STATE AGENCY ACTION REPORT - ahca.myflorida.comahca.myflorida.com/MCHQ/CON_FA/Batching/pdf/10070.pdf · STATE AGENCY ACTION REPORT ON APPLICATION FOR CERTIFICATE OF NEED A. PROJECT

STATE AGENCY ACTION REPORT

ON APPLICATION FOR CERTIFICATE OF NEED

A. PROJECT IDENTIFICATION

1. Applicant/CON Action Number

Catholic Hospice of Central Florida, Inc./CON #10069

14875 N. W. 77 Avenue, Suite 100 Miami Lakes, Florida 33014

Authorized Representative: Ms. Julie E. Smith (850) 425-2444

Memorial Hospital-Flagler, Inc. d/b/a Florida Hospital HospiceCare/CON #10070

770 West Grenada Boulevard, Suite 304 Ormond Beach, Florida 32147

Authorized Representatives Mr. David Ottati Ms. Diane Godfrey

(386) 671-2138 (407) 303-9659

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida/CON #10071 717 North Harwood, Suite 1500

Dallas, Texas 75201

Authorized Representative Mr. Jason S. Howard (214) 922-9711

United Hospice of Florida, Inc./CON #10072 1626 Jeurgens Court

Norcross, Georgia 30093 Authorized Representative Mr. Neil L. Pruitt, Jr.

(770) 925-4788

CON Action Numbers: 10069, 10070, 10071, & 10072

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2. Service Area/Subdistrict

Hospice Service Area 7B, Orange and Osceola Counties

B. PUBLIC HEARING

A public hearing was not held or requested regarding the proposals to establish a hospice program in Hospice Service Area (SA) 7B. However, letters of support were submitted, as discussed below.

Catholic Hospice of Central Florida, Inc. (CON #10069) submitted

approximately 248 letters of support with its application. The letters of support were from physicians, businesses, commissioners, educators, faith-based organizations, government leaders, community organizations

and other members of the community at large. One hundred and forty seven letters had Orange or Osceola County (SA 7B) addresses. These

include letters from 70 residents, 33 churches and faith based organizations, 27 community organizations and businesses, 10 physicians, five local government officers, and five local health care

facilities. The applicant‟s support letters generally indicate that: Catholic Hospice has excellent educational and outreach services; project approval would increase access to faith-based services, the community

would benefit from a faith based approach to hospice care, Catholic Hospice will have bilingual staff ideally suited to meet the needs of the

diverse community, and that Catholic Hospice provides quality compassionate care to its patients.

Mildred Fernandez, Orange County Commissioner, John “Q” Quinones, Osceola County Commissioner, Orlando City Commissioner Tony Ortiz, Osceola County Sheriff Robert E. “Bob” Hansell, and Captain Miguel A.

Pagan of the Orange County Sheriff‟s Department provided letters which contained one or more of the above statements. The applicant‟s letters

from local health care facilities include Shannon Elswick, President, Orlando Regional Medical Center, Orlando Health; Clarence H. Brown III, M.D., President and CEO of MD Anderson Cancer Center – Orlando,

John S. Lord, Chairman, Nemours Board of Directors (Nemours has an Orlando outpatient clinic and CON approval to construct a children‟s

hospital in Orange County), Diane Boodram, NHA, Executive Director of Rio Pinar Health Care (a 180-bed nursing home in Orlando), and Kevin Johnson, Executive Director of Bishop Grady Villas (an ALF in St. Cloud

- Osceola County). The applicant‟s support letters from local physicians, churches and faith-based organizations, and community organizations and businesses all essentially contain one of more of the above

statements.


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The remaining 101 letters of support were from physicians, businesses, organizations and residents of Seminole, Miami-Dade and Monroe

Counties.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) submitted 53 letters of support with its application. The letters of support were from clergy, community leaders and

organizations, assisted living facilities, volunteers, skilled nursing facilities, and Seventh Day Adventist Church/Sunbelt, Inc. Florida Hospital affiliates. Twenty-two of the letters of support were from Florida

Hospital or one of its affiliates such as Florida Hospital Orlando Palliative Care Program, Florida Hospital Cancer Institute, or Florida Hospital

Memorial Home Health. These letters emphasized that the addition of a hospice program would be a complimentary extension of the continuum of care that already exists as a part of the Florida Hospital network.

Thirteen letters of support were submitted by community leaders and organizations. The applicant‟s letters generally indicated that: Florida

Hospital is a multi-faceted health care system that has the infrastructure to support a hospice organization; Florida Hospital provides quality care and has “a deep understanding of the medical, social and end of life

needs of the residents in our service area”, and various training and educational opportunities would be available should the applicant be awarded the CON.

John “Q” Quinones, Osceola County Commissioner and Rick Daigneault,

LMHC, Health Services Administrator for Orange County Government Health Services Division, provide letters which contained one or more of the above statements. The letters from representatives of local

organizations also cite several of the above statements. The Rev. Lizette M. Acosta, Director of the Latino/Latina Studies Program (LLSP) at Asbury Theological Seminary indicates that LLSP students are provided

supervised ministry experience at Florida Hospital East Orlando and that the addition of hospice would be of great service to the (Latino)

community. Marinella Castroman RN, CEO and Marketing Director of Select Specialty

Hospital – Orlando and Rose O‟Neil CEO of Select Specialty Hospital – Orlando North provided general letters of support. Ms. Castroman stated

that she sees the need based on their (Select‟s) patient population and fully supports Florida Hospital‟s application. Ms. O‟Neil cites her facility‟s partnership with Florida Hospital and the need for hospice care

for patients discharged from Select. Representatives of nursing homes providing general letters of support include: Diane Boodram, NHA, Executive Director of Rio Pinar Health Care (a 180 bed nursing home in

Orlando), Abigail Ashe, NHA Rosewood Health & Rehabilitation Center (120 beds - Orlando), Tristan S. Mohadeo, Executive Director of Colonial

Lakes Health Care (180 beds -Winter Garden) and Mindy Wright, MHSA,


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Regional Sales Consultant for Sea Crest Healthcare Management, which manages several Orange and Osceola County facilities. Texus Wallace,

representing Almark Health Services, Inc. indicates his company‟s three small ALFs have worked with Florida Hospital for over 16 years and that

the addition of hospice care for Florida Hospital would effectively improve continuity of care for the ALF population.

The majority of the applicant‟s letters are from representatives of facilities that are part of the Seventh Day Adventist Church/Sunbelt, Inc. health care chain. Some of these are summarized below.

Joseph D. Portoghese, MD, Chief Academic Officer and General Surgery

Residency Program Director at Florida Hospital, indicates that the hospice program will open the possibility of establishing an accredited training program in Palliative Care Medicine. Dr. Portoghese concludes

that the project has the potential for multiplying the positive effect for the community by alignment with a hospital big enough to support medical

education. Gregory K. Ellis, M. Div., B.C.C., Administrative Director for Pastoral

Care at Florida Hospital indicates that through the hospice program, Florida Hospital would be able to serve the community in terms of training opportunities for pastors in its Clinical Pastoral Education (CPE)

program. CPE provides training for pastors in the specialized ministry of spiritual care within the clinical context and Mr. Ellis indicates that the

hospice environment is a “very fertile ground for such learning and training to take place”. He indicates that his CPE training included both traditional hospital and hospice and that the hospice portion “was

transformational and life changing”. Kenneth Zill, Executive Director of Volunteer Services at Florida Hospital

states his program presently has over 3,000 volunteers who provide nearly 300,000 hours annually. They serve in all Florida Hospitals,

urgent care centers, community clinics and numerous administrative roles across the system. Mr. Zill indicates that this network will yield a much faster ramp-up of dedicated hospice volunteers than would

otherwise be possible.

Cary Smith, NHA, Vice President of Regional Operations of Adventist Care Centers which operates four nursing homes in the Orlando area indicates that his “facilities would greatly welcome an opportunity to

effectively collaborate with a Florida Hospital HospiceCare program by providing support for their long-term care patients (and that) having this type of program with Florida Hospital would improve the continuity of

care for these residents of our community”. The applicant states it


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intends to enter into contracts with one or more Florida Hospital facilities, Adventist Care Center skilled nursing facilities and other

providers in the service area.

Eight of the letters were from either volunteers of Florida Hospital HospiceCare or families that were served by the hospice in Ormond Beach and Palm Coast, Florida.

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida (CON #10071) submitted 50 letters of

support with its application. These were from assisted living facilities, nursing homes, retirement communities, and families that received

services through Odyssey‟s other hospice programs. The 15 letters provided by nursing homes, assisted living facilities and retirement communities stated that having an additional hospice provider in the

area could only cause all other area hospices to provide better care and services to its patients. The letters also expressed a need for better

hospice education and a belief that the applicant can adequately provide such education. The remaining 35 letters of support were from families that received services from Odyssey-Daytona and Odyssey-Miami. These

letters expressed gratitude to Odyssey for its caring and compassionate attitude when providing comfort and a sense of dignity for its patients and their families. Although the applicant provided letters of support

from area ALFs and nursing homes, none provided agreements to contract for inpatient services.

United Hospice of Florida, Inc. (CON #10072) provided 58 letters of support with its application. These were from hospitals, nursing homes,

assisted living communities, local businesses and physicians. The applicant also provided letters of support from UHS-Pruitt Subsidiaries and patients and families who have received services from United Health

Services in the past. Thirteen letters were from the local service area. A social worker from Florida Hospital Cancer Institute offers her support of

United Hospice to provide additional hospice services. A letter from the CEO, Rebecca Brewer, of St. Cloud Regional Medical Center states they are willing to work cooperatively with this hospice provider, and will

enter into appropriate contractual relationships to ensure that hospice patients in need of inpatient care receive it at their hospital. The other

letters of support emphasized the importance of allowing families to choose the provider that best fits their needs and that adding a new hospice program to the local service area will raise the standard through

competition with existing hospice providers. United Hospice‟s subsidiaries provided five letters of support. United Medical stated its interest in coordinating to provide medical equipment services for

patients in the service area. United Pharmacy Services stated its willingness to supply pharmaceuticals and medical supplies to United

Hospice. UHS Pruitt-Corporations states its interest in working with


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United Hospice in coordinating and providing assessment and dietary counseling to the residents of Orange and Osceola Counties. United

Rehab stated it is prepared to provide physical, occupational, speech and respiratory therapy services under a contracted agreement with United

Hospice. The remaining 40 letters of support were from families previously served by UHS. The letters expressed thanks and gratitude for superior hospice services.

C. PROJECT SUMMARY

Catholic Hospice of Central Florida, Inc. (CON #10069) proposes to

establish a new hospice program in Hospice Service Area 7B, Orange and Osceola counties. Catholic Hospice of Central Florida, Inc. is a newly formed entity whose sole member is Catholic Hospice, Inc. and as such

has no operational history. Catholic Hospice, Inc., a faith-based organization, has a history of providing hospice services in Miami-Dade,

Monroe and Broward Counties. The proposed total project cost is $334,800 with year one total operating

costs of $2,207,564 and year two costs of $5,065,314. The applicant agrees to condition award of the CON as follows:

1. Catholic Hospice will respond to patient referrals within two hours of receipt of the referral.

2. Catholic Hospice staff will contact all patients admitted within 48

hours after admission and then again after seven days to ensure

patient/family needs are being met. 3. After hours phone calls to Catholic Hospice by patients and

families will be answered by hospice staff

4. Catholic Hospice RN case managers, social workers and chaplains will use laptop computers in the field to collect and input clinical information into the patient database system in order to maximize

available clinical information and responses to patient and family needs.

5. Catholic Hospice will assess the quality of care via meetings with

all contracted hospitals and long term facilities to review services

provided to patient and families as well as service and responsiveness to the needs of these providers.


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6. Catholic Hospice will provide an emergency pharmaceutical kit (E-Kit) to all hospice patients admitted in their home, as appropriate

and ordered by a hospice physician, in order to provide emergent access to palliative medications in the event of a medical crisis by

the patient at night or on weekends, when the patient‟s access to palliative medications may be limited or not timely. The E-Kit will be provided in accordance with all applicable state and federal

dispensing laws and is intended to be responsive to patient and family needs as well as enhanced patient care after regular business hours at night and on weekends.

7. Catholic Hospice will contract with OnePoint Patient Care

Pharmacy, a hospice pharmacy, for hospice related drugs, pharmaceuticals and biologicals in accordance with state and federal dispensing requirements and statutes. OnePoint Patient

Care Pharmacy will dispense the hospice related drugs, pharmaceuticals and biological for Catholic Hospice patients. The

dispensing will include home delivery of medications at no cost to Catholic Hospice patients and families in order to improve hospice services and reduce the caregiver burden of the family caregivers

while promoting patient satisfaction. 8. Catholic Hospice will contract for durable medical equipment

(DME)/home medical equipment (HME) from a specialty hospice medical equipment provider who understands and is responsive to

the unique needs of hospice patients and families. 9. Catholic Hospice will offer individual and group grief counseling

services to any resident of the service area in need of such services regardless of any prior relationships with Catholic Hospice.

10. Catholic Hospice will conduct annual memorial services for those primary caregivers and families served Catholic Hospice as well as

any other resident of the service area. 11. At initiation of service, Catholic Hospice will become an

organizational member of Florida Hospice and Palliative Care (FHPC) as well as the National Hospice and Palliative Care

Organization (NHPCO). 12. At initiation of service, Catholic Hospice will become a member of

the Tri-County Volunteer Organizations Active in Disasters (Tri-VOAD) in order to collaborate with the Community Emergency Response team (CERT) on disaster preparedness.


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13. Catholic Hospice will provide community support groups for those primary caregivers and families served by Catholic Hospice as well

as any other resident of the service area.

14. Catholic Hospice will provide a children‟s annual grief camp, Camp Hope, for those families and caregivers who have children served by Catholic Hospice as well and any other resident of the service

area. 15. Catholic Hospice will target diversity and cultural outreach

activities to Hispanics. Catholic Hospice will advertise in Hispanic language papers, and provide culturally relevant material in

Spanish. 16. Catholic Hospice will provide cultural diversity and sensitivity

training to all staff members, including but not limited to Hispanic culture.

17. Bereavement services will include special outreach to Hispanic

children, including introduction to hospice at school counselor

level, offering grief counseling through school administration to grief-stricken children throughout the school year, and identifying children who would benefit from Camp Hope.

18. Catholic Hospice will target the recruitment and retention of

bilingual (English/Spanish) staff. Catholic Hospice will commit that at least 20 percent of its staff in Orange and Osceola Counties will be bilingual.

19. Catholic Hospice will provide community education seminars on

the following topics: Bridging the Gap at End of Life, Care at the

Time of Dying, Care of the Actively Dying, Advanced Directives, Alzheimer‟s and Related Disorders, Domestic Violence, End of Life

Communication, Fall Prevention, Florida Assisted Living, and Hospice 101.

20. Catholic Hospice will initiate the “Wishes Granted” program in Service Area 7B.

21. Catholic Hospice commits to opening its main office in the

Kissimmee area to best serve all the people of Service Area 7B.

Memorial Hospital-Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) proposes to establish a new hospice program in Hospice

Service Area 7B, Orange and Osceola Counties. Memorial Hospital-Flagler, Inc. is one of the 17 acute care facilities in Florida owned by

Adventist Health System. Florida Hospital and Florida Hospital


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HospiceCare are a part of the Adventist Health System. Six Florida Hospital facilities are located in Service Area 7B: Florida Hospital

Apopka, Florida Hospital Celebration, Florida Hospital East Orlando, Florida Hospital Kissimmee, Florida Hospital Orlando and Winter Park

Memorial Hospital. The proposed total project cost is $306,380 with year one operating costs

of $2,323,888 and year two costs of $3,261,895. The applicant agrees to condition award of the CON as follows:

1. Florida Hospital HospiceCare will provide programs and services for residents of Service Area 7B that are outside the Medicare

hospice benefit which will include community hospice education and community bereavement. This would also include the development of Project StoryKeeper as a means of providing

training for hospice staff and volunteers that can be put to use in establishing a patient's family history/legacy. Project StoryKeeper

allows patients to record their life stories as part of their legacy to their loved ones, so that their stories can be told and shared long after they have passed away. Also included is the development of a

pet therapy program for hospice patients. Pet therapy offers psychological benefits in terms of emotional connection, stress reduction, and reduced feelings of loneliness or isolation.

2. Florida Hospital HospiceCare will provide an ongoing education

program on hospice care to provide easily accessible information for medical staff members of the Florida Hospitals in Orange and Osceola Counties and resident physicians and fellows in Florida

Hospital's teaching program.

3. Florida Hospital HospiceCare commits to develop and offer a

structured curriculum for Florida Hospital's Chaplaincy Residents. At a minimum the program will include hospice overview,

admission requirements, patient and family satisfaction results, and spiritual considerations in end-of-life care.

4. Florida Hospital HospiceCare commits to the following initiatives to improve the quality of hospice care offered:

Pain assessment on admission and by the second day of

admission (within 48 hours);

Provide palliative care modalities including radiation therapy;

Encourage additional staff credentialing for physicians, nurses, chaplains, and social workers through a certification

reimbursement program;


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Maintain accreditation by The Joint Commission (formerly

known as the Joint Commission on Accreditation of Health Care Organizations)

5. Florida Hospital HospiceCare commits to enter into agreements with one or more of the six Florida Hospital hospitals (Apopka,

Celebration Health, East Orlando, Kissimmee, Orlando and Winter Park Memorial) and one or more Adventist Care Centers (skilled nursing facilities) in Service Area 7B to provide inpatient hospice

services to residents of Orange and Osceola Counties. 6. Florida Hospital HospiceCare commits to provide volunteer services

to hospice patients that substantially exceeds the five percent requirement mandated under the Medicare Conditions of

Participation. Based on the success of its Flagler and Volusia program, Florida Hospital HospiceCare commits to a minimum of 10 percent of its hours of care being provided by hospice

volunteers. The additional commitment of volunteer hours will begin with the second year of operation.

7. Florida Hospital HospiceCare commits to provide programs for the

Hispanic population which will include support from or

involvement of bilingual staff and volunteers, translated literature, training on cultural differences and competencies, and flexible programming to meet identified needs. Bereavement services will

include outreach to the Hispanic population of Service Area 7B.

8. Florida Hospital HospiceCare commits to develop a community resource information website in the first year of operation. This educational site will include various lay and professional education

pieces related to chronic illness, death, dying, and bereavement.

9. Florida Hospital HospiceCare commits to develop a community advisory board composed of residents inclusive of both the Orange and Osceola communities. The purpose of the community advisory

board is to provide input and feedback about service area needs and recommendations for consideration in future program development.

10. Florida Hospital HospiceCare commits to minimum annual funding

of $10,000 towards a "Special Wish Fund" designated for the end-of-life wishes for Florida Hospital HospiceCare patients and their families. This commitment would begin in the second year of

operations.


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11. Florida Hospital HospiceCare commits to open two offices in the

first year of operation. One office will be opened in Osceola County on the campus or in proximity to Florida Hospital Kissimmee. The

Orange County office will be located on the campus or in close proximity of an Orange County facility to best suit the needs of the Clinical Pastoral Education, Medical Education, and Palliative Care

programs. Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey

HealthCare of Central Florida (CON #10071) proposes to establish a new hospice program in Hospice Service Area 7B, Orange and Osceola

Counties. The applicant states that its sole shareholder and parent is Odyssey HealthCare Operating B, LP. The parent is stated to have 92 Medicare-certified hospice programs in 29 states. Odyssey is licensed in

Florida as Odyssey HealthCare of Marion County, Inc. and serves three hospice service areas (SA): SA 11 (Miami-Dade and Monroe Counties),

SA 4B (Volusia and Flagler Counties) and as of January 1, 2010 SA 3B (Marion County).1

The proposed total project cost is $635,608 with year one operating costs of $1,945,888 and year two costs of $3,490,434. The applicant agrees to condition award of the CON as follows:

1. The applicant will provide supportive hospice services, such as but

not limited to: palliative radiation therapy and palliative chemotherapy related to the patient's terminal diagnosis. This will be measured via a signed declaratory statement by applicant which

may be supported via a review of patient medical records.

2. The applicant will provide continuous care. This will be measured

via a signed declaratory statement by applicant, which may be supported via a review of patient medical records.

3. The applicant will implement the "Care Beyond' Program. This will

be measured via a signed declaratory statement by applicant.

4. The applicant will provide hospice services 24 hours a day, seven

days a week including weekend care as indicated by the patient's medical condition. This will be measured via a signed declaratory statement by applicant, which may be supported via a review of

patient medical records.

1 Odyssey HealthCare of Marion County, Inc. became licensee for hospice Service Areas 4B & 11

effective November 1, 2009 and added Marion County to its license effective January 1, 2010. Odyssey had previously operated as Odyssey HealthCare.


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5. The applicant will admit all eligible patients without regard to their

ability to pay. This will be measured by the applicant's Medicare certification which requires this standard.

6. The applicant commits to having every patient being assessed by a

physician upon admission to the hospice. This will be measured

via a signed declaratory statement by the applicant, which may be supported via a review of patient medical records.

7. The applicant will immediately implement its performance improvement (PI) plan including the following assessments: pain

management, family satisfaction, employee satisfaction, and referral source satisfaction. This will be measured via a signed declaratory statement by the applicant, which may be supported

via a review of patient medical records.

8. The applicant will make available a range of non-covered supplementary therapies such as but not limited to: pet, music, massage, aroma and other holistic treatments. This will be

measured via a signed declaratory statement by the applicant, which may be supported via a review of patient medical records.

9. The applicant will implement Odyssey's triage and on-call programs upon licensure. These programs provide for

uninterrupted 24-hour care seven days a week. Further explanation of the program is offered in the application narrative. This will be measured via a signed declaratory statement by the

applicant.

10. The applicant will establish a local ethics committee within the

first year of operation. This will be measured via submissions of the names and other relevant information of the ethics committee

members and the related schedule of meetings to the Agency. 11. The applicant will establish a local medical advisory committee

within the first year of operation. This will be measured via submissions of the names and other relevant information of the

Medical Advisory Committee members and the related schedule of meetings to the Agency.

12. The applicant will provide educational programs, including but not limited to, in-service training (components of Odyssey University) resources to the community, including nursing homes, assisted

living facilities, and the Council on Aging. In-service training would be offered to registered nurses, social workers,

administrators and other staff that would benefit from an


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increased knowledge of hospice care and services. The applicant will host at least one seminar annually during the first two years of

operation for clergy and community faith leaders (The Clergy End of Life Education Program), to enhance spiritual support for

hospice patients in the district. This will be measured via a signed declaratory statement by the applicant.

13. The applicant will provide patients, family members and referral sources with information of services provided by the Dream Foundation. The Dream Foundation is the first national group of

its kind that exists for terminally ill applicants over the age of 18. Through its Day Dreams (a program for terminally ill adults over

the age of 65), Emergency Dreams and Quality of life Dreams, the Dream Foundation provides patients and families with a sense of completion and fulfillment. Odyssey has partnered with the Dream

Foundation to improve care for our patients and to advance our mutual interests in the field of hospice. This will be measured via

a signed declaratory statement by the applicant.

