What Hospice Really is and Why Families Need to Know Sooner with Rachel Rankin

Narrator: Welcome to the Voices of Hospice Leadership Podcast, uh, the show that reveals how to take your hospice to the next level. We cover all things hospice, from marketing and automation to billing and operations. You'll also hear from professionals in the industry as they share their stories of success and practice growth tactics. Here is your host, Brian Franks.

Brian France: Okay. Welcome to the Voices of Hospice Leadership Podcast. I'm your host, Brian France. Rachel, thank you for being here.

Rachel Rankin: Thank you for having.

Brian France: Really looking forward to this conversation. Would you start us off? Um, I'd love for you to share a little bit about your background and what led you to start Bosque Trails Hospice.

Rachel Rankin: Yes, thank you. Thanks for having me. Um, uh, my name is Rachel Rankin and I am, um, part owner and medical director for Bosque Trails Hospice here in Albuquerque, New Mexico. Um, my colleagues and I, or I guess I should say my partners and I, we are owned by myself and three nurses, um, worked together at a previous hospice that was run by physicians. It was physician owned and local and grassroots and a pretty wonderful place to work and care for patients. And that's where we all got to know each other. Um, unfortunately, as our physician owners were ready to retire despite trying their hardest to find a good buyer, the company that they sold the hospice to was a pretty classic corporate, um, agency. And we got to learn firsthand about the differences of, um, how, how we were treated both as employees and how we were allowed to practice, um, medicine for our hospice patients under this new ownership. And not too far into that new ownership, we decided that our community really needed and deserved more local, grassroots, individualized, um, care for hospice. And so we started Bosque Trails Hospice in response to that.

Brian France: Awesome. Yeah, I love that foundation. I think really helps explain the heart behind what you guys are building. Um, so let's talk a little bit more about what actually makes Bosque Trails, uh, different in practice. What do you think sets Bosque Trails apart from other hospices in New Mexico?

Rachel Rankin: That's a good question. I think there are a number of factors by nature of being locally owned, um, grassroots. We, I think, have our finger on the pulse of our community and what they need a little bit different than some of the corporate entities that we have in our state. Um, we are clinicians, all four of us, owners, nurses, and a physician. And so we really and have all worked doing the jobs in hospice or alongside the jobs in hospice. So each one of us started as a hospice employee doing this work. And so we really understand what it's like to be out there and what it's like to feel Good. And, um, to be empowered to take care of your patients in a way that you've been trained. We have, um, three physicians at the moment who are hospice and palliative medicine board certified, which is pretty unheard of in hospice care. We also have nurse practitioners who are palliative certified. So the attendings taking care of the patients are board certified. We do home visits. So we go see our patients in their homes, um, with their nurses, we meet their families, we get a sense of their symptom needs. And, um, that is a pretty unique thing in hospice care. Not a lot of hospices even have physicians who are located in the same city, um, unfortunately. So we go see our patients. We love caring for them. We do a lot of medical treatments that are pretty outside the box for a lot of hospices. We, um, can get into those details later, but we really offer things that other hospices don't in terms of, um, ways to keep people comfortable, keep them home, um, support. And the reason we can do that is because we're hospice trained. Um, those are the big things. We really, really firmly believe that by taking care of our employees and treating them well and letting them perform at the highest level of their degree, that they will then downstream provide excellent, um, patient and loved one care and support. And that has really proven to be true.

Brian France: Awesome.

Rachel Rankin: Um, those are, I think, the big things that set us apart.

Brian France: Yeah. Direct owner involvement.

Rachel Rankin: Right.

Brian France: That's unique.

Rachel Rankin: Yeah.

Brian France: That was one thing. Yeah. Uh, how does having a clinician led team or leadership team change the care you give to patients?

Rachel Rankin: I think it changes the care because we understand what the care is. We know what it's like to be out there in the field with, um, people who are suffering, whether it's pain or existential suffering or spiritual suffering. We know what it's like to have panicked or scared loved ones right next to you, wondering what we're gonna do. So as we move forward and make decisions about how we want to run our company, you know, I'm out there providing care. My, um, partners were out there providing care before they became administrators. And so we get it. We've been there, and we really want to support our team, um, being out there because we understand what it's like to be in the field and what's needed.

