An intense bundle of energy, Amy Crookshanks, the woman in charge of communications, fundraising and marketing at the non-profit medical company Partners in Home Care, is constantly on the move, and almost always seems to be working a piece of hard candy in her mouth. With her propensity for getting things done-and perhaps the added vigor of a constant sugar high-Crookshanks must have struck Partners administrators as a perfect addition to the staff when she was hired in June of 1998.
A veteran fund-raiser with plenty of public relations ex-perience with the Rocky Mountain Elk Foundation and Planned Parenthood of Missoula, Crookshanks was hired in part to help Partners shore up the bottom line.
It's unclear how profound the money problems faced by Partners are right now, but individuals close to the organization claim that cost-cutting has led to diminished care for the patients in Missoula's touted hospice program. Recent allegations reflect concerns that staffing has been inadequate at the hospice house, while care for those who can't afford to pay has been put on the chopping block because of business concerns.
Most agree that if these charges are true, they violate the implicit understanding that hospice is a charitable community entity not to be run akin to a for-profit enterprise.
Staff turnover and the resignation of top administrators paint a not altogether healthy picture of this private, non-profit company, which for the past couple of years has been struggling to balance patient care, shrinking reimbursements and financial needs.
Along with Missoula's vaunted hospice program, including the Mountain Valley Hospice House, Partners in Home Care oversees agencies which provide home assistance to the ill and injured. The hospice care provided by the group, initially established by famed hospice doctor and author Ira Byock nearly a decade ago, marks one of the company's most important contributions to the community.
Between the hospice house Partners runs on Mullan Road and the contracts it holds with nursing homes and private individuals, the operation has made Missoula a place where the elderly and infirm can find a comfortable place to die.
Now, for many who have departed the company in recent months, including Byock and his longtime professional colleague Peggy Schlesinger-who abandoned her role as medical director at Partners on the first of September-concerns over end-of-life care stand paramount.
"This is a hard time in which to be providing health care," Byock says. "The pressures of providing ever increasing symptom management combined with falling reimbursement rates make it hard to provide a first rate program while remaining fiscally sound."
Sitting in her small, windowless office, decorated with pictures of her dogs, Crookshanks admits that there are financial difficulties at Partners. But Crookshanks, current administrators at Partners and board members also maintain that care levels are high throughout the organization.
And despite the abrupt disappearance of the woman brought in to create a new plan for the company, Jane Theriault-who left her position as executive director under extremely murky circumstances-those within the organization say that business continues as usual and patients are getting the care they need.
To make up losses, Crookshanks adds, she plans on launching a money-making blitzkrieg full force in November, to coincide with National Hospice Month. In addition to a $30,000 raised by the Hospice Ball, which was handed over as an endowment two weeks ago, the effort is meant to rescue the company from continuing debt.
"Hospices are not known as money making organizations," Crookshanks says. "The board felt a little restructuring was necessary. The goal is to keep hospice. We believe taking care of the dying is for the whole community."
In modern, Western culture, generally speaking, the hospice movement is recognized as an alternative to mainstream medicine and the knee-jerk compulsion to save lives at all costs. For many doctors, the idea that patients need pain control and not treatment as their bodies cease to function seems anathema to the Hippocratic Oath-which calls for them to save lives, not help end them.
In hospice, there's an acceptance of the idea that death is simply the final stage humans pass through as they head from cradle to grave. Such a philosophy has led to a system of providing teams of professionals to attend the dying and their families, usually in a patient's home. Hospice care, likewise, aims to treat the indigent regardless of a patient's ability to pay.
To that end, community donations play an integral part in keeping hospice afloat. That way, those without family or financial resources have somewhere to go when they are passing on. Those principles helped guide Hospice of Missoula until the group merged with Partners in Home Care a little over a decade ago.
But in conversations late this summer, more than one critic charged that administrators at Partners lack the ability to run an effective, community-based hospice program. These sources say the ongoing struggle to get adequate reimbursement in these times of managed care have diminished the medical attention hospice patients receive. Private insurers and public funds such as Medicare only provide so much money to cover costs.
As a result, questions over accounting and fundraising efforts have drawn skepticism from those who want hospice to be run in full view of the community it aims to serve. The corporate climate which has afflicted Partners in recent years, they say, has made it impossible for the bosses to prioritize the needs of patients-especially those who are dying.
Critics still say the community should be sure of what their money is paying for, fearing that funds go first to feed debt and second to pay for indigent care, contrary to what is stated on the back of Partners' brochure. They accuse the board of running hospice like an asset rather than a community resource, which is counter to what its founders intended.
And with staffers and administrators headed out the door at an alarming rate, those charged with overseeing hospice have been faced with further challenges.
In addition to Byock, Schlesinger and Theriault leaving this summer, Partners' volunteer coordinator for hospice quit her job and the resident volunteer at the house was not replaced when her term came to an end in August. Patient coordinator Gail Kerscher, meanwhile, now works as a hospital liaison, and director of clinical operations for hospice and home health care, and Nancy Heyer, a nurse at Partners for 12 years, has taken over as acting executive director.
