FRONT RANGE HOSPICE: Recognized by the Studer Group as Health Care Organization of the Month

May 1, 2015

FRONT RANGE HOSPICE: Recognized by the Studer Group as Health Care Organization of the Month

The Studer Group is a Health Care consulting firm that has a large base in the United States and is also in Canada, Australia, and South East Asia. “Studer Group partners with healthcare organizations to build a sustainable culture that promotes accountability, fosters innovation, and consistently delivers a great patient experience and the best quality outcomes over time.” says BG Porter, the CEO of the Studer Group.

Front Range Hospice has been recognized by the Studer Group as the first hospice to receive HealthCare Organization of the Month for May, 2015. This award is given to a Health Care Organization that achieves excellence in employee retention and patient and family experience of the care provided. This is the first time this prestigious award of excellence has been earned by a small hospice. “When the heart and the intention are given proven tools, amazing things can happen” says Pam Ware, MSW, LCSW, Founder and CEO of Front Range Hospice.

Ms. Ware practiced oncology social work for twenty five years, providing support and education to cancer patients, especially those that were considered terminal and had chosen very aggressive treatment. After twenty five years she wanted to do more to improve end of life care and create a workplace that supported professionals in the healthcare field to do the work that makes their heart sing. She worked as the Administrator for a hospice in Metro Denver for about three years before investing her life savings into Front Range Hospice, a small hospice that serves North East Colorado.

In 2006, during the startup phase of Front Range Hospice, Ms. Ware made the decision that the agency needed to be aligned with the Joint Commission (JC). JC is considered the gold standard for health care organizations. Front Range Hospice was the first privately owned hospice in Colorado to achieve JC accreditation.

In December of 2011, Ms. Ware,  read Hardwiring Excellence by Quint Studer. She immediately called the Studer Group office and began to explore how she could align Front Range Hospice with the Studer Group. Front Range Hospice began its formal consulting relationship with Studer Group in Feb of 2012.

At the end of 2014, after partnering with The Studer Group for three years, Front Range Hospice’s employee retention rate went from 33% to 98% and the Family Experience of the Care went from below the National average in all six domains to above the National Average in all six domains measured. These domains are: Coordination of Care, Attending to Family Needs, Informing and Communicating about Patients, Providing information about Symptoms, the Overall Quality of Care and finally, the Response to Evening and Weekend needs. These results are achievable once the leadership of an organization sets realistic goals, is transparent in its operations, and hardwires its processes.

“The leadership team and staff at Front Range Hospice have made a tremendous commitment of quality and service to the community. With this commitment came a promise to be relentless in doing whatever it takes to ensure that they not only meet the expectations of those that come to them for service, but exceed those expectations.  I have found that these leaders are never ok with average: they are committed to their belief that their community deserves only the best,” says Donny Cook, Studer Group Rural Regional Account Leader.

The mission statement of Front Range Hospice is to provide Legendary End of Life Care. The mission of the Studer Group is to make healthcare a better place for employees to work, physicians to practice medicine and patients to receive care.  The Studer Group has trained the leadership team on how to create a culture of excellence even in an environment of constant change. “Although the HealthCare Organization of the Month award was given to Front Range Hospice to acknowledge their commitment to excellence it would not be possible if we did not have the trust of the patients and families who chose us to provide their end of life care” says Ms. Ware.

“Health care is constantly changing which means processes need to be constantly analyzed for their appropriateness in our changing environment. The tools we have in place today may not work in the future but with our clearly defined goals, we are capable of changing our processes rapidly” say Lisa Foster, RN, Director of Nursing for Front Range Hospice.

The team at Front Range Hospice and most hospice professionals feel called to do this work. The care providers at Front Range Hospice understand that there are no do overs in end of life care. With the help of the Studer Group, Front Range Hospice has developed into an organization where that passion is ignited and shared with our patients, families and community partners.

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Who Cares For the Doctor?