Brian France: You mentioned the out of the box kind of care. What are some examples of that out of the box care that your team is willing to provide, that, uh, you know, when it aligns with the, uh, patient's goals?

Rachel Rankin: Yeah, I'm glad you said that. One of the things that we really, really focus on is making sure that we understand what somebody's goals and values are. Um, hospice and really all medical care should be value based care, right? We shouldn't be making recommendations on how to treat somebody medically if we don't know what's important to them. Once we have a sense of what's important to them, we try to align the care that we provide with what that is. So if it's staying home and they're in a symptom crisis, we can, um, essentially provide, ah, the equivalent of IV pain medications in a pump at a continuous infusion rate with a button you can push like when you're in the hospital. We can do that at home. We can support tpn, which is basically IV nutrition or tube feedings. If somebody is coming home with that, not necessarily forever, but if there is a goal, um, that somebody's only method of receiving nutrition is via the IV and they have a particular goal that's not too far off will support that. Um, we do crisis management, of course, crisis patient visits when it's needed. We do some pt, OT and speech therapy in the home, which all hospices are required to do. But we can get creative about how to prolong that support for some patients because that's a really hard thing for people to give up. Um, we can have the PT or OT teach our CNAs what the movements are and then our CNAs, when they go in to do their care multiple times a week can then provide some of that PT or ot. Um, we have brought somebody home before on pressors, which is an IV medication to keep your blood pressure up. It's essentially life support. But we had a patient who otherwise wouldn't have made it out of the hospital and really wanted to say goodbye to their dog. So we figured it out, we brought them home on that and they died fairly shortly after. But the goal was to say goodbye to their furry best friend and they were able to do that. Um, we will entertain bringing somebody home ventilated with a breathing tube again so that they can get home and be home and say goodbye to people or animals or just be home. And then we can extubate or take that breathing tube out at home with support and keeping them comfortable. And then one of my other favorite, um, stories of how we think outside the box is we have a patient, um, with a severe neurologic life limiting disease. And she's very young and she had a specialized wheelchair made for her and it's the only way that her mom could get her in and out of bed to feed her. It held her in place with a strap for her forehead and. And allowed her to be out with the family. And once Medicare realized that she was then on hospice services, they came and they took her wheelchair away. And her mom couldn't get her. You know, her mom is getting on in age and couldn't get her out of bed anymore. And so our team came and advocated, hey, is there any way that we can try to get that wheelchair back? And it took a lot of work and phone calls and emails, and we ended up buying out the contract for the wheelchair, and we got it back for her so her mom could do that. And, um, it took a lot of legwork and a little bit of money, but it made all the difference for that patient and her family. And because we're small and we're local and we get to make the decisions, we get to decide whether or not we do stuff like that.

Brian France: Yeah. And I kind of care doesn't happen by accident.

Rachel Rankin: Yeah. It's a shared mission, Right. A shared passion.

Brian France: Yeah. It takes the right people and, um, the right culture behind it. So maybe we could spend a little time there. Uh, you said if you take care of your employees, they take better care of your patients, right?

Speaker D: Yeah.

Brian France: What does that look like in practice?

Rachel Rankin: What we've seen is that when we allow people to practice their specialty, whether it's nursing or chaplaincy or social work or, um, hospice aid, whatever the specialty is, when you allow them to practice at the highest level of their degree with some autonomy and say in terms of how long they need to be with a patient or how often they need to be with a patient, or you really listen when they advocate for a patient, like with the patient with the wheelchair, and they don't fear any retribution for maybe getting feisty and advocating for their patient, um, they feel seen and heard. They feel like they're doing the work that they're passionate about. And that's what we saw when we started. And we worked with, um, some of those specialties, some people from those specialties from our previous organization. And we just saw that sort of. That passion and light had been beaten out of them by telling them you can only see the patient once a month. You can only spend 60 minutes. You don't get to talk during our meetings because it takes too long. And then when we started, you could kind of see them emerge as they recognized, wait, I'm going to get to do this work the way that I love to do this work. And the rest just goes from there.

Brian France: Can you share what you look for when you're hiring team members?

Rachel Rankin: Yeah, we are pretty picky. We obviously look for excellence in terms of credentials. We pay a lot of attention to recommendations, um, both word of mouth, but also the formal recommendations that a candidate gives us. We really look for a passion for this kind of care.

