Thursday, July 25, 2019

One year, two CEO's, and lots of money.

Disclosures: I became an employee of this agency when it acquired the one I was working for. Here’s my profile on LinkedIn. Jeanne and I were enrolled in the agency’s outpatient palliative care program from January to October, 2015.

The longtime reader of this blog knows I like to page through a non-profit hospice’s IRS Form 990 to help get an idea of what they’re all about. It provides useful information about a hospice agency’s finance and operations, including the scope of their activity and how much their executives are paid.

There are easily over 50 standalone hospice agencies and corporate hospice chains here in Eastern Massachusetts. Some are well-established in their communities, others have been attracted here by the smell of death and money.

One of the agencies I follow rebranded itself a few years ago as ‘Care Dimensions.’ They were founded as Hospice of the North Shore - not ‘North Shore Hospice,’ which would have been my pick until I realized it’s pronounced ‘Nawth Shaw,’ and best articulated through lightly-clenched teeth and upturned chin.

Back in 2010, I was an RN case manager at the hospice agency owned by local behemoth Partners Healthcare as part of its "Partners Healthcare at Home" post-acute portfolio that also included rehab and home care, when we were suddenly sold off to Hospice of the North Shore because Partners wanted out of the hospice business for some reason.

That transaction bought me a new employer with the revised name phrase, ‘Hospice of the North Shore and Greater Boston.’ That was the start of their growth from an average daily census of about 350 to the current ADC of 1,000+/-.

Yikes! That's a lot of patients. They need a lot of nurses. I wonder what's the average case load for an RN case manager working with patients and families in the home - 10? 15? 20?


The new name Care Dimensions has a special irony, since the agency that was under Partners’ umbrella had previously passed through a series of transactions and originally had been named, ‘Health Care Dimensions.’

I wonder if some consultant was actually paid to come up with the idea…

I’ve been looking at Care Dimensions’ 990’s for as long as I’ve been looking at 990’s, and one of the things that’s always stood out is how much they paid their longtime and now-former CEO. She easily out-earned, by a few hundred thousand dollars, her next highest-paid Massachusetts CEO colleagues, all of whom headed combined nonprofit home care and hospice agencies.

She announced her resignation in early 2016, and in May 2017 a new CEO finally took over. The local newspaper also seems to be interested in CEO salary.

The agency’s 2017 finally became available through GuideStar not long ago, so I looked through to see if the new CEO was being treated as well. Here's what I found:

$284,931 + $726,451 = $1,011,382

According to the financial information filed with the IRS, it seems Care Dimensions paid their former CEO $726,451 for working January-April, and $284,931 to their new CEO for working May-December. At least, that's how I read it.

So I reached out by email to their chief operating officer, to see if I was reading things correctly:

“I hope my note finds you well on this sunny picture-perfect June day. 

I was looking at the most recent (2017) Care Dimensions IRS 990, and appreciate your help in clarifying something. Since that was the year your CEO changed, both are listed in Part VII Compensation of Officers, etc.

Diane's listed compensation is $726,451. Pat's is $284,931.

It's also noted that Diane was CEO through May 2017, and Pat became CEO effective May, 2017.

My questions:

- Are these the amounts each was paid for the full year? If so, does that mean each were paid a full year's compensation, but each only 'worked' for half of the year?

- Or is their compensation based on having worked for about half of the year? If so, does this mean that the annual compensation for each is (roughly) twice that listed (~ $1.4 million for Diane, and ~$606,000 for Pat)?

I guess the compensation information on the form 990 for 2018 would be helpful in answering this, since Pat would be the only CEO listed. But that form isn't available through GuideStar yet.

Anyway, thanks in advance for shedding some light on this."

I didn't hear back after a week, so reached out to the CFO by email, since after all this is about accounting and finance.

When again I didn't hear back, I called the agency and to my surprise was put through directly to him. I think he was surprised, too.

He apologized for not responding to my email, and added, "The agency's policy is to not discuss compensation." I don't know if he meant just executive compensation or everyone's at the agency.

When I asked if my understanding was correct - that the agency paid two CEO's combined over a million dollars, and that each CEO worked only 4 and 8 months, respectively - he responded that the Form 990 "is very complicated" and required Care Dimensions to hire an accounting firm specializing in them.

He also insisted my reading of the data was not correct, but wouldn't say how or why because, "The agency's policy is to not discuss compensation."

That's some catch, that Catch-22. It's the best. 

I also came across this little nugget:

How many nurses does $700k get you in Eastern Mass?

