a hotel where I checked in. The minute I got to my room, I thought, “This is amazing.” They have already checked in and asked me, how am I doing? Was the check-in too long? Did it go okay? It wasn’t a robust survey. It was just, “I’m Bob. I’m your butler,” or “I’m your help. I’m your helper for today. Can you let me know how things are going?”

I really thought about that and said, “How do we apply that to health care?” Likewise, I wanted to find ways for access data. I absolutely believe that the root-cause analysis necessitates data. If your CAHPS scores say communication is low, then you’ve got to understand, what are your end-of-shift reports trend? What isn’t happening? What kind of protocols could be improved to really enhance the teaching and communication we need in health care?

Again, I was looking for major, major family and patient engagement. I wanted something that embraced and solved for how can I get to my patients faster? Can I stop the one issue that takes a family from happy and satisfied and all the services wrapped up in a big bow to this one issue ruining the entire satisfaction? As an example, I had a patient who had three beautiful weeks in hospice. From the referral to the admission to the case manager, everything went along beautifully.

Then there was an after-hours need where there was an infection and there was an antibiotic order. The antibiotic was not delivered timely, and the choice was not communicated to be able to go to a local pharmacy and get that antibiotic right away. Instead of the antibiotic coming within a matter of hours, it happened 24 hours later. That small window of time, even though that after-hours nurse responded beautifully, that little piece of miscommunication, those few hours that were missed giving that antibiotic ended the entire experience satisfaction in zeros.

I do think that’s what we’ve seen much of the time with our patient population, because of that expectation, it isn’t an allowance for grace. Rather, it’s just becoming upset automatically. I had to find a way to try to get better at this. I found that to be an actionable approach. I used the situation with the hotel and said, “How can I reach out to patients during the path and know how they’re feeling and not find out later, even if they don’t want to tell the clinician, even if they don’t have that rapport with the clinician?”

That’s when I found the CareXM mechanism for patient satisfaction, which was fully HIPAA-compliant, and allowed me to start with the first touch personally. Personally, a first touch with my patients and families. We filmed our own video. The video was of me. From the moment my admissions nurse brought that patient in on the initial assessment, the cell phone got a text message with a play of a video that said, “We are going to help you every step of the way.”

I went through all of our services and went through ways to reach out for patient satisfaction and even ended that with my cell phone number, which I’ve been giving out for 20-some-odd years of doing health care, and it has never been abused. I’m a firm believer in that tool and communication. The next CareXM outreach came just a couple of days later. How was the admissions process? Did everything go perfectly? Very simple questions, 1-5 rating, not much effort on the part of the patient or family.

If they did not rate a four or five, what happens? That drops to a trigger to our indirect staff in medical records who immediately is triggered to call a patient or family and say, “I see that you did not rate us ‘very good’ or ‘excellent.’ Please tell me what is going on. Has something fallen short?” Two things happened in that pilot that I loved. We were able to give our understaffed staff tools for help because, number one, whatever complaint was not going to be laid on the ears of the case manager who visited four or five days later. We were going to get ahead of it. Hopefully, we were going to correct it before that case manager ever came out.

Number two, we were involving folks who were behind the desk in fieldwork. Not only did that give them the opportunity to help field staff, direct staff, but it also gave them the opportunity to be as much a part of the mission as they’ve ever been because as we know, at all levels, we’re a part of the mission. Beyond that, it gave them patient contact. We trained them on how to script and discuss what was going on. Then that data was sent to the clinical coordinators.

If there was a clinical issue, the clinical managers called immediately. In a matter of hours, even on a weekend, assigned to the on-call, we had that resolved. Unbelievable difference in patient satisfaction and care. I brought my own scores for everyone to see because what are we, if not vulnerable, for our other partners to say we’ve certainly had times of negative scores? We have months where we only collect six or seven surveys.

If we have a zero, you’re going to see a 70. I’ve had a month where I saw a 60 or 65 on some of these issues. Since we have done this CareXM pilot, the first part of the pilot was for my patients who were unassigned. That was 30 patients who had no case manager, and we were using PRNs. It wasn’t necessarily regular contact. That went so very well. We extended it across the universe of all patients.

