Vol. 16, No. 6 June 2015 | hospice compliance letter | Page 1

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Vol. 16, No. 6 June 2015

INSIDE THIS ISSUEHospice 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 complianceletter

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 ImprovementTrained, 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

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HOSPICE COMPLIANCE LETTERThe Hospice Compliance Letter is published by the Hospice Compliance Network (a service of Weatherbee Resources, Inc.)

Subscribing hospices are permitted to reproduce this newsletter for their internal use only. Other than that encouraged exception, no part of this publication may be reproduced, in any form or by any means, nor may it be forwarded to non-subscribers, posted to a website, or otherwise violate its copyright, without prior written consent.

This newsletter strives to provide timely and accurate information related to hospice care, corporate compliance issues and other selected matters. Items in the newsletter are brought to our readers from a variety of sources, all of which are thought to be accurate and reliable. Nevertheless, it is specifically understood that the publication is not intended to provide legal or other professional services, counsel or advice. Readers requiring such services are encouraged to contact appropriate professionals.

Chief Executive Officer: Heather Wilson, PhD

Editor: Larry Beresford | lberesford@weatherbeeresources.com

Comments / Suggestions: 510.263.9446

Subscriptions / Information: 866.969.7124

Address: 540 Main Street, Suite 16B, Hyannis, MA 02601

Website: www.hospicecompliance.net

©2015 Hospice Compliance Network. All rights reserved.

between a chaplain and a pastor,” says Rev. Dr. Carla Cheatham, Spiritual Caregiver Section Leader for NHPCO’s National Council of Hospice and Palliative Professionals. Through her personal consulting and training work,

Cheatham developed a Spiritual Care Counselor Hiring Tool to help guide questions during a job interview. The NCHPP section also conducted a survey of spiritual care in hospice in 2013, with results published in the January 2014 NHPCO Newsline newsletter. Of 1,047 respondents, 71 percent identified themselves as paid spiritual care staff, and 31 percent have worked in the field for more than 10 years.

But only 19 percent are board-certified—through either ACP or another group. Only 8 percent of respondents had supervisory training through the Association for Clinical Pastoral Education. But 82 percent have graduate level or equivalent education, with the majority of those a Master’s Degree in Divinity. What do they call themselves? Seventy-three percent say hospice chaplain and 14 percent say spiritual care provider. In addition to providing spiritual care to patients and families, other common roles for spiritual caregivers identified in the survey include liaison activities and

relationship building in the community, bereavement counseling, and in-service education for hospice staff.

Empowering Chaplains to Advocate for their Role“A big part of what I do is education and advocacy to improve quality spiritual care and to empower chaplains to

step up and advocate for their role,” Cheatham says. That means encouraging them to gather quality data. “One thing we talk about in the section is the whole issue of caseload and frequency of visits. Generally speaking, one FTE should carry a caseload of no more than 40 patients, depending on factors such as patient acuity, driving distance

and other roles or duties the spiritual care counselor fulfills,” she says. Another key metric is utiliza-tion, or the percentage of patients and families who accept—or decline—spiritual care services. “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?”

There is a fundamental paradox at work when it comes to measuring the quality of spiritual care with quantifiable data, says Dr. Joy Berger, a board-certified chaplain and consultant who works with HospiceAnalytics of Colorado Springs, Colo. “Quality of life and the dying experience don’t always fit into neat little measurable boxes, so spiritual care can get devalued. Then staffing is unbalanced and the chaplains have unrealistic caseloads, so they don’t get utilized properly, which

in turn makes it harder to demonstrate their true value. Are you staffed with trained, trusted, top-quality chaplains and are you setting up systems to help them succeed?”

But Berger believes there is a lot that can be recognized, quantified, measured and improved in the spiritual realm. Take, for example, pain. “If somebody’s pain is not resolved after 48 hours, is there also spiritual or psy-

Hospice Spiritual Care an Important Target for Quality Improvement (cont’d from p1)

Rev. Dr. Carla Cheatham

Dr. Joy Berger

(cont’d on p6)

Vol. 16, No. 6 June 2015 | hospice compliance letter | Page 3

IDC-10 Is Coming—Ready or NotNarrative 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.”

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Heart Failure Patients Deserve Special Attention from HospicesPalliative 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)

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)

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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