This need is related solely to the planning horizon of July 1, 1986 established by HRS for Hospice's CON batch and other home health applications filed before the end of 1984. This need is not related to the later planning horizons applicable to District IX home health agency CON applications filed after 1984. Therefore, applicants in batches following Hospice's, which was the last batch submitted in 1984, are not substantially affected by this determination of need.
For the purposes of this hearing, there are only two
(2) denials by HRS of certificates of need for home health agencies in District IX and proposing service in Palm Beach County in CON batches prior to Hospice's (Joseph Morse Geriatric Center, CON Action No. 3621; A Professional Nurse, CON Action No. 3492) that have been challenged in administrative proceedings and are still pending without Final Order in those proceedings.
Thus, Hospice's CON application as a home health agency is, in the worst case, third in line for licensure as a home health agency in District IX, without regard to the special circumstances of Hospice's case and assuming these denials by HRS are reversed in final agency action.
Since there is a need for more than 3 new home health agencies in District IX and Palm Beach County based on the planning horizon applicable to Hospice's batch and no other valid request is pending in Hospice's batch, there is a numeric need for granting a CON to Hospice as a home health agency.
There is a special need for access within Hospice's actual service area in Palm Beach County to home health services for the terminally ill, which services are provided by a hospice as opposed to existing or other proposed traditional home health agencies.
There is additional need for access by the medically indigent to home health services within Hospice's service area in Palm Beach County, and within Palm Beach County in general.
The 1985 District IX Hospice Services Plan provides that hospices generally should be licensed as a special type of home health agency.
Of all pending applicants in this and the immediately prior batching cycles since 1984 seeking a certificate of need to provide home health services in Palm Beach County, Hospice is committed to providing the greatest percentage of its services for Medicaid and other medically indigent patients, in accordance with the State Health Plan.
Hospice, due to its existing and proposed provision of home health services to the medically indigent, its service in Belle Glade, and its service to AIDS patients, as well as its services to the elderly, serves the need for care of low-income persons, medically underserved groups and the elderly.
Hospice can provide higher quality of home health care to the terminally ill in its service area than any other existing home health provider or current applicant for a certificate of need to provide home health services in Palm Beach County.
Hospice offers a new type of home health service within its service area for terminally ill patients and their families, including a special pediatric program for children with irreversible diseases. This type of service is an alternative to inpatient care, nursing home and traditional home health services.
The applicant home health agencies affiliated with hospitals in District IX in Hospice's batching cycle have not shown that they can achieve greater economies or improvements of service than Hospice.
Hospice provides the following research and health educational facilities: a) rotational internships for fourth- year medical students at the University of Miami Medical School;
training for R. N. candidates at Florida Atlantic University;
research support service to the Tropical Disease Center and Palm Beach County Public Health Department through Hospice's care for AIDS patients in the Belle Glade area; d) training for graduate students in psychology at Florida Atlantic University;
e) training for seminary students at St. Vincent's Seminary in Boynton Beach; f) training for candidates for master's degrees in social work from Florida State University; and g) designation as second research and training site by the International Hospice Institute, an international research and professional education accrediting institution.
No other home health agency in Palm Beach County provides or has proposed to provide the research or educational facilities referenced in the preceding paragraph.
Hospice proposes to control its home health agency rather than to allow the home health agency to control its hospice functions.
Hospice will have a positive effect on the clinical needs of health professional training in hospice care and related services in District IX and will make such training available to health professional schools.
Hospice's proposal, which is based on a conservative growth projection of its historical patient service care needs, demonstrates the immediate and long-term financial feasibility of Hospice's non-profit project goals.
Hospice's provision of home health services under a certificate of need will have a positive effect on the costs of and charges for home health services for the terminally ill and their families.
Due to its inpatient hospital capability, Hospice is a regional resource and teaching center for the care of the terminally ill.
Hospice has a positive impact on competition among providers of care to the terminally ill.
Hospice has a positive impact on promotion of quality assurance due to its accreditation by the Joint Commission on Accreditation of Hospitals.
No other home health agency in District IX is accredited by that national joint commission for provision of home health services.
According to HRS' own determination, the District IX health plan calls for evaluation of home health services needs within the subdistrict of Palm Beach County. Under HRS' determination, that county subdistrict needs five additional home health agencies without regard to the special needs of the terminally ill.
In addition, the 1985 District IX plan for hospice health services provides that hospices should be licensed as special home health agencies.
Nothing in the 1985 District IX Health Plan suggests that "surplus" home health agencies in other District IX counties can provide access to service needed by the terminally ill and their families within Palm Beach County.
According to HRS' determination, the provision of the State Health Plan addressing home health services deals with access of Medicaid and medically indigent patients to home health services. Hospice's proposal meets this goal of the State Health Plan because Hospice will provide 25% of its care to the medically indigent, even if Medicare reimbursement is available as a result of CON approval and home health agency licensure.
