Wednesday, November 13, 2019

Orange Crate Update #4 - Welcome Our New Robot Brain Friends to the Hospice Team

robot brains for 
rolling robot talking doctor heads

From the investment site SeekingAlpha
(audio for SeekingAlpha subscribers only)

Transcripts | Healthcare Humana's (HUM) CEO Bruce Broussard on Q3 2019 Results - Earnings Call Transcript Nov. 6, 2019 5:21 PM ET  | About: Humana Inc. (HUM) Q3: 11-06-19 Earnings Summary Press Release 10-Q EPS of $5.03 beats by $0.47 Revenue of $16.24B (14.32% Y/Y) beats by $89.34M.

Here's how it looks from the ground as reported by friend and critical observer Anonymous at Strange Tony's Generic Hospice Blog:

Big Picture for Kindred at Home

"Two web meetings addressed Kindred at Home's future under the ownership of Humana and two financial rapscallions, TPG and Welsh, Carson, Anderson and Stowe (WCAS).  The first occurred on November 5th when KAH President David Causby and Hospice President/Curo Health Services founder Larry Graham held a fireside web meeting for employees.

...Causby wants Kindred to be know for stellar clinical care and being innovative.  Management's priorities are to provide enhanced benefits and show appreciation.  The Curo way at our hospice has been the opposite of everything he stressed.  Humana et al delivered poor clinical care, rigidity under bad systems, benefit cuts and zero acknowledgement of hard work and high performance by dedicated staff (most of whom are now gone).

The dastardly duo ended with a dark future under Humana with artificial intelligence determining the level of care and what day that should be delivered.  The goal is to decrease hospitalizations for Humana's Medicare Advantage enrollees and decrease the live discharge rate for hospice.  That might mean only admitting patients who actually qualify for hospice.  The pressure to meet targets for admissions and average daily census had patients sneaking onto service that clearly did not qualify.  That pressure grew after Humana, TPG and WCAS bought us in July 2018."

Read the whole thing

Also too:

Blast from the past - NYT 

When a Health Insurer Also Wants to Be a Hospice Company
By Reed Abelson
June 22, 2018
"Humana is teaming up with two investment firms to become the nation’s largest provider of hospice care, dominating a rapidly growing — and controversial — business."

Thanks for reading. See you next time. Happy Hospice Month!

*not a solicitation or financial advice, for education purposes only

Wednesday, November 6, 2019

November is hospice month! How do you find a good hospice?

Not enough staff?
Do not pass 'Go'

Hospice in America is a $19B+ industry. We're talking about real money from a customer everyone knows can pay the bill - the federal government. Almost two-thirds of the players are corporate for-profit regional and national hospice chains, and they're selling hard.

They're also well-organized, including with an industry trade group and paid flaks lobbying Congress and churning out press releases.

Hospice is also probably the least transparent industry operating today - even compared to others that have long been notorious for their secrecy, like the funeral business. I haven't met anyone who's selected a hospice based on the kind of detailed comparison shopping they've done for a new car or vacation destination.

I can understand why - looking for hospice sounds like a grim task, so it's easy to avoid.

But the bigger reason is simple - there's very little useful information available that can help a patient, family, referring provider, or even just a curious, highly motivated, death-positive individual looking to check out their options, just in case.

I'm working on a longer piece that explores this conundrum in greater detail, and it's taking more time and has gotten more detailed than I first anticipated.

So in the meantime, I thought it would be helpful to revisit the suggestion of my friend, colleague, and data wonk Boo Boo, who made the argument here two years ago that it's possible for us to get a good sense of a hospice based on one important number.

Here's my own "bottom line" about evaluating a potential hospice, in an environment where that term "bottom line" has assumed greater importance over the past 20 years: if they don't have enough staff, they can't even begin do the work reliably, consistently, safely, or with any expectation of decent quality.

What if a hospice can't clearly satisfy you with an answer to, "Do you have enough staff?" 

My suggestion - walk away.

