Stillwater Hospice CFO: A Winning Recipe for Improving Rural Hospice Care

Montana-headquartered Stillwater Hospice has found a successful rhythm to strategic rural-based growth and sustainability.

The strategy hinges on building culture, staffing resources and a reputation for quality, according to CFO and Co-founder Chris Graham. Launched in 2017, the hospice company serves predominantly rural-based populations in Montana, northern Wyoming and South Dakota. Stillwater’s geographic service region spans large remote, mountainous areas with rancher, farming and tribal communities.

While some innovative technology trends have aided in improved rural hospice care delivery, regulatory and reimbursement challenges remain a pain point for providers trying to burgeon access among hard to reach, underserved communities, Graham told Hospice News.

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Chris Graham Photo courtesy of Stillwater Hospice
Chris Graham, co-founder and CFO, Stillwater Hospice

What are the most significant concerns among rural-based hospice providers currently? How have the challenges of rural care delivery evolved in recent years?

Staffing is very hard. You’ve got to find staff who are willing and like to travel because they have a lot of windshield time.

It’s also the logistics of remote care. We have patients that live 75 miles or more outside of a town, then once you get there it’s another 20 miles on a dirt road that could be covered in snow and ice. We’re also providing services on tribal reservations, rancher and farmer communities, and seeing people who live in a home in the middle of nowhere. From a cost standpoint, paying for that mileage is very expensive.

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As we look at diversity, language barriers and being more inclusive, we’re doing a better job of providing Medicare beneficiaries with more care. So why let diversification of geography stop us from delivering care to people with different languages, ethnicities and cultural beliefs? We need to have the same respect for geography of where people choose to live and make sure we’re adhering to what the family and community wants.

The rural care delivery challenges have always existed, but I think that hospice has become more broadly known across the country and people want access to that benefit. There’s just more of a need and requirement for hospice, so those challenges we’re facing have come more to light. The constraints we deal with have increased costs and make it very difficult.

What is needed at the operational, regulation or reimbursement levels to improve and address rural-based hospice challenges?

If you’re a rural hospice, you may have higher reimbursement needs. For example, we try to buy vehicles for our nurses, home health aides, social workers and chaplains. They drive for miles on ranch roads at times that ruin their personal vehicles. We have a fleet of about 22 vehicles that we have them drive and we insure them. That saves us a little bit versus paying for mileage. But there needs to be some increased reimbursement to help rural providers, that has to happen.

We also need to have expanded flexibilities that allow us to do hospice care in other ways. Telehealth has been a positive evolution in recent years to help address some of our challenges — that definitely helps in rural care. We’re very glad for the recently extended flexibilities, and we hope that continues indefinitely. We have a hard time finding clinicians sometimes to do all the face-to-face visits, so if the flexibilities expire that would be a big hit to rural hospices. We have towns that we serve where there are no physicians there. Allowing social workers and chaplains to do check in with telehealth, that would allow for more mid-level association with patients beyond the physicians involved in their care. We have a medical director who flies to see hospice patients.

Rural hospice has been around a long time, so let’s figure this out in a way that gets care into these communities. These people in rural areas have earned the hospice benefit as much as anyone else, and we need to find a better way to deliver it to them.

How does Stillwater Hospice approach growth? What are some important pieces of strategic planning to bear in mind for a rural-based hospice?

Growth is tough in rural hospice care for a couple of reasons. Number one is that availability is difficult. We want to maintain a contiguous geographic footprint but we’re limited in that geography. Another way that this is hard is that we’re not running like an urban hospice, and the challenges we face are going to be very different.

We’re running with about 140 employees who see about 250 patients, so it’s harder to cover the distance.

We’ve done acquisitions and we’ve done de novos, but the de novos are a hard, long grind with a lot of time and manpower to do. We’ve found that if a location is five or six hours away, it really has to be an acquisition that already has staff there. If we can find the right people to hire and work with, that’s helpful.

Our strategy that has worked for us thus far is to look at areas in the states we serve that maybe don’t have coverage, have less options or have less competition. Right now we’re working on an acquisition in Missoula, Montana, which is the very far west part of the state. That would give us a very big portion of the state and at that point we’d be the largest hospice provider in Montana.

We actually finished an acquisition at the end of 2023 of Easterseals-Goodwill Northern Rocky Mountain Inc. They are a huge nonprofit operating across four states and have revenue streams in behavioral health, hospice and other services. It took a year and a half to get to know their administrative and clinical teams, and they decided to sell to a for-profit like us because our mission and values aligned. We’ve since doubled the census and are serving more people.

What are some of the strategies that Stillwater Hospice employs to sustain rural hospice care delivery across its service regions?

We use strategic geographic staffing. We’ll make sure we have nurses on call in different regions who can serve people in that local community. It’s very difficult to have enough patients in a community to sustain paying a full-time nurse.

We also purchase all of our own durable medical equipment (DME), buying all of our own beds, oxygen machines, walkers, wheelchairs, everything. We don’t have a licensed DME program, but we do maintain the equipment properly and deliver it to patients. That’s been incredibly helpful for patients.

The other strategy is maybe more philosophical. We are a privately owned, for-profit hospice, but we don’t ever talk about the bottom line. It’s just not a thing that we care about. We have to keep the lights on and keep staff, but our mantra is to find a way to say yes to patients’ needs. The success of serving the community is more important than profit. That strategy has helped us sustain services.

What is key to rural-based hospice workforce recruitment and retention? Can you share some of the initiatives that have aided in staff retention?

When we first started we grew fast. After a couple of years of that, we became much more intentional about culture. We’ve come to learn how important core values are, so our culture is our biggest retention tool. When we find the right combination of the right person to fit with Stillwater culture and who believes in end-of-life care, that’s gold.

Providing vehicles for staff is also a big way to retain people. No other hospice care provider is offering vehicles where we are. Those vehicles help fill gaps of coverage in certain regions and provide the right resources for staff.

We also operate in small towns where everyone knows everyone and word of mouth is big. Sometimes they know someone who works for us, or they knew a patient that was on our services. So a good or bad review can spread like wildfire. In big city areas, provider names can get washed together, but an advantage for us is that our name recognition has grown in these small towns. The vast majority of our people stay on with us. Some that do leave us have come right back. Our turnover rates are very, very low.

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