Hospice Demographic and Outcome Measures

RICK SCOTT GOVERNOR CHARLES T. CORLEY SECRETARY 2012 REPORT Hospice Demographic and Outcome Measures elderaffairs.state.fl.us 1 Bureau of Planning & Evaluation, September 2012 Revised February 2013

Table of Contents 1.0 Legislative Directive and Purpose of the Report... 1 2.0 Data Collected... 1 3.0 Outcome Measures... 2 3.1 Outcome Measure 1... 2 3.2 Outcome Measure 2... 5 3.3 Outcome Measure 2A... 6 4.0 Accreditation... 7 5.0 Individual Hospice Information... 7 6.0 Hospice Geographical Coverage... 12 7.0 Inpatient Facilities and Residential Units... 13 8.0 Admitting Primary Diagnosis... 18 9.0 Patient Race/Ethnicity... 19 10.0 Patient Age... 20 11.0 Discharges by Disposition Type... 22 12.0 Patient Days by Location... 23 13.0 Reimbursement... 23 14.0 Additional Hospice Data Available... 24 15.0 New Outcome Measures for the Centers for Medicare and Medicaid Services... 25 APPENDIX... 26 i

1.0 Legislative Directive and Purpose of the Report Section 400.60501, Florida Statutes, requires the Department of Elder Affairs, in conjunction with the Agency for Health Care Administration, to develop outcome measures to determine the quality and effectiveness of hospice care for hospices licensed in Florida. This statute, along with Rule 58A-2.005, defines the outcome measures, as well as demographic and diagnostic information hospices are required to submit to the Department of Elder Affairs annually. Hospices are also required to conduct patient surveys using the National Hospice and Palliative Care Organization (NHPCO) Patient/Family Satisfaction Survey or a similar survey. Two of the three hospice outcome measures were promulgated on August 11, 2008. Calendar year 2011 is the third year for which a full year s results for all three outcome measures are available. This report contains an analysis of the data submitted by Florida s 43 licensed hospices for calendar year 2011. Two prior reports describe the analysis of hospice data and outcomes for calendar years 2009 and 2010. 1 2.0 Data Collected Hospices licensed in Florida are required to submit outcome measure, demographic, and diagnostic information to the Department each year. A newly developed secure online form was made available January 1, 2010, to all hospices for the purpose of data collection. A copy of the form that lists the information required (DOEA Form H-002) is included in the Appendix. The information provided by each hospice organization includes the following: Basic hospice and contact information; Counties served; Facility and residential unit information including the number of beds, facility admissions, and facility patient days; Proportion of patients reporting a reduction of pain (Outcome Measure 1); Proportion of patients receiving the right amount of pain medicine (Outcome Measure 2); Proportion of patients who would recommend hospice services to others (Outcome Measure 2A); Diagnosis, age, race, and reimbursement information for patients admitted; of patient days by location; and of discharges by death/non-death. 1 http://elderaffirs.state.fl.us 1

Most of the required information is reported at the hospice organization level (not for each facility or residential unit). 3.0 Outcome Measures Hospices are required to report on three outcome measures (see Table 1 below). These measures were designed to be used as a tool for evaluating hospice quality. Results from calendar year 2011 indicate that all but two hospices that reported outcome measure data met the standards set for these three measures. Table 1 below lists the standard set for each outcome measure and the percentage of hospices that met the standard. The acceptable standard for all three outcome measures was set at 50 percent of the survey responses received by the hospice. Table 1: Percentage of Florida Hospices That Met Outcome Measures for 2011 Outcome Measure Description of Outcome Measure and Standard Percent of Hospices Met Standard 1 50 percent or more of patients who reported severe pain on a 0- to-10 scale reported a reduction to five or less by the end of the fourth day of care in the hospice program. 2 50 percent or more of patients reported they received the right amount of medicine for his or her pain. 98% * 100% 2A 50 percent or more of patients and/or family members recommended hospice services to others based on the care the patient received. 100% * Florida Hospital Hospice Care did not meet this standard. Heartland Hospice Services II did not submit data on patients level of pain. 3.1 Outcome Measure 1 As required in Chapter 2006-155, Laws of Florida, Outcome Measure 1 measures the percentage of patients who had severe pain (seven or higher on the 0-10 scale) at admission and whose pain was reduced to a level of five or less by the end of the fourth day of care. Forty-two hospices reported data on this measure. Forty hospices reported they met or exceeded the 50 percent standard for decreasing pain to a level of five or less by the end of the fourth day, while two hospices did not meet this standard. 2 Compared to 2009 and 2010, there were fewer hospices in 2 2 2012 Report Hospice Demographic and Outcome Measures

