Tuesday, April 11, 2023

New! Update for Updated Update: Game Over Updated

Four white dudes doing what they do

I returned to The Ira and VITAS! Show today for the first time since the 6th, and managed to follow along for another four (4!) of the episode's fifty-one (51!) minutes

Here's what I said in the comments this time...

OK so today I could handle about 4 minutes

I got re-oriented with Ira tossing out some nightmare clinical scenarios like bowel infarct, seizures and status epilepticus, though he didn't mention my personal favorite - massive sudden arterial bleed for tumor and tissue damage in head and neck cancer (dark towels?) - to emphasize the need for hospices to provide crisis levels of care (via continuous care in the home or general inpatient care at a licensed staffed facility)

Sure absolutely the IDT has to be prepared for the worst - part of every plan of care should be to ask: what's the worst that could happen? Then make sure to assess monitor prevent and intervene if needed because you were prepared

Now THAT's a great quality indicator

OK, now Ira's jabbering about "kind of have our hair on fire" - kind of? - then goes on to point out the many lost opportunities and failures by the professional orgs (oops) to do anything as it all happened under your nose and under your watch [ref above Christian admitting y'all haven't don't squat about it for 20 years]

I need to be honest with you here: you've been captured, the war is over and VITAS! dude's side won it all

Seriously, consider yourselves captives owned by the financial rapscallions who have taken over hospice, and they're just getting started, so really from here on out your jobs are all about harm reduction and keeping your heads down in order to survive in the current environment

Also too the orgs AAHPM RacistHPNA, of course the trade groups most notably NHPCO and org of orgs NCHPC (Ginger's new gig), etc - they're not just responsible for lots of the problems we're all in, but now also central to whatever "solutions" creep out of this mess or more specifically exploit it

Consider their whacky idea that one indicator of quality should be the number of nurses on staff who are certified CHPN etc via RacistHPNA - which is an excellent idea for RacistHPNA because dues + certification test prep and testing are pretty much the main revenue channels for orgs like RacistHPNA that still follow the model

I'm sure AAHPM is making that same play because orgs are platforms for commerce and careers and that's it

So, to repeat the obvious - you've lost everything at what''s likely the biggest board game most of you have ever played - your battleships are sunk, your king is surrounded etc etc etc

Your jobs are now harm reduction and keeping your head down in order to survive in the current environment

So Lauren has her hair on fire because there's no reason for 1,000 hospices in LA County (Ira says 800 so of course he does), then there's some chuckling about scammers and inside info because VITAS! dude knows where they live

Anyway Lauren asks the burning question - how do we regulate hospice to assure quality BUT! don't make regulations (?)

Or what she's really saying is don't keep dumping everything on the nurses, which is a universal complaint and valid - but seriously Lauren of course rules etc will have lots of implications that need to be figured out and whatever else you want they're not going to be "free," especially the way VITAS! dude's handlers need them to be free or as close to zero as possible, divided by 2

You just negotiated against yourself - you were advocating for something then immediately advocated against it with the other side's own argument

Anyway, Ira droned on and on about three great policy recommendations from some in-group but after he ran out of breath and stopped talking we still have no idea what these great things are in even the most general sense, which at this point we can all just chuckle and say oh Ira... and move on

Eric tosses out another fat slow juicy grapefruit of a pitch to VITAS! dude - hey so I don't suppose you and your bosses like regulations all that much do you? 

And with a mighty swing VITAS! dude smashes a really slow roller down the first base line until it stops at about halfway no he thinks self-regulation is definitely the way to go, then he and Ira fist pump and hug because it's all about quality

Then there's quibbling and second guessing and more negotiating against themselves in an incoherent mess until at one point Eric brings up amyloid eaters the Alz Assoc/pharma scam - and since he's a bright guy of course he sees the connection and the irony of it all before he says let's not bring that up (which was Ira's point a moment ago that the orgs just don't even want to talk about these topics let alone look at them with a critical eye  and basic understanding of financial concepts (making money with money)

Then I stopped watching at about 34:00 - thanks, until next time

Tuesday, April 4, 2023

UPDATED! Updated Game Over Update


Rare shot of Ira with mouth closed

Today I celebrated the halfway point of my journey to listen and annotate the GeriPal podcast video talkapalooza from Montreal - this is not a trip for the fainthearted, especially when it comes to air

It's not that the air gets thinner with altitude - it's the combination of naivety, bullshit, willful ignorance and detached indifference 

Sure, this is a 'professional conference' so the voices of patients and families are notably absent...