Speaker D: Hospice work is a calling.

Rachel Rankin: Not everybody can do it, not everybody wants to do it. So we try to figure out their why, for why they either went into it before or want to go into it now. We've had a number of people who have done their initial hospice work with us, and it really just is getting a sense for whether we think it'll be a good fit. And the other thing is that we really try to picture them as part of our team. Our team works so incredibly well together with support. They are flexible, they are, um, compassionate. But also they help each other out a ton of. Throughout the week, we see a bunch of messages on our text messaging app of, uh, hey, I need help with this, or I need an extra set of hands for that, or. And just watching how many people jump in. Um, so it really is a special kind of person who's willing to be a part of a team like that.

Brian France: Love it. How do you create a culture where staff feel heard and supported?

Rachel Rankin: I was thinking about this question a lot. I think we just hear them when they have something to say. We support them even if we can't do whatever it is they're asking. Um, and we always explain why if we can't do what they're asking, we'll try to do something as close to that as we can, and we'll explain why we can't if we can't. We try to be as transparent as possible. Um, the balancing, obviously, of the, the clinical piece and the business piece is new to the four of us. And we're working really hard to always make the right decision for the patient, but also not jeopardize the business. Um, so we're pretty transparent about that. But I think that our staff enjoy working for us. We try to have fun, we try to support each other. We try to celebrate when there are things to be celebrated. And really our team has championed us, things. They're proud of what we've all done. And it's as much them as it is us. And so watching them get excited when we hit new milestones or, um, do something that we haven't been able to do before, it's pretty exciting that they're as excited as we are.

Brian France: That's awesome. Yeah. And has there been a moment where a staff member brought an idea forward and uh, you guys were able to implement it?

Rachel Rankin: Yeah, yeah, there's been a number of times I think you and I spoke briefly. We, um, deliver what we call a comfort kit to every family on admission to their house. And it has a number of medications for just in case and pain medicines and meds for constipation or anxiety. Um, and one of our nurses said, hey, why isn't this other constipation medication in our comfort kit? We always talk about it on admission when we first meet the patient. And I'm always ordering it, but there's always a delay. And constipation is a really significant symptom, um, because it can cause not only constipation, but delirium and pain and all sorts of stuff, hallucinations even. And so I thought it was a great idea and talked to my partners about it, pulled the whole team. Does everybody think this is a good idea? And they did. And within a week, um, we were talking to our electronic health record about adding it to our order set and to our pharmacy about putting it in our standard kit. And now it's part of our standard comfort kit. And I think the clinical care is better because of it.

Brian France: Love it. Yeah. It sounds like that culture has not only shaped the care experience but also the way Bo Skippers Bow Sky Trails has, has grown in the community, I think. So you guys have grown quickly since launching in 2023. What do you think, uh, has driven the growth?

Rachel Rankin: I think there was a need in our community for excellent grassroots, community based local care. We understand New Mexicans and New Mexico. We've all worked in this community for quite a while. And I think once people recognized the quality, the honesty, the integrity, it just exploded because there was a need.

Brian France: Uh, how important have the online reviews, uh, the word of mouth and uh, the reputation, uh, been with building trust, uh, with the community.

Rachel Rankin: I mean I think that is the most important thing we've done is build, um, we've built a business that provides care that people want to share about. And so, you know, we have the most five star Google reviews in the state. Not by accident. I think people, that's how people share. And so we have Google reviews and word of mouth and people talk. And I think that's probably a common tenet of business is that you gotta be careful and be aware that people will share both the good and the bad. Obviously the bad usually more than the good. But um, but the word of mouth is out there and I think it's 100% the most important piece for us of the growth. We had a really fun story recently. Um, we always ask how people heard about us. And we asked and the family said, well, you know, we were in the living room discussing as a family what to do about mom. And hospice came up and we were talking about it and we were also getting our kitchen redone. And the contractor came in from the other room and said, I'm super sorry, I didn't mean to eavesdrop, but I couldn't help it.

Speaker D: Overhear.

Rachel Rankin: You guys have to use bosque trails.

Speaker D: Hospice.

Rachel Rankin: And then went on to share his experience. Um, and sure enough, that's how we got them. And so I think the community wants to support each other. And once they've been through something as serious and, um, hard as hospice can be, and it's a good experience, they really want to tell people about it.

