Finding N Direction - National Hospice and Palliative Care ... · Direction When Things ... comprehensive article on service recovery—how . Newsline 5 ... This should prompt a review

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W E

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Finding DirectionWhen ThingsGo Wrong

National Hospice and Palliative Care

Organization

Quarterly Insights Edition June 2008

NeW ONliNe ResOuRces: Advocacy—see Page 41

Regulatory—see Page 55

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Table of contentsJune 2008

insights:

introduction:

Learning from Our Mistakes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

section 1: The service Failures

NCHPP members provide feedback on four case studies which are based

on actual problems that occurred in hospice programs around the country . . . . . .6

section 2: service Recovery

Two hospice leaders share their insights on handling problems confidently

when things go awry—a key component of service excellence . . . . . . . . . . . . . . .24

special section: Joining NcHPP

The National Council of Hospice and Palliative Professionals supports staff

and volunteers of NHPCO provider members by providing resources for their

professional and personal development . Empower your staff to do better . . . . . .32

Newsline:

Chronic Kidney Disease: Challenging Hospices to Assure Access . . . . . . . . . . . . .37Short Takes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41People and Places . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 Marketplace Picks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54Dates to Remember . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54NHPCO’s New Regulatory and Compliance Center . . . . . . . . . . . . . . . . . . . . . . .55

NewsLine is a publication of the National Hospice and Palliative Care Organization • ISSN 1081-5678 • Vol. 19, No. 6

Vice President, Communications: Jon Radulovic Communications Manager: Sue Canuteson Advertising Inquiries: Barry Black, 703/647-1577 Membership Inquiries: 800/646-6460

Copyright © 2008, NHPCO and its licensors. All rights reserved. Newsline 3

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learning from Our Mistakes

Introduction

Hospice and palliative care programs serve more than 1.3 million Americans each year—and serve the majority of these

patients very well. But even in hospice, there are problems .

Sometimes the problems are due to the confluence of circumstances affecting patients and families—from physical discomfort, fear, and anxiety to grief and sadness. Other times, the problems are due to inadequate training, inefficiencies and flaws in our systems and processes, or simply miscommunication. With

every problem that occurs, however, we suffer as an industry. When one hospice fails in the eyes of the patient, family, or referral source, the reputation of every hospice suffers .

This issue of NewsLine/Insights points the spotlight on actual problems that have occurred in hospice programs around the country. But along with the problems is feedback from members of the interdisciplinary team on ways the problems could have been mitigated or even avoided . Also featured in this issue is a comprehensive article on service recovery—how

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learning from Our Mistakesto spot the problems before they occur as well as steps you should take when they do happen .

This is a critical time for our field. Today, hospice care has come under intense governmental scrutiny. At the same time, the Centers for Medicare and Medicaid Services has issued new Hospice Conditions of Participation—which are far more focused on quality outcomes.

While we should all be proud of our success, we will only learn from an honest appraisal of our service failures. And that, in turn, will lead to better, more consistent care for all patients and families. The information imparted in the pages that follow is a constructive first step.

While we should

be proud of our

success, we will

only learn from an

honest appraisal of

our service failures.

Newsline 6

Section I

The service Failures

PRObleM cAse 1Eighty-five year old David K. and his wife, Barbara, were practicing Episcopalians and had been active in their faith community throughout their marriage. In recent years, however, it was becoming more difficult for them to stay as involved. In addition to the challenge of traveling 25 miles to their church, some of their long-time church family had died while others had relocated out of the area. To make matters even more difficult, a change in the pastor occurred right around the time David was diagnosed with stage 4 cancer, a time when both he and his wife needed the support of their faith community.

When David was admitted to hospice, he was grateful to be able to remain at home and receive services there. David’s time under hospice care, however, was quite short; he received services only during the final eight days of his life. When he was first admitted, Barbara, who was 73, asked the admitting nurse if hospice staff could help her bathe him, since he was a large man and she could not safely manage the task by herself. The nurse said that “hospice does not provide such custodial care,” but Barbara could hire a home-health agency for assistance. The nurse said she would provide a list of agencies to contact, for which Barbara was

very grateful. During the eight days that David was under hospice care, only one nurse called on him and Barbara—and only on two occasions: on admission and for the post-death visit.

Shortly after David’s death, Barbara received a letter from the hospice requesting a donation—even though she had had no previous relationship with the program (as a donor or otherwise). When she called the program, inquiring about the letter, the hospice staff member indicated the letter was sent in error and that he would update their mailing list so she would not receive future solicitations. Unfortunately, rather than just remove her from the program’s donation list, he removed her from the database. Consequently, she did not receive any other communication from the program— including the bereavement support to which she was entitled—until she called six months later to inquire about local grief support groups.

The issues RaisedThis case presents the perfect storm: a series of independent events that combine to have a greater effect than the sum of its parts . The patient and his wife lost critical spiritual support from their faith community as well as hospice support to manage end-of-life issues and personal care when they needed it most . The wife was deprived of the usual hospice bereavement support provided when her name was mistakenly removed from the program’s database. And, to add insult to injury, she was asked for money shortly after her husband’s death .

In this case, we must ask if we are able to identify and respond to emotional and spiritual needs as quickly as we confront pain and symptom management concerns? Do our services meet the Medicare Hospice Conditions of Participation (Hospice CoPs) as fully as they should? Do hospice team members understand the services that we are committed to provide and do we have the resources to provide them?

This case also raises the question of checks and balances. Is there a culture in the organization that allows the wife’s phone call to be quickly recognized as a service concern? How does hospice staff record such concerns? Who reviews these concerns and follows up on their resolution? How do different departments communicate with

Newsline 7continued on next page

one another about concerns that could affect patient and family care, especially during bereavement?

Finally, how does the culture of our organization support taking responsibility when we do not meet our own standards? Does everyone in the organization embrace the concept that errors occur and that we can only do better if we acknowledge and analyze them?

Joan Harrold, MD, MPH, FAAHPM, medical director and vice president of medical services for Hospice of Lancaster County, and NCHPP’s physician section leader.

Feedback from NcHPP sectionsPerformance Improvement/Quality Assurance Section:

Several key issues regarding customer service and systems improvement present themselves in this case study—and all of them have implications for fulfilling the QAPI requirements of the Hospice CoPs.

The most noticeable issue is the general lack of hospice presence during this patient’s stay . This should prompt a review of the patient’s medical record to see if:

the initial interdisciplinary comprehensive assessment was completed, • and subsequent visit frequency was met and recorded;

a check-in call within the first 24 hours following admission had • occurred;

signs that the patient was rapidly declining were noted during • admission and communicated to the clinical team; and

the family’s bereavement needs had been identified by the clinical • team, and a plan for follow-up after the patient’s death had been developed .