Which is the whole freaking problem with the same old models we see here, so as long as y'all keep doing this please don't expect anything different, and none of us should expect y'all to find a way through this mess with the same old models  

You can check out all of my comments at YouTube, here are today's annotations - 

April 4 - OK today I was able to tolerate 2-3 more minutes plus some rewind of Ira's waxing poetic about how great things used to be when the for-profit owners were satisfied with "reasonable" ROI (reasonable to who?) operating "efficiently" (we'll hear that one again) which sounds nice when you're talking about an assembly line but we're talking about patients and families facing serious illness and end of life - oh, wait 

Ira wraps up his monologue with the insistence that "our field has a role to play," and probably means himself more than anything because someone so un-self-aware isn't going to realize it's time to STFD and STFU

Eric steps up again and before you know it launches into an upbeat commercial for VITAS, and the punchline is a physician even cleaned the house! he's never seen another hospice do THAT before!!! 

So Eric there's this role in the IDT called 'hospice aide' where a person goes into the home and provides personal care including light housekeeping and meal preparation if that's part of the individualized plan of care - check it out (warning - irony ahead) 

Anyway after stepping all over what should have been his main question to VITAS dude (what do YOU think of the tension (conflict) between 'excellent hospice care' and 'making lots of money, as much as possible but always more than last time') ...

VITAS dude takes a swing - and there's a slow roller to third, it's not a bunt just really weak contact

Something something Chicago (economics?), then he's in Florida to join a parent facing serious illness

Now he reports to the CEO and is held to metrics so of course he always asks what's best? (for?)

Then he name drops RacistHPNA Board Member Ab '6-Pac' Brody and I'm not sure if he's talking about having or not having an EMR, something about paper and pharmacy and knowing everything and VITAS is great (gonna start writing VITAS!)

Funny story about me and '6-Pac' - he expressed righteous indignation as RacistHPNA BOD member when y'all announced plans to hold in-person in pandemic in freaking Nashville Tenne-freaking-See racist homophobic transphobic Confederate hotbed and thus a risky unsafe place for big swaths of memberships (well, not so big really), and I responded nah - y'all will be there because commerce and careers are more important than caring

How did he respond to that? Let's just say you don't have to be a cishet abled white woman to be a brittle white feminist - in a world of problematic nursing orgs RacistHPNA pretty much heads the list

Anyway VITAS! dude's main point is that his factories are the best - he and Ira high-five chest bump yell 'EFFICIENT!!' - and the only question he asks himself every morning is how many terminally ill people can he help today? HOW MANY?! don't forget he reports to the CEO who reports to the BOD etc

QUANTITY is the only thing that really matters - comps, same store sales - get them to sign on the line that is dotted because even if we have to send a physician over to clean the toilets we'll do whatever it takes, we don't make money on every admission but when you have lots and lots of admissions you can make lots and lots of money

That's the simplest most uncomplicated part of this whole thang

Peace out until next time


Thursday, March 30, 2023

Updated Game Over Updated

Don't piss off the puppeteers

Time to throw this baby out

So I've been slowly making my way through this podcast, because like any good journal article there's a reason (need?) to stop at about every 6th word - either to check out a footnote that turns into a multi-day  rabbit hole, think about what you just read and read it again, or just mutter quietly WTAF?

Anyway, the only thing I can manage today is to reflect back on a phrase VITAS dude leaned into right out of the gate - "tax status" 


I just remembered something VITAS dude said in his first 10 seconds of the podcast - "tax status" - that's an important rhetorical misdirection on his part even if clumsy shallow Weaselspeak

Sure, one difference between not-for-profit and for-profit hospices is that the not-for-profit hospices are exempt from paying the IRS  because they're recognized as charitable entities, like your favorite local church

They have to state their case and show evidence - most notably by filing IRS Form 990 every year to report on their finances and operations, including how much the highest earners get paid

It's all very transparent - orgs have to make their filings open and available for public inspection, and legit orgs like Doctors Without Borders and Partners in Health make theirs available right from their websites

For whatever reason I haven't found any hospices that do the same, but online resources like Guidestar provide access independent of the orgs - though they may not be too recent

Plenty of non-profit hospices have reason to be hinky about their finances (exec comp and bonuses in particular), but at least with a little digging it's possible to get some idea

Here's the problem with VITAS dude's memorized propaganda - if the issue is simply one of "tax status," can you seriously imagine this conversion between VITAS godfather Don Gaetz (yeah, he's the dad) and his financial backers in 1984 when non-profit Hospice Care, Inc. became for-profit Hospice Care, Inc:

Don Don - We haven't been paying taxes since 1978, even though we've done a ton of business and now we're looking at even more business paid for by the federal government, the freaking sky is the limit!