2011 that reported that 87 to 100 percent of their patients pain was reduced to level five or less, i.e., 17 in 2011 and 21 in both 2009 and 2010. The majority (21) of the hospices in 2011 reported they reduced the pain level to five or less by the end of the fourth day for 75 to 86 percent of their patients in 2011 (see Chart 1 below). This represents an increase of hospices in this category from the prior two reporting years, i.e., from 15 in 2009 and 16 in 2010. In 2011, one hospice did not meet the standard for minimum pain reduction in four days, compared to two hospices reported in the prior two years. See Table 4 for a list of the names of the hospices and the percentages of their patients that met this outcome measure. Chart 1: Percentage of Patients Whose Pain Was Reduced to Level 5 or Less by Hospice n=42; 2011 Statewide, hospices reported pain level data for 55,730 patients at the time of admission. Sixteen percent of these patients (8,652) reported having severe pain at admission (see Chart 2 below). 3 2012 Report Hospice Demographic and Outcome Measures

Chart 2: Florida Hospices Pain Level at Time of Admission n=55,730; 2011 Of those patients reporting severe pain at the time of admission, 60 percent reported a reduction in pain to a level five or less by the end of the fourth day of care. Twelve percent reported their pain level was six or higher by the end of the fourth day of care. Twenty-eight percent were unable to report their pain level by the fourth day (see Chart 3 below). These totals may include patients who chose not to receive pain medicine. Chart 3: Status of Florida Hospice Patients at End of Fourth Day of Care for Those Who Had Severe Pain at Admission 4 2012 Report Hospice Demographic and Outcome Measures

severe pain at admission= 8,652; 2011 Inconsistencies in data collection for this outcome measure were identified. Namely, not all hospices reported the level of pain on the fourth day after admission. Furthermore, the first day on which pain measures are collected may vary by hospice, as some hospices start reporting pain on the day of admission while others start on the first day of care received. In addition, when multiple pain scores were reported on the fourth day, the score selected varied; some hospices use the first pain score reported, some use the lowest pain score reported, and others use the highest pain score reported. 3.2 Outcome Measure 2 Outcome Measure 2 measures the percentage of patients/families who said the patient received the right amount of pain medicine. All reporting hospices exceeded the standard that at least 50 percent of their patients receive the right amount of medicine for their pain. Hospice organizations reported that 78,872 surveys were initiated during the reporting period that included a question about whether or not the patient received the right amount of medicine for his or her pain. Thirty-three percent (25,830) of the surveys were returned with this question answered. Ninety-five percent of all patients/families said the patient received the right amount of medicine for his/her pain (see Table 2 below). 3 This proportion has not changed over the past two years of reporting. Table 2: Florida Hospice Patients Outcome Measure 2 Results Did the patient receive the right amount of medicine for his or her pain? of Patients Percentage of Patients of survey responses received during reporting period indicating the patient received the right amount of medicine for his or her pain. 18,695 95% of survey responses received during the reporting period indicating the patient did not receive the right amount of medicine for his or her pain. 972 5% Total survey responses received indicating whether or not the right amount of medicine was received. 19,631 100% 3 5 2012 Report Hospice Demographic and Outcome Measures

3.3 Outcome Measure 2A Outcome Measure 2A measures the percentage of patients who would recommend hospice services to others. All of the 43 hospices reported data on this measure. All of the reporting hospices exceeded the standard that at least 50 percent of their patients and/or family members would recommend hospice services to others based on the care the patient received. The hospice organizations reported that 78,872 surveys were initiated during the reporting period that included a question about whether or not the patient or responsible party would recommend hospice services to others. Thirty-three percent (25,830) of the surveys were returned with this question answered. Ninety-seven percent of all patients/families who responded to this question said the patient or responsible party would recommend hospice services to others (see Table 3 below). 4 This proportion has not changed from year 2010, even though it decreased slightly from reporting year 2009, when 98 percent of patients and/or family said they would recommend hospice services to others. 4 6 2012 Report Hospice Demographic and Outcome Measures

Table 3: Florida Hospice Patients Outcome Measure 2A Results Based on the care the patient received, would the patient and/or responsible party recommend hospice services to others? of Patients Percent of Patients of survey responses received during the reporting period answering yes to this survey question. of survey responses received during the reporting period answering no to this survey question. Total survey responses received indicating whether or not hospice services would be recommended to others. 23,280 97% 781 3% 24,061 100% 4.0 Accreditation Accreditation is a voluntary process that requires a hospice organization to submit to an extensive on-site evaluation. The evaluation covers many areas of patient care and patient safety. Many see accreditation as a tool for measuring the quality of an organization. The number and proportion of accredited hospices increased from the two prior years: 22 of the 43 hospices (51%) identified themselves as being accredited, compared to 18 of all hospices (41%) in 2009 and 17 of all hospices (41%) in 2010. The hospices that have been accredited are identified in Table 4 along with the name of the accrediting entity. The proportion of not-for-profit accredited hospices increased from the two prior years, from 50 percent in 2009 and 48 percent in 2010, to 55 percent in 2011.The proportion of accredited forprofit hospices also increased from 14 percent in 2009 and 25 percent in 2010 to 42 percent in 2011. 5.0 Individual Hospice Information The names of the 43 hospices licensed in Florida are listed in Table 4 along with the city in which the organization is located. In addition, outcome measure results are listed for each hospice. Table 4 also contains the name of the accrediting entity for hospices that are accredited. In 2011, 49 percent (21 of 43) of hospices were accredited, compared to 41% (17 of 41 hospices) in both 2010 and 2009. The accreditation status of individual hospices continued over the years evaluated. The Profit Status column contains FP if the hospice is a for-profit hospice (the field is blank for not-for-profit hospices). In 2011, 12 of the 43 (28%) hospices were for-profit which compares to 9 of the 41 hospices (22%) in 2010, and 7 of 41 hospices (17%) in 2009. The number of patients admitted to each hospice for 2011 is also listed. 7 2012 Report Hospice Demographic and Outcome Measures