I don't know what Care Dimensions pays its nurses, or if they've also gotten bonuses for doing the work that comes with a climbing census. I'd like to ask their executives, but since their policy is to not discuss compensation perhaps someone else could speak up.

Thanks for reading. See you next time.

Previous posts about the IRS Form 990

Searching for hospice at a place in Massachusetts, Part 1

Boo Boo talks $$$ and non-profit hospice

Thursday, July 11, 2019

Nursing orgs resisting concentration camps and genocide - so far, not so good

It sounds like a simple charge, and it is - leverage your privilege. It means we need to use our advantages to benefit more than just ourselves.

Simple and easy are two different things. The privileged act to protect their privilege, and at most give over the tinniest crumbs with great reluctance, loud complaints, and never for very long.

Organizations exist to perpetuate themselves, and reward those who protect the organization's interests most fiercely.

Those are my general observations. Your mileage may vary, and I'm open to hearing from those who think otherwise. But, those are my general observations.

I thought of a question to ask nursing professional organizations - How are you leveraging your privilege (money, members, media platform, political relationships, etc.) to openly stand in resistance to the genocide currently taking place along the Southwestern US border, and to the concentration camps where it is taking place?

I thought of a way for nursing orgs to respond:

First, by watching a recent 56-minute film on YouTube called, "Caring Corrupted," produced by the Cizik School of Nursing featuring contemporary nurses talking about nurses and nursing organizations in Nazi Germany who supported and participated in genocide. 

In case you missed it, the film is about "nurses and nursing organizations in Nazi Germany who supported and participated in genocide."

After watching the film, I ask nursing orgs to do the work to earn a passing grade in a seminar put together especially for nursing orgs. 

You can read all about it in my post, Seminar: How nursing organizations are leveraging their privilege to resist concentration camps.

The seminar is modeled on Howard Dean's seminar on democracy: participants can earn a passing grade of 'D' by voting (literally the least you can do); earn a grade of 'C' by donating money to a cause or candidate (maybe a little painful for a moment, but still easy); earn a grade of 'B' by knocking on doors, making calls, and otherwise working on behalf of a candidate or cause (nice work, keep going); and earn an 'A' by running for office or serving on a government board, committee, or similar capacity.  

So, how have nursing orgs responded so far??

Let's start with my own professional org, the Hospice and Palliative Nurses Association - HPNA.

HPNA earned a grade of "NOPE" twice last year, the only nursing org I'm aware of that specifically, intentionally, and very clearly, when asked to stand against genocide, said "NOPE" not just once but TWICE.

HPNA did not sign the June 19, 2018 letter written by the Nursing Community Coalition and sent to the former administration* secretary responsible for overseeing genocide in the form of separating families at the border, even though HPNA is a member of the Nursing Community Coalition.

2018 letter of concern about genocide 
from 33 nursing orgs but not HPNA (and others)

HPNA said "NOPE" a second time, after I spoke directly with the former HPNA President to make my case, and followed up via email.

She subsequently wrote back: 


Today I had the chance to speak with Len Mafrica, HPNA's chief operating officer and expert on the use of Twitter by nurses. I've been pestering him via Twitter via HPNA's official account run by their social media guy, but it led to nothing.

I was glad for the chance to ask him about last year's decision to say "NOPE." He responded that he really didn't have any details for me about the decision, and whether there are minutes or some other record.

He noted that the Executive Committee consists of the HPNA President, President-Elect, and Clerk/Treasurer, though I'm not clear if it also includes the CEO of HPNA.

Ms Wiegand died last November. I made a donation in her memory to RAICES TEXAS, and also one acknowledging the resignation of HPNA's former CEO.(pdf)

Len noted he was aware of my request to participate in the seminar about how HPNA is leveraging its privilege to resist concentration camps, but had nothing new to report at this time, and would maybe get in touch with me after it was discussed.

I asked if the time frame for the discussion was a matter of hours, days, weeks, months, or years. He responded, "Weeks."

So at this point HPNA's transcript features:

- two NOPES -  Org says it wont do anything: because standing against genocide alongside over 30 fellow nursing organizations has nothing to do with the organization's public policy guiding principles, as evidenced by the email I received from the President following her discussion with the Executive Committee; and for some unknown reason, as evidenced by its failure to sign the June 19, 2018 letter sent by the Nursing Community Coalition, even though HPNA is a member.

- one DecBec - Replied, declined to talk (further) because: it's going to take weeks before HPNA leadership even talks about it, as evidenced by my phone conversation with Len Mafrica, HPNA's Chief Operating Officer.

More to follow. Thanks for reading. See you next time.

