Hospice And Palliative Medicine Physicians Address Their Concerns About Quality Hospice Via “Core Roles And Responsibilities Of Physicians In Hospice Care”
- A group of individual physicians are speaking out with their concerns “about troubling variability and quality of U.S. hospice care.” The statement speaks to these “core roles and responsibilities of hospice medical directors,” and then describes key elements within hospice programs that offer “structure and function required for hospice physicians to fulfill” these tasks. Thirdly, the statement notes “characteristics and circumstances of the work environment that should raise a hospice physician’s concerns that hospice patients and families are at risk of receiving low-quality care.”
- The statement is published in Journal of Palliative Medicine, authored by Dr. Ira Byock, signed by many physicians who support the statement, and online with free access for a limited period of time. The statement is meant to be a resource for hospice physicians, and a reference point for patients, advocate, industry leaders, regulators and legislators—all in hopes to “ensure the safety, quality, and reliability of hospice care. . .”
- The statement recognizes the important work and tasks that compose the work of the hospice physician. These tasks, and the importance of them, are described within the document. This includes a grouping of tasks under patient care responsibilities, and another list of administrative responsibilities. The document says that hospice physicians, while not needing a lot of “technical tools and expensive medical resources to do their jobs well,” do need enough time to do their jobs well. That said, the statement specifically lists these critical tasks.
- Also shared are the conditions that the hospice program will need in order to enable hospice physicians to function well. These include adequate staffing, provision of all four levels of care, and outreach to patients and families that fully support the care that they need. Hospices should also support their physicians by providing adequate training and skills.
- Next, the statement names specific “circumstances that should raise physician concern.” Reasonable caseloads are important, which are named as no more than 100 patients at a time. Physicians should also be concerned, says the statement, if nurse managers have caseloads that “limit their visits, inhibit their responsiveness to calls, questions and urgent problems, or cause nurse strain and moral distress.” Given variances, that nursing caseload is about 12-15 patients. One way to test this is to ask how often nurses are able to complete their clinical documentation or notes during regular business hours. Additionally, IDT meetings should “allow for substantive interdisciplinary discussion of patient and family needs and creative problem-solving.”
- “Physicians should be very concerned,” says the statement, “if their hospice program does not provide CHC and GIP,” both of which are essential services when patients need them.
- The statement calls for “corrective actions” and stresses the important role of the physician to lead this effort. Also noted are the roles of legislators, regulators, associations and others. While physicians cannot “correct the deficiencies and variable quality of hospice care,” they are a critical part of this work. (Journal of Palliative Medicine, 4/21)
CMS, for the first time, has publicly posted the owners of all Medicare-certified hospices and home care agencies. HHS Secretary Xavier Becerra said, “‘It’s plain and simple: families deserve transparency when making decisions about hospice and home health care for their loved ones.’” The move follow’s last year’s decisions by CMS to publicly share information about “mergers, acquisitions, consolidations, changes in ownership from 2016-2022 for hospitals and nursing homes enrolled in Medicare”; detailed information about the ownership of over 7,000 hospitals; and public information about ownership of about 15,000 Medicare Skilled Nursing Facilities. CMS plans to update the database, which is searchable, every quarter. In its press release about this latest action, NHPCO says that the recommendations made by hospice stakeholders in January, 2023, included a recommendation “for ownership disclosure for all hospices. (HHS.gov, 4/20; NHPCO, 4/20)
NHPCO issued a response to CMS’s announcement of the 2024 proposed rule. The major concern, stated clearly, says, “The 2.8% proposed rate increase for hospices is not enough to support the care hospices provide.” With high inflations costs, workforce challenges, and sequestration cuts, the increase will actually be, says NHPCO in a press release, about 1%. The release also notes opportunities for CMS to use “the proposed rules to advance hospice program integrity measures, curb fraudulent and abusive practices within the system, advance health equity, and increase hospice utilization.” NHPCO expresses its willingness and desire to be a part of this process. The organization also notes recent research about the reduced Medicare spending provided by hospices, and the overall value of hospice. (NHPCO, 4/17)
