R stock plenary the changing role of the physician-2014
Spiritual Care - QAPI - JUN 2015
1. Vol. 16, No. 6 June 2015 | hospice compliance letter | Page 1
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Vol. 16, No. 6 June 2015
INSIDE THIS ISSUE
Hospice Spiritual Care an
Important Target for
Quality Improvement..............1
ICD-10 Is Coming.
Ready or Not............................3
Heart Failure Patients
Deserve Special Attention
from Hospices..........................4
Hospice and Palliative Care
Updates....................................6
hospice compliance
letter
Main points of cover story
about spiritual care:
u Hospice spiritual care is
a legitimate and important
target for quality improvement
activities;
u Spiritual care professionals
need reasonable caseloads
and support from the rest of
the team;
u They can help with difficult
cases involving pain, family
conflict and even falls; and
u The search for meaning
is a fundamental concern in
hospice care.
(cont’d on p2)
Hospice Spiritual Care an Important Target for
Quality Improvement
Trained, supported chaplains can contribute to the quality of hospice care
The Board of Chaplaincy Certification, Inc., an affiliate of the Association for
Professional Chaplains, now offers specialty certification for chaplains in hospice
and palliative care. Recognizing “the expertise, specialized skills, advanced educa-
tion and unique experience of professional hospice/palliative care chaplains,” BCC
created this advanced certification beyond board certification to credential the
chaplain’s important role and responsibilities in hospice and palliative care. The
application process requires essays, documentation of experience, and applying
hospice/palliative care literature in a case presentation and a quality improvement
project, followed by an interview with a certification committee.
APC, based in Schaumburg, Ill., offers a variety of other resources, including
publications, conferences and professional standards based on National Consen-
sus Project Guidelines. Martha Rutland, a board-certified chaplain and exhibitor
representing ACP at the recent National Hospice and Palliative Care Organization
(NHPCO) Management and Leadership Conference, recommends specialty cer-
tification as an aspiration for hospice chaplains. It also offers a path for hospice
teams to approach their spiritual care services in a more systematic way, applying
the tools and perspectives of quality improvement. Not all hospices currently do
that, but the 360-degree approach to evaluating all aspects of a hospice’s services,
which underpins Medicare-mandated Quality Assurance/Performance Improve-
ment (QAPI) activities, logically extends to spiritual care, as well.
Specialty certification and other guidelines for hospice chaplains can help man-
agers evaluate their chaplains—the only professional discipline on the hospice
team that isn’t licensed by the state, Rutland says. “Hospices need to set their own
requirements for credentialing. Looking
at the chaplains they already have on
staff: What are their credentials? Is their
education from an accredited school? If
they are ordained, where is their ordi-
nation based—and are they still in good
standing?”
Hospices continue to struggle against
the tendency for teams to want to hire
a local caring person they already know
and like, regardless of how deep that person’s patient care skills go, she says. And
it’s hard to find credentialed people. “One thing you can do is help your chaplains
advance on the ladder of certification at ACP. There are levels they can progress
through. Hospices should challenge their chaplains to move forward and obtain
additional competencies,” Rutland says.
“A lot of hospice administrators and managers don’t understand the difference
“ “If there’s one team or one nurse
where the chaplain is utilized less
than half of the time, for example,
why is that? Is it the nurse’s
presentation of spiritual care, or
does the chaplain need support to
improve his or her skills?
— Rev. Dr. Carla CheathamWhat about ICD-10?
“Tell your readers it’s not going
to be delayed ... You should be
spending your summer running
a dual system and making your
own chart of common diagnoses
under ICD-10.”
— Judi Lund Person, NHPCO
3. Vol. 16, No. 6 June 2015 | hospice compliance letter | Page 3
IDC-10 Is Coming—Ready or Not
Narrative attestation, Notice of Election continue to challenge providers
CMS has declared, and the experts have advised: do
not assume that the transition from ICD-9 to ICD-10-CM
(the International Statistical Classification of Diseases
and Related Health Problems, 10th revision, Clinical Mod-
ification) will be postponed any further past its currently
scheduled implementation date of October 1. Are hos-
pices ready for it—or are they still hoping for a last-min-
ute reprieve from the need to revamp their Medicare
billing practices to incorporate this revised system for
classifying and coding 68,000 diagnoses and procedures?