14. The applicant, through Odyssey HealthCare, Inc. or the Odyssey

VistaCare Hospice Foundation, will make a $25,000 contribution to an appropriate not-for-profit entity in the community to fund education for end-of-life issues. Upon approval, Odyssey will meet

with the Area Council on Aging or similar organizations to identify and determine the most appropriate entity within the community

related to education for end-of-life issues. This will be measured via a signed declaratory statement by the applicant and evidence of funds provided to the not-for-profit entity.

15. The applicant will commit to 0.5 FTE the first year of operation to

evaluate the need, if any, for an expanded children's hospice

program in the community including, but not limited to, the need for a children's program that offers an expanded hospice benefit for

patients up to age 21. The program would focus on longer term services for patients who may not otherwise qualify for hospice such as those with developmental conditions, cancers, chronic

illnesses or brain injury that shorten lives and place special demands on families. If during the first year of operation it is

determined that existing children's hospice services in the community are available to meet local needs, the applicant will donate $25,000 to support existing local children's hospice

programs. If after this first year there is found to be a need for additional children's hospice services, a child and family support program interdisciplinary team will be established to support the

needs of this target population. This will be measured via a signed declaratory statement by the applicant.


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16. The applicant will commit to 0.5 FTE the first year of operation for development efforts regarding community bereavement programs

in the community. The bereavement programs will be broadly based to extend beyond the families of patients admitted to

Odyssey HealthCare. These programs will be an extension of the programs currently offered in the hospice service area. The applicant will provide bilingual staff to provide bereavement

services to the Hispanic population, including Hispanic children. At a minimum, one bereavement group consisting of approximately eight sessions will be offered by the end of the first year of

operation. As the bereavement client census increases after one year, full-time staff will be employed. This will be measured via a

signed declaratory statement by the applicant. 17. The applicant will commit to the provision of programs for the

Hispanic and other minority populations which will include support from or involvement of bilingual staff, translated literature,

training on cultural differences and competencies and flexible programming to meet their unique needs. Hospice staffing will reflect the racial and ethnic mix of the local community served.

This will be measured via a signed declaratory statement by the applicant.

18. The applicant will develop a community resource library during the first year of the proposed hospice's operation. The library will

include various lay and professional education pieces related to chronic illness, death, dying and bereavement. This will be measured via a signed declaratory statement by the applicant.

19. The applicant commits that the Odyssey VistaCare Hospice

Foundation will facilitate the provision of a children's bereavement

camp in Florida by the end of the first year of operation, similar to what Odyssey currently provides via Odyssey's SkyCamp, Camp

Healing Tree and Camp Odyssey. This will be measured via a signed declaratory statement by the applicant.

20. The applicant will have a minimum staff of at least three community education representatives, expanding community

awareness of hospice services and educating local medical staff, community leaders and potential hospice patients as to the benefits of and availability of hospice care. Compliance with this

condition will be measured via submission of an annual report confirming that at least three community education representative staff members are employed at the proposed new service and active

in the local community. Additionally, if approved, Odyssey will provide education, training and assistance in development of

respite care policies, procedures and protocols to nursing homes.


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21. Hospice Service Area 7B includes two counties: Orange and

Osceola. Odyssey commits to the immediate development of its main office in Orange County and a satellite office in Osceola

County by the end of year one of operation. The applicant commits to become accredited by the Joint Commission and the National Institute for Jewish Hospice by the end of its second year of

operation.

22. The applicant commits to medical directors assessing every patient

on admission and providing visits in home or place of residence. The medical director is to be board-certified in hospice and

palliative care medicine or will apply for board-certification within five years of employment.

23. The applicant commits that every patient will be contacted on a daily basis. The applicant commits to sponsoring two to four

education seminars per year for physicians, long-term care facilities and assisted living facilities (ALFs). The focus of these seminars is to educate the local health care community on the

provision of hospice services within ALFs and other long-term care facilities: a coordinated plan of care for the patient, increased support for patient, family and facility staff, and the provision of

equipment, medication and supplies.

United Hospice of Florida, Inc. (CON #10072) proposes to establish a new hospice program in Hospice Service Area 7B, Orange and Osceola Counties. United Hospice is a wholly owned subsidiary of United Health

Services of Florida, Inc. The parent company, United Health Services, Inc., is a part of the United Health Services-Pruitt family of companies. United Health Services, Inc. is a holding company which owns and/or

operates, through its subsidiaries, 71 long-term care facilities, 25 hospice programs, 13 home health care agencies, five pharmacies, a

health care management company, a nutritional services company, a clinical services company, and medical supply company and 14 SOURCE offices.2 United Health Services, Inc. (UHS), manages its many

subsidiaries through its corporate office located in Norcross, Georgia.

The proposed total project cost is $247,009 with year one operating costs of $1,841,126 and year two costs of $4,775,746. The applicant agrees to condition award of the CON as follows:

2 The State of Georgia & UHS-Pruitt websites indicate UHS-Pruitt subsidiary UniHealth Solutions oversees UHS participation in SOURCE. SOURCE is an acronym for Service Options Using Resources

in Community Environments and is the State of Georgia‟s Medicaid long-term care diversion program.


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1. UHS Home and Community Based Services Provider: Upon CON approval, United Hospice's ultimate parent, UHS, will develop, in

conjunction with United Hospice, UHS' family of services and companies in Subdistrict 7B and will enhance the hospice services

available to area residents by making such a service available not only to United's hospice patients, but also to any other existing hospice provider who wishes to contract for such services. These

services and companies include United Home Care, United Rehab, United Medical, United Pharmacy Services and United Clinical Services. This will be measured by a signed declaratory statement

submitted by United Hospice to the Agency.

2. Hispanic Outreach: Reflective of its commitment to enhancing access to end-of-life care of Hispanic residents in Subdistrict 7B, the applicant has conditioned approval of its application on the

provision it will implement and maintain an African American outreach program.

• A bilingual (Spanish speaking) staff member will be responsible

for the outreach initiatives. This individual's objective will be to

coordinate staff activities, plan events and serve as a key contact within community leaders.

• By the end of the second full year of operation, 40 percent of the staff serving Osceola County will be bilingual to reflect the

demographic make-up of the community, including Spanish speaking physicians, nurses, home health aides, chaplains and social workers.

• Marketing and family educational materials, as well as all

hospice admissions forms, advance directives, bereavement

materials and any other written materials used in the provision of hospice services to patients and families will be available in

both English and Spanish. • United Hospice will form a planning and outreach team

consisting of staff, volunteers and community members. This team will provide support for the staff person assigned primary

responsibility for outreach effort. • United Hospice will host listening sessions with Hispanic

community leaders, Hispanic clergy and other members of the Hispanic community to develop an understanding of attitudes and beliefs regarding end-of-life care.

• Based on listening sessions, United Hospice will develop a

message, presentation and marketing materials that address


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needs and issues expressed by focus group respondents to ultimately deliver the message that addresses needs and

concerns of the community.

• United Hospice will continually assess existing tools and obtain or develop new resources as needed to provide culturally meaningful and appropriate educational opportunities for the

Hispanic community.

• The applicant will provide ongoing comprehensive training for

staff and volunteers who are actively involved in the outreach program. These individuals will plan quarterly town hall

meetings with members of the community to engage, educate and energize individuals to begin end-of-life conversations in their organizations, congregations and so forth.

• United Hospice will develop and maintain a calendar of events

that address, support and celebrate Hispanic issues, heritage and health care concerns. Staff members will attend various calendar events with the goal of making United Hospice of

Florida the name and face known throughout the community. • The applicant will develop a census tracking tool to routinely

track referrals generated by the outreach program to measure its ongoing success.

• By the time of final CON approval, the United Hospice website

will be available and accessible in the Spanish language.

• The applicant will report its admissions annually by ethnicity to

measure success and increase in percentage of Hispanic

admissions. This condition will be measured by a signed affidavit submitted to the Agency.

3. CHAP Accreditation – United Hospice has conditioned approval of

this application on the provision it will seek and obtain CHAP

accreditation upon certification. This will be measured by submitting United Hospice's accreditation certificate to the Agency

upon receipt.

4. Membership Organizations - Upon licensure, United Hospice will

become a member of the following community organizations: • Florida Hospice and Palliative Care;

• Hispanic Chamber of Commerce of Central Florida; • Orlando Regional Chamber of Commerce; and

• Kissimmee/Osceola Chamber of Commerce;


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This will be measured by a signed affidavit submitted to the

Agency.

5. United Hospice Foundation - United Hospice Foundation will make available to Florida residents, its annual scholarship program targeted at those who are studying nursing, pharmacy or therapy

with an interest in end-of-life care. The scholarship is available each year to four students in the amount of $2,000 for the school year. This will be measured by a signed affidavit submitted to the

Agency.

6. Office Locations – United Hospice will open two office locations immediately upon licensure; at least one location will be in a Hispanic area of Osceola County. A third office location will open

in the third year of operation.

7. Staffing Ratios and Qualification – United Hospice will meet or exceed all NHPCO Guidelines for qualifications and staffing ratios for patient care staff. This will be measured by a signed

declaratory affidavit submitted to the Agency. ALL: None of the applicants proposed to condition to voluntary reporting

of the Agency‟s „Family Evaluation of Hospice Care (FEHC) Satisfaction Survey‟ found at the FloridaHealthFinder.gov website. Hospice programs

are required by federal and state law to provide services to everyone requesting them and therefore the Agency would not place conditions on a program to provide legally required services. Rule 59C-1.013(4) Florida

Administrative Code contains condition compliance reporting criteria that the Agency uses for an approved CON that has conditions.

D. REVIEW PROCEDURE

The evaluation process is structured by the certificate of need review criteria found in Section 408.035, Florida Statutes, rules of the State of

Florida, and Chapters 59C-1 and 59C-2, Florida Administrative Code. These criteria form the basis for the goals of the review process. The

goals represent desirable outcomes to be attained by successful applicants who demonstrate an overall compliance with the criteria. Analysis of an applicant's capability to undertake the proposed project

successfully is conducted by evaluating the responses provided in the application, and independent information gathered by the reviewer.


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Applications are analyzed to identify various strengths and weaknesses in each proposal. If more than one application is submitted for the same

type of project in the same district (subdistrict or service planning area), applications are comparatively reviewed to determine which applicant

best meets the review criteria. Section 59C-1.010(2) b, Florida Administrative Code, prohibits any

amendments once an application has been deemed complete. The burden of proof to entitlement of a certificate rests with the applicant. As such, the applicant is responsible for the representations in the

application. This is attested to as part of the application in the certification of the applicant.

As part of the fact-finding, the consultant, Cheslyn Green, analyzed the application in its entirety with consultation from financial analyst,

Everett Broussard, who evaluated the financial data.

E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA

The following indicates the level of conformity of the proposed projects with the criteria found in Florida Statutes, Sections 408.035 and 408.037; applicable rules of the State of Florida, Chapter 59C-1 and

59C-2, Florida Administrative Code.

1. Fixed Need Pool

a. Does the project proposed respond to need as published by a fixed

need pool? Chapter 59C-1.008, Florida Administrative Code and Chapter 59C-1.0355, Florida Administrative Code.

In Volume 35, Number 39 of the Florida Administrative Weekly, dated October 2, 2009, the Agency for Health Care Administration published a

need for one hospice program in Hospice Service Area 7B for the January 2011 Hospice Planning Horizon. Hospice Service Area 7B is currently served by four licensed hospice providers: VITAS Healthcare Corporation

of Florida, Hospice of the Comforter, Inc., Samaritan Care Hospice, and Cornerstone Hospice and Palliative Care.

Each co-batched applicant is applying in response to published need for a hospice program in Hospice Service Area 7B, Orange and Osceola

Counties. However, all applicants provided additional arguments in support of need for their projects as discussed below.

Catholic Hospice of Central Florida, Inc. (CON #10069) states that Service Area 7B has experienced rapid population growth between April

1, 2000 and April 2009, 32 percent compared to 19 percent in the state


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as a whole. Within Osceola County the population increased by 62 percent. Orange County grew by 27 percent. Growth within service Area

7B‟s Hispanic community was even more dramatic, according to the applicant, increasing by 94 percent since 2000, nearly double the

statewide growth rate of 51 percent. The applicant provides percentages only for the majority of its population discussion, actual population numbers are included when provided. The applicant states that the April

2009 estimated service area population of 1,414,362, includes 425,505 Hispanic residents. Catholic Hospice indicates that Orange County trails only Miami-Dade and Broward Counties in total number of Hispanic

residents. Osceola County, with 43 percent Hispanic residents, ranks third among all Florida counties while Orange County at 27 percent

ranks seventh in percent Hispanic residents. Overall, 30 percent of 7B residents are Hispanic compared to 21 percent statewide. The applicant states that rapid growth is projected to continue over the next five years,

especially among Hispanics. Between April 1, 2009 and 2014, the resident population of the service area is expected to increase by 12

percent as compared to eight percent in the state as a whole with projected growth in Osceola County of 19 percent and 11 percent in Orange County. Hispanic population growth of 23 percent is projected

within the service area as compared to 16 percent statewide. By 2014, the applicant states that Service Area 7B is expected to have 524,316 Hispanic residents, representing one-third (33 percent) of the area‟s total

1.6 million population.3 The applicant concludes that demand for hospice services should increase with population growth.

Catholic Hospice next discusses the Pew Foundation‟s Forum on Religion and Public Life, U.S. Religious Landscape Survey of February 2008 and

states that based on its research, the foundation estimates that between 65 and 68 percent (roughly two-thirds) of the Hispanic/Latino population is affiliated with the Catholic Church. The applicant states it is

committed to providing hospice care oriented to the language, cultural and religious beliefs of the Hispanic/Latino community. The applicant

states that its sister organization Catholic Hospice, Inc., currently provides hospice care in Service Areas 10 and 11 which along with Service Area 7B have the highest concentration of Hispanic/Latino

residents in the state of Florida.

Catholic Hospice states that during calendar year 2008 Hispanics accounted for 10 percent of all deaths in Service Area 10 and 58 percent of deaths in Service Area 11. By comparison, Hispanics constituted 31

percent of the patients serviced by Catholic Hospice Inc, in Service Area 10 and 78 percent of those served in Service Area 11. The applicant states that it has a long standing commitment and record of serving the

3 Catholic Hospice indicates that the population estimates are based on the Florida Office of Economic

and Demographic Research (EDR) data.


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Hispanic Community and is ideally suited to addressing the documented need for a new hospice program in Service Area 7B.

The applicant states that consistent with the low percentage of elderly

residents within the service area, the proportion of deaths accounted for by persons age 65 or older (65.9 percent) lags behind the statewide average (74.1 percent). Persons age 85 and older use hospice care

services at a higher rate than all other age groups. Within Service Area 7B, persons in this advanced age category made up 25.3 percent of all deaths as compared to 31.0 percent of deaths among all Florida

residents. The applicant contends that the low percentage of deaths accounted for by elderly and extremely elderly residents within Service

Area 7B implies hospice penetration rates below the statewide rate. Catholic Hospice states that historically, non-Hispanic whites have used

hospice services at a higher rate than other ethnic and racial groups, including Hispanics, Black/African Americans, and persons of

Asian/Pacific Island descent. During calendar year 2008, there were 1,343 deaths among Hispanic residents of Service Area 7B representing 16.3 percent of all service area deaths. By comparison, Hispanics

accounted for 11.1 percent of all Florida resident deaths. The same year there were 1,322 deaths to Black/African American residents of the service area. These deaths make up 16.0 percent of all resident deaths.

By comparison, African Americans accounted for 10.7 percent of all Florida resident deaths.

Catholic Hospice contends that the high percentage of both Hispanic and Black/African American deaths in the service area leads to the

expectation of a hospice penetration rate below the statewide rate. The applicant states that the hospice admissions and admission rates may be depressed due to a high proportion of sudden/unexpected deaths by

suicide, homicide, perinatal conditions, unintentional injury (accidents) or other external causes. Catholic Hospice contends that within the

service area, hospice appropriate deaths accounted for a somewhat lower percentage of all resident deaths as compared to the state as a whole (89.3 percent versus 91.7 percent). While the use of hospice services had

grown among persons with non-cancer diagnoses, cancer patients continue to make up a disproportionate share of all hospice users.

Cancer patients accounted for 23.2 percent of service area deaths in 2008 compared to 23.9 of all Florida resident deaths.

The applicant states that historically, higher rates of hospice utilization have been found among higher income populations. Orange County ($31,589) ranked above the Florida median county per capita income of

$26,072 in 2005. However, the per capita income fell below the 2005 statewide average per capita income level $34,001. Per-capita income in

Osceola County ($22,008) fell 35 percent below the statewide average.


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The applicant states that per capita income may exert downward pressure on hospice utilization within some lower-income portions of

Service Area 7B.

According to the applicant, between 2001 and 2008 hospice admissions in Florida grew by 51 percent despite just a two percent increase in resident deaths over that same period. Hospice admissions in Service

Area 7B grew somewhat slower (46 percent) despite a much greater increase in resident deaths (seven percent). As a result, Service Area 7B‟s hospice admissions rate for calendar year 2008 (59.6 percent)

lagged behind the state median rate of 62.3 percent. The applicant asserts that this lag in hospice admissions within 7B is consistent with

the presence of various factors impeding hospice use, as discussed above. Catholic Hospice concludes that these factors must be addressed and overcome in order for hospice use rates to grow to a level more

consistent with the true needs of the service area.

The applicant states that after sending out several members of its staff to speak to members of the community, several concerns were identified within the Osceola County area. The applicant states that a local

hospital administrator identified a poor response time to patients and families in need of immediate end-of-life care within the Osceola County area, which the applicant states leads to the perception of insensitivity to

patients and families as well as an inability to meet their needs. The next concern as identified by area residents was a need to have an

additional choice of hospice. The third area of concern voiced by many residents was the need for a faith-based, not-for-profit provider that would offer those patients and families that needed to access hospice

care an alternative to the current providers. Catholic Hospice states that its staff visited all skilled nursing facilities in

Kissimmee and it was very apparent there was a desperate need for a hospice experienced in hospice services that meet the needs of the

Hispanic population. The need for a hospice with bilingual staff that speak Spanish in addition to English was also identified. According to the applicant, concerns were also raised as to the number of field staff

who are unable to communicate with the clients, residents and patients for whom they are caring. The applicant also identified a need for

children‟s grief counseling and bereavement services within the service area. Catholic Hospice states that this should be in a therapeutic environment such as a camp and amongst peers in order to resolve grief

issues as well as to have grief issues identified by bereavement professionals. The applicant states this is why the development of the camp is a condition to this application.

The applicant cites Catholic Hospices‟ service to the Hispanic

community, states that it has a mission of service to the indigent and low


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income population and that it will make a concerted effort to reach out to all segments of the service area‟s population. Catholic concludes that its

market assessment affirms the Agency‟s finding of need for an additional hospice program to serve Area 7B and hospice admissions in the 2011

horizon year should equal or exceed the level forecast by the Agency.

Catholic Hospice contends that its strengths will spur utilization

throughout all segments of the population, particularly among lower income and ethnic residents.

The applicant states that it will place its main office in Kissimmee because the location addresses a variety of considerations including: an

emphasis on service to the Hispanic community, the location of existing hospice programs, access to the transportation network serving the area and population size and projected growth within the service area.

Catholic Hospice also states that three of the four have branch offices in the Kissimmee area. The city of Kissimmee is centered in zip code area

34741 which has the largest number of Hispanic residents (28,164 of 48,629 total or 58 percent) of any zip code within the service area. Zip code area 34743 which includes the eastern terminus of the city has

nearly as many total Hispanics (26,125) and the highest percentage of Hispanic residents (26,125 of 38,079 total or 69 percent) within the service area. The second largest concentration of Hispanics is in the

Union Park area of Orange County, east of downtown Orlando.

Hispanic Population by Zip Code Area: 2009 Within 10-mile radius of Kissimmee

Area County Hispanic Total % Hispanic

32824 Orange 18,378 33,025 56%

32837 Orange 16,200 48,098 34%

32831 Orange 2,261 13,678 17%

34741 Osceola 28,164 48,629 58%

34743 Osceola 26,125 38,079 69%

34744 Osceola 17,008 42,162 40%

34746 Osceola 11,827 33,317 35%

34758 Osceola 14,631 30,910 47%

34769 Osceola 3,995 23,120 17%

138,589 311,018 45%

7B 397,649 1,419,409 28% Source: CON Application #10069, page 19.


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Hispanic Population by Zip Code Area: 2009

Union Park Area of Orange County Area County Hispanic Total % Hispanic

32792 Orange 9,981 45,729 22%

32807 Orange 15,818 32,193 49%

32817 Orange 10,069 38,289 26%

32822 Orange 27,117 56,464 48%

32825 Orange 22,834 55,696 41%

32826 Orange 5,621 21,989 26%

32828 Orange 15,662 52,297 30%

107,102 302,657 35%

7B 397,649 1,419,409 28% Source: CON Application #10069, page 19.

Hispanics make up 40 percent of Kissimmee and Union Park residents while only 19 percent of the service area population outside these two areas is Hispanic. The applicant states that while three of the four

existing 7B hospice programs maintain a satellite office in Osceola County, all within the Kissimmee area, it would be the only hospice program to establish Kissimmee as its primary office location. The

applicant states that a primary office location in Kissimmee will afford lower income residents a high level of access to the full range of

community outreach and family support services it offers. Agency records indicate that the three existing providers with branch offices in Kissimmee are Hospice of the Comforter and VITAS in zip code 34741

and Cornerstone in zip code 34744. The applicant does not demonstrate that having a primary office in the same area that has three branch offices within a 10-mile radius of Kissimmee would have any impact on

the provision of hospice care.

Over the next five years, Kissimmee and the surrounding area is projected to continue its rapid growth. The nine zip code area (as previously defined) is expected to realize a 19.5 percent increase in

population from January 2009 to January 2014. By comparison, the previously defined Union Park area (which has the area‟s second highest

concentration of Hispanic residents) is expected to grow by 11.5 percent. The remainder of the service area is projected to grow by 12.4 percent.

Projected Population Growth within 7B

January 2009 to January 2014 Difference

Area 2009 2014 # %

Kissimmee 311,018 371,803 60,785 19.5%

Union Park 302,657 337,603 34,946 11.5%

Other 7B 805,734 905,580 99,846 12.4%

7B 1,419,409 1,614,986 195,577 13.8% Source: CON Application #10069, page 22.


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The applicant states that the continuing trend of rapid population growth in and around the city of Kissimmee lends added support to its selection

of Kissimmee as its primary office location. As program needs become established and patient census grows, a satellite office will be developed.

The applicant states its first, second and third year admissions are estimated at 161, 413, and 508 respectively. The first year‟s market

share will be three percent, the second year share will be 7.5 percent and the third year share will be 9.0 percent. The following is an illustration of projected admissions for the applicant in Service Area 7B.

