If you or a loved one were dying in San Juan County and needed urgent inpatient care, you could be required to travel to Island Hospital in Anacortes rather than PeaceHealth Peace Island hospital on San Juan Island.

Peace Island administrators are quick to make their priorities clear, saying, “If we see a need, we will care for that person regardless of their ability to pay.” But Medicare will not reimburse Peace Island for care provided to hospice patients, potentially creating a financial burden for the hospital.

Medicare has guidelines for reimbursing hospice care: both the patient and doctor must agree to categorize the patient as terminally ill and not likely to live more than six months. Once the patient is designated as “hospice,” they renounce their standard Medicare insurance coverage, and all care related to their condition must be provided through the hospice agency. For San Juan County residents, the only hospice agency is Mount Vernon-based organization Hospice Northwest, which serves Skagit, Island, San Juan and Snohomish counties. And at present, Hospice Northwest does not authorize patients to receive care from Peace Island.

“We do not have a contract with Peace Island,” said Hospice Northwest executive director Bob Laws, who just took the helm this August. At present, island hospice patients needing inpatient care must travel to Island Hospital in Anacortes, which does have a contract with Hospice Northwest. But Laws said they are currently fine-tuning a contract proposal that will be submitted to Peace Island.

And PeaceHealth manager of communications Bev Mayhew told the Journal that PeaceHealth is “beginning to explore options” to contract with Hospice Northwest.

Mariluz Villa, a hospice physician and the main operations manager for Hospice San Juan, said she is concerned that hospice patients in the islands – especially those living on San Juan – are directed by hospice not to access hospital care at Peace Island.

“The emphasis on end-of-life care in this county has been on death with dignity,” she said. “It really needs to be on end-of-life care so people can be surrounded by their friends, their family and their support groups at the end of their life. The hospice care should enable people to live and die in their homes, if they so desire. My concern is that access to Medicare hospice services in the county are not the way they should be.”

She was quick to clarify: “The Hospice Northwest social worker, the nurses and support staff are really great; and the services they do provide are amazing. But they don’t have a contract for in-patient care with Peace Island Medical Center, despite the fact that Peace Island built a gorgeous room specifically designed for hospice patients.”

Villa adds that Peace Island currently goes above and beyond expectations to help islanders get the care they need. “In my experience, Peace Island tries really hard to allow people to stay here,” she said. “For example, the doctors do house calls even though there is no formal house call program; they’re amazing.”

An extra-large room designed with hospice capacities in mind was built into the Peace Island hospital, and is currently used to provide comfort care and family presence to dying patients.

“Should a contract with Hospice Northwest become a reality, that room could be turned into a hospice room,” said Mayhew. At present, she said, “If [patients] have a contract with some other facility, they should go to that facility. We provide charity care for those without coverage.”

Villa notes that 30.6 percent of the county’s population is 65 years or older, more than double the statewide percentage – indicating a significant population relying on Medicare. While she doesn’t have statistics on the number of hospice patients who actually need inpatient care, Villa has recently helped care for islanders whose last days were made more difficult by the current policy.

“There was a woman who died last year who did not want to leave the island, her friends, and her support system,” she remembers. “She would rather live with the pain than go off-island … She had a lot of unmanaged pain.” Other patients have moved their entire families to Seattle or Whatcom so that they could be near the hospice patient receiving hospital care. Laws, who has served at Hospice Northwest for nearly 10 years in various nurse management positions, said he is not aware of cases in which pain was left unmanaged.

Villa and other end-of-life care providers in the islands also cited distance and logistics as a potential difficulty for islanders receiving care from a mainland hospice provider.

“Given the geographic challenges, [Hospice Northwest] actually does a pretty amazing job,” she said. “Considering what they have to go through to get stuff out here, it’s pretty amazing what they can do.”

Bellevue Medical, Hospice Northwest’s direct supplier of durable medical equipment, delivers to the islands only on Wednesdays. While Hospice San Juan and other island senior care organizations do lend some durable medical equipment as well, Villa says sometimes they run out.

But Laws says Hospice Northwest is willing to authorize delivery of medical equipment on an emergency basis, as well.

