NAHC URGES CMS TO ALLOW TELEHEALTH PERMANENTLY
Guidelines surrounding the use of telehealth were relaxed by the Centers for Medicare & Medicaid Services (CMS) as part of their pandemic response. Now, hospice providers are asking that these relaxed guidelines continue after the threat of COVID-19 is diminished.
President of the National Association for Home Care & Hospice (NAHC) William A. Dombi writes a letter to CMS Administrator Seema Verma, urging that these flexibilities be made permanent. “Roughly 98 percent of hospice care is delivered at the Routine Home Care (RHC) level of care, in a patient’s place of residence,” Dombi writes. He highlights pandemic-related barriers to home care such as visitation restrictions for patients who live in nursing facilities and limited control over potential exposure in home environments. Expanded telecommunications use makes it possible to continue delivering important hospice services, he argues.
A number of specific requests are made by Dombi in his letter. He asks that CMS clarifies the permission granted to hospice providers to use telecommunications technology to deliver services. “Fast-track development of modifiers or revenue codes that reflect various types of telecommunications-based visits for use in reporting on hospice claims,” he urges. He also asks for clarity that hospice providers can include telehealth visits as part of visit reporting. He urges CMS to “Develop regulations that permanently allow the hospice F2F recertification to be completed using telecommunications technology where feasible and appropriate.”
Dombi writes that it is too soon to predict when the pandemic will subside, but it is widely held that health care will be affected by it for some time to come – particularly for those with serious illnesses. “Given this likelihood, we believe it is an appropriate time to begin discussions around steps that can be taken by CMS to establish permanent Medicare policies related to the ongoing use of telecommunications technology in hospice care,” he writes. “Further, it may be time to set in motion actions that will allow for proper monitoring of utilization of technology-based visits and for assessment of their impact on quality of care outside of the current public health emergency.” (Home Care News, 5/20, www.homecaremag.com/news/nahc-urges-permanent-medicare-flexibilities-use-technology-hospice; mHealth Intelligence, 5/20, https://mhealthintelligence.com/news/hospice-care-providers-ask-cms-to-make-telehealth-coverage-permanent; NAHC, 5/15, https://www.nahc.org/wp-content/uploads/2020/05/Hon-Seems-Verma-Hospice-Use-of-Telecomunications-FINAL-1.pdf)
CULTIVATING EMOTIONAL INTELLIGENCE IS EFFECTIVE AGAINST HEALTHCARE WORKER BURNOUT
The level of stress, anxiety, and physical demands that health care workers are experiencing during the COVID-19 crisis is expected to take an emotional toll. Before coronavirus, the risk of burnout was already particularly high in healthcare. The pandemic has only made matters worse, Harvard Business Review (HBR) says.
Research shows that cultivating higher emotional intelligence is the best safeguard against burnout. Expected outcomes of improved emotional intelligence include “more trust among patients, higher levels of patient satisfaction and less physician burnout,” says HBR. For these purposes, emotional intelligence can be broken down into four categories: “self-awareness, self-management, social awareness, and relationship management.”
Because medical training is so focused on patient awareness and diagnosis, self-awareness can be hard to come by for healthcare workers. It is important that workers prioritize their own needs alongside those of the patients. Throughout the article, queries for self-reflection are suggested.
