The number of patients Our Hospice cares for daily — its census average — has declined in recent years because of increased competition and confusion about who is actually providing hospice services, said Laura Hurt, president of Our Hospice since November 2013.

Although Our Hospice is the only provider with a facility located in Bartholomew County, hospice care also can occur in a patient’s home or a nursing home. As a result, more than two dozen other hospice providers are licensed to serve Bartholomew County or the other communities that Our Hospice of South Central Indiana serves, according to state health records.

Nine in particular provide intense competition with Our Hospice of South Central Indiana, Hurt said.

Multiple hospice providers can offer their services to patients through nursing homes, for example. It’s not uncommon for a patient to sign up for hospice care and think it’s being provided by Our Hospice of South Central Indiana when in fact it’s by another provider, Hurt said.

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As recently as 2012, Our Hospice’s daily census was 210 patients. However, that number dipped to 168 last year, Hurt said.

The decline matters because hospice providers are reimbursed by the federal Medicare and Medicaid insurance programs based on how many patients they have, Hurt said.

Compounding that concern is a change with Medicare that requires hospice providers to provide more care with the same reimbursement. Previously, hospice providers were responsible for all patient needs related directly to the diagnosis. Now they also have to cover medications for other illnesses patients have that might be affecting the course of the disease, Hurt said.

Our Hospice went through a rebranding campaign starting at the end of 2012 to clear up confusion about who provides hospice services and set itself apart from the competition. The nonprofit’s name was changed to add “Our” to Hospice of South Central Indiana, to reflect community attachment to the hospice provider, and a new logo was introduced.

The changes were helpful for a while but no longer have the same impact, Hurt said. The informal use of “our” has become too common with all hospice providers, she said.

Our Hospice of South Central Indiana finds itself in a time of transition again, Hurt said.

“We’re not at the point we want another rebranding. We want to help the community understand how our care is different. We need to change something, obviously, but we don’t know what,” Hurt said.

Changes in providers

Hospice care — end-of-life care for patients — started in the United States in the 1970s, and the Columbus-based agency began in 1980. Hospice care started with nonprofits, meaning they didn’t answer to corporate owners or shareholders, said Sandy Carmichael, who was a driving force in the Our Hospice’s founding and who retired as president in 2013.Fundraising and donations help Our Hospice cover the cost of care for patients, but those revenue streams were even more important in the early years because reimbursement by Medicare and Medicaid wasn’t possible in Indiana then, Carmichael said.

Nonprofits wanted and supported reimbursement from the federal insurance programs to help cover patient care costs. However, when those revenue streams became available in the late 1980s and 1990s, that opened the door for for-profit companies to get into the hospice business, Carmichael said.

One of the first trends with for-profit hospice providers was for companies that operated nursing homes to begin offering hospice services, Carmichael said.

Initially, other providers weren’t successful penetrating Our Hospice’s market because the communities it served — particularly Bartholomew County — felt a sense of ownership of the agency, Carmichael said. But that has changed.

Changes locally and regionally are reflective of those nationwide.

A study published in 2014 in JAMA Internal Medicine, a publication of the Journal of the American Medical Association, showed that while only 5 percent of hospices in the U.S. were for-profit in 1990, about 51 percent of hospices were for-profit by 2011. Also, from 2000 to 2009, four of every five hospices to enter the market were for-profit.

Carmichael said that through the years a lot of nonprofit hospice providers have sold to for-profit companies. She said that while she was president of Our Hospice, she received overtures about selling. Hurt said she has received such offers, too. They have been rejected.

The steady increase in for-profit hospice providers has raised questions about the differences in services provided by nonprofit and for-profit agencies, the study published in JAMA Internal Medicine noted.

Among the study’s findings, for-profit hospices:

Were less likely than nonprofit hospices to provide charity care

Were less likely than nonprofit hospices to provide community benefits, including serving as training sites

Were less likely than nonprofits to conduct research

Cared for a larger proportion of patients with longer expected hospice stays, including those in nursing homes, than nonprofits

Patients with longer hospice stays are more profitable for hospices, the study said.

The issues of training and research are important, the study concluded, because of a shortage of hospice and palliative medicine physicians, and the need to provide training settings to help build the needed workforce.

The study also highlighted previous research that noted differences between the two models, notably that for-profit hospices:

Tend to offer a narrower range of services to patients and families

Offer less comprehensive bereavement services to families

Have a less professionalized staff

Different models?

Alice Strahl, administrator for Intrepid USA’s hospice agency in Indiana, said she doesn’t think the nonprofit and for-profit models really differ.“We all follow the same conditions and protocols, so there’s not any differences in services,” Strahl said.

Intrepid is a home health agency, and it decided about three or four years ago to offer hospice services, Strahl said. Intrepid became certified to provide hospice services in Indiana in December 2014, and Indiana was a logical choice because Intrepid already offered home health services in the state, Strahl said.

The company has offices in Indianapolis, Shelbyville, Terre Haute and Greencastle.

Intrepid is licensed to serve hospice patients in Bartholomew, Brown, Jackson, Johnson, Rush and Shelby counties — all areas Our Hospice of South Central Indiana serves, Strahl said.

Intrepid currently doesn’t serve any Bartholomew County patients, Strahl said, but Johnson is one of its most active counties for services, and it also serves patients in Shelby County.

Typically, Intrepid gets patients through doctor referrals and extended care facilities, Strahl said.