The initial assessment should include how personal care needs were assessed, as well as an evaluation of patient and family preferences and how these were integrated into the plan of care. Bathing is a component of personal care, a service that would customarily be part of a hospice plan of care and provided by a home health aide at an appropriate scope and frequency, based on the RN’s assessment of need and as specified in the Hospice CoPs . Home health aide services for David K should have been initiated by the hospice as soon as possible . Findings in the review of this individual case may indicate that corrective action is only required by the team leader of the involved staff; however, it may also point to the need for a more comprehensive performance improvement project . This may entail an investigation of aggregated complaint data, unusual occurrence data, family satisfaction data, and home health aide utilization to identify the existence of any trends . A performance improvement plan would begin to identify the origins of the problem: Is there confusion about the process? Are staff members lacking in knowledge or skill in this area? Is the policy and procedure clear? Once this information has been identified and analyzed, participants in the project will begin to brainstorm possible interventions for improvement . Staff education on the Medicare Hospice Benefit requirements for personal care would be one likely intervention.

in this case, we

must ask if we are

able to identify

and respond to

emotional and

spiritual needs

as quickly as…

pain and symptom

management

concerns.

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continued from previous page

Outcomes would be monitored to gauge the success of each intervention over time to ensure sustained improvement .

From a customer service perspective, there are several opportunities for improvement in this particular case . Effective service recovery involves contacting the spouse and offering an apology and explanation of how the hospice intends to prevent this situation from recurring with other patients . The reassessment of hospice services provided may also help to identify key tenets of customer satisfaction . Feedback from the community we serve—patients, families, physicians, discharge planners and others—is a critical component of continuous quality improvement and should always be encouraged .

Systems improvement concerns are also evident in this case, namely the deletion of the patient/family information from the program’s database . Was this an isolated case or part of a larger problem? An investigation of this incident should be conducted and should include a full process review to identify the problem’s root cause. If findings indicate more than just an isolated incident, the situation may call for the initiation of another performance improvement project to analyze non-clinical systems operations. The analysis will likely reveal the need for some additional checks and balances, such as (1) maintaining separate mailing lists for patient care and development, and (2) reviewing how data is shared between patient care and development to ensure that development cannot modify relevant patient care data or access personal health information, thereby ensuring compliance with HIPAA’s “need to know” rule. A review of the program’s policy on solicitation during the period of bereavement could also be addressed within the scope of this performance improvement project .

Rhonda Fisher-Brown, LCSW, director of quality management for Hospice By The Bay; Martha Tecca, senior director of Hospice and PeerForum for OCS, Inc; Patricia Vigilante RNC, CHPN, MPA, director of quality improvement and education for Visiting Nurse Service of New York Hospice Care; and Susan Zimmerman, performance improvement coordinator for Delaware Hospice and NCHPP’s PI/QA section leader.

Spiritual Caregiver Section:

Perhaps one of the most sobering messages in David K and Barbara’s story is that there was no hospice team supporting them. In fact, it appears there was just a team of one . More importantly, this case told of the many things the hospice would not do—but little of what it would or could do .

Now it is likely that there were reasons why this situation played out as it did. It might have been hard for team members to be there because they might have had five other situations like David and Barbara’s as part of their caseload that week and there was simply not enough staff to tend to all needs . Or it could be that the line of

communication between team members was not efficient enough to get some of the vital information disbursed to all staff fast enough. I can only assume that something was lost in the shuffle. While that can happen, it would seem that we should be better than that. We know the importance of getting to the heart of the matter and providing immediate response and support because we also know that none of us knows how long anyone may live. Were other team members involved, the clear lack of support in this case would not have occurred .

As a chaplain, I would have wanted information about David and Barbara’s faith community on my voicemail as soon as the intake was completed. I would have wanted to contact community members as quickly as possible to let them know what was going on and encourage them to visit the patient and family. I would have also planned to meet with David and Barbara myself to see how I might support them and “help them hold the meaning of the experience they were going through.”

As a spiritual caregiver, part of my job is to look at the whole picture: to see what is there, what is missing, who is speaking, and who is silent; to notice the effects of change on everyone, including myself. And I do this as part of a greater, wiser whole. I am collaborative because I am not a rock or an island. An estuary maybe, or the roots of an Aspen grove, but the lone outcropping I am not. I am not this way because


it is not as effective . As a whole we complete each other and can bring a deeper bandwidth of vision to the whole situation. We do this whether we are all visiting the patient or not. We still work together. If this hospice had involved more staff, then the end of David and Barbara’s story would have been radically different .

Carlyle Coash, BCC, chaplain for Kaiser Permanente, and NCHPP’s spiritual caregiver section leader.

Bereavement Professional Section:

The lack of bereavement programming can be found throughout this case study, starting with the patient’s admission.

At the time of admission, the assessment should include the grief and loss needs of both the patient and family to provide the groundwork for bereavement care. In addition to addressing patient’s needs, the hospice team should also complete a Survivor Risk Assessment. Intervention and care is based on the needs outlined in this SRA and should be documented in the plan of care. After the death of the patient, a bereavement assessment should then be completed and documented on the bereavement plan of care. Additionally, the hospice program may send information about its bereavement services and grief resource materials to family members and other identified caregivers. Each of these steps help to ensure the continuity of care that is the hallmark of hospice. In this case study, due to a disconnect of services, Barbara was not afforded any of this support—support that she was entitled to .

Using separate databases for patient/family information and fundraising could have also eliminated the errors that occurred after David’s death (i.e., the donor solicitation sent in error and the subsequent removal of Barbara’s name in the program’s database). In fact, during the 13 months that a person is followed in the bereavement program, he/she should not be directly solicited for donations . Families are often grateful for the services they have received and may—and often do—make donations or memorial gifts; however, this must be of their own accord. It is permissible, on the other hand, to send bereaved loved ones family satisfaction surveys, agency newsletters, and mailings about special events.

Although not apparent in this case study, and unfortunately so, one of the goals of the bereavement team is to bring full circle the care provided to the family and other caregivers since the time of admission . Often the patient care team has become an integral part of the patient’s family during his/her hospice care; in a sense, family members often see these hospice staff members as an extended part of their family. When their loved one dies, this can contribute to an added sense of loss because the hospice team is no longer in contact with the family. With the support and care of the bereavement team, however, the bereaved can process these feelings while eventually connecting with their own support systems and reinvesting in activities of their daily lives. It is not unusual for a hospice program to care for multiple family members over time, further building on the trust that has developed. When this happens, family members may also develop a new relationship with the hospice program, supporting the mission through volunteering, community connections and philanthropy. It is the circle of care and giving back that can actually strengthen a person’s healing .

Lisa De Sieno, MSE, LPC, director of outreach for Unity-Leaders in Hospice and Palliative Care.

At the time of

admission, the

assessment should

include the grief

and loss needs of

both the patient

and family to

provide the

groundwork for

bereavement care.

Newsline 10


Allied Therapist Section:

In addition to providing home health aide/CNA services to assist Barbara in David’s personal care, a referral to physical therapy would have been appropriate. Hospice-trained physical therapists offer services that support safety, comfort, and independent function for as long as possible during the different stages of the dying process .

For example, David’s physical therapy evaluation would have included a detailed review of mental status, functional level, cardiovascular status, signs and symptoms of infection, and environmental/social factors (including the caregiver’s ability to provide care) as well as a detailed pain assessment . The physical therapist would have also assessed this patient and family’s equipment needs, and would have ordered and provided safety instructions for any that were needed .

