Thursday, April 11, 2019

Fun Time Patient-Centered Graphic Nursology

Pay attention

Rachel Lindsay has Four Awesome Strengths(TM):
  1. Smart
  2. Funny
  3. Talented
  4. Brave
She's drawn them together and laid them out for us in her amazing story, Rx.  

Key point: It's. Her. Story. 

Her commitment to telling it goes back eight (8) years. It's that important.

It's a story about serious and repeated failures in response to simple, basic, and obvious human needs: to be seen, heard, and validated; to be given clear and useful information; to have advocates with standards for practice and ethics.

We're the failures in the story - systems and agencies and teams and clinicians.

Get the book and see how it influences your practice. 

Learn more about Rachel in this most excellent Interview on the T with Emoji Nightmare and Nikki Champagne, which also includes the bonus Time-lapse filmed by Meghan O'Rourke - August 2015. Music "Maybe it's Love," by R, 2007.

Tuesday, April 9, 2019

Manifesto Tuesday - 3 questions

it's not rocket science

Please also read my earlier post on the 4 admonitions in Death Nurse Manifesto, since these 3 questions directly relate to the admonitions that hospice agencies be transparent and not abuse their staff.

1. Do they have enough staff?

Every patient's and family's first need is for care that's safe.  One of the best indicators of an agency that can provide safe care is safe staffing - having enough staff on hand and available to provide good care.

What's the agency's average daily census (ADC)? 

It should be a simple number to obtain, and will generally range from less than 100 up to several hundred or more.

If the agency operates in multiple offices, get the ADC for the office that will be responsible for your care. 

You should also specify that you want the number for the same setting as yours (residing at home, in a long term or memory care facility, etc.)

How many full time hospice RN case managers (RNCM) does the agency currently have on staff to care for that population?

The RNCM is the most critical role in hospice, responsible for coordinating and supervising the hospice interdisciplinary group (IDG) that also includes health aides, social workers, chaplains, physicians, nurse practitioners, and others both inside and outside of the agency - like your longtime family physician, or your oncologist.

It's a full-time Monday-Friday gig, and there's never a dull moment.

Also ask if the RNCMs have other responsibilities, like covering evening or weekend on-call, and admitting patients and families. Additional duties undermine the purpose of the RNCM role.

Also, too: ask what the average case load is for RNCMs at the agency. It's sort of a trick question, but jot down the number if they answer: ______

Average Daily Census (ADC): _______
Full Time RN Case Managers: _______

ADC / RNCM = ______ (calculated average case load)

Compare with their answer, if given: ______

The given and calculated average RNCM case load can help us start to learn if they have enough staff. 

Beware of agencies that routinely overburden staff with high caseloads and/or require them to cover evenings, weekends,new admissions, etc. That's abuse. 

You need to also know the numbers and case loads for social workers, chaplains, and home health aides.

But if an agency can't find or retain enough staff, it will most often show up first among the RNCMs. An abusive agency culture means abuse for everyone.

Please also see Boo Boo's 2017 post Can one number tell us if this hospice is any good? (includes handy chart!)

2. Are the staff any good?

If you're satisfied that the agency seems to have an adequate quantity of staff, you next want to understand its quality.

Of course an agency is going to say their staff is universally qualified, and may even mention certifications and awards, or point to a press release.

Humans are biased about their own skills, and tend to overestimate what they know. They can also become defensive when confronted by a demand to, "Prove it!" 

You're not asking an individual about the quality of their work - you'll see it when you meet them. 

But you can get a sense of whether or not the agency is a place where people who do good work want to be by asking, "What's your annual turnover?"

It's important to know the turnover in general, but it's even more important as it applies to clinical staff and location.

For example, a 350-person agency that brags about 20% annual turnover is still talking about 1/5 of its staff - 70 people.

They're not telling the full story, either. The agency operates two locations - one site houses 300 people, including administration and back office staff, while the other houses 50, all of whom are clinical.