Saturday, July 6, 2019

Case Study: Bullying behavior by physicians - cause or effect of nurse passivity?

figure 1 - two hoops and some question marks

figure 2 - memo to HPNA members, annotated

figure 3 - the solution starts with each doc & nurse

The problem isn't individual physicians and nurses. 

The problem is a physician culture perverted by power and privilege. 

The problem is a nursing culture perverted by powerlessness and passivity.

Find the sordid details from my earlier post, "This is f'd up in too many ways to count."

Read the official details at AAHPM.

Read the official details at HPNA...Oops, sorry, nothing about it on their website.

This case is both superficial and deeply disturbing.

It’s about a hashtag for a conference, and not a very good one (I mean the hashtag. The conference is awesome, been twice!)

It’s about the toxic dance of bullying behavior and passivity, and it stops now.

We need to reverse the power dynamic.

Doctors as a group need to give it up.

Nurses as a group need to take it, along with pretty much every other clinical discipline and non-physician ‘team member.’

This isn’t a petty gripe. 

This is the tectonic shift we need to get power back where it belongs - in the hands of patients and families.

Resources for case discussion

Important for nurses to read first
from a piece in Vox about Gaslighting

"How do you recognize that gaslighting is happening?

Take a look at the list below. If any part of the list resonates with you, you may be involved in a gaslighting relationship and need to look further.

  1. You ask yourself, “Am I too sensitive?” many times per day.
  2. You often feel confused and even crazy in the relationship.
  3. You’re always apologizing.
  4. You can’t understand why you aren’t happier.
  5. You frequently make excuses for your partner’s behavior.
  6. You know something is wrong but you just don’t know what.
  7. You start lying to avoid put-downs and reality twists.
  8. You have trouble making simple decisions.
  9. You wonder if you are good enough.

While all of these symptoms can occur with anxiety disorders, depression, or low self-esteem, the difference with gaslighting is that there is another person or group that’s actively engaged in trying to make you second-guess what you know is true. If you don’t typically experience these feelings with other people but do with one particular individual, then you might be a victim of gaslighting."

by Kate Abramson, Indiana University 
in Philosophical Perspectives, 28, Ethics, 2014

"...the phenomenon that’s come to be picked out with that term is a form of emotional manipulation in which the gaslighter tries (consciously or not) to induce in someone the sense that her reactions, perceptions, memories and/or beliefs are not just mistaken, but utterly without grounds—paradigmatically, so unfounded as to qualify as crazy. Gaslighting is, even at this level, quite unlike merely dismissing someone, for dismissal simply fails to take another seriously as an interlocutor, whereas gaslighting is aimed at getting another not to take herself seriously as an interlocutor. It almost always involves multiple incidents that take place over long stretches of time; it frequently involves multiple parties playing the role of gaslighter, or cooperating with a gaslighter; it frequently involves isolating the target in various ways. And there are characteristic things gaslighters say: indeed it is remarkable how much overlap there is between phrases that Gregory uses in the movie, and the sorts of proclamations that are made by gaslighters to their targets in real life."

Nurses and doctors: Pick one or more from the following to supplement your new understanding


from Elite Readers

from the New York Times

from Slate

Now a little reward for scrolling to the bottom...

David Bowie died just a few days before Jeanne. That enormous coincidence led me to develop a special devotion to David Bowie in the same way my departed catholic mother in law developed special devotions to a long list of saints and other religious figures.

I told this to a nursing colleague once, and a little sheepishly. His response? "At least David Bowie is real."

Well, to some. It's really a matter of faith.

David Bowie will always be helping me grieve, and here's a particularly inspirational service at a YouTube shrine of his.

"Don't ever say I'm ready, I'm ready, I'm ready
I'll never say I'm better, I'm better, I'm better
Don't ever say I'm ready, I'm ready, I'm ready
I never said I'm better, I'm better, I'm better, I'm better than you"

Wednesday, July 3, 2019

I remember the day

We went out to the ballgame...

Google reminded me about 2013 this morning, but didn't really have to. I remember it well.

I started my last full time regular nurse/employer gig in February, as the hospice staff educator in a nurse-run home care association. The association model is your basic group practice, in this case with nurses instead of dentists, accountants, lawyers, or physicians - though somehow the nursing group practice model is required by law and regulation to have a physician medical director on board, and the nurses can’t really do anything themselves without some physician first saying do it - or at least anything they’ll get paid for.

The association had tacked-on hospice care at some point in its history, and a few months before I was hired had acquired the home care and hospice ‘business’ of the local university medical center. It was pretty much a merger of equals from what I could tell, based on staffing and census. And of course it was a chaotic mess.

Back to the 2nd of July.