Massage therapy for pain management, caregiver training, and transfer training would have also been coordinated with members of the interdisciplinary team, including the volunteer coordinator . Depending on the patient’s diagnosis and condition on the evaluation date, the physical therapist may have implemented a plan such as “rehab light,” which calls for one to two visits per week and a slow approach to treatment to achieve some quality of life goals. In this case, however, a “supportive care model” would have most likely been established, which focuses more on safety and comfort .

A physical therapist would have also been able to provide a skilled medical

assessment of the patient’s condition and corroborate information relating to other IDT services, helping to fill the gap left by having a very limited nursing presence in the home .

Allied therapists, such as physical, occupational and speech therapists as well as complementary therapists, often find themselves in quickly established relationships with patients and families . The connections that form from providing care that is hands-on, much like that of the home health aide/CNA, can open up meaningful dialogue. Had a physical therapist visited with David and Barbara, he/she could have engaged in last-days education with Barbara, better preparing her for his death and the bereavement support that should have followed .

Valarie Hartman, RN, CHPN, CTRN, complementary therapy program coordinator for Holy Redeemer Hospice, and NCHPP’s allied therapist section leader.

Nurse Section:

This hospice program did not come close to meeting the minimum requirements of the Hospice CoPs. But, beyond this, we were very saddened by this case study since it represented a perfect opportunity to do what hospice does best—provide education, care,

support and guidance to a loved one who wanted to care for her

husband in the final days of his life .

One of the important ways hospice could have supported Barbara was through caregiver training . It is the hospice’s

responsibility to train and

educate


caregivers, based on the caregiver’s comfort level, and make sure the information has been processed and understood. In addition, actual hands-on care should have been assessed .

When providing caregiver training, the hospice team member should actively demonstrate everything twice and ask questions to make sure the information covered has been understood and will be remembered . We need to be ever-mindful that most caregivers have never received training in providing care to anyone, let alone a loved one—and now they are receiving instruction during a time of high anxiety . Part of our job is to help ensure these caregivers have a sense of fulfillment in the goals they have set for themselves and a feeling of success when the patient dies. We are responsible for the memories of those left to grieve. We must listen to what they are asking of us, rather than simply provide what we think they need .

Teresa McCreary, RN, CHPN, access services manager for Hospice of Lancaster County; and Pat Gibbons, BSN, CHPN, director of Beacon Place at Hospice and Palliative Care of Greensboro, and NCHPP’s nurse section leader.

PRObleM cAse 2Mary L., a patient with cancer of the pancreas, was admitted to hospice by her daughter, Karen. While she had been experiencing significant pain throughout her illness, Mary had had a good relationship with her primary care physician, who had succeeded in identifying the medication and dosage level (at four-hour intervals) needed to keep her pain under control.

Upon Mary’s admission to hospice, her daughter, who was a nurse by training, had shared with hospice staff that “dying in pain” was one of her mother’s gravest concerns. Mary had faced many tragedies in her life with tremendous grace and dignity, as both a Holocaust survivor and a parent who lost her first child to cancer. Now, as Mary neared the end of life, Karen wanted to make sure her mother was spared of any further pain. Karen also confided to hospice staff that she didn’t want to serve in her professional role during her mother’s illness; she just needed and wanted “to be a good daughter” during Mary’s final days.

During the admission intake, hospice staff told Mary that her current pain medication, which had been prescribed by her primary care physician, was not in their program’s formulary—that only medication at eight-hour intervals could be administered; however, they felt this would be sufficient.

When Mary did not respond to the new pain formulary, her daughter called the hospice for some assistance and guidance, which happened to be on a weekend. She was told by hospice staff that no one was available to help her until Monday.

Mary ended up dying in terrible pain over that weekend. Her last words to her daughter were, “But you had promised me I wouldn’t have to die in pain.”

The issues RaisedThis case raises a host of “whys.” Why was the formulary invoked while the patient still likely had a supply of medication that was effective? Why was her successful medication regimen changed so quickly upon meeting her for the first time? Why was follow-up not routine after changing

We are responsible

for the memories of

those left to grieve.

We must listen

to what they are

asking of us….

Newsline 12


medication? Why was severe pain, previously controlled, not considered an emergency? Why was no one available on the weekend?

There are, of course, the usual answers. The formulary is usually effective at controlling both pain and costs. We must be good stewards of our resources. We need consistency in our approach to pain and symptom management. We expect people to call us when they have a problem; we don’t dictate timing of visits. We can’t be everywhere, especially on nights and weekends . After sorting through the expected answers, there are deeper questions that are more useful to creating change.

What is our basic philosophy about meeting the needs of patients and their families? How do we meet the unique needs of patients and simultaneously practice in a clinically consistent and cost-effective manner? How do we equip staff to meet fear and anxiety in people they don’t know—and who are just learning to trust them? Do all members of the team have the words that they need to clarify usual practice? Do they have the authority—or the access to authority—to make reasonable exceptions? What are staff expected to do when resources appear to be exhausted? Do they know what those expectations are? How do we create a culture that asks these questions instead of taking refuge in policies, procedures, or common practice?


Feedback from NcHPP sectionsCEO/Executive Director/President Section:

The first question that jumped out at me was “Is this an isolated incident or a symptom of a bigger problem?” The situation that occurred is certainly tragic. It is absolutely unacceptable that anyone would have had to endure this experience in their last days and hours, let alone a hospice patient. To get at the heart of the dilemma, however, the key issue for the hospice executive is whether the episode is a one-time anomaly or a festering sore that has just become visible. In analyzing this case, I will address each possibility separately.

Were this a one-time anomaly, the executive’s response can be brief and to the point . The incident provides a clear example of “what should not happen to our patients and their families.” Although the hospice may have strived to be the best, its staff members lost focus and missed what

they were aiming for in the care of this patient . The incident offers the executive an opportunity to remind staff of the high standard that hospice professionals are held to and the critical role they play in patients’ lives . The primary goal should be to make certain the staff involved understand the ramifications of what transpired.

If analysis reveals that the incident represents much deeper, systematic issues, the executive’s involvement must be much more significant and intense; otherwise, the organization could suffer “permanent and irreversible” damage. For example, the actual cause of the incident may be related to the practiced culture of the organization.

In evaluating this case study, these immediate questions come to mind:

Why does the formulary not allow for any • variation based on successful drug usage prior to admission?

Why does the policy only allow medication • administration every eight hours?

Does staff understand the patient and family • goals for those being cared for?

Why would a patient and family need to • wait days or even hours to have their needs addressed?

Are the program’s policies/systems structured • to meet the patient/family needs or the hospice’s needs?

If this could happen to one patient, how many • more have had this experience that we are not aware of?

What in the organizational culture could • allow staff to think that what happened was acceptable?

What role did the organization’s leader play in • creating an environment that allowed this to happen?

These questions point to structural and/or system issues and, in order to be addressed, need strategic evaluation of the root cause .

Whether it was a one-time anomaly or a deeper, systemic issue, the hospice executive for this program has a serious issue on his/her hands. What’s more, the incident not only impacts the hospice involved and its role and purpose in the community, but also impacts hospice providers in general. As stated in the NHPCO manual, “Ethical Principles” (2006), “Not only are we held accountable for our own actions, but we are also


judged by the conduct of our peers—those who operate in the same field.” The incident is definitely a direct assault on everything that the hospice stands for: quality end-of-life care.

