Updated Nov. 25, 2020 —

Kathryn Clary’s father died of cancer 18 years ago on San Juan Island without hospice services.

A month later, she enrolled in nursing school to provide others the care her father didn’t receive.

“No one ever talked to us about end-of-life care,” she said. “I didn’t know hospice was available then. [My father’s death] was horrible to witness, as his daughter. I felt helpless.”

At the end of their lives, patients may choose to enter hospice and stop treatments to cure illnesses. They may take pain-relieving medication and prepare to die in the comfort of their homes.

Clary, who now works as a registered nurse (RN) for the nonprofit Hospice of the Northwest, said her father’s symptoms could have been managed better — if someone had offered hospice services.

“[Now], we recognize that someone is at the end of their life and … that that’s a precious, tender time and people want dignity,” she said. “That was just never given to my dad.”

Today, Hospice of the Northwest serves about 18 patients a day in the San Juans, and 190 patients a day, total, in San Juan, Skagit, Snohomish and Island counties. While Hospice of the Northwest has operated in the region since 1989, patient load in the San Juans has increased, almost tripling in the last seven years. 

“We have worked so hard in the last decade to increase services on the islands,” said Clary.

However, with a possible sale of the local nonprofit to a national for-profit, Bristol Hospice, community members such as Clary are worried that services could revert to those offered to islanders, like her dad, years prior.

An unsolicited offer

Brian Ivie, president and chief executive officer of Skagit Regional Health, said the owners of Hospice of the Northwest received an unsolicited letter from a “national organization” about purchasing the nonprofit more than a year ago.

Hospice of the Northwest is a nonprofit government entity, which is jointly owned by two public hospital districts in Skagit County: Skagit County Public Hospital District 1, which operates Skagit Regional Health, and Skagit County Public Hospital District 304, both nonprofit entities.

Members of the hospital district would not say who sent the letter. However, both hospital districts and Bristol Hospice representatives said there was a virtual conference call on Oct. 22 about Bristol potentially purchasing the nonprofit.

To approve the sale, both public hospital district boards would have to agree. There is no deadline to make a decision, according to the owners.

The review of the potential sale was delayed due to the COVID-19 outbreak, but the parties are still in discussion. Considering the sale, said Ivie, is a way to see how Hospice of the Northwest services can maintain and grow.

“The goal of the board is to ensure that hospice is not only here, but offering exceptional service like it currently is,” he said. “That would be a very important part of the ultimate [sale] agreement, should there be one.”

According to statements from Hospice of the Northwest, the nonprofit ended 2018 with a net income of almost $420,000.  However, it lost almost $730,000 in net income between 2018 and 2019.

When asked if Hospice of the Northwest is sustainable, owners said yes. Staci Beltran, mergers and acquisitions manager for Bristol Hospice, said that a change in ownership could benefit patients. 

“Bristol has found through its discussions with Hospice of the Northwest that we share many of the same beliefs and operational systems,” she said. “Bristol feels it can add support to Hospice of the Northwest being a hospice-focused entity that has dedicated leadership and resources to allow individual communities to do what they do best and provide exceptional care to patients and families.”

Private equity owner

Bristol operates 34 hospice locations in Arizona, California, Colorado, Florida, Georgia, Hawaii, Nevada, Oregon, Texas and Utah.

Bristol is owned by the private equity firm Webster Equity Partners. Private equity firms invest in companies that are not publicly traded. A typical strategy is to build up companies to earn quick rewards and sell them, according to the Harvard Business Review.

As of September, Bristol had acquired nine hospices in 2020, and 14 since it became a Webster portfolio company in 2017.

According to the Washington State Department of Health, Bristol tried to establish services in Washington with six different applications between 2018-19, including in Snohomish, King and Thurston counties. All were denied.

A review letter states that the 2019 application to serve in Snohomish County didn’t prove a need for more hospice services in the area, as it would be “an unnecessary duplication of hospice capacity.” 

To operate certain health care facilities, providers must apply for a Certificate of Need from the state. State employees review such criteria as whether there is a need for the hospice, whether the applicant can afford the project and whether the applicants have a history of quality care. 

If Bristol purchased Hospice of the Northwest, the company would inherit the current Certificate of Need, which includes allowing the services Hospice of Northwest currently provides in the areas they currently serve. Multiple Certificates of Need can be awarded to the same areas.

Foundation’s role

Ted Brockmann, superintendent of the Skagit County Public Hospital District 304, said more than 80% of Hospice of the Northwest is funded by Medicare, and the organization also accepts Medicaid and private insurance. 

A separate 501(c)(3) called the Hospice of the Northwest Foundation gathers donations to cover the cost of care if patients aren’t insured. The foundation also covers services that are not funded by Medicare, like grief programs for the communities they serve, not just patients. 

Clary said the foundation recently provided apartment rent for a homeless person on San Juan Island for the last few months of his life. 

Beltran said that Bristol also accepts Medicare, Medicaid and private insurance and does not deny services based on ability to pay.