If 35 of the 70 people who left in one year worked out of the small office, and were clinicians, their effective turnover rate is 70% (35 out of 50). I'd want to know why, though simply knowing turnover was so high might be enough.

You may get a blank stare in response to your question about staff turnover. Or a hostile one. That's because the answer can be the clearest indication of an agency's negative practice environment, and the brightest red flag waving everyone away - clinicians, caregivers, and the community.

Don't give up, but if they won't answer, that's your answer. You can also search employee reviews at websites like Glassdoor and Indeed. There may not be large numbers of them compared to that pizza joint down the street, but things like the details of negative reviews, and their timing, can provide some insight.

If they won't talk about clinical staff turnover, I'd look for another agency. You could also ask about their use of temporary and contract clinical staff, often called 'travelers.' Bottom line: not a good idea in hospice.

3. Who are the staff?

I've visited lots of hospice agency websites over the years. Most of them fall into one of two categories, and often both:

- Awful
- Unhelpful

Lately it seems corporate hospice sites are moving to a model with little information beyond stock photos of sunflowers, bland brochure weaselspeak, and an 800-number direct to sales.

Those that still include any mention of actual people usually do it two ways:

- Shiny happy people smiling 
- Our leaders

Both are stupid, wrong, awful, and unhelpful.

Every hospice agency needs to list their staff roster on their web site - names, credentials, and roles. Bonus points for photos and extra bonus points for bios and staff-generated content. 

The only reason for an agency to not list staff is the same reason for not talking about safe staffing and staff quality - because the answer is unfavorable to the agency. 

You'll meet staff when they visit. But it would be best to have some idea of who they are, and who they work for, before they walk through your door. 

Please also see this post from 2018 about things that can go wrong - Sadly, not rare - #hospicefail

Thanks for reading, See you next time.

With love and respect for the memory of Melissa Reina
For her children, family, friends, and community

Wednesday, April 3, 2019

Orange Crate Update Number 2

It's money that matters

Quick update

The sole purpose of the Death Nurse Orange Crate of Publicly-traded Corporate Hospice is to educate clinicians, caregivers, and the community about companies looking to make a profit from providing services to patients and families facing serious illness and end of life.

1. People are dying.
2. ??????
3. Profit!!

Our first lesson is that the stock prices for all of the companies are lower at the end of the Orange Crate’s first month. 

Other news

Amedisys continues its strategy for inorganic growth with its purchase of RoseRock Healthcare. “RoseRock provides specialized hospice care to approximately 200 patients daily in northeastern Oklahoma. Amedisys currently operates six home health care centers in Oklahoma, including an agency in Tulsa.” 

The company posted an announcement in Facebook with the following message from CEO Paul Kusserow, “You’ve joined a nationwide team committed to the same principles of honoring life through excellent patient care that have made your company so successful - welcome to the family!"

I asked how getting bigger makes things better for patients and families, and the company responded: “Hi Jerry - By strengthening our family, we're able to serve more patients with purpose and ultimately improve how end-of-life care is delivered in the country. In joining forces with other hospice companies, we can introduce more scale, structure, regional support, technology and professional development to allow for better patient care.”

The language sounds like something from a brochure. The reasoning is unclear to me, but the thinking seems to be that buying other hospices is a way to get stronger and leads to taking care of more people (makes sense); “with purpose” means something that isn’t explained but is supposed to impress us; and will eventually make everything better for everybody in the country somehow sometime ("ultimately improve").

They also exude the singular confidence that by getting even bigger ("more scale"); imposing hierarchies, processes, and rules ("building structure"); adding bosses ("regional support"); getting laptops and/or smartphones and/or IT nerds and/or playing with data ("technology"); and making everyone watch webcasts ("professional development"); and by somehow doing all of this by “joining forces” (how?) with “other hospice companies” (who?).

