Elusive blessing: Some Washington providers say state certificate hinders hospice care

There came a point when Susan Kilgore was no longer able to care for her ailing husband, Dale Goble, on her own. Even with help, she was struggling to meet his needs and running out of options.

“I had hired somebody else who would come at night and somebody who would come and help me move him from chair to bed and all of this stuff, but they were all kind of halfway measures,” she said.

The help the couple needed ended up coming from hospice care.

Kilgore, a Moscow resident, is one of the many family members of people who benefited from hospice. Hospice allowed for additional care and medical equipment that improved both Susan’s and Dale’s quality of life, she said.

“I think hospice made the difference between a good death and a bad death for us,” said Kilgore said, whose husband died in April.

Hospice generally provides care for patients expected to live six months or less, but can be renewed for longer.

It offers services such as access to nurses and home health aids, help with pain management and medical equipment, and spiritual and bereavement counselors. Providers often say the service is misunderstood and underutilized.

But in the past year, even among families who wanted hospice, fewer were able to access services like the kind Kilgore’s family got. That was especially true in Whitman County, where this spring, patients faced a 12-week waiting list for the county’s only hospice provider.

“Most people would already be dead, if they had to wait that long to be admitted,” said Elizabeth Hillman, director of social work and care coordination at Pullman Regional Hospital.

Wait times dropped back down this summer after Kindred Hospice was able to hire more nurses, and another agency, Elite Home Health and Hospice, started providing care in Pullman using an emergency COVID-19 waiver.

A nationwide nursing shortage and challenges hiring in a rural community are partially to blame for the shortage. But

Hillman says another cause is Washington state rules regulating the number of hospice providers — and it’s been a frustration for her and other providers since before the pandemic.

In Washington, hospice care is regulated by something called a certificate of need. Only agencies that hold one can provide care, and Kindred is the only hospice provider with it in Whitman County.

According to the state Department of Health, the certificate of need program is used to “ensure access to needed, safe, and affordable care within the communities of Washington.”

DOH uses population and “utilization” rates to determine the number of certificates of need a county receives for any given service. The department also offers a mechanism to measure “unmet needs.” Its full methodology is posted on its website. But DOH doesn’t account for, or have a protocol to, monitor providers’ admission rates.

“You don’t have to let the public know that like, ‘Hey, I didn’t end up admitting these 10 patients because I was gonna make them wait six weeks and they weren’t going to need me anyway,’ ” said Ashley Contreras-France, the director of business development at Elite Home Health and Hospice. “Or, ‘I didn’t end up admitting this patient onto hospice because I have a 12-week wait and they died at week three.’  ”

According to a statement from DOH, “the current methodology measures utilization of hospice services in the respective planning areas. … As we look to modernize the CN program (the admission rate) may be one area for further consideration.”

The state also doesn’t account for the difference in how population density in a county affects how many patients one provider can serve, Contreras-France said.

Large counties with a bigger geographic range can end up with one provider, and smaller, population-dense counties end up with more.

When Elite started providing care this spring, Contreras-France said it had to limit its services to the city of Pullman to provide adequate service.

Hospice providers like Elite that have been using the emergency COVID-19 waiver have also been hesitant to hire for positions when they’ll have to eliminate them late this month when the waiver expires.

“We couldn’t in good conscience hire anybody to work in Whitman County,” Contreras-France said, “knowing that effectively we would have to fire them because we can’t support their job after Oct. 27.”

Elite was asked by some providers to consider applying for a second certificate of need in Whitman County, Contreras-France said, and did submit a letter of intent to the state.

But right now, it doesn’t seem likely to move forward, she said. The state does not generally issue certificates of need if its own methods don’t demonstrate a need.

“What the community has reported has not led to the state opening another (certificate of need) for Whitman County, or started an inquiry into needs within Whitman County and if those needs are being met with the current and only provider,” Contreras-France wrote in a follow-up email.

Hospice providers are also charged a $24,666 application fee. Between June 16, 2019, to now, the state approved 24 applications and denied 37.

Kindred’s hospice care also is not contracted with several of the major insurance providers in the area, Hillman said, including the one for Pullman Regional Hospital’s own staff.

“If I was dying, I couldn’t have Kindred Hospice,” Hillman said.

Kindred’s public information officer did not respond to requests for comment for this article.

Of the service Kindred Hospice has provided, Tanya Carper, a Pullman resident, said the care was “wonderful.”

Kindred helped her mother in her final months before she died with things like managing dementia symptoms, taking showers and staying on top of prescriptions.

“It was a very peaceful dying (process), there was no trauma at all. But the hospice nurse was there, and he was doing all the paperwork that needed to be done,” Carper said.

The problem with hospice access isn’t the quality of care or one agency, Hillman said, but patients being limited to only what the state will allow.

Today, the waitlist is back down to pre-pandemic standards averaging around five days, Hillman said, but she still considers that too long.

Hospice is one of the only end-of-life services covered by Medicare and Medicaid, Hillman said, so if there’s ever delays in service and a family can’t afford a respite bed at an assisted living facility, it doesn’t have any other option.

“The certificate of need inhibits healthy competition,” Hillman said. “It doesn’t matter if you’re five days out, if people can’t go anywhere else, they have to wait.”

Not all counties have struggled as much as Whitman, Hillman said, though several have benefited from the COVID-19 waiver that allowed other providers to step in.

“I don’t understand why they think (the certificate of need) benefits communities,’’ Hillman said. “There’s no statistics, no data to show that it is still effective. But we have been collecting data for March, April, May, June, proving that it’s not working for us.”

Many families are hesitant to get hospice care immediately. But Contreras-France said she’s worried about the system as it is. Even people who understand the benefits may be unable to use it.

“I would say that the tragedy that’s happening right now is that people that want hospice, that understand the benefit — the community that understands the benefit hasn’t been able to get it,” she said.

Sun may be contacted at [email protected] or on Twitter at @Rachel_M_Sun.

This report is made possible by the Lewis-Clark Valley Healthcare Foundation in partnership with Northwest Public Broadcasting, the Lewiston Tribune and the Moscow-Pullman Daily News. It was produced with assistance from the Public Media Journalists Association Editor Corps funded by the Corporation for Public Broadcasting, a private corporation funded by the American people.