Birth of a New CoP for Medicare Hospice, Part 1

After three years of waiting, the final rule for Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers (CMS-3178-F) was finally posted in the Federal Register on September 16, 2016.

The Centers for Medicare and Medicaid Services undertook the architecture of specific emergency preparedness regulations to establish national emergency preparedness requirements for Medicare and Medicaid participating providers and suppliers to ensure that they adequately plan for both natural and man-made disasters, and coordinate with federal, state, tribal, regional, and local emergency preparedness systems.  CMS also wanted to ensure that providers were adequately prepared to meet the needs of patients and families during disasters and emergency situations.  Disasters can disrupt the environment of health care and change the demand for health care services. Regulatory requirements make it necessary that health care providers and suppliers integrate emergency management into their daily operation and culture.

Prior to the posting of the final rule, the federal hospice Conditions of Participation (CoPs) at § 418.110 (c) only included hospice inpatient facilities to have a written disaster preparedness plan that is periodically rehearsed with hospice employees, with procedures to be followed in the event of an internal or external disaster, and procedures for the care of casualties (patients and staff) arising from such disasters.  This final rule has emergency preparedness requirements for both homecare and inpatient hospice providers. Hopefully, most hospice providers have some type of emergency or disaster plan in place right now that contains most of the components in this new CoP which will make the implementation less onerous. Whether your hospice is enhancing your current plan or starting from scratch, including your assessment of your current compliance and development of a plan to become compliant is a must for either a hospice compliance program or quality assessment performance improvement (QAPI) program.

The CoP for hospice providers contains four main standards that specify requirements for the hospice to develop an emergency plan, specific policies and procedures for emergency preparedness, a communication plan, and a program for preparedness training and testing that is based on the emergency plan. The good news for hospice providers is that the implementation date for this new CoP is November 16, 2017.

Next up for discussion (in Part 2) are the hospice emergency preparedness plan and policies/ procedures.

Jennifer Kennedy, MA, BSN, RN, CHC
NHPCO Senior Director, Regulatory & Quality 

Back to School in Baltimore

Learn About Your Options…Before a Health Crisis Hits 

Eight years ago, I stumbled upon the National Hospice and Palliative Care Organization. I was returning to the workforce after being at home with my younger children for two years. Although I did not know much about hospice and practically nothing about palliative care, neither was required for the position I was applying for. I began my journey here as the program assistant to the professional development department. Lots of committee work, lots of conference prep, lots of administrative tasks and tons of processing CE/CME certificates for social workers, counselors, nurses and physicians. At the time, I was more interested in the income for my family’s sake as opposed to the outcomes of work we were doing at NHPCO.  I did my job and I did it well. I listened in on webinars, enjoyed meeting faculty at conferences and I have probably processed ten thousand CE/CME certificates. Fast forward to today.  

Today, I am the senior manager of access programs. Over the past eight years, I have come to realize and am more aware of the work we do and its affect on patients and families. I’m also more aware of the health disparity in our field, as well. My team and I work on programs that allow patients, families and caregivers to access end-of-life care services on a national and local level through our member organizations and vice versa. NHPCO is committed to championing access to the right care at the right time for all people.  Yet, the utilization of hospice and palliative care among African Americans remains disproportionately low.  Of all patients utilizing hospice care in 2014, an estimated 7.6 percent were identified as black or African American, which reflects a slight drop from the previous year. Several studies have shown the reasons for underutilization range from lack of education and awareness about end-of-life care services, religious beliefs and to just not wanting to talk about the subject. 

NHPCO’s strategic plan includes expanding hospice and palliative care access to African American communities where a disparity of care exists. This year through a collaboration between NHPCO and Morgan State University we have worked hard to move this initiative forward. Morgan State University is a HBCU located in Baltimore, MD.  Historically Black Colleges and Universities (HBCUs) are relevant and play an essential part in today's higher education and serve as a hub for gatherings in many African American communities.

This spring, we invited Baltimore area pastors to join us for fellowship and open dialogue with Pastor Corey Kennard who provided guidance and inspiration for addressing the spiritual needs of those dealing with serious illness, end-of-life and grief within the faith community. He also touched on the effectiveness of the faith community and forming healthcare partnerships in this work. We had a great time. We learned a lot.  We were also left with a lot to think about.