Shiny happy people laughing*

The hospice industry trade group is trying to being helpful with a glossy Consumer's Guide to Selecting a Hospice Program (pdf), along with a one-page cheat sheet of questions to ask,  Choosing a Quality Hospice for You or Your Loved Ones. (pdf, header above).

I find most of the questions unhelpful, because they don't lead to the kind of information that could differentiate one hospice from another in any meaningful way. The third question prospective patients and families are instructed to ask is blatantly self-serving - Is the hospice you're considering part of our hospice industry trade group?

That statement reminds me of a speech Jimmy Carter made in 1974 as Governor of Georgia. It's called his "Law Day Address" because it took place at a luncheon event on that day - May 4. Someone there also made a low-quality audio recording, perhaps on a portable cassette tape player. Here's the relevant passage:

"The regulatory agencies in Washington are made up, not of people to regulate industries, but of representatives of the industries that are regulated. Is that fair and right an equitable? I don't think so.

I'm only going to serve 4 years as governor, as you know. I think that's enough. I enjoy it, but I think I've done all I can in the governor's office. I see the lobbyists in the state capital filling the halls on occasions. Good people, competent people, the most pleasant, personable, extroverted citizens of Georgia. Those are the characteristics that are required for a lobbyist. They represent good folks, But I can tell you that when a lobbyist goes to represent the Peanut Warehouseman's Association of the Southeast, which I belong to, they go there to represent the peanut warehouseman. They don't go there to represent the customers of the peanut warehouseman.

When the Chamber of Commerce lobbyists go there, they go there to represent the businessman of Georgia. They don't go there to represent the customers of the businessman of Georgia.

When your own organization is interested in some legislation there in the capitol, they're interested in the welfare or prerogatives or authority of the lawyers. They are not there to represent in any sort of exclusive way the client of the lawyers.

The American Medical Association and its Georgia equivalent - they represent the doctors, who are fine people. But they certainly don't represent the patients of a doctor."

To their credit, towards the end of the one-page cheat sheet the hospice industry trade group includes a muddled indirect version of the single most important question to ask any hospice:

Do you have enough staff?

But this weak sauce is still too strong for some members of the hospice industry trade group, because the long-form glossy adds in this great example of weaselspeak - hemming, hawing, dodging, and obfuscating: 
Gotta read the fine print weaselspeak

This weaselspeak begs another question - why wouldn't a hospice be willing to share that information? 

The most obvious reason is simple - because the answer isn't a favorable one, and the hospice would rather keep the public in the dark about its unsafe staffing

Unsafe staffing should eliminate any hospice from consideration. A hospice with unsafe staffing is a hospice that abuses its staff with unreasonable demands, subjects its patients and families to risky poor quality care, and makes you wonder what else they're trying to hide.

One of my favorite online and social media pastimes is asking hospices about their staffing:
The biggest hospice in Massachusetts has never responded

Two years ago Medicare rolled out HospiceCompare, their early attempt to support the first of the four admonitions of the Death Nurse Manifesto: Patients and families need to know more and demand better.

At this point one of the best features of HospiceCompare is a their version of a two-page cheat sheet Suggested Questions to Ask When Choosing a Hospice (pdf) which includes a form of the most important question:
Do you have enough staff?

Finally, here's an interview with Naomi Naierman, the founder and former CEO of the now-defunct American Hospice Foundation, about how to chose a hospice. This is an important exchange:

Q. " can families interview hospices?"

A. You might find they’ll come to your home... That’s a time to ask questions. Or you can call on the phone. How receptive a hospice is to these questions is the first signal of their quality."

Thanks for reading, see you next time.

*with apologies to REM

Saturday, November 2, 2019

November is Hospice Month! So, what's news in corporate hospice? A story told mostly in pictures.

"It's money that matters.
You know that it's true."
  Randy Newman

November is the month to be aware of hospice, and that means it's time to look at hospice's biggest and fastest growing sector, the privately-held and publicly-traded companies trying mightily to get their hands on as much as they can of the *$19,000,000,000.00 +/- Medicare paid out for hospice in 2017.

*That's nineteen billion dollars, give or take.

Whose Hospice?