We’ll see,

I replied, “Thanks for your response. I'm a shareholder, nurse, and severe skeptic of corporate and for-profit hospice. What you're doing bears close watching. In my experience, hospice doesn't scale. Also too: you said nothing about transparency, so I hope you're prepared and willing to honestly answer questions like, What's the average caseload for a full time RN case manager working with patients and families who live in their own homes? What's your turnover for clinical staff? Patients and families are starting to know more and demand better. I look forward to talking with you more.”

Encompass surprised watchers when it announced its plans to acquire privately-held Alacare Home Health & Hospice for $217.5M. That’s more than twice the amount the company previously told investors it planned to spend on its strategy of inorganic growth (i.e., to get bigger by buying other hospices).

Founded in 1970 by the Beard family, Birmingham-based Alacare operates 23 home health locations and 23 hospice locations in Alabama, generating revenues of approximately $117 million last year.”

“John Beard, Alacare’s president and son of Alacare’s founder, Charles D. Beard Jr., said the company was “fortunate to be able to choose" Encompass Health from a number of interested partners.”

“Susan Brouillette, Beard’s sister and Alacare’s CEO, said the company and Encompass Health have had a close working relationship for many years on policy and other issues affecting the industry.”

Maybe that’s what the PR folks at Amedisys meant by, “joining forces with other hospice companies.”

Also, too: Keep reading Generic Hospice Blog.

Thanks for reading. See you next time.

Thursday, March 28, 2019

Orange Crate Update Number 1

Earlier this month I announced the Death Nurse Orange Crate of Publicly-Traded Hospice Companies*. Timing is everything, because now is when these guys tell the world how much money they've made and/or try to explain why they didn't make enough.

I'm sifting through their assorted filings and reports, dense with legal disclaimers, marketing braggadocio, and accounting. I'm not going to tell you that I understand it all, because I don't. I'm not a lawyer, accountant, of Master of the Universe.

However, my bullshit detectors are finely tuned, and there's plenty of that kind of stuff in these reports, and in the associated materials that make up your typical investor road show.

My detectors quickly sniffed out two examples from Humana's (NYSE:HUM) latest, courtesy of my new friends at Seeking Alpha. They're not the only ones, but ya gotta start somewhere. 

Before we do, a quick review of the fundamental premise behind every company in the Orange Crate*:

1. People are dying.
2. ?????
3. Profit!!

Number one is fact. Number three is the goal. Number two? A combination of magical thinking and messy details. Do you see what I'm saying? Good, let's begin.

HUM's base business is selling health insurance, an industry where making money depends entirely on nickle-and-diming vulnerable patients, denying their claims, and squeezing their providers. 

They're doubling down on the whole Medicare Advantage thing because it's their direct pipeline to seniors, and we all know about seniors and health care dollars.

It's like when someone asked Willie Sutton why he robbed banks - you go where the money is. For our friends at HUM, that means the United States Department of Health and Human Services. The Centers for Medicare & Medicaid Services is its drive-up teller window.

So, right now they can pick the pockets of about 4 million people over age 65. Of course they want more, but it's enough to get started on exploiting the opportunity (People are dying).

Since we've already identified the final objective (Profit!!), the only thing that remains is replacing the question marks with... a circle and two pieces of the world's easiest puzzle. 

Wasn't that easy? Who says healthcare is hard? Next slide, please.

I previously posted about HUM's entry into corporate hospice through their minority (40%) partnership with two leveraged buyout firms (they'd rather we say "private equity") in the $5.4 billion blender called, "Kindred at Home." (smoothie still in progress) It's key to their "success" - $$ from the dying.

You'd think that HUM, which can arguably claim to be in the healthcare business, would insist on running the show. Surprise! 

Thanks for reading. See you next time.

Also too: Get thee to Generic Hospice Blog.

*For education only. This is not financial advice.

Tuesday, March 19, 2019

World Premiere - Death Nurse Cartoons!

A student film

I chose the name 'Death Nurse' without fully thinking through what it meant, but this is how it's evolving - as a character in a cartoon world that touches on contemporary life, serious illness, death and everything associated as frequently and in as many different ways as six seasons of the Sopranos (plus every episode of Deadwood, Six Feet Under, The Wire...). 