The meeting with the local pastors served as a “kick-off” to our 4-Week workshop series on end-of life care. During this series we offered the following free, non-credit courses:

• Faith and Hope at the End of Life
• What is Hospice and Palliative Care?
• How To Plan and Communicate Your Future Healthcare Wishes (my class!)
• Loss, Grief and Bereavement

Let’s face it, none of these subjects are “sexy” but very necessary.  Making decisions by the bedside is not the right time to discuss any of these topics.  Our goal is to encourage you, your family and caregivers to learn more about your options so you’ll be able to make informed decisions about end-of-life care. Imagine your mom or dad being diagnosed with a serious illness and you and your siblings, and your parent’s extended family trying to make tough decisions during a time when emotions are high. Sound familiar?  I know the feeling.  I’ve been there and don’t want to be there again.  

So, what happened at MSU?  The courses went well. Our faculty members were great. Here are a few of the many participant comments we received about the courses:

“Thank you for this course. Information is power when dealing with myself or a loved-one’s healthcare & end of life decisions.”

“Very interesting, informative and educational.”

“Pastor Corey is a motivational, engaging, informed facilitator.”

“Really like the non-threating approach to difficult subject, varied methods to learning, and practical approach.”

“This course really made me think of how I can be supportive to those who are experiencing grief.”

“It was extremely amazing. I never knew so much went into hospice and that palliative care existed.” 

“I’m glad I came, really informative! Both Kennedy and Coleman were great and knowledgeable about the subject.”

I even learned a little more about each subject. Who knew! I met some great folks in Baltimore. Participants were very engaged in each course; the questions were interesting. Many ideas and family stories shared.

I was blessed to be able to teach the course, How to Plan and Communicate Your Future Healthcare Wishes. This course was all about advance directives and advance care planning. I wanted to leave participants with tools they could use when talking to their families about their personal wishes, including their healthcare provider in the conversation, and choosing a fitting healthcare proxy to be his/her decision maker.  Advance care planning is much more than completing an advance directive. That paper means nothing if you have not had any conversations with your healthcare providers and family. Have you explained to them who your healthcare proxy will be? Does everyone in your family have a copy? Does your healthcare provider have a copy?  Have you asked your healthcare provider questions about the medical treatments you don’t understand?  I covered some serious topics but also played a game and showed videos to keep it fun.

Now what?  Phase II of this collaboration is taking place this fall. These courses will be offered for free to Baltimore families, caregivers and anyone interested in learning more about end-of-life care.  All courses will be hosted at MSU’s University Student Center. Refreshments will be provided. Parking is available. Encourage your friends, family and neighbors to take advantage of this learning opportunity.

You can register yourself, a friend or a group for one or more of the courses. To reserve a spot, REGISTER ONLINE or call 443-885-3155.   When you know better, you do better. Get the conversations started today.  Attend a course, learn about your options and become your own healthcare advocate. Baby steps.  If there is a topic about end-of-life care that you’d like to learn more about, mention it in the comments section of this post. I’d love to hear from you.

Special Thanks to the Infinity Hospice Foundation for providing financial support to Phase II of this collaboration.

Cozzie M. King
Senior Manager, Access Programs
Staff Liaison, NHPCO’s Diversity Advisory Council

 

The End of the GIP Building Era

In the early years of my work as a hospice consultant, I spent a great deal of time conducting hospice facility feasibility studies. Many of my clients were freestanding non-profits, i.e., hospices that were not part of a hospital system or larger entity. The common wisdom at that time was that while hospice inpatient facilities were unlikely to break even on the basis of their operating revenue, they nevertheless fulfilled a need for patients and families. In addition, they were seen as visible symbols of service to the community and reliable magnets for fund raising.

One of the biggest questions in these projects was always how big to build it. (Rarely was the question whether to build.) I had a number of rules of thumb in helping clients plan these facilities. While typical hospices without a GIP facility might expect to see 1% to 2% of their patient days at the GIP level of care, hospices with facilities routinely exhibited much higher proportions. Utilization as high as 6% was much more typical, and usually the metric I used to estimate the need for beds in new facilities. In fact, even after using that aggressive planning target, one of my clients reported after an expansion project that their occupancy rate was running far ahead of projections.

My, how times have changed.

These days I find myself advising disappointed clients not to build at all. One client had already lined up donated land and was set to launch the capital campaign. However, when shown the size of the probable operating deficit their proposed facility would carry year after year, the board decided to put the project on indefinite hold.