The increased workload, stress, and grief that the pandemic causes can make relationship management particularly difficult at the moment. Along with attention to patients and self, healthcare providers are advised by the article to practice patience with their colleagues. HBR says “Research has shown that sometimes we need to slow down to increase our effectiveness, especially at key moments. You can defuse a tense conversation or ease the tension around a crucial decision simply by saying, ‘This is important, let’s go slow.’” (Harvard Business Review, 5/20, https://hbr.org/2020/05/how-health-care-workers-can-take-care-of-themselves)
* Hospice chaplain Chris Sikora writes about the helpful effect music can have on people who are grieving. Sikora shares how music has personally helped him grieve, beginning with the loss of his best friend in high school. “Music saved me from drowning in my grief, a buoy that kept me afloat in those dark waters,” he says. We are all now experiencing collective grief for everything lost in the coronavirus pandemic, he says. “The path through grief is mourning, and it’s music that can meet us on the path and help us keep walking,” he says. Sikora describes the role music plays in his work as a hospice chaplain. Music has helped families hold vigil around dying loved ones. It can help memorialize the deceased, and it can bring hope to the bereaved. Sikora suggests we need music to carry us through lockdown and the uncertainty of the pandemic. “Locked down in our houses, uncertain when this pandemic will end, we have to keep dreaming of days ahead,” he says, adding that we need songs about love, touch, and all of the simple things we miss. “Let these songs fuel our dreams and embolden hope,” he says. (The New York Times, 5/21, www.nytimes.com/2020/05/21/well/mind/music-grief-coronavirus.html)
* New York Times editor and writer Devi Lockwood shares her experience caring for her grandmother who was in hospice care during the coronavirus lockdown. Lockwood writes that her grandmother’s death was not due to COVID-19, but it was influenced by it. Her family chose home-based hospice care for her grandmother after failing to find any hospice facilities in their area that could allow visitors during the pandemic. Lockwood describes how her whole extended family worked together to care for her grandmother, saying it was reminiscent of when her siblings were newborns. While all who cared for her grandmother were tired, she says, they were also grateful to be with one another. Lockwood was asleep, holding her grandmother’s hand during her night watch shift, when her grandmother died. “The small blessing of quarantine is that we were all at home,” she reflects. “We weren’t going anywhere: We couldn’t and we didn’t want to.” (The New York Times, 5/13, www.nytimes.com/2020/05/13/opinion/coronavirus-hospice-home-death.html)
* Columnist Froma Harrop writes about how end-of-life care is made much more difficult by COVID-19. She shares her experience caring for a friend who very recently died of cancer. Though he was not medically affected by COVID-19, his care was influenced by the pandemic. “When my friend exhibited signs of a stroke, I had to weigh the dangers of sending him to a hospital, where he might have gotten infected,” Harrop says. Though his symptoms turned out to be cancer-related, he was hospitalized for a few days, during which time he was isolated from his caregivers due to coronavirus concerns. After his return home, Harrop reports difficulties in receiving remote care from his palliative care doctor. She says other patients and caregivers have fears of allowing hospice workers or even family into their homes to visit or offer care and support. Hospices have had to cancel many of their comfort-focused services. Funerals and bereavement groups have been disrupted by the virus too. “Caring and grieving have always been arduous work,” Harrop concludes. “As with so many other life events, the pandemic has made it all that much harder.” (Observer-Reporter, 5/19, https://observer-reporter.com/op-ed-pandemic-makes-end-of-life-care-harder/article_a649f7d4-99ea-11ea-a135-4371c37850f8.html)
* Religious leaders and hospice chaplains share their perspectives of loss during coronavirus with Daytona Times. “As we continue to add value and uplift people, we must be aware and reflect on how the pandemic affects us and our ministries to meet the needs of those we serve,” says chaplain Carmen Royster-Caldwell of Vitas Healthcare in Palm Coast. She was one of over 1000 participants who recently attended a webinar titled “Hospice Foundation of America (HFA) – Providing Spiritual and Pastoral Care During COVID-19.” Daytona Times shares that bereavement services manager for Vitas Healthcare in the Greater Chicago area, Rev. Wanda Henry-Jenkins, says that we must leverage technology to “create alternate ministry practices” to adapt to our current condition and reach those who are isolated. Senior bereavement consultant to HFA in upstate New York Kenneth Doka, Ph.D., MDiv, focused on the personal, individualized nature of grief. “We’ve now begun to talk about personal pathways of grief,” he says. “Everybody grieves in their own individual way, rather than through a predicable set of stages.” (Daytona Times, 5/21, https://daytonatimes.com/2020/05/21/chaplain-shares-information-on-hospice-care-during-covid-19/)
