It touches everyone’s life in some fashion, and yet no one has developed an exact science on how to deal with death. People, whether they are affected by it directly or indirectly, respond to the eventual passing of human life in a multitude of ways. Some prefer quality time spent with family and friends, others retreat to quiet meditation with spiritual guides. Some may even muster the strength to fulfill a dream once deferred. But no matter what the coping method, there is a wide consensus that no one wants to go it alone.

“Every hospice organization promises the same thing: ‘You didn’t come in this world alone and you won’t go out alone,’” says Perry Farmer, president of Oklahoma-based Crossroads Hospice. “But the actual average rate of attended deaths by the entire hospice industry is between 20 to 25 percent. We’ve got to change that. I would like to see our rates go much higher, three to four times higher than the national average.”

Crossroads’ attended death rate is in fact higher than the national average. Most of their branches have even achieved higher than an 80 percent rate, which the organization has set as its overarching goal. And those that have not hit 80 percent have achieved more than 70 percent. “We have sites that routinely achieve over 90 percent, which is a big calling card for us because it says we will be there,” Farmer says. “Of course, we always strive for 100 percent and we’ve hit that number in a couple of months at a couple of our sites, but overall 80 percent is our goal. It’s a hard number to hit, but it’s an achievable goal.”

It’s not readily apparent how Crossroads is able to achieve that goal, however. From its list of services it seems that Crossroads is the average hospice care network itself, so why doesn’t it track with the average rates? Like other hospices, it deals with patients in their end-of-life stages who have either opted out of or are no longer responding to curative care. They work with the patient and a host of other people such as the physician and family members to develop a care plan. They chart the patient’s progress and adhere to a pain management program. Also, like the average hospice, it’s all managed at the patient’s preferred place of care, whether it is a home or hospital, or assisted living or long-term care center.

Different Kind of Care

Where the difference enters is how aggressively Crossroads completes these tasks compared to many of its competitors – a culture that Farmer set in motion from the moment he, his father and uncle formed Crossroads in 1995. Farmer began his healthcare career as a nursing aide in long-term care facilities before moving up to healthcare administration positions. As a nursing aide doing the daily work of patient care, he noticed that the quantity and quality of time spent with patients suffered when nurse-to-patient ratios rose above a certain number. He found the same to be true with the hospice workers who travelled to and from the long-term care facilities where he worked.

“Lower ratios became our philosophy because of what I noticed during my time spent as an aide,” Farmer explains. “Average staffing ratios may have been one to 15 or one to 16, but we said we are going to start at one to 12, which was better than most. We also vowed to see our patients every day.” So when Crossroads opened its doors in 1996, the patient staff ratio did indeed begin at one to 12, but even that was too high. The organization decreased to one to eight in 1998, eventually landing at one to six in the 2000s.

Farmer found that the key to keeping the promise to be there in the last moments was to be there at every moment – period. “In the beginning, we would tell the facility’s nurses that it was important for them to communicate and call us when things were going bad,” he says. “My light bulb went off when I scheduled a meeting with a hospital administrator to talk about why they were not calling us when patients declined and halfway through the meeting they said, ‘Well Perry, I though you were the expert.’ And that’s when I realized we made a promise to our patients to be there. Our promise was not to make the nurses or family call us, our promise was to be there. So, we went from one to 12, then one to eight and now we are at one to six.”

Crossroads’ vowed to take a more active role with each patient. The company developed in-house programs such as EvenMore Care, its Watch Program and Gift of a Day. With its lower than average patient-to-staff ratio, Crossroads commits itself to seeing every patient every day for at least an hour.

The company staffs two types of workers to accomplish this goal. The registered nurse case manager coordinates the care plan with the patient’s primary physician and Crossroad’s hospice medical director. The nurse then visits the patient two to three times a week to see the care plan through by tending to the patient’s needs and charting detailed assessments. Crossroads is even developing an in-house electronic medical records system to improve charting efficiencies and access. In addition, a home health aide supplements the RN’s work by visiting on the days the RN cannot and assisting the patient and family with personal care and light housekeeping. Other integral members of the care team include chaplains, social workers and grief recovery specialists. Like their other employees, Farmer maintains that Crossroads requires more of these team members than regulatory demands specify.

Seeing the patient every day and charting their conditions in minute detail achieves two major things: It builds rapport with the patient and their family or primary physician, and provides a monitoring system on the patient’s condition, which makes it easier for nurses and aides to detect the sudden decline of a patient’s health. When sudden decline does occur, the hospice team implements its Watch Program.