So what happened? I attribute the change directly to the transformed environment for compliance oversight and increased scrutiny of general inpatient level care. The OIG study released in March this year was titled, “Hospices Inappropriately Billed Medicare for $250 Million for General Inpatient Care.” Only in their document, that title is in ALL CAPS. There is no doubt this analysis is guiding their enforcement action. Since June of this year, two hospices have been assessed civil monetary penalties for misuse (read over-use) of GIP level care. I expect there will be more to come. In addition, we’re hearing from hospices across the country that their MACs are aggressively rejecting claims and requiring much more thorough documentation of the appropriateness of each day of GIP level care.

So what do we do about it? We’ve already built the facilities using a different set of assumptions about their use. If we assume that today’s tight scrutiny is here to stay, how do we ensure that our facilities receive their best and highest use while remaining compliant with Medicare regulations?

I’ll be publishing more about this topic over the coming weeks. In the meantime, I urge you to consider attending our upcoming event devoted to this topic. On October 30, prior to the start of The Intensives conference, I’ll be facilitating the NHPCO Edge Thought Leader Forum. Our focus is “Optimizing Freestanding Hospice Facilities: Stemming Losses in an Era of Shrinking GIP Utilization.” We’ll gather leaders in hospice facility management from around the country to share what works, what doesn’t and how they are adjusting to the new reality. For more information, see the event announcement here. 

Sue Lyn Schramm, MA
Director, Consulting Services, NHPCO

See the previous NHPCO Edge Blog article, "Community-based Palliative Care."

Touchstones

Those of us who are more seasoned as hospice providers, often comment to one another “hospice isn’t what it used to be.”  Usually we are shaking our heads wistfully; sometimes hindsight gives our memories a rosier glow.  Well, it’s not as it used to be.  And it will be different in the future.  Like the rest of healthcare, we will face more chronic illnesses, greater medical complexity in care and treatments, varied cultural values around death and dying, family stresses, and less resources.

Yet I believe wholeheartedly that what we offer and what we do will remain vibrant and valuable. Our challenge is to stay in touch with our roots, our purpose, and have that be the driving force. To quote the Denver Hospice Mission Statement: “To encircle those facing advanced illness with unprecedented levels of comfort, compassion, and expertise.”

To do so with efficiency, we will need to consistently remind one another to shift our perspective and utilize skills with discernment. Often we find ourselves advocating for what we think is best and becoming frustrated as we meet resistance. 

The experience model reminds us to uncover what is hindering the patient/family from identifying and reaching their goals.  Sometimes it is us! We can learn to listen, really listen, to each unique patient/family constellation, allowing what is truly best to unfold and become apparent. Then we step in to support and guide and serve. When our compassion fatigue comes from trying to answer the unanswerable, we will learn to say “I don’t know---but we will walk with you each step of the way.” By taking time for debriefing and extrapolating lessons, particularly from our most challenging situations, we can build resilience, skills and confidence in ourselves and our teams.

As passionate as I am about hospice, I am equally fervent about social workers and recognizing the psychosocial in whole person care.  All members of the team have a role in psychosocial support, just as they do in other aspects of care; we can integrate our interdisciplinary nature so that we blossom and grow as we serve.

Patricia A. Goodwin, ACSW, LCSW, ACHP-SW
Tallahassee, FL

Patricia Goodwin is one of the faculty members for the Psychosocial & Spiritual Care Intensive that is part of NHPCO's new professional development offering, THE INTENSIVES (Oct. 31 to Nov. 2) in Hollywood, Florida.

Register Now: Advance registration ends October 7.

STAR - Survey of Team Attitudes and Relationships

NHPCO Provider Members: Does your hospice use STAR?

Employees play a fundamental role in the success of any organization and astute administrators recognize the value in a stable and committed workforce.  Research has shown that employees who have higher job satisfaction care about the quality of their work, have higher retention rates, are more productive, and more committed to the organization.  Other sectors of the healthcare industry use job satisfaction surveys tailored to their specific health care environment. STAR is the first and only staff satisfaction survey that reflects the unique needs and work environment of hospice care delivery.  

Utilization of STAR is a benefit of NHPCO provider membership at no additional cost.

Elements of STAR:

• 45 questions that assess hospice staff job satisfaction (40 items relevant to all hospice staff and 5 questions relevant only to clinical staff).
• Additional demographic questions.
• Domains: Work rewards, teamwork, management support, organizational support, workload, global satisfaction.
  

Administrators find STAR to be a valuable tool for promoting workforce excellence and delivery of quality hospice care. Participation in the NHPCO STAR administration and reporting process provides the information needed to make adjustments to improve staff satisfaction and retention.  Assessing - and improving - staff satisfaction with STAR should be part of each hospice’s comprehensive QAPI program.