Financial Rapscallions (in unison) - What should we do, Don Don?

Don Don - We should definitely start paying taxes!
Financial Rapscallions (in unison) - What a great idea, Don Don!! Yes, let's start paying taxes!!!

You guys crack me up. Please push back on the nonsense, it's literally the least you can do.


Note - I have deep respect for the GeriPal dudes that goes all the way back to the early days of blogging about this stuff, and even wrote a thang for them back in the day, as well as a thang about their thang in tribute

I'm glad they did this podcast, and also very sad because it shows how bleak the future of hospice is

Imagine yourselves as energetic go-getters from Toys R Us completely convinced that those dudes at Bain Capital will have a complete change of heart once they listen to what you have to say 

Sunday, March 26, 2023

Game Over - UPDATED!


why are these white dudes smiling?

So the latest GeriPal thang took place just a few days ago during the annual AAHPM corporate lovefest and awards ceremony with HPNA tagalong - that's a whole other story

I'm taking in this video slowly, in bites - there's a lot to chew on, like a long obituary for a beloved figure who's not quite dead yet

I made it 10 minutes in on this first go - we'll see when I have an appetite for more - my first comment:

"this is worth line by line analysis, nobody can hide (even though there's abundant Weaselspeak right out of the gate). 

VITAS dude is unhappy about the investigative report on hunger in America because it didn't mention his favorite restaurant. 

Only a hit dog howls and they do it every time

Every nurse working at a for-profit with their eyes open sees the ugliest of corporate greed, fraud and malpractice as a matter of routine. 

"I'm not against for-profit hospice- private equity - publicly  traded..." 

Ira just negotiated against himself and walked away from the table empty handed. 

Nice work, doc. Check your pockets.

It's over, folks.

The financial rapscallions have won, they've captured hospice including the trade groups and professional orgs.

There's nothing for them to do besides mop up, and you've got no choices besides keep on dancing to their tune or step away to make all  things new. 

This discussion was over just 10 minutes in.

#RacistHPNA #CorporateShillsAAHPM #hapc #hapc23 #hapc2023


UPDATED 3/27/2023 4PM+/-

Let's call everything up there 1 - Intro

2 - physician cheers business without understanding business

Ira wants for-profit hospice to succeed by providing excellent care, but since that requires supporting proficient staff and safe staffing, they gotta cough up for both and that's just too expensive. 

That's always been the bottleneck even in the best times, which these are not.

It's money that matters, Paul Kusserow came back to make sure they'd meet their numbers - and BEAT their numbers, especially in the short-term

You can want whatever you want - they just want ROI that meets expectations and BEATS expectations!

It's the only success

3 - yeah we’ve been blowing it for 25 years but this time we’re serious  

Ira's against bad hospice - good position to take

He also admits that y'all in the awards club he helped found and guide have just been looking on for the past 25 years - though not really just looking, since y'all have to work somewhere so you've participated

Here's a question - how do you expect the people and the structures like AAHPM and bastard stepchild HPNA who have been on the scene throughout the theft to have any role or credibility in figuring out how to clean up the mess this has become?

I think this is a hint that whatever you've done is wrong, and that your best contribution to the discussion moving forward is to just stop talking and go sit over there

4 - “get big or get out” Earl Butz - USAgSec, racist and stand up comic

Now VITAS dude makes a pitch for scale in hospice, which is great for factories like theirs because they can meet their numbers and BEAT their numbers the same way McDonald's churns out whatever it is they churn out, some call it food. 