Table 4: Outcome Measure (OM) Results, Accrediting Entity, Profit Status and of Patients, by Hospice Hospice Name City OM 1 OM 2 OM 2A Accrediting Entity Profit Status Patients Avow Hospice, Inc. Naples 97% 96% 99% The Joint Commission 1,800 Big Bend Hospice, Inc. Tallahassee 76% 91% 96% CHAP 1,382 Catholic Hospice, Inc. Miami Lakes 82% 93% 91% 2,229 Community Hospice of Northeast Florida, Inc. Compassionate Care Hospice of Miami Dade, Inc. Covenant Hospice, Inc. Emerald Coast Hospice Jacksonville 88% 96% 98% 6,024 Bartow 80% 100% 98% CHAP FP 119 Pensacola 83% 96% 98% The Joint Commission 4,011 Panama City 86% 97% 87% 1,330 Florida Hospital Hospice Care Ormond Beach 49% 96% 89% The Joint Commission 772 Good Shepherd Hospice Temple Terrace 89% 97% 97% The Joint Commission 3,233 Gulfside Regional Hospice Inc. New Port Richey 73% 93% 97% 1,281 Halifax Hospice, Inc. Port Orange 93% 97% 99% 3,440 Haven Hospice Gainesville 82% 93% 94% ACHC 3,349 8 2012 Report Hospice Demographic and Outcome Measures

Table 4: Outcome Measure (OM) Results, Accrediting Entity, Profit Status and of Patients, by Hospice (continued) Hospice Name City OM 1 OM 2 OM 2A Accrediting Entity Profit Status Patients Heartland Home Health Care and Hospice Jacksonville 100% 100% 82% CHAP FP 212 Heartland Hospice 5 Plantation 100% 100% 98% The Joint FP 930 Commission Heartland Hospice Services II Homestead missi ng 100% 100% CHAP FP 58 Hope Hospice and Community Services, Inc. Hospice by the Sea, Inc. Hospice Care of South Florida Hospice of Citrus County, Inc. Hospice of Gold Coast Hospice of Health First Hospice of Lake & Sumter, Inc., dba Cornerstone Hospice & Palliative Care Fort Myers 88% 95% 98% CHAP 5,136 Boca Raton 76% 95% 97% The Joint Commission 3,584 Miami 100% 100% 100% 135 Lecanto 71% 97% 99% The Joint Commission Fort Lauderdale 2,201 87% 99% 98% CHAP 537 Melbourne 75% 95% 98% The Joint Commission 1,054 Tavares 79% 94% 92% 4,200 Hospice of Marion County, Inc. Ocala 96% 95% 98% The Joint Commission 2,880 Hospice of Okeechobee, Inc. Okeechobee 94% 90% 95% 182 5 Formerly known as Hospicecare of Southeast Florida. 9 2012 Report Hospice Demographic and Outcome Measures

Table 4: Outcome Measure (OM) Results, Accrediting Entity, Profit Status and of Patients, by Hospice (continued) Hospice Name City OM 1 OM 2 OM 2A Accrediting Entity Profit Status Patients Hospice of Palm Beach County, Inc. West Palm Beach 87% 96% 97% The Joint Commission 6,623 Hospice of St Francis, Inc. Titusville 78% 98% 99% ACHC 891 Hospice of the Comforter, Inc. Altamonte Springs 85% 95% 97% 2,737 Hospice of the Florida Keys Hospice of the Treasure Coast, Inc. Key West 60% 95% 100% 219 Stuart 78% 95% 97% 1,945 HPH Hospice Hudson 81% 96% 94% 4,222 LifePath Hospice Temple Terrace 85% 94% 97% The Joint Commission 5,862 Odyssey Healthcare of Marion County, Inc. Regency Hospice of Northwest Florida, Inc. Samaritan Care Hospice of Florida Seasons Hospice and Palliative Care of Southern Florida Miami 100% 64% 92% FP 896 Pensacola 100% 100% 100% FP 276 Orlando 57% 95% 100% FP 266 Miami 75% 89% 89% FP 700 Suncoast Hospice Clearwater 81% 94% 98% 7,629 10 2012 Report Hospice Demographic and Outcome Measures