* Hospice doctor and author Chris Kerr discusses death and loss during difficult times in an article for mindbodygreen. “In times of illness, we are drawn closer to those in need and endure tragedy through gestures of compassion and concern,” Kerr says. “The global calamity of the coronavirus has not just brought death—it has also separated us from each other and from those we love.” When confronting the idea of death, Kerr prompts readers to look beyond a medical event or physical pain and consider it “a human experience.” He says that those who are dying often describe peaceful end of life experiences. They are often recounting moments of their lives, or feeling the presence of loved ones who have passed before them. “While we may envision ventilators and ICUs, the dying experience love, presence, and even touch of predeceased loved ones,” he says. “They revisit the memories of being held and cherished, the apotheosis of a life rather than its demise.” How we experience or conceptualize the death of a loved one affects our grieving, he explains. This can add difficulty to those experiencing a loss during such times of isolation. “While there are no words to lessen or detach us from the realities of loss, those of us who work at the bedside of the dying can attest that patients do experience love, meaning, and even grace in their final moments,” he says. (mindbodygreen, 5/23, www.mindbodygreen.com/articles/hospice-doctors-message-to-anyone-dealing-with-loss)
END-OF-LIFE AND PALLIATIVE CARE NOTES
* Episode 247 of the End of Life University podcast, “Reimagining Death During the COVID-19 Pandemic with Lucinda Herring,” is available now. Herring is a home funeral and green burial consultant and author of Reimagining Death: Stories and Practical Wisdom for Home Funerals and Green Burials. Herring discusses how we may rethink funeral and burial practices during and after the coronavirus crisis. Topics include the work of a home funeral/green burial consultant, how home funeral practices can be helpful to families dealing with an unexpected death, how it can benefit us to be in the presence of the deceased, how to be a companion to dying loved ones from a distance, why a green burial could be a good alternative to a traditional burial during the pandemic, and several other topics. (End of Life University, 5/18, https://eolupodcast.com/2020/05/18/ep-247-reimagining-death-during-the-covid-19-pandemic-with-lucinda-herring/)
* In a letter to the editor of Journal of Palliative Medicine, researchers describe the benefits of virtual reality (VR) in palliative care during the coronavirus crisis. The researchers argue that while video conferencing (VC) has been the main form of communication for isolated COVID-19 patients, VR can provide a much more satisfying experience. VR can simulate locations of the patient’s choosing, such as “bucket list” experiences or a preferable setting for a good death. “VR can also be used to record patients in their last few weeks during their lucid moments,” the researchers say. “The recordings, with its hologram-like projections, will enable loved ones to treasure their last memorable moments with the patient in a way that VC is unable to rival, and is better able to offer emotional closure and fulfillment.” Current VR applications are also under development which would allow real-time interaction with loved ones, creating a more realistic sense of being surrounded by family members and friends. “If done appropriately, VR technology can bring psychological care and comfort for patients and their families by enabling remote interaction with dying patients or fulfilling dying wishes,” they conclude. (Journal of Palliative Medicine, 2020, www.liebertpub.com/doi/pdf/10.1089/jpm.2020.0212)
ADVANCE CARE PLANNING NOTES
* Clinician Joseph Shega speaks to the importance of discussing end-of-life wishes during the coronavirus crisis in a column published by McKnight’s Long-Term Care News. “Ask most clinicians why they opted for a career in healthcare, and they’ll say they were driven by a desire to help others. COVID-19 reminds us that to fulfill this mission, facility clinicians must be willing and prepared to have an open dialogue with long-term care residents and their families about their goals, values, and wishes for care,” Shega says. “They must also understand how long-term care teams can honor patients’/residents’ desires, especially near the end of life.” Shega says that though 99% of physicians agree that advance care planning discussions with patients are important, only 68% say they’ve received any training in this area. Many physicians report concerns that the conversation will be uncomfortable (51%) or that they don’t want their patients to give up hope (46%). However, having goals of care conversations should never feel like a failure, Shega stresses. It’s a powerful tool that honors the patient and puts them at the center of their care. “Having a goals-of-care conversation is not about giving up or feeling like a failure. It is an act that honors long-term care residents and respects them for who they are.” “No clinician should ever feel uncomfortable ‘having the conversation’ about end-of-life care with patients and their families, especially when situations like COVID-19 demonstrate how quickly symptoms and prognoses can change,” he concludes. (McKnight’s Long-Term Care News, 5/18, www.mcknights.com/blogs/setting-minds-and-hearts-at-ease-a-clinicians-guide-to-end-of-life-care-conversations/)