Paul D. Longenecker, RN, PhD, assistant professor of leadership studies at Lourdes College.

Pharmacist Section:

With respect to meeting the patient’s needs, formularies should always be treated as a guide to care, not an absolute. Particularly during the initial admission visit to hospice, staff should be more conscious of the need to build trust rather than the need to adhere to formulary medications . Some of the unintended messages patients and families might “hear” when we talk about changing to formulary medication can hinder the development of trust . Messages such as:

“Even though you don’t know us, we know what is best for you and we only use our medication choices.”

“Your physician hasn’t done a good job of caring for you with respect to the medication he/she has prescribed.”

“It is okay to waste medications you purchased. The money you spent on your current medication is unimportant.”

“It doesn’t matter what you want.”

Changing medication at the time of admission is confusing to patients and families. What’s more, replacing the medications in the home can cost the hospice money. It can also take more of your staff’s time if the alternative is not as effective. Thus, some medications aren’t worth changing.

When a change in medication is warranted, we have had great success with a couple of strategies to set the stage for the change. First, use up the medication already in the home unless the medication is not effective or is causing adverse effects. Second, explain to the patient that the hospice team will be asking his/her physician for changes in the medication as time goes on; this is recommended so that optimal treatment is provided and the right medication is in the home to prepare for the unexpected .

There really is no need to use the word “formulary” when speaking with patients and families . The emphasis should be on providing best practice drug therapy for each patient. If a program does wish to move to a formulary medication, staff should look for “windows of opportunity” to change the current medication to the desired (formulary) medication once trust has been established .

Phyllis Grauer, RPh, PharmD, CGP, vice president of clinical services for HospiScript Services, LLC, and NCHPP’s pharmacist section leader.

Bereavement Professional Section:

Given the daughter’s experience with hospice in this particular case study, she may well not want anything to do with hospice bereavement services . However, an early indication of the daughter’s openness to contact with a bereavement counselor may come from the staff who attended the mother’s death .

Receptivity to bereavement services after the death of a loved one varies from person to person. With a variety of offerings, individuals can choose services such as individual counseling, group support, memorializing

There really is no

need to use the

word “formulary”

when speaking

with patients

and families. The

emphasis should

be on providing

best practice drug

therapy for each

patient.

Newsline 14


opportunities, and written resources. The death and the time preceding the actual death can have a significant impact on the transition from patient care to bereavement care .

This is a crucial time in the transition of care . As hospice professionals, we need to understand that reactions of family members and caregivers surrounding the time of death can range from absence of outward signs of emotion to dramatic displays of emotion, from no tears to intense sobbing. There is no “right” or “appropriate” textbook reaction. Therefore, how we transition to bereavement services is important. Because every individual is different, it may be more effective to say that “someone from the bereavement team will be in contact to explain available services” rather than ask the person if he/she would like a call from the counselor . Leaving some written literature about the nature of grief can also be helpful. While everyone may not have the need or ability to concentrate on reading, others crave information and affirmation that what they are experiencing is “normal.” Sometimes an individual will reject the offer of bereavement services initially, but may not realize all the opportunities that are available to them. So whenever possible, “leave the door open.”

It is possible that Mary’s daughter has been traumatized by how her mother’s death occurred, despite her efforts to get the best possible care . She placed her trust in hospice and may feel that she had been abandoned at her mother’s greatest time of need. In this case, having a bereavement counselor who the daughter has not met make the initial contact might work well. She may refuse bereavement support and, if so, it is important to respect that decision. However, if she is receptive to contact, the bereavement counselor could provide a safe

place for her to process the upsetting experience which may include feelings of anger, guilt, regret, and betrayal. At first, these feelings may be too “hot” to touch. Over time, as the counselor establishes rapport with Mary’s daughter, she may be able to move through the intensity of her grief experiences . Eventually she may be able to look ahead a bit more and find some sense of peace and healing . Of course it will never be the goal for Mary’s daughter to make it “okay” that her mother died in this manner, but rather to realize the she did everything in her power to do the right thing for her mother and that she was, indeed, a “good daughter.” It may not be realistic to think that reactions of how her mother died won’t resurface from time to time. When she is able, focusing on the good memories and meaningful connections with her mother may be a helpful alternative to her more painful feelings .

Lisa De Sieno, MSE, LPC, director of outreach for Unity-Leaders in Hospice and Palliative Care.

Social Worker Section:

In end-of-life care, social workers are witness to many family promises: “I told my dad I would never put him in a nursing home…. I promised myself I would never stop fighting this disease…. I promise I will be with you to the end…. I promise you won’t have to go back to the hospital.”

So often social workers hear family members utter promises they intend to keep, only to find that the future can present circumstances families never expected . Social workers are unfortunately also familiar with the crushing guilt that can occur when individuals are not able to keep a promise .

The situation presented here is an example of a daughter promising her mother that she won’t die in pain . The promise is between the mother and her daughter. The word promise is defined as a declaration that something will or will not be done…. But, was another promise broken?

How does the industry represent hospice services to the public? Does your literature say that hospice will manage symptoms? Does your admission packet say you will respond after hours? Does your Web site say the organization will focus on improving quality of life? What happens when a program fails to deliver? Mary’s parting words to her daughter, “but you promised me I wouldn’t have to die in pain,” will no doubt linger and cause the daughter much emotional distress . The patient’s parting words should also cause distress for our industry .


How Can Social Workers Help?

Teach, teach—and keep teaching

Case studies are one of the most powerful teaching tools of our profession . A collection of case studies can enrich discussions and allow for problem solving on micro and macro levels. Ethics, theoretical frameworks, and practice skills can all be topics woven into case studies. Case studies allow us to feel, to take sides, to want to jump in and make it better . Every complaint is a case study and an opportunity to learn .

Assess for role conflict

Mary’s daughter is a nurse . Did her mother’s hospice team expect her to be more than just the daughter? It’s impossible to know if the team caring for Mary made assumptions about the daughter’s ability to respond to Mary’s pain . Assumptions about the caregiver could have contributed to the failure of the hospice to manage the patient’s pain . Social workers are trained to assess the impact of role conflict within families . A discussion with the rest of the team might have determined how the daughter was being viewed and what if any expectations and/or assumptions existed .

Take a systems approach

Social workers are trained to analyze problems from a systems perspective. As a system, hospice has numerous vulnerabilities in communicating. Information given from one team to another—from on-call staff to day staff, from admitting teams to patient care teams—are all areas of vulnerability . Social workers might use systems theory as a framework to seek solutions to communication breakdowns .

Use a team approach

Where is the rest of the team in this case study? Would it have helped if the social worker knew about the promise? Who was addressing anticipatory grieving? Even though the reader has limited information about Mary and her daughter’s relationship, we can all imagine how hard it must be for a daughter trained as a nurse to watch her mother experience pain . The emotional toll on the daughter is evident . This family needed—and should have received—more psychosocial assistance .

Avoiding heartbreak and damage caused by broken promises is a worthwhile goal for social workers and other hospice team members . Our industry can and must learn from our mistakes .