“If it is determined that the patient is uninsured and does not have the financial resources to pay for care, Bristol will provide charity care and does so regularly,” she said. “Bristol will not deny hospice care to any individual based upon individual’s ability to pay, national origin, age, physical disabilities, race, color, sex or religion.”

Wendy Coates, executive director of the Hospice of the Northwest Foundation, stressed that the foundation would not be included in a possible sale of Hospice of the Northwest. 

Ed. — Updated Nov. 25, 2020: The foundation contributed $524,095 and $566,712 to Hospice of the Northwest in 2018 and 2019, respectively. From these gross donations, Hospice of the Northwest netted $178,886 and $336,945 in 2018 and 2019, respectively, after deducting the foundation’s expenses, such as staff payroll and the cost of building space shared between the two organizations.

“If a change in the hospice agency’s ownership were to take place, the mission, vision and goals of the Hospice of the Northwest Foundation remain the same — to fund dignity and compassion [at] every moment of life,” she said. “Our responsibility is to the community and not the agency or the shareholders of an agency.”

Coates said the foundation does not currently support any other hospice, but could supply donations to a for-profit with a similar mission as the foundation. However, Beltran said that Bristol does not accept donations, but the foundations Bristol supports can accept aid.

Comparing services

Hospice of the Northwest has the only Certificate of Need in San Juan County. The nonprofit provides two main medical doctors, as well as on-call lines to reach an RN or a counselor 24 hours a day.

There are also two volunteer hospice organizations in the San Juans: Lopez Island Hospice & Home Support and Hospice of San Juan.

Mariluz Villa, with Hospice of San Juan, said the organizations’ volunteers often assist Hospice of the Northwest. Hospice of San Juan does not have the same regulations as Hospice of the Northwest, she explained. 

For instance, Hospice of the Northwest staff are required by Medicare to provide medication, whereas Hospice of San Juan does not offer medication. Hospice of San Juan’s volunteers can help patients under volunteers’ individual licenses when patients aren’t charged, whereas when volunteers serve Hospice of the Northwest, they cannot provide medical care.

But how would services with Bristol compare to Hospice of the Northwest?

Clary said Hospice of the Northwest staff has specialized staff to care for pediatric patients, which she said she belives is not Bristol’s “strong suit.” However, Beltran said that Bristol serves children, just as Hospice of the Northwest does today. 

‘Death with Dignity’

Debra O’Conner is an RN for Hospice of the Northwest, and primarily serves Orcas and Lopez Island. She said up to 30% of her patients have elected to use Death with Dignity and can choose to enact the process anytime. The Death with Dignity Act allows terminally ill Washington state adults to request lethal doses of medication from physicians to end their lives.

Clary said that during the virtual meeting between the two companies’ staffs, she did not get the impression Bristol staff would participate in Death with Dignity services.

Beltran, however, said that, if the sale went through, Bristol would retain Hospice of the Northwest’s “current policy … in place” concerning the Death with Dignity Act. 

Clary said she worried Bristol would focus on dementia patients, rather than others. Hospice of the Northwest’s patients, she said, tend more often to suffer from cancer or lung or heart diseases than dementia. Clary said caring for dementia patients is usually easier than others, as dementia patients require fewer visits, and therefore less staff, which could save the company money. 

Beltran said Bristol does not focus on dementia patients, but “on providing hospice to all patients who are eligible.”

Beltran also confirmed that Bristol uses both contract and full-time physicians, and sometimes hires contract nurses. 

Rural realities

O’Conner fears that hiring contract staff, instead of full-time employees, could cut island services. O’Conner added that it’s especially important for families to feel confident with their level of care in the San Juans, since there are limited health care providers on the rural islands. 

“[Patients in the San Juans] can’t just get in the car and take their loved one to the emergency room when they have pain. They can’t just go to the doctor’s office on a Saturday. They can’t just go to the pharmacy on a Sunday to pick up something,” said O’Conner. “We don’t want the services to decrease at all up here.”

Brockmann of the hospital district reiterated that services should remain the same, even if ownership changes.

“Hospice of the Northwest is a great organization. It is very important to both boards that the care continues into the future and that if we went with this national organization that it would continue to expand and grow,” he said. “We would continue to supply great hospice services in the communities.”

Clary, who lives on San Juan, hopes to partake in that care.

“Someday I’m going to retire,” she said. “I just want someone to take care of me and my husband like I’ve been taking care of our community these last years.”

The Journal of the San Juan Islands reported Nov. 10 that commissioners of San Juan Hospital District No. 1 signed a letter on Nov. 5 to the Skagit Regional Health Care District No. 1 Commissioners opposing the sale. 

The next Skagit County Public Hospital District 1 Board meeting is at 8 a.m., Nov. 20. More information is at skagitregionalhealth.org/. The next Skagit County Public Hospital District 304 Board meeting is at 8 a.m., Nov. 18 (unitedgeneral.org/about-district-304/commissioners/).

— Reported by Hayley Day