Jean Acevedo of Acevedo Consulting in Delray
Beach, Fla., urges hospices to begin dually coding as
soon as possible. “While you cannot submit a Medicare
claim with ICD-10 codes until November of 2015 for
October dates of service, every organization would be
well served by putting a small team together to deter-
mine if today’s services could be coded in ICD-10. This
will be a critical step in determining what additional
information your nurses and physicians must have to
document with the specificity this new code set re-
quires. You just can’t wait until October to find out the
patients’ charts do not have enough information to
have ICD-10 codes assigned,” she says.
Acevedo thinks getting practice in dual coding and
using the MACs’ Local Coverage Determinations (LCDs)
to set priorities are the keys to being prepared for ICD-
10. “Get your MACs’ LCDs that have been revised to list
ICD-10 codes. This is a great place for a small or medi-
um-sized organization to help determine what diagnoses
you should be paying attention to. Once you have those
that impact your patients, have some clinical and billing
folks check some current patients’ charts. Would the
existing documentation support the granularity of the
ICD-10 codes if you had to submit with ICD-10 today?”
Other resources are out there to help, including:
u NHPCO’s March 24 training seminar for hospices.
u The National Association for Home Care and Hos-
pice’s ICD-10 resource page, with a round-up of vendor
resources, contacts and coaching programs.
u The American Academy of Hospice and Palliative
Medicine’s recording of a webinar on what hospice and
palliative care practitioners need to know.
u CMS is offering another opportunity to test ICD-10
readiness with MACs and common electronic data in-
terchange contractors during the week of July 20-24.
u For instructions on how to access lists of LCDs
with ICD-10 codes converted from ICD-9, see the MLN
Matters newsletter on the CMS website at http://www.
cms.gov/Medicare/Coverage/Coverage GenInfo/ICD10.
html.
For more information, contact Jean Acevedo at:
jacevedo@acevedoconsulting.com. And tell us how you
are preparing for this momentous transition. Do you
believe you are ready? Send comments to Editor Larry
Beresford at: lberesford@weatherbeeresources.com.
Narrative Attestation; Notice of Election
The physician narrative attestation mandate for
hospices is emerging as a new compliance challenge
for hospices, Weatherbee Senior Physician Consultant
Suzanne Karefa-Johnson, MD, wrote in a May 21 blog
posting. She urges hospices to pay attention, given
that a hospice medical director was convicted last year
in Pennsylvania of making false hospice eligibility certi-
fications. A more nuanced era of regulatory oversight,
she says, is looming on the horizon for the certifying
physician “who has either reviewed the patient
record, or examined the patient, prior to composing
the physician narrative for certifying terminal illness….
Claims are currently being disallowed on the basis that
evidence is lacking to show that the certifying physician
actually reviewed the patient’s record.”
In order to support the prognosis, the physician
narrative should contain language that references the
findings of the face-to-face encounter by the hospice
physician or designee, if applicable, and should reference
relevant findings. “Remember the signed attestation is
required for technical compliance, but must be support-
ed by evidence within the narrative or review of the med-
ical record… by the certifying physician of any physician
examination of the patient,” says Dr. Karefa-Johnson.
Ongoing issues with hospice’s Notice of Election
process include identification of the patient’s chosen
attending physician on the patient’s election statement
and getting all necessary information onto the Notice
of Election Form with the timeliness and accuracy
needed to ensure that a claim doesn’t get kicked back
to the hospice, delaying payment.
CMS Transmittal 209 for CR 9114, dated May 8,
2015, rescinded transmittal 205, dated April 3, which
had required including the physician’s National Provider
Identifier (NPI) on the patient’s election form. The NPI
is no longer required, but it still necessary to have infor-
mation identifying the attending physician recorded on
the election statement with enough detail so that it is
clear which physician or nurse practitioner was des-
ignated as the attending, with the patient’s acknowl-
edgement that the designated physician was the indi-
vidual’s choice. The challenge of getting all necessary
information on the Notice of Election is multi-faceted
and problematic on lots of levels, NHPCO’s Judi Lund
Person says. “NHPCO has worked hard to communicate
to MACS and CMS about providers’ concerns.”
4. Page 4 | hospice compliance letter | Vol. 16, No. 6 June 2015
Heart Failure Patients Deserve Special Attention from Hospices
Palliative approaches can be better for patients with advanced disease
Can hospices provide better, more targeted and more skilled care for patients with congestive heart failure
(CHF)? Heart disease is the most common cause of mortality in the United States, accounting for a quarter of all
deaths, and is the primary diagnosis for 100,000 hospice patients per year, as well as a major source of avoidable
30-day hospital readmissions.