Projected Admissions for CHI in Service Area 7B

Based on the Hospice Rule Mortality Methodology and Inputs

Year 1 Year 2 Year 3 Year 4

CY 2011 CY 2012 CY 2013 CY 2014

July 1 Population 1,485,528 1,523,278 1,560,902 1,598,043

Under 65 1,337,443 1,368,055 1,398,382 1,428,110

65 and over 148,085 155,223 162,520 169,933

Estimated Deaths

Cancer Under 65 769 789 808 827

Cancer 65+ 1,370 1,405 1,440 1,474

Non-Cancer Under 65 2,370 2,430 2,490 2,549

Non-Cancer 65+ 4,512 4,626 4,741 4,853

All Diagnoses, All Ages 9,021 9,250 9,479 9,704

Penetration Rates

Cancer under 65 92.0% 92.0% 92.0% 92.0%

Cancer 65+ 93.7% 93.7% 93.7% 93.7%

Non-Cancer under 65 21.3% 21.3% 21.3% 21.3%

Non-Cancer 65+ 63.8% 63.8% 63.8% 63.8%

All Diagnoses, All Ages 59.6% 59.6% 59.6% 59.6%

Hospice Admissions

Cancer under 65 708 726 744 761

Cancer 65+ 1,284 1,317 1,349 1,381

Non-Cancer under 65 505 518 530 543

Non-Cancer 65+ 2,878 2,952 3,024 3,096

All Diagnoses, All Ages 5,537 5,513 5,647 5,781

Market Share

Catholic Hospice 3.0% 7.5% 9.0% 11.0%

Others 97.0% 92.5% 91.0% 89.0%

Total 100% 100% 100% 100%

Admissions by Program

Catholic Hospice 161 413 508 636

Others 5,214 5,100 5,139 5,145

Total 5,375 5,513 5,647 5,781

Source: CON Application #10069, page 23.

The applicant states that the annual patient admissions for its proposed

program is based primarily on: the aggregate experience of hospice programs initiating operations in Florida since the beginning of calendar year 2002 and the size of the Service Area 7B market.

The applicant asserts that projected growth in hospice admissions within

the service area is sufficient to achieve its goal of building a viable new program within the area, while also allowing existing hospice programs to continue growing their admissions.


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Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) proposes to establish a hospice program in Service Area

7B and to open two offices in the first year of operations. One office will be in Osceola County on the campus or in proximity to Florida Hospital

Kissimmee. The applicant states that the other office will be located in Orange County on the campus or in proximity of an Orange County facility to best suit the needs of the (Florida Hospital) Clinical Pastoral

Education, Medical Education and Palliative Care programs. Florida Hospital HospiceCare indicates that there are several

characteristics that distinguish it from existing providers and other applicants, which makes it the best applicant to meet the published need

and serve as a complement to existing hospice providers. These include its mission, chaplaincy and pastoral care, integration and continuum of care, and medical education for physicians, residents and other health

professionals.

In discussion of its mission, the applicant indicates that there are six principles that Adventist Health System draw motivation and direction to guide how employees and patients are treated. These are:

Christian Mission - We serve the needs of our communities in

harmony with Christ‟s healing ministry and incorporate Christian values at every level of service.

Quality and Service Excellence - We meet or exceed both the service

standards of the health care industry and the expectations of the patients we serve and measure through continuous surveying of

patient satisfaction.

Compassion – We are sensitive to the needs of the individuals and

families we serve and meet their needs with kindness and empathy.

Focus on Community Wellness – We commit time, talent and financial

support to educate our neighbors in the principles of illness prevention and healthful living.

High Ethical Standards – We conduct business with integrity, honesty and fairness. As responsible stewards, we use our financial resources

wisely by choosing business practices which are cost-effective, productive and result in a fair return on investment.

Cultural Diversity – We value the diversity of our patients, employees,

business colleagues and visitors and treat them with kindness and respect regardless of their background, race, religion or culture.

The applicant indicates that Florida Hospital HospiceCare provides

hospice services consistent with its mission statement and this program will complement other services through education concerning hospice within the organization and promote timely referral of patients.


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In reference to chaplaincy and clinical pastoral education, the applicant indicates that Florida Hospital is one of 13 Clinical Pastoral Education

(CPE) programs in Florida and one of two in SA 7B that is accredited by the Association for Clinical Pastoral Education (ACPE). ACPE is a 2,600

member group that includes 350 ACPE accredited CPE Centers and 600 ACPE-certified faculty members (called CPE supervisors). There are 113 Theological Schools Members and 23 Faith Groups and Agencies who

partner with ACPE in seeking to provide excellence in theological education. Asbury Theological Seminary is the ACPE accredited theological school in SA 7B and is described as an institution in the

Wesleyan tradition that collaborates with the Florida Hospital CPE

Center. The Florida Hospital CPE Center is stated to provide several programs including:

Full-time, one-year ACPE-accredited residency (currently eight full-time residents),

Part-time, six-month ACPE-accredited residency (35 residents per semester, 70 per year),

ACPE-accredited training for CPE supervisors,

An intensive 11-week unit of CPE during the summer months which

is open to clergy, laity, religious workers, and students for the ministry; designed to integrate personal, interpersonal and

professional learning in ministry formation,

A summer program offered at Florida Hospital East Orlando in

conjunction with the Asbury Seminary Latino/Latina Studies Program (LLSP); the entire program is conducted in Spanish language,

Programs and resources to community organizations - Association of Professional Chaplains, Andrews University (Adventist university and

seminary in Orlando), and many others,

Continuing education for ministry and training for institutional

chaplains. FloridaHospice Care indicates that hospice care represents a natural

extension of the pastoral care provided by Florida Hospital chaplains.

In reference to the integration and continuum of care as an existing provider the applicant indicates that:

As a hospital-based applicant for a hospice program, FloridaHospice Care will be an integrated part of Adventist/Sunbelt and Florida Hospital. Florida Hospital has provided health care to residents of central Florida

for over 100 years, earning a reputation of excellence and the trust of patients and physicians. As a trusted provider of care across the entire

service continuum, Florida Hospital is well-positioned to inform and raise


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awareness of the benefits of hospice care. Six Florida Hospital acute care and two Adventist Care Center skilled nursing facilities provide

geographic coverage to residents of Orange and Osceola Counties:

Florida Hospital Orlando, a state-of-the-art 1,080-bed facility located in Orlando in Orange County, is the largest of the six Florida Hospital

facilities in Service Area 7B.

Florida Hospital Orlando is an accredited Community Comprehensive

Cancer Center, provides organ transplant services, open heart and other state-of-the-art cardiovascular surgery, behavioral health,

orthopedic, and rehabilitation services, comprehensive services and education in a Diabetes Center, and other inpatient and outpatient services along the continuum of care.

The applicant‟s integration and continuum of care discussion included

Table 1 on page nine of the application which documented individual Florida Hospital facilities discharge volume. Florida Hospital facilities discharged 66,238 Service Area 7B residents (excluding normal

newborns) during the 12 months ending June 2009. The applicant contends that a hospice program affiliated with a hospital is more likely

to increase awareness of hospice as an option and to maximize the resources available within the health care system, particularly with residents who do not have cancer. The applicant cites a 2001 National

Hospice & Palliative Care Organization and the Center for Palliative Care, study entitled “Hospital-Hospice Partnerships in Palliative Care: Creating a Continuum of Service” as support for its project. Page 11 of the

application includes the following summary of the benefits of integration Florida Hospital HospiceCare contends apply to this project.

Benefits of Collaboration for Hospital and Hospice Partners For the Hospital: Improve the quality of care for hospitalized seriously and terminally ill

patients and their families.

Learn more about the nature and value of hospice services, including psychosocial, spiritual, and bereavement components and the functioning of the hospice interdisciplinary team.

Launch palliative care and end-of-life services in collaboration with an experienced provider.

Improve continuity of care with post-hospital settings.

Utilize training opportunities for staff.

Affiliate with hospice's positive community image and philanthropic success.

Draw upon a new avenue of reimbursement (the Medicare Hospice Benefit) for terminally ill hospitalized patients.

Improve resource utilization for seriously ill patients and reduce the costs of their care, according to recent research.


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For the Hospice: Access more patients who will benefit from hospice care earlier in the course

of a terminal illness.

Learn more about the challenges and practice of end-of-life care in the acute care setting.

Gain access to the organizational resources of the hospital.

Learn more about inpatient palliative care treatments.

Establish new or improved organizational linkages to larger health systems.

Participate in palliative care expansion by applying knowledge and expertise to a setting where many patients with life-threatening illnesses receive their care.

Integrate hospice services within a broader continuum of palliative care.

Achieve more appropriate and timely referrals through participation in the

broader continuum.

Clinical Benefits of a Hospital-based Palliative Care Program For the Patient:

Reduction in symptom burden.

Care concordant with patient-family preferences.

Patient-family-professional consensus on the goals of medical care.

Improved patient and family satisfaction.

The applicant states that approval of Florida Hospital HospiceCare will

benefit the overall health care system in several ways:

Heightened awareness of hospice as an option for care for patients

throughout the continuum of care, including with patients with partnering community organizations and other health care providers;

Potentially earlier placements in hospice care; and

Increased educational opportunities for physicians, medical residents,

and other health care providers.

However, many of these benefits could be obtained by hospice and hospital collaboration regardless of the licensure relationship between the two entities.

In reference to medical education for physicians, residents and other

health professionals, the applicant notes that Florida Hospital is a statutory family practice teaching hospital with residencies in family practice and surgery and fellowships in geriatric medicine and

gynecological oncology. The applicant indicates that Florida Hospital is uniquely qualified to provide ongoing education and communication

about this important service (hospice) to these physicians in training. Florida Hospital‟s teaching program is described and the applicant indicates that it will initiate a comprehensive and ongoing physician

education program targeted to providing information and ease of access to the physicians in Orange County and specifically those on staff at


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Florida Hospital‟s Orange and Osceola hospitals. Education topics will include „Death, Dying and Bereavement‟, „Hospice 101‟, „Hospice

Eligibility Requirements‟ and „Spiritual Considerations at the End of Life‟. The applicant indicates that these programs will be expanded to meet the

educational and training needs of health care professional students. The applicant also contends that there are additional Florida Hospital

HospiceCare attributes and qualifications that distinguish its application. These include the following:

Florida Hospital HospiceCare has a history of providing excellent

services for patients and their families, including proven practices and policies and a compassionate understanding of the nature of hospice

care.

Florida Hospital HospiceCare will provide a volunteer service that is

integrated with the community, leveraging the success of Florida Hospital and Florida Hospital HospiceCare in recruiting and utilizing

community volunteer resources.

Florida Hospital HospiceCare will develop a Community Advisory

Board once the application is approved to appropriately guide program and service development.

Florida Hospital HospiceCare and related entities have in-place the

resources and infrastructure needed to successfully implement the hospice service in Service Area 7B.

Referral relationships with area physicians, post-acute providers, community organizations, and charities;

Agreements for inpatient care needed by hospice patients will be entered into with one or more Florida Hospital facilities in Service

Area 7B (Florida Hospital Apopka, Florida Hospital Celebration Health, Florida Hospital East Orlando, Florida Hospital Kissimmee, Florida Hospital Orlando, and Winter Park Memorial Hospital), the

Adventist Care Center skilled nursing facilities, as well as other area providers; and

Support and billing cycle services, recruiting, and staff training, and other administrative services will be provided by the existing offices of

Florida Hospital HospiceCare. Florida Hospital HospiceCare will provide services that go beyond the Medicare Hospice Benefit.

Florida Hospital HospiceCare concludes that it provides excellent and compassionate hospices services in Service Area 4B and is the best

applicant to meet the identified need in Service Area 7B. The applicant next provides a discussion of Service Area 7B.

The applicant states that Service Area 7B had an estimated population of 1,420,611 residents in 2009 and is projected to grow rapidly to a population of 1,598,043 residents by 2014, representing an increase of


31

12.5 percent. Both counties have a relatively young population, with the proportion of elderly residents (age 65 and over) in Orange County

projected to be 10.3 percent of the total population and 11.8 percent in Osceola County in 2014.

The applicant contends that the growth in the Hispanic population in Service Area 7B has been significant. In Orange County, the Hispanic

population grew from 18.8 percent of the total population in 2000 to 26.4 percent in 2008. In Osceola County, the number of Hispanic residents doubled during the period, from 50,727 in 2000 to 121,599 in 2008. The

applicant contends that as a result, Hispanic residents as a percent of total population increased in Osceola County from 29.4 percent in 2000

to 44.5 percent in 2008 and increased in Service Area 7B from 20.5 percent to 29.9 percent during the same time period. The applicant states that although the Hispanic population is younger than the overall

population, the number of Hispanic elderly residents increased in Service Area 7B from 13,762 in 2000 to 27,840 in 2008. HospiceCare contends

that the increase in Hispanic population presents a growing need for a hospice that can accommodate residents of diverse ethnic backgrounds, provide bilingual programs and culturally sensitive programming to serve

this population. The applicant states that the Hispanic population in Service Area 7B meets the definition of a special needs population.

HospiceCare states that mortality in Service Area 7B increased from 2000 to 2008 by a total of 9.8 percent. Although Hispanics make up a

small percentage of total deaths that occur within Service Area 7B (7.2 percent in 2000 and 16.3 percent in 2008), the number of deaths increased by 149.2 percent compared to population growth of 91.0

percent during this period4. The applicant contends that while the number of deaths in Service Area

7B has been relatively stable over the past few years, HIV/AIDS deaths remained fairly consistent except for a brief increase in 2003. The 122

cases of HIV/AIDS deaths in the service area for 2003 were relatively higher than what has been experienced in recent years. HospiceCare states that while the number of deaths caused by HIV/AIDS is not large,

it does represent a segment of the population who are more likely to utilize hospice services. HospiceCare states that another area of focus

has been patients with Alzheimer‟s disease and has therefore, developed their program to include strategies for providing traditional palliative care to patients suffering from the disease.

4 Tables 6 and 7, CON Application #10070, pages 34 and 35: Service Area 7B Deaths by Age and

Ethnicity, 2000 to 2008.


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The applicant provides analysis of historical utilization of hospice services in Florida and Service Area 7B. There are currently four hospice

providers in Service Area 7B, Cornerstone Hospice and Palliative Care, Inc., Hospice of the Comforter, Inc., Samaritan Care Hospice, and VITAS

Healthcare Corporation of Florida. Analysis in this section includes number of admissions by category and age over a two year period for each existing hospice provider. The applicant reports that for the twelve

months ending June 2009 in Service Area 7B Cornerstone had 638 admissions, Hospice of the Comforter 1,882, Samaritan 485, and VITAS had 1,886 admissions.

HospiceCare states that it is confident that it can manage a hospice

program in Service Area 7B that satisfies community needs. HospiceCare states it projected its future hospice utilization using the guidelines and methodology in the hospice rule. An average death rate of

0.006073 was calculated for 2005 through 2007, and then used to project deaths for years 2010 to 2011. The applicant states the result is

a need for 484 additional hospice admissions for the January 2011 Planning Horizon. The applicant states the next step was to apply the three-year death rates to the projected population for 2010 to 2011 to

project deaths by disease category and age. The methodology results in a net need for 484 admissions, which according to the applicant is conservative in projecting need since it assumes constant hospice

penetration rates which have historically increased 5. The applicant contends that based on the Agency‟s hospice need methodology, Service

Area 7B residents who do not have cancer are projected to have an unmet need of 259 hospice admissions in 2011. In addition, residents under 65 without cancer were projected to have an unmet need of 174

admissions in 2011. The applicant‟s need projections are consistent with the Agency‟s publication for this batch as revised on October 13, 2009.

HospiceCare contends it will meet the need identified for residents of Service Area 7B. It will achieve market shares between 5.3 and 7.6

percent, resulting in projected utilization of 280 admissions in 2010 and 410 in 20116. The applicant states it will achieve its utilization without substantial impact on the existing hospice providers in the area.

Odyssey HealthCare of Collier County, Inc., d/b/a Odyssey

HealthCare of Central Florida, (CON #10071) proposes to establish a hospice program in Service Area 7B. The applicant states that based on the market forecast there is adequate hospice volume growth in Hospice

Area 7B to maintain the four existing hospice programs at current

5 Tables 10 and 11, pages 39 and 40, CON Application #10070: Historical Population and Deaths by

Cause/Age 2005-2007 and Projected Utilization for HospiceCare Service Area 7B. 6 Table 14, page 42, CON Application #10070: Projected Market Share for HospiceCare Service Area

7B.


33

volume levels while at the same time providing adequate new incremental hospice volume to establish a viable new hospice provider. The applicant

states that in addition to the Agency identified need it will present evidence of the existence of special and not normal circumstances in the

hospice system that also demonstrate the need for the proposed hospice program in Service Area 7B to better serve area residents in need of hospice services.

The applicant states its hospice will be located in Orange County within Service Area 7B and will establish a satellite office in Osceola County by

the end of year one of operation. The 2009 total population of Hospice Service Area 7B accounts for 59 percent of the District 7 total population

(1,420,611/2,418,538). From 2009 to 2012 the hospice service area population is projected to grow from 1,420,611 persons in 2009 to 1,523,278 persons in 2012; an increase of 102,667 persons or 7.2

percent during this three year period.

The percentage increase in total population is well above the growth rates District 7 (6.2 percent) and the State of Florida (4.9 percent). The applicant states that while the projected growth in the total population is

important, a more important consideration is the projected population of the older age cohorts of the service area population which are most likely to use hospice services. The older age cohorts will experience a greater

percent increase in population than the younger age cohorts or the population as a whole. Hospice Service Area 7B is home to a significant

proportion of persons‟ age 65 years and older: 45 percent of District 7‟s 65 and older population live in Hospice Service Area 7B. Hospice Service Area 7B population age 65 and older will increase by 18,414 persons

(+13.5 percent) between 2009 and 2012; a growth rate well above the 7.2 percent growth forecast for the population as a whole. The increase of 18,414 persons represents 50.5 percent of the total increase in the

number of persons‟ age 65 years and older in District 7 (18,414/36,447).

The applicant states that an effective Hospice Service Area 7B hospice provider must be able to support and provide care to a wide array of patients groups with unique needs and service requirements. Cancer

accounted for the largest number of deaths in Hospice Service Area 7B (23.3 percent), closely followed by heart disease accounting for 22.8

percent of deaths. The applicant states it has the ability and experience base to treat all patients in need of hospice care and is prepared to do so in Hospice Service Area 7B. In addition to the gross number of deaths by

cause, providing an estimate of the potential pool of patients for the proposed hospice program, the applicant also profiled chronic disease mortality in the service area comparing the age-adjusted death rates for

the service area versus the State of Florida. The age-adjusted mortality rates provide an estimate of the patients who eventually succumb to

these chronic diseases and therefore, a more accurate estimate not only


34

of the potential pool of patients, but also the range of diagnosis of patients eligible for hospice services. The applicant states that its

assessment of chronic disease mortality shows that both Osceola and Orange Counties have rates well above Florida levels for coronary heart

disease, stroke, heart failure, colorectal cancer, breast cancer, chronic lower respiratory diseases and diabetes.

Odyssey states that there are special not normal circumstances within Hospice Service Area 7B and warrant the approval of another hospice provider:

The residents of Hospice Service Area 7B have been consistently

underserved by the existing hospice providers as evidenced by the total hospice utilization rate that has been consistently lower than the

Florida average hospice utilization rate,

The consistently underserved patient group: cancer patients under

the age of 65, and

The consistently underserved patient group: non-cancer patients under the age of 65 years.

The applicant states that for the most recent 12 months of data, Hospice

Service Area 7B ranked 20th out of 27 hospice service areas in Florida for total hospice utilization. In Hospice Service Area 7B, 60.35 percent of patients dying were served by a hospice agency. Statewide, the

percentage of patient deaths served by hospice providers reached as high as 84.73 percent with the Florida average at 62.47 percent. The applicant states that Hospice Service Area 7B has been below the state

average for utilization of hospice services for all patients for eight of the past 12 batching cycles (April 2004 to the current cycle, October 2009).

Odyssey states that cancer patients under the age of 65 years have been consistently underserved by the existing hospice providers in Hospice

Service Area 7B. Comparing the Hospice Service Area 7B utilization rate to statewide data for this patient category shows that only 79.59 percent

of this patient group accessed hospice care in Hospice Service Area 7B as compared to the statewide experience where hospice served 91.92 percent of the patients under the age of 65 years dying of cancer utilized

hospice care. The applicant states that this lower level of hospice service to cancer patients under the age of 65 years is not just a one-time event but had been a consistent trend in Hospice Service Area 7B.


35

Percentage of Cancer Patients Under the Age of 65 years Served by Hospice:

Hospice Service Area 7B and Florida Apr

2004 Oct

2004 Apr

2005 Oct

2005 Apr

2006 Oct

2006 Apr

2007 Oct

2007 Apr

2008 Oct

2008 Apr

2009 Oct

2009

7B 73.03% 75.66% 72.18% 73.03% 84.14% 87.97% 85.89% 88.01% 88.16% 86.61% 77.65% 79.63%

FL 82.65% 80.25% 80.77% 84.23% 88.36% 89.42% 85.48% 85.76% 86.28% 88.87% 91.56% 91.92%

Source: CON Application #10071, page 60

With the exception of the three batching cycles between April 2007 and April 2008, the current Hospice Service Area 7B providers have consistently served a lower percentage of patients under the age of 65

years who have died from cancer, than hospice providers statewide have been able to achieve. The applicant states that while the existing Hospice Service Area 7B hospice providers have been serving a lower-

than-expected number of cancer patients under the age 65 years, the number of Hospice Service Area 7B residents under the age of 65 years

dying of cancer has steadily been increasing. The applicant asserts that non-cancer patients under the age of 65 years

have also been underserved by the existing providers. For example, based on data for the January 2011 Planning Horizon, there were 2,129 Hospice Service Area 7B resident non-cancer deaths (under the age of 65

years); at the statewide utilization rate of 21.23 percent, 452 of these residents would have been served by hospice. At the lower Hospice

Service Area 7B utilization rate of 15.45 percent, only 329 residents were actually served by hospice; 123 additional Hospice Service Area 7B residents should have benefitted from hospice but did not receive those

services. The applicant states that this lower level of service to non-cancer patients under the age of 65 years is not just a onetime event but

has been a consistent trend in Hospice Service Area 7B.

Percentage of Non-Cancer Patients Under the Age of 65 years Served by Hospice:

Hospice Service Area 7B and Florida Apr

2004 Oct

2004 Apr

2005 Oct

2005 Apr

2006 Oct

2006 Apr

2007 Oct

2007 Apr

2008 Oct

2008 Apr

2009 Oct

2009

7B 12.07% 12.15% 12.30% 11.97% 14.37% 16.32% 17.10% 17.38% 15.08% 15.27% 16.23% 15.45%

FL 15.98% 16.72% 16.85% 17.42% 19.01% 19.16% 19.26% 20.71% 20.49% 20.70% 21.04% 21.23%

Source: CON Application #10071, page 63

Odyssey states that Hospice Service Area 7B providers have consistently served a much lower percentage of patients under the age of 65 years who die from causes other than cancer, than would be expected from

2004 to the present, based on comparing the local utilization to the statewide average percentage of these patients served by hospice. The

applicant states that it is clear that this large and growing patient group of non-cancer patients under the age of 65 years and older has been consistently underserved by the current hospices‟, further demonstrating

that a special circumstance exists that warrants the approval of an additional hospice provider in Hospice Service Area 7B.