AARP published a two-part podcast titled “A Texas Hospice Provider’s Deadly Scheme.” The subject of the podcasts is the fraud of Texas-based Novus and CEO Broadly Harris. The podcasts are online at the links below. (AARP, 3/3)
PALLIATIVE CARE NOTE
“ASCO and National Comprehensive Cancer Network guidelines recommend all patients with advanced cancer receive early palliative care (PC) within 8 weeks of diagnosis,” notes an article in Journal of Clinical Oncology. The reality, however, is that this demand for PC is greater than the availability of the palliative care providers. The authors of the article “propose adoption of precision PC, a pragmatic approach that captures heterogeneous, time-varying, and complex patient/caregiver needs, while considering limited human and system resources.” (Journal of Clinical Oncology, 4/22, https://ascopubs.org/doi/full/10.1200/JCO.22.02532)
Connecticut legislators have once again failed to pass a bill that would allow terminally ill persons to have aid-in-dying. “The Legislature’s Judiciary Committee defeated the plan Wednesday over concerns that patients could be pressured to end their own lives.” (news12 Connecticut, 4/19, https://connecticut.news12.com/aid-in-dying-legislation-fails-again)
Nevada’s Senate has barely passed a medical aid-in-dying bill, with all Republicans and some Democrats voting against the bill. The bill now goes to the Assembly. (Las Vegas Review-Journal, 4/19, https://www.reviewjournal.com/news/politics-and-government/nevada/2023-legislature/nevada-senate-oks-medically-assisted-suicide-2764436/)
Oregon’s House Bill 2279 would remove a part of Oregon’s statute that says only Oregon residents are eligible for assistance in dying. If passed, Oregon would become the second state, after Vermont, to allow non-residents to request assisted dying within the state. Last year, Oregon settled a lawsuit that accused the state of violating patients’ constitutional rights. Since then, Oregon has stopped enforcing the old law and three non-residents have applied for the assistance. Opponents are concerned about a surge of out-of-state residents seeking assistance, but advocates do not anticipate this, saying the requirements for anyone to see this help creates a process with safeguards. (Oregonlive.com, 4/20, https://www.oregonlive.com/politics/2023/04/oregon-lawmakers-appear-poised-to-extend-right-to-medically-assisted-suicide-to-out-of-state-residents.html)
GRIEF AND ADVANCE CARE PLANNING NOTES
End of Life University offers a podcast on ”Grief Rituals and Transcending the ‘Five Stages,’” with Dr. Terri Daniels. Daniels talks about the use of rituals in managing grief, and shares “what the Five Stages model gets wrong about grief.” An author of books on death, grief and the afterlife, Daniels shares her own journey, and about her work with others. The podcast is online at the link below. (End of Life University, 4/17, https://eolupodcast.com/2023/04/17/ep-399-grief-rituals-and-transcending-the-five-stages-with-dr-terri-daniel/)
On 4/18, President Biden issued “an executive order to expand access to affordable, high-quality care and provide support for care workers and family caregivers.” The order includes over 50 directives for various governmental agencies. The White House says the order “is the most comprehensive set of executive actions any President has ever taken to make care more affordable for hardworking families and further support care workers and family caregivers.” The release includes statements from various legislators, public advocacy groups, and labor leaders. (WhiteHouse.gov, 4/18, https://www.whitehouse.gov/briefing-room/statements-releases/2023/04/18/fact-sheet-biden-harris-administration-announces-most-sweeping-set-of-executive-actions-to-improve-care-in-history/)
A study reported in Journal of Nursing Regulation found that 20% of “nurses could leave the workforce” within the next five years. This would be a loss of a million nurses, and 80% of these would be RNs. This change is attributed to increasing demands on nurses. Burnout is high. Of particular concern is the fact that number of nurses surveyed to reach these conclusions were young nurses. The study was reported in Journal of Nursing Regulation, and is online at the link below. (Journal of Nursing Regulation, April 2023, https://www.journalofnursingregulation.com/article/S2155-8256(23)00063-7/fulltext)
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Hospice Analytics is the national sponsor of Hospice News Network for 2022. Hospice Analytics is an information-sharing research organization whose mission is to improve hospice utilization and access to quality end-of- life care. For additional information, please call Dr. Cordt Kassner, CEO, at 719-209-1237 or see www.HospiceAnalytics.com.