Despite such changes-or perhaps because of them-key players with Partners, ranging from employees to board presidents, refused to speak with the Independent.
Board president Larry White of St. Patrick Hospital, through his secretary, claimed he doesn't know enough about what was happening with hospice to discuss the shake-up. Interim medical director and board member Dr. Anne Murphy didn't return a multitude of phone calls. Hospice chaplain Tom King, a longtime staffer, also didn't respond to requests for an interview.
In the meantime, Crookshanks was present at every meeting any Partners employee had with the Independent, replaying the same message-that nothing major is wrong with Partners or hospice.
Heyer, who replaced Theriault as executive director, offers another explanation for such machinations. "This turn of events really reflects what's happening nationally," she says. "The board understands the nature of the beast. We have a balanced program. When everything is working right, the agency can run in the black."
Fortunately for the residents at Missoula's hospice house on Mullan Road, the setting continues to be much more serene than the reported scene at Partners' main office downtown.
The inscription on the front door knocker, which reads "Grace and Peace," describes the feeling one gets inside the Mountain Valley Hospice House. The spacious kitchen smells of home-cooked food. The carpeting and furniture is plush. Homemade patchwork quilts are draped over the easy chairs.
During a recent visit, Ruth Blackburn, a 92-year-old Alzheimer's patient, sat quietly on the couch with her daughter, Dorie Halpern. Halpern said, "She's really content to be here. Even at my house, she always wanted to go home to the ranch she grew up on. On her first day here, she looked out the window and said, 'Ranch!'
"We thought her eyesight was gone, but she'll sit on the couch and look at the mountains." Halpern also adds that the hospice staff is "wonderful."
What occurs at Missoula's hospice house differs from the care given in hospitals in a number of ways. Chief among these is the fact that the house cannot provide acute care, which means that those who need constant care must go to an area medical center. Care in the house is also provided a truly home-like setting. Volunteers visit with the patients, offering emotional support to family members. The chaplain or a staff social worker discuss death candidly, facilitating the patient's self-discovery or providing a peaceful setting in which to die.
At the beginning of August, then-executive director Theriault stood in the home's living room, and said with pride, "I think you always have to listen to staff. We'll implement their suggestions when we can, and it can further our mission. And we'll let them know why we can't."
Signs that things were becoming unraveled at Partners became apparent when two top managers announced their decision to leave the company. Last month, after a long professional partnership, hospice founder Byock and Schlesinger-associate medical director and medical director, respectively-announced their joint resignation.
Earlier that week, the Independent hoped to learn of new developments under Jane Theriault and was told no fresh news was expected. But before the week was out, on Wednesday, August 5, the Missoulian carried a story that the top medical administrators at the company were out the door.
At that time, Byock told the daily paper that he was "disheartened."
Named Hospice Person of the Year in 1995 by the National Hospice Association and author of the book Dying Well: A Book About Living, Byock has, in some ways, the most at stake. As a Missoula hospice founder and a nationally known palliative care pioneer, he has lobbied for dignified death for 20 years.
Of his decision to resign, Byock told the Missoulian: "I feel sad that what was a jewel of a program, which certainly received real attention even nationally, no longer exists. The program has been scaled back a number of times in recent years. Some very, very talented people and experienced people have left over the years."
Schlesinger, the medical director, was unavailable for comment when news of her resignation broke; although last week in a brief conversation with the Independent, she allowed, "My leaving was a result of differing opinions on patient-care issues."
In response to those early news reports, Crookshanks maintained that the departure of Byock, one of the top hospice doctors in the country, was not newsworthy. She called the imminent changes "small and mostly internal" and credited Theriault, who was then overhauling aspects of both hospice and the company at large, as being "proactive."
Instead of addressing worries that Missoula's gem of a hospice program-featured in The New York Times Magazine and on a televised HBO special-was being tarnished, Crookshanks trumpeted Theriault's qualifications. She emphasized that the new executive director held a Masters Degree in Business in addition to being a registered nurse.
"If I was to write an article," Crookshanks suggested, "I'd say 'Kudos to Jane for staying on top of her game.'"
But just two weeks after Crookshanks offered that insight, Theriault was suspended by the board that governs Partners. Within hours, witnesses say, she cleaned out her desk and marched out of the office. Officers at Partners refuse to field questions on the incident, explaining that the matter is internal.
But those close to the heart of the matter say that Theriault traveled the halls of Partners with a cadre of administrators and assistants. When she unveiled her intentions for cost-effectiveness to the board, sources say, she wowed them with a deft display of business know-how-despite the fact that at least one person describes the presentation a mere "dog and pony show."
Theriault's aborted stay at Partners lasted six months. Today nobody can say where Theriault can be found. Crookshanks reports she has no phone, and that Partners cannot get in touch with her. The Independent's attempts to track her down led nowhere.