In his way of thinking, small community-based agencies are the real problem

I guess he's correct in a way - they couldn't pay $75 million to DOJ in a settlement for fraudulent practices over an 11 year period as easily as VITAS (Chemed, NYSE CHE - a holding company whose other division is Roto-Rooter the jokes write themselves)

The sanctimony is palpable

I'm curious if any women will be allowed to speak

On to the next few minutes or as much as I can stand in one sitting

5 - that’s what trade orgs and biz groups and prof orgs are for

Since corporate has captured hospice and that includes their trade group, don't be surprised to see them pushing hard for crap like this that favors their business interests which are NEVER the same as the interests of patients and families (and most clinicians)

Yeah they'll jabber on about how that's not true - but always ask yourselves who really benefits and 10/10 it's money that matters

Please consider opening your eyes

6 - i’m not afraid to say when someone’s right

Ira says "it's not complex" and y'know he's right

I'll listen more to what he thinks is important but I expect it'll be hugely physician biased since y'all have a hard time thinking about others besides yourselves

FWIW the most important indicator of quality are the answers to these questions:

- do you have enough staff?
- can you keep your staff?
- who is your staff?
- are they any good? 
- who owns you?


Yeah his advice was marginally helpful, of course physicians figure prominently; lots of features features (useless when you're trying to sell something); but he legit earned a cookie repeating Medicare's most useful questions (How many other patients does my hospice nurse see? Who comes for a nighttime emergency?) 

Also too see above wrt staff

I once asked a hospice how many full time RN Case Managers they had on staff to support a census of 850+/= and about their average case loads

Long story short - none of your business!

Story behind the story - not nearly enough

7 - ugh ok that's enough for now 
  • the financial rapscallions have won, it's over, nothing left to do but some mopping up
  • four white dudes talk talk talk talk while Vanna White holds a mic
  • what I anticipate moving forward
    • best case - "If we get a seat at the table with captains of industry and masters of the universe, surely they'll listen"
    • worst case - everyone except Ira and VITAS dude just put everything down and walk away in disgust
    • most likely - "oooo Curo's looking for a new medical director in Norman, Oklahoma!"
Thanks for reading! See you next time!

Friday, March 17, 2023

Private equity and public corps capture hospice - How it begins


This 10-minute clip is from a project I call, "How to find the best hospice? How to make money in hospice!" It's a working document, the story and pictures are set but the unscripted narration is awkward.
There's lots more to the story, including what we can do about the current hospice mess* and how patients, families, caregivers, clinicians and the community can best separate those rare grains of wheat from the overwhelmingly crappy chafe**

I'm working on it***

* know more
** demand better
*** nobody is coming to save us

Wednesday, February 22, 2023

How to make BIG money in hospice - financial engineering


Park Place?

"The largest Louisiana transaction announced in 2022 was LHC Group’s pending merger with Optum, a subsidiary of UnitedHealth Group, in a deal valued at $5.4 billion. Approximately 70% of LHC’s revenue is derived from home health care services.  UnitedHealth positioned the move as helping to advance value-based care and said it would accelerate the combined companies’ ability to deliver integrated care, leading to improved outcomes.  The merger follows the larger trend of healthcare moving toward hospital-at-home services which provide both patient care and economic benefits. LHC expects the deal to close during the first quarter of 2023, after completion of an FTC review."

Louisiana experienced 206 mergers or acquisitions in 2022

Thursday, February 16, 2023

To find and choose the best hospice, first separate the useful grain from the useless chaff


2 contrasting images of a woman The image on the left is from the Medicare.gov website, it’s a contemporary straight-on photo closeup of a smiling woman including her upper chest shoulders and head, wearing a light blue denim button shirt open at the neck, with long wavy reddish hair flowing, her face is turned up and to the left as she smiles broadly The image on the right is an antique engraving illustration of Italian woman wind winnowing in Roman countryside, published on Magasin Pittoresque, Paris, 1845 This woman is standing at a basket in an open field with her arms outstretched in front of her as she holds threshed grain in her hands, letting it slowly pour down to the basket as the wind separates the useful grain from the chaff
Now THAT's Italian!

I'm out here trying to put together something that could actually be useful for patients and families, while "industry stakeholders" just keep doing their thing, because hospice is captive to profiteers 

Thursday, February 9, 2023

Shocked and mortified

The nice white ladies are positively apoplectic in this run-on sentence:

"This type of behavior is antithetical to all standards and guidelines within the hospice and palliative care profession and does not represent the majority of hospice professionals, the nurses, physicians, physician assistants, social workers, chaplains, pharmacists, and other members of the inter-disciplinary team who deliver care to patients (and their caregivers) that focuses on quality of life for people who are experiencing a life-limiting illness."