Who Cares For the Doctor?
By Victor Montour

The hospice concept places the patient and family at the center of care, surrounded by the hospice team.  This last month I was forced to look at this concept and found the referring doctor is a loose member of the hospice team we may forget about. The doctor who is involved in the care of their patient may not be involved in the hospice meetings but they are a part of the team.  The potential problem with this model is that after taking care of a patient for a long time, the doctor is often close to the patient and more or less, emotionally attached.  Referring a patient to hospice may result in a significant loss to the doctor. Who cares for the doctor now?

Most hospices usually do not maintain a close conversation or bond with the primary doctor. The hospice sends the required paperwork and calls with the occasional emergency, but often the next significant contact after the original referral, is to notify the physician of the patient’s death.  For those doctors who are not comfortable with end-of-life care, this professional and functional distance may be acceptable.  However, for many doctors who fight fatal diseases month after month or even year after year in each patient, the loss of connection is draining.

This last month Front Range Hospice again raised the bar on quality. We do and will say, “Hey doc, how are you doing? This must be hard on you.”  The doctor’s loss and pain should be acknowledged. Generally, that is OK.  It is not the job of the health care system to heal a physicians wound, but the right thing to do is to reach out to that doctor, offer a caring gesture of concern and willingness to support them during a time of loss. I can’t help but wonder if one of the causes of the late hospice referral is the abrupt severing of invested patient-physician relationships.  Front Range Hospice cannot and will not ignore the pain which comes from loosing patient after patient and having no one say, “Are you alright?” This is just another way Front Range Hospice stands out from its competitors.

Front Range Hospice is committed to supporting all care providers closely involved in the care of our patients. After all the doctor explains hospice to the patient and family, they make a point of saying that they will still take care of them, that they would be closely involved and that the hospice is not “taking over.”

We as hospice providers must remember that doctors are human and, not rarely, they fall in love with the patients and families held gently in their hands.  Perhaps, sometimes, it might help if someone would hold the doctor as gently and say, hey doc, we care about you.

If you would like more information about Front Range Hospice and how we support and care for all of our healthcare providers and partners please call 303-957-3101 or 970-776-8080 or email us at

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Volunteering at the End of Life

Volunteering at the End of Life
By Victor Montour

In honor of National Volunteer Week Front Range Hospice would like to take a moment to say Thank You to our wonderful volunteers. Your selfless acts of kindness and unwavering strength are appreciated by all of us at Front Range Hospice.

Hospice care is an end-of-life-care model that focuses on enhancing quality of life when time is short. It involves an inter-disciplinary team – including doctors, nurses, social workers, chaplin, and social worker, — working together addressing the medical, physical, social, emotional and spiritual needs of the patient, as well as providing bereavement support to the family. In keeping with hospices deeply humane and community-service the team also includes volunteers.

“Front Range Hospice Volunteers are an integral and valued part of the team,” says Jen Jackson, Volunteer Coordinator for Front Range Hospice. “They provide that extra level of care and comfort that neighbors used to provide for free, without thinking about it.”

Volunteers provide nonprofessional services but are required to undergo intensive training, including interviews and background checks. Our organization asks volunteers to commit to at least one year of service, visiting with one patient one hour per week in the home or where the patient calls home. This could be in an assisted living, skilled nursing facility or small board and care home. Volunteer services can be as varied as those of any personal relationship and can include but not limited to:

  • Support for patients
  • Respite and support for family members
  • Vigil services (when death is imminent)
  • Bereavement support

Volunteers might sing show tunes with patients, talk about the Yankees, share in watching a favorite soap opera, help compile “final projects” or life reviews and bring in pets for comfort (only at the patient’s request, of course). Fundamentally, volunteers provide the most elemental of life’s needs, a hand to hold or an ear to listen. It’s really about showing up and being present that day, that minute, that hour — meeting the patient where they are.

Sometimes our volunteers are asked if it is difficult to be a hospice volunteer, to get to know someone only to have them pass away. The short answer is no. It is rewarding, transformative and life-affirming. The longer answer involves death as part of the continuum of life, understanding expectations, maintaining personal boundaries and undergoing adequate training and education.