As reported in the Joliet Herald News,1
Joliet Area Community Hospice, Joliet, Ill., provides education and refer-
ence tools on CHF to patients, family caregivers and the larger community. Its Palliative Consulting Service is open
to patients with chronic heart failure who are not ready for hospice, with a focus on symptom relief, improved quali-
ty of life, and better understanding of disease process. “There’s not a lot of research to call on for optimal hospice
and palliative care for heart failure patients,” says the hospice’s medical
director, J.D. Wright, MD. A lot of hospices find information on their own.
Dr. Wright’s team gathered quality research and guidelines on the
management of CHF and then discussed how to apply these to its hospice
patients with heart failure.
“Shortness of breath, or dyspnea, is a very common symptom, which
is experienced by many patients at the end of life. So how can we make
patients like this more comfortable?” Dr. Wright tells HCL. “Presumably
they’ve been treated for their heart failure with a variety of approaches, but medical treatments are no longer
effective or cause significant side effects. We certainly use supplemental oxygen with these patients. The truth
is that enriching the oxygen in the air patients breathe has a limited physiological effect, but it has a definite
psychological, or placebo, effect. At times this can be more important than the physiological effect,” he says.
“We look at specific problems that are real issues for our patients, like difficulty in breathing, which is very scary,
not just for the patient but for the family, as well. We often use morphine for that, and it does have an extra
effect in easing breathing.” Dr. Wright says hospices should not be afraid to give adequate dosages for this
purpose. “Sometimes we might overshoot the dose, and usually that means the patient goes to sleep.” But wide-
spread concerns about the dangers of morphine and other prescription drugs are making the hospice’s job more
difficult, even though overdoses are a rare occurrence with these patients.
“Because anxiety is such a major problem for these patients, we also use med-
ications to treat it specifically. Here at JACH, we commonly use Ativan (generic
name lorazepam), which is in the same class as Valium. As with all treatments, the
interventions have to be individualized for each patient.”
Palliative Care’s Role in Heart Failure
Not all cardiac medications need to be stopped at this time, however. Contin-
ued use of diuresis and other medications can help improve cardiac function, says Marie Bakitas, a nursing professor
at the University of Alabama-Birmingham and a researcher on quality of life for patients with serious, life-limiting
illnesses. Her program was recently awarded a $3.5 million grant from the National Institute of Nursing Research to
study whether palliative care improves quality of life for older adults with heart failure. The research will compare
symptoms, mood and quality of life in older adult patients with New York Heart Association Stages III and IV heart
failure and their family caregivers between those receiving traditional heart failure care and those receiving
traditional care plus a new, primarily phone-based palliative care intervention.
In a paper now in press at the journal Circulation, Bakitas and colleagues found that heart failure patients
referred to hospice at the time of hospital discharge had fewer 30-day, all-cause readmissions. However, most heart
failure patients died within six months of hospital discharge without benefit of a hospice referral. Palliative care
can help reduce hospital readmissions and costs, but there is an urgent need to increase its availability to older
patients with advanced illnesses, especially in the South, which has the lowest availability of these services and
higher incidence of heart failure, Bakitas says.
“I could speculate on what types of services hospice provides that may have been responsible for reduced admis-
sions, but I would encourage hospices to talk to heart failure patients now on their caseloads and see how many
had to go to the hospital and why. Then try to correct that,” she says. “From a clinician perspective, we are learning
1 Wright JD. Hospice helps those with congestive heart failure. Joliet Herald News, February 23, 2015
“ “We look at specific problems that
are real issues for our patients, like
difficulty in breathing, which is
very scary, not just for the patient
but for the family, as well.
— J.D. Wright, MD
“ “Patients who are close to
the end of life benefit when
you stop pills. That includes
statins, anticoagulants and
blood pressure medications.
— Staci Mandrola, MD
(cont’d on next pg)
5. Vol. 16, No. 6 June 2015 | hospice compliance letter | Page 5
that many heart failure guidelines now recommend the
use of palliative care as patients develop symptoms
and their disease is progressing. But very few of these
recommendations have actually made their way into
everyday practice. There are exemplar programs that
are having some success with integrating palliative care
early into care for patients with heart failure, but most
programs’ approaches to integrating palliative care are
inconsistent or unorganized.”