There are lots of players bouncing around the for-profit hospice space, but here's one that caught my attention and continues to educate me about corporate hospice, Caris Healthcare.

First, take off any rose-colored glasses that may obscure the proper understanding about the true nature of our work in hospice.

I'm not kidding

This also explains something I've been hearing since I first started digging more deeply into for-profit corporate hospice, namely the term, "same store sales."


My nursing colleagues, physicians, and other clinicians often describe our knowledge and practice as the skillful combination of art and science. In the world of corporate for-profit hospice, the main difference between a hospice nurse and the kid who hands over a bag of fries is that the hospice nurse's boss needs to watch them more closely.

Service failure

Being on the Board of Directors of a industry's national trade group is a valuable platform. Very valuable.

Spoiler alert - pills fell on the floor

The corporate website is one way to learn more about a company. I also like to assess the company's approach to its website and other materials, because I think it provides useful insight into their mindset and culture. Here, for example, Caris has chosen to put their own people front and center instead of using stock photos. 

Absolutely positively perfect

Of course they're tooting their own horn in this blog post, and who wouldn't? It's a compelling story and deserves telling. Then I clicked on the photo...

Is this somebody's idea of a joke?

Or, maybe their hosting platform has a technical requirement that all pictures must be uploaded sideways.

Is this somebody's idea of a joke?

I didn't know much about Caris before their CEO shared his vision for the best hospice earlier this year in the online version of The Hill, a popular news outlet covering politics, policy, business, and international relations.

Deadly serious

I think this might be the same Nashville location that was practically perfect in every other way.

No joke

Maybe it's because burdensome regulations create needless and time-consuming administrative work?

Irony died

“We have significant expertise in investigating hospice fraud, as this part of the country unfortunately has seen more than its share of these schemes,” said Special Agent in Charge Derrick L. Jackson for the Office of Inspector General for the region including Tennessee.  “When hospices increase their bottom lines by billing taxpayers for unneeded services, they are diverting money from vulnerable, terminally-ill individuals.” 

United States Department of Justice

Kicking Irony's corpse

Part of the cost of doing for-profit corporate hospice business.

The source

I wanted to see what else the company had to say about itself, especially coming straight from the founder. So, click on 'About,' then click, 'Message from our founder.'

Founder says null?

In the words of Norman MacRae, Founder and CEO of Caris Healthcare: "N;"

Mission, vision, and values null?

Leadership team null?

There's not much else to say, so let's have the final slide, please...

Two words - pulp fiction


Links to sites mentioned in this post:
Thanks for reading. See you next time!

Thursday, October 24, 2019

Quick Taste of an Upcoming Post - What's News in Corporate Hospice?

I'm not kidding. I wish I was kidding.

With bonus Bible quotes!

Ezekiel 25:17

  • Pulp Fiction: "The path of the righteous man is beset on all sides by the inequities of the selfish and the tyranny of evil men. Blessed is he who, in the name of charity and good will, shepherds the weak through the valley of the darkness. For he is truly his brother's keeper and the finder of lost children. And I will strike down upon thee with great vengeance and furious anger those who attempt to poison and destroy my brothers. And you will know I am the Lord when I lay my vengeance upon you."
  • King James Version (25:15-17): "Thus saith the Lord GOD; Because the Philistines have dealt by revenge, and have taken vengeance with a despiteful heart, to destroy it for the old hatred; Therefore thus saith the Lord GOD; Behold, I will stretch out mine hand upon the Philistines, and I will cut off the Cherethims, and destroy the remnant of the sea coast. And I will execute great vengeance upon them with furious rebukes; and they shall know that I am the LORD, when I shall lay my vengeance upon them."
  • Young's Literal Translation (25:15-17): "Thus said the Lord Jehovah: Because of the doings of the Philistines in vengeance, And they take vengeance with despite in soul, To destroy — the enmity age-during! Therefore, thus said the Lord Jehovah: Lo, I am stretching out My hand against the Philistines, And I have cut off the Cherethim, And destroyed the remnant of the haven of the sea, And done upon them great vengeance with furious reproofs, And they have known that I [am] Jehovah, In My giving out My vengeance on them!"
Plenty more BibleHub 

Saturday, October 12, 2019

Death Nurse Special Blog Post Number 150! Weekend Interlude - Peak Bowie

a foreshadowing

I think Life on Mars? is Bowie's most amazing song in a long list of them, and I hope you enjoy this one, accompanied by longtime band member Mike Garson on piano. David Bowie is helping me grieve.


