This month I had the absolute pleasure of sitting down and speaking with Natalie McNeal, Executive Director at WellStar Community Hospice, part of WellStar Health System. Natalie was so much fun to speak with. Below is our conversation and the topics include:
What got Natalie interested in hospice
Why Natalie cares about emergency preparedness
How you can prepare your hospice for emergencies
Natalie’s advice to other hospice leaders
Natalie [00:00:49] I am really enthusiastic when it comes to Emergency Preparedness. So, the regulations changed in 2017. November of 2017 and before regulations for Emergency Preparedness were more of a state level or accreditation standards (ex. The Joint Commission) that agencies had to meet but it became a national standard in 2017. Emergency preparedness is fairly new to many hospices.
Seth [00:01:34] OK. So it sounds like a situation where you should have been doing it before and now you actually might get in trouble if you don't have a plan in place?
Natalie [00:01:44] Right. And it can be really daunting and overwhelming the way in which the regulations were written with concepts we had not utilized in our industry in the past. In Emergency Preparedness there's something called an “All Hazards Approach.” Basically this says that your processes should be essentially the same every single time regardless of the situation. Granted there's going to be a few small differences in specific situations but your overall approach should be the same. The authors of the 2017 regulations wrote them in a format outlining requirements for multiple health care sectors in this one document. This document seems very long due to so many types of providers being incorporated at once. Say for example you have a section on testing. It says if you’re this kind of provider you're going to do this kind of testing and if you're this kind of provider you're going to do this. If you were to take out just the pieces that apply to hospice, it would be a fraction of what that document actually is. Initially it seems daunting because you see page after page of items that you must comply with, but then it becomes more manageable after sorting through the items directly pertaining to your agency.
Seth [00:03:18] Yeah it sounds like it. Natalie, I’d love to learn a little about your background and what got you into hospice.
Natalie [00:03:47] My mom's youngest sister was born with hydrocephalus and she had a procedure that was supposed to be a miracle procedure when she was a baby. It actually ended up making things much worse. She learned to walk when she was seven. And by the time she was nine she could no longer walk because her condition deteriorated. It took her a long time to meet developmental goals and then she lost those very quickly. As an adult she was blind and deaf. She was completely bedridden and she couldn't speak. I watched my grandparents take care of her and as they aged they had to look at other options and that of course included a nursing home. They physically could not lift her and care for her in the way that they had when they were younger. My grandparents grappled with that decision. I think that we all expect at some point that we might have to deal with a long term care for our parents or grandparents and we see that as part of the aging process. But it was really hard on my grandparents because it was their child and they never expected to have to allow someone else to care for her. There was a program called Money Follows the Person in the state of Georgia. They call it something else now but my grandparents were the first people to participate and they were able to bring her home with financial assistance to hire someone to assist with the physically challenging care tasks. She loved her last few years at home. And that long story brings us to why I went into nursing home administration. I wanted to create a place that a parent felt like they could place their child and have peace of mind that the care met their expectations. Most nursing facilities were not designed for younger people. Working in the nursing homes industry, I was exposed to the hospice philosophy of care. One of the hospices we utilized noticed that I had a passion for hospice and had been contemplating adding a nursing home administrator to their program to better meet the needs of this population. I thought, “You know what? This is a good time in life to change what I'm doing and I knew this was a great opportunity.” In hospice I have learned that there is a general gratefulness for the care my team provides.
Seth [00:08:37] Yeah. People often say that home care and hospice workers are angels on earth.
Natalie [00:08:42] Yes! You never know the safety of a situation you’re going into and what the general condition is going to be. People choose to live in situations that others may not be comfortable with, but that is their choice. Our team has to really meet people where they are and it can be hard to understand when they may not choose the same situations for themselves.
Seth [00:09:25] Absolutely. Well that was an awesome backstory. Thank you for providing that.
So you know we at SONO work a lot with executive directors and administrators of hospice. I would love to hear about the biggest challenge you're facing right now as your role and as an executive director.