A hospice RN case manager in one of the offices asked if I was interested in a pair of Red Sox tickets for the next night’s game. She had grown up the daughter of a fan dad, watching together through the long season whenever the games were on TV, and listening on AM radio whenever they weren’t.

Her dad had died the year before. They had been season ticket holders since before the Red Sox won the World Series for the first time since 1918. She would never give them up, but knew she couldn’t go to every game. She was, as you would expect, a terrific hospice nurse.

I snatched the tix, a night on the town for me and Jeanne before we joined her siblings by the seaside for the holiday. I also worked out the final details for my July 3rd work day with the music therapist. She had four visits scheduled, including two in facilities and one in a home where the final trajectory was… trajecting?

I’ve treasured the few opportunities I’ve had to be with music therapists as they do their work, to watch and listen to what they’re doing, and to what happens all around when they do it, and to me. They add to IDG. I think a lot of people don’t fully appreciate who music therapists are, or what they bring to patients, families, and the rest of the team.

First - I love a good hootenanny, and can bite my tongue through endless choruses of ‘Michael, Row the Boat Ashore.’ I especially love lounge singers at senior facilities, crooning and scatting to karaoke Frank and Ella. Music and flowers make us smile, touch the deepest parts of our brain different from cognition.

That’s not what music therapists do, as I understand.

Well, they know a lot about the deepest parts of our brain, and they certainly know a lot about music. But the basic path for a certified music therapist is as rigorous as any clinical discipline I’ve ever seen, and quite a bit more than some.

A music therapist has undergraduate credentials in music, including actually being able to do awesome music; and graduate credentials, including supervised clinical practice, in using that exquisite talent therapeutically.

One thing that helped me appreciate the role of music therapists was the on-call rotation at another hospice. Social workers, chaplains, and music therapists were included together as ‘supportive care and counseling,’ and the usual reason for off-hours supportive care and counseling was the need for crisis intervention. 

Who’s on supportive tonight? Oh, it’s Julia. The singer? Excellent!

More about the music therapy program at Berklee.

Anyway, it was about 8:30 when I rolled into the dank cubbyhole of my office where the music therapist and I had planned to meet at 8:45, and the phone rang before I put down my bag. It was my nominal boss, the director of the association’s education department.

“What’s your plan for today?” she asked. 

“I’m meeting up with the music therapist. We’ve been talking about doing joint visits for a while, and since today’s pretty quiet around the office…”

She cut me off. “No, Annabelle already told her you won’t be joining her. You need to work on the orientation manual.”


Annabelle was a nurse manager who had a long association with the… association. A lifer who before had been a lifer in the Army, she frequently reminded everyone how she was counting off the remaining days to retirement number two with a chain of paper clips. At the end of each day, one less paper clip. She usually flipped it at a secretary.

“That’s bad luck,” the secretary told her. “You’ll die before you retire if you don’t stop doing that.”

Annabelle didn’t give a shit. Annabelle did whatever she wanted. Just a year before she had decided being a nurse manager in hospice was much easier than being a nurse manager in home care, or at least that’s how she played it.

Annabelle still took the managing part of her nurse manager role seriously, and applied herself diligently to prying into the lives and activities of anyone within earshot, and interfering however best she could. Apparently the day before, maybe even at about the same time I was exchanging money for Red Sox tickets with a colleague in one office, the music therapist had casually noted to another colleague in another office that she and I were doing joint visits.

Annabelle overheard, and the rest is history. She lit up, then the phone line to my nominal boss lit up, and at the end of it all I spent a few hours in the dank cubbyhole sifting though milk crates full of 3-ring binders of outdated policies and procedures.

Jeanne and I drove in to Brookline, and parked the car at a secret spot in my old Coolidge Corner neighborhood. It’s a straight shot from there down Beacon Street to Kenmore Square and Fenway Park.

Every picture tells a story, so please enjoy whatever pictures catch you, and listen. The day is now.

edited 7/6

Tuesday, July 2, 2019

This is f'd up in too many ways to count


This is f'd up in too many ways to count, but we can boil it down to:

Physician culture is perverted by power and privilege.
Nursing culture is perverted by powerlessness and passivity.

Also, too: the chase - Nursology and Nursing own the word "care" and its related "caring." 

This issue is not up for discussion.

Back story...

I got an email from my nursing professional organization, the Hospice and Palliative NURSES Association - HPNA. It was a joint digital celebration between them and the American Academy of Hospice and Palliative MEDICINE - AAHPM.