The surprising secret of hospice care is that it’s not depleting, what Front Range Hospice volunteers do is useful, and someone needs them. These patients would be going through what they’re going through whether or not our volunteers are there. Front Range Hospice volunteers, as with all those involved in hospice, understand that death is a part of life. They accept the process.

Some hospice volunteers are inspired to become a volunteer because of the immense support they felt from hospice when their loved one died.  Some hospice volunteers call the work a gratifying, loving experience. There’s no pretense, no façade — just honesty. The bond volunteers have with a patient usually escalates because of the limitation of time, so they have to seize the moment.

Whether you’ve had a family connection to hospice care and want to give back, or are interested in learning more about how to support and comfort those in their final days, I encourage you to explore this truly rewarding volunteer opportunity.

Thank you again to all of those who volunteer. The services you provide are priceless.

If you would like more information about Front Range Hospice and how you can become one of our volunteers please call 303-957-3101 or 970-776-8080 or email us at

Watch out for our next blog: Who Cares for the Doctor?

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Morphine and Pain

Morphine and Pain
By Victor Montour

Hospice advocates good pain control for terminally ill patients, even to the point of using narcotic drugs (we call them opiates) such as morphine as they are needed. With all the concern about drug abuse, patients, families and friends sometimes question the use of narcotics. Are we pushing “dope”? Or are we practicing good medicine? I want to explore some of the myths about the use of narcotics for pain control with you

Myth #1: Morphine is offered to patients only when death is imminent.

It is not the stage or phase of a terminal illness, but the degree of pain a patient is having that dictates which medicine to use. We start low with the mildest medicine and if it works, we stop there. If it doesn’t we move slowly onto the next best level of pain control. We move to morphine when it’s appropriate. Some people never need morphine, while others will require it for quite a while. Patients can live for a long time while appropriately taking morphine for pain control. Low and slow is the best way to progress any pain medication.

Myth #2: People who take morphine will become addicted.

Let’s talk a bit about drug addiction. Drug addicts are people who are driven by their need for narcotics; they may commit crimes or harm others to get their needs met. Hospice patients usually don’t have drug-seeking behavior. When a patient’s pain is in good control, they don’t desire more pain medications. Sometimes we can even decrease the dosage. If patients take morphine for a while, their body may become used to it and it should not be suddenly stopped. Stopping the medication abruptly may cause side effects to occur. Side effects of a medication should not be confused with addiction or withdrawal.

Myth #3: People who take morphine will become so sedated (sleepy) that they can’t function.

When patients start to take medications like morphine or other opiates, they often feel drowsy, this drowsiness usually diminishes within a few days and their bodies usually will very quickly build up a resistance to the sedating effects. Most patients whose pain is well controlled on morphine are not bothered by unusual sleepiness. Some people, however, notice a difference in their alertness and might choose somewhat less than perfect pain control as a tradeoff.

Myth #4: People who take morphine die sooner.

Because morphine is used regularly in hospice, patients quickly adjust to any effect that morphine may have. We prescribe a small initial dose, gradually increasing it if needed. In fact; morphine is a drug of choice for breathing distress, commonly referred to as air hunger, in people with end-stage heart and lung disease. It will relax the heart or lungs making the patient more comfortable. This is especially true in patients with lung disease. In the end stage of lung disease the patient is not able to take a deep breath so the inhalers that they may have been using for years are no longer effective.

Myth #5: I’m allergic to morphine: once I had a shot of morphine after an operation and I felt very strange.

Of course you can be allergic to morphine just like any other medicine. But feeling strange is not a sign of morphine allergy usually. Some people may have unpleasant mental sensations temporarily when they start to take morphine. But that is not an allergy; and it might never recur. There are other opiates available for those people who are truly allergic to morphine. To learn more about allergic reactions see our blog post “Speak UP”.

Myth #6: Morphine must be given by injection.