Can you see the second month of CareXM impact? The numbers are clear. If you have tired eyes like mine, 93, 92, 100, 97, 93, 84, 100, 100. Excellent scores. I have to believe that is the value of these tools in better communication. It is not dehumanizing with more technology. It is finding the balance between taking a technological-savvy tool and finding staff that have the time, the value, and the impact, and grouping them together to make a beautiful service that will actually impact the whole organization.

Again, therefore, the direct staff and maybe you’ve been in meetings like this where they say, “What are you going to do about the staffing?” Now, I can certainly say, “We have seven contracts with recruitment companies.” I can say, “We’re going to have four recruitment events a year,” but they’re already used to that. We’ve been doing that for the past three years. They know that we do receive value out of that, but is retention always there? Certainly not. With patient growth, the need is more.

Again, facing the population and facing the culture that we’re in right now, when they say to me, “What are you going to do about staffing?” I instead like to respond, “I’m going to innovate staffing. I’m going to innovate it in two ways. I’m going to find the tools that are going to make your job easier. They’re going to help you and be your teammate in this job. I’m going to be a personal part of this.”

I can tell you; I believed in CareXM from the beginning, I invested my personal money in the initial education and consultant pilot because I wanted them to know that I was personally invested in helping this to grow better. When we started, we really wanted the team to understand that this wasn’t just one more thing. In fact, the case managers and the CNAs, the direct staff, are not involved with this at all. It is all of us that are indirect that are involved, including myself, because I am on call in the rotation of administrative calls.

Certainly, if a trigger comes in during the week, then I have to be a part of that. I wanted them to know that we’re going to be on the other side of it and while we’re not doing initial assessments and we’re not doing face-to-faces, no, we’re not doing those. We’re trying to take the other things that can be cumbersome in your role. It was a real call to action. Then the other thing I explained to them is my second goal with CareXM, which is if Domino’s and other pizza companies can tell people that they’re five minutes away, then so can I, using technology.

My next goal in the use of CareXM, again, in meeting the population of high expectations, is to be able to say, “Rose is on the way. Sammy is on the way.” That technology will help that CNA or that nurse not to have to pick up the phone and call and say they’re delayed, but it will be a tool for communication so that the family feels control. That CNA, that nurse, that social worker, that chaplain feels supported in the field by this robust tool.

Then the third way is AI in really embracing the technological world and getting in as a beta for AI and EHR. That is my vision for the future. That’s where I think we all need to be. As leaders, we need to sit down and say, “We are not necessarily where we need to be in staffing and we may not ever reach that point, but we have to grow a culture of support another way, and that is looking at our environment where it’s at.” Where it’s at is brilliant technology and companies that really do care about the patient.

Your delivery and your pilot may be very different from mine because your culture may be different. You may have different “indirects” and you may have less staff. You may have to pivot or tweak how you deliver this. What I will say is the CareXM staff worked with us the whole way, learned our process, learned our protocols, learned what works for us and our culture alone. That is why I think we are having such success with this. The organization has now embraced it. I have three organizations.

Next, the palliative care organization would like to use it for their own staff. We’re going to look at a pilot there first. We have great plans for the continued use. We really do believe in it. The organization is happy with it. They feel supported. They feel that we’re invested in trying to make this different. They know the population of caregivers. They understand what we’re all up against. We’ve got to look at doing it together so that we try our best to avoid burnout. We try to promote a culture of absolute teamwork.

I hope that your future vision for your organization will include innovation. I tell my leaders all the time, “If you are not failing, then you are not doing.” We have got to continue to try and to throw in innovation. Some will work, some will not. Our first pilot didn’t have all the right questions, didn’t have all the right videos, but we kept at it. I hope that you will consider this as well.

I am always a resource for this pilot and others. I think hospices, we make a choice in doing this kind of work to take care of the vulnerable. We certainly need to do it together so we’re not out there trying to reinvent the wheel when one of our peers has done something very robust and successful. I certainly thank you for your time and would welcome any questions. Jim?

HSPN: What resources did you find to be most successful in supporting families?