Brian France: Yeah, yeah. And I think you shared with me that people have called after reading reviews, right? That you guys have heard that before, right?

Narrator: Mhm.

Rachel Rankin: Oh yeah. Uh, we always ask, like I said, and, and a lot of times, oh, I read all the reviews and you guys have the best reviews. So here we are.

Brian France: Love it. What have you learned about how families choose a hospice today?

Rachel Rankin: We have learned that a lot of people do their homework. So they read the reviews, they look at the websites, they ask around. Um, they will hospice shop, which I think is good. They'll interview a number of hospices and ask them good questions. Um, everybody, that's a great idea. Ask them where they're, you know, their medical director lives, ask them if they do home visits, ask them how they treat symptoms in a crisis, ask all those really hard questions and then they pick. Unfortunately, I think a lot of institutions, medical institutions, you know, they're, they're required to provide choice, which is good, but they don't always give all the choices. And so they might be given three options, none of which are local or community owned. Um, we do see a fair number of transfers in those situations. Um, or stories. We'll hear stories after the fact of care that maybe was different than we would have provided.

Brian France: Trust piece is huge. Especially, uh, I think so many families making these decisions with very limited information and uh, a lot of emotion.

Rachel Rankin: Correct. Yeah.

Brian France: That brings me to the, uh, education side of this. What, what are some of the biggest misconceptions people still have about hospice?

Rachel Rankin: There are so many, um, this could probably be an entire podcast on its own, but I Would say the big ones are. Hospice is not about giving up. It's about focusing on a different kind of care. Right. Being home, being comfortable, being with loved ones. The goals shift, but the care remains excellent. It's not only for the last few days of life. Um, it's a six month benefit period for a reason. And Congress passed unlimited benefit periods in the 1980s on purpose because people outlive that prognosis. There is good data to show that you receive your maximum benefit from hospice at three months or 180 days. But the average time on hospice right now is 24 days. Nationally, 20% of patients live one to four days on hospice and about 60% of patients live between one and 30 days on hospice. That's a huge amount of people who don't ever even get close to the maximum benefit. And hospice benefits not only the patient with comfort, um, and relief of suffering, but it supports their loved ones. Anybody who loves that patient is a patient of hospice and receives support. One of the other things I think that's a huge misconception is that hospice hastens death. Right?

Speaker D: You hear a lot.

Rachel Rankin: Hospice just takes away all the medications and stops treating the diabetes and the hypertension and just gives a lot of morphine and then they die. Unfortunately, people come onto hospice so late and so close to death anyways that by the time we get them comfortable in the first few days, they do often die. But it's not because of the morphine. It's because they were referred way too late. And then the last thing is that hospice isn't a place, it's a service. It's a layer of support and a team who cares for that patient wherever they call home. So it's not. Hospice isn't the end of caring for somebody. It's just a completely different kind of care.

Brian France: Right. And, uh, what, why do you, why do you think so many families get referred to hospice too late?

Rachel Rankin: Also could be a whole separate podcast. I think there are a lot of factors. I think our culture doesn't discuss death very well. I think it's a bit of a taboo subject. I think that families are afraid. I think the word hospice scares a lot of people for the reasons I just said. They think it just means somebody's gonna die and we're gonna take away everything and hasten death. So they're resistant. I think people feel like it's giving up. Um, there's a lot of battle, um, focused vocabulary in disease processes, especially cancer. Right. You lost the battle. You fought a good fight. You're such a survivor, you're a warrior. And so then turning away from that kind of care can be perceived as weak. And the last thing, although there are many I think, is that our medical system, all of us doctors and nurse practitioners and PAs, all of us in general, do a pretty terrible job of educating people on their disease processes and their prognosis. And I think we don't recognize when somebody might be at six months very well. Um, there's really great data to show that doctors are afraid of telling people truthfully what their prognosis is because they think it's going to take away their hope. But there's also really good data that shows that people want this information. They want it delivered compassionately and gently, but they want the information because they want to be able to plan, right? That goes back to the goals and the value based care and that it doesn't, in fact this has been studied. It does not take away people's hope. It allows them to focus their hope on something else, something that might be a little more attainable or realistic. You know, so we're in April right now. Maybe somebody is hoping to make it through till Christmas to see their grandkids fifth Christmas, but that's not realistic. And if you gently and compassionately share that with them, well then maybe they're just hoping to get to their grandkids birthday in July instead. And that can be really valuable for people. So you know, it's interesting, right? There's an entire subspecialty for hospice and palliative medicine. And palliative medicine is the step before hospice where we walk alongside somebody with an illness that we can't necessarily cure. Um, but all physicians are trained or should be trained or can learn how to have these kinds of goals of care conversation. They can learn how to share this kind of information in a dignified and compassionate way. So I think we've got some work there to do. And I do believe a lot of medical schools are incorporating that training more and more. Um, but we medical system, we don't do a great job there either.