More about Life on Mars?

Here's a look back at other posts featuring David Bowie

Also, too: 100,000!

Wednesday, October 2, 2019

A blog post about hospice eligibility that doesn't include the words criteria or guidelines

This looks like the place

Note the absence of "guidelines" and "criteria"

Here are the Medicare regulations. The words “criteria” and “guidelines” don’t appear here either.

§ 418.22 Certification of terminal illness
(DeathNurse abridged version)

The individual’s prognosis is for a life expectancy of 6 months or less if the illness runs its normal course, based on the physician’s or medical director’s clinical judgment regarding the individual’s illness. Clinical information and documentation that support the medical prognosis must accompany certification, and also include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less. The narrative must reflect the patient’s individual clinical circumstances and cannot contain check boxes or standard language used for all patients.

§ 418.22 Certification of terminal illness 

(b)Content of certification. Certification will be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness. The certification must conform to the following requirements:

(1) The certification must specify that the individual's prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course.

(2) Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification as set forth in paragraph (d)(2) of this section. Initially, the clinical information may be provided verbally, and must be documented in the medical record and included as part of the hospice's eligibility assessment.

(3) The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms.

(i) If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician's signature.

(ii) If the narrative exists as an addendum to the certification or recertification form, in addition to the physician's signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum.

(iii) The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient's medical record or, if applicable, his/her examination of the patient.

(iv) The narrative must reflect the patient's individual clinical circumstances and cannot contain check boxes or standard language used for all patients.

(v) The narrative associated with the 3rd benefit period recertification and every subsequent recertification must include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of 6 months or less.

Related Posts

Thanks for reading. See you next time.

Friday, September 20, 2019

Death Nurse Film Fest V-1.3 (2019) - Bubba's Dumb Rass

Maybe not so dumb

Here's an old favorite, an attempt to blend information with entertainment. One of my biggest nursing bugaboos is the casual and unhelpful use of words like agitated, sedated, and confused. They're problematic because they can be interpreted so many different ways. Communication, decision making, and tracking progress is so much easier when everyone is on the same page about describing what they see.

So, here's a look at the Richmond Agitation Sedation Scale (RASS). It can help us all be more specific about what's going on. Narrated by my BBC-British-voiced friend Adam Wheeler with illustrations by Ahna.

Thanks for watching. See you next time.

Thursday, September 19, 2019

So Edo Says No No

no more mister nice guy?

If you're late to the game

I guess if Edo's not going to listen to the good stuff, we might as well drag out some horror stories. 

Her's one I posted on October 10, 2017:

It's a pretty cranky piece, but it's about a pretty serious problem that persists. 

I was certain to include important educational material about delirium that's simple, straightforward, and creatively presented through YouTube by noted delirium experts David Meagher and team. 

When you get lemons, make a souffle.

If you want to read more about nonsense, onward...

I was surprised to see that Edo blocked me - ugh, that sounds like something out of middle school. 

Still, I was surprised to see that Edo blocked me, and went over to the NHPCO website to see if maybe I could send him a note. 

Hi, Edo:

I'm not sure what blocking someone on Twitter accomplishes, unless of course that someone is actually a bot.

But, seriously, I'm not a bot. I'm an expert nurse in this field, and was the primary caregiver to my wife Jeanne through her decline and death from Alzheimer's. We used outpatient palliative services and community based hospice. It was an adventure. I understand this work from both sides of the bed, and am committed to making it better.

I hope you still find a way to enjoy #WhoseHospice Stories for Info and Edo, the series I've been posting at my blog that was prompted by your request last month, when Michael reported on Twitter about how a VITAS office in Florida failed his father. You wanted accounts of hospice going "above and beyond," as well as "horror stories."