* End-of-life plans should be discussed while we’re still healthy, palliative care doctor Laura Schellenberg Johnson, M.D. writes in The New York Times. Schellenberg Johnson shares a recent experience with a COVID-19 patient who spent 17 days in ICU on a ventilator before dying. The family had been given no previous indication of the patient’s care preferences. “The most powerful thing that patients and families can do to take control of their health care is the simple act of thinking through what is most important if they become seriously ill and identifying a person they trust to speak for them if they can’t speak for themselves,” Schellenberg Johnson says. However, only 56% of adult Americans have had serious conversations about their care preferences, 27% have written them down, and only one in ten have discussed it with their doctors, according to a Kaiser Family Foundation study. The quick effects of COVID-19 make these conversations even more important, Schellenberg Johnson says. She gives several tips for having these conversations before a health emergency occurs: choose a durable power of attorney for health care, complete a living will and consider who has copies, and discuss your wishes and values with your backup decision maker. (The New York Times, 5/19, www.nytimes.com/2020/05/19/well/live/coronavirus-end-of-life-health-care-proxy-hospitals-doctors.html)
* A recent study reported in JAMA Network finds an opportunity for improved family-centered pediatric advance care planning interventions, News-Medical.Net says. The study finds that families of teenage cancer patients do not have a good understanding of when to approach advance care planning discussions. Eighty-six percent of the teens in the study say they prefer these conversations to take place early in their illness, while they’re still healthy and/or right after diagnosis. However, only 39% of families knew this was the preference. Many of the families in the study share that they knew these conversations are important to have, but they weren’t sure how to “break the ice” or get started. “Teens need to have a voice in their care and families are eager to know what their teens want, but those conversations can be difficult,” says principal investigator of the study and Children’s National Hospital clinical psychologist Maureen E. Lyon, Ph.D. Interventions for teens and their families “create a space where they can ask questions and be honest with each other,” she says. (News-Medical.Net, 5/22, www.news-medical.net/news/20200522/Parents-lack-understanding-of-teens-preferences-for-best-time-to-talk-about-end-of-life-decisions.aspx)
EDUCATIONAL OPPORTUNITIES NOTES
* The Conversation Project shares a recording and slides from their COVID-19 Community Call. The call centered on “bright spots” in the pandemic, focusing on hopeful stories and opportunities. The Conversation Project is also providing other COVID-19 specific resources on their website, such as a new guide called “Being Prepared in the Time of COVID-19.” The guide was developed by The Conversation Project and Ariadne Labs with the support of the Cambia Health Foundation. It is free to download from their webpage, alongside links to many other COVID-19 resources. (The Conversation Project, 5/20, https://theconversationproject.org/; Community Call Slides, https://theconversationproject.org/wp-content/uploads/2020/05/Bright-spots-May-2020.pdf; Community Call Recording, https://ihi.webex.com/recordingservice/sites/ihi/recording/playback/95a17f69b3ba466ab870b12652be3fd8; “Being Prepared in the Time of COVID-19,” https://theconversationproject.org/covid19/)
* The Coalition to Transform Advanced Care (C-TAC) announced the agenda and speakers for their National Policy Forum. The event , which will take place remotely this year, will be held on June 24th and will be free of cost. Free registration and further details on discussion topics and speaker lineup is available at the provided C-TAC link. (C-TAC, 5/20, www.thectac.org/policyforumagenda/)
* A free webinar from South Dakota Association of Healthcare Organizations titled “Difficult Conversations and Ethical Considerations for Patients with Terminal Illness” is to take place June 18th. Internal medicine specialist and Assistant Medical Director at Cedar Valley Hospice in Waterloo, Iowa, Dr. Michael Deters, M.D. will be presenting. With a focus on ethical considerations, Deters will share techniques for communicating with patients and their families about end-of-life decision-making. Participants will also learn “how to apply the role of advance directives in preventing ethical dilemmas, and discuss ethical issues and dilemmas that may arise in end-of-life/palliative care.” Registration is required and is available at the provided link. (South Dakota Association of Healthcare Organizations, 6/18, https://sdaho.org/events/webinar-difficult-conversations-and-ethical-considerations-for-patients-with-terminal-illness/)
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