Table 4: Outcome Measure (OM) Results, Accrediting Entity, Profit Status and of Patients, by Hospice (continued) Hospice Name City OM 1 OM 2 OM 2A Accrediting Entity Profit Status Patients The Hospice of Martin and St. Lucie, Inc. Stuart 85% 97% 99% 1,449 Tidewell Hospice, Inc. Sarasota 91% 95% 97% CHAP 6,908 Vitas Healthcare Corporation of Florida Vitas Healthcare Corporation of Florida VITAS Healthcare Corporation of Florida VNA Hospice of Indian River County Wuesthoff Brevard Hospice and Palliative Care Average outcomes; Total number of patients North Miami Beach 82% 94% 97% FP 6,647 Melbourne 82% 93% 97% FP 5,827 Boynton Beach 86% 94% 96% FP 7,333 Vero Beach 83% 96% 99% The Joint Commission 1,115 Viera 100% 97% 97% FP 817 83% 95% 96% 112,441 CHAP = Community Health Accreditation Program ACHC = American Commission for Healthcare, Medicare Deeming Authority for Home Health, Hospice, and DMEPOS accrediting FP=For Profit 11 2012 Report Hospice Demographic and Outcome Measures

6.0 Hospice Geographical Coverage As in the prior two years of reporting, each of Florida s 67 counties was served by at least one hospice organization in 2011. The number of hospice organizations serving each county is listed in Table 5 below. Table 5: 2011 Geographic Coverage of Florida s Hospices County Hospice Organizations Serving County County Hospice Organizations Serving County County Hospice Organizations Serving County Alachua 2 Franklin 2 Lee 1 Baker 4 Gadsden 2 Leon 2 Bay 2 Gilchrist 2 Levy 2 Bradford 2 Glades 1 Liberty 2 Brevard 4 Gulf 2 Madison 2 Broward 6 Hamilton 2 Manatee 1 Calhoun 2 Hardee 4 Marion 2 Charlotte 1 Hendry 1 Martin 3 Citrus 2 Hernando 1 Miami Dade 7 Clay 4 Highlands 4 Monroe 5 Collier 2 Hillsborough 1 Nassau 4 Columbia 2 Holmes 2 Okaloosa 3 Desoto 1 Indian River 1 Okeechobee 3 Dixie 2 Jackson 2 Orange 5 Duval 4 Jefferson 2 Osceola 5 Escambia 3 Lafayette 2 Palm Beach 3 Flagler 5 Lake 1 Pasco 2 12 2012 Report Hospice Demographic and Outcome Measures

Table 5: 2011 Geographic Coverage of Florida s Hospices (continued) County Hospice Organizations Serving County County Hospice Organizations Serving County County Hospice Organizations Serving County Pinellas 1 Sarasota 1 Volusia 5 Polk 4 Seminole 2 Wakulla 2 Putnam 2 Sumter 1 Walton 3 Saint Johns 4 Suwannee 2 Washington 2 Saint Lucie 3 Taylor 2 Santa Rosa 3 Union County 2 7.0 Inpatient Facilities and Residential Units During 2011, Florida s hospice organizations operated 94 inpatient facilities and residential units. These include inpatient wings or rooms within a hospital or skilled nursing facility that were operated by the hospice as well as freestanding hospice inpatient facilities and residential units that appear on the hospice license. Each facility/unit must meet the following criteria: (1) Consist of one or more beds that are owned or leased by the hospice, (2) Be staffed by the hospice organization, and (3) Have policies and procedures set by the hospice. The hospice organizations in the state operated between zero and 16 facilities/residential units (see Table 6 below). The number of hospices without facilities/residential units increased to 15 in 2012, compared to 10 hospices in 2009 and 12 hospices in 2010. The number of hospices with one to two facilities/residential units in 2012 decreased slightly from 2009 and 2010, i.e., 18 and 19, respectively. 13 2012 Report Hospice Demographic and Outcome Measures

Table 6: of Facilities/Residential Units Operated by Florida s Hospices in 2011 of Facilities/Residential Units of Hospices 0 15 1 8 2 8 3-8 11 16 1 During 2011, there were 39,799 admissions for 1,545 hospice beds in facilities/residential units for a total of 365,010 facility patient days (see Table 7). While these numbers increased by nine to 11 percent from 2009 to 2010, there was a three percent increase in admissions, a two percent increase of hospice beds, and a two percent decrease of patient days from 2010 to 2011. Table 7: Admissions, Hospice Beds, and Facility Patient Days, 2009 through 2011 Admissions 2009 2010 2011 Difference 2009 to 2010 Difference 2010 to 2011 34,719 38,469 39,799 11% 3% Hospice Beds 1,329 1,445 1,545 9% 2% Facility Patient Days 340,080 372,983 365,010 10% -2% On average, there were 30 admissions per bed and 268 patient days per bed (see Table 8). This compares to 26 and 27 admissions per bed in 2009 and 2010, and 256 and 258 patient days per bed in those prior two years. While the average occupancy rate in 2011 ranged from 24 to 97 percent, the overall average occupancy rate across counties was 74 percent. The average occupancy rates in 2009 and 2010 were 70 and 71 percent, respectively. The number of beds, admissions, and patient days by county is listed in Table 8 below. 14 2012 Report Hospice Demographic and Outcome Measures