36

Odyssey proposes to locate its main hospice in Orange County and conditioned to establish a satellite office in Osceola County by the end of

the first year of operations. The 2009 total population of Hospice Service Area 7B accounts for 59 percent of District 7‟s population (1,420,611/

2,418,538). From 2009 to 2012 (the second year of operation for the proposed hospice program),the hospice service area population is projected to grow from 1,420,611persons in 2009 to 1,523,278 persons

in 2012; an increase of 102,667 persons or 7.2 percent. The percentage increase in total population is well above the growth rates for District 7 (6.2 percent) and the State of Florida (4.9 percent).

Odyssey states that the older age cohorts will experience a greater

percent increase in population than the younger age cohorts or the population as a whole. Osceola and Orange Counties are home to a significant proportion of persons age 65 and older: 45 percent of District

7‟s 65 years plus population lives in Orange and Osceola Counties. The hospice service area‟s population age 65 and older will increase by

18,414 persons (13.5 percent) between 2009 and 2012. With mortality rates directly tied to the age of a population, the Hospice Service Area 7B death forecast, based on total population growth with no reflection of the

higher elderly population growth rate can be expected to under-predict the actual number of 2009 deaths in the target Hospice Service Area 7B market.

Odyssey presents three market forecasts for the Hospice Service Area 7B.

The first is the Agency‟s need methodology which the applicant states is a conservative estimate of future market size due to its use of a forecasted 2011 cancer over age 65 and non-cancer over age 65 hospice

penetration rates that are lower than the July 2008 through June 2009 actual penetration rates observed in the local Hospice Service Area 7B. The second market forecast approach is a modification of the Agency‟s

methodology utilizing the July 2008 through June 2009 actual local Hospice Service Area 7B cancer and non-cancer over age 65 market

penetration rates along with the state of Florida July 2008 through June 2009 average penetration rates for cancer and non-cancer patients over age 65. With penetration rates consistently increasing over time and

forecast to continue to increase in the future, the applicant states that this is a reasonable and likely conservative approach to forecast future

market size. Odyssey states that this approach incorporates the assumptions that real need within the service area should assume that local penetration rates will not decline from current levels, and that

where the local market penetration rates are below statewide averages they will at least reach the Florida average level.

Odyssey‟s third methodology is based on a continuation of historic growth rates of hospice admissions in Hospice Service Area 7B through a

review of historic hospice volume data for Hospice Service Area 7B. The


37

service area‟s hospice admission growth rate has been relatively strong over the past five-year period. However, while consistent, the applicant

states it is important to note that during the most recent 2008-2009 timeframe, volume actually declined by 1.8 percent. Odyssey states that

this is opposite of what would be expected based upon a strong elderly population growth estimate in Hospice Service Area 7B. The three methodologies result in a forecast of between 5,431/ 5,561/ 5,876 total

hospice admissions for Hospice Service Area 7B by the second year of operation for the new services for +540/ +670/ +985 new incremental hospice admissions in Hospice Service Area 7B by the second year of

operation.

Odyssey states that during its first year of Medicare-certified operations, patient admissions are anticipated to be 229, with an average daily census starting at 3.0 ADC during the first month post-Medicare

certification growing to 41.5 ADC by the 12th month. Odyssey expects to have 445 admissions in year two with ADC growing from 45.0 to 83.5

ADC. Odyssey projects that the 229 year one (2011) admissions will result in Odyssey having only a 4.0 to 4.4 percent market share, while year two‟s (2012) 445 projected admissions will result in Odyssey having

only a 7.6 to 8.24 percent market share. The applicant states that it can reach its target volume levels without materially impacting the existing hospice providers within the market.

United Hospice of Florida, Inc. (CON #10072) states that while there is

projected net need for 484 additional hospice program admissions for the January 2011 planning horizon, all cohorts are currently underserved with the greatest numeric need in the two under 65 age cohorts cancer

and non-cancer. The applicant states that more than 36 percent of the projected need is within the under 65 age cohort while 32 percent of the need is within the cancer under 65 age cohort, representing 69 percent of

the projected need in the under 65 age cohort. The applicant states that for the 12 months ending June 30, 2009, there were 4,891 admissions to

hospice. Based on 2007 deaths, the subdistrict-wide hospice penetration rate is 60.4 percent. Using 2008 deaths of 8,248, the penetration rate is even lower, 59.2 percent.

United states that it has identified several patient populations in need of

increased awareness and access to hospice and has therefore committed to serving these patients. The applicant has identified the terminally-ill Hispanic population and patients with a terminally-ill non cancer

diagnosis as two underserved groups in Subdistrict 7B. The applicant states that Hispanics are the largest ethnic minority

population in the Hospice Service Area 7B and are underserved. Hispanics are less likely to seek and receive healthcare services, which

might contribute to their poorer health status and higher rates of


38

morbidity and mortality particularly at a younger age. The applicant states that Hispanics comprise 28.4 percent of the total Hospice Service

Area 7B, 25.1 percent in Orange County and 41.6 percent in Osceola County. The applicant states that in calendar year 2008, Hospice

Service Area 7B had 8,248 resident deaths. Of those, 1,342 or 16.3 percent were Hispanic; 954 Orange County residents and 388 residents of Osceola County. More than 14 percent of all Orange County deaths

were Hispanic and 25 percent of all deaths in Osceola County were Hispanic, resulting in a subdistrict average of 16.3 percent. Hispanics were 11.1 percent of the state total.

In order to further examine the extent to which Hispanic terminally-ill

residents have available and accessible hospice services, the applicant analyzed CY 2008, Osceola and Orange County hospital discharge data to determine the number of Hispanics discharged to hospice. Osceola

County hospitals discharged 337 patients to hospice; and of those discharges only 40 cases (11.9 percent) were Hispanic. United contends

that since approximately 25 percent of the Osceola County deaths were Hispanics, the two ratios should more closely align. The applicant states that while at least 25 percent of patients discharged to hospice from both

Florida Hospital Celebration and Florida Hospital Kissimmee were Hispanic, the other hospitals, Osceola Regional Medical Center and St. Cloud Regional Medical Center discharged less than nine percent of

Hispanic patients to hospice.

United states that to further analyze the Hispanic access issue it also analyzed oncology cases at each of the above hospitals to determine Hispanic patient discharges to hospice. The applicant states that only

1.3 percent of all Hispanic oncology patients in Osceola County hospitals were discharged to hospice whereas 13 percent of non-Hispanic oncology patients were discharged to hospice. However, United‟s chart shows

there were 45 or 43 total Hispanic oncology discharges and four were discharged to hospice, so the result is 8.89 or 9.3 percent. The table also

shows 45 (or 43) Hispanic oncology discharges and a total of 456 oncology discharges, so Hispanics are 9.87 (or 9.43) percent of the total. Regardless, Hispanic oncology discharges to hospice is slightly lower

than the 12.9 average for non-Hispanics. The applicant notes that it has a letter from St. Cloud Regional Medical Center CEO (zero Hispanic

oncology discharges to hospice) stating it will enter into appropriate contractual relationships to ensure hospice patients in need of inpatient care can receive services at its hospital.

The applicant states that “In CY 2008, Orange County hospitals discharged 4,442 oncology patients. Of those, 373 non-Hispanic patients

(8.4 percent) were discharged to hospice. In contrast, only 60 patients (1.4 percent) of all Hispanic oncology cases were discharged to hospice.”

However, the percentages provided are actually the number of non-


39

Hispanic patients divided by the total (373/4,442) resulting in 8.40 percent and the number of Hispanic patients divided by the total

(60/4,442) resulting in 1.4 percent. This does not demonstrate that 1.4 percent of all Hispanic oncology patients were discharged to hospice,

only that Hispanics account for 1.4 percent of the total oncology discharges. We do not know how many of the 4,442 patients were Hispanic. We do know that 60 Hispanic patients and 373 non-Hispanic

patients or 433 oncology patients were discharged to hospice. Sixty of the 433 oncology patients discharged to hospice or 13.86 percent were Hispanic. The applicant‟s chart on page 12 indicates that Hispanics

accounted for 14.2 percent of Orange County‟s 6,695 deaths during CY 2008. The applicant states it is committed to increasing awareness,

access and utilization of hospice service among terminally-ill Hispanic residents of both Orange and Osceola Counties.

United states that the greatest projected need for hospice services in Hospice Service Area 7B falls within the non-cancer patient population.

The applicant states that of the 484 projected gap in hospice admissions for the January 2011 batching cycle, 259 projected admissions or 54 percent of the total incremental need resides within the non-cancer

cohort. Of the 259 projected non-cancer admissions, 175 will be under 65 years while 84 will be 65 years or older. Of the 3,213 resident deaths in Hospice Service Area 7B that did not have the benefit of formal end-of-

life care, only 156 were cancer related; the remaining 3,057 (95.1 percent of total) were non-cancer related deaths. The applicant asserts that this

clearly reflects a gap in service of which it has extensive experience caring for the hospice needs of non-cancer terminally-ill non-cancer patients.

United states that it has experience in serving patients of all disease categories. Some of these include but are not limited to Alzheimer‟s

Disease, dementia, heart disease, HIV, failure to thrive, liver disease and pulmonary disease. The applicant‟s supporting Volume 2, Tab 21

included United‟s „indicator sheets‟ for the diseases listed in the preceding sentence which it states it uses and will use in Service Area 7B. United projects 192 admissions in year one and 450 in year two of

operations. The applicant states that only two of the four hospice programs have grown in admissions during the past year (Cornerstone

Hospice & Palliative Care and Hospice of the Comforter). The other Hospice Service Area 7B providers Samaritan Care Hospice and VITAS have decreased admissions by 31.5 percent and 17.1 percent

respectively.


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2. Agency Rule Criteria and Preferences

a. Rule 59C-1.0355(4)(e) Florida Administrative Code - Preferences for

a New Hospice Program. The Agency shall give preference to an applicant meeting one or more of the criteria specified in the below listed subparagraphs: (1) Preference shall be given to an applicant who has a

commitment to serve populations with unmet needs.

Catholic Hospice of Central Florida, Inc. (CON #10069) states it

has identified a large and growing Hispanic population in Hospice Service Area 7B that needs hospice services. The applicant states Catholic Hospice has developed a high level of knowledge, skill,

and expertise both in identifying, approaching and educating the Hispanic community regarding hospice care, as well as actually

delivering care to this population in an effective, culturally sensitive manner. The applicant states that notwithstanding this cultural knowledge and understanding regarding traditionally

Catholic groups, it will serve patients and families of all faiths and ethnicities. Catholic Hospice states that it has English and Spanish versions of virtually all of its patient, family , and

community communications materials and this will be replicated in central Florida. The applicant states that more than 70 percent

of its existing staff, both employees and volunteers is bilingual in English and Spanish. Catholic Hospice concludes that chaplains are required to complete chaplaincy training, known as Clinical

Pastoral Education (CPE) and that it is important to note that Catholic Hospice of Central Florida is guided by a set of principles set forth by the United States Conference of Catholic Bishops

known as Ethical and Religious Directives for Catholic Health Care Services.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) states that it seeks to serve the

unmet needs of the population eligible for hospice through a variety of approaches, each of which will seek to improve

awareness and understanding of benefits of hospice within a community. HospiceCare contends that it is also committed to offering ongoing staff and medical community education and

training programs designed to provide information, enhance services and expand understanding of hospice needs. The applicant lists the following as examples (and target audiences) of

HospiceCare‟s educational offerings in Service Area 7B include:


41

Pain Management

Cancer and the Caregiver

The Patient With Decreased Mobility

How to Talk to Patients and Their Families About Hospice

Spiritual care education (hospital nurse interns)

Advanced Directives seminars provided quarterly

Hospice Care: What is it all About?

HospiceCare contends its commitment to serving the unmet

hospice needs of the community will be expanded to Service Area 7B.

The applicant states that as part of Florida Hospital, it will benefit from existing outreach efforts to populations with unmet needs and discusses such program at Florida Hospital East Orlando

called Cuidate, which in Spanish means, “take care of yourself”. Cuidate targets a largely Hispanic population in east Orlando

which suffers from chronic diseases, including a high incidence of heart disease and diabetes. This population includes many residents who are uninsured and often seek health care in the

emergency room for their chronic conditions. The applicant states that the program will be staffed by a program manager, two health

care coordinators, and a Medicaid financial specialist. The program will utilize a chronic disease self management program from Stanford University which is recognized by the Centers on

Disease Control for its reduction in 30-day hospital readmission rates and return to hospital rates.

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida (CON #10071) states it has

committed to serve populations with unmet needs and the proposed project will address the special and not normal circumstances that exist within the Hospice Service Area: the

consistently underserved patient group cancer patients under the age of 65 years and; the consistently underserved non-cancer

patients under the age of 65 years. United Hospice of Florida, Inc. (CON #10072) states that the

most severely underserved patient population in Hospice Service Area 7B is the Hispanic community and re-states its earlier analysis. In this response the applicant states that 40 of the 337

patients discharged to hospice in 2008 from Osceola County hospitals were Hispanic which is 11.9 percent compared to

Hispanics accounting for approximately 25 percent of Osceola County‟s total deaths. The applicant states that health disparities


42

for Hispanics can mean a decreased quality of life, loss of economic opportunities and perceptions of injustice. Hispanics are less

likely to seek and receive health care services, which might contribute to their poorer health status and higher rates of

morbidity and mortality, particularly at a younger age. The applicant states that its Spanish outreach efforts will be

ongoing. The applicant states it will continually assess existing tools and obtain or develop new resources as needed to provide culturally meaningful and appropriate educational opportunities

for the Hispanic community. The applicant states it will provide ongoing comprehensive training for staff and volunteers who are

actively involved in the outreach program. The applicant states it is committed to increasing the awareness, access and utilization of hospice services amongst terminally-ill Hispanic residents of both

Orange and Osceola Counties.

(2) Preference shall be given to an applicant who proposes to provide the inpatient care component of the hospice program through contractual arrangements with existing health care

facilities, unless the applicant demonstrates a more cost-efficient alternative.

Catholic Hospice of Central Florida, Inc. (CON #10069) proposes to provide approximately 6.6 percent of its total patient

days to inpatients during the first two years of operation in Service Area 7B, consistent with its sister organization‟s experience in Service Areas 10 and 11. The applicant states that this level of

care is expected to require a total of 1,582 inpatient days of care for the second year of operation in the proposed program, or the equivalent of just over four inpatient beds. All inpatient care in

Service Area 7B is expected to be delivered through contractual arrangements with existing health care facilities. The applicant

states Catholic Hospice, Inc. is experienced in establishing inpatient relationships with hospitals and nursing homes and will assist Catholic Hospice in developing this capability. The applicant

states it has an email message from the manager of discharge planning at Osceola Regional Medical Hospital in Kissimmee,

Florida documenting their interest in working with the applicant on this issue. However, the email in question was not located within Catholic Hospice‟s application materials

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) states intent to contract with one or

more Florida Hospital facilities (Florida Hospital Orlando, Florida Hospital East Orlando, Florida Hospital Apopka, Winter Park

Memorial, Florida Hospital Kissimmee, and Florida Hospital


43

Celebration Health) and two Adventist Care Center skilled nursing facilities, all located in Hospice Service Area 7B, to provide

inpatient beds. Florida Hospital HospiceCare states it will provide inpatient care through contractual arrangements with existing

hospitals, skilled nursing homes, and assisted living facilities in Orange and Osceola Counties. The applicant states that it may also contract with non-Adventist hospitals and skilled nursing

facilities in the district to ensure that each patient served will have access to inpatient hospice care.

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida (CON #10071) proposes to use

existing licensed hospital and skilled nursing facility beds to serve patients in need of inpatient hospice services. Odyssey states it will contract with acute care providers and skilled nursing facilities

in Hospice Service Area 7B. The applicant asserts that it continues to have full support of the market and is currently

involved in ongoing discussions to obtain memoranda of understanding for general inpatient contracts and with other potential provider partners in Hospice Service Area 7B.

United Hospice of Florida, Inc. (CON #10072) proposes to have contractual agreements with nursing homes and hospitals, as well

as other health care providers designed to meet patient‟s needs in Hospice Service Area 7B. The applicant states that upon approval

it will establish inpatient agreements within the service area. The applicant states that the following have indicated a willingness to enter into contractual agreements with United Hospice upon

licensure: St. Cloud Regional Medical Center, Good Samaritan Society Health Care Center, Avante at St. Cloud Nursing and Rehab Center and Osceola Health Care Center. All facilities listed

are located within Osceola County. The applicant also states it anticipates the ability to also contract with other providers

including the Florida Hospital/Adventist Health System and Orlando Regional Healthcare System.

The applicant has letters of support from the aforementioned Osceola County facilities. However, only one of the four letters of

support indicates a willingness to contract for inpatient services (St. Cloud Regional Medical Center).

(3) Preference shall be given to an applicant who has a commitment to serve patients who do not have primary caregivers at home; the homeless; and patients with AIDS.

Catholic Hospice of Central Florida, Inc. (CON #10069) states it

has a history of and commitment to exceeding federal and state


44

licensure requirements, and to extending care to non-traditional elements of the service area population. The applicant states that

its commitment is specifically addressed in Catholic Hospice‟s Non-discrimination in Services Provided Policy, which specifies that

Catholic Hospice staff and volunteers: [S]hall not discriminate in providing services to patients because of race, creed, color, gender, orientation, national origin, age, qualified individual with a disability, military status, marital status, pregnancy, or other protected status. Catholic Hospice shall not discriminate in providing services to patients because of diagnosis or caregiver status. Catholic Hospice services shall seek to find placement, when possible for homeless patients. The applicant states it will adopt the same policy. Catholic

Hospice states that its open access approach to hospice care delivery will attempt to prevent denial or delays of admission to

hospice caused by restrictive admission criteria, caregiver status, diagnosis, type and nature of palliative treatments, refusal of a DNR order, complexity of care, site of care, reimbursement source

or cost of care. The applicant states its commitment to admit all patients who qualify for hospice care within its licensed service area, including homeless persons, persons without primary

caregivers, and persons with HIV and AIDS. The applicant states that Catholic Hospice does not keep records directly reflecting

homelessness or caregiver status, but these groups are being served in its current operations.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) states it does not discriminate against anyone seeking its services and has been committed to serve

patients who do not have primary caregivers at home, are homeless, and/or have HIV/AIDS. The applicant states that some

patients are unable to develop a caregiver network and may not be physically or mentally able to remain at home and receive hospice services. If a patient is unable to care for him/herself and has no

caregiver support, Florida Hospital HospiceCare may recommend that the patient enter an assisted living facility, nursing home, or

inpatient hospice facility. Florida Hospital HospiceCare‟s staff and volunteers will continue to provide hospice care in these settings. The applicant states that it is willing to work to establish

relationships with various nursing homes, assisted living facilities, and hospitals within the area. The applicant states it has a letter of support from Health Care Center for the Homeless.


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Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey

HealthCare of Central Florida (CON #10071) states it will provide services to all patients who meet the criteria for admission to

hospice. This will include patients who do not have a primary care giver at home, the homeless and patients with AIDS. Odyssey‟s non discrimination policy states:

Odyssey offers palliative care to terminally ill patients and support to those patients and their families without regard for diagnosis, gender, sexual orientation, national origin, race, creed, disability, age, place of residence or ability to pay. The applicant states that in the event a patient is impaired with physical problems that can no longer be managed at home, or if a

patient is homeless, the Odyssey nurse evaluates the patient for possible inpatient admission to a hospital or long-term care

facility. The applicant states it has a history in its other programs of demonstrating its commitment to servicing all patients.

United Hospice of Florida, Inc. (CON #10072) states it is committed to serving all residents, including homeless patients who do not have primary care givers at home and patients with

AIDS. The applicant states that its primary focus will be to enable patients to remain in the least restrictive and most emotionally

supportive environment possible. In the event a terminally-ill patient has no at-home support, the applicant states it will develop a plan detailing the means by which the daily care and safety

needs of the patient will be met. United Hospital will make every effort to assist patients in developing a caregiver network from among neighbors, nearby relatives, friends, church groups, sitter

services and volunteer organizations. If a patient is not able to care for him/herself, has no caregiver support group or is

homeless, the applicant states it may recommend placement in an assisted living facility or nursing home. The applicant states it will institute a program to ensure terminally-ill individuals with HIV

have access to hospice services. Staff will be trained in infection control and exercise precautionary measures.

(4) In the case of proposals for a hospice service area comprised

of three or more counties; preference shall be given to an

applicant who has a commitment to establish a physical presence in an underserved county or counties.

Hospice Service Area 7B consists of two counties, Orange and Osceola. This criterion is not applicable to this review.


46

(5) Preference shall be given to an applicant who proposes to provide services that are not specifically covered by private

insurance, Medicaid, or Medicare.

Catholic Hospice of Central Florida, Inc. (CON #10069) states that it currently offers a variety of services that are not covered by private insurance, Medicaid, or Medicare, and will continue to do

so in the proposed program. Working together with community service organizations and accessing donated funds, Catholic Hospice states that it provides care to those people who are not

served by traditional medical entities. This would include individuals with too many assets to qualify for Medicaid, who are

not old enough to qualify for Medicare, whose health insurance company dropped them when they could no longer work and had little cash to carry them through their health care crisis. The

applicant states that specific non-covered services include:

Bereavement and Grief Support Programs (available to all service are residents regardless of any relationship to Catholic

Hospice)

Wishes Granted Program, which serves as an extension of our

mission. We have learned through the many years that our patients and families often have unique requests that, if met,

could have a significant impact on our patients‟ quality of life, and the potential to create profound memories for the surviving family members. Some of the requests that we have received

have involved cleaning a home or so our patient can proudly welcome visitors, to providing transportation and arranging an

outing to our patient‟s favorite restaurant so the patient and family can celebrate their family unit, often for the last time, and rekindle the feeling of “how things used to be” before the

patient received a terminal diagnosis.

Music Therapy

Pet Visitor Program

Supportive counseling or consultation with patients or families addressing issues of serious illness even if they do not qualify

for a hospice benefit.

Non-health care related services such as homemaker services

and errands, as well as minor purchases to foster quality of life and maintenance at home, such as telephone installation and

service or wheelchair ramp installation.


47

Recruitment, training, and use of volunteers to augment

Catholic Hospice‟s capabilities.

Services to citizens of other countries residing in our service area if they have no hospice coverage.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital

HospiceCare, Inc. (CON #10070) states that it has developed a number of services that fall outside any insurance coverage when developing their hospice program for other counties in Florida,

such as bereavement services. HospiceCare states community services that will be provided at no charge to recipients include community hospice education, volunteer services, programs geared

toward the Hispanic population, community resource information web site, community advisory board, special wish fund, clinical

pastoral education, medical education and palliative care programs. The applicant restates its conditions listed in the project summary.

HospiceCare projects a total of 1.5 percent of its patient revenues

will be charity patients. Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey

HealthCare of Central Florida (CON #10071) states it will provide services that are not specifically covered by private insurance, Medicaid or Medicare. These services include: pet, music,

massage, and aroma therapies, dialysis, palliative radiation, and palliative chemotherapy treatments. The applicant states that

while the importance of vast resources of a national provider should not be underestimated, neither should the ability of the provider to identify and respond to the unique needs of the local

community. The applicant contends that it consistently creates programs and services to meet the needs of the local community,

even if the needed programs and services are not reimbursable. United Hospice of Florida, Inc. (CON #10072) states it will serve

all medically qualified patients who meet the state/Medicare definition of “terminally-ill” who select the hospice care alternative. Any decision to stop or limit hospice care must come from the

patient or family or the physician. The applicant states that in fiscal year 2009 it provided more than $223,000 in unfunded care.