Natalie [00:00:33] For me, it's GIP care. We have two inpatient hospice units and are part of a system that embraces the full continuum of care. But GIP care is only reimbursed at about 80 percent of the costs that incurred. Because the goal of hospice is to keep patients in their homes, the reimbursement was allocated to home care. It can be difficult to justify the expense of having two inpatient units in a relatively small geographic area. My hope is that the proposed changes for hospice reimbursement will better support the operational needs for the GIP level of care. I'm really excited about what that's going to look like. But at the same time, from an industry perspective, I'm worried that more hospices will open hospice units to directly serve this level of care but won’t have the expertise necessary to deliver a high quality of care from the start. I do think they will achieve quality through performance improvement initiatives eventually, but with anything new is difficult to achieve quality without trial and error.
Seth [00:01:43] Absolutely at the beginning. So what steps are you at WellStar taking to put yourself in a position where that's not going to be a challenge for you? How do you plan to overcome that?
Natalie [00:01:57] So from the reimbursement perspective we talk a lot with our system about the financial impact that hospice has on our system through reduced mortality rates, shortened length of stay, and reduced readmission rates back to the hospital. These metrics, along with improved care, honoring patient preferences, and our system goal of a full care continuum, are areas where we are able to justify our value. Our system leaders have been very accepting and have provided resources to ensure that we provide excellent care. From an industry perspective, I don't know that there's a lot that we can do other than direct hospices expanding their GIP services to industry resources on quality practices.
Seth [00:02:45] Well it sounds like you're on it and you're in a good position for that. So good for you. Kudos. Why don't we jump to question 3?
Interestingly enough, you seem to be well known in your industry for your emergency preparedness. What makes this so important to you and why are you so passionate about it?
Natalie [00:03:24] Well I think there are a lot of parallels between emergency preparedness and hospice. To start off, I enjoy the challenge of hospice in that we leverage resources to help patients with terminal illnesses as they encounter exacerbations of symptoms related to their disease process. We know that sometimes there's agitation, increased pain, anxiety, restlessness, or issues related to breathing as the end of life approaches. We have care plans to address these symptoms utilizing various interventions that include medications in the home, complementary therapies, and spiritual and psychosocial support. We try to be proactive and ask how can we be best prepared to make this as easy of a transition for the family and the patient as possible. I feel like emergency preparedness is very similar. We might know that a storm is coming, but we don’t know the path of the storm. We anticipate the path of the storm and the complications it will bring and then we prepare for these scenarios. How many times have we cancelled school in the south because we think it's going to snow and then it does not snow and people are like “Oh great, we cancelled school because it's 20 degrees outside.” In hospice and emergency preparedness, we make decisions based on what is a high probability and prepare our resources accordingly to best meet the needs of our communities.
Seth [00:04:45] Haha, right.
Natalie [00:05:16] So I think there's a lot of parallels and I think that's why I find it interesting. Just this past weekend, our competitor had to evacuate their inpatient unit. We received the first call at about 9:00 p.m. and by 2:00 a.m. we had their last patient in our building providing care for them. Had we not had our plan in place as to how we would handle a surge, those patients would have been in limbo and it would have taken a lot longer for them to move and get settled. We already had agreements in place with the other hospice. Because we've practiced our plan, our team knew exactly what to do and how to handle the situation. It didn't go perfectly, it never does. But we anticipated the things that would happen in our exercises and walked through the process with our teams when there was not an emergency and they were able to incorporate the concepts into this situation. We've done a lot of testing with our plan. How would this look. How would this work. I believe if you prepare for a situation it probably isn't going to happen. But when an emergency does occur and you have tested your plan, you're prepared because you have practiced and you understand how to approach the situation. A year and a half ago in one of our buildings, we had a fire incident and, again, the staff knew exactly what to do and how to handle it. They were calm and the patients at the end of the night were giving my staff hugs and told them, “thank you so much, I felt like I was so well cared for the entire time.” We have a hospital that is right across the street from this unit. The hospital team heard that the patients were moved outside because of the smoke, so they brought down warm blankets fresh out of the dryer. They brought cookies because they knew that we couldn't get into our kitchen until the Fire Department cleared for our patients to come back in. We had a relationship with a provider who was more than willing to help us in our time of crisis. It was amazing. Having been on both sides of an emergency, helping another hospice relocate their patients and then on the other side having a hospital help us, I feel that there's a real sense of community when relationships have been established. Even though it's a potentially horrible experience, the patients feel like their needs are met.
Seth [00:08:40] Absolutely. I love that. I love that answer. That was great.