The Older Americans 2012 Key Indicators of Well-Being 6 reports that 34 percent of hospice patients nationwide stayed seven days or fewer and 18 percent more than 90 days. Approximately 40 percent of patients admitted to Florida hospices in 2011 stayed for an average of seven days or less and 59 percent stayed on average between more than seven days up to 90 days. One percent stayed more than 90 days. The overall average days per hospice admissions for Florida patients in 2011 was 13 days; the median was nine days. 6 Federal Interagency Forum on Aging-Related Statistics. (2012). Older Americans 2012: Key Indicators of Well-Being. Washington, DC: U.S. Government Printing Office. June 2012, p. 66. 15 2012 Report Hospice Demographic and Outcome Measures

Table 8: 2011 Inpatient Facility/Residential Units Operated by Florida Hospices, by County County Total Beds Total Facility Admissions Total Facility Days Average Admissions Per Bed Average Days Per Bed Average Occupancy Rate Average Facility Days per Admission Alachua Brevard Broward Charlotte Citrus Collier Columbia Desoto Duval Escambia Flagler Hernando Highlands Hillsborough Indian River Lake Lee Leon 18 636 6,072 35 337 92% 10 42 1,268 9,676 31 233 64% 10 104 2,243 29,773 20 299 82% 44 19 686 6,440 31 338 93% 18 12 251 3,353 25 272 74% 15 27 1,173 7,089 37 256 70% 8 16 500 5,096 31 319 87% 10 8 106 2,463 13 308 84% 23 87 1,629 30,709 19 353 97% 19 34 1,029 8,023 30 236 65% 8 8 270 1,703 34 213 58% 6 56 1,104 9,136 15 244 67% 23 23 616 4,062 29 189 52% 7 48 2,323 14,420 48 300 82% 6 12 554 3,388 46 282 77% 6 16 655 4,740 44 297 81% 7 100 3,225 33,714 33 338 93% 12 12 267 2,792 22 233 64% 10 16 2012 Report Hospice Demographic and Outcome Measures

Table 8: 2011 Inpatient Facility/Residential Units Operated by Florida Hospices, by County (continued) County Total Beds Total Facility Admissions Total Facility Days Average Admissions Per Bed Average Days Per Bed Average Occupancy Rate Average Facility Days per Admission Levy 16 310 3,211 19 201 55% 10 Manatee 20 947 6,051 47 304 83% 7 Marion 64 1,178 1,5012 21 261 72% 13 Martin 16 564 3,933 35 246 67% 7 Miami-Dade 91 1,486 23,324 17 256 70% 17 Okeechobee 11 258 1,623 26 109 30% 4 Orange 28 779 7,809 27 274 75% 10 Palm Beach 10 150 2,962 15 296 81% 6 Pasco 247 3,776 1,8125 22 89 24% 12 Pinellas 121 2,154 1,8814 17 191 52% 10 Polk 102 2,761 2,9907 30 295 81% 6 Putnam 19 933 5724 48 294 81% 11 Sarasota 12 330 3689 28 307 84% 8 Seminole 18 805 6326 45 353 97% 18 St. Lucie 22 1,037 7291 36 330 90% 13 Sumter 12 252 3,306 21 276 75% 6 Volusia 58 2,107 1,5263 35 256 70% 8 Total; Average 1,545; 58 39,799; 2,107 365,010; 15,263 30 268 74% 13 Note: The number of admissions may not equal the number of patients since a patient can be admitted more than once during the calendar year and a person may be a patient during the calendar year but admitted prior to the start of the calendar year. 17 2012 Report Hospice Demographic and Outcome Measures