The applicant states it is willing to accept any such conditions on its CON based on any representations made throughout its application. The applicant states it will provide all required core

components of hospice care set forth by Medicare conditions of participation as well as Florida hospice licensure requirement


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including the provision of all four levels of service (routine, continuous care, general inpatient and respite) to all types of

patients without regard to race, ethnicity, gender, age, religious affiliation, diagnosis, financial status, insurance status or any

other discriminating factor.

b. Chapter 59C-1.0355, Florida Administrative Code contains the

following general provisions and review criteria to be considered in reviewing hospice programs.

(1) Required Program Description (Rule 59C-1.0355(6), Florida Administrative Code): An applicant for a new hospice program

shall provide a detailed program description in its certificate of need application, including:

(a) Proposed staffing, including use of volunteers.

Catholic Hospice of Central Florida, Inc. (CON #10069) states that its staffing ratios are based upon its sister organization Catholic Hospice Inc.‟s current operations in its

existing service areas. The applicant states that year one calls for hiring 22.72 FTEs to fully staff the planned new office and care team and that year two staff will increase by

24.28 FTEs primarily in direct care categories. Total FTEs would be 47.00 based on this response. However, Schedule

6A shows year one 23.37 FTEs and year two will increase by 28.98 FTEs, for a total of 52.35 FTEs.

The applicant lists the following as its staffing standards for year one of operations: 1.0 FTE volunteer coordinator/ community education, 2.04 FTEs RNs, 2.80 FTEs hospice

aides, 0.50 FTE chaplain, 0.50 FE social worker (MSW), 1.00 FTE secretary, 0.50 FTE bereavement counselor, 0.00 FTE

hospice physicians will be contracted, 3.10 FTEs continuous care LPNs, 2.53 FTEs continuous care hospice aides, 1.00 FTE team manager (RN), 0.40 FTE hospice medical director,

2.00 FTEs on-call RNs and LPNs (runners), 1.00 FTE admissions nurse, 1.00 FTE hospice administration, 3.00

FTEs hospice representative and 1.0 FTE human resources coordinator. The applicant does not provide FTE for dietary counseling, which is required by statute.

The applicant states that volunteers are not included in its Schedule 6 staffing detail; however, it will vigorously recruit,

train, and use volunteer staff in the proposed program.


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Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) states that trained members of

an interdisciplinary team will be comprised of nurses, physicians, social workers, chaplains, home health aides and

volunteers. The applicant‟s Schedule 6A accounts for a total of 22.75 FTE‟s dedicated to serving the program in year one and 29.85 FTE‟s in year two. The schedule indicates 1.0

FTEs for volunteer services for year one and year two. The applicant provides 0.50 FTE for dietary counseling for both years one and two, which is required by statute. The

applicant states that Dr. John Steely will serve as the initial medical director and will assist in recruiting a designated

medial director for Service Area 7B. Dr. Steely‟s Curriculum Vitae is in the application‟s attachment Q.

HospiceCare states volunteers will be trained to provide respite, companionship, transportation, supportive visiting,

homemaking, sharing of special talents, and bereavement support. Some volunteers and groups of volunteers may participate in fundraising activities and volunteers will be

supervised by a designated staff member. The applicant commits to a minimum of 10 percent of its hours of care will be provided by hospice volunteers in its second year of

operations. This is twice the five percent requirement mandated under the Medicare program and the 10 percent

commitment is conditioned by the applicant. Odyssey HealthCare of Collier County, Inc. d/b/a

Odyssey HealthCare of Central Florida (CON #10071) states it will provide each patient and family with a “Circle of Care”; an interdisciplinary team of its employees and the

patient‟s physician dedicated to providing a high-level of care and assistance to patients and their families as designed and

in sue by Odyssey. The applicant proposes to provide 17.7 FTEs for year one and 29.3 FTEs for year two of operations. Schedule 6 provides the following staffing ratios: 3.0 FTEs

community relations rep, 1.0 FTE general manager, 0.10 FTE admissions coordinator, 1.0 FTE office manager, 1.0

FTE receptionist, 1.0 FTE patient care manager, 0.10 FTE medical director, 4.2 FTEs RNs, 0.50 FTE LPNs, 2.6 FTEs HHAs, 0.50 FTE director of patient care services, 0.80 FTE

bereavement coordinator, 1.0 FTE volunteer coordinator, 0.10 FTE dietician, and 0.80 FTE medical social worker. In year two of operations the applicant proposes 2.8 FTEs

community relations rep, 1.0 FTE general manager, 0.9 FTE admissions coordinator, 1.0 FTE office manager, 0.3 FTE

receptionist, 1.3 FTEs patient care manager, 1.2 FTEs


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patient care sec/med records coordinator, 0.1 FTE medical director, 7.3 FTEs RNs, 1.5 FTE LPNs, 6.2 FTEs HHAs, and

0.5 FTE admission RN/field coordinator, 0.8 FTE bereavement coordinator, 1.3 FTEs spiritual care

coordinator, 0.5 FTE volunteer coordinator, 0.8 FTE manager continuous quality improvement, 0.1 FTE dietician and 1.8 FTEs medical social worker.

United Hospice Florida, Inc. (CON #10072) states that in year one it will have 16.07 FTEs increasing to 39.29 FTEs in

year two. In both years one and two there will be one volunteer half-time. The applicant states this will increase

with census. Schedule 6 reflects the following staffing ratios: 1.0 FTE administrator, 1.0 FTE director of nursing, 0.50 FTE volunteer, 2.0 FTEs administrative support, 1.0 FTE

chaplain, 2.0 FTEs hospice representative, 2.5 FTEs RNs, 0.49 FTE LPN, 3.33 FTEs nurse‟s aides, 1.0 FTE dietician

and 1.25 FTEs social services director in year one. Year two FTEs consist of: 1.0 FTE administrator, 2.0 FTEs director of nursing, 1.0 FTE volunteer, 2.0 FTEs administrative

support, 1.92 FTEs chaplain, 3.0 FTEs hospice representative, 7.08 FTEs RNs, 4.18 FTEs LPNs, 12.36 FTEs nurses‟ aides, 1.0 FTE on call nurse, 1.0 FTE dietician and

2.75 FTEs social service director.

(b) Expected sources of patient referrals.

Catholic Hospice of Central Florida, Inc. (CON #10069)

states that based upon the experience of Catholic Hospice management, it expects to receive 40 percent of referrals from physicians, 20 percent from patient family or friends,

10 percent long-term care facilities and 30 percent hospitals.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) states that referrals will be received from the following sources: hospitals, physicians,

nursing homes, assisted living facilities, home health agencies, patient self-referrals, families and friends,

managed care companies, and faith communities. Odyssey HealthCare of Collier County, Inc. d/b/a

Odyssey HealthCare of Central Florida (CON #10071) states it will actively seek referrals throughout the community and anticipates the referrals will originate from

physicians, long-term care facilities, hospitals, patients/patient families, managed care companies and

insurance companies. The applicant states it is in the


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process of obtaining memoranda of understanding for general inpatient contracts from local Hospice Service Area

7B providers.

United Hospice of Florida, Inc. (CON #10072) asserts that due to the area‟s immense need for hospice services and the quality of care it provides, attracting patients will not be

difficult. The applicant anticipates referrals from physicians, hospitals, nursing homes and other health care providers, family members and patients themselves. The applicant also

has an agreement for willingness to contact for inpatient services from St. Cloud Regional Medical Center.

(c) Projected number of admissions, by payer type,

including Medicare, Medicaid, private insurance, self-

pay, and indigent care patients for the first two years of operation.

The table below is provided to illustrate projected admissions for years one and two for each applicant.

Total Projected Admissions By Applicant

for Years One and Two CON # Applicant Year One Year Two

10069 Catholic Hospice 161 413

10070 Florida Hospital Hospice 280 410

10071 Odyssey HealthCare 229 445

10072 United Hospice Florida 192 450 Source: CON Application #’s 10069, 10070, 10071, and 10072.

Catholic Hospice of Central Florida, Inc. (CON #10069) provided the following table illustrating its projected number of admissions by payer type for the first two years of

operation.

Projected Number of Admissions by Payer Type For Catholic Hospice of Central Florida, Inc.

Service Area 7B Payer Type Year One Year Two

Medicare 120 307

Medicaid 12 30

Private Insurance 19 50

Self-Pay/Indigent 10 26

Total 161 413 Source: CON Application #10069, page 35.

The applicant projects Medicare will comprise 75.0 percent of admissions, Medicaid 7.0 percent and indigent/self-pay

6.0 percent during the first two years of operations.


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Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070): The following table delineates

the number of admissions by payer type for the first two years of operation.

Expected Admissions by Payer Type

Florida Hospital HospiceCare


Medicare 238 349

Medicaid 11 16

Private Insurance 22 33

Self-Pay/Indigent Care 9 12


As shown in the table above, the applicant intends to serve 280 and 410 patients in its first and second year of

operation respectively. It is noted that the applicant‟s provision of Medicare will comprise 85.0 percent of

admissions, Medicaid 3.9 percent and self-pay/indigent care 3.2 percent during the first two years of operations.

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida (CON #10071):

The following table illustrates the number of admissions by payer type for the first two years of operation.

Odyssey HealthCare of Central Florida

Projected Admissions by Payer Type


Medicaid 7 13

Medicare 213 414

Commercial/Charity/Other 9 18


As shown in the table above, the applicant intends to serve 229 and 445 patients in its first and second year of operation respectively. It is noted that the applicant‟s

provision of Medicare will comprise 93.0 percent of admissions, Medicaid 3.1 percent year one and 2.9 percent

year two and commercial/charity/other 3.9 percent during year one and 4.0 percent for year two of operations.

United Hospice of Florida, Inc. (CON #10072): The following table illustrates the number of admissions by payer

type for the first two years of operation.


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Projected Payer Source for Admissions

United Hospice of Florida, Inc.


Medicare 178 416

Medicaid 10 23

Indigent 2 4

Insurance/Managed Care/Other 3 7


As shown in the table above, the applicant intends to serve

192 and 450 patients in its first and second year of operation respectively. It is noted that the applicant‟s provision of Medicare will comprise 92.7 percent of

admissions year one and 92.4 percent in year two, Medicaid 5.2 percent year one and 5.1 percent year two, indigent care 1.0 percent year one and 0.90 percent year two and

insurance/managed care/other 1.6 percent during the first two years of operations.

(d) Projected number of admissions, by type of terminal

illness, for the first two years of operation.


provided the following table illustrating the projected number of admissions by type of terminal illness for the first two years of operation.

Projected number of Admissions by Diagnosis

For Catholic Hospice of Central Florida, Inc.

Service Area 7B Disease Year One Year Two

Cancer 67 173

Non-Cancer 94 240


The applicant projects to serve 161 patients in year one and

413 patients in year two. Memorial Hospital Flagler, Inc. d/b/a Florida Hospital

HospiceCare (CON #10070) provided the following table illustrating the projected number of admissions by type of

terminal illness for the first two years of operation.


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Florida Hospital HospiceCare


Cancer 98 150

AIDS 2 4

COPD 20 30

End Stage Renal Disease 8 13

Congestive Heart Failure 30 45

Other 122 168


The applicant projects to serve 280 patients in year one and

410 patients in year two. Odyssey HealthCare of Collier County, Inc. d/b/a

Odyssey HealthCare of Central Florida (CON #10071) provides the following table for the projected number of

admissions by payer type.

Projected number of Admissions by Diagnosis Odyssey HealthCare of Central Florida


Cancer 71 138

Alzheimer‟s Dementia 32 62

Congestive Heart Failure 39 76

COPD 21 40

Debility 27 53

End Stage Renal Disease 7 13

Liver/Other 32 63


The applicant projects to serve 229 patients in year one and 445 patients in year two.

United Hospice of Florida, Inc. (CON #10072) provides the following table for the projected number of admissions by payer type.


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Cancer 58 135

HIV/AIDS 7 11

Respiratory 17 46

Cardiac 28 74

Renal Failure 10 28

Alzheimer/Cerebral Degen. 20 55

Cerebrovascular/Stroke 30 56

Other 22 45


The applicant projects to serve 192 patients in year one and 450 patients in year two.

(e) Projected number of admissions, by two age groups,

under 65 and 65 or older, for the first two years of

operation.

Catholic Hospice of Central Florida, Inc. (CON #10069) provides the following table for the projected number of admissions by age cohort.

Projected Admissions by Age Group for

Catholic Hospice of Central Florida, Inc.

Service Area 7B Under 65 Over 65 Total

Year One 67 125 192

Year Two 93 320 413 Source: CON Application #10069, page 36.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) projects 280 admissions in its

first year of operations and 410 in the second year. The projected number of admissions by age groups under 65 and

over 65 appears in the following table.

Projected Admissions by Age Group for Florida Hospital HospiceCare


Year One 98 182 280

Year Two 143 267 410 Source: CON Application #10070, page 52. Odyssey HealthCare of Collier County, Inc. d/b/a

Odyssey HealthCare of Central Florida (CON #10071) provides the following for the projected number of

admissions by age cohort.


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Projected Admissions by Age Group for Odyssey Health Care of Central Florida


Year One 23 206 229


United Hospice of Florida, Inc. (CON #10072) provides the

following as the projected number of admissions by age cohort.

Projected Admissions by Age Group for



Year One 38 154 192


(f) Identification of the services that will be provided

directly by hospice staff and volunteers and those that

will be provided through contractual arrangements.

The hospice care team shall directly provide the following core services: nursing services, social work services, pastoral or counseling services, dietary counseling, and bereavement

counseling services. Physician services may be provided by the hospice directly or through contract. A hospice may also use contracted staff if necessary to supplement hospice

employees in order to meet the needs of patients during periods of peak patient loads or under extraordinary

circumstances. Catholic Hospice of Central Florida, Inc. (CON #10069)

states that the core services will be provided by the hospice staff and volunteers, in addition to homemaker and chore

services. Other services, such as physical therapy, occupational therapy, speech therapy, respiratory therapy, pharmacy services, medical supplies, durable medical

equipment, patient transportation services and fusion therapy will be provided through contractual agreement.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) states that it will provide

directly by hospice staff or volunteers the following: routine home care, continuous care, physician services, bereavement services, hospice aide services, medical social services,

dietician services, volunteer services; spiritual counseling


57

services, and patient and family education support. The following services are stated by the applicant as available on

a contractual basis as needed: therapy services (physical, occupational and speech), clinical pharmacist, and inpatient

services and respite services. Odyssey HealthCare of Collier County, Inc. d/b/a

Odyssey HealthCare of Central Florida (CON #10071) states that with the exception of physicians and a minimal level of contract care provided by physical, speech or

occupational therapist, the vast majority of hospice services will be provided by the hospice care team, including

volunteers. The case manager of each interdisciplinary team will be a registered nurse who assesses the needs of the patient and family and develops a specific plan of care with

the physician. The applicant states that all case managers are registered nurses who coordinate care with others on the

team while the patient‟s physician works with the hospice‟s medical director and other team members to assure that the symptoms are controlled, pain is managed and the patient

and family are informed. Odyssey‟s interdisciplinary team includes a home health aide, chaplain, social worker, volunteers, bereavement counselor and on-call nursing

team. When needed, additional contracted services such as physical, speech, or occupational therapies are determined

on an individual basis by the interdisciplinary team in consultation with the patient, family and attending physician.

United Hospice of Florida, Inc. (CON #10072) states that all core services including physician services, nursing, social

work, pastoral counseling, bereavement and dietary counseling will be provided for by United Hospice of Florida

staff and volunteers. Complimentary services such as massage therapy, pet therapy and aroma therapy will be provided by United Hospice staff and volunteers as well. The

applicant states it will contract for certain services as needed. Durable medical equipment, pharmacy services,

rehabilitation and certain clinical services will all be contracted through United‟s family of companies.

(g) Proposed arrangements for providing inpatient care. Catholic Hospice of Central Florida, Inc. (CON #10069)

expects to provide approximately 6.6 percent of its total patient days to inpatients during the first two years of

operation in Service Area 7B, consistent with its sister


58

organization‟s experienced in Service Area 10 and 11. The applicant states that all inpatient care in Service Area 7B is

expected to be delivered through contractual arrangements with existing health care facilities.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) intends to provide inpatient

care through contractual arrangements with existing hospitals and skilled nursing homes in Orange and Osceola Counties. HospiceCare states that contracts for inpatient

care needed by hospice patients will be provided by one or more of the six Florida Hospital facilities in the Service Area

7B – Orlando, East Orlando, Apopka, Kissimmee, Celebration Health, and Winter Park. The applicant states that may also contract with various other hospitals in the

district to ensure that each patient served will have access to inpatient hospice care.

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida (CON #10071)

states that it will arrange for providing inpatient care through contractual arrangements with hospitals, nursing homes and other appropriate settings. The applicant states

it is in the process of obtaining memoranda of understanding for general inpatient contracts from local Hospice Service

Area 7B providers. The applicant states it will establish arrangements with local nursing homes and/or adult congregate living facilities to ensure that patients in these

types of facilities can remain in their “home” and receive the appropriate level of hospice services the care setting allows.

United Hospice of Florida, Inc. (CON #10072) states its intent to have contractual arrangements with nursing homes

and hospitals designed to meet patient needs in service area 7B. The applicant states this is the most cost-efficient alternative as the inpatient and respite needs of these

patients can be easily met by existing hospital and nursing home facilities. United Hospice has an agreement for

willingness to contract for inpatient services with St. Cloud Regional Medical Center.


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(h) Proposed number of inpatient beds that will be located in

a freestanding inpatient facility, in hospitals, and in nursing homes.

None of the applicants intend to provide inpatient beds in a freestanding hospice facility. However, Catholic Hospice

provided the percentage of total patient days anticipated to be devoted to inpatient care, 6.6 percent which will result in a low average daily inpatient census of about 1.5 during year

one and just over four in year two. None of the other applicants have provided the numbers of expected inpatient

beds in hospitals or nursing homes but all propose to contract for inpatient beds with existing providers.

(i) Circumstances under which a patient would be admitted to an inpatient bed.

Catholic Hospice of Central Florida, Inc. (CON #10069) states that patients are admitted to an inpatient bed

according to the guidelines set forth in the federal Medicare guidelines for hospice inpatient care. At the patient‟s request and with their physician‟s order, patients are

admitted for management of severe pain and symptom management related to end-stage dying process, or medical

crisis. In addition to the general admissions criteria, admission to a Catholic Hospice general inpatient bed will be based on one or more of the following acute care admissions

criteria: pain control, symptom control, imminent death, short-term medical or surgical procedures or therapies aimed at palliation of symptoms and provision of a safe and

supportive environment to the terminally ill individual during periods of acute psychosocial and/or spiritual

breakdown of primary caregiver(s). The applicant states that when admitting a person to the inpatient component of care, it will assure that the inpatient services are arranged,

administered, and managed in a manner so that to provide privacy, dignity, comfort, warmth, and safety to the

terminally ill patient and his or her family. Memorial Hospital Flagler, Inc. d/b/a Florida Hospital

HospiceCare (CON #10070) states that short-term inpatient hospice care will be provided to manage symptoms such as acute pain that cannot be adequately managed at home.

The applicant states it provides most hospice services to patients in their homes and the interdisciplinary team

frequently evaluates patients to determine the continued


60

need for inpatient care. The applicant states that inpatient care is also appropriate temporarily for emergency situations

in which the caregiver is unable to provide the patient with skilled care at home (for instance, sudden illness/

impairment/death of primary caregiver). HospiceCare contends that to meet the need for inpatient care, it will contract with hospitals and nursing homes in Service Area

7B. Odyssey HealthCare of Collier County, Inc. d/b/a

Odyssey HealthCare of Central Florida (CON #10071) states that inpatient care is dictated by a patient‟s medical

need. If possible, symptoms are addressed and care is provided in the patient‟s home setting. Patients are encouraged to seek the level of care with which they are

most comfortable, including inpatient hospice care. The applicant states that in order to meet this need it will secure

inpatient contracts with hospitals and nursing homes in Hospice Service Area 7B. However, Odyssey explains that it strives to allow the patient to remain in the home setting at

all times and is committed to providing continuous care to minimize the need to utilize inpatient care.

United Hospice of Florida, Inc. (CON #10072) states that short term inpatient hospice care may be indicated or

required when the patient‟s condition or disease progression must be closely monitored in order for pain and symptom control to be managed. Hospice patients may be admitted if

their pain and other medical symptoms cannot be managed adequately at home. United Hospice states that it has budgeted this application to provide 2.5 percent of its total

annual patient days by the end of year two to continuous care services.

(j) Provisions for serving persons without primary

caregivers at home.


states that for those patients without a suitable primary caregiver at home, an appropriate caregiver network will be sought from among neighbors, nearby relatives and friends

who are capable of providing the necessary amount of supervision and assistance to the patient within the patient‟s or caregiver‟s home. If there are too few qualified caregivers

available to guarantee the safety of the patient, or if 24-hour care giving is required, qualified sitter services may be

recommended to the patient/family in order to keep the


61

patient in the home. Alternatively, placement in an assisted living environment or nursing home may be appropriate in

some cases, and would be arranged by the applicant through its relationships with ALFs and nursing homes in the area.

The applicant states that it would also seek temporary residential placement at one of the area shelters as appropriate.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) states an objective for every

patient to be able to remain in the least restrictive and most emotionally supportive environment possible. It is also

stated that patients who have no support at home will receive increased support from the hospice staff and volunteers whenever possible. The HospiceCare team will

help each patient without a caregiver develop a plan of care that may include the patient‟s network of friends, family,

neighbors, and other members of the community to help assist them and remain in their home.

For those hospice patients that are unable to develop a caregiver network and are not physically or mentally able to remain at home, HospiceCare states it may recommend that

the patient enter an assisted living facility, nursing home, or inpatient hospice facility and hospice care will continue to be

provided by hospice staff and volunteers. Odyssey HealthCare of Collier County, Inc. d/b/a

Odyssey HealthCare of Central Florida (CON #10071) states that it will provide services to all patients who meet the criteria for admission to hospice. This includes patients

who do not have a primary care giver at home, the homeless and patients with AIDS. The applicant states that in the

event a patient is impaired with physical problems that can no longer be managed at home, or the patient is homeless, the patient will be evaluated for possible inpatient admission

to a hospital or long-term care facility.

United Hospice of Florida, Inc. (CON #10072) asserts that its primary focus will be to enable patients to remain in the least restrictive more emotionally supportive environment

possible. Upon admission, the patient will be asked to designate a primary caregiver. In the event that the terminally-ill patient has no at home support, the applicant

states it will develop a plan detailing the means by which the daily care and safety needs of the patient will be met. United

Hospice states it will make every effort to assist patients in


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developing a caregiver network from among neighbors, nearby relatives, friends, church groups, sitter services and

volunteer organizations. If the patient is not able to care for him/herself and has no caregiver support group, United

Hospice may recommend placement in an assisted living facility or nursing home.