On a percentage basis, Hospice proposes to provide 3 times more home health care services to the medically indigent than any other District IX applicant in its batching cycle and even a greater incidence than any District IX home health agency applicant in the immediately preceding batching cycle.
Hospice's proposal also satisfies other goals and priorities of the State Health Plan not considered by HRS, including but not limited to the continued fostering of the hospice care alternative, potential increased provider
participation in the Medicaid home health services program, and creation of funding mechanisms for hospice care of the medically indigent.
Hospice is the only hospice program located within Palm Beach County providing and proposing to provide home health care to terminally ill patients and their families in its service area.
Hospice can provide a higher quality of home care for the terminally ill than any other existing home health care provider in Palm Beach County due to its accreditation by JCAH and qualification for the Medicare hospice program including home health services.
Hospice's home health care, due to provision of additional hospice services, and continuity of home health personnel serving each patient and patient family, is also more appropriate for the terminally ill than other traditional home health services.
Hospice's on-call home health personnel must, by Hospice policy, reside no farther than 30 minutes from patients to be served on a round-the-clock basis.
The 1985 District IX Health Plan endorses the 30-minute travel maximum for provision of hospice care at home.
Even prior to Hospice's provision of service in Belle Glade, nearly one-third of Hospice's patients were members of ethnic minorities.
The Belle Glade area served by Hospice is populated by ethnic minorities in need of home health care service.
Hospice's development of a special program to serve AIDS patients in Belle Glade and throughout Palm Beach County will make needed home health care available to this underserved group.
Other home health agencies recognize the special type of home health care provided by Hospice through their referrals to it.
The existence of the Gold Coast Home Health Agency serving Broward County was the basis for HRS' determination that of all five applicants, only Hospice did not meet the criterion in Section 381.494(6)(c)6, Florida Statutes, evaluating the need for special services in adjoining areas.
Both traditional and hospice-based home health agencies exist in adjoining District IX areas.
Hospice has at present a paid staff of 33 and approximately 270 volunteers.
As shown in its financial statements submitted with its application, Hospice has a broad base of community support sufficient to achieve its goals with the aid of the Medicare reimbursement mechanism.
Since home health care is a vital component of hospice care, the operation of a home health agency by a hospice is both logically and philosophically a natural outgrowth of the developing hospice movement in the United States.
Hospice has excellent prospects for the immediate and long-term financial feasibility of its project, especially if the regular Medicare reimbursement mechanism is made available.
Hospice served more than 565 patients in fiscal 1985 and currently serves approximately 110-20 patients per month.
Its estimated patient census used to calculate its 1985 and 1986 operating income and expenses in its CON application, therefore, is based on historical data and is conservative.
Since Hospice has received approval for the first free- standing inpatient facility for the terminally ill in Florida, it will serve as a regional resource and training center for care of complex cases. Hospice, unlike any other applicant, will offer services complementary to home health care not available in adjacent service districts.
Hospice's market entry as a licensed home health agency should stimulate other hospices to seek to meet the rigorous JCAH standards.
Hospice provides many services not offered by traditional home health agencies at per visit charges that are competitive with those presently charged by those agencies.
Hospice's market presence encourages competition among all home health agencies serving Palm Beach County, particularly for care of patients who are terminally ill or in the near-final stages of a catastrophic illness.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties and subject matter of this proceeding.
HRS must determine whether Hospice's application to establish a home health agency in Palm Beach County should be granted under the criteria contained in Section 381.494(6)(c), Florida Statutes (1985), and any additional criteria in Rule 10- 5.11, Florida Administrative Code.
Section 381.494(6)(c) contains 13 separate criteria, plus subparts, that must be used by HRS to evaluate Hospice's CON application.
A "balanced consideration of all the statutory criteria" is required in evaluating Hospice's CON application. Johnson and Johnson, supra, 447 So. 2d at 363.
The only criteria in Section 381.494(6)(c), Florida Statutes (1985), that are not applicable to this case are the criteria contained in Sections 381.494(6)(c)10 (health maintenance organizations) and 381.494(6)(c)13 (costs of construction). In addition, Section 381.494(6)(d) is not applicable to this proceeding.
In light of the findings of fact set forth above, and based on a balanced consideration of the criteria in Section 381.494(6)(c), Florida Statutes, Hospice satisfies HRS' statutory requirements for issuance of a CON as a home health agency. Hospice's application should therefore be granted.
Approval of this CON application should be predicated upon Hospice's commitment to provide 25% of its patient services to Medicaid patients and the medically indigent, unless Hospice seeks to modify this commitment pursuant to Section 381.494(8)(g), Florida Statutes (1985).
Finally, because there is no requirement in Chapter 400, Part III, Florida Statutes, that a home health agency operated by Hospice be autonomous, there is no statutory impediment to Hospice's operation of a home health agency as a subdivision of its existing hospice organization. See Section 400.462(2), Florida Statutes (1985).