Goals of care discussions do not occur as often or
as early as they should with heart failure patients, says
Maureen Carroll, coordinator of the Heart Failure Pro-
gram at University of California-San Francisco Medical
Center. “Although we have come a long way in the past
five years, there is still a great misconception regarding
what palliative care actually is. Many believe it is synon-
ymous with hospice. Heart failure patients have a very
serious chronic disease and deserve to have these con-
versations with their families so that discussions can oc-
cur and decisions be made based on those discussions.
There is a gap in communication of this information
across the continuum of care. It is often difficult to find
in the hospital electronic medical record whether a goals
of care discussion has occurred, when, and with whom.”
Staci Mandrola, MD, palliative care and hospice phy-
sician in Louisville, Ky., gave the only presentation on
palliative care at this year’s American College of Cardi-
ology Scientific Sessions in March. As reported by her
cardiologist husband, John Mandrola, MD, in a March
16 Medscape column, she outlined 15 things cardiolo-
gists should know about palliative care, for example,
that recurrent hospital admissions, cessation of eating
and immobility are all signs of approaching death.
“Patients who are close to the end of life benefit
when you stop pills. That includes statins, anticoagu-
lants and blood pressure medications,” she told the
doctors. Deactivating an ICD is not the same thing as
physician-assisted suicide or euthanasia, a judgment
confirmed in a 2010 Expert Consensus Statement by
the Heart Rhythm Society. “Cardiologists call death a
bad outcome, and they consider palliative care the end
of the road,” Dr. Mandrola writes. “I think a change in
perspective on these two themes may give cardiologists
more of the heart, humanity and connection they seek.”
For more information, see the chapter on Advanced
Heart Disease in the new Oxford Textbook of Palliative
Medicine.2
See also:
u 2013 ACCF/AHA Guideline for the Management of
2 Pantilat SZ, Steimie AC, Davidson PM. “Advanced Heart Disease.”
In Cherny N, Fallon M, Kaasa S, Portenoy RK, Currow DC. Oxford
Textbook of Palliative Medicine. Oxford University Press, 2015.
Heart Failure, A Report of the American College of
Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines. Circulation. 2013;
128: e240-e327; and
u Allen LA, Stevenson LW, Grady KL, et al. Decision
making in advanced heart failure: a scientific statement
from the American Heart Association. Circulation. Apr
17 2012; 125 (15):1928-1952.
Hospice and Diabetes Care
A recent article in the American Journal of Hospice
and Palliative Medicine3
argues that diabetes care for
hospice patients can also be improved. Lead author
Sei J. Lee, MD, MAS, in the division of geriatrics at the
University of California-San Francisco, emphasizes the
importance of
discussing with
patients and fam-
ilies at the time of
hospice admission
that diabetes
medications can
be safely reduced
or discontinued
for patients with a life-limiting diseases and hospice-
appropriate prognoses.
Overly tight glycemic control is still common for pa-
tients in hospice care because the conversation about
cutting back makes doctors uncomfortable, while
patients and families are conditioned to believe that
mild hyperglycemia causes treatable symptoms—even
though such treatment is rarely appropriate for hospice
patients, Dr. Lee says. Even the diabetes care guidelines
recommend a less aggressive approach for patients
with life-limiting illnesses. In reality, easing up on
glycemic control should reduce the risk of hypoglyce-
mia in hospice patients, improving their quality of life.
Dr. Lee encourages hospices to educate clinicians
that HEDIS measures of compliance with glycemic
control now specifically exclude patients on hospice.
“Primary care providers should not worry that
providing less intensive diabetes control would lead to
being identified as an underperforming provider,” he
says. “Hospice enrollment is a natural juncture where
patients and families should be educated that the
dying process often leads to less food intake and lower
sugars. Thus, nearly all diabetes patients will need less
medicine as the dying process plays out.”
3 Lee SJ, Jacobson MA, Johnston CB. Improving Diabetes Care for
Hospice Patients. American Journal of Hospice and Palliative
Medicine. Published online before print, April 7, 2015.
Heart Failure Patients Deserve Special Attention ...
“ “Hospice enrollment is a natural
juncture where patients and
families should be educated
that the dying process often
leads to less food intake and
lower sugars.
— Sei J. Lee, MD
(cont’d from p4)
6. Page 6 | hospice compliance letter | Vol. 16, No. 6 June 2015
cho-social suffering going on? Could you add to the
medical intervention the involvement of the chaplain?