Hospice is a leader in demonstrating the effectiveness of morphine and other opiates taken orally. People who required injections of morphine in the hospital (the most common way of giving morphine there) will probably be able to be well controlled on oral morphine at home. There are also long-acting preparations of morphine which can be given every twelve hours, or opiate skin patches which can be applied every 72 hours, to simplify the routine of pain control.

Myth #7: People should wait until their pain is bad to take morphine so it will be effective when it’s really needed.

There is no upper dose limit to the use of morphine or other opiates. If pain increases we can increase the dose; this is true of very few other medications. Using it when it’s needed early in the course of a terminal illness does not mean that it won’t continue to work later in the disease process.

Morphine, one of the oldest drugs in existence, has found a well-deserved place in the field of hospice whose mission is the relief of pain and other symptoms. We recommend opiates for pain control only if they are needed.

If you would like more information about Front Range Hospice and the use of Morphine, call 303-957-3101 or 970-776-8080 or email us at

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Hospice Care While Living In a Nursing Home

Hospice Care While Living In a Nursing Home
By Victor Montour

Some patients with a terminal illness call a nursing home “home”. At Front Range Hospice, we specialize in providing hospice care in the place patients call home. A nursing home or also known as a skilled nursing facility is one of the many places we provide our hospice services to patients. Due to our fantastic reputation and strong relationships with the nursing homes in our service territory we are able to assist families looking to have their love one move into a nursing home, and provide care to residents who already call the nursing home, “home”.

In a nursing home, hospice helps patients, families, and nursing home staff by providing:

  • Regular visits by a hospice Registered Nurse to the nursing home.
  • Consultations by a specialized hospice physician as needed.
  • Expert management of pain and other symptoms, such as problems breathing or swallowing.
  • Education for nursing home staff, patients and families about patients’ condition, symptoms, medications, and how to best care for patients’ medical needs during this phase of their illness.
  • Emotional and spiritual support for both the patient and their family during this phase of life. This includes help for the family before and after the patient dies.
  • Provides medications and supplies related to the patient’s terminal illness
  • Coordinating the patient’s care and medications across all of the patient’s medical providers, including the patient’s own doctors, hospice doctors, hospice nurses, hospice aides and all nursing home staff.

The nursing home is responsible for:

  • Communicating and coordinating patient’s care with the hospice.
  • Monitoring the patient’s condition and reporting any changes to the hospice.
  • The routine daily care for patients at the nursing home, like eating, bathing and activities.
  • Normally scheduled medical care and examinations by the attending physician and medical director.
  • Providing medications and supplies for care not related to the patient’s terminal illness.

Things you should know:

I you are looking at moving yourself or a loved one into a nursing home while on hospice there are a few things you need to know to make the transition easier for all of you.

  • The hospice benefit does not cover the room and board cost for a nursing home stay. This cost will be the responsibility of the patient or the patient’s family. This cost could start anywhere from $200 to $500 dollars a day or more, depending on the facility you have chosen.
  • Most nursing homes will require a 30 day room and board payment be made up front on the day of admission.
  • Most secondary insurances do not cover the room and board payment. If you think your plan will cover the room and board cost, you will want to contact the insurance company prior to selecting a nursing home to ensure your selection is within their network of care providers.
  • Colorado Medicaid will cover the room and board cost with the patient’s social security income being turned over to the nursing home.
  • Turning the patient’s social security over to the nursing home is a Colorado Medicaid requirement, not the nursing homes. Medicaid considers this payment to be the “patient’s liability payment”.

As you might imagine moving someone into a nursing home is not a very easy process. If you would like more information about Front Range Hospice or Hospice Care in a nursing home call 303-957-3101 or 970-776-8080 or email us at

Watch out for our next blog: Morphine and Pain

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Taking Responsibility for Reductions in Hospital Readmissions: Be Careful

Taking Responsibility for Reductions in Hospital Readmissions: Be Careful

 By: Elizabeth E. Houge, Esq.