They're all excited because they've apparently devoted substantial talk and energy to a bold new plan, well, I'll let them tell it...   

tl:dr The hashtag #hpm for 'hospice and palliative medicine' was felt exclusive to non-physicians, so a bunch of docs came up with the idea of stealing the word 'care' from nursing for a new improved hashtag #hpac for 'hospice and palliative care.'

"A diverse group of AAHPM and HPNA Twitter leaders met earlier this year to discuss the 2020 Annual Assembly hashtag. 

The leaders concluded that a change in the hashtag was necessary - #hapc was more representative of the growing and evolving field. 

Participants in the discussion were 

Amy Davis MD
Ashley Deringer MD
Kyle Edmonds MD 
Allison Jordan MD 
Christian Sinclair MD 
Holly Yang MD 
Allison Lundberg not a doc, marcom
Laura Davis not a doc, mktgconsult

Harry Crytzer not a nurse, marcom
Len Mafrica not a nurse, assoc exec

A "diverse group?" 

No, there were eight reps from the physician's org, and two from the nursing.

Six of the eight from the physician's group are physicians. One's a marcom staffer, the other's a marketing consultant.

Both of the reps from the nursing org were men (nursing is 90%+ women), and neither of them are nurses.One does marcom, the other runs the biz side of the org.


First, to the docs: 

What is wrong with you? Is this what you learned and practiced through pre-med, med school, residency, and since - when you want something, just take it. 

You get no credit for disguising your attempted theft with a bogus "diverse group." 

Your actions are even more shameless than when I first read about the silly hashtag nonsense and assumed you docs just rolled over the relatively numerically matched nurses in your usual ways - brute force, slowly whittling away, whining how "everybody cares, I care, we all care," and/or bribing them with food.

But holy crap - you didn't even let any actual nurses into the room! Just two flunky dudes. Was the HPNA accountant unavailable?

It stops here and now. If that bothers you, tough. 

This is about patients and families, not you. For once.

The only way to begin addressing the gross imbalance of power between medicine and nursing (and every other freaking clinical discipline on the team you like talking about) is for doctors to give it up and/or for nurses and allies to take it.

Don't worry, you'll be fine. Doctors will always be fine.

Here's a quick lesson in language, clinical disciplines, why our industry is such a mess, and what you need to do about it.

Medicine uses science to explore and identify illness in the organs or systems of someone's body, which is seen as a problem to be dealt with through various ways, mostly involving some form of burning, cutting, or poisoning.

Doctors diagnose and treat. Science never stops, and neither does the ability to identify illness and develop treatments. Battle metaphors abound, and people like winning. In this context, you personify the intersection of science and skill at its best. Success beats failure. Nice work, but remember it's still baseball - the season is long, and Ted Williams didn't get a hit roughly six times out of ten in his best season, and he was the greatest hitter who ever lived.

You play an important role, physician friends, but it's only one of the many roles and contributions in our system that benefit patients and families. Somehow lots of people, including you all, decided doctors were pretty much the only folks who mattered, or at least who mattered much more than anyone else.

If you don't think you're the most important player, think again and harder. If you still say you're an outlier physician in a culture perverted by power and privilege, why'd you do this? How do you explain a doc/nursing discussion stacked 8/2 and with no actual freaking nurses?

If you now say, "Damn, you're right. This is f'd up. That hashtag is gone." I say, excellent. Be an outlier, then change the culture.

Part of being an outlier physician in its perverted culture also means you have to stop talking and give up your seat to someone who hasn't been to the table. You invite that person to take your seat, and you stand by them not over them. That person should probably be a nurse, but they could also be a pharmacist, chaplain, social worker, volunteer, formal caregiver, informal caregiver, family member - you get the idea.

Being an outlier physician in a perverted physician culture means you do this again and again, you call out your physician colleagues when you see them flaunting their privilege and abusing their power no matter who they are in your pecking order, especially when they're higher, and you hold the door open and keep it open for all of those who haven't been able to get in.

As for "everybody cares, I care, we all care." Of course you do, it's a human capability. Your human caring is evident in your choice to use science in ways that benefit patients and families.

But you don't get to steal the word "care," dilute its meaning by including everybody on the clinical team within its definition, you no longer get to do all of the talking, or make every decision.

Care is the philosophical foundation of knowledge (nursology) and the science basis of practice (nursing). 

Care is why and how nursing exists. Caring is what nurses do. 

Medicine is science for diagnosis and treatment.
Nursing is political action and intelligent care.

I'll stop here for now, except to say that I'm even more troubled by my nursing colleagues who either don't see the problem, go along with it because, or worst of all think they somehow benefit by it.

Also too: Maybe more important than a hashtag - Previous Post