Sherri Weisenfluh, MSW, LCSW, associate vice president of counseling for Hospice of the Bluegrass and NCHPP’s social work section leader.

Nurse Section:

What are the predominant problems in this case? To begin with, as hospice professionals it is our responsibility to assure that pain and symptom management at the end of life are controlled to the patient’s and family’s satisfaction. In this situation, the hospice failed that responsibility. While it is easier to stick with our formularies and not step out of the box and think critically, there are times when we need—and must—evaluate what we are providing. This patient, prior to having hospice, said she had had successful pain control. The daughter alerted the hospice staff that one of the patient’s greatest fears was dying in pain. It was the hospice staff’s responsibility to assure this fear was alleviated. Have we adopted a formulary/protocol mentality in which

case studies

are one of the

most powerful

teaching tools of

our profession….

every complaint is

a case study and

an opportunity to

learn.

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the patient’s and family’s wishes are ignored? If nothing else, hospice staff could have given the patient and family the option to purchase the preferred medication themselves; families do have the option to continue with a plan of care that is not the same as that of the hospice team .

Perhaps the worst issue that is presented in this case was the unavailability of staff over the weekend; quite frankly, this cannot be an option. Even for smaller hospice programs with very limited staffing, on-call availability is one of the requirements of the Hospice CoPs. Each hospice needs to assess how it can make this work by rotating weekend and evening staff as on-call personnel, offering weekend-only options for some nursing staff, or considering other models suitable within the program’s geography .

Teresa McCreary, RN, CHPN, access services manager for Hospice of Lancaster County; and Pat Gibbons, BSN, CHPN, director of Beacon Place at Hospice and Palliative Care of Greensboro, and NCHPP’s nurse section leader.

PRObleM cAse 3Eighty-eight year old Rose G. had moved into a nursing home after her husband died five years ago. She had been struggling with Congestive Heart Failure for the last eight years and following a sixth hospitalization for that illness, was admitted to hospice by her son, who lived in a neighboring county. She was assigned to one of the hospice’s inpatient beds at the hospital and remained there until her death seven days later.

Rose’s daughter had arrived from out of town three days after her mother had been admitted. She was considerably distressed that the hospice made no contact with Rose—or with her— during the four days she was by her mother’s side. The daughter said that she did not even know the name of the hospice that was presumably treating Rose since there had been no attempt at contact and no literature, business cards, or other material had been left at her mother’s bedside.

The issues Raised Why was no contact made with this patient or her family following the admission? Analysis of this case could easily be sidetracked by discussion of family dynamics, HIPAA, and the responsibilities of the hospital staff. But the questions must go deeper than that .

How do we establish a high standard for the continuity of hospice care when patients change

locations before we really get to know them or their caregivers? What does the best care look like when a patient receives inpatient hospice care in a non-hospice setting? How do we ensure that we are, as required by Medicare, managing the plan of care in such a setting? How do we train our staff to interact with hospital staff when sharing the care of a hospice patient? Once symptoms are controlled, professional caregivers are providing care, and there are no obvious needs, how do we identify, assess, and meet the needs that are not so obvious?

What drives the scheduling of visits on our teams? How do we integrate hospice volunteers into the care of hospice patients in hospital settings? When it is difficult to make contact with families, what expectations and resources have we created to connect more easily? These are some of the questions that must be answered when situations like this occur in our programs .


Feedback from NcHPP sections CEO/Executive Director/President Section:

A hospice team will often work with and develop relationships with several different family members of the patient— and sometimes those family members are not “on the same page” with respect to communicating with each other. As a result, it is part of the hospice team’s responsibility to communicate with all members of the patient’s family, as designated by the patient.

If this patient designated her daughter as someone for the hospice team to communicate with, it is tragic that something like this happened . As an executive director, it is very disappointing to hear that a family member is not pleased with the


hospice care of their loved one and it is important that both the patient/family and the hospice team know that leadership will respond .

The executive director can ask questions such as:

How many visits did we make during the time frame in question?•

By what method did we, as a team, communicate with the patient and • family during the visits?

Were we given permission to communicate with the daughter as well • as the son?

If we made visits and provided support to the patient during this time • frame and the daughter was to receive updates and information from the team, where did the communication break down?

It is also very important for the hospice organization to meet with the family member, in this case Rose’s daughter, and (1) defuse the emotional component of the situation by thanking her for the courage and willingness to share her concerns, and (2) provide her with information based on the hospice team’s story and documentation, while apologizing for not meeting the expectations of the family . There is nothing wrong with apologizing, especially when a family member feels neglected and out of touch with hospice team members and their support. If the hospice team’s communication broke down, it is also vital to share that information with the family member, apologize and speak to efforts being made—or to be made—that will avoid this from occurring again .

Finally, it is important that leadership educates the hospice team on the variety of ways to communicate with the family. For example, when family members are not present with the patient during a personal visit, hospice team members should make sure they follow up with the designated family members. They can leave their business cards, make a personal phone call to the family member upon leaving the patient’s bedside, or send a personal note every so many days to update the family about the most recent visit . Leadership must also stress the importance of documenting all activity with the patient, not only because it is quality hospice care and is required, but also because it may be needed should the incident require further investigation.

Gregory Wood, LBSW CHA, president of the Oklahoma Hospice & Palliative Care Association, executive director of the Hospice of North Central Oklahoma, and NCHPP’s CEO/executive director/president section leader.

Volunteer/Volunteer Management Section:

A strong volunteer program would have been instrumental in avoiding this situation. While we don’t know the type of relationship Rose had with her daughter or whether or not she wanted her daughter informed of her condition, it is clear that a hospice volunteer could have helped bridge the communication gap that is so evident here .

The utilization of volunteers who are specially trained to contact patients and families upon admission to hospice would have provided an immediate opportunity to communicate with Rose’s family and identify how volunteer services could help meet their needs .

For example, a cadre of trained volunteers, including volunteer chaplains, can be assigned to hospice inpatient beds at the hospital to offer daily support and a caring presence. Volunteer “business cards” with the

A hospice volunteer

could have

helped bridge the

communication gap

that is so evident

here.

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name of the hospice, contact information, and the volunteer’s name can be left at the bedside of patients so that anyone visiting would know that they are hospice patients and a volunteer is involved in their care . A journal can be left in the patient’s hospital room so both the patient and visitors can record their thoughts and the time and date of the visit . Using a journal in this way also gives all hospice interdisciplinary staff, as well as hospital staff, an opportunity to document the care and comfort being provided and demonstrate their attention to the patient’s and family’s needs . As another gesture of caring, programs can also have their volunteers deliver small welcome gifts to patients .

In this particular case, were a volunteer assigned to support Rose, he/she could have written a note to all family members letting them know that Rose was receiving care and support from the hospice program and that volunteers were attending to her needs and wishes . A volunteer brochure could have been included with the note, describing the available volunteer services and how the family could help by notifying the hospice of any special wishes their mother may have expressed in the past .

The volunteer could have also offered Rose the chance to connect with family members who lived in other areas. With assistance from the volunteer, Rose could have composed letters to them, or told her life story in the form of a video, audio tape, journal or scrapbook . This can help patients with life review and closure and, at the same time, provide a legacy to family and friends .

