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					      St. Luke’s Hospital




              Hospice:
          Connecting Earlier
                           Market Strategy
                             May 2005




Lindi Roelofse  Gary Gu  Gabriel Hansen  Myungkyu Noh  Lauren Olson
Agenda

    I. Abstract
    II. Analysis Overview
    III. Market Segments and Sampling
    IV. Results
    V. Recommendations
    VI. References


                             St. Luke’s Hospice
    Abstract
         The objective of this study is to suggest
         strategies to facilitate earlier enrollment for
         hospice eligible persons. Structured interviews
         from a broad base of hospice constituencies
         and quantitative Press Ganey data analysis
         suggests that there is a general misconception
         and stigma associated with hospice.

         This report will provide five low cost strategies
         to address this problem.




I                                                    St. Luke’s Hospice
Analysis Overview
     Social Issue
     •   Offer more caring for people who have a terminal illness;
     Campaign Focus
     •   Increase patients’ awareness of hospice service, including specific
         service benefits, financial requirements, and decision-making options;
     •   Increase doctors’ likelihood of connecting with patients sooner to
         discuss hospice as an entitled option for end-of-life care;
     Campaign Purpose
     •   Provide referrers, family members, and those who are in their end-of-life
         phase with the necessary information to enroll in the hospice program
         earlier


II                                                            St. Luke’s Hospice
Analysis Objective
                        Average Length of Stay                                     Average Daily Sensus                    • Actual
                                                                                                                           numbers
        100                                                           70
                                                                      60

                                                                                                                           • SLH
        80
                                                                      50
        60
 Days




                                                                      40




                                                               Days
        40
                                                                                                                           expectations
                                                                      30
        20                                                            20

         0                                                            10                                                   • More
              2000   2001     2002       2003    2004   2005           0                                                   conservative
                                                                           2000   2001    2002    2003    2004     2005
                                                                                                                           trend estimate



Campaign Goal
Increase the average length of stay from 48 days in 2004 to 77.7 days in 2005. By
implication, this should also result in an increase in the average daily census from 49.6
patients in 2004 to 66 in 2005


II                                                                                                               St. Luke’s Hospice
  Market Segments & Sampling
      Quantitative                                        Qualitative
      Press Ganey and internal statistics were analyzed   Structured interviews were conducted to
      to understand the current internal and national     understand the different perspectives of the
      situation.                                          SLH constituencies. Convenience sampling
                                                          was used.

                                                                      constituency            n
                                                                  Physicians                  6

                                                                  Long-term care facilities   4

                                                                  Past users                  4

                                                                  Non-users                   8

                                                                  SLH Staff                   4

                                                                  Competitors’ Staff          4

                                                                  Legal Professionals         2




III                                                                            St. Luke’s Hospice
        - quantitative
ResultsDuration of Service
         How long did you use hospice                   How long did you use Hospice
                 (Last Period)                                  (This period)
                                                                             1-3 days
                  >6 mths                                                      10%
                                1-3 days
                   10%
                                  17%                                          4-7 days
             >2 mths to                                       >6 mths            10%
               6 mths                                          39%
                                  4-7 days                                     >1 week to
                24%
                                    22%                                           1 mth
               >1 mth to 2                                                        19%
                             >1 week to                         >2 mths to   >1 mth to
                  mths         1 mth                              6 mths      2 mths
                  13%           14%                                12%         10%




     Less than 10 days : about 40%                Less than 10 days : about 10 %
     Less than 1 month : about 30 %               Less than 1 month : about 30%
     Over 1 month : about 30%                     Over 1 month : about 60%


     Compared with last period, the average duration of care has been increasing. This
     data shows that effort to increase the duration of care does work. Further, 39% of
     over 6 months is a good sign. But St. Luke’s Hospice has to find a way to maintain
     this trend as long as possible.

IV
            - quantitative
     ResultsAppropriate Time
            Was referred at appropriate time               Was referred at appropriate time
                     (Last Period)                                   (This Period)

                         No. Too                                         No. Too
                          early                                           early
                    NO. Too                                       NO. Too 2%
                           1%
                     late                                          late
                      1%                                           12%



                        Yes, Right                                           Yes, Right
                          time                                                 time
                          98%                                                  86%



      This data shows that there is a conceptual gap between customer perception and actual
      hospice service. Hospice patrons think that they were referred to hospice services at the
      appropriate time (86% of this period). SLH should utilize this result to improve the
      general concept. The sooner patients are referred to the service, the more they show
      preference to hospice service.
IV
     Internal vs. Patient Priorities
          Correlation Coefficient
                                                 Internal
      Independent Variables                      Priority   Correlation
      Coord of care among hospice team               5          93
      Hospice staff's concern for privacy                       93        • This data indicates that there are
      Efforts to include you in decisions                       91        some gaps in general priorities
      Concern keep you informed about cond                      89        between St. Luke’s Hospice and its
      Overall quality of care provided                          89        patients. Patients regard the
      Honor given to religious traditions            3          89
                                                                          coordination of care among the
                                                                          hospice team and the staff’s concern
      Likelihood of recommending                                89
                                                                          for privacy as the top priorities, but St.
      Staff's sens to persnl difficulties            6          89
                                                                          Luke’s Hospice treats responsiveness
      Rspnsvness evning/wknd on-call svc             1          85        with evening and weekend on-call
      Helpfulness employee made arrngmnts                       84        service as the most important priority.
      Staff addressed spiritual needs                4          83
      How well nurse taught you to care              8          82        • This indicates that St. Luke’s
      Educ and training about how to care                       82
                                                                          Hospice can re-organize priorities to
                                                                          satisfy patients and their families e.g.
      Approp of Hosp servcs to meet needs                       79
                                                                          “coordination of team,” “privacy” and
      Nurse' concern for comfort                                79
                                                                          “inclusiveness” are generally more
      Control of other symptoms                      2          77        important than the expected “on-call
      Ease of changing the care schedule                        76        response”, “control for symptoms,”
      Staff addressed emotional needs                           75        and “religion customization.”
      Helpfulness of bereavement program                        75
      Info provided hospice mission                  6          74
IV   Dependent variable : Overall Satisfaction
                of Stay
Average Lengthcomposition
     Average Length of Stay
     Customers
     VOLUME STATISTICS        2000     2001       2002      2003     2004    AGE           2000       2001      2002        2003     2004
     Number of Referrals      281      288        318        344      425
                                                                             0-30 years     0          3           2         4        1
     Number of Admissions     216      213        238        275      357
                                                                             31-40 years    6          3           4         4        1
     Percent of Referrals
     Admitted                 77       76          75          80     84     41-64 year    37         20           39       36       41
     Average Daily Census     28       40.6       49.66     37.5     49.65
                                                                             65-80 years   81         100          92       96       118
     Average length of Stay
     (Days)                   37.2     50.3        68       57.7      48     80+ years     91         87        101         135      196

                              2000 ~     2001 ~         2002 ~      2003 ~
                                                                                           2000 ~      2001 ~           2002 ~     2003 ~
     VOLUME STATISTICS         2001       2002           2003        2004
                                                                             AGE            2001        2002             2003       2004
     Number of Referrals       2%            9%           8%         19%
                                                                             0-30 years     100%            -50%          50%      -300%
     Number of Admissions      -1%          11%           13%        23%
                                                                             31-40 years   -100%             25%           0%      -300%
     Percent of Referrals
     Admitted                  -1%          -1%           6%         5%      41-64 year     -85%             49%           -8%       12%
     Average Daily Census      31%          18%           -32%       24%
                                                                             65-80 years        19%          -9%           4%        19%
     Average length of Stay
     (Days)                    26%          26%           -18%      -20%     80+ years          -5%          14%          25%        31%


          • Overall criteria show positive results as number of referrals and admissions are growing.
          • However, average length of stay decreased. This result might come from the medical
          process or the character of diseases.
          • Finally, older patients are getting more involved in hospice service.

IV
     Disease/Referrals/Discharge
       Disease/Referrals/Discharge
      Diagnosis               2000   2001   2002   2003    2004                             2000 ~   2001 ~    2002 ~    2003 ~
                                                                    Diagnosis                2001     2002      2003      2004
      Cancer                  153    147    139     148     160     Cancer                     -4%      -6%        6%        8%
      Non-Cancer              63     66      99     128     197     Non-Cancer                  5%      33%       23%       35%

      PHYSICIAN TYPE          2000   2001   2002   2003    2004                             2000 ~   2001 ~    2002 ~    2003 ~
                                                                    PHYSICIAN TYPE           2001     2002      2003      2004
      Family Practice         96     112    120     137     190
                                                                    Family Practice          14%       7%       12%       28%
      Oncologist              70     51      66      66     84      Oncologist               -37%     23%        0%       21%
      Internist               26     47      52      72     103     Internist                45%      10%       28%       30%

      Other                   24      3      0       0       0      Other                   -700%    #DIV/0!   #DIV/0!   #DIV/0!

      DISCHARGE                                                     DISCHARGE               2000 ~   2001 ~    2002 ~    2003 ~
      Disposition             2000   2001   2002   2003    2004     Disposition             2001     2002      2003      2004
      Number of Deaths        186    186    222     237     309     Number of Deaths            0%      16%        6%       23%
      At home                 174    177    191     181     237     At home                     2%       7%       -6%       24%
      In-Patient (hospital)   12      9      31      56     72      In-Patient (hospital)     -33%      71%       45%       22%


     • Importance of non-cancer patients: As time goes by, the number of non-cancer patients has been increasing. St.
     Luke’s Hospice should utilize a marketing plan for improving the reputation of service for non-cancer patients. The aim is
     to counter Amenity Hospice’s marketing plan regarding non-cancer care.
     • Strategic concept of distributional factor: From 2001, the importance of family medicine doctors as a referral has
     been increasing. It is important to cultivate opinion leader groups in the family medicine field for early reference.
     • Number of patients: Trend of in-patients at hospitals has also increased. St. Luke’s Hospice should find a way to
     advertise its strength in this area.
IV
Results – qualitative
     Common behavior and beliefs about hospice
     •   People generally do not have a lot of knowledge about hospice
         care. If they are aware of it, they know hospice handles pain
         management issues toward the end of a person’s life.
     •   The general public does not think about hospice as an option for
         them to consider independent of a doctor’s recommendation.
     •   Even though enrolling in hospice is a major decision, it is
         typically treated with what might be considered routine problem
         solving behavior: the doctor says hospice is needed and the
         patient does little or no research to choose an appropriate
         service.


IV                                                      St. Luke’s Hospice
     Results - qualitative
         Common social misconceptions related to hospice that need to be
         eliminated:

     •   All patients fight to the end: At some point, relationships and comfort may become
         more important and that is normal.
     •   Doctors should never stop trying to find a cure: Doctors should consider the all
         options, especially when it becomes apparent that he/she can not stop the
         deterioration process.
     •   Don’t talk about death when it is not relevant: Discussing end-of-life issues before
         entering the actual phase is both normal and important so that people know how to
         better support a loved one.
     •   Hospice is only for poor people: Many believe that a 24-hour nurse fulfills the same
         service as hospice. This is not true. Hospice offers an expert support team that goes
         beyond the functions and resources available to a nurse.
     •   Enrolling a loved one in hospice proves that you are incapable of taking care of
         your own family: Especially in the Midwest some families prefer to handle difficult
         situations with “pride” (internally and behind closed doors). In actuality one would be
         able to take better care of a loved one during the end-of-life phase if the family and
         friends also receive support form hospice experts.



IV                                                                      St. Luke’s Hospice
Conclusion
               Estimated position
               of the hospice
               market today
    growth




                                    time


             • SLH finds itself in a growing market
             • Early stage of the market development
             • Professionals are unable to differentiate the services
             • Customers are unable to differentiate and identify what
             hospice they use


V                                                             St. Luke’s Hospice
    Service Differentiation
    Some specific messages to communicate the differences of
    SLH compared to competitors:

    Legacy: SLH provides personalized activities to provide a therapeutic outlet beyond
    what others offer. For example, pet therapy, massage therapy, music therapy, notated
    photo albums, genealogy charts and legacy packets
    Convenience: It is possible to ask for a specific service from SLH, such as easy
    check-in/check-out procedure and access to relevant information about SLH via
    telephone, guest speakers, and the internet
    Trust: That SLH can offer the high quality service each patient needs as corroborated
    by high satisfaction scores
    Dignity: Respect for patient privacy at all times and during all services




V                                                                  St. Luke’s Hospice
Factual Knowledge to Disseminate
    Hospice in General                        St. Luke’s Hospice Specifically
    •   Location: Patients remain in          •   Customization: To individual needs
        home, hospital, and/or LTCF
    •   Cost: No person should be turned      •   Length of enrollment: Start at 6
        away because of a lack of                 month life expectancy. Longer
        insurance to cover the cost               enrollment translates to greater
    •   Services: Go beyond the                   comfort and better customization
        physiological to include emotional,   •   Satisfaction: Extremely High (97%)
        spiritual, and social benefits
    •   Patient: Non-cancer as well as        •   Tradition: Longest history of
        cancer patients in last 6 months          hospice service in the area
    •   Expertise: Hospice offers             •   Specializes: In promoting dignity
        expertise that a 2-hour nurse would       and purpose for non-cancer and
        not have
    •   Why: These services would be              cancer patients
        important to a person during the      •   Referrals: From any doctor or
        end-of-life phase                         hospital within a 50 mile radius




V                                                               St. Luke’s Hospice
Price: Benefits

    There are major financial benefits to enrolling in hospice
    since Medicare and/or insurance covers all expenses.
    Every person has a right to this service if they qualify
    based on a doctor’s prognosis of their life expectancy.
    There is no price differentiation between competing
    hospice organizations.




V                                              St. Luke’s Hospice
Place: Convenient Access
    Because hospice-eligible patients generally experience decreased
    mobility, the ideal place to administer services are in their own homes,
    long-term care facilities or hospitals. Further, response time is important
    which supports the 50 mile radius of service as a good policy.
    There is a major need for additional initiatives to increase access to
    information through the internet and at community engagements which
    address issues related to the end-of-life stage.
    Additionally, informational exhibits inside St. Luke’s Hospital would be a
    good way to reach all levels of the target audience. This would allow hospital
    staff, visitors, and patients to have access on a daily basis.




V                                                              St. Luke’s Hospice
    Promotion: Strategies
Key Messages:
To the General Population                                 To Physicians
1.   There are two decisions you need to consider          1.   Patients are unaware of the full range of
     regarding hospice care:                                    services that hospice offers.
             •     When is hospice care appropriate for    2.   Patients do not understand that they are
                  you?                                          entitled to the hospice benefit.
             •     From whom do you want to receive        3.   We’re not asking you to recommend hospice
                  your hospice care?                            services earlier. We’re only asking that you
2.   You are entitled to hospice care.                          introduce the hospice option early on so
3.   Hospice decisions should be discussed well in              patients and their families can ask questions
     advance of when you actually have to make the              and do research well before the actual
     final decision (i.e., engage these topics now!).           decision needs to be made.
4.   There are benefits to hospice care that reach far
     beyond pain management and comfort care:
     Financial Advice, Family Support, Speech
     Therapy, Music Therapy, Pet Therapy




V                                                                            St. Luke’s Hospice
Promotion: Strategies
        Style and tone of messages:
To the General Population                         To Physicians
                                                     •   The current style and tone is
    •    Clear, specific, unambiguous terms              probably appropriate.
         must be used for all                        •   Professional and honest
         communication. Avoid the use of
         phrases like palliative care or social          communication must be used at all
         worker without specifically                     times.
         explaining the meaning of them.             •   Try to instill the idea that you are
    •    Use an informative tone, but note               working as a team within the medical
         that the audience is not only a                 community by using a cooperative
         patient, but also a customer whose              tone while offering assistance in a
         primary need involves a painful                 tough subject area.
         subject. As such, in addition to
         information, hospice customers are
         also looking for comfort.



V                                                                     St. Luke’s Hospice
Promotion: Strategies
    Copy, format and graphic recommendations

    • Copy for all marketing materials should focus exclusively
      on the specific message objectives. Detailed information
      can be delivered using other means.
    • Graphics and formatting should be uniform throughout
      the campaign. Use the official St. Luke’s Hospice
      trademark on all written media.



V                                              St. Luke’s Hospice
Media Vehicles
         Strategy                              Vehicle


    Advertising      PSA, TV, radio, newspaper, magazines, internet, blogs,
                     support chat forums
    PR               Stories on TV and radio, articles in newspapers and
                     magazines, videos, exhibits, meetings, conferences
    Printed Material Brochures, newsletters, calendars, booklets, mouse pads,
                     flashlights, hangers
    Signage and      Road signs, signs, and posters on government property
    Displays
    Personal         Face-to-face meetings, presentations, conferences,
    Selling          workshops, seminars, training sessions, telephone calls.



V                                                           St. Luke’s Hospice
 Recommendations
     Primary Target Audience: families who currently need hospice service or
     may need it in the future. The St. Luke’s Hospice current service area of a
     50 mile radius around Cedar Rapids will serve as the primary target area.
         • Education of the full range of hospice services is needed for this
         group, so they may be better informed when faced with a life-
         threatening illness.

     Secondary Target Audience: physicians and medial personal who would
     refer potential service takers
          • Distribution occurs primarily through physicians and medical
          personnel in the form of referrals
          • Encourage conversation about hospice at an earlier stage




VI                                                           St. Luke’s Hospice
Objectives
                             Change Behavior

                             Develop strategies to influence
                             potential patients and
                             health care professionals to inquire
                             about or to recommend SLH earlier.




Change Knowledge                                             Change Beliefs

Patients who enroll in hospice at an                         Enrolling in hospice will improve the
earlier point of eligibility                                 quality of patients’ lives
experience specific benefits. Many                           and those who care for them. Those
patients have                                                who discuss and/or enroll in
misconceptions about hospice. This                           hospice earlier rather than later will
must be corrected.                                           not be viewed negatively.


VI                                                                      St. Luke’s Hospice
 Recommendations
Recommendations

    Brochure: Revise to include more basic marketing message and theme.
    Emphasize full range of services and differentiation.

    Website: Re-design to become a comprehensive, one-stop information
    source about St. Luke’s Hospice. People at all stages of readiness should
    be able to find the information they need from the website.

    TV and/or Radio PSA: This will target the secondary audience and
    should serve as a way to raise awareness about hospice in general, as
    well as a way to affect attitudes and perceptions about hospice service.

    Rotating Exhibits at St. Luke’s Hospital: Use hospital space to educate,
    raise awareness and affect attitudes of secondary target audience.



V                                                            St. Luke’s Hospice
 Recommendations
Recommendations

    Legacy Pamphlet: This could be used two ways, depending upon which
    way St. Luke’s Hospice thinks it would be most beneficial, and upon
    budgetary or volunteer hour constraints.
        • Distribute to LTC facilities for residents’ use. This method of use
        would serve to raise awareness about St. Luke’s Hospice, and may
        serve as an entry point into some facilities. This use can also help
        shape brand attitudes regarding St. Luke’s Hospice.
        • Use with St. Luke’s Hospice patients. Volunteers could work with
        patients, helping them create some of the ideas in the pamphlet. This
        use would be a point of differentiation in service between St. Luke’s
        and other hospice services in the area.




V                                                          St. Luke’s Hospice
 Recommendations
Recommendations

    Form a strategic alliance with other non-profit hospices: There is a
    great opportunity to increase the number of people in Iowa who use
    hospice service. In order to accomplish this, a large educational
    campaign needs to be undertaken, which most non-profit hospices could
    not afford to do on their own.