Intrepid serves patients where they are, Strahl said, whether that is in a nursing home, assisted living facility or at home. A medical director and a mix of full-time and part-time employees, including nurses, social workers, clergy and volunteers, provides the care, she added.

The number of patients a nurse cares for daily varies, Strahl said.

Intrepid accepts private insurance, Medicare and Medicaid and does have a process for helping the indigent, but Strahl said that involves only a couple cases per year.

The company’s community outreach includes talking to senior citizen groups and working with veterans. Intrepid is part of the We Honor Veterans program that educates veterans about hospice services and hospice employees about veterans, Strahl said.

Messages left with four other for-profit hospice providers that serve some of the counties that Our Hospice of South Central Indiana serves, to learn about their service models, were not returned.

Volunteer support

Carmichael said it is what’s above and beyond reimbursement that she believes sets apart nonprofits such as Our Hospice of South Central Indiana from for-profit hospice providers.“It is important when choosing a hospice provider that you ask questions and understand first which hospice you are selecting, and second, the quality, comprehensiveness and frequency of services you will be receiving,” Hurt wrote in a column published in The Republic on March 14, 2015.

Our Hospice, which has 135 employees and 131 volunteers, has an inpatient facility — which opened in 2004 — located in Columbus that features 14 beds, a bereavement center for families and office space for medical staff.

By regulations, Hurt said, a hospice must have at least 5 percent of the day-to-day administrative and/or direct patient care services performed by volunteers. That total exceeded 9 percent at the end of last year and is nearly 9.5 percent year-to-date, she said.

“These numbers are a clear demonstration of how much our organization is valued in the communities we serve,” Hurt said.

When patient costs are not covered by private or public insurance, Our Hospice uses donations and philanthropic contributions to cover the expenses, Hurt said. Last year, that amounted to $190,000 in charity care, she said.

Our Hospice’s participation in the We Honor Veterans program includes a pinning ceremony in which family members are invited to see the veterans honored, Hurt said.

The nonprofit’s bereavement assistance — for which it is not reimbursed, Hurt said — includes separate grief education and support programs for adults and teenagers, contact from a bereavement team and connections to bereavement resources that deal with the loss of a child, and some that are faith-based.

Our Hospice manages a $12 million annual budget. Hurt said the nonprofit has a solid endowment, investments and cash reserve and thinks it has done well for the community despite competitive and financial challenges.

“Some years the gains are better than the losses, but for the last couple of years, because of adverse market forces and needed technology investments, we have had a shortfall that has required us to tap into our cash reserves. This year, thus far, we are in an upward trend in our recovery,” Hurt said.

About the competitors

Here is a summary of the nine for-profit hospice providers that Our Hospice of South Central Indiana president Laura Hurt identified as its main competitors, because their services reach into Our Hospice’s 15-county county area.

Kindred at Home

Publicly traded company. Purchased Gentiva Hospice in 2015, making it the largest hospice and home health organization in the United States. Has offices in Indianapolis and Jeffersonville.

Americare Home Health & Hospice

Privately owned company with headquarters in Pompano Beach, Florida. Has a branch office in Franklin. Bartholomew, Brown, Johnson and Shelby among the eight counties the Franklin office serves.

Premier Hospice

Limited liability company founded in 2003. Subsidiary of Abode Healthcare Inc. Has headquarters in Phoenix and offices in Seymour, Carmel and Kokomo.

SouthernCare

Affiliate of Curo Health Services. Serves more than 3,200 patients in 14 states. Has nine locations in Indiana, including Indianapolis and Bloomington.

Amedisys

Its hospice and home health footprint reaches about 40 states and 70,000 patients. Began hospice care in 2003 with the acquisition of another provider. Has an office in Jeffersonville.

Intrepid USA

Subsidiary of Patriarch Partners, a holding company. Provides hospice and home health services. Company reaches 21 states. Has offices in Indianapolis, Shelbyville, Terre Haute and Greencastle. Became certified to serve hospice patients in Indiana in December 2014.

Heart to Heart Hospice

Headquarters in Plano, Texas. Operates in Texas, Indiana and Michigan. Has six locations in Indianapolis, including Indianapolis.

Heartland Home Health & Hospice

Subsidiary of the Carlyle Group, a global asset management company. Has operations throughout the Midwest, East Coast, Southwest and West Coast. Has four locations in Indiana, including Indianapolis.

Seasons Hospice

Founded 1997. National office located in Rosemont, Illinois. Fifth-largest hospice company in the U.S., reaching 19 states. Has office in Indianapolis.

Sources: Company websites

About Our Hospice

Our Hospice of South Central Indiana

Nonprofit hospice provider.

Founded 1980.

Headquarters and in-patient facility at 2626 E. 17th St., Columbus.

In-patient facility features 14 patient beds. Also provides care at nursing homes and in patients’ homes.

Also has offices in North Vernon and Greensburg.

Serves 15 counties: Bartholomew, Brown, Jennings, Jackson, Johnson, Decatur, Shelby, Rush, Ripley, Dearborn, Ohio, Switzerland, Jefferson, Scott and Clark.

Information: ourhospice.org; 812-314-8001; 800-841-4938, ext. 8000

 Source: Our Hospice of South Central Indiana

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Kirk Johannesen is assistant managing editor of The Republic. He can be reached at johannesen@therepublic.com or (812) 379-5639.