That’s raising the quality bar—at least to have the
team consider these questions.” Or self-determined
life-closure, she adds. “That’s more than just do they
want CPR or to go back to the hospital. Behind those
questions may be ethical issues or family conflicts. The
chaplain can be brought in when there are higher level
conflicts.” Or if a patient falls, are there considerations
involved such as depression, loss of independence,
family members’ expectations, or lack of acceptance of
the disease’s progression? “The chaplain can help with
all of those deeper issues.”
Chaplains can also have a role in a number of the
questions raised in the Consumer Assessment of
Healthcare Providers and Systems Hospice Survey
(CAHPS); and in Hospice Item Set quality measurement.
“Are nurses asking the spiritual question for HIS—but
without training or comfort with spiritual questions?”
Cheatham poses. “Better to have the spiritual care pro-
fessional ask the spiritual question.” But spiritual care
professionals may be asking hospice patients about
their spiritual needs in the gentlest way possible, such
that families do not even realize at survey time that
their religious
and spiritual
beliefs were
discussed. “At
some point,
you need to
have a clear
conversation about whether their
spiritual care needs are actually being met.”
Spiritual care is a logical target for QAPI, which
is about finding the gaps and the opportunities for
improvement and making things better, Berger adds.
“The chaplain and spiritual care are about standing in
those volatile places with grace, saying ‘It’s enough,’
helping people find meaning and wholeness in life at
the end of life. Chaplains can bring so much more. It’s
the search for meaning and purpose that’s at the crux
of spiritual care—and that’s what hospice care is all
about,” she says.
“With patients who are non-religious, the chaplain
is still responsible for their existential needs—what
brings them peace, meaning and comfort. We can help
our staff be there in a way that helps,” she says.
For more information about elevating the quality
of hospice spiritual care services, contact Berger at
jberger@hospiceanalytics.com or Cheatham, who
provides training and consulting for hospice agencies
and staff to promote excellence in spiritual care at
carla@carlacheatham.com.
Hospice Spiritual Care ...
“ “If somebody’s pain is not resolved
after 48 hours, is there also spiritu-
al or psycho-social suffering going
on? Could you add to the medical
intervention the involvement of the
chaplain? — Joy Berger
(cont’d from p2)
The hospice industry is digging deeper into
Medicare’s Notice of Proposed Rule-Making, an-
nounced May 1 and proposing to make the hospice
routine home care per-diem rate a two-tiered system,
with higher payment for the first 60 days and lower
payments thereafter (see HCL, May 2015). “We’ve been
looking at the fine print, and the biggest question is
whether all parties—providers, vendors, MACs, CMS
itself—will be ready by October,” when the finalized
rule might be expected to be implemented, says
NHPCO’s Judi Lund-Person.
Comments on the NPRM are due by the end of June,
and a final rule—with responses to all comments—
could be out as early as August. But it’s a big change
in hospice payment. In a May 6 Open Door conference
call, CMS representatives dismissed concerns that the
industry won’t be ready on time. The other big con-
cern, Lund Person says, is the impact on providers of
the government’s continuing emphasis on ensuring
that virtually all pharmacy and other treatments need-
ed by the hospice patient would be the responsibility
of the hospice to cover.
The Care Planning Act of 2015 was introduced in
Congress June 10 by Sens. Johnny Isakson (R-GA) and
Mark Warner (D-VA). NHPCO endorses the legislation,
which is designed to assist Americans facing advanced
illness to navigate complex health care needs and
address advance care planning challenges.
A hospice in Lakeland, Fla., that was closed down
by the state’s Agency for Health Care Administration
because its license renewal apparently got lost in
the mail has reopened just two months after closing.
The local ABC TV station reported the reopening of
Compassionate Care Hospice, which was facilitated by
emergency legislation, on June 10. Before closing, the
hospice had a census of 250 patients and 150 staff; it is
not known how quickly those numbers will be able to
grow back to those pre-closure levels.
A new service called the Palliative Care Network
of Wisconsin or PCNOW was unveiled in April with a
mission to support the growth of professional pallia-
tive care services in the state and across the country.
Of 535 early adopters, about a third each were doctors
nurses and “other,” says Wisconsin-based palliative care
expert David Weissman, MD. “We welcome hospices
across the U.S. to join. It’s a great place for disseminat-
ing resources and other materials.”
The project grew out of palliative care-oriented
advocacy issues that emerged in the state last year,
prompting palliative care professional to band togeth-
er. For more information, contact Dr. Weissman at
wiscpallcare@gmail.com.
Hospice and Palliative Care Updates