Eleventh Hour volunteers could have also provided a caring presence during the final hours of Rose’s life and offered support to family members, including Rose’s daughter when she arrived . Following Rose’s death, these volunteers could have also helped with making phone calls, picking up relatives from the airport, preparing food, and attending to other practical matters .

The work of both these inpatient and Eleventh Hour volunteers would have been invaluable in helping to bridge the communication gaps during this brief, but critical time for Rose and her family.

Deborah A. Braun, CVA, Hospice of Northwest Ohio; Lisa Gallagher, RN, Hospice of the Western Reserve; Tia Hovatter Stevens, BA, Mountain Hospice; Sandra Huster, BA, Covenant Hospice; Catherine C. Kobacker; and Kathy Roble, MS, The Hospice of the Florida Suncoast, and NCHPP’s vice chair and volunteer/volunteer management section leader.

PR/Development/Marketing Section:

For the purposes of discussion from the public relations perspective, let us make some assumptions about this very troubling case .

Rose’s son lived in nearby Orleans County while her daughter lived in South Texas. A recent hospital admission led to procedures, consultations and a difficult conversation. Her doctor believed it was time to change the focus of care to comfort and recommended hospice to her son. Doctors were measuring Rose’s life in days. The hospice liaison explained that Rose would be in one of the two ‘hospice rooms’ in the hospital and that care would start immediately and continue for as long as Rose needed. When her daughter arrived, Rose was sleeping. She stayed in her mother’s room, holding her hand for 10 hours. The next morning, while her daughter was gone, the hospice nurse visited Rose. Rose’s daughter was disappointed that she had missed her. The remainder of Friday flew by and she was determined not to leave her mother’s bedside. She also felt frustrated that she did not know who the mysterious hospice provider was. Saturday brought a change in Rose’s status; she was now actively dying. Her son and daughter kept vigil at her bedside until her death at 11:58 a.m. The daughter was now angry that she had not met anyone from hospice and that she didn’t even know the name of the hospice program.

Could this be your hospice? As hospices face shorter lengths of stay and must deal with families spread throughout the country, it could be any hospice . Are there ways to reach out to your patient’s other family members? We looked at this case study through the eyes of a customer and developed suggestions on how to brand a hospice, increase recognition, and enhance communication—thereby helping to avoid the type of situation presented here .

During the Admission/Consultation

Telephone the patient’s out-of-town family • member(s) to explain hospice services;

Direct the family member(s) to your program’s • Web site for more information;

Place a cover sheet in the patient’s chart, • indicating “this patient is receiving hospice care from [name of your hospice and its logo)”;

Put an extra copy of your hospice’s patient and • family handbook in the patient’s room;

Place a tent card in the patient’s room with the • name and phone number of your hospice .


Education

Provide hospital staff with guidelines for hospice care in the inpatient • setting, such as Hospice Inpatient Units in Healthcare Facilities (available from nhpco.org/marketplace; Item 820569). This manual serves as a resource for hospital staff involved in the hospice plan of care, positions your hospice as “the experts,” and ensures that the hospital staff knows that hospice is available 24/7.

Encourage hospital staff to communicate with your hospice. In the • case study, hospital staff could have/should have called the hospice to arrange an emergency visit from a social worker .

General Branding of Your Hospice

Present the hospital with a plaque to place on the wall where the • hospice beds are located which reads:

(Name of Hospice) Recognizes (Floor of the Hospital with Hospice Beds) for their dedication to providing excellent end-of-life care. (Hospice Logo)

Display a poster in the family waiting room with a tear-off sheet and • telephone number for families to access more information .

Distribute brochures—regarding general hospice information, • bereavement services, acute inpatient care, and what to expect as death approaches—in common areas such as family waiting rooms .

Establish a dress code/uniform for hospice staff that incorporates your • hospice logo and colors . This will increase hospital staff recognition of hospice staff when they are on the floor and prevents questionable work attire .

Wear high-quality name tags that show photo, first name and • discipline .

Provide labcoats bearing your hospice logo to nurse liaisons, • palliative care physicians and RNPs who are routinely in the hospital . This connotes professionalism and supports the position that you are “the experts.”

Place a removable label inside the patient’s chart indicating any • spiritual tradition that was or was not requested.

Work with the hospital to install a small 3x5 acrylic holder on the wall • above the hospice bed to hold a card that identifies your program, the service being provided (i.e., the patient is under GIP care), and contact information .

Provide hospice staff with “You had a visitor” cards, containing their • contact information . These cards can be left behind when patients are sleeping or otherwise unavailable when a visit is made .

Since there is a perception throughout the country that all hospices are part of “one organization,” employing some or all of these suggestions will help your hospice develop its brand identity within the community you serve .

Michele Clayborne, director of hospital and physician relations, and Pam Taylor, director of communications, for Home & Hospice Care of Rhode Island.

since there is a

perception that all

hospices are part of

“one organization,”

some or all of these

suggestions will

help your hospice

develop its brand

identity….

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PRObleM cAse 4

An elderly patient, John C., was admitted to hospice following hospitalization for end-stage lung cancer. The hospital released him on a Friday afternoon, without any pain medication; however, the hospital staff did provide him and his family with a prescription for pain medication, which the family never filled. His release occurred at the start of Memorial Day weekend which, in that particular community, usually draws thousands of visitors.

During the hospice intake, staff ordered the appropriate pain medication for delivery on Memorial Day. Due to transportation delays, however, the medication arrived on Tuesday rather than on Monday. John ended up dying in severe pain, without having received the necessary medication. The angry family members accused the hospice of negligence. The incident was investigated by the state’s Division of Healthcare Quality, which concluded there was no substantiation for the claim.

The issues RaisedIt is so tempting to feel vindicated when someone else, especially someone in authority, determines that we did nothing wrong . There is a collective sigh of relief when it is declared that what went wrong was not “our fault.” In this case, however, we would do everyone a disservice if we stopped there . Answering the “whys” and “hows” could go a long way toward keeping this situation, and the resulting investigation, from happening again.

The first questions are the “whys.” Why didn’t the family call us when the medication didn’t arrive?

Were our instructions unclear or easily forgotten under duress? Were they written down so that the family could refer back to them? Do the systems for ordering medications need to be examined, especially for medications that are ordered after hours or during weekends and holidays?

How do we follow up with newly admitted patients? How do we respond to the additional needs of a patient just released from the hospital? How do we reconcile medications and treatments ordered upon hospital discharge to the hospice plan of care? How do we access medications rapidly when they are needed, but not readily available? How do we prepare our patients, families, and staff to anticipate and cope with weather, holidays, or other events that are likely to challenge our usual practices and procedures or our ability to reach our patients?


Feedback from NcHPP sectionsCEO/Executive Director/President Section:

There are several difficult matters to address in this situation. First, from the family’s perspective, the hospice was negligent because their loved one died in pain and without the presence and support of the hospice team . Perception is oftentimes our reality and this should be addressed by the hospice team and leadership immediately .

