Hospices are facing significant headwinds in the coming year when it comes to balancing rising demand with limited clinical resources, according to Croí Health CEO Renee McInnes, who is also a registered nurse.

Hospice News recently spoke with McInnes following Massachusetts-based Croí Health’s recent rebrand, a change designed to better reflect its diversifying scope of services. Formerly Norwell Visiting Nurse Association (NVNA), the nonprofit was founded in 1920 and provides hospice, home-based and palliative care across 27 cities in its home state. Croí Health operates an inpatient facility, Pat Roche Hospice Home.

Sustainability in the current hospice landscape comes with careful consideration around recruitment and retention, referral relationships, as well as ways to meet evolving patient needs, McInnes told Hospice News.

Photo courtesy of Croí Health.

How have you seen the hospice space evolve over the years, and how has your organization responded to these evolutions?

It’s really important to do advocacy work. It’s about how we elevate and highlight our value proposition to payers, the government and our local communities.

I’m advocating on behalf of my organization to say that we’re the prevention model that keeps patients home and out of the hospital. We want to highlight the importance of hospice and end-of-life care and how important it is to have those conversations with your health care proxy and team.

The data shows hospice saves overall health care dollars, but it’s not all about how hospice saves money. Death is inevitable, but what we do is try to have people die with dignity, peace and comfort. Hospices need to do a lot of education and advocacy. It’s working with legislators, your state’s [hospice] associations.

What are some of the significant challenges that hospices face today, and what are the issues that lie ahead in the coming years? How is Croí Health addressing these challenges?

The cost of employees’ salaries and benefits keep going up, and our revenue doesn’t increase enough. Pretty soon we won’t be able to take Medicare Advantage coverage, it’s just so below our direct care costs and the worst payment we receive for the frailest people that we serve. We want to serve those people, but we can’t do it forever if it’s not going to be sustainable. So, it’s working at the national level.

Also, it’s about understanding the red alerts and how we highlight fraud and abuse in hospice and home care. The [U.S. Centers for Medicare & Medicaid Services (CMS)] has asked hospices for our recommendations on how to decrease the regulatory burden and not affect patient quality of care. It’s really looking at how to combat fraud and abuse and be solution-driven.

What are the keys to quality in the future of hospice care delivery amid changes in reporting systems, regulatory oversight and patient and family needs?

You can’t compromise quality. One bad care delivery experience or bad ending of someone’s life comes at a high cost. So, it’s having a great infrastructure around person-centered care. You need preceptorship in your education and training.

I’m actually an advocate for value-based care, because I think it does put the pressure on to make sure you’re meeting value-based patient goals. But it comes at the cost of supporting clinicians in the field with training and investing in compliance. Healthy competition isn’t a bad thing to be held to high standards. Are we spending more money to deliver care? Yes, but that supports quality.

What is your organization’s approach to recruitment and retention of both staff and volunteers?

We have a great retention rate of 96%. That rate is two-fold on not just upfront screening, but also how we treat employees and volunteers. We have an engagement committee with employees as part of the whole solution to what’s important to staff.

We improved our recruiting model about two years ago. We are really screening people on whether they are the right fit for the job, and is the job that you know right fit for them? We now have [new employees] shadow others to see how a day may look in home health and in hospice. It’s about supporting them.

In terms of recruiting, we have found who the nurses are that tend to go into hospice and we’re targeting that group. Sometimes it’s an intensive care unit (ICU) or emergency room nurse who really loves hospice and working with patients and families. We do a lot of targeted recruiting such as geographically fencing areas and looking in certain areas.

It’s a little more challenging for our palliative program and home health, because those nurses are potentially in many different positions in health care. They could be working in the hospital, but then they could be working in an outpatient or a clinic. It’s really looking at the right fit, because it’s not for everybody.

We also work a lot with colleges around Boston. I’ve gone out to speak to them about ways to attract nurses and other people to this industry. It’s something hospices need to do a better job at, which is explaining and understanding how valuable it is. Most people want to do a good job and feel like they’ve made a difference.

What are some of the immediate and long-term goals for Croí Health?

We went through a whole year of rebranding as Croí Health, which means “heart” in Gaelic.

We’ve expanded and grown so much over the past 10 years. We’re expanding our chronic disease, serious illness and palliative care program. Palliative care can be many things to many people, but ultimately these are sick people with high costs that we could better support in the community and want to be at home.

It’s expanding our palliative care and also transitions to hospice that are more timely. How do we talk to patients and families ahead of time? We’re really looking at how we work in a population health model with other providers to support the continuum of care from the ICU all the way through to hospice. We’re working with several primary care providers to develop better processes and workflows to get us patients sooner. It’s having those goals-of-care conversations and starting to work with families to understand how to navigate the health care system and what that means. That’s our future state.

Health care has been siloed, and now is the opportunity for solutions in the crisis of health care. How do we become part of the solution to support the overall health care system? We’re very committed to access and growth.

What is the outlook of your hospice and palliative care programs? Do you have plans to grow these services, as well as any other services? If so, can you elaborate on your growth plans?

We’ve really redesigned the organization as among the only ones in our region delivering primary palliative care in the home. We have restructured the program many times to look at efficiency, but also at increasing access for our patients.

Our caseload of 750 home health patients could have about 10% to 30% of those patients with chronic diseases who are very sick and likely palliative, or even actually hospice. We’ve trained our clinicians and everybody on the care team to have goals-of-care conversations early on. Maybe about 32% to 35% of our home health patients transition to palliative or to hospice because we have these support resources and conversations.

We are definitely growing in our region to cover 27 towns now. When we look at the claims-based data, it shows us the patients who are dying without hospice, who are dying in the hospital. We are not expanding into other towns or in the state, but working on prevention and getting people the care in our region. We are working closely with primary care physicians, with hospitals, with Massachusetts General Hospital and the Dana-Farber Cancer Institute.

It’s all about workflows, processes, communication and collaboration, because we have people in a very fragmented system.