8.0 Admitting Primary Diagnosis Hospices reported on the primary diagnosis for 112,441 patients at the time of admission. These totals were not limited to admissions to facilities or residential units. The following diagnosis categories were used: cancer, AIDS, end-stage pulmonary disease, end-stage renal disease, endstage heart disease and other. Forty-one percent of patients had a primary diagnosis included in the other category. Thirty-four percent responded that cancer was the primary diagnosis, followed by 13 percent for heart disease, and nine percent for pulmonary disease. AIDS and renal failure comprised the remaining three percent (see Chart 4 below). While the proportion of patients primary diagnoses at time of admission to hospices in 2011 are similar to those of the two prior years, the proportion of patients diagnosed with AIDS was half of that reported in 2011, i.e., 0.5 percent compared to one percent in 2009 and 2010. Chart 4: Primary Diagnosis at Time of Admission to a Florida Hospice n= 112,441; 2011 A study in the February 2011 Journal of the American Medical Association looked at the differences in the diagnoses of patients cared for by for-profit and not-for-profit hospices. 7 The study included a nationally representative sample of 4,705 patients discharged from hospices. Results showed lower proportions of cancer patients and higher proportions of patients with dementia in forprofit hospices compared to non-profit hospices. A similar and significant (.01 level) pattern of a lower percentage of cancer diagnoses in for-profit hospices compared to not-for-profit hospices (29% and 36%, respectively; see Table 9) occurred in Florida. In addition, more than double the proportion of patients in for-profit hospices had AIDS, compared to the proportion in not-forprofit hospices (1% and 4%, respectively). 7 Wachterman, M.W., Marcantonio, E.R., Davis, R.B., and McCarthy, E.P. Association of Hospice Agency Profit Status With Patient Diagnosis, Location of Care, and Length of Stay, Journal of the American Medical Association, February 2011. 18 2012 Report Hospice Demographic and Outcome Measures

Table 9: 2011 Patient Diagnoses at Time of Admission to Florida Hospices, by For-Profit Status Cancer Renal Heart Pulmonary AIDS "Other" Total Not-For- Profit 36% 2% 13% 10% 0.4% 39% 100% n=112,441; 2011 For-Profit 29% 2% 13% 8% 1% 48% 100% The finding for the proportion of patients with dementia could not be replicated, as hospices are not required to report this diagnosis. However, the higher occurrence of patients diagnosed with other diagnoses in for-profit hospices compared to not-for-profit hospices (level of significance at.09) included in this data set may include a substantial number of patients with dementia. The National Hospice and Palliative Care Organization reported dementia as one of the four non-cancer primary diagnoses for patients admitted to hospice in 2010, representing 13 percent of diagnosed patients. 8 An additional 13 percent of hospice patients in this study were diagnosed with debility unspecified. The proportions of the primary diagnoses except for those quoted in the other category were very similar to those found in this study of Florida hospices. 9.0 Patient Race/Ethnicity Hospices reported on the race and ethnicity of over 112,441 patients at the time of admission. These totals are not limited to admissions to facilities or residential units. The following race/ethnicity categories were used: Asian, Black, Caucasian, Hispanic, and other. Hospices reported that a majority (78%) of their patients were Caucasian; 10 percent identified themselves as Hispanic, regardless of race; seven percent were black; and 0.5 percent were Asian (see Chart 5 below). 8 The National Hospice and Palliative Care Organization (2012). NHPCO Facts and Figures: Hospice Care in America. 2011 Edition. 19 2012 Report Hospice Demographic and Outcome Measures

Chart 5: 2011 Reported Race/Ethnicity at Time of Admission to a Florida Hospice n=112,441; 2011 The majority of patients were admitted to non-profit hospices (73%). Eighty-three percent of the patients admitted to not-for-profit hospices during the 2011 reporting period were Caucasian compared to 66 percent admitted to for-profit hospices. The proportion of Caucasian patients admitted to for-profit hospices in 2011 increased by 11 percent from 2010, while the distribution of Caucasians in not-for-profit hospices between 2009 and 2011 remained the same. 10.0 Patient Age Hospices reported on the age of 112,441 patients at the time of admission. These totals are not limited to admissions to facilities or residential units. Each person admitted was grouped into one of three age categories: age 0-18, 19-64, or 65 or older. Eighty-four percent of all hospice patients admitted were age 65 or older. Sixteen percent of patients admitted were between the ages of 19 and 64. Less than one-half percent of those admitted were under the age of 19 (see Chart 6 below). These proportions have not changed from previous years of admissions evaluated. 20 2012 Report Hospice Demographic and Outcome Measures

Chart 6: 2011 Reported Age at Time of Admission to a Florida Hospice n= 112,441; 2011 For-profit hospices served slightly more clients age 65 and older than not-for-profit hospices (87% compared to 84%). Table 10 below shows the percentage of patients admitted by age category and hospice profit status. The age distribution of patients admitted to hospices over the past two years remained very similar. While the proportion of patients for the two older age categories by profit status of hospice did not vary from previous years analyzed, the proportion of patients age 0 to 18 in for-profit facilities fluctuated from 0.1 percent in 2009 to 0.04 in 2010 to 0.2 percent in 2011. In 2011, the proportion of patients age 0 to 18 in both not-for-profit and forprofit facilities was 0.2 percent 21 2012 Report Hospice Demographic and Outcome Measures

