Alivia Care CEO Susan Ponder Stansel came to the hospice field in 1985 as a volunteer clinical social worker at Northeast Florida Hospice, which was later renamed Community Hospice & Palliative Care. . Six years later, in 1991, she was CEO of the nonprofit, putting the organization on a growth trajectory that saw the daily hospice census drop from about 60 to 1,200.
Last year, Ponder Stansel spearheaded the creation of Alivia Care, a larger post-acute care organization that maintains Community Hospice & Palliative Care as a wholly owned subsidiary. In addition to palliative and palliative care, Alivia’s subsidiaries will provide home care, private nursing services, personal care, PACE programs and advanced care management. Alivia serves nearly 8,000 palliative care patients and 9,000 palliative care patients each year in addition to its other service lines.
In this Changemakers interview, Ponder Stansel talks to Hospice News about the impetus behind Alivia Care, how a changing payments environment can transform hospice and critical illness, and how looming shortages of workforce can change the delivery of long-term care.
Would you like to introduce Alivia Care and talk about your rebranding experience and the impetus for it?
Alivia Care is the parent company of not only Community Hospice & Palliative Care, but also our home care brand A Better Life. We operate a private Medicare certified child care service, our PACE program, our physician business, and now Alivia Care of Georgia. We now have some kind of family, which is why we changed our name.
Alivia Care’s goal is really to be an executive. It’s not necessarily consumer-oriented. Rather, it’s this “50,000-foot view” of how we, as a home care provider, can truly be prepared for the changes to come, and also make sure that we are well aligned with consumer preferences. and reimbursement. going.
A lot of changes are happening in the health care system right now. Can you talk about some of the most significant changes you have seen in end-of-life and critical illness care over the past few years?
One of the things I see is demographics. When you look at how many of us are living longer – and with chronic illnesses that will eventually become advanced. It’s been a huge change, especially in palliative care.
When you look at when I started with a hospice in 1985, almost 90% of our patient count had advanced cancer. Today, for my program and for most hospices, it’s 30 to 40%. Other patients tend to have diagnoses which tend to have a less predictable trajectory. It is sometimes difficult to obtain this end-of-life prognosis for conditions such as dementia and congestive heart failure. And then you look at who doesn’t get palliative care, like those who have end-stage kidney disease.
I think the reason palliative care gets some of these diagnoses that we didn’t really have years ago is that there really is no other place in the system for patients. who are trying to live well with these diseases to go and seek something other than fragmented care. Unfortunately, I think the response from [the U.S. Centers for Medicare & Medicaid Services (CMS)] has been to double regulatory oversight, with hospices looking after these patients. Some of us are afraid to admit them. It is a symptom of a real gap in our system.
COVID was like steroids for on-demand home care and consumer-centered care. It was already coming, but I see a real change. My parent’s generation was quite willing to let the system evolve them in the way that made the most sense for the system, and a lot of that was payment-based care. I’m a baby boomer, and a lot of us really don’t want to do this. We are looking for things that give us more control and more involvement in our care.
The hospice is a good alignment for this particularly sensitive and patient-centered care and always has been.
I would be remiss if I did not also mention the pilot under the [value-based insurance design (VBID)] – the Medicare hospice carve-in. I think this will probably be the biggest disruptive force in hospice care since Medicare started paying for hospice care in 1983. I think it will change everything, some things for the better and some things I don’t like so much. .
The stated goal was to ensure that more patients had access to care more quickly. I see a major disruptor coming.
Could you clarify the aspects that you don’t like about VBID?
The program designed for VBID includes bridging services that help support patients who are facing advanced disease and help them make better decisions. The theory was that more of them will choose the hospice, and more of them will choose it in a more timely manner.
Most of us face median lengths of stay of 8, 10 or 12 days. Timely access is a huge problem, and COVID has only made it worse. The idea was that health plans would work with hospice providers and other types of providers to perform advanced care planning, palliative care, transitional care, and community-based hospice care. But what has ended up already appearing is the tendency of health plans to want to own all the means of production and to use the service lines they have, or to acquire service lines, to provide palliative care. , and in some cases also acquire palliative care programs.
For those who want to network, we are already seeing requests for volume discounts. âIf we send you a lot of patients, can you give us a 10% discount on the rate? “
I don’t take any of this personally, but for community nonprofit programs like mine that don’t have a 10% margin, we may give a 10% rebate but we will lose money. One of the trends I see that could really change the way consumers receive palliative care is that community programs will have to find ways to cut costs so that they can offer those kinds of discounts, or they will really be in. somewhat marginalized in the market as Medicare Advantage spreads.
This assumes that the carve-in is working and Medicare Advantage continues to grow. I think CMS wants to get out of the fee-for-service market, especially with those high-need, high-cost populations. So I’m assuming Medicare Advantage will continue to grow. I think this will have some impact on the organizational structure of some of the palliative care providers that are out there now.
How do you think some of the work you have done with Alivia is helping to drive the change?
I often sit there and think about what we can do in our backyard when it’s happening a lot on a macro level with big companies merging, consolidating and launching new businesses. But I think we have to think globally and act locally. So for us, this is our region.
We truly view Alivia Care as a way for us to better leverage our resources and avoid duplicate spending. In doing so, you have a parent company and a lot of the services you develop that any business will need, like [human resources], [information technology], compliance marketing, you can spread them out more broadly to be more effective. You spend more money on care than administrative overhead. So that was part of what we wanted to do, knowing that there will always be downward pressure on reimbursement and more costs associated with finding and maintaining good staff. We are already seeing some of these staff shortages and competition for clinicians.
The other reason we wanted to do Alivia Care is that we really see opportunities among physician offices in our area, bringing PACE into this community where it didn’t exist before. We looked at where we had both interest, resources and opportunities to fill the gaps in our local care market. We really did this by thinking about where we could be a good partner with those who care for patients, either further upstream or at particular times in their illness when they could use someone to fill in their gaps.
We have tried to take a systems approach. We focus on home care. We are certainly seeing more care being propelled into the community for patients who really need it and who are costly. We wanted to include those who wanted to age independently in the community and try to avoid institutional care for as long as possible.
All of these things are really focused on caring for people who want to live better with advanced disease. More of us will live longer with advanced diseases. We saw this as a way to really build capacity and expertise that could be of use to consumers, payers, and other partners in healthcare.
How do you think the staff shortage problem might affect change in the industry, for better or for worse?
Yeah, it’s gonna be fascinating. We will all need to consider doing a lot of things to deal with some of the shortages that we are already seeing. I think using technology where it makes sense to make your clinicians more efficient should definitely be part of it. I think a lot of us must have used it during COVID, and now we’re assessing where it works well and where it doesn’t.
I also think the ability to ensure that your internal structure and workflows allow everyone to practice at the top of their license is really going to be important. It is not just compensation. You have to look at things like your electronic health records, so your clinicians have to spend an inordinate amount of time using them. It is not user friendly. This is a factor in staff loss sometimes or a feeling of burnout because they see patients and then have to spend hours documenting. It’s all of these things together. It’s not just about better marketing and better wages. There are also other considerations on what you can do to really make sure that you are using the talent you get as effectively as possible.
I know there are national initiatives to really pave the way for nursing schools and certified palliative care physicians and geriatricians, but it will take years. In the short term, I think most of us need to raise wages and then we’re really looking to keep people once we get them by making sure we don’t make their lives difficult. We also need to use them effectively indoors, as they are scarce resources. This includes people like the technicians who support our clinicians. There is a lot of demand for them.