Hospital administrators are increasingly focused on decreasing readmission as they continue to receive penalties in the form of reductions in reimbursement from the Medicare Program. Hospital staff appropriately seek assistance from post-acute providers in order to achieve reductions. There is no doubt that Medicare-certified home health agencies, HME suppliers, private duty home care agencies, hospices, skilled nursing facilities (SNFs), assisted living facilities (ALFs), outpatient therapists, etc. can assist hospitals to reduce readmissions. The post-acute industry generally welcomes the recognition that it has a crucial role to play in this regard.

BUT, BE CAREFUL! It appears that staff at some hospitals have only a superficial understanding of how reductions can be achieved. This is true, in part, because there is a general lack of evidence and data to show what activities contribute to reductions in readmissions. It remains unclear whether hospital discharge planning activities, for example, can have a substantial impact on reductions in readmissions.

There is a tendency on the part of hospitals, however, to put the entire responsibility for reductions on the shoulders of post-acute providers. This point of view may lead to some potentially harmful results, including failure to reduce readmissions. It may also support the argument that hospitals should be able to choose post-acute providers for patients since they suffer the financial consequences when patients are readmitted.

On the contrary, it seems likely that reductions in readmissions will be achieved only through partnerships between hospitals and post-acute providers of all kinds. The operative word is clearly “partnership.” This point of view is supported by Conditions of Participation (CoPs) of the Medicare Program for hospitals that govern discharge planning. Specifically, discharge planners/case managers at hospitals are required to:

  • Screen all inpatients soon after admission to determine which ones are at risk of adverse health consequences post-discharge if they lack discharge planning. Screening must include consideration of the following factors:
    • Patients’ functional status and cognitive ability
    • Type(s) of post-hospital care that patients require, such as:
      • Home Health, attendant care, and other community-based services
      • Hospice or palliative care
      • Respiratory therapy
      • Rehabilitation services (PT, OT, Speech, etc.)
      • End Stage Renal Dialysis services
      • Pharmaceuticals and related supplies
      • Nutritional consultation/supplemental diets
      • SNFs
      • ALFs
      • Medical equipment and related supplies
      • Home and physical environment modifications
      • Transportation services
      • Meal services
      • Household services, such as housekeeping, shopping, etc.
    • Whether the type(s) of post-hospital care require(s) the services of health care professionals or facilities
    • Availability of required post-hospital health care services to patients
    • Availability and capability of family and/or friends to provide follow-up care in the home
  • Evaluate post-discharge needs of inpatients identified in the first stage, or of inpatients who request an evaluation, or whose physician requests one. Evaluations must include the ability of patients to self-care post-discharge. An evaluation of the ability to self-care requires hospitals to actively solicit information regarding this issue not only from patients or their representatives, but also from family, friends, and support persons.
  • Develop a discharge plan, if indicated by the evaluation or at the request of the patient’s physician
  • Initiate implementation of the discharge plan prior to the discharge of inpatients. This requirement includes provision of inpatient education/training to patients for self-care, or to patients’ families or other support persons who will provide care in patients’ homes. It includes arrangements for:
    • Transfer to rehabilitation hospitals, long term care hospitals, or long term care facilities
    • Referrals to home health agencies or hospices
    • Referrals for follow-up with physicians and therapists
    • Referrals to pertinent community resources that may assist with financial, transportation, meal preparation or other post-discharge needs

Anecdotally, it appears that hospital discharge planners/case managers are not consistently engaging in these activities and others required by the CoPs. Compliance with the CoPs for discharge planning may have a significant impact on reductions in readmissions in partnership with post-acute providers of all types.

©2015 Elizabeth E. Hogue, Esq.  All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.

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Do You Know The 4 Levels Of Care?

Do You Know The 4 Levels Of Care?
By Victor Montour

Most people are unaware there are four levels of care provided by all hospices in the United States. Every patient receiving hospice services in the United States will be on one of these four levels. A hospice patient can move from one level of care to another level of care and back, depending on the services required to fulfill his or her needs. The clinical needs of the patient will be used to determine if the patient meets the appropriate criteria for a higher level of care.