Say you had a friend who's also an executive director or administrator of a hospice and they're starting from ground zero on emergency preparedness. What steps would you recommend they take to get a process in place where they can be as prepared as they should be? Not just for the regulations, but for the good of their patients?
Natalie [00:09:07] So I actually came up with a list and I sent it to my contact at our local EMA to be sure I was not making this too simple.
Here’s the list:
1. Read the regulations/industry resources and design your policy accordingly based on hazard vulnerabilities.
2. Educate your team on the policy.
3. Test your plan-make it realistic, but have some fun.
4. Go to your coalition meetings or reach out to your community-understand your role during an emergency and what resources are actually available.
5. Don’t forget to complete your after action review!
So the first thing I always say is of course read the regs. Read your industry resources. NHPCO has a lot of information out there. If you're accredited by CHAP, The Joint Commission, or any similar accrediting body, read those resources because they're going to help you figure out how to organize your plan. You will need to conduct a hazard vulnerability analysis which is referred to as an HVA. This helps determine your areas of highest risk in your geographic area so that you can design your plan around that.
The next piece is talk to your team educate. I don’t know that you can overeducate on this topic. During an emergency, people remember what you've talked about and practiced. There are really fun ways to educate your team on this. There are tabletop exercises and full scale exercises. The regulations spell out the required combination of exercises.
The third thing is to test your plan.
It needs to be realistic but you need to have some fun with it. My feeling is that if you don't have fun at work you're not going to come back and if you're not having fun during education you're going to tune out and not learn anything. Keep it light but take the time when you test to talk about why you're doing things. The more people know why the more likely they are to do it when the time comes.
The next one is probably my favorite one and it's go to your coalition meetings and reach out to get to know the people in your community. It is extremely important to understand what your organization's role is and what the available resources are. For instance many people think there are unlimited resources stored somewhere, but there probably aren’t. So, once you know there are only a limited number of provisions, you are able to determine what items you will likely need to have on hand instead of relying on false assumptions. We have an excellent coalition here. Our state has coalitions and every state has them. But our coalition has taken a real interest in bringing people together and assisting each organization in testing their plans. They know that we are prepared for an emergency and if I'm asking for something, it is a true need. We have built a trust in each other through the coalition meetings, which is helpful to establish before an actual event.
And the last thing is that after you do your test or you have an actual event, you must complete your after action review. That’s a document that's provided by CMS and it's long but it goes through questions like:
What went well?
What system did you test?
Where do you need to improve?
Who's going to make the improvement?
In order to meet your regulatory obligations, you have to conduct an after action review. It helps you evaluate your plan and determine if changes are needed. Sometimes your plan doesn't need to be updated, sometimes there are a few tweaks, and sometimes you realize, “whoa that is not at all how we do things. We need to change this in our plan because if somebody relies solely on that during an emergency they're not going to be successful.”
Seth [00:14:38] Those are great things. I think people are going to love those.
Natalie [00:14:41] Yes. And my EMA contact recommended adding in some links. Specifically, a link to the list of coalitions like the one we participate in. So many people don't know their coalitions exist.
Seth [00:15:06] OK. Yes I will. I will try to find that and add that to the article. I think that'd be great.
Natalie [00:15:11] He also recommended for you provide the link to the Centers for Medicare and Medicaid Services. They have an E.P. link that has a lot of great resources.
Seth [00:15:36] Well so the last question I have is, “If you could leave the hospice community with one message not necessarily related to emergency preparedness but just as an executive director serving the hospice community, what would you say?”
Natalie [00:15:51] I would say. Your team is really important and we become desensitized to the incredible work that we do; just like people become desensitized to the violence in video games. It's the same concept. We need to remind our staff and our leaders that what they do is not routine in the normal life of our patients and their families. Keep that at the forefront and remember the impact that this work has on others, and just because we do it every single day does not take away the importance from those that we serve.
Seth [00:16:33] I think that's beautiful. Thank you for sharing that.
Natalie [00:16:37] You're welcome.That’s the end of my conversation with Natalie. As you can see she has a wealth of knowledge related to EP and hospice in general. To connect with her, check out her LinkedIn page here.
Thank you for reading and I hope this was helpful in your emergency preparedness.
Project Director of SONO Hospice Solutions
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