Dr. Benton: I really feel like the patient satisfaction survey supported families because, like I had said in the beginning of this, our families have a huge lack of control and when they are able to give feedback and get involved right away to make a difference. Much of the time, they end up waiting until after the patient is deceased to complain about something that occurred. That’s just because they don’t have the energy or the thought that they might be able to make a difference. Putting it right in their face made it very easy. It is hugely important to reestablish their ability to control the situation and let them be a part of resolve right away.

HSPN: If a patient or family has a poor experience after hours, what guidance do you have to course-correct? How do you re-earn that trust with the patient and family?

Dr. Benton: I’m of the thought and this is not proven with any kind of data, but it seems to me when you exercise good service recovery, oftentimes, the family is more satisfied than if the issue never occurred in the first place. In other words, whatever went wrong, if it didn’t go wrong, if it stayed perfect, oftentimes, they’re not as satisfied as they were when something didn’t go perfect, and then we recover it. A lot of that is because I think at everyone’s root, we all know we’re not perfect. We’re all human.

Certainly, the hospice nurses, hospice clinicians, hospice staff are just the same, not perfect and human. When you’re really able to take the time in an after-hours or other situation to reach out, to listen, if it can’t be resolved, to push it up the chain and listen again, and reinforce the fact that your staff are humans and that we actually are extremely compassionate to their concern. We just want to make it better in any way. Some of the complaints are very emotionally charged and may seem minimal to staff. As I said earlier, the lack of control can make something minimal, huge.

I think the worst response is no response and to try to avoid it. The best response is apologetic. We’ve gotten way too used to healthcare not apologizing, because we live in such a litigious world, but there’s always something to be sorry for. You’re sorry that it didn’t go the way they needed it to go. You’re sorry that they didn’t listen to exactly what the needs were. You’re sorry that our organization doesn’t have what they thought it had, but we do have X, and can we do this instead? That kind of scripting is really important. Usually, it has a better outcome than no action at all.

HSPN: How did staff perceive the technology as you implemented it and how much training was required for them to get comfortable?

Dr. Benton: In the beginning, I think the staff thought it was going to be one more thing. We created a committee because we wanted input from everyone. We didn’t just want to put it upon them. We wanted it to work seamlessly with the admission service. I think it was about three months of training to make sure that the staff, especially those who weren’t used to being patient-facing, understood how to talk through these issues and did not feel off-put by anyone. After three months, everyone seemed to use it seamlessly. Everyone loved it. The nurses were hearing good feedback. The CNAs were hearing good feedback. Of course, the scores showed.

HSPN: From a PBM perspective, the asker of this question wants to humanize our relationship with their hospices as well. What would you recommend to a PBM to be able to support a hospice and not just provide data and metrics but really make a hospice feel supported?

Dr. Benton: Partnering alongside satisfaction is key. Drugs that do not come in are a huge issue. Them being willing to receive that feedback and be a part of the service recovery would be forever valuable. Then it becomes, it’s not just about supplies and data and metrics. Again, it’s humanizing the PBM and saying, “Oh, well, this came late. Certainly, it was the delivery service, but we partner with the delivery service, so it’s our fault. Let me call and see, how can we make it up to this family? Let me help explain to this family what happened.” I think people are afraid to get out there in front of the complaint and really, by default, most folks are non-confrontational. I think sometimes there’s just a time for being confrontational and getting in front of the problem. When our partners are willing to do that alongside us, it makes it a lot easier.

HSPN: What was the communication method that you used for the first touch video and the second touch survey?

Dr. Benton: CareXM gave us the communication, so we bought into a CareXM program that goes through the phone. It simply triggered CareXM, worked with us, and triggered uploading the video to the library, came to their text chain, and the video appeared right in front of them. They don’t have to be in front of a computer or anything like that. They have all of the tools necessary, and it is their patient satisfaction survey tool.

With over 35 years of experience serving healthcare, CareXM understands the complexities of delivering care while managing incoming calls and coordinating care. Deliver an elevated care experience for patients, caregivers, and providers with the #1 after-hours triage and patient engagement solution. To learn more, visit: https://www.carexm.com/.