Aim high. Keep swinging.

Friday, March 15, 2019

Ceci n'est pas un robot

Index card version

Simple is different than easy

I'm still working on the video, but wanted to show my cards.

Tuesday, March 12, 2019

Manifesto Tuesday - 4 admonitions

It's pretty simple, which is not the same as easy.

I had it all planned - 'Manifesto Monday' has a nice ring to it. But it's Tuesday. Better late than never.

The biggest challenges for developing the blogging portion of my practice have been consistency and reliability. That's a problem, because if posting useful content is Blogging Rule #1, then #2 is being consistent in posting that useful content. Daily, weekly, or whatever matters less than following the schedule.

So, I'm going to start observing that rule by scheduling content based on the day of the week. I plan to build up to posting a different theme on each weekday.

I'm starting with a commitment to post every Tuesday because that's what day it is today, and I'm starting with Death Nurse Manifesto as Tuesday's focus... because. 

I announced the Manifesto back in early December, though the idea has been rattling around my skull for much longer. 

What is Death Nurse Manifesto?

It's fortune cookie wisdom, Burma Shave haiku, bumper sticker philosophy, short attention span theater, earworm verse chorus verse, card catalog entry, ticker tape data, distilled and filtered, essence of knowledge, cheat sheet, quick reference guide, the right tool for the right job, solemn advice, half-baked fantasies, rules for living, a reason to tweet, a reason to block, an invitation, a doorway, a bridge, a chasm, an obstacle, completely meaningless and without merit, helpful, funny, offensive and repugnant, a cry for help, the beginning of a longer conversation, a cry in the wilderness, a plea to consider what really matters.

What is "this mess" you're talking about?

It's the overall heath care system in general, and more specifically the many ways we fail with advance care planning, making informed decisions about treatment options in serious illness, goals for care at end of life, caring for the dead and bereaved.

Why four (4) parties? Why not three (3), or eleven (11)? 

Because that's how it shakes out. The number is four (4). Who am I to argue? Each party is essential, but if you're wondering if any party is more important than the rest, think you already know, or simply want to know, just ask this question: Whose needs are being met?


C'mon, just give it a try.

Thanks for reading. More soon - next Tuesday at the latest.

Saturday, March 9, 2019

Captain Obvious wants to know

Which approach is better for talking with patients and families about prognosis and options for treatment in serious illness, and goals for care at end of life?

A: Nurse and Social Worker, live and in person
B: Remote talking doctor head on video screen riding a robot trolley

Bonus: WTAF is this even a question?

AP Story here

Monday, March 4, 2019

This is not financial advice, continued

power tie + magic pen

Last week I wrote about my goal to purchase one (1) share of stock in each of six (6) publicly-traded hospice corporations.

Willing Buyer met Willing Seller with the help of our good friend The Invisible Hand, and I've collected my shares in an orange crate for safe keeping. 

Actually, there's just an electronic record of the whole mess 'o transactions somewhere out in space. No physical money was exchanged, and I don't know if anyone still even issues stock certificates.

Anywhoozle, it's done.

Why did I do this? 

I didn't do it to get rich. One share won't cut it. 

And it's not an 'investment' in the sense of my wanting to end up with more money in my pocket because of this particular decision.

Also, too: this is not financial or investment advice.

I'm interested in what's going on in the hospice space, and these folks are messing in it. I'd rather learn about them from this perspective. They're in charge, and I get to pester them with questions, opinions, and advice.

Thanks for reading. See you next time.

Saturday, March 2, 2019

4 panel cartoon of a four panel cartoon, with links

how many ways can we access the same information?

I'm just starting to learn Twitter. 

I got a re-Tweet by Diane Meier (@DianeEMeier) of a Tweet by PallMedEd (@PallMedEdof an article that appeared over 4 years ago in McKinght's Long-Term Care News, "Tomorrow’s nursing homes must integrate palliative care."