“We developed an internal program called the Watch Program [and] it comes from the basis that if we are there every day then we should be able to spot these signs of decline,” Farmer explains. “At that point, instead of going out once a day, we say why not go three times a day? So the family is not caught between trying to reach us and take care of their loved one, we will already be there. We are able to handle that and our Watch Program is what enables us to. And if we are there three times a day that means even more care is being given, which is really our mantra – ‘do even more.’”

This approach gives more credibility to the Crossroads name and to hospices in general, which is an industry rife with misconceptions about what it is and what it isn’t. One of the reasons for the misconceptions, Perry says, is because the industry is covered by Medicaid but regulated differently from other healthcare facilities. Regulations usually enforce what types of health conditions qualify for hospice and how often the patient needs to be treated. However, the type of care is largely left to the hospice, family and primary physician to decide.

The History of Hospice

Another reason misconceptions endure is because hospice care is something people will encounter only once or twice in a lifetime to care for a spouse or parent. Also, this industry in its present form began taking root only in the 1960s and more aggressively with the 1969 book penned by Dr. Elisabeth Kubler-Ross On Death and Dying. It details the five progressive stages of the terminally ill while arguing for the benefits of home care as opposed to institutional care. Her work inspired Congress to enact the Medicare Hospice Benefit in 1982 to reimburse hospice caregivers. It was made permanent in 1986.

Even as the government invests in hospice care, hospices still battle misinformed beliefs, the No. 1 being that obtaining hospice care means you and your family members have given up on life. “Hospice care is actually not that utilized,” Farmer says. “People sometimes see it as losing hope, but it’s not that. This is about cancer patients saying no more radiation. This is about giving patients a better quality of life, not necessarily quantity. That does not mean giving up.”

In some cases, improving the quality of life actually does increase the quantity of life. According to 2007 research published in the Journal of Pain and Symptom Management, hospice patients lived an average of 29 days more than patients with similar profiles who were not on hospice care. Much of that is due to proactively minimizing pain and symptoms. In fact, Perry notes that primary physicians are turning more often to hospice caregivers to gain advice and learn best practices on how to manage the pain and symptoms of their own patients still seeking curative care.

Medicare typically covers pain and symptom management to a certain degree depending on the patient. If the patient’s Medicare plan covers $4,500 for pharmaceuticals but the patient actually requires $6,000 worth of pharmaceuticals, Crossroads will cover the full plan and take a $1,500 hit rather than have the patient suffer. Farmer says his organization has begun talks with pharmaceutical companies to deliver a flat-rate program so patients can continue to receive their proper pain management without affecting Crossroads’ bottom line.

Putting in the Positive

Pain and symptom management is a hospice forte, and it definitely increases the quality and sometimes quantity of the patient’s life, but it is not the only thing that can help, Perry says. Having something to live for is an adage that has been preached by philosophers, religious leaders and humanity in general. “At hospices, we do a great job of taking away the negatives – the physical pain, emotional pain and spiritual pain,” Farmer explains. “Once you take all that away, you have more quality time to spend because those things are gone. But what if we also added in positives. What would that look like?”

At Crossroads, it looks like a variety of things. It’s Gift of a Day program, inspired by the Jim Stovall book The Ultimate Gift, provides patients with a “dream day.” It might be a former songstress who gets professionally dolled up to do the musical recording she’d always dreamed of, or perhaps a 102-year-old thrill-seeker who wanted to ride on the back of a motorcycle one last time. These programs are implemented across all 11 Crossroads’ facilities. For instance, its veterans recognition program was the brainchild of its Kansas City, Mo., branch but is now practiced at each facility.

Crossroads also works with college students who record the lives of hospice patients and transcribe them into a book of memories for the patient’s family. Family members can participate in a grief recovery program led by a Crossroads employee. It’s free of charge to the patient’s family and healthcare provider, as are the memorial services Crossroads hosts to honor former patients.

These programs are part of Crossroads EvenMore Care – a system that many said was unsustainable, especially when it comes to that one-to-six nurse-to-patient ratio. However, Crossroads has been able to grow through 11 start-up branches in six states. Last year, Crossroads’ staff grew by 30 percent and the organization opened two new sites in 2011 – one in St. Louis and the other in Kansas City, Kansas.

“After we started, we slowly but surely began developing a plan and in 1998, we realized we were doing this much more different than most hospices, which has led to the policies and procedures that have stuck with us today,” Farmer says. “In 2006, we had a consultant come in and she said, ‘You’re not going to be able to continue to do things this way.’ But we would say, ‘We made our bed and this is the way we are going to do it.’”

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