Tuesday, January 31, 2023

NHPCO CEO Clutches Pearls, 2014 Edition


This is what so badly bothered J. Donald:

"the data analysis, based on hundreds of thousands of Medicare patient and hospice records from 2013, shows that the gap between the for-profits as a whole and nonprofits is striking and consistent, regardless of hospice size."

Sunday, January 29, 2023

Preview Presentation: How to Make Money in Hospice - Spin-off Stock Price Wipeout!!


It's a slide show, you can maximize screen size, advance the slides or auto loop

This is an excerpt from a work in progress - How to find the best hospice? | How to make money in Hopsice!! and specifically an excerpt that takes a look at the way to make the BIG money in hospice: financial engineering

Inspired by the reporting of journalist Ava Kofman

How Hospice Became a For-Profit Hustle

The final(?) version(s) will be video(s) with scripted narration

This is just some of the storyboard that takes a look at one form of financial engineering - the spin-off special dividend - and how it's turned out so far in the case of Encompass | Enhabit

I believe it's essential that patients and families, caregivers, clinicians and the community understand what's happening with hospice from every perspective - especially including the investors' point of view

They see the business opportunity as plain as you should be able to see the nose on your face in a mirror in broad daylight

Boomers are getting old, sick and dying - it's a demographic wave 

Surf's up!

In their own words:

"Investment to strengthen and scale... leadership in a fast-growing and fragmented market"

Advent International Acquires AccentCare

Inside Joke

Thanks for reading, see you next time!

Sunday, January 22, 2023

More on the dangers of for-profit corporate hospice

I’ve been observing for-profit-corporate hospice for a while, and have long believed it’s the single greatest threat to a patient and family’s opportunity to achieve a peaceful death

Ava Kofman’s recent piece emphasized yet again the need to develop ways to help people negotiate the minefield that for-profit corps have made of hospice, and to help patients, families, caregivers, clinicians and the community understand the difference between good hospice and predatory crappy hospice

There are so many rabbit holes in the space, as just one example:

  • Curo Health Services didn’t exist until 2010, when it was founded by some hospice sharpies and a private equity firm to acquire other hospices - classic rollup small players
  • 2014 second PE firm buys Curo $730 million, first PE exit strategy
  • 2018 third PE firm buys Curo $1.4 billion, second PE exit strategy
  • 2022 fourth PE firm buys 60% of Curo + remains of Kindred Hospice for $2.4 billion, third PE exit strategy
  • Humana owns other 40% (they also love Medicare Advantage)

Like I said, that’s just one story there’s so much M&A going on because Boomers are getting old sick and dying - it’s a demographic wave

Surf’s up!

Working on the material also leads to the questions - so what? What can we do?

Here's what I think:

We need easy access to reliable information that supports informed decision making

“WE” = patients, families, caregivers, clinicians and the community

  • Every hospice must be required to post and update the following information daily, prominently on their websites, transmit it daily to the hospice compare section at medicare.gov, and be prepared to convey by phone when requested:
  • Post ownership 
  • For-Profit must include parent corp, whether public/private, list PE & major shareholders, and post links to investor info 
  • Not-for-Profit must post links to past 5 years IRS 990
  • Post ADC (total, home, LTC, ALF, other) 
  • Post staff #’s (FT - RNCM, MSW, SC, HCA, NP/PA, MD, Other; PT - RN, MSW, SC, HCA, NP/PA, MD, Other) 
  • Post actual case load # and average case load calcs @ NHPCO 2010 workload guidelines
  • Post staff #’s open positions 
  • Post current quality scores
  • Post notice deficiencies & complaints
  • Post all staff bios

FWIW I have also assembled links to my previous blog posts on the topic

Appendix B

Death Nurse: Boo Boo talks about hospice

Death Nurse: Boo Boo talks $$ and non-profit hospice


Death Nurse: When your hospice medical director is a useless idiot…


Hospice 101 - Part 1: Meet your nurse

Death Nurse: This could be the start of something big

Death Nurse: Another point about suffering

http://www.deathnurse.com/2018/12/searching-for-hospice-at-place-in.html Part 1

http://www.deathnurse.com/2019/01/searching-for-hospice-at-place-in.html Part 2

Death Nurse: Peeking up from the rabbit hole…

Death Nurse: At least it's not a meat grinder

Death Nurse: This is not financial or investment advice

Death Nurse: Failing CMM-101

Death Nurse: This is not financial advice, continued

Death Nurse: This is not financial advice, continued (different one)