Routine Home Care – Patient at home with symptoms controlled

Routine level of care is the level of care most patients will be placed in at the time of admission. This level of care can be provided to patients while they reside at home (or a long-term care facility) and does not have symptoms which are out of control. These symptoms could include—but aren’t limited to—severe pain, continuous nausea and vomiting, bleeding, acute respiratory distress, and unbearable restlessness or agitation. A patient at this level may have access to the following services:

  • Registered Nurse Visits
  • Social Worker Visits
  • Chaplain Visits
  • Home Health Aide Services
  • Counselors
  • Medications
  • Equipment

The needs of the patient determine the number of visits from hospice staff members. These needs are established and outlined in a plan of care formed by the patient or Medical Power of Attorney, the hospice team and the patient’s physician. The care plan serves as a guideline to assist all those serving the patient with care. At this level of care the patient also has access to an on-call hospice nurse twenty-four hours a day seven days a week.

Respite Care – Patient at facility with symptoms controlled

A patient may be moved to respite care when the caregiver needs a break. Many hospice patients live at home, with their family providing most of the care, sometimes around the clock. Caring for their loved one can be exhausting and very stressful. The family members and/or caregivers need time to themselves and it’s important that they take that time. Respite care allows a patient to be temporarily placed in a facility with 24-hour care so the family can rest. If the patient is willing and the family requests it, hospice must provide placement in a facility or a hospice home for the patient. The patient will be transferred to the facility, and according to Medicare regulations, can stay for up to five days before being transferred back home. A patient at this level may have access to the following services:

  • Registered Nurse Visits
  • Social Worker Visits
  • Chaplain Visits
  • Home Health Aide Services
  • Counselors
  • Medications
  • Equipment

Continuous Nursing Care – Patient at home with uncontrolled symptoms

A patient would receive continuous nursing care if he or she has symptoms that are out of control and choose to stay at home. This is similar to inpatient care, except that the patient remains in his or her home instead of being placed in a facility. A hospice nurse is required to provide continuous around-the-clock nursing care if the symptoms cannot be controlled while on routine home care. Hospices are required to provide this level of care if it is needed. This level of care requires certain criteria be met to be placed under this level of care. This level of care is a short lived benefit. Patients in this level of care must have their symptoms under control within 72 hours. Once symptoms are under control the patient must be moved back to the routine level of care. A patient at this level may have access to the following services:

  • Registered Nurse Visits
  • Social Worker Visits
  • Chaplain Visits
  • Home Health Aide Services
  • Counselors
  • Medications
  • Equipment

Inpatient Care – Patient at home or in a facility with uncontrolled symptoms

A hospice patient may require inpatient care when his or her symptoms have gotten out of hand and can no longer be managed at home. When these symptoms cannot be controlled on routine home care, then the patient requires extra attention until these symptoms subside. Hospices take aggressive actions to control the symptoms and make the patient comfortable. In order to do this, the patient may be temporarily placed in a hospice home, skilled nursing facility or an acute care hospital. At this level of care, a moment-to-moment assessment of what’s happening and what needs to be done takes place. The hospice team and the patient’s physician work together to ensure the patient obtain and maintain a tolerable comfort level. Once this has been achieved, the patient will return home and back to routine home care. Again certain criteria must be met to be placed in this level of care. The only physician who can determine a patient meets criteria is the hospice physician or hospice medical director. This level of care is a short lived benefit. Patients in this level of care must have their symptoms under control within 72 hours. A patient at this level may have access to the following services:

  • Registered Nurse Visits
  • Social Worker Visits
  • Chaplain Visits
  • Home Health Aide Services
  • Counselors
  • Medications
  • Equipment

If you would like more information about Front Range Hospice or the 4 levels of care call 303-957-3101 or 970-776-8080 or email us at

Watch out for our next blog: Taking Responsibility for Reductions in Hospital Readmissions: Be Careful

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