Brian France: What do you wish more people understood about what hospice really is? And you know what it's not?

Rachel Rankin: I wish more people understood and really could believe and trust, um, that hospice is not the end of us caring for their loved one, that it's not giving up. I really wish that they could trust and believe that it's just a different kind of care that really focuses on comfort and compassion and dignity and that it's this extra layer of support not only for the patient, but the family people. Uh, there's more, you know, data and studies that show that some people live longer on hospice than they would with regular community care. And the reason is you get to be home and you get to be with your animals and you get to eat your favorite food and be with your loved ones and have your symptoms well controlled. Um, so I wish people could trust

Speaker D: that it's really, truly there to support them in living the best they can in the setting of the disease that they have. And it's not really about dying as much as it is about living with dignity.

Brian France: Love it. That's an important point. And I, uh, think it naturally leads into, uh, a question for families who may be listening and wondering, uh, you know, what, what they should be watching for.

Rachel Rankin: Yeah.

Brian France: What are some signs family should, should look for that, uh, you know, maybe it is time to start asking about hospice.

Speaker D: Yeah, I think that's a really good question. When I teach about that exact same question. I teach that if you look at a body, you generally have a sense of that body is thriving or, or not thriving.

Brian France: Right.

Speaker D: So if you're seeing more frailty, if you're seeing a loss of weight, even if somebody maybe is eating the same, or a loss of appetite in the setting of also losing weight, um, infections, so urinary tract infections, skin infections, pneumonias, if you're seeing falls, um, if you're seeing hospitalizations, ER visits, urgent care visits over and over, sometimes for the same things, sometimes for different things. If you're seeing that somebody is having a harder time doing their day to day, feeding themselves, putting their clothes on, getting to the bathroom on time, bathing themselves, we'll often hear, oh, you know, my loved one used to take a shower three times a week or every

Rachel Rankin: day or twice a day.

Speaker D: But now it takes so much time, or they're afraid of falling, or it makes them so fatigued that they're either only doing it once a week or they're not doing it at all anymore. Anything of that nature that's showing that the body is just not thriving should raise an alarm bell or signal. Hey, maybe we should ask, uh, the question, is it maybe time for some more support?

Brian France: Yeah, what, what should families do if they're, you know, not. Not sure whether their, their loved one qualifies?

Speaker D: Yeah, that's a great question. Um, you can always self refer to a hospice for an evaluation to find out if you qualify. You don't have to worry about your doctor, your PCP or oncologist or pulmonologist making the referral. The hospice will reach out to one of those doctors to get a referral if needed. But any loved one or patient can call themselves and say, I'd like to

Rachel Rankin: know if I'm a candidate.

Brian France: Yeah. What do you think physicians and other clinicians can be doing differently when it comes to, you know, earlier hospice conversations?

Speaker D: I think it's surprising the things that qualify a patient.

Brian France: Yeah.

Speaker D: So there are Medicare criteria that are very specific, but outside of those criteria, even if they're not met, if the body is doing any of those things that I just talked about, somebody can meet criteria. So I think physicians being a little bit more aware of what could qualify somebody and keeping it on their radar that it might be time. So that's number one. Number two is not being afraid to initiate the conversation. When done with compassion, people are more accepting. And over time, the better we are at these conversations, the more accepting people will be. It's scary to be told you might meet criteria for hospice or it might be time for a different level of care. But it's also important for people to hear. So not being afraid to gently initiate the conversation and then looking for resources, our website, Bosque trails hospice. Um, I have a whole section for professionals, uh, supporting how to have the conversation, supporting what meets criteria with different diagnoses. And so I think just educating yourself about when somebody might. Especially if you're caring for people who can be at end of life. Right. People with heart failure, dementia, chronic obstructive pulmonary disease, obviously cancer, Parkinson's. I could go on and on, but if you're any of those types of physicians, chances are you've had a patient who's hospice eligible. Um, and they can get better care. Their end of life, their loved ones can survive it better if they end up in hospice. On the earlier side.