I think it's important for patients, families, clinicians, and the community to understand more about advance care planning, and their options for facing serious illness and end of life. So many ways into these topics. 

Best, Jerry

I got an email response from the org's Senior Director of Communications and Digital Strategy, Amanda Bow

Dear Mr. Soucy,

Thanks for reaching out to us at We are always interested in learning more about the experiences hospice patients and families have, both the good and the bad. I appreciate your expertise and commitment to improving hospice and palliative care. We support the hospice and palliative care community and we advocate for quality, compassionate, and compliant care. With that, we also know how important it is to increase transparency and education, and we are working with many folks to make that happen.

If you have any questions, please feel free to send me an email.

Best, Amanda

I did have a question for her - what's Edo afraid of?

Also too: Wait - What? "Compliant care?"

Thanks for reading. See you next time. We still need to finish the story about Jack and Jill and Golf and the Hill.

Thursday, September 12, 2019

Death Nurse Film Fest V-1.2 (2019) - Ice Cream, a Love Story

"I dreamed I saw you in an ice cream parlor, 
drinking milkshakes cold and long."*

Ice Cream, a Love Story (2015)

The first collaboration with my daughter, who illustrated this story about a loving couple making their way through the minefield of serious illness. We developed it in late 2015 as part of a presentation at a local conference for hospice and palliative clinicians, but didn't have it finished as a video soon enough - I narrated it as a slide show.

The narrator is Redd Horrocks, an amazing voice actor in the UK. I got royalty-free music at Bensound.

A young version of Jeanne was the model for Suzy, and I was the model for Mark (except for the hair).

Death Nurse Film Fest V-1 (2019)

V-1.1 - Boo Boo interviews Jessica Zitter

* That's a line from 'Five Years' by David Bowie. Here's one of many terrific performances, this with a toned-down Ziggy Stardust and the Spiders from Mars.

David Bowie is helping me grieve

Jeanne and David Bowie died a few days apart, and were also close in age. My last days with her included a lot of his music, and it's been that way ever since - the music, I mean.

The lyrics and sentiments in this song are also tightly tied to our experience, because the overall trajectory of her illness took us through a period of about five years, from mid-2010 to January 2016.

Five Years
David Bowie

Pushing through the market square,
So many mothers sighing
News had just come over,
We had five years left to cry in

News guy wept and told us,
Earth was really dying
Cried so much his face was wet,
Then I knew he was not lying

I heard telephones, opera house, favorite melodies
I saw boys, toys, electric irons and T.V.'s
My brain hurt like a warehouse, it had no room to spare
I had to cram so many things to store everything in there
And all the fat-skinny people, and all the tall-short people
And all the nobody people, and all the somebody people
I never thought I'd need so many people

A girl my age went off her head,
Hit some tiny children
If the black hadn't a-pulled her off,
I think she would have killed them

A soldier with a broken arm,
Fixed his stare to the wheels of a Cadillac
A cop knelt and kissed the feet of a priest,
And a queer threw up at the sight of that

I think I saw you in an ice-cream parlor,
Drinking milk shakes cold and long
Smiling and waving and looking so fine,
Don't think you knew you were in this song

And it was cold and it rained so I felt like an actor
And I thought of Ma and I wanted to get back there
Your face, your race, the way that you talk
I kiss you, you're beautiful, I want you to walk

We've got five years, stuck on my eyes
Five years, what a surprise
We've got five years, my brain hurts a lot
Five years, that's all we've got
We've got five years, what a surprise
Five years, stuck on my eyes
We've got five years, my brain hurts a lot
Five years, that's all we've got
We've got five years, stuck on my eyes
Five years, what a surprise
We've got five years, my brain hurts a lot
Five years, that's all we've got
We've got five years, what a surprise
Five years, stuck on my eyes
We've got five years, my brain hurts a lot
Five years, that's all we've got
Five years
Five years
Five years
Five years

Source: LyricFind
Songwriters: David Bowie
Five Years lyrics © Tintoretto Music, BMG Rights Management