Hospice of the Valley: Redefining the End-of-Life Care Delivery Outlook
Hospice News
Feb. 10, 2025
by Holly Vossel
Rising competition in the hospice space has fueled pivotal changes in end-of-life care delivery — both for better and for worse, according to Arizona-based Hospice of the Valley Executive Director Debbie Shumway.
Healthy competition can be a good thing, driving innovation and quality improvement, Shumway stated. More providers can also mean greater access during a time of growing demand among swelling aging populations. However, some hospices are competing in increasingly crowded and unfair markets that have become wrought with program integrity risks, Shumway recently told Hospice News.
The difference between hospices thriving and surviving will in part hinge on much needed changes in the regulatory and reimbursement landscape, she said.
Walk me through Hospice of the Valley’s history. When was your organization launched and how has it evolved since then?
We began in 1977 as a nonprofit hospice, and we are still a nonprofit today. We were really birthed out of a church basement. One of our community members was a pastor of the church here and became interested in the concept of hospice when it was first introduced. He was so intrigued that he gathered a few volunteers and began Hospice of the Valley, which was largely a volunteer organization living off of a few grants here and there prior to when hospice Medicare reimbursement came around in the early 1980s.
There was a lot of community involvement. At that time, people didn’t really understand the concept of hospice, not that everybody does today. Over the years, Hospice of the Valley has grown. When I began 30 years ago, we were caring for about 140 hospice patients on any given day, and we had just shy of 100 employees.
We’ve expanded our programs beyond hospice care. Today, we have more than 1,800 employees with more than 6,000 patients in a variety of programs that we support each day. Really, our focus has been around serving all in need, regardless of their ability to pay. As a nonprofit, that’s been incredibly important to our community, to our board and, quite frankly, to our employees.
How has your organization expanded beyond hospice care? What are the other services or programs that Hospice of the Valley offers?
At least half of our census receives services that are not hospice. Where we started providing care is with adult and pediatric hospice and palliative care. While most care is provided wherever a patient calls home, we [also] have nine hospice inpatient units, which really serve to support patients that might be dealing with pain management issues or the family needs respite.
One of these hospice units is for pediatric populations. It’s very special, because everything from the moment you walk in focuses on serving children and their families. It has been an important part of really supporting the pediatric community, in addition to working with the hospital systems that are focused on caring for pediatric patients. Having that continuity with those providers, whether it’s hospice or palliative care, and really working alongside those team members helps to create the best care possible for those kids and their parents.
We also have a home-based primary care practice called Geriatric Solutions. The program came to fruition roughly nine years ago because the community would call and there would be a need for someone who might not be eligible for hospice, but who needed a certain type of care. Geriatric Solutions was about being able to be that patient’s primary care provider when they were too ill to go see one. We do what we can to support them, to help them get stronger and able to get back into their primary care provider, avoid utilizing the emergency department and improve their quality of care.
We also built a campus a couple of years ago that has an adult day club for individuals in the early stages of dementia. We have a very small assisted living facility, and we have a hospice inpatient unit there also. The campus has a child care preschool program operated by the YMCA. Those preschoolers interact and participate in activities with our adult day club members every day, and it is honestly magical. We have an education center on that campus. What we hear a lot from community members is that in addition to getting some more tools, they’re also able to connect with others that are going through the same journey.
Some hospices have embraced service diversification while others have remained focused on end-of-life care. What are some of the challenges and opportunities in service diversification?
As far as opportunities, it’s educating the community on the different services you have. It’s hard to help them understand all the different levels of care. How do we continue to raise awareness around all these amazing services and also what hospice can provide?
The challenge with palliative care is how it is funded and defined. We call our palliative program Arizona Supportive Care, and Medicare does not fund these services in the same way that hospice is reimbursed. It’s reimbursed for the clinician or provider visit, versus more of an interdisciplinary team approach. Some insurance companies have realized how these services reduce unnecessary hospitalizations and readmissions, and how a stronger reimbursement model is needed for this interdisciplinary approach in the home. But payment is a big obstacle we’ve got to figure out as a society, because the care is needed.
Are there any new services, locations or innovative programs in the works that you’d like to highlight? What drove these initiatives forward?
We expanded into the Tucson, Arizona area about a year ago. We have an incredible team in that geographic market that really knows what the community needs. That local leadership and local connection is so important.
Additionally, starting in July we are participating in the [Guiding an Improved Dementia Experience (GUIDE)] payment model. We essentially will be providing dementia care education in the home. We have actually had the program going for the last five years, but we are very excited to think about how this GUIDE demonstration could help show Medicare the benefits of providing palliative care components to those dealing with dementia. We have almost 100 patients on these services already. I think we’ll be able to show strong results both on the patient side receiving great care, but also how it reduces caregiver burden. We’re looking at other areas in our state of where this makes sense to branch out into.
What are your biggest concerns as a hospice operating in Arizona, among the four states facing difficult program integrity challenges? How are you addressing these issues?
We are in one of several states that have experienced huge growth of hospice operators coming in for the wrong reasons. We went from somewhere around 150 hospices in Arizona to more than 500 hospices in a matter of a few years. I think we literally had one strip mall in our state with about 29 hospices in it, which is incredibly concerning to us. When the moratorium in California hit, many folks packed up their bags and headed to states like Arizona, Texas and Nevada. There are other states experiencing this competition.
Competition is a good thing. But the competition that we’re looking at in our state and others is really not about these folks providing good hospice care. For the bad actors, it’s about selling licenses, with patients who do not qualify for hospice on these services and people who are sadly unaware that they’re being taken advantage of.
Fraud has become such a huge concern in Arizona and these other states. Quality providers are really being impacted by it, and we’re really trying to raise awareness and work closely with the state to address it. There’s just not enough resources. So many hospices were certified during the pandemic online and got deemed accreditation statuses as well. It’s just not okay and quite shocking that they can choose to receive a slight reimbursement reduction and avoid quality metric reporting and remain off the radar.
Where do you see the future of hospice care delivery heading?
The future is always grounded in making sure we’re focused on patients and families, and being able to provide what they need and want, which is a continuum of care. We need to listen to what they and their families are asking of us if we’re ever going to hit the mark. Expanding services to them prior to Medicare’s current definition of hospice is how an individual has support that really walks alongside them. That is the future. We need to create a level of reimbursement that works within the Medicare system for a longer period of time. Right now our health care system continues to be so fragmented. We need to redefine what hospice looks like.
Our reimbursement in hospice is going to need to look different in the future. Maybe paying for performance and quality results makes sense, but data will be a large key in the hospice world. We don’t always have information about someone before they enter hospice. If we better understood what’s going on, then we’re able to affect change better and create better reimbursement models. Some payment value-based demonstration projects have already given us that information. Among the examples was the [Medicare Care Choices Model (MCCM)] and looking at what worked and what didn’t. There were some flaws, but the takeaways were that guardrails are needed to help palliative care from becoming a runaway train. If we [have] a model that covers the full range of palliative care, that’s a huge opportunity for hospice providers in the future. There is so much opportunity to expand beyond the traditional hospice care we know right now.