(k) Arrangements for the provision of bereavement services. Catholic Hospice of Central Florida, Inc. (CON #10069)

states that support begins at the time of admission and continues through least 13 months post-death for the family

members and friends of Catholic Hospice patients. Catholic Hospice patients and significant family members and other caregivers will be assessed for grief and bereavement needs

before and after the patient's death. During the comprehensive assessment of the patient, an initial

bereavement assessment will be conducted to determine the cultural, social and spiritual factors that may affect the ability of family members or other involved individuals to

cope with the patient's death. Findings from the initial bereavement assessment are incorporated into the patient's plan of care, as well as the bereavement care plan developed

for identified affected individuals following the patient's death. Throughout the course of the patient's care,

members of the interdisciplinary team reassess, document and address the needs of the patient, family, caregivers and significant others.

After the patient's death, contacts with family and the primary caregiver are made by the patient's nurse, social

worker, chaplain, or bereavement counselor or coordinator as appropriate to assess the affected individuals and their

needs and desires. Grief support services range from individual and group counseling and support, to telephonic and written support. At 30 days after the death, the

bereavement coordinator sends the family a letter reiterating the scope of grief support available to them.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) states it provides bereavement

services both to the families of its patients and the families in the community. HospiceCare states intent to reach out to the community and offer families the opportunity to work

through the grief process by providing them with the necessary tools, resources, and support for healing.


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HospiceCare indicates that it makes one-on-one counseling available for those that need extra help with the grief

process. This counseling is short-term and specific to the bereavement need. As part of the continuum of care

provided by HospiceCare, these programs not only enhance the life of the community, but also provide points of access to other hospice services. HospiceCare states many persons

served by these programs have no relationship to a hospice patient, but have been affected by caregiver or loss issues.

HospiceCare also provides counseling for staff at any agency (schools, businesses, hospitals) that requests help with

bereavement issues. Bereavement support is provided to HospiceCare staff and volunteers, who face their own grieving process following the deaths of their patient or if one

of their own family members dies.

If approved to provide hospice services in Orange and Osceola Counties (Hospice Service Area 7B), HospiceCare states intent to work with the local community to identify

needs and offer a range of programs based on community input. These services will be modeled after the bereavement programs HospiceCare currently offers in Flagler and Volusia

Counties (Hospice Service Area 4B).

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida (CON #10071) states it will continue to care for the family even after the

patient‟s death. Odyssey‟s bereavement services begin with the initial assessment upon admission of the patient. Odyssey offers condolence correspondence, written

materials, articles, and resources, one on one counseling, bereavement letters, grief support groups, memorial services

and holiday bereavement program. Odyssey offers “Sky Camp” which is a free weekend camp for children ages 7 to 17 grieving the death of a loved one. Finally, specific to non-

traditional bereavement resources associated with the project, Odyssey has conditioned its application to include

0.5 FTE staff resources for development of community bereavement services and the facilitation of a Florida-based Children‟s Bereavement Camp modeled after its existing SKY

Camp. United Hospice of Florida, Inc. (CON #10072) states that

bereavement counseling will be provided by a staff social worker or chaplain with an emphasis on patient and family

support with maximum utilization of community resources.


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Bereavement and grief counseling will be offered to family members, significant others and other loved ones identified

in the bereavement plan of care for a minimum period of up to 13 months after the patient‟s death or longer if needed

due to complex grief issues. Core grief services to be offered by United Hospice include: home visits, bereavement group activities, volunteer support, patient/family education

materials, quarterly follow-up/correspondence, memorial gatherings, sympathy cards, assistance with memorial services, community resources and referrals, staff

bereavement support and community education/relations. United Hospice also offers Camp Cocoon, a three-day

bereavement camp for 60 children ages 5 through 17 held each supper in north Georgia, typically during the first week of August.

(l) Proposed community education activities concerning

hospice programs. Catholic Hospice of Central Florida, Inc. (CON #10069)

states its commitment to providing community education activities regarding hospice services to residents of Service Area 7B, and will tailor its program to address community

needs. Community education activities will include educational programs offering an overview of the goals,

objectives and philosophy of hospice care, educational seminars and support groups for caregivers and family members. The applicant states that it plans to offer

presentations to the general public free of charge on topics such as alternative care, seasons of grief, companionship in dying, wills and trusts and wise use of over-the-counter

medications. Catholic Hospice also plans to make available a training class entitled, an introduction to hospice, which

will be open to the public. The applicant states it will also provide training and education to the public that includes information on the following topics: what is hospice care;

who is eligible for hospice services and its costs; quality of life for the terminal patient; coping with loss; progression of

terminal illness-what to expect and how to act; the important role of family and friends; what is the difference between home care and hospice; the role of grief and its expression as

a part of life; and progression of grief. Memorial Hospital Flagler, Inc. d/b/a Florida Hospital

HospiceCare (CON #10070) estimates that in 2008 alone, HospiceCare likely “touched” almost 800,000 residents in

Service Area 4B with the message of hospice, through


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various modalities such as health fairs, small group lectures, and educational presentations at local colleges, newspaper

coverage, and radio interviews. The applicant states it partners with other hospice agencies in the area to provide

superior educational presentations on care giving, grief, and bereavement. Networking with these agencies is stated to create a strong presence and promotes education and

awareness. HospiceCare states it provides community, consumer and

professional education services as a part of its mission to serve everyone in the community affected by life-limiting

illness, care giving and bereavement. Educational programs are stated to be a way of supporting all people anticipating and experiencing illness, care giving, or bereavement.

Several educational topics available to patients and their families include booklets, readings, journals, etc.

As part of its proposed plan for community education, the applicant states it will develop medical education programs

for medical staff members who maintain privileges at Florida Hospital facilities Service Area 7B. Hospice organizations have made concerted efforts to improve physician education

on hospice benefits to patients and their families. HospiceCare will work with their Florida Hospital partners to

provide training both within Florida Hospital facilities and at medical staff meetings. Several goals of this training and education are:

• Increasing the physician‟s comfort level in discussing

hospice referrals with patients and families.

• Understanding the characteristics of hospice care – so that physicians become familiar with how hospice is an

alternative to inpatient hospital or home health services for providing care to terminally-ill patients.

• Reviewing the interdisciplinary approach of hospice – so

that physicians understand the interdisciplinary approach and role of team members by discipline and the

array of services available to meet the physical, spiritual, and emotional needs of patients and their families.

• Dealing with cultural “objections” to hospice care –

physicians learn and understand how to address concerns that may be voiced by diverse populations regarding the use of hospice care.


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HospiceCare states it has found that providing education about hospice to employed physician groups, emergency

room physicians and hospitalists, as well as discharge planners, case managers, and other clinical staff, is a

particularly effective way to identify non-cancer patients who are medically eligible for hospice services.

The applicant further states it is developing a community resource information web site targeted at hospice education. This educational site is stated to include various lay and

professional education pieces related to chronic illness, death, dying, and bereavement. Patients and their families

will be able to access this site and educate themselves in regards to hospice care and the options available for end-of-life care.

Odyssey HealthCare of Collier County, Inc. d/b/a

Odyssey HealthCare of Central Florida (CON #10071) states that it will implement a community education plan designed to address the specific needs of the local residents

and local patient referral sources in the market area and to promote the quality, responsive and comprehensive service that Odyssey will provide to patients and their families.

Odyssey will conduct local educational campaigns that promote hospice care and seek to increase public awareness

of hospice care. Frequently requested topics of education include: hospice and Medicare regulations; pain management, advance directives, personal perspectives on

dying, grief and loss, symptom management, Alzheimer‟s Disease and hospice, is my patient appropriate for hospice, and stress management. Odyssey states it has

comprehensive orientation programs for each of these interdisciplinary team members, including clergy.

United Hospice of Florida, Inc. (CON #10072) states that it will provide extensive community education activities

surrounding the benefits of hospice to increase hospice awareness and utilization. United Hospice representatives

will educate nursing home and assisted living facility constituents on the myths and benefits of hospice. United states that it will host hospice educational events at senior

organizations, religious affiliated groups, Veterans organizations, health fairs, African American organizations, and more, all in an effort to educate the community at large

on the benefits of holistic end-of-life care through hospice.


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(m) Fundraising activities.


states that its sister organization, Catholic Hospice, is an effective fundraising organization, and it expects to develop similar capability and expertise for the proposed Area 7B

program. The applicant states it is aware that the fundraising environment in each area varies depending on a number of factors, including level of awareness of hospice

activities and goals, existing fundraising activities by other charitable and non-profit organizations, and area economic

conditions. The applicant expects to consider a wide variety of fundraising activities and to adopt the most appropriate. These include contributions, bequests, endowments,

memorials, and restricted donations from families, friends, and others who have been positively impacted by Catholic

Hospice‟s services or believe in and support its activities. Catholic Hospice states it may sponsor or participate in or otherwise support a wide array of community benefit events

and activities, including: silent auctions, casino nights, golf tournaments, gala, radio marathons, walk/run events and luncheons featuring well-know speakers.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital

HospiceCare (CON #10070) states that its current foundation was established to raise and manage charitable contributions in support of its faith-based mission and

various patients and family care services. The applicant claims that most fundraising proceeds are reinvested in the local community through hospice services, caregiver

education and support, community education, family support, and bereavement services.

HospiceCare states that strong community support resulted in donations for the majority of funds needed to build the

Stuart F. Meyer Hospice House in Palm Coast (Hospice Service Area 4B). HospiceCare has also conditioned this

application to provide a minimum annual funding of $10,000 towards a “Special Wish Fund” designated for the end-of-life wishes for HospiceCare patients and their families.

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida (CON #10071)

states that it will not perform any local fundraising activities in direct support of its operations and all program services

and activities will be funded by the hospice‟s operations.


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The applicant states that it will have no impact on the fundraising activities of the local existing providers. The

applicant states that its parent company, Odyssey HealthCare, has an active national contributions program

which in 2008 gave approximately $5.8 million in charity care back to the communities it serves and approximately $878,000 through the Odyssey VistaCare Hospice

foundation in 2007. The applicant states that Odyssey and Odyssey VistaCare Hospice Foundation make contributions to organizations nationally and to organizations in the

communities Odyssey serves. Odyssey‟s annual community program includes: providing charity hospice care for needy

patients; providing assistance to patients and families when their financial circumstances prevent them from covering basic needs such as utility bills, travel for relatives to visit

the terminally ill patient, burial expenses, air conditioning units, etc.; and providing financial contributions to non-

profit agencies. United Hospice of Florida, Inc. (CON #10072) states that

it does not actively raise funds from the community and therefore does not compete with other existing hospice organizations or other groups in obtaining funds from the

community. The applicant states that United Hospice Foundation will make available to Florida residents, its

annual scholarship program targeted at those who are studying nursing, pharmacy or therapy with an interest in end-of-life care. Tab 5 in United‟s application Volume Two,

includes a United Hospice Foundation Inc. pamphlet. This pamphlet states that the scholarship is “for students in Georgia, South Carolina, North Carolina, and Florida (italics

added), who are studying to be nurses, pharmacists, or therapists”. “Ideal candidates will have an interest in end-of-

life planning care and be willing to invest the time to successfully complete a short, online course in end-of-life planning, hospice and palliative care”.

3. Statutory Review Criteria

a. Is need for the project evidenced by the availability, quality of care,

efficiency, accessibility and extent of utilization of existing health care facilities and health services in the applicant’s service area?

ss. 408.035(1)(a) and (b), Florida Statutes. The co-batched applicants are applying to establish a hospice program in

Hospice Service Area 7B, where there is published numeric need.


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The following chart illustrates the increase in hospice admissions for the

past five years. As shown below, admissions have increased from 3,532 in year ending June 30, 2004 to 4,891 in year ending June 30, 2009.

There was a decline in hospice admissions from 5,071 in year ending June 30, 2008 to 4,891 in year ending June 30, 2009.

Hospice Admissions for Service Area 7B

12-Months Ending June 30, 2004 – 2009 Admissions

07/08 – 06/09 07/07 – 06/08 07/06 – 06/07 07/05 – 06/06 07/04 – 06/05

07/03 – 06/04

4891 5017 4738 4295 3711

3532 Source: Agency for Health Care Administration Florida Need Projections for Hospice Programs, Published during October 2004 - October 2009.

Catholic Hospice of Central Florida, Inc. (CON #10069) proposes to

open its main office in the Kissimmee area, stating that the existing providers are not operating main offices in Hospice Service Area 7B with the exception of Samaritan Care. The applicant asserts that placing its

main office in the Kissimmee area is consistent with the intent to be available to all residents in need and notes that the large and growing Hispanic population within Service Area 7B is concentrated primarily in

and around the city of Kissimmee. The applicant contends that this main office location in Kissimmee will enable it to offer an optimal level of

service to the Hispanic community. As previously stated, there is no indication that a main office in an area that three branch offices within a 10-mile radius improves hospice care.

The applicant states that one of the strengths of its sister organization Catholic Hospice is its culturally and ethnically diverse staff, many of

whom are bilingual. All of its literature is translated into Spanish and its website is available in Spanish as well. The applicant states that

Catholic Hospice is very sensitive and responsive to the needs of the Hispanic community and that responsiveness will be carried over to Service Area 7B. In the process of developing a CON proposal that would

enhance accessibility for the residents of Orange and Osceola Counties, the applicant states it undertook an in-depth analysis and on-the-ground

field survey in order to identify and educate members of the local community about the services it provides.

Catholic Hospice states it identified several concerns within the Osceola County area. The first being a lack of response time to hospice referrals. The applicant states that a local hospital administrator identified a poor

response time to patients and families in need of immediate end of life care within the Osceola County area. The second concern was that of


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residents stating an additional hospice choice was needed in the area. The third area of concern voiced by the residents was the need for a

faith-based, not for profit provider that would offer patients and families that need to access hospice care an alternative to current providers. The

applicant states that skilled nursing facilities in Kissimmee were visited and according to the applicant, it was apparent there was a desperate need for a hospice experienced in services that met Hispanic population

needs. The applicant states that one of the last areas identified by the local residents was the need for a children‟s grief camp. Catholic Hospice asserts its strong belief that its program will be instrumental in meeting

the identified need and closing any gaps in hospice service.

With regard to extent of utilization, the applicant provides a chart of Hospice Service Area 7B‟s admissions trends from 2005 to 2009. According to the information provided by the applicant three of the four

hospice providers in Service Area 7B experienced a net gain in admissions from 2005 to 2009. The applicant states that only VITAS

reported fewer admissions in 2009 compared to 2005. However, VITAS continues to rank number one in Service Area 7B in both number of annual admissions and market share. The applicant states that Service

Ares 7B has experienced continuous growth in admissions with the exception of 2008-2009, when total admissions declined by 126.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) proposes to enhance availability, quality of care, efficiency

and accessibility of hospice services within Service Area 7B by serving any patient in the service area requiring hospice care, without regard to diagnosis, ability to pay, or ethnicity. The applicant states it will offer

additional hospice services well beyond the core Medicare hospice benefit. HospiceCare states it is a Medicare-certified and Florida Hospital HospiceCare is surveyed and Joint Commission accredited in

conjunction with Florida Hospital. The applicant also states that it is a member of the National Hospice Palliative Care Organization and Florida

Hospice Palliative Care, Inc. Florida Hospital HospiceCare also has an extensive performance improvement plan in place, which includes quarterly reporting to its advisory board.

As a current hospice provider, HospiceCare contends it can offer

centralized services that will improve efficiency in the program. Services such as human resources, billing and collections, training, performance improvement, 24/7 phone coverage, and IT services can all be

coordinated from a centralized office. Other services like nursing care, pastoral care, and physician oversight would be managed locally with local personnel. The applicant states that its experience and existing

infrastructure will enable the proposed program to be cost-effective, creating a foundation for greater financial stability of an operation in

Service Area 7B. As a part of its continuum of care, the applicant states


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it has the advantage of six affiliated hospitals and two skilled nursing facilities in Service Area 7B and will be able to provide care to patients by

utilizing established resources within the community. Florida Hospital HospiceCare states its projected utilization in its second year of operation

is less than the identified unmet need, indicating that the existing providers will not be adversely affected by the approval of this project.

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida (CON #10071) states its objective is to increase the availability, quality of care, efficiency and accessibility of

hospice services in Hospice Service Area 7B. Odyssey states that based upon the three market forecasts presented previously, there is adequate

forecasted hospice volume levels to maintain the current providers while at the same time providing adequate new incremental hospice volume to establish a viable new hospice provider. Odyssey contends that the

existence of special and not normal circumstances in the hospice service area confirms the need for an additional hospice program to ensure

adequate availability of and access to require hospice care. The applicant states that since competition is service-based rather than price-based, the introduction of another hospice provider will provide

incentive for the existing hospice providers to improve and expand the level of service provided to the residents. The ability to consistently provide responsive, quality service to patients and their families and to

provide a comprehensive array of hospice care services have been key factors in communities embracing Odyssey and its services, asserts the

applicant. Odyssey contends it has the specific resources required to expand and complement local service offerings and to provide the competition necessary to improve the level of hospice care provided in

Hospice Service Area 7B. Odyssey states it has and will conduct local educational campaigns that promote hospice care and seek to increase public awareness of hospice care.

The applicant states it will be held to the same high standards of

efficiency and quality that all Odyssey hospice programs are held to nationwide. Odyssey asserts it will be cost-effective and operationally efficient, provide a level of patient-focused care not currently available

with the local market and expand the existing hospice market by serving a broader base of patients than is currently served in the Hospice Service

Area. The applicant states that while many Florida hospices do not actively participate in disaster planning, it strongly believes in disaster planning and has firsthand knowledge and experience in managing

hospice programs in disaster situations, with the operation of Odyssey‟s programs in the Gulf Coast Region following Hurricane Katrina. The applicant provides a copy of the Emergency & Disaster Plan policy in

appendix J.


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Nationally, the applicant states it has made efforts towards becoming a “greener” company. It uses scanners to transmit invoices electronically

and also in its Florida based offices, utilizes a paper shredding/recycling company.

United Hospice of Florida, Inc. (CON #10072) states that the approval of its program will directly address the underserved populations, improve

access and result in enhanced quality of care by increasing competition in the service area. The applicant states it will provide all residents of the two-county service area with a choice in hospice providers while

reaching out to underserved Hispanic population group in turn increasing hospice market penetration.

Reflective of its commitment to serve any and all terminally-ill residents of Service Area 7B, the applicant states it is willing to accept any

conditions on its CON based on any representations made throughout its application. The applicant will provide the core components of hospice

care set forth by Medicare Conditions of Participation as well as Florida hospice licensure requirements including provision of all four levels of service (routine, continuous care, general inpatient and respite).

Even though a specific site has not been selected for the UHF offices, upon approval the applicant states it will concurrently select a location

for its main office in Orlando, Orange County and a second office in Osceola County. The applicant states it will provide health care services

to patients in need regardless of factors relating to coverage or ability to pay, race, gender, sexual preference, creed, ethnic background, disability or diagnosis. While state regulations require hospices to take patient

without regard to their ability to pay, the applicant states it is well known that it presents no obstacles, and welcomes charity care patients. UHF states that United Hospice provided more than $223,000 in unfunded

care in fiscal year 2009.

United Hospice will extend its educational collateral materials to inform and educate community decision makers who are the referral sources for potential hospice patients such as physicians, discharge planners,

nursing home administrators, assisted living directors, case managers, Veterans organizations, Alzheimer Association and other community

organizations. The applicant states it will spend considerable time educating these referral sources regarding the high quality of care provided to patients in an effort to build affiliations and serve the needs

of the community. The applicant states that it will also focus its efforts on increasing hospice awareness and access to Hispanic residents.


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United states it will ensure its staff is educated in the provision of appropriate, high quality effective and efficient services enabling patients

to receive the most appropriate pain and symptom management to meet their needs. The applicant will meet the underserved needs of the

community using these methodologies.

b. Does the applicant have a history of providing quality of care? Has

the applicant demonstrated the ability to provide quality care? ss. 408.035(1)(c), Florida Statutes.

Catholic Hospice of Central Florida, Inc. (CON #10069) is a newly formed non-profit Florida corporation. Catholic Hospice, Inc. however

has a history of providing hospice services in Miami-Dade and Monroe Counties since 1988 and in Broward County since 2007. For the three year period ending January 20, 2010, Catholic Hospice, Inc. has one

confirmed administrative complaint.

The applicant states that Catholic Hospice, Inc. is certified to provide Medicare and Medicaid services and is accredited by the Joint Commission, and is a member of both the Florida Hospices and Palliative

Care, Inc. and the National Hospice and Palliative Care Organization. The applicant states that Catholic Hospice, Inc. currently has an effective quality assessment and performance improvement plan. The existing

performance improvement plan is in compliance with the quality assessment and performance improvement (QAPI) standards

incorporated within the Medicare Conditions for Participations, 42 CFR, Part 418, as required by Florida licensure rules.

According to the applicant, state and local regulations require hospices to have emergency management plans. The applicant states it will be fully capable of working with the Office of Emergency Management to

develop and implement a plan for Orange and Osceola Counties similar to the one that is currently in place.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) states full accreditation by the Joint Commission and

highlights efforts to assure high quality services. The applicant currently has a hospice program in Hospice Service Area 4B, Flagler and Volusia

Counties.


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For the three-year period ending January 20, 2010, the applicant has one confirmed patient care complaint. Florida Hospital HospiceCare also

participates in the Adventist Health System‟s internal and external audit programs. The applicant states that it is an active member of the

National Hospices and Palliative Care Organization and Florida Hospices and Palliative Care. The applicant states its desire to strive to provide

the best quality of care for its patients by having extensive performance improvement plan allowing them to constantly monitor and ensure that their patients are not at risk for poor performance quality.


HealthCare of Central Florida (CON #10071) states it is one of the largest providers of hospice care in the United States in terms of both average daily census and number of locations. Odyssey currently has

hospice programs in Hospice Service Area 4B, Flagler and Volusia Counties, SA 11 Miami-Dade and Monroe Counties and SA 3B Marion

County as of January 1, 2010. For the three-year period ending January 20, 2010, Odyssey had one

confirmed administrative complaint. The applicant states it will hold the same quality standards that are expected of all Odyssey hospice programs. Odyssey states that its hospices are members of the National

Hospice and Palliative Care Organization, and are Medicare and Medicaid certified (or pursing certification). The applicant commits to become

accredited by the Joint Commission and the National Institute for Jewish Hospice by the end of its second year of operation. The applicant highlights its 14-point service standard which stresses: patient

admissions within three hours after receiving a physician‟s order for hospice care; daily contact with patients and their families to assess their needs; and satisfaction of individualized patient and family needs.

United Hospice of Florida, Inc. (CON #10072) is a newly formed

corporation and therefore has no history of providing care. However, the applicant is a wholly owned subsidiary of United Health Services of Florida, Inc. which is a member of the UHS-Pruitt family of companies.

The applicant states that UHS-Pruitt is a highly integrated family of long-term care services that owns and operates 25 hospices throughout the

southeast region, each one committed to the most comprehensive and highest quality standards. United Hospice states that it parent company UHS is dedicated to patient comfort, patient dignity and collaboration

with patients and their loved ones during the grieving process.