When looking at this situation as an executive director, I would address two matters quickly. First, inner policies and procedures should be reviewed to ensure there exists a protocol for evening and weekend admissions and team follow-up with new patients. If the policies are in place, I would then investigate the events of the weekend by interviewing the field and weekend staff members. Second, after getting details and facts from the hospice staff, I would approach the family with the details of what happened, what we could have done differently, and what we regret—and let the family know how deeply sorry we are that their loved one died in pain without the necessary medication .

When questioning a hospice team for details surrounding a case such as this, it is important to make sure there is a protocol for evening and weekend admissions and clear procedures on how on-call staff will follow up with patients. This is especially important when new patients


clear written

and verbal

communication

regarding when

and what the

patient and

caregiver should

anticipate provides

a framework

for meeting

expectations.

are admitted and the team is in the early stages of the learning curve with that particular patient; in fact, it is vital that the hospice monitor and communicate daily during these early stages. In this case study, had on-call staff maintained daily contact with the patient and family during the initial days following admission, they would have been aware of the delivery delays sooner rather than later and could have taken appropriate action .

Gregory Wood, LBSW CHA, president of the Oklahoma Hospice & Palliative Care Association, executive director of the Hospice of North Central Oklahoma, and NCHPP’s CEO/executive director/president section leader.

Pharmacist Section:Much attention has been given to the importance of medication reconciliation as patients move between care settings to maintain continuity of care. However, even when we feel we have put the necessary details into place to provide for our patients’ medication needs, common sense tells us that we need to build in safeguards to prepare for the unpredictable. As case managers, the hospice team is not only responsible for their own delivery of services, but also those provided by outside vendors—which, in this case, was medication delivery. Here, the problem was compounded by the patient’s and caregiver’s failure to fill the initial prescription. By implementing a couple of processes, the hospice may have been able to better address this service issue—as well as other breakdowns—before it became a crisis. Going forward, this hospice should consider taking the following steps:

First, the hospice team must empower the patient and caregiving unit • to partner with the hospice by communicating in a timely manner when there is an unmet need . The importance of communication between the patient and caregiver and the hospice must be stressed during the admission process and at each visit . Clear written and verbal communication by the hospice team regarding when and what the patient and caregiver should anticipate provides a framework for meeting expectations. In this case, the patient and caregiver may have been told that they were to receive the medication at a specified time, however, it may not have been stressed that if this did not occur, they should call hospice immediately. Also, it is imperative to emphasize the importance of immediately filling the prescription they were given at the hospital in order to prevent unnecessary suffering . It is easy for those of us in healthcare to assume that patients and families already know the importance of these things, but that’s often not the case .

Second, many hospice programs have a proactive process for • monitoring and providing for service failures. Having a “tuck in” policy for both new patients and existing patients—especially before and during weekends and holidays—can prevent problems like this from occurring .

Regardless of who is to blame under these circumstances, the focus must remain on having adequate processes in place to prevent the unexpected. Proactive, rather than reactive, processes prevent misadventures.

Phyllis Grauer, RPh, PharmD, CGP, vice president of clinical services for HospiScript Services, LLC, and NCHPP’s pharmacist section leader.

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Allied Therapist Section:

Gaps in service can happen for many reasons . Being able to offer patents and families more options can help bridge some of these gaps . For example, complementary therapy services are gradually making their way into primary and ancillary hospice care—and with good reason. In a case such as this, a referral for massage/bodywork therapy could have made a significant difference.

A massage/bodywork therapist would have been able to provide John with some relief until medication arrived—or until he was psychologically ready to start using it . The therapist would have assessed John’s stress level, respiratory status, and response to treatment targeting pain or dyspnea from tension, and could have facilitated contact with the nurse on call. However, the bodywork session alone could have broken the tension pain cycle. What’s more, the therapist could have conducted brief training with the family members, showing them how to identify nonverbal body cues that indicate pain or anxiety and, more importantly, techniques they could employ to ease John’s discomfort until pharmacological support arrived .

If this hospice program had access to a complementary therapy hospice nurse (CTRN), a referral made for symptom support through bodywork therapy could have also turned into a hospice nursing visit once the CTRN assessed a status change. For example, it is not uncommon for a CTRN to see symptom management from the perspective of fear, stress-related symptoms that increase with patient decline, or worsened symptoms related to disease progression. In this case, a bodywork session could have temporarily eased such symptoms while adding an anti-

anxiety medication in addition to, or instead of, a pain medication, may have better targeted the underlying cause of the symptoms. It’s also important to note that in cases of respiratory distress, it is very difficult to distinguish symptoms of lung disease from increased respiratory distress related to the sympathetic nervous system response to fear. A light-pressure foot reflexology session using a blend of Juniper and lavender essential oils for secretions and relaxation would have probably integrated nicely into John’s plan of care.

Providing purposeful complementary therapy sessions like this can also help convey the hospice commitment to holistic options that many patients and families perceive as compassionate . Family anger, fear, or deep grief can be diffused when given an avenue for expression through the use of complementary therapies . Although bodywork is the therapy of choice for this particular situation due to John’s disease and need for direct symptom relief, other therapies can provide similar support for patients, and help fill important gaps in service (see sidebar below) .

Finding Complementary Therapists

Some hospice programs utilize volunteers who are certified practitioners. In fact, according to a recent survey of Bastyr University, 85 percent of hospices in the state of Washington utilize some form of complementary therapy, most often provided by a volunteer therapist .

Other hospice programs pay for certification of interdisciplinary members who then utilize their certified skills in a dual role—such as a CTRN. Other therapeutic combinations that serve hospice program needs include the pastoral care member

sOMe cOMPleMeNTARy THeRAPies eFFecTive iN HOsPice

Aromatherapy • Art Therapy • Hypnosis • Massage/Bodywork Energy Therapies • Music Therapy • Rehabilitation Therapies

An overview of many of these therapies can be found in “Complementary Therapies in End-of-Life Care,” the beautifully written handbook produced by NCHPP’s Allied Therapist Section . This handbook includes case studies supporting the value of these therapies in hospice, training/certification requirements, and even job descriptions for some therapists. Visit nhpco .org/marketplace (Item 700290; Member Price: $39.99).

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some Helpful Ways to Find Therapists

American Physical Therapy Association: www.apta.org > Find a PT

American Occupational Therapy Association: aota.org > OT JobLink

American Speech-Language-Hearing Association: asha.org > Find a Professional

American Music Therapy Association: musictherapy.org/find.html

American Massage Therapy Association: amtamassage.org/findamassage/locator.htm

American Art Therapy Association: arttherapy.org

complementary

therapy sessions

can help convey the

hospice commitment

to holistic options that

many patients and

families perceive as

compassionate.

who is certified in therapeutic bedside harp and the social worker who has a 40-100 hour reflexology certification.

For information on hiring and training complementary therapists, see the article “Help Wanted: Hospice Therapist” in the September 2007 issue of Insights (nhpco.org/insights). Also, shown below are organizations and helpful links for finding therapists in your area.

Valarie Hartman, RN, CHPN, CTRN, complementary therapy program coordinator for Holy Redeemer Hospice, and NCHPP’s allied therapist section leader.