“If there is an urgent need, we can deliver,” he said. “It would not take more than 24 hours, and if you let them know early enough in the day it would probably be same day.” Bellevue Medical charges $250 for emergency deliveries. Laws said if the emergency delivery is medically needed for the patient’s comfort, Hospice Northwest will cover the charge; if it is for convenience, the family may be asked to pay it.

Laws said the logistics of providing care in the islands from a mainland organizational base do not detract from the quality or quantity of end of life care Hospice Northwest provides to islanders.

“We provide whatever care is needed for symptom control,” he said, emphasizing the distinction between hospice and care-giving services. “If a patient needs two hours, or 24 hours of nurse availability in the home for symptom control, we will provide that.” Laws said Hospice Northwest makes a special effort to train island hospice patients in the comfort measures they can personally control, allowing hospice nurses to provide guidance over the phone if needed.

“It would be difficult to have a nurse go see them in the middle of the night; that’s really the only difference [resulting from island logistics],” he said.

Hospice Northwest currently has a nurse and a nurse practitioner living on Lopez Island as well as a nurse living on San Juan Island, all of whom provide care in the islands. While they actively recruit in the islands whenever there is an opening, Laws said Hospice Northwest is fully capable of sending nurses to the islands to provide care, even if that means putting them up in a hotel room.

Villa raised the question of whether PeaceHealth might in the future obtain permission to provide hospice facilities actually located in the San Juan Islands. To become a hospice provider, an entity must obtain a “certificate of need” from the state for a particular geographic area. The determination is based on population metrics, and to date just one certificate has been issued to serve our county, to Hospice Northwest. Mayhew said PeaceHealth is “not currently involved in trying to get the certificate of need.”

Lopez Island

For Lopez Islanders, “Since we don’t have a hospital on Lopez, [the lack of contract with PeaceHealth] affects us less,” said Elizabeth Landrum, a board member of the all-volunteer Lopez Island Hospice and Home Support. Manager of Client Services Mary O’Bryant said Hospice Northwest has consistently provided needed care on Lopez Island, including weekly social worker visits and volunteers from the mainland.

“We’ve had an excellent relationship with them,” she said. “Their care has only improved over the years; it’s the best it’s ever been, and we’re very pleased with their care and their level of professionalism.” She added that most Lopezians seem to use mainland doctors and hospitals rather than heading to Peace Island, anyway. And when Lopez hospice patients in their last days need more intensive support, the Lopez hospice sends more volunteers to fill the need.

Orcas Island

Volunteer hospice nurse Molly Roberts has provided home health care and hospice care for 25 years.

She says, “[Hospice Northwest] has done an incredible job; this is the best it’s ever been.” She cites regular, weekly in-home visits by nurses and the weekly delivery of clean, working-order durable medical equipment by trained technicians, saying, “The nurses can’t be there all the time; they can visit once or twice a week; so the challenge is to put together a care team of family members and neighbors.”

She allows, “Individual people have had concerns – some would say it certainly would be better if they were based closer. It is a ferry ride, and they do have a schedule. They have a 24/7 nurse on call so you can talk 24/7; they can’t travel to your house that day.” Sometimes when Hospice Northwest can’t get a nurse to the islands to meet an urgent need, they call Roberts, and she is happy to step in. Roberts noted that in her experience, it is rare for a hospice patient to need hospital care.

Lahari executive director Dennis King said Orcas Island has a less developed network than Lopez or San Juan Islands for providing volunteer support and home care. Citing changing demographics, he says, “One of my concerns is that as the island gets older, our need for hospice will increase; there are some potential issue with Hospice Northwest being so far away.” He said it could be helpful to have a hospice based closer in order to meet immediate needs more quickly, but noted that it would be difficult to justify the need, based on Medicare’s population-based metrics.

“There is a disconnect between federal regulations and local geography,” he said; the government tends to look at the county as a whole without realizing that short distances as the crow flies can actually require hours of grueling travel.

“What would it take to establish a San Juan County hospice?” he asked. “Is it a possibility to establish a San Juan office of Hospice Northwest?

That discussion may be one that is raised again in the years ahead, as islanders continue to age and to need more extensive end-of-life services. But one thing seems certain: Life could be a little easier for terminally ill islanders if Peace Island and Hospice Northwest succeed in negotiating a contract to provide hospital care on San Juan Island for hospice patients.