Table 10: 2011 Florida Hospice Patients Age and Organization s Profit Status Percent Patients Age 0-18 Percent Patients Age 19-64 Percent Patients Age 65+ Total Not-For-Profit 0.2% 16% 84% 100% For-Profit 0.2% 13% 87% 100% n=112,441; 2011 11.0 Discharges by Disposition Type Hospices reported on the disposition of discharges, whereby each discharge was grouped into one of two categories: death and non-death. Individuals who died during the 2011 calendar year are included in the death category. The vast majority of discharges were due to patient death (82%; see Chart 7 below). Chart 7: 2011 Florida Hospice Patient Discharges by Disposition n=109,628; 2011 Discharge dispositions due to death were slightly higher in not-for-profit (83%) than in forprofit hospices (79%). The distribution of dispositions of discharges was similar across the past three years; however, the proportion of discharges due to patient death in for-profit hospices declined from 83 percent in 2010 to 79 percent to in 2011. 22 2012 Report Hospice Demographic and Outcome Measures

12.0 Patient Days by Location Hospices reported on the days patients spent by type of location. A majority (52%) of hospice patient days were spent in private residences (see Chart 8). About a quarter of all hospice days were spent in a nursing home contracted non-inpatient bed. Twenty percent of patient days were spent in an assisted living facility. Only three percent of all hospice patient days were in a freestanding hospice inpatient facility. One percent or less of all hospice days was spent in each of the following: Hospital - Other Than Dedicated Hospice Unit Hospital - Dedicated Hospice Unit Hospice Residential Facility Adult Family Care Home Nursing Home - Contracted Inpatient Bed The distribution of patient days spent by type of location varied very little from the past two years. Chart 8: 2011 Florida Hospice Patient Days by Location n= 8,650,748; 2011 13.0 Reimbursement Hospices reported on their reimbursement sources by providing the percentage of their income that came from each of six categories: Medicare, Medicaid, third-party, self-pay, uncompensated 23 2012 Report Hospice Demographic and Outcome Measures

and other. Eighty-seven percent of all hospice reimbursement came from Medicare. Medicaid paid seven percent, and four percent came from third parties (see Chart 9 below). Chart 9: 2011 Average Florida Hospice Reimbursements by Source n=43; 2011 For-profit hospices received a slightly higher percentage of reimbursement from Medicare (89% compared to 86%), a similar percentage from Medicaid (6% compared to 7%), and a lower percentage from third parties (2% compared to 4%). The sources of reimbursement to hospices in 2011 were very similar when compared to the two previous reporting years. 14.0 Additional Hospice Data Available Additional information about Florida s licensed hospices is available on Florida s Agency for Health Care Administration (AHCA) website. Included are results of the Family Evaluation of Hospice Care Satisfaction Survey, a survey given to families whose friend or family member received hospice care. It asks family members about their view on the care provided to the patient, as well as their own hospice experience. In general, ratings were very positive and only one hospice received a rating on a survey question that was below the highest score. This lower rating was related to the question about whether the hospice team responded to needs during the evening and weekends. All respondents agreed that patients were always treated with respect. In addition, AHCA s website provides information about inspection results and legal sanctions levied for each hospice. AHCA inspections through May 2012 cited 10 hospices with one or more 24 2012 Report Hospice Demographic and Outcome Measures

deficiencies. Deficiencies identified during inspections included the failure to provide quality of care, to ensure a patient s rights, to update information for care plans, and to conduct annual reviews of rules and by-laws ensuring that new employees get basic information about interacting with patients who have Alzheimer s disease or dementia-related disorders. You may access AHCA s website at the following web address: http://www.floridahealthfinder.gov. 15.0 New Outcome Measures for the Centers for Medicare & Medicaid Services In March 2012, the Centers for Medicare & Medicaid Services (CMS) introduced two new outcome measures for hospices. The first measure is a structural measure designed to ascertain whether hospices participate in a Quality Assessment and Performance Improvement (QAPI) program that includes three or more quality indicators related to patient care. Patient care-related indicators address patient care domains such as symptom management (e.g., pain), care coordination, patient safety, and care provision in accordance with documented patient/family preferences. The second measure, National Quality Forum #0209, assesses the number of patients who report being uncomfortable because of pain at the initial assessment that report pain was brought to a comfortable level within 48 hours. Hospices will begin collecting data for these two new measures in the fourth quarter of 2012 (October 1 through December 31, 2012) and submit data on the structural measure to CMS by January 31, 2013, and for the measure on pain by April 1, 2013. 25 2012 Report Hospice Demographic and Outcome Measures

APPENDIX STATE OF FLORIDA DEPARTMENT OF ELDER AFFAIRS HOSPICE DEMOGRAPHIC and OUTCOME MEASURES REPORT Reporting Period: January 1 through December 31 Report for Calendar Year Report Due no later than March 31 of the following year. SECTION A: BASIC HOSPICE AND CONTACT INFORMATION Hospice Name (as it appears on license) Telephone Physical Address Mailing Address, if different City State Zip Code 26 2012 Report Hospice Demographic and Outcome Measures

SECTION B: HOSPICE INFORMATION Facility License Medicaid Medicare Accreditation Status If Yes, enter Organization Name: Yes No SECTION C: CONTACT PERSON Name Telephone Fax E-Mail Address 27 2012 Report Hospice Demographic and Outcome Measures