Death Nurse: Orange Crate Update Number 1



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

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


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


Death Nurse: November is hospice month! Hospice Fraud Wall of Shame Update

Death Nurse: November is Hospice Month! BREAKING!! Amedisys continues to acquire and disrupt

Death Nurse: Ending the year with a look back at a hospice service failure

Death Nurse: Sneak peek magnum opus - how to find the best hospice    

Death Nurse: How to choose a hospice





Death Nurse: The problem is crappy corporate hospice 

Thanks for reading, more to come

Friday, January 20, 2023

FWIW - New Yorker/ProPublica piece isn’t the first one, by far

 WaPo 2014 - “... data analysis, based on hundreds of thousands of Medicare patient and hospice records from 2013, shows that the gap between the for-profits as a whole and nonprofits is striking and consistent, regardless of hospice size

“Unfortunately, a lot of people have come into the business for the wrong reasons,” said Michael Girard, who with his wife Deb owns the Circle of Life for-profit hospice in Reno, Nev. “A lot of the problems we have in hospice today have happened with the entry of what I call the ‘vulture capitalists.’ ”

WaPo 'Business of Dying'

NHPCO 2014 - “In an article appearing in today’s Washington Post, “Dying and profits: The evolution of hospice,” examination of federal hospice cost report data points out differences among provider types. It may be inferred that tax status influences the quality of care a hospice provider delivers to patients and their families. The National Hospice and Palliative Care Organization is concerned that this article –  like others in the Post’s “The Business of Dying” series – may confuse the public seeking care at the end of life. Assessing quality is not as simple as identifying whether a hospice provider is a non-profit or for-profit organization or looking at a single statistic.”

“As the need for hospice and the awareness of the services hospice provides has increased, the number of both non-profit and for-profit providers has grown.”

NHPCO is simply mortified

**NOTE: The statement above is not correct - the total number of not-for-profit hospices reached a peak of 1,400+/- in 1998 and has declined to about 1,200 in 2022, while between 1998 and 2022 the number of for-profit hospices has increased from 700+/- to over 3,600.

“Between 2000 and 2013, the number of Medicare beneficiaries served by chain hospices more than quadrupled, and FP chain agencies are now the largest category of hospice agencies nationally… Our results highlight the value of more detailed analyses of hospice ownership to offer a more nuanced assessment concerning the role of structural and organizational dimensions in care delivery. Such a focus will help guarantee that clinicians, patients, researchers, and policymakers have the tools necessary to assess care provided by particular companies and to ensure greater transparency in the hospice marketplace.”

Tracking ownership changes in hospice - HHS

“In this longitudinal study of hospices active in Medicare during 1999–2009, we analyzed Provider of Services files to understand key shifts in the industry. We found evidence of substantial turbulence. One-fifth of Medicare-certified hospices active in 1999 had closed or withdrawn from the program by 2009, and more than 40 percent had experienced one or more changes in ownership. The most prominent trend was the shift in ownership type from nonprofit to for-profit ownership. Four out of five Medicare-certified hospices that entered the marketplace between 2000 and 2009 were for-profit. Hospices also became larger, as the proportion with 100 or more full-time employees doubled to 5 percent from 1999 to 2009.”

Hospice industry turbulence in shift to for-profit

“We… physicians haven’t been bold in the past TWO decades during multiple OIG & news reports of fraud in hospice. We should be bold now.” 

Christian Sinclair, MD via Twitter

HPNA via email - “ I hope that you read our advocacy update in Friday’s HPNA Happenings newsletter on this topic. We were mindful to update the entire membership with the work we have done to this point on the Ava Kofman article.  The national office staff has also been monitoring the community message boards and may distribute a similar advocacy update message in the days ahead.  As HPNA continues to work with its Coalition partners on this issue, which has a high-level of complexity, the national office staff will be sure to share additional information when it becomes available.  Our staff looks forward to continuing to highlight the significant role hospice nurses play in providing care to patients and families throughout the process.”