I don't know if today is the tomorrow they were talking about, but I was immediately reminded of a blog post I'm still fond of, featuring a video cartoon based on a terrific podcast I heard about a year ago - an interview with Caroline Stephens, a nurse on faculty at UCSF, by Eric Widera and Alex Smith, two physicians also at UCSF, about her current research which had recently been published in an issue of JAMA concerning the use of palliative care for nursing home residents.

2014, 2019.....

Thanks for reading. See you next time.

Thursday, February 28, 2019

This is not financial advice, continued

House of cards?

These are the publicly-traded companies I've identified that are currently working the hospice space. You can read more about them at their respective websites.

I've decided to buy one (1) share in each of these companies.

I'm doing it in order to be able to obtain information and ask questions as a shareholder. This is not investment advice, and I'm not suggesting that anyone else go out and do this.

At the market close on February 28, 2019 I own AMED, EHC, and ENSG. I entered limit orders, and am waiting for my price on HUM, CHE, and LHCG.

Humana (NYSE: HUM) is 40% (minority) owner of a 3-way investment consortium whose other two (majority) owners split the remaining 60% - private equity firms Welsh, Carson, Anderson & Stowe and TPG Capital. They're trying to combine the hospice operations of three former companies: Kindred, Gentiva, and Curo.

It's also the story behind the amazing blog, Generic Hospice.

Amedisys (NSDQ: AMED) is pursuing "non-organic growth."

CHEMED Corporation (NYSE: CHE) has two divisions, Vitas and Roto Rooter.

Encompass Health (NYSE: EHC) is the re-branding of the scam and scandal-ridden HealthSouth, leveraging its 2015 acquisition of Encompass Home Health and Hospice based in Dallas.

LHC Group (NSDQ: LHCG) is one company where I haven't quite got a handle on their business model yet.

The Ensign Group (NSDQ: ENSG) is also a little difficult to figure out. It looks like they own a bunch of nursing homes and different sorts of rehab and retirement facilities, as well as a home care and hospice business of some kind. But they also refer to "affiliate entities" in a vague, unhelpful way (to me).

And, can someone please tell me what the 2:42 video on their main page (scroll) is supposed to mean?

meanwhile, back in 2005...

That's a screen snap of the abstracted results and conclusions from McCue,M. Thompson,J. (2005). Operational and Financial Performance of Publicly Traded Hospice Companies. Journal of Palliative Medicine,8(6),1196-1206. DOI: 10.1089/jpm.2005.8.1196

On PubMed.

The 2005 study by McCue and Thompson examined the performance of four publicly-traded hospice companies. 

Odyssey Healthcare - 65 hospices

VistaCare - 38 hospices

Heartland* - 89 hospices

Vitas Healthcare** - 22 hospices

Total: 214 hospices

* subsidiary of Manor Care 

** division, CHEMED Corporation (NYSE: CHE)

Since 2005, Odyssey bought VistaCare in 2009 for $147.1M, before itself being bought by Gentiva for $1B in 2010, which was subsequently bought by Kindred for $1.8B in 2015, which itself was sold to the Humana/TPG/WCAS consortium in 2017 for $4B, which had since gone on to also acquire Curo for $1.4B in 2018. 

Since 2005, Heartland/HCR Manor Care became privately-held, underwent various spinoffs, reorgs, and other financial transactions, entered bankruptcy protection in 2018, and was acquired in 2018 by ProMedica Health System.

Thanks for reading. See you next time.

Monday, February 25, 2019

Failing CMM-101

re-branding includes PhotoShop

I've been tracking down information on the companies maneuvering to dominate the hospice industry in the coming years, as Boomers get old, sick, and die. 

That's easy for the publicly-traded ones like Amedisys (NASDQ-AMED) - snag their annual reports.

Most of the reading is pretty tedious. I'm not a lawyer, accountant, or finance-type, which I think are the best skill sets to have for going over the fine numeric and related details.

