End of life care specialists live with other people’s pain, and through contact with their suffering become close to individuals they may only know for a few months, or a few days.
Having heartstrings touched at this level on a daily basis takes a certain kind of professional. It is people of this mold that the Alamo Hospice directors assembled their staff.
"I'm the fortunate one who gets to educate the family," said Monica Ann Garcia, the for-profit agency's head of community relations.
Through relations cultivated with directors of assisted living communities and nursing homes, Garcia usually meets families by referral. She's heard the old saying about "not getting attached," and generally ignores it. Garcia even attends funerals.
"It's a life-cycle. If I don't see that part - it's what keeps this job real," Garcia said.
That attitude tends to permeate the organization. Dale Hicks, once head of the medical malpractice section at Maloney & Maloney P.C., helped found the company in late 2005 out of a desire to give back to the community.
Gary Merchant left the post of chief operating officer at American Hospice in Fort Worth for a chance to take an ownership position in a hospice enterprise he believed had tremendous potential.
“Dale and Gary, they'll go out and sit for hours and hours with a family," said Dr. Leo Edwards, the hospice's first medical director. "It's a different brand of ownership."
Hicks offers a similar description of Edwards. One of the first traits Hicks noticed of Edwards during a patient visit was the doctor's empathic habits; Edwards went down to one knee to allow a bedridden woman eye-to-eye contact without lifting her head.
"He's the most compassionate physician that I, personally, have ever met," Hicks said. "He's just wired up in a way that makes him shine when he is delivering care."
Erin Adkins, vice president of clinical services, is a nurse with a consulting background in quality assessments for the hospitals and insurance industries. “I'm the boss of all the people that go in the field," Adkins said.
Her staff of 65 to 70 includes registered nurses, certified nurse assistants, social workers, chaplains, a couple of massage therapists and a registered dietitian. Also a part-owner, Adkins chose to dedicate herself to hospice care because it offered the full range of activities for which nurses train.
"In a hospital, it's very different. You work in one area, such as cardiac or surgery," Adkins said. "In hospice, you get a very broad spectrum of patients. You work with the entire patient, not just the patient illness. You work with the psychological-social aspects, all the clinical, the family dynamics."
Adkins thrives through the dedicated team approach that hospice provides.
"You get to sit in a room with 10 other professionals and talk about one patient," Adkins said. "You hear everybody have their say about what is the best thing we can to for this patient at this time."
The team includes a second physician. Dr. Joe Gonzalez, a Well Med affiliate and geriatrics specialist, became the organization's second medical director in January 2009. And as steeped as Edwards is in the East Side community, Gonzalez comes out of the Hispanic West Side culture.
"For the most part, my role is in fielding medical questions," Gonzalez said. "It's about giving guidance on what would be the next step."
The team approach, over which Adkins has significant input, meets her perfectionist expectations about what quality care should be. The ultimate goal is to provide what she calls, "a good death." That is a death she defines as one where pain is manageable, the family comes to terms with and is able to say goodbye, and the patient can do likewise.
Alamo Hospice is growing and it is doing so dramatically.
"Our company grew 400 percent in the last 18 months," said Hicks. "That growth has been driven by the quality of care that we provide."
The company had a slow start born of caution. There was a six-month process to get licensed, and it operated for nine months before it received Medicare certification; hospices are heavily dependent on the Medicare benefits provided for hospice care.
"It's a lot risky, and very expensive," Hicks said of the start-up scenario. "We started with a very small patient population, and really were trying not to grow."
That is, until certification came through. Soon after, Merchant entered the picture.
Merchant created H&PC of America, a holding company intended to acquire hospices. To date, Alamo Hospice is its only acquisition.
"Alamo Hospice had the basic structure. What it didn't have was growth structure," Merchant said.
Prior to making an offer, Merchant looked at 30 hospices and performed due diligence on five. It was the organization's leadership and San Antonio's potential that drew him to Alamo Hospice; he bought into the company in March 2008. "I saw San Antonio as fertile ground for developing a program," Merchant said.
Utilization of hospices in Bexar County is about 45 percent of the eligible population – those determined by attending physicians as having six months or less to live. That fits in with the national trend of 40 to 50 percent, but well below the competitive market Merchant left.
Dallas-Fort Worth is pretty saturated, Merchant said, noting the patient population there is up to 60 percent of the eligible pool. Hospices never reach anything close to 100 percent of the eligible population, Merchant added, because so many people struggle with accepting death.
"It's not only patients, but doctors and care providers," Merchant said. "Doctors tend to be overly optimistic with their prognosis because they don't want to give their patient the bad news."
It is that impediment to the use of hospice care that led to furious public discussions last year over the so-called "death panels." The misnomer referred to a provision in an early version of the national health care reform bill that would have required Medicare to pay for some end of life counseling sessions with a health care practitioner.
Unfortunately, the health care bill as finally passed ended up being somewhat detrimental to the hospice industry. Medicare will still pay for hospice care, but the industry will sustain a rate cut, Hicks said.
"Our reimbursements will be lowered incrementally over seven years," Hicks said.
Medicare, which provides about 85 percent of the industry's income, already caps benefits to a maximum of about $25,000 per patient, which works out to about six month of care. However, most patients expire within 90 days, Hicks said.
Another challenge for hospice providers in San Antonio is the city's ethnic composition. The city is majority Hispanic, but Hispanics under utilize the service.
Garcia estimates 8 percent of their patient population to be Hispanic, slightly above the national estimate of 5 percent.
Despite these hurdles, the present is robust and the future bright for those in the industry. As Hicks points out, hospice care is less costly and more efficient than the extraordinary means used to prolong life in a hospital setting.
"A hospice patient saves Medicare about $25,000 over the acute care system," Hicks said.
Finally, most Baby Boomers - the largest population segment - will be dying out over the next 30 years. These factors promise growth for Alamo Hospice, and not just in San Antonio. Merchant intends to grow the company through acquisitions. He is scouting properties in the Austin area, and despite his acknowledgment that Dallas-Fort Worth is saturated, he wants to go back.
"D-FW is an area that I've had so much success in, I'd be foolish not to," Merchant said.
Beyond profit, Merchant stays in the business of hospice care knowing it is a service greatly appreciated by the families of the dying. Bringing families through the transition of fighting in one moment to keep a loved one alive to preparing for loss is something each team member has words for.
"There is a joy I get in seeing their anxiety lessen," Gonzalez said.
"You try your best by almost incorporating yourself into that family, feeling what they are feeling, helping them look beyond their loss," Edwards added.
"After the first year, I realized the relief we feel from our patients' families," Hicks said. "You see the stress level go way down when they see a team of people take care of this."
Strangers suddenly becoming family is a recurring theme amongst staff. Monica Ann Garcia literally believes she was born to do this. She never knew her grandmothers, so by proxy she became attached as a young child to the three old ladies who lived on her block in the little town of Snyder.
She recalls that one day, when she was about 7 years old, she called her father to help a “grandmother” who had fallen and broken her hip and could not open her door.
"My dad broke a window and lifted me inside so I could open the deadbolt," she said. "I've always worked with seniors. This is the best job ever."