SECTION D: COUNTIES SERVED of Florida counties served under this license: Check all counties served by this hospice license: Alachua Duval Holmes Miami-Dade Santa Rosa Baker Escambia Indian River Monroe Sarasota Bay Flagler Jackson Nassau Seminole Bradford Franklin Jefferson Okaloosa Sumter Brevard Gadsden Lafayette Okeechobee Suwannee Broward Gilchrist Lake Orange Taylor Calhoun Glades Lee Osceola Union Charlotte Gulf Leon Palm Beach Volusia Citrus Hamilton Levy Pasco Wakulla Clay Hardee Liberty Pinellas Walton Collier Hendry Madison Polk Washington Columbia Hernando Manatee Putnam DeSoto Highlands Marion Saint Johns Dixie Hillsborough Martin Saint Lucie 28 2012 Report Hospice Demographic and Outcome Measures

SECTION E: INPATIENT CARE AND RESIDENTIAL UNITS List the number of inpatient facilities and residential units that were operated by this hospice within the past year: This number should include inpatient wings or rooms within a hospital or skilled nursing facility that are operated by the hospice as well as the freestanding hospice inpatient facilities and residential units that appear on the hospice license. Each facility/unit should meet the following criteria: (1) Consist of one or more beds that are owned or leased by the hospice, (2) Be staffed by the hospice organization; and (3) Have policies and procedures set by the hospice. Please provide the following information for each facility/unit included in the count above. Include every admission into the facility (a patient may have more than one admission) in the of Facility Admissions column and count all patient days for every admission for the Total Facility Patient Days number column. Please duplicate this page as necessary. Facility Name and Address County Beds of Facility Admissions Total Facility Patient Days 29 2012 Report Hospice Demographic and Outcome Measures

SECTION F: OUTCOME MEASURES- Reference: Rule 58A-2.005(4), F.A.C. OUTCOME MEASURE 1 1 Total number of patients reporting pain on a 0-to-10 scale at time of admission to the hospice program. 2 Of the patients reporting pain, the number of patients who reported severe pain (7 or higher) at time of admission to the hospice program. 3 Of the number of patients reporting severe pain at admission, the number of patients who reported a reduction in pain level to five or less by the end of the fourth day of care in the hospice program. 4. Of the number of patients reporting severe pain at admission, the number of patients who continually reported pain level of 6 or higher by the end of the fourth day of care in the hospice program. 5. Of the number of patients reporting severe pain at admission, the number of patients who were unable to report pain level by the end of the fourth day due to death/discharge, transfer, or disease progression. OUTCOME MEASURE 2 Patient/Family Satisfaction Survey Question: Did the patient receive the right amount of medicine for his or her pain? Total number of surveys initiated during the reporting period. Total number of survey responses received during the reporting period. of survey responses received during reporting period indicating the patient received the right amount of medicine for his or her pain. of survey responses received during the reporting period indicating the patient did not receive the right amount of medicine for his or her pain. 30 2012 Report Hospice Demographic and Outcome Measures

OUTCOME MEASURE 2A Patient/Family Satisfaction Survey Question: Based on the care the patient received, would the patient and/or responsible party recommend hospice services to others? Total number of surveys initiated during the reporting period. Total number of survey responses received during the reporting period. of survey responses received during the reporting period answering yes to this survey question. of survey responses received during the reporting period answering no to this survey question. SECTION G: AGGREGATE DATA Reference: Rule 58A-2.012, Program Reporting Requirements, F.A.C. Admitting Primary Diagnosis During Reporting Period Cancer Illness due to Acquired Immune Deficiency Syndrome (AIDS) End-Stage Pulmonary Disease End-Stage Renal Disease (ESRD) End-Stage Heart Disease Other Age of Persons Admitted During Reporting Period Age 0-18 Age 19-64 Age 65 and older 31 2012 Report Hospice Demographic and Outcome Measures

Race of Persons Admitted During Reporting Period Asian Black Caucasian Hispanic Other Percent of Reimbursement by Payor Source During Reporting Period Medicare Medicaid Third Party Self-pay Uncompensated Other Total of Patient Days by Location During Reporting Period Private residence Adult Family-Care Home Assisted Living Facility Nursing Home Contracted Non-Inpatient Bed Nursing Home Contracted Inpatient Bed Hospital Dedicated Hospice Unit Hospital Other than Dedicated Hospice Unit Hospice Residential Facility Freestanding Hospice Inpatient Facility Other Total of Discharges by Disposition During Reporting Period Deaths Non-Deaths 32 2012 Report Hospice Demographic and Outcome Measures

SECTION H: AUTHORIZED SIGNATURE I HEREBY ACKNOWLEDGE THAT ALL INFORMATION PERTAINING TO THIS DOCUMENT IS TRUE, CORRECT AND COMPLETE. Print Name Title Signature Date 33 2012 Report Hospice Demographic and Outcome Measures