The text is generally corporate weaselspeak - extraordinary claims surrounded by disclaimers.

But ya gotta start somewhere.

Anyway, I always manage to find a chuckle or two buried in the pile.

any alternatives to 'shiny happy people?'

I've spent almost half of my nursing practice in business roles, including marketing and marketing communication, but can't believe I'm the first person to notice this.

AMED annual reports - collect 'em all!

Also, too: My mother always said, "Follow the money. In the end, no matter what else they want you to believe, it's always about the money." (includes full video!)

Thanks for reading. See you next time.

Friday, February 22, 2019

This is not financial or investment advice

PowerPoint, the worst possible way to convey information

What the slide tells me, IMO

Get the full AMED roadshow at Seeking Apha.

Here's a their filing with the SEC.

Thursday, February 21, 2019

At least it's not a meat grinder

Blender cost is up to $5.4B +/-

Here's another index card graphic, or slide panel - I'm not sure what to call it - from the presentation or video I'm working on. Anyway, the text is from a press release available through the SEC or the online press room at TPG Capital.

Here's the full paragraph I used to pull the quote:

" The Consortium members partnered with the objective of investing in and building businesses that can help modernize, enhance and transform home healthcare in America. Curo brings a highly capable management team and a tech-enabled, centralized model for hospice care that presents the opportunity for Humana and its Consortium partners to be a leader in managing the continuum of home health, palliative care and hospice in an integrated fashion, creating a positive and differentiated experience for patients and their families – as well as their care providers. This integrated model will leverage data and analytics to measure and advance evidence-based clinical outcomes for patients and seamlessly coordinate the transition from home care, to in-home palliative care, and thoughtfully into hospice, as chronically ill patients’ disease burdens progress."

That's the plan, as they say.

MOST IMPORTANT: Catch up on the story, or jump in at any point, over at Strange Tony's Generic Hospice blog.

Wednesday, February 20, 2019

Peeking up from the rabbit hole...

After getting that fateful call from a colleague (Part 1 Part 2) I've been researching what's happening here in the Commonwealth ("God save it!") with regards to hospice, and it's brought me into the murky world of private equity (PE) investing in corporate mergers and acquisitions (M&A), a place where MBA's armed with algorithms and hubris confidently predict to rich people and others with big money that they can become even richer and bigger by investing in their schemes.

They are masters of the universe.

Here's the most current list I could find of the one-hundred biggest US hospice corporations, companies, agencies, and other players. I've highlighted the first 10. Ranking by LexisNexis:

Yeah, that's not so helpful. Let's really focus on the ten biggest players in the nationwide hospice sandbox, based on their percentage share of a total national market:

I've crossed-off #9-Hospice of the Valley because as a tax-exempt not-for-profit agency, they're not relevant to our current discussion.

But, since they're non-profit we can easily review Hospice of the Valley's financial and operating information by looking up their IRS Form 990.  

The latest available for 2015 shows $131,481,031.00 ($131M) in service revenue. Their 2017 LexisNexis ranking shows their market share at less than 1% (0.81%).

I'm going to estimate each percent of market share at $150M, just because. You can go higher or lower.

Two significant deals have gone down since the LexisNexis list came out. Here's how they've shaken the board:

There's no reason to expect this to end anytime soon. The top player, either Vitas or Kindred/Curo, still has less than 5% of total national market share. 

Only seven players, or five, have more than 1%

We're looking at a classic "fragmented industry" as taught in business schools everywhere - one ripe for consolidation, with lots of money to be made buying and selling hospices. 


Boomers are getting old, sick, and dying. It's a demographic wave, and the surf is most definitely up.


Note: I developed these graphics as part of a project to present the overall story as a presentation or video. That's part of the rabbit hole. I'll get it done.

Also, too: be sure to follow Strange Tony's ongoing saga of corporate psychopathy at Generic Hospice, and the deeply personal reporting by Steve Lopez at the LA Times about how a hospice agency failed his mother and family

Thanks for reading. See you next time.