Charles Page, a board member, says Theriault won't be returning to her job. "I don't know how this will play out," Page says. "The same management team is in place, we're still following the same plan. I'm very comfortable and confident with the leadership in place."
Crookshanks says, "Jane was instrumental in coming up with the new plan. We're still sticking with that. As fresh and recent as the changes have been is not relevant. We haven't missed a beat."
Contrary to local administrators' approach to finances, Rosemary Johnson-Hurzeler, a national founder of hospice based in Connecticut, says that end of life care needs to be evaluated by its own set of standards. Johnson-Hurzeler explains that if you imagine financial return as more than just numbers on paper, hospice can be seen as quite profitable.
It keeps people off unnecessary life support, she says, and out of hospital beds, while providing needed emotional support to grieving families.
"It's not unheard of for hospices to be in trouble around finances and allocation of resources," Johnson-Hurzeler says. "But you have to have the energy of will and commitment of soul. If hospice is done the right way, it saves a tremendous amount of money."
Since 1987, Partners has been responsible for providing nurses, aides, medical supplies, technical support and virtually everything else for hospice patients in Western Montana. Administrative decisions about where funds go are made by a board of directors, consisting solely of representatives from St. Patrick Hospital and Community Medical Center, Western Montana's two largest hospitals.
Byock says he recognizes the financial struggles and realities of running a hospice program under the auspices of a larger health care organization. But he also clearly believes that because the medical establishment doesn't altogether grasp the grassroots nature of hospice, its role in Missoula is hard for them to understand.
Although he's unwilling to go into the reasons behind his resignation, Byock adds that the expansion of the board is key if Missoula's hospice is going to survive. By adding community members, major donors and the families that have been touched by hospice, he says, Partners can provide needed accountability to its patient base and those likely to keep the program endowed.
"I deeply want the hospice program to succeed," Byock says.
Another former administrator, describing his current mindset as that of a soldier suffering shellshock due to the undue stress of working at Partners in Home Care, says that the problems with the hospice program date back to the "revolution" in September of 1996, when 11 staff members walked out.
At the time, the crew cited "differences in values and vision between the management of the Partners corporation and the hospice caregivers."
Although hospice was run by a different set of administrators when the initial disruption took place-Dan Reiner took the reins from Dallas Rychener in the aftermath of that struggle-the charges against Partners today are nearly identical. In '96, deserters accused the upper management of being unqualified to run a hospice program, claiming that they were pinching pennies in order to improve the bottom line while ignoring patient needs. They claimed that a lack of community members on the board was harming the organization.
Current critics say that Theriault exacerbated the lingering tensions in the halls of Partners, and that it has adversely affected patient care. Policy decisions, these sources say, have become budget-driven across the company. Theriault's plan turned the focus at hospice from quality care to cutting costs and the bottom line.
According to Crookshanks, staff was scaled back at the house this summer, and the cost of staying there was increased by $5 per night, to $110 for a single room and $80 for a double-unless patients qualify for a sliding fee scale. The house holds eight patients at full capacity. A licensed nurse and two aides are on hand weekdays. An aide sleeps in an extra room at night.
The entire hospice program, which served 427 patients in 1997 and has served 383 patients so far in 1998, has only one nighttime on-call nurse. Crookshanks goes on to compare the house to a restaurant, saying it would be impractical to utilize the maximum number of staff members if the situation didn't warrant it.
In Missoula, most hospice care is given in the home, but some patients don't have a primary residence or family members to care for them. It's one of the reasons why the Mountain Valley Hospice House is so important to local hospice advocates. The house is the only one in Montana, and it's theoretically open to anybody sick enough to need it.
The ideal would be to treat all comers, a socialized concept unpopular among hard-core capitalist number crunchers, but by no means beyond the capacity of Missoula's medical establishment.
Even Crookshanks, for all her spinning, apparently recognizes the crucial synergy between hospice and the Garden City: "Each community wraps itself around hospice in a different way. I have a 'three degrees' of separation theory for Missoula's hospice program. A person would only have to go a maximum of three friends or family members away to find someone touched by it."
The same point is driven home by the moving 1996 HBO documentary Letting Go: A Hospice Journey. The show reflects this community's commitment to making life's end a spiritually fulfilling passage.
For the conclusion to this week's Feature, please pick up a copy of the Missoula Independent at one of more than 500 locations around Western Montana.
When the electric candle is lit at the Mountain Valley Hospice House, it means somebody has died there or is actively dying.
Photo by Lise Thompson
This year, Amy Crookshanks took over the fundraising and public relations job at Partners in Home Care. In August, she told the Independent, "I'd say 'Kudos to Jane [Theriault] for staying on top of her game.'" Two weeks later Theriault, who'd been the executive director, was suspended by the Partners board. She promptly disappeared.
Photo by Lise Thompson