Brian France: Yeah, Part of this is, you know, also helping families understand that they, they do have the, they do have options and rights in, in this process. And I think a lot of people may not realize that. Yeah.

Speaker D: Uh, they don't.

Brian France: Yeah. What rights do patients and families have that, ah, they often don't realize and um, like switching providers or you know, trying hospice sooner.

Speaker D: Yeah. So you can advocate for yourself and ask for a referral or an evaluation. You. Hospice is not a one way street. You do not sign the paperwork and it's like a prison sentence. If hospice then becomes not the right thing for you, you can revoke your hospice benefit. Um, hospice is both a philosophy of care, which we've talked a lot about, but it's Also an insurance benefit. So insurance says you get to pick hospice or what we call sort of community care. When you sign on to hospice, you give up your community care. But if it's not the right fit, you come off. There's no, it's fine. Um, you can come off and on. Um, you can switch your hospice provider. So if you're on hospice and maybe some of the things you're seeing are not consistent with maybe some of the things I've described, you can find another hospice and you don't have to do anything. The new hospice will do all the legwork. So a lot of people have told us, oh, I wish I knew sooner. I wish I knew I could switch.

Rachel Rankin: I was afraid I was going to

Speaker D: have to have a confrontation, um, and do all this hard work. But you don't. So you have a lot of control. Hospice doesn't want to take away any of your control. It's all about you and your loved one and how you want this last chapter to look.

Brian France: Yeah, Hospice, um, is also. It's not only for the patient. Right. It also for the family. How does your team support loved ones and you know, through the, through the whole process.

Speaker D: That's a great question. Yeah. Every person who loves that human who's being cared for by hospice is also somebody that the hospice team cares for or cares about. And so that can be, um, anticipatory grief support with either our social worker or our chaplain or other, our bereavement team. That can be just getting out of the house for a coffee with one of the team members just to get a break that can.

Rachel Rankin: Or, um, with one of our team

Speaker D: members or maybe we get a volunteer in to spell that person.

Narrator: Um,

Speaker D: it can be any number of conversations or, um, whether somebody is physically here, where we are, or far away. We've done video, um, conferences to support that person. We've done lots of phone calls. And then, of course, there's bereavement post death of the patient. Medicare says 13 months. We do it indefinitely. And that can be, um, mailings, phone calls, group sessions, um, helping to refer to a therapist. Um, we have potlucks at our office, uh, for people who are grieving to come and just enjoy each other's company. Um, all sorts of things. They're just as important because they're walking this journey just as much as the patient is just in a different capacity. And if you think about it, they have to survive this death the best that they can. And so our goal is to help them survive it more intact than they

Rachel Rankin: would have without us.

Speaker D: And we believe that helps somebody walk through the world a little bit differently.

Brian France: Um, yeah, I love that, Uh, I think this has been such a valuable conversation and, um, before we wrap up, I wanted to give you a chance to lead listeners with a final takeaway. If there is one thing you want families and providers to take away from this conversation, what would it be?

Speaker D: I think it's just that good, honest, excellent.

Rachel Rankin: Hospice is really a bonus. It's extra support.

Speaker D: It helps in almost every end of life scenario and, um, just not being afraid of it and understanding that it

Rachel Rankin: is, you know, death is the only

Speaker D: thing that is for sure for all of us. So why not accept extra help? Um, it is scary and sad and hard, but we really help all of that when we're allowed to love it.

Brian France: Rachel, thank you so much for being here and sharing both your experience and your heart behind this work.

Speaker D: Thank you.

Brian France: Really appreciate your time. And I know this conversation is going to help a lot of people.

Narrator: If you're looking to attract more families and share your hospice mission with a Wider community, visit hospicecaremarketing.com uh, schedule to schedule your free consultation with with marketing expert and founder Brian France. Plus, join our free hospice marketing mastermind group on LinkedIn to connect with other practice leaders and stay up to date with the latest strategies. If you enjoyed this episode, please take a moment to leave us a five star review. We'd love to hear from you.