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The applicant states that UHS has a history of regulatory compliance with no deficiencies in conditions of Medicare participation, no Medicaid

CAP issues, has never been investigated by OIG and has never had to adhere to court ordered corporate integrity agreements. The applicant

states that UHS follows the National Hospice and Palliative Care Organizations model for hospice care and adheres to the same quality assessment/performance improvement plan set forth by the United

Hospice Policy and Procedures Manual. The applicant states that UHS has several mechanisms for tracking

quality indicators and monitoring facility performance. These proprietary benchmarking and feedback systems include the Monthly Quality

Indicator Report (for skilled nursing facilities), the Quality Assurance Alert Levels and My Innerview. United states that reports flow down to the patient level and roll up to facility and regions. These and other

assessment tools are designed for use by program staff at all levels to seek continuous improvement. The applicant states that United Hospice

and its hospice offices are members of various organizations including but not limited to the following: American Health Care Association, American Hospice Foundation, National Association for Home Care,

National Hospice and Palliative Care Organization, Georgia Hospice and Palliative Care Organization, Association for Home & Hospice Care of North Carolina, and Carolina‟s Center for Hospice and End of Life Care.

In order to further demonstrate its ability and determination to provide

the highest quality care, United Hospice has conditioned its application on becoming accredited by the Community Health Accreditation Program (CHAP) upon licensure.

c. What resources, including health manpower, management

personnel, and funds for capital and operating expenditures, are

available for project accomplishment and operation ss. 408.035(1)(d), Florida Statutes.

Catholic Hospice of Central Florida, Inc. (CON #10069), a development stage company, was established on October 26, 2009, as a

Florida not-for-profit organization for the purpose of providing hospice services in Orange and Osceola Counties in central Florida. As a

development stage company, the applicant indicated total assets and equity of $100. The company‟s sole member is Catholic Hospice, Inc. (the “Parent”).

The applicant states that funding for the proposed project will be provided by the parent from available cash and Investments. In support

of this statement the applicant provided a letter of commitment from the parent stating it would provide the funds necessary to develop and

operate the proposed project from available resources as demonstrated in


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its audited financial statements for the periods ending September 30, 2007 and 2008.

The parent‟s financial statements were analyzed for the purpose of

evaluating its ability to provide the capital and operational funding necessary to implement the project.

Short-Term Position: Parent: The parent‟s current ratio of 2.1 is average and indicates current assets are slightly over two times current liabilities, a good position. The

ratio of cash flows to current liabilities of 0.5 is slightly less than average and an adequate position. The parent‟s working capital of $3.4 million is

a measure of excess liquidity that could be used to fund capital projects. Overall, the parent has a good short-term position. (See Table).

Long-Term Position: Parent: The parent company audit listed no long-term debt, a good

position. The cash flow to assets ratio of 17.9 percent is well above average and a strong position. For the period ended September 30, 2008, the parent had excess revenues over expenses of $1.9 million,

which resulted in a margin of 8.7 percent. Overall, the parent has a good long-term operating position. (See Table).

Capital Requirements: The applicant indicated on Schedule 2 total capital needs of $364,800,

which consisted entirely of the year one and two capital costs associated with this CON application. In addition to the total cost projected for the project, the applicant anticipates a first-year incremental operating loss

of $612,122. The applicant would have to fund this operating loss in addition to the capital projects listed on Schedule 2.

Available Capital: As mentioned above, the capital budget requirements for the proposed

project are $334,800. The applicant states that the funding for this project will come from the parent company. The parent has working capital of $3.4 million and $1.9 million in operating income, and in

addition, cash flow from operations was $1.5 million.

Staffing: Schedule 6A indicates for year one, the applicant forecasts 23.37 FTEs to fully staff the planned new office and care team. Year two will increase

by 28.98 FTEs, for a total of 52.35 FTEs, primarily in direct care categories.


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The applicant lists the following as its staffing standards for year one of

operations: 1.0 FTE volunteer coordinator/community education, 2.04 FTEs RNs, 2.80 FTEs hospice aides, 0.50 FTE chaplain, 0.50 FE social

worker (MSW), 1.00 FTE secretary, 0.50 FTE bereavement counselor, 0.00 FTE hospice physicians will be contracted, 3.10 FTEs continuous care LPNs, 2.53 FTEs continuous care hospice aides, 1.00 FTE team

manager (RN), 0.40 FTE hospice medical director, 2.00 FTEs on-call RNs and LPNs (runners), 1.00 FTE admissions nurse, 1.00 FTE hospice administration, 3.00 FTEs hospice representative and 1.0 FTE human

resources coordinator. The applicant does not provide FTE staff for dietary counseling, which is mandatory according to statute7. Year two

of operations consist of the following additions: 3.9 FTEs RNs, 5.36 FTEs hospice aides, 0.95 FTE chaplain, 0.95 FTE social worker (MSW), 1.00 FTE secretary, 0.95 FTE bereavement counselor, 5.92 FTEs continuous

care LPNs, 4.85 FTEs continuous care hospice aides, 1.0 FTE team manager (RN), 0.10 FTE hospice medical director, 2.0 FTE on-call RNs

and LPNs (runners), 1.0 FTE admission nurse, and1.00 FTE hospice representative.

The applicant states Catholic Hospice has been effective in recruiting high quality staff to meet its personnel needs, and has appropriate recruitment and retention policies, procedures, approaches and

techniques in place. The applicant asserts that it will hire an executive director as quickly as possible. The executive director‟s immediate task

would be to identify best practices of Catholic Hospice regarding staff recruitment and retention and to develop and implement a recruitment plan that will be used to meet the staffing and volunteer needs of the

proposed program.

7 Section 400.609(1)(a), Florida Statutes


78

CON #10069 -- Catholic Hospice of Central Florida, Inc.

9/30/2008

9/30/2007

Current Assets (CA) $6,515,379

$3,467,123

Cash and Current Investment $2,865,584

$1,703,229

Assets Limited as to Use N/A

N/A

Total Assets (TA) $8,140,290

$5,051,556

Current Liabilities (CL) $3,118,645

$2,257,625

Total Liabilities (TL) $3,118,645

$2,257,625

Net Assets (NA) $5,021,645

$2,793,931

Total Revenues (TR) $22,174,442

$16,312,330

Interest Expense (IE) $0

$0

Operating Income (OI) $1,926,921

$277,348

Cash Flow from Operations (CFO) $1,458,768

$85,265

Working Capital $3,396,734

$1,209,498

FINANCIAL RATIOS

9/30/2008

9/30/2007

Current Ratio (CA/CL) 2.1

1.5

Cash Flow to Current Liabilities (CFO/CL) 0.5

0.0

Long-Term Debt to Net Assets (TL-CL/NA) 0.0

0.0

Times Interest Earned (OI+IE/IE) N/A

N/A

Net Assets to Total Assets (NA/TA) 61.7%

55.3%

Operating Margin (OI/TR) 8.7%

1.7%

Return on Assets (OI/TA) 23.7%

5.5%

Operating Cash Flow to Assets (CFO/TA) 17.9% 1.7%

Conclusion: Funding for this project should be available as needed.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare

(CON #10070) is a Florida non-profit corporation that was licensed in June of 1997. The audited financial statements of the applicant, for the periods ending December 31, 2007 and 2008 were analyzed for the

purpose of evaluating the applicant‟s ability to provide the capital and operational funding necessary to implement the project.

Short-Term Position: The applicant‟s current ratio of 5.0 indicates current assets are five times

the current obligations; this is well above average and a strong position. The working capital of $66.4 million is a measure of excess liquidity that could be used to fund capital projects. The ratio of cash flow to current

liabilities of 1.5 indicates cash flows are one and a half times current obligations. This is well above average and is a strong position. Overall,

the parent has a strong short-term position. (See Table).


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Long-Term Position:

The ratio of long-term debt to net assets of 1.0 is above average and indicates the applicant is fully leveraged and may have difficulty

obtaining additional debt financing if needed. The ratio of cash flow to assets of 14.5 percent is well above average and a strong position. The most recent year had $16.7 million in operating income, which resulted

in a 17.0 percent operating margin. Overall, the applicant has an acceptable long-term position. (See Table).

Capital Requirements: Schedule 2 indicates total capital projects of $33,134,457 which consist

of the CON subject to this review and other capital projects. The Applicant is projecting a year one operating loss of $91,852. The Applicant will have to fund the year one operating loss until profitability

can be reached.

Available Capital: The applicant states that it will provide funding for the project through existing cash and investments. Funding for the entire capital budget will

be provided through cash reserves, cash from operations, proceeds from bond issues designated for capital expenditures, and/or other financing methods commonly employed in the health care industry. Operating

cash flows for the most recent year were $25 million with working capital of $66.4 million. (See Table).

Staffing: The applicant‟s Schedule 6A accounts for a total of 22.75 FTE‟s

dedicated to serving the program in year one and 29.85 FTE‟s in year two. The schedule indicates 1.0 FTEs for volunteer services for year one and year two. The applicant provides 0.50 FTE for dietary counseling for

both years one and two, which is required by statute. Year one of operations is a follows: 6.0 FTEs administration, 0.25 FTE physicians,

12.50 FTEs nursing, 0.50 FTE dietary, 2.0 FTEs social services, 0.50 FTE spiritual care, 1.0 FTE volunteer services. Year two staffing consists of: 6.0 FTEs administration, 0.35 FTE physicians, 17.0 FTEs nursing, 0.5

FTE dietary, 4.0 FTEs social services, 0.5 FTE chaplain, 1.0 FTE volunteer services, and 0.5 FTE secretary.

The applicant states that Dr. John Steely will serve as the initial medical director and will assist in recruiting a designated medial director for

Service Area 7B. Dr. Steely‟s curriculum vitae is in the application‟s attachment Q. The administrative director of Florida Hospital


80

HospiceCare‟s operations in Service Area 4B will have the same responsibilities for the proposed hospice in Service Area 7B. JoAnne

King‟s curriculum vitae is provided in Attachment S. The applicant states it will partner with Florida Hospital‟s human resources personnel

in identifying qualified candidates that mesh well with its mission and values.

CON #10070 -- Memorial Hospital -- Flagler, Inc.

2008

2007


$65,312,770


$54,888,200

Assets Limited as to Use $1,562,841

$1,573,221


$157,793,309


$17,536,500


$95,488,075


$62,305,234


$89,739,632

Interest Expense (IE) $4,345,772

$3,809,357


$17,560,769


$33,230,936


$47,776,270

FINANCIAL RATIOS

2008

2007


3.7


1.9


1.3

Times Interest Earned (OI+IE/IE) 4.9

5.6


39.5%


19.6%


11.1%




HealthCare of Central Florida (CON #10071): The audited financial statements of the applicant and its parent were reviewed to assess the financial position as of the balance sheet date and the financial strength

of its operations for the period presented.


81

The applicant is a Florida for-profit corporation, incorporated on October 18, 2006, for the purpose of operating a hospice and related businesses

in the State of Florida. As of December 31, 2008, the applicant had no assets and $227,731 in liabilities, with a $227,731 cumulative operating

loss. This amount is an inter-company payable.

The applicant provided audited financial statements of its ultimate

parent company and subsidiaries, Odyssey Healthcare, Inc. (parent), a for-profit corporation, for the periods ending December 31, 2008 and 2007. These statements were analyzed for the purpose of evaluating the

parent‟s ability to provide the capital and operational funding necessary to implement the project.

Short-Term Position: The parent‟s current ratio of 1.7 indicates current assets are over one-

and-a-half times the current obligations, this is slightly below average and an adequate position. The working capital of $82.4 million is a

measure of excess liquidity that could be used to fund capital projects. The ratio of cash flow to current liabilities of 0.2 is well below average and a weak position. Overall, the parent has a slightly weak but

adequate short-term position. (See Table).

Long-Term Position:

The ratio of long-term debt to net assets of 0.7 is above average and indicates the parent may have difficulty obtaining additional debt

financing if needed. The ratio of cash flow to assets of 4.6 percent is below average and a weak position. The most recent year had $30.8 million in operating income, which resulted in a 5.0 percent operating

margin. Overall, the applicant has a slightly weak but adequate long-term position. (See Table).

Capital Requirements: Schedule 2 indicates total capital projects of $1,906,825 which consist of

the CON subject to this review, CON #10068 for a hospice in District 5B, and CON #10062 for a hospice in District 4A. The applicant is projecting a year one operating loss of $643,403. The applicant will have to fund

the year one operating loss until profitability can be reached.

Available Capital: Funding for this project will be provided by the parent. The parent has working capital of $82.4 million and $30.8 million in operating income.

In addition, cash flow from operations was $21.0 million. The project would only represent 0.77 percent of the parent‟s working capital and 3.02 percent of operating cash flows.


82

Staffing: Schedule 6A of the application provides 17.7 FTEs for year one and 29.3

FTEs for year two of operations. Schedule 6A provides the following staffing ratios: 3.0 FTEs community relations rep, 1.0 FTE general

manager, 0.10 FTE admissions coordinator, 1.0 FTE office manager, 1.0 FTE receptionist, 1.0 FTE patient care manager, 0.10 FTE medical director, 4.2 FTEs RNs, 0.50 FTE LPNs, 2.6 FTEs HHAs, 0.50 FTE

director of patient care services, 0.80 FTE bereavement coordinator, 1.0 FTE volunteer coordinator, 0.10 FTE dietician, and 0.80 FTE medical social worker. In year two of operations the applicant proposes 2.8 FTEs

community relations rep, 1.0 FTE general manager, 0.9 FTE admissions coordinator, 1.0 FTE office manager, 0.3 FTE receptionist, 1.3 FTEs

patient care manager, 1.2 FTEs patient care sec/med records coordinator, 0.1 FTE medical director, 7.3 FTEs RNs, 1.5 FTE LPNs, 6.2 FTEs HHAs, and 0.5 FTE admission RN/field coordinator, 0.8 FTE

bereavement coordinator, 1.3 FTEs spiritual care coordinator, 0.5 FTE volunteer coordinator, 0.8 FTE manager continuous quality

improvement, 0.1 FTE dietician and 1.8 FTEs medical social worker.

Odyssey Healthcare, Inc. and Subsidiaries

12/31/2008

12/31/2007


$151,455,000


$62,179,000


$275,209,000


$76,180,000


$92,372,000

Net Assets (NA) $200,071,000

$182,837,000


$398,232,000


$208,000


$24,000,000


$12,814,000


$75,275,000

FINANCIAL RATIOS

12/31/2008

12/31/2007


2.0


0.2


0.1


116.4


66.4%


6.0%


8.7%



83

Conclusion: Funding for the project should be available as needed.

United Hospice of Florida, Inc. (CON #10072): The audited financial

statements of the applicant and its parent were reviewed to assess the financial position as of the balance sheet date and the financial strength of its operations for the period presented.

The applicant is a Florida for-profit corporation, incorporated on October 16, 2009, for the purpose of operating a hospice and related businesses

in the State of Florida. As of November 25, 2009, the applicant had $10,000 in assets and $9,000 in liabilities, with no operations.

The applicant provided audited financial statements of its ultimate parent company and subsidiaries, United Health Services, Inc. (parent), a

for-profit corporation, for the periods ending June 30, 2009 and 2008. These statements were analyzed for the purpose of evaluating the

parent‟s ability to provide the capital and operational funding necessary to implement the project.

Short-Term Position: The parent‟s current ratio of 0.9 indicates current assets are less than current obligations. This is below average and weak position. This

results in a working capital deficit of $14.2 million. The ratio of cash flow to current liabilities of 0.4 is below average and a weak position.

Overall, the parent has a weak short-term position. (See Table). Long-Term Position:

The ratio of long-term debt to net assets of 3.4 indicates the parent is highly leveraged and may have difficulty obtaining additional debt financing if needed. The ratio of cash flow to assets of 11.9 percent is

well above average and a good position. The most recent year had $16.9 million in operating income, which resulted in a 2.9 percent operating

margin. Overall, the applicant has a slightly weak but adequate long-term position. (See Table).

The weak short and long-term position of the parent appears to be the result of cash and debt used to make a number of health care facility

acquisitions. The subsequent events note in the audit indicates that the parent entered into four additional health care facility acquisitions after the fiscal year end date.


84

Capital Requirements: Schedule 2 indicates total capital projects of $535,517 which consist of

the CON subject to this review, CON #10064 for a hospice in District 4A, and other capital projects. The applicant is projecting a year one

operating loss of $498,929. The applicant will have to fund the year one operating loss until profitability can be reached.

Available Capital: According to the application, the parent will fund this project through operating cash flows. The parent‟s audited financial statements indicate

cash flow from operations was $39.8 million. Although the parent shows weakness in both the short and long-term, this project, including

funding the year one operating loss, would only represent 1.87 percent of operating cash flows.

Staffing: Schedule 6A reflects 16.07 FTEs in year one increasing to 39.29 FTEs in

year two. In both years one and two there will be one volunteer half-time. The applicant states this will increase with census. Schedule 6 reflects the following staffing ratios: 1.0 FTE administrator, 1.0 FTE

director of nursing, 0.50 FTE volunteer, 2.0 FTEs administrative support, 1.0 FTE chaplain, 2.0 FTEs hospice representative, 2.5 FTEs RNs, 0.49 FTE LPN, 3.33 FTEs nurse‟s aides, 1.0 FTE dietician and 1.25 FTEs

social services director. Year two staffing consists of: 1.0 FTE administrator, 2.0 FTEs director of nursing, 1.0 FTE volunteer, 2.0 FTEs

administrative support, 1.92 FTEs chaplain, 3.0 FTEs hospice representative, 7.08 FTEs RNs, 4.18 FTEs LPNs, 12.36 FTEs nurses‟ aides, 1.0 FTE on call nurse, 1.0 FTE dietician and 2.75 FTEs social

service director.


85

United Health Services, Inc. & Subsidiaries

6/30/2009

6/30/2008


$80,304,743


$2,609,207


$285,565,941


$85,137,811


$244,469,013


$41,096,928


$518,137,965


$11,139,539


$12,512,127


$21,188,644

Working Capital ($14,206,609)

($4,833,068)

FINANCIAL RATIOS

6/30/2009

6/30/2008


0.9


0.2


3.9


2.1


14.4%


2.4%


4.4%



d. What is the immediate and long-term financial feasibility of the proposal? ss. 408.035 (1)(f), Florida Statutes.

Catholic Hospice of Central Florida, Inc. (CON #10069): For year two of operations, the applicant projected the following percentage of total

patient days by group: Medicare at 85.8 percent, Medicaid at 5.4 percent, self-pay/charity at 3.0 percent, and commercial insurance at 5.8

percent. The applicant indicated on Schedule 7 that the service it intends to

provide is routine home care, continuous home care, inpatient respite, and general inpatient care, and for which the Department of Health and


86

Human Services sets rates. The federal rates were calculated for Orange and Osceola Counties, Florida Wage Index for Medicare Hospice

payments of 0.9618 and inflated through December 2012. The average price adjustment factor used was 2.8 percent per year based on the new

CMS Market Basket Price Index as published in the 1st Quarter 2009 Health Care Cost Review.

Estimated patient days for each level of service from Schedule 7, year two were multiplied by the calculated reimbursement rate for that service in order to estimate the total revenue that would be generated by that

number of patient days. The results were then compared to the applicant‟s estimated gross revenue. The results of the calculations are

summarized in table below. The applicant‟s projected gross revenue was 6.59 percent, or $311,393,

less than the calculated gross revenue. A small portion of the difference is due to the applicant projecting a 2.0 percent inflation rate compared to

the average 2.8 used by staff. Projected revenues appear to be understated. Understating revenues is a conservative assumption and therefore considered reasonable. Operating profits from this project are

expected to increase from a loss of $612,122 for year one to a profit of $303,605 for year two. It should be noted that the applicant listed several conditions some of which could have a financial impact. The cost

of these items appears to have been included in the financial projections.

This project appears to be financially feasible.


87

HOSPICE REVENUE TABLE

CON #10069 -- Catholic Hospice of Central Florida, Inc.

Wage Index for Orange and Osceola Counties (0.9618)

Wage

Component Wage Index

Adjusted Wage

Amount Unadjusted Component

Payment Rate

Routine Home Care $98.19 0.9618 $94.44 $44.72 $139.16

Continuous Home Care $573.11 0.9618 $551.22 $260.99 $812.21

Inpatient Respite $80.02 0.9618 $76.96 $67.81 $144.77

General Inpatient $406.94 0.9618 $391.39 $228.80 $620.19

Payment

Rate

Inflation Factor Year

Two

Inflation Adjusted

Amount

Patient Days Year 2,

December

31,2012

Calculated Gross

Revenue

Routine Home Care $139.16 1.064 $148.05 21,437 $3,173,690

Continuous Home Care $812.21 1.064 $864.08 1,421 $1,227,862

Inpatient Respite $144.77 1.064 $154.02 10 $1,540

General Inpatient $620.19 1.064 $659.81 963 $635,394

Total 23,831 $5,038,487

From Schedule 7 (Gross) $4,727,094

Difference

-$311,393

Percentage difference -6.59%


(CON #10070): For year two of operations, the applicant projected the following percentage of total patient days by group: Medicare at 85.0 percent, Medicaid at 4.0 percent, self-pay/charity at 3.0 percent, and

commercial insurance at 8.0 percent.

The applicant indicated on Schedule 7 that the service it intends to provide is routine home care, continuous home care, inpatient respite, and general inpatient care, and for which the Department of Health and

Human Services sets rates. The federal rates were calculated for Orange and Osceola Counties, Florida Wage Index for Medicare Hospice payments of 0.9618 and inflated through December 2012. The average

price adjustment factor used was 2.8 percent per year based on the new CMS Market Basket Price Index as published in the 1st Quarter 2009

Health Care Cost Review.


88

Estimated patient days for each level of service from Schedule 7, year two were multiplied by the calculated reimbursement rate for that service in

order to estimate the total revenue that would be generated by that number of patient days. The results were then compared to the

applicant‟s estimated gross revenue. The results of the calculations are summarized in table below.

The applicant offered 11 conditions to its proposed hospice program. Several of these conditions would likely have a financial impact on the applicant. Based on the notes accompanying the projections, it is

unclear if the applicant has taken into consideration the costs associated with the proposed conditions in the financial projections.

The applicant‟s projected gross revenue was 1.24 percent, or $45,301, more than the calculated gross revenue. This difference in revenue

projected is not deemed material. Operating profits from this project are expected to increase from a loss of $91,852 for year one to a profit of

$125,880 for year two. This project appears to be financially feasible.

HOSPICE REVENUE

CON #10070 Memorial Hospital --Flagler, Inc.

Wage Index for Orange and Osceola Counties (.9618)

Wage Component Wage Index

Adjusted Wage


Payment Rate





Payment Rate


Two

Inflation Adjusted Amount


December 31 -2012

Calculated Gross

Revenue


Continuous Home Care $812.21 1.064 $864.08 198 $171,088


General Inpatient $620.19 1.064 $659.81 1,424 $939,565

Total 18,450 $3,602,926

From Schedule 7 $3,648,227

Difference

$45,301

Percentage difference 1.24%


89

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida (CON #10071): For year two of

operations, the applicant projected the following percentage of total patient days by group: Medicare at 93.0 percent, Medicaid at 3.0 percent,

self-pay/charity at 2.0 percent, and commercial insurance and other at 2.0 percent.

The applicant indicated on Schedule 7 that the service it intends to provide is routine home care, continuous home care, inpatient respite, and general inpatient care, and for which the Department of Health and

Human Services sets rates. The federal rates were calculated for Orange and Osceola Counties, Florida Wage Index for Medicare Hospice

payments of 0.9618 and inflated through December 2012. The average price adjustment factor used was 2.8 percent per year based on the new CMS Market Basket Price Index as published in the 1st Quarter 2009

Health Care Cost Review.

Estimated patient days for each level of service from Schedule 7, year two were multiplied by the calculated reimbursement rate for that service in order to estimate the total revenue that would be generated by that

number of patient days. The results were then compared to the applicant‟s estimated gross revenue. The results of the calculations are summarized in table below.

The applicant offered 25 conditions to its proposed hospice program.

Several of these conditions would likely have a financial impact on the applicant. Based on the notes accompanying the projections, it appears that the applicant has taken into consideration the costs associated with

the proposed conditions in the financial projections. The applicant‟s projected gross revenue was 2.86 percent, or $113,055,

less than the calculated gross revenue. The applicant used a lower inflation rate (2.0 percent) which is a conservative assumption. When

the difference in inflation rates are considered, the difference in revenue projected is not deemed material. Operating profits from this project are expected to increase from a loss of $643,403 for year one to a profit of

$314,403 for year two.

This project appears to be financially feasible.


90

HOSPICE REVENUE

CON #10071 Odyssey Healthcare of Collier County, Inc.

Wage Index for Orange and Osceola Counties (.9618)

Wage Component Wage Index

Adjusted Wage


Payment Rate





Payment Rate


Two



December 31 -2012

Calculated Gross

Revenue





Total 23,533 $4,064,920

From Schedule 7 $3,951,865

Difference

-$113,055


United Hospice of Florida, Inc. (CON #10072): For year two of

operations, the applicant projected the following percentage of total patient days by group: Medicare at 92.5 percent, Medicaid at 5.0 percent,

charity at 1.0 percent, and commercial insurance at 1.5 percent. The applicant indicated on Schedule 7 that the service it intends to

provide is routine home care, continuous home care, inpatient respite, and general inpatient care, and for which the Department of Health and Human Services sets rates. The federal rates were calculated for Orange

and Osceola Counties, Florida Wage Index for Medicare Hospice payments of 0.9618 and inflated through June 2012. The average price

adjustment factor used was 2.8 percent per year based on the new CMS Market Basket Price Index as published in the 1st Quarter 2009 Health Care Cost Review.

Estimated patient days for each level of service from Schedule 7, year two

were multiplied by the calculated reimbursement rate for that service in order to estimate the total revenue that would be generated by that number of patient days. The results were then compared to the

applicant‟s estimated gross revenue. The results of the calculations are summarized in table below.


91

The applicant calculated continuous care revenues based on 16 hours of

care rather than 24 hours. The applicant indicated that due to death or other causes, some patients will not, however, receive 24 hours of

continuous care and will not, therefore, be eligible for reimbursement for a given day. In our calculation, we made the same adjustment of a partial 16 hour payment. Based on our calculation, the applicant‟s

projected gross revenue was 2.8 percent, or $131,989, less than the calculated gross revenue. Understating revenue is a conservative assumption and therefore reasonable. Operating profits from this project

are expected to increase from a loss of $498,929 for year one to a profit of $430,638 for year two.

This project appears to be financially feasible. HOSPICE REVENUE

CON #10072 -- United Hospice of Florida, Inc.

Wage Index for Orange and Osceola Counties (0.9618)

Wage

Component Wage Index

Adjusted

Wage Amount

Unadjusted Component

Payment Rate


Continuous Home Care $573.11 0.9618 $551.22 $260.99 $541.47**



Payment

Rate

Inflation Factor

Year Two


Patient Days Year 2, June

30, 2012

Calculated Gross

Revenue





Total 29,039 $4,839,770

From Schedule 7 (Gross) $4,707,781

Difference

-$131,989


e. Will the proposed project foster competition to promote quality and

cost-effectiveness? ss. 408.035(1)(g), Florida Statutes.

Each co-batched is offering a new choice of provider in the hospice service area.


92

The impact of the price of services on consumer choice is limited to the

payer type. Most consumers do not pay directly for hospice services rather they are covered by a third-party payer. The impact of price

competition would be limited to third-party payers that negotiate price for services, namely managed care organizations. Therefore, price competition is limited to the share of patient days that are under

managed care plans.

With the large majority of patient care being provided from fixed-price

government payer sources, a new hospice provider is not likely to have any discernable positive impact on competition to promote quality

assurance or cost-effectiveness. However, with price not considered a major factor, competing hospice programs will likely focus on quality of service to remain competitive in the market. Therefore, although a new

hospice provider is not likely to have any discernable positive impact on competition to promote cost-effectiveness, it should have a positive

impact on quality of care. Catholic Hospice of Central Florida, Inc. (CON #10069): The

applicant is projecting 5.8 percent of its patient days from managed care/commercial insurance payers with 91.2 percent of patient days expected to come from fixed-price government payer sources (Medicare

and Medicaid), with the remaining 3.0 percent as self-pay/charity.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070): The applicant is projecting 8.0 percent of its patient days from managed care/commercial insurance payers with 89.0 percent

of patient days expected to come from fixed-price government payer sources (Medicare and Medicaid), with the remaining 3.0 percent as self-pay/charity.


HealthCare of Central Florida (CON #10071): The applicant is projecting 2.0 percent of its patient days from managed care/commercial insurance payers with 96.0 percent of patient days expected to come

from fixed-price government payer sources (Medicare and Medicaid), with the remaining 2.0 percent as self-pay/charity.

United Hospice of Florida, Inc. (CON #10072): The applicant is projecting 1.5 percent of its patient days from managed care/commercial

insurance payers with 97.5 percent of patient days expected to come from fixed-price government payer sources (Medicare and Medicaid), with the remaining 1.0 percent as charity.


93

As providers offer new or enhanced services to patients and families as a means to compete on quality measures, cost-effectiveness would be

impacted since the new or enhanced services would be offered despite the large percentage of fixed-priced government payers. In other words,

the potential exists for new or enhanced services to be provided for the same federal and state dollars.

Approval of any project is not likely to result in price-based competition.

f. Are the proposed costs and methods of construction reasonable? Do

they comply with statutory and rule requirements? ss. 408.035(1)(h), Florida Statutes and Ch. 59A-3 or 59A-4, Florida

Administrative Code.

Each of the co-batched applicants is requesting approval to establish a

new hospice program. There are no construction costs and methods associated with the proposals.

g. Does the applicant have a history of providing health services to

Medicaid patients and the medically indigent? Does the applicant

propose to provide health services to Medicaid patients and the medically indigent? ss. 408.035(1)(i), Florida Statutes.

Catholic Hospice of Central Florida, Inc. (CON #10069) states it is a newly-formed entity and as such has no operating history. However, its

sister organization, Catholic Hospice, Inc. has a history of providing health care services to Medicaid patients and the medically indigent in Broward, Miami-Dade and Monroe Counties. The applicant states that

in 2007 and 2008 Catholic Hospice provided 3.6 and 3.7 percent of patient days to Medicaid; and 1.3 and 0.9 percent of patient days to indigent/charity care during the same two-year period.

Schedule 7A shows 5.4 percent patient days Medicaid and 2.0 percent

patient days indigent/charity for years one and two respectively. Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare

(CON #10070) states that the applicant‟s parent, Florida Hospital, in 2007, provided over $14,586,585 in care to Medicaid patients or 5.6

percent of $258,737,194 in gross charges. The applicant projects that Medicaid patients in the proposed service area will receive care equal to 4.0 percent of gross charges. The applicant, Memorial Hospital Flagler,

Inc. states it provided $14,340,000 in charity care on $98,150,405 in net patient service revenue (14.6 percent) in 2008 and $10,088,000 in charity care on $89,431,068 in net patient service revenue (11.3 percent)

in 2007.


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Schedule 7A shows $43,267 for charity/self-pay care in year one, and $65,668 for charity care year two. This applicant separately categorizes

bad debt for year one at $24,037 and at year two, $36,482. The applicant projects 4.0 percent Medicaid patient days for years one and

two respectively. Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey

HealthCare of Central Florida (CON #10071) states it has consistently provided care to all patients in need of its services, including the traditionally underserved Medicaid/charity/indigent populations. The

applicant states that 55 percent of Odyssey HealthCare Inc.‟s fiscal year 2008 non-Medicare net revenue is Medicaid; and approximately 9.5

percent of non-Medicare services are provided to indigent/charity patients.

Schedule 7A shows 2.0 percent self-pay patient days and 3.0 percent Medicaid patient days for years one and two respectively. Notes to the

schedule state that charity care is reflected in the self-pay column and was forecasted at two percent of patient days for both years.

United Hospice of Florida, Inc. (CON #10072) is a newly formed corporation for the sole purpose of providing hospice services in Florida. The applicant is a wholly owned subsidiary of United Health Services of

Florida, Inc. whose ultimate parent company is United Health Services, Inc. United Hospice states that United Health Services, Inc. has

significant experience providing services to Medicaid and medically indigent patients in its hospice operations throughout the southeast region of the country. The applicant states that United Hospice provides

between 8.6 and 10.0 percent of its patient days to serving Medicaid patients and an additional 0.4 to 1.2 percent providing care for indigent patients.

Schedule 7A shows 5.0 percent Medicaid patient days and 1.0 percent

patient days charity in years one and two of operations respectively.

F. SUMMARY The applicants are applying to establish a hospice program in Hospice

Service Area 7B. Each co-batched applicant is applying in response to published need for a hospice program in Hospice Service Area 7B, Orange and Osceola Counties. However, all applicants provided

additional arguments in support of need for their projects as discussed below.

Catholic Hospice of Florida, Inc. (CON #10069): The proposed total project cost is $334,800 with year one total operating costs of

$2,207,564 and year two costs of $5,065,314.


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Catholic Hospice of Florida proposes 22 conditions which briefly stated

include the following: two-hour referral response time, patient contact within 48 hours of admittance, staff answers after-hours phone calls,

laptop use in field, quality of care assessments, provide emergency pharmaceutical kit to patients, contract with one-point patient care pharmacy, contract for durable medical equipment, individual and group

grief counseling, annual memorial services, membership in FHPC and NHPCO, membership in TriVOAD, collaborate with CERT on disaster preparedness, provide community support groups, children‟s annual

grief camp, diversity and cultural outreach for Hispanics, cultural diversity and sensitivity training, bereavement services, targeted

recruitment and retention of bilingual staff, provide community education seminars, initiate “wishes granted” program and commits to main office in Kissimmee area. See pages 3-6 for in-depth description of

the applicant‟s proposed conditions.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070): The proposed total project cost is $306,380 with year one operating costs of $2,323,888 and year two costs of $3,261,895.

Florida HospiceCare proposes 11 conditions which briefly stated include the following: provide programs and services for residents of Service Area

7B who are outside of the Medicare hospice benefit, provide ongoing education program on hospice care, develop and offer a structured

curriculum for Florida Hospital‟s chaplaincy residents, commitment to initiatives that improve the quality of hospice care offered, provide volunteer services to hospice patients beyond Medicare requirements,

contract for inpatient services with one of the six Florida Hospital hospital‟s in the service area, provide volunteer services to hospice patients, provide programs for the Hispanic population, develop a

community resources website, develop a community advisory board and provide a minimum of $10,000 annually towards a “Special Wish” fund.

See pages 7-8 for an in-depth description of the applicant‟s proposed conditions.

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida, Inc. (CON #10071): The proposed total

project cost is $635,608 with year one operating costs of $1,945,888 and year two costs of $3,490,434.

Odyssey proposes 23 conditions which briefly stated include the following: provide supportive hospice services, provide continuous care, implement “Care Beyond” program, provide hospice service 24/7, admit

all eligible patients regardless of ability to pay, provide physician assessment to every patient upon admission, implement performance

improvement plan, make available a range of non-covered supplementary


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therapies, implement triage and on-call programs, establish local ethics committee, establish local medical advisory board, provide educational

programs, provide information of services provided by the Dream foundation, monetary contribution to fund end-of-life education, commit

to evaluate need for expanded child services, commit to development efforts regarding community bereavement programs, provision programs for Hispanic and other minority populations, develop community

resource library, facilitate the provision of a children‟s bereavement camp in Florida, retain a minimum of three community education representatives, development of main and satellite offices in Orange and

Osceola Counties, assessment by medical director for each patient and daily contact with patients. See pages 8-13 for an in-depth description of

the applicant‟s proposed conditions. United Hospice of Florida, Inc. (CON #10072): The proposed total

project cost is $247,009 with year one operating costs of $1,841,126 and year two costs of $4,775,746.

United Hospice proposes seven conditions which briefly stated include: develop other services and companies in Subdistrict 7B, implement

outreach programs to underserved populations, obtain CHAP accreditation, seek membership in community organizations, make scholarship funds available to Florida residents, open two office locations

and exceed all NHPCO guidelines for qualifications and staffing ratios. See pages 13-16 for an in-depth description of the applicant‟s conditions.

Need/Access:

Each applicant is applying to establish a hospice program in Hospice Area 7B. Although there is published need for one new hospice program, each applicant states that there is unmet need in Orange and Osceola

Counties, which ranged from undocumented access issues for minority populations including Hispanics, perceived failure of existing providers to

meet the needs of residents in Osceola County, to chronically ill patient populations with Alzheimer‟s disease, HIV/AIDS, cancer patients under the age of 65 and non-cancer patients under the age of 65.

Catholic Hospice of Central Florida bases its need to not only serve the

projected growth in hospice utilization shown in the Agency need methodology, but also to increase the penetration rates by targeting historically underserved populations which it has identified as the

Hispanic population and residents of Osceola County. Beyond the statistical averages presented by the applicant and support letter statements that the project would be a benefit to the Hispanic

community, insufficient or otherwise deficient service to the Hispanic community in the current hospice arrangement is not verified. Catholic

Hospice intends to meet the needs of the underserved in Osceola County


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by establishing its primary office in the Kissimmee area, with a second office to open in Orange County by the end of year two of operations. It

is noted that three of the four existing 7B providers have branch offices in Kissimmee (Osceola County).

HospiceCare essentially contends that the Agency‟s initial determination of need for one hospice is correct and discusses factors in the Agency

need methodology. Factors such as projected population 65 and over, hospice penetration rates, hospice use by patients, are discussed. The applicant contends that the increase in Hispanic population presents a

growing need for a hospice that can accommodate residents of diverse ethnic backgrounds, provide bilingual programs and culturally sensitive

programming to serve this population. Service Area 7B‟s, HIV/AIDS and Alzheimer patients are also discussed.

Odyssey states that in addition to Agency identified need, it presented evidence of special and not normal circumstances in Hospice Service

Area 7B. Odyssey contends that residents of 7B have been consistently underserved by the existing hospice providers as evidenced by total hospice utilization rate that has been consistently lower than the Florida

average hospice utilization rate. Odyssey also identified and discussed the underserved patient groups of cancer patients under the age of 65 and non-cancer patients under the age of 65 years.

United Hospice states that while there is projected need for 484

additional hospice program admissions, all cohorts are currently underserved with the greatest numeric need in the two under 65 age cohorts, cancer and non-cancer. United also discusses the terminally-ill

Hispanic population and patients with a terminally-ill non cancer diagnosis.

Each co-batched applicant provided evidence that they have local support for their proposals to enter the service area. Local letters of

support essentially express a need for an additional hospice program that is willing to improve access to hospice services for the residents of the service area.

All applicants agree to measurable conditions, if awarded the CON, to

ensure that its proposed program offers improved access to hospice care, improved education regarding available hospice services, and to address any cultural barriers to hospice care in Orange and Osceola Counties.

None of the applicants agreed to condition the CON upon providing a minimum of patient days per year to charity patients. Recent changes in hospice licensing law indicate that hospice programs that fail to meet

their CON condition without good cause could lose their license.


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The Agency‟s need methodology resulted in need for a new hospice program in Orange and Osceola Counties for the January 2011 planning

horizon. The applicants provided total projected admissions for years one and two of operations in Service Area 7B.

Total Projected Admissions By Applicant

for Years One and Two CON # Applicant Year One Year Two Both Years

10069 Catholic Hospice of Florida, Inc. 161 413 574

10070 Florida Hospital HospiceCare 280 410 690

10071 Odyssey HealthCare of Cent. Florida 229 445 674

10072 United Hospice of Florida, Inc. 192 450 642

Quality of Care: Each applicant offered evidence of its ability to provide quality care.

Financial Feasibility/Availability of Funds:

Catholic Hospice of Central Florida, Inc. (CON #10069): Based on the applicant‟s parent company having both a good long and short-term

position funding for this project should be available as needed. The applicant states that funding for this project will be provided by the parent company from available cash and investments.


(CON #10070): The applicant has an acceptable long-term position and a relatively strong short-term position. Funding is available for this project and it appears to be financially feasible.

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida, Inc (CON #10071): The applicant‟s

parent company has a slightly weak but adequate short and long-term position. Although the ratio of cash flow to current liabilities is well

below average and a weak position, funding for this project should be available as needed.

United Hospice of Florida, Inc. (CON #10072): The applicant‟s parent company has a slightly weak but adequate long-term position and a

weak short-term position. The weak short and long-term positions of the parent appear to be the result of cash and debt used to make a number of health care facility acquisitions. However, funding for this project

should be available as needed.


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Medicaid/Charity Care:

Catholic Hospice of Central Florida, Inc. (CON #10069) states it is a newly-formed entity and as such has no operating history. However, its

sister organization, Catholic Hospice, Inc. has a history of providing health care services to Medicaid patients and the medically indigent in Broward, Miami-Dade and Monroe Counties. Schedule 7A shows 5.4

percent patient days Medicaid and 2.0 percent patient days indigent/charity for years one and two respectively.

Memorial Hospital Flagler, Inc. d/b/a Florida Hospital HospiceCare (CON #10070) states it has a history of providing health services to

Medicaid patients and the medically indigent. Schedule 7A shows $43,267 for charity/self-pay care in year one, and $65,668 for charity care year two. The applicant projects 4.0 percent Medicaid patient days

for years one and two respectively.

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida (CON #10071) states it has consistently provided care to all patients in need of its services, including the

traditionally underserved Medicaid/charity/indigent populations. Schedule 7A shows 2.0 percent self-pay patient days and 3.0 percent Medicaid patient days for years one and two respectively. Notes to the

schedule state that charity care is reflected in the self-pay column and was forecasted at two percent of patient days for both years.

United Hospice of Florida, Inc. (CON #10072) is a newly formed corporation for the sole purpose of providing hospice services in Florida.

The applicant is a wholly owned subsidiary of United Health Services of Florida, Inc. whose ultimate parent company is United Health Services, Inc. United Hospice states that United Health Services, Inc. has

significant experience providing services to Medicaid and medically indigent patients in its hospice operations throughout the southeast

region of the country. Schedule 7A shows 5.0 percent Medicaid patient days and 1.0 percent patient days charity in years one and two of operations respectively.


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G. RECOMMENDATION

Approve CON #10070 to establish a new hospice program in Hospice

Service Area 7B, Orange and Osceola Counties. The project involves a total project cost of $306,380 with year one operating costs of $2,323,888 and year two costs of $3,261,895.

CONDITIONS:

1. Florida Hospital HospiceCare will provide programs and services for residents of Service Area 7B that are outside the Medicare

hospice benefit which will include community hospice education and community bereavement. This would also include the development of Project StoryKeeper as a means of providing

training for hospice staff and volunteers that can be put to use in establishing a patient's family history/legacy. Project StoryKeeper

allows patients to record their life stories as part of their legacy to their loved ones, so that their stories can be told and shared long after they have passed away. Also included is the development of a

pet therapy program for hospice patients. Pet therapy offers psychological benefits in terms of emotional connection, stress reduction, and reduced feelings of loneliness or isolation.

2. Florida Hospital HospiceCare will provide an ongoing education

program on hospice care to provide easily accessible information for medical staff members of the Florida Hospitals in Orange and Osceola Counties and resident physicians and fellows in Florida

Hospital's teaching program.

3. Florida Hospital HospiceCare commits to develop and offer a

structured curriculum for Florida Hospital's Chaplaincy Residents. At a minimum the program will include hospice overview,

admission requirements, patient and family satisfaction results, and spiritual considerations in end-of-life care.

4. Florida Hospital HospiceCare commits to the following initiatives to improve the quality of hospice care offered:

Pain assessment on admission and by the second day of

admission (within 48 hours);

Provide palliative care modalities including radiation therapy;

Encourage additional staff credentialing for physicians, nurses, chaplains, and social workers through a certification

reimbursement program;


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Maintain accreditation by The Joint Commission (formerly

known as the Joint Commission on Accreditation of Health Care Organizations)

5. Florida Hospital HospiceCare commits to enter into agreements with one or more of the six Florida Hospital hospitals (Apopka,

Celebration Health, East Orlando, Kissimmee, Orlando and Winter Park Memorial) and one or more Adventist Care Centers (skilled nursing facilities) in Service Area 7B to provide inpatient hospice

services to residents of Orange and Osceola Counties.

6. Florida Hospital HospiceCare commits to provide volunteer services

to hospice patients that substantially exceeds the five percent requirement mandated under the Medicare Conditions of

Participation. Based on the success of its Flagler and Volusia program, Florida Hospital HospiceCare commits to a minimum of 10 percent of its hours of care being provided by hospice

volunteers. The additional commitment of volunteer hours will begin with the second year of operation.

8. Florida Hospital HospiceCare commits to provide programs for the

Hispanic population which will include support from or

involvement of bilingual staff and volunteers, translated literature, training on cultural differences and competencies, and flexible programming to meet identified needs. Bereavement services will

include outreach to the Hispanic population of Service Area 7B.

9. Florida Hospital HospiceCare commits to develop a community resource information website in the first year of operation. This educational site will include various lay and professional education

pieces related to chronic illness, death, dying, and bereavement.

10. Florida Hospital HospiceCare commits to develop a community advisory board composed of residents inclusive of both the Orange and Osceola communities. The purpose of the community advisory

board is to provide input and feedback about service area needs and recommendations for consideration in future program development.

11. Florida Hospital HospiceCare commits to minimum annual funding

of $10,000 towards a "Special Wish Fund" designated for the end-of-life wishes for Florida Hospital HospiceCare patients and their families. This commitment would begin in the second year of

operations.


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12. Florida Hospital HospiceCare commits to open two offices in the

first year of operation. One office will be opened in Osceola County on the campus or in proximity to Florida Hospital Kissimmee. The

Orange County office will be located on the campus or in close proximity of an Orange County facility to best suit the needs of the Clinical Pastoral Education, Medical Education, and Palliative Care

programs. Deny CON #‟s 10069, 10071 and 10072.


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AUTHORIZATION FOR AGENCY ACTION

Authorized representatives of the Agency for Health Care Administration adopted the recommendation contained herein and released the State Agency

Action Report.

DATE:

James B. McLemore Health Services and Facilities Consultant Supervisor

Certificate of Need

Jeffrey N. Gregg Chief, Bureau of Health Facility Regulation

Documents

STATE AGENCY ACTION REPORT - ahca.myflorida.comahca.myflorida.com/MCHQ/CON_FA/Batching/pdf/10070.pdf · STATE AGENCY ACTION REPORT ON APPLICATION FOR CERTIFICATE OF NEED A. PROJECT