        • Alliance could be regional or state-wide

        • Other hospices have expressed an interest in working together

        • Other benefits besides resource pooling could include: information
        sharing, increased innovation, better service(s) to patients, and
        establishment of local best practices



V                                                           St. Luke’s Hospice
Implementation
    BROCHURE
    1.       Sample (link)
    2.       Message strategy
         –     Offering basic and necessary information about SLH for target
               audience
    3.       Action
         –     Redesign and reproduce the brochure
         –     Deliver to target audience and distribution channels
    4.       Monitoring & Evaluation
         –     Monitor feedback from target audience through interviews, focus
               group and questionnaire, etc
         –     Monitor feedback from distribution channels, such as doctors and
               social workers


V                                                              St. Luke’s Hospice
Implementation
    LEGACY PAMPHLET
    1.       Sample (link)
    2.       Message strategy
         –     Convey LEGACY message for primary target audience
    3.       Action
         –     Produce the pamphlet
         –     Delivery to primary target audience through health fair and exhibition,
               etc
    4.       Monitoring & Evaluation
         –     Monitor feedback from primary target audience
         –     Participation ratio among patients


V                                                                St. Luke’s Hospice
Implementation
    TV/RADIO COMMERCIAL

    1.       Sample (link)
    2.       Message strategy
         –     Promote SLH services by focusing on dignity and value
    3.       Action
         –     Produce a 30-second video/radio commercials in a uniform style
         –     Negotiate with local TV/Radio stations about air time and frequency
    4.       Monitoring & Evaluation
         –     Timely airing report from local TV/Radio stations
         –     Monitor feedback from target audience



V                                                                  St. Luke’s Hospice
Implementation
    ROTATING EXHIBIT

    1.       Sample (link)
    2.       Message strategy
         –     Promote hospice service with more accessibility for primary target
               audience
    3.       Action
         –     Produce the rotating exhibit frames
         –     Negotiate with relevant hospitals and agencies for timely exhibition
         –     Update concept and location on a quarterly basis
    4.       Monitoring & Evaluation
         –     Monitor feedback from target audience through focus group and/or
               surveys
         –     Monitor feedback from participating hospitals and agencies


V                                                               St. Luke’s Hospice
Implementation
    WEBPAGE

    1.       Sample (link: http://www.stlukescr.org/body.cfm?id=84)
    2.       Message strategy
         –      Create a full information resource about SLH services
    3.       Action
         –      Add specific hospice service items, including specialized items
         –      Link with 30-second video commercial about SLH services, focusing on new message of
                Legacy for target audience
         –      Add an animation of regular service process for target audience, particularly those older
                patients more than 60 years old
         –      External link with a community site, much like eBay’ site so people sharing the same
                interests can easily get together
         –      Move the Read about one family's experience with St. Luke's Hospice to the right column,
                redesign the text and change the hyperlink to an external one
    4.       Monitoring & Evaluation
         –      Add a recorder to monitor the number of visitors on a monthly basis
         –      Collect feedback from target audience through online surveys or questionnaires


V                                                                             St. Luke’s Hospice
References

1.  Tapke, Melissa. St. Luke’s Hospice Application Letter, January 2005
2.  St. Luke’s Hospice Agency Evaluation FY2004, February 2005
3.  Tapke, Melissa. Email Interview, March 21, 2005
4.  Tapke, Melissa and Cindy. Personal Interview, February 17, 2005
5.   http://www.stlukescr.org/body.cfm?id=84, April 3, 2004
6.  http://www.amenityhospice.com/, April 3, 2004
7.  http://www.mercycare.org/services/hospice/index.aspx, April 3, 2004
8.  http://www.dhs.state.ia.us/dhs2005/dhs_homepage/index.html, April 3,
    2004
9. Tapke, Melissa and Cindy. Personal Interview, February 17, 2005
10. "Hospice Service Report - 2004", Press Ganey




                                                        St. Luke’s Hospice

				
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