How and when to participate:

• Visit nhpco.org/star and review the Administrator’s Manual 
• The first step after reading the manual is to update your hospice’s roster. Email star@nhpco.org.
• Get started now to have your hospice’s results included in the 2016 National STAR Report! 
• The annual deadline to complete administration of STAR is December 15. 

Kristi Dudash, MS
NHPCO Research Manager

Bereavement

A series of blogs on the upcoming event THE INTENSIVES from educational content team members. 

Working with the NCHPP Bereavement Professionals Steering Committee to help develop the Bereavement Intensive for bereavement professionals at first seemed like a daunting exercise. 

Taking into account the NHPCO educational needs assessment, the discussion threads on My.NHPCO.org and our own personal experiences led to a wonderful brainstorming discussion resulting in topics that would advance bereavement services to our grieving hospice families and the community. Finding speakers was the next step and great effort was taken to the find just the right speaker. And we did. We are so excited for this Intensive!

The NCHPP Steering Committee believes that social and cultural implications impact grief reactions. Understanding these are critical for bereavement professionals who all work with clients of diverse backgrounds. The Intensive will cover social complexities as well as the complexities of grief and set the stage for learning about treatment innovations in grief work from EMDR to utilizing digital media. Exciting stuff!
 
In my community, as well as throughout the country, there has been an epidemic of deaths from heroin overdoses. In our grief center, we are treating a number of parents who have experienced these deaths. In addition, many bereaved are struggling with addiction and recovery.  We have a session designated to this topic which will be helpful to bereavement professionals who have had no previous experience with chemical dependency or substance abuse or could use a refresher on this important topic. 
 
We also have a session on self-compassion. So many of us have experienced personal deaths or have co-workers who have experienced a personal death. We may even have had a co-worker die. In addition, we are experiencing the death of our patients and listening to the stories of our bereaved families daily. This can be exhausting and takes a toll on our hearts and minds. Learning how to manage personal loss in a professional world is a must not only for ourselves but to help those with whom we work.
 
The Bereavement Intensive was designed for the advanced professional bereavement and those attending will find it well worth the investment.

Diane Snyder Cowan, MA, MT-BC, CHPCA
Director
Elisabeth Severance Prentiss Bereavement Center

See the other blogs that are part of this series.

Register Now: Advance registration ends October 7.

Community-Based Palliative Care

A series of blogs on the upcoming event THE INTENSIVES from educational content team members.

It started with a conversation that sounded like the dialogue from an episode of “Mission Impossible.” There was one big difference, however; I don’t remember hearing the words “should you choose to accept this mission…”  The mission was ours; the task was to create an educational program, a Community-Based Palliative Care Intensive about what’s next in community-based palliative care. It was described as “next practices.”  Community – Based Palliative Care 2025 was to be the topic!

“Palliative care outside of the hospital is still fairly new,” we thought, “even though hospice has always been providing it.”  Community-based palliative care is an even more recent addition to the healthcare continuum.  We know the names of some very successful programs but most of these are less than ten years old.  Who could possibly guess where they might be in ten years? 
 
Suddenly, one of us thought of those little Russian nesting dolls.  Inside every large doll is a series of smaller dolls. One has to peel down to get to the core; to get to the smallest doll.  Conversely the largest doll is built on the others. Our task was to build up!  We already have the kernel.
 
After discussing the topic with several “experts” in the field, we had some great ideas about what “futuring” might possibly look like for community-based palliative care.  The first bit of advice, however, was not to attempt to look ten years into the future. That was the end of “Palliative Care 2025.”  We were cautioned that change is continually happening – we are in the midst of it –  and trying to predict ten years down the road is likely impossible. 

So we did some research on the topic of “futuring.”   What is it? Why is it important? The authors of Dance of Change warn that futuring, while not easy, is essential for program planning and development.  It challenges us to look forward not just ahead. We analyze internal assumptions, scan the environment and use data to identify emerging issues.  We were convinced that futuring would be our goal.
 
Putting the Intensive together has been an opportunity for us to learn and grow; to look at things in a different way. 
 
Attending the Intensive will be your gift to yourself and to your program. We’ll be stimulated and challenged together and may even “…boldly go where no one has gone before.”  Join us, your colleagues and experts in the field as we co-create the future of community-based palliative care.

Judith A. Skretny
Director of Palliative Care
National Hospice and Palliative Care Organization

See the other blogs that are part of this series.

Register Now: Advance registration ends October 7.