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Section II

sTRONGeR iN THe bROkeN PlAces:


Service excellence and service recovery go hand in hand in hospice and palliative care . No doubt we’d all prefer to focus on service excellence in the hope that, if we do, we will never

disappoint a patient, family member or referral source. That’s a great hope, and there are some concrete things we can do to reduce the likelihood that a service failure will occur within our organizations. The reality, however, is that part of being a “world class” organization is to prepare to handle service recovery confidently when things go awry.

It is an irony that confidently handling service recovery also creates an opportunity that wasn’t there before the service failure occurred. In his novel, A Farewell to Arms, Ernest Hemingway wrote that the human spirit, like a broken limb, actually grows stronger in the place where it had been broken. The same is true about human relationships, such as the ones we have with our patients and their families . Handling service recovery well actually can make these relationships stronger in the broken places .

broken RelationshipsWe start with the most broken of relationships, by looking at what motivates people to sue a healthcare provider .

In reviewing a large sampling of depositions from malpractice suits, H. Beckman and his associates learned several important lessons. A key lesson was that 71 percent of the patients who sue doctors already had a problematic relationship with the doctor before the incident that became the proverbial “straw that broke the camel’s back.” Believe it or not, there’s good news for us in this statistic. It speaks to a tolerance within the healthcare consumer such that most people won’t jump to a lawsuit with just one mistake . This gives us a chance to recover and regain the confidence of the complainant.

Although we’re talking about an extremely “broken” situation—one in which a patient has made the decision to sue a healthcare provider—the implications are far reaching. We need to create a culture within our organizations in which we seek to identify those patients at risk for service failure and take steps to avoid such service failure whenever possible. While this may seem easier said than done, it is possible! Here are some of the ways to help make this happen .

sTRONGeR iN THe bROkeN PlAces:Doing Service Recovery Well

and Why That Mattersby Malene Davis, MsN, MbA, cHPN

and bob Miller, bA, MDiv

confidently

handling service

recovery creates

an opportunity that

wasn’t there before

the service failure

occurred.

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Be Proactive

How can we proactively identify the patients at risk for service failure? Start with your complaint logs . Those who have had service failures in the past may be more likely to have them in the future, especially if these situations weren’t handled well from the patient’s and family’s perspective . Checking in with these individuals on a regular basis is your single best way to rebuild trust with them .

Don’t stop there, of course. There’s another log in your program that will likely reveal patients at risk for service failure—your on-call logs. Who are your “frequent flyers” after hours and on weekends? Your service to these patients may be superb from a clinical standpoint, but it stands to reason that these are patients and families under stress and feeling out of control. It might not take much to turn those overwhelming feelings into frustration or even hostility toward the provider who disappoints them, even if only by a little.

There are many other places where you can proactively seek out patients at risk for service failure . Listen for the names of patients or caregivers about whom staff complain. Be aware of patients with problematic clinical conditions, such as respiratory distress, bleeding, odious wounds and chronic constipation. Be aware of patients who have had difficulty with other healthcare providers, patients with APS (autoimmune polyendocrine syndrome) or ombudsman referrals in the past, and patients with family issues such as caregiver fatigue, financial conflict or estrangement. Encourage your teams to discuss patients at risk for service failure . Do whatever you can to assure them that everybody in your organization is aware of these patients . Talk about them in your management meetings . Check in with these families frequently.

Other things you might consider to help build trust with all patients, and especially those at risk for service failure, include:

Making a phone call after hours to “tuck in” • newly admitted patients;

Ensuring patients have the contact numbers • for key members of the team, including the manager;

Asking team managers to contact patients • soon after admission to establish a trusting relationship;

Setting up a toll-free “complaint line” so that • family members who live at a distance know

you’re serious about wanting to hear from them if they have a concern;

Finding a way for managers to get out regularly • and meet patients and families, perhaps as part of ride-along supervision of staff;

Assuring that your orientation process lays the • groundwork for effective customer service .

When a Service Failure Occurs

When a service failure does occur, managers will want to ensure that staff members are equipped to interact positively with those who are making the complaint . The most important things managers can do are to (1) lead by example and (2) model a sense of urgency about dealing with service issues and infuse it throughout the organization.

It is critical that every hospice and palliative care organization creates a culture that encourages a positive response to complaints when they happen . This includes responding immediately—and in person if possible—by thanking the person for sharing his or her concern, and equipping those who hear the complaint to take ownership of the resolution process . Taking ownership of the process probably will include apologizing for failing to meet their needs or expectations and agreeing together on a follow-up plan.

You may feel anxious in these situations; that’s natural. It is never easy to face someone who believes that the care you or your organization delivered missed the mark . The good news is that all people are equipped to handle these situations by virtue of one fact: we all have two ears. While it may sound deceptively simple, the most important thing anyone can do is to listen .

Listening is the first step in the complaint resolution process, but it is easier said than done. Staff members sometimes are inclined to treat complaints as ineffective coping and to discount the concern . Even if a patient or family has ineffective coping skills, they have a right to be heard . Every patient has the right to be our most “difficult” patient. After all, we’re caring for them during some of the most vulnerable moments of their lives .

Effective Listening

Going back to the research on lawsuits, a number of studies have shown that physicians who are good listeners and who demonstrate concern, accessibility, and open and honest communication are less likely to be sued .

An interesting study led by Wendy Levinson

every patient has the

right to be our most

“difficult” patient.

After all, we’re caring

for them during

some of the most

vulnerable moments

of their lives.


emphasized the importance of communication. The study analyzed audiotapes of physician office visits and found that physicians with the best communication skills were also the ones who hadn’t been sued. It’s interesting to note that one factor was strongly correlated with reduced malpractice claims—length of office visit. How much longer were the visits of physicians who didn’t get sued? Three minutes .

Can it really be that simple? Lengthen your visits by three minutes and increase your satisfaction scores? Probably not—but those physicians inclined to give patients three extra minutes are most likely to be the ones who are listening more effectively .

Going back to the Beckman study, there were four other factors identified as contributing to a decision to sue a healthcare provider .

1. Feelings of having been deserted Even with the most tender loving care, patients or families can feel deserted. Things that might contribute to this feeling are inadequate discharge planning, delivery issues, no-shows for visits, or lack of staff continuity . Consider this scenario:

The patient was feeling weak, and noted to the social worker, “One time in the past a transfusion helped.” The social worker responded, “I’m very sorry, but we don’t do that in hospice. Hospice is about letting nature run its course without aggressive intervention.”

Where did the social worker get the idea that we don’t do transfusions in hospice? Maybe because the program has a process in place to review and approve unusual treatments, thus causing the social worker to infer—incorrectly—that such treatments were considered inappropriate by the hospice’s administration .

2. Having concerns discounted Staff may not be aware of the subtle ways in which patients or families might get the feeling that their concerns are being discounted . Consider this scenario:

Newsline 28


Shortly after the COPD patient was admitted, she complained that she didn’t feel she was “getting enough air” through the oxygen concentrator. The nurse demonstrated that the concentrator was working by putting the nasal canula in a glass of water. The nurse thought it would be comforting to the patient to see the bubbles and that this would demonstrate that the concentrator was working. The next day, however, the patient called the office to revoke the hospice benefit and go back to her home health provider.

Why did the patient want to go back to her home health provider? Well, she felt she wasn’t getting enough air through the concentrator, and she wasn’t reassured by the nurse’s demonstