The case for independence

I recently received an email from an individual in Temple Terrace, Florida, informing me that two northern California nonprofit hospices – with historically close ties to YoloCares – have decided, via affiliation, to turn their keys over to a Florida-based health system that has had no previous presence in California.

Much like YoloCares, these two providers (Hospice of Santa Cruz County and Hospice of the East Bay in Pleasant Hill) grew out of the Civil Rights Movement in the 1970s, and for nearly five decades, they used their scrappiness and independence as a strength.? These same treasured qualities have empowered other like-organizations to be nimble, responsive, innovative, and deeply connected to the communities that initially gave them life.??

At first, I wondered how much Florida’s ultra-conservative politics and values have influenced this out-of-state healthcare provider.? Will these community treasures still be allowed to support California’s End-of-Life Option Act, which allows terminally ill adults to request life-ending medication from their physician?? Only 11 states have “Death With Dignity” laws, and Florida is not one of them.

Will support and programming for LGBTQ patients and families shift or change in any way?? Currently, most insurances in California provide gender-affirming care as a covered benefit.? Since Santa Cruz has long been known as a hippie town and Pleasant Hill has established itself as the Bay Area’s backyard, how will the local work culture mesh with the ethos of a giant mothership based 3,000 miles away?? Earlier this year, Florida’s House of Representatives passed a trio of anti-LGBTQ+ bills jeopardizing gender-affirming medical care, teachers’ rights, and workplace discrimination protections.? If these bills become law, what will the implications be for California employees whose company is based in the politically conservative Sunshine State?

This past spring, I joined fellow CEOs for a half-day sales pitch presented by this Florida company.? The presentation was impressive, but I had vital questions that needed to be sufficiently answered.? If merging into a larger provider is supposed to help independent organizations like ours achieve sustainability, then why does it not show in the data?? From a high level, only two key measures matter:? Quality of care and financial sustainability.

After digging into publicly available reports, I saw that our suitor had quality scores below the national average and financial performance marked by a seven-figure loss.? By comparison, the currently independent Hospice of Santa Cruz County boasts an enviable quality score (called a STAR RATING) of 4 stars out of 5, while affiliates of the Florida-based group show a collective quality score of just 2.5.??

According to Bill Taylor, president of DataSharks consulting and hospice data firm, “Based on our statistics, alignment with a larger entity appears to result in patient care scores that are far worse than the average independent hospice provider.” ? For instance, he says, “It is disappointing to me that the primary hospice in our nation’s capital – once the flagship nonprofit hospice in the country – now has one of the worst quality scores in the US.? Following their affiliation with a larger provider, their quality has dropped to a two-star rating.”? Taylor explains, “It appears that an affiliation weakened that organization.? It did not make them better.”? These scores come from a survey called the Consumer Assessment of Healthcare Providers and Systems (CAHPS).? It is?a standardized survey that measures the experiences of family caregivers and patients who received hospice care.

Taylor has worked with hundreds of hospice providers over the last 15 years.? He says, “A key focus for me is working with troubled hospices that want to raise both quality scores and financial performance.”???

Before moving to California in 2014, my hospice career was primarily shaped by years of work at Journeycare (previously Midwest CareCenter) in Chicago.??At the time, the CEO of the National Hospice & Palliative Care Organization referred to our agency as one of the top three in the country in terms of quality of care, innovation, culture, and leadership.??In the months following my departure, Journeycare engaged in a three-way merger with two other legacy nonprofit providers.??The boards and leadership of those three institutions happily swallowed the consultant’s guidance . . .? hook, line, and sinker.??They were told that achieving scale is the only way to survive the future.??Becoming bigger and bigger and bigger was the silver bullet that would bring sustainability.?

Following the merger, Journeycare became the largest end-of-life provider in Illinois.??The combined hospices cared for 2,500 patients daily in a metropolitan market of nearly 10 million people.??Collectively, the new organization employed 800 healthcare professionals and generated over $100 million in revenue.??But by 2021, it became clear that merging and getting bigger did not yield the anticipated results.??By 2022, Journeycare was sold to Addus HomeCare (NASDAQ: ADUS)?for $85 million, ending the organization’s independent and nonprofit standing.? Since no one I worked with remains at the company, I have assumed that organizational history, expertise, and culture have evaporated.

The last project I championed at Journeycare was raising $15 million to build a three-story, five-star hospice residence and healing garden.? During the capital campaign, my husband Joe and I made a $10,000 gift to name a portion of the healing garden after his younger sister, who had just died.? Less than 10 years after Addus took ownership, we received a letter informing us that the property was no longer a hospice residence and likely to be sold.? As a result, the letter stated, “The garden plaque installed in memory of Joe’s sister has been removed, and we are writing to inquire if you would like it shipped back to you in California.”? Ouch!? It made me wonder if the million-dollar donor whose husband’s name was on the front of the building was receiving a similar letter.

Clearly, bigger does not mean better. ?Better means better.? This month’s news headlines for Addus include the following paradox: “Addus HomeCare’s Promising Earnings May Rest On Soft Foundations” (Yahoo Finance 11/12/24) and “Addus HomeCare seeks more acquisitions” (Modern Healthcare 11/6/24).

Being focused on financial results is a necessity for any nonprofit.? However, focusing on being better (as opposed to just being bigger) means embracing the independence that allows us to make decisions that are not always based on business sense or profitability but on what is best for patients and families. What is right? What is good?? What is a loving and compassionate response to someone who is suffering???For nonprofit hospices, reconnecting with the founding spirit that grew out of the Civil Rights Movement is more important than ever.? Sometimes, the promise of profitability comes with a price . . .? and it does not always work out.

Hospice administrators and board members listening to sales pitches to become part of something bigger are really searching for quality leadership. If an organization lacks confidence in its ability to thrive into the future, its dilemma is more about leadership than choosing an affiliation partner. Achieving sustainability and missional relevance is hard work, regardless of the organization's path.? I advise other providers to not give themselves away for an unsecured promise of financial sustainability because your community may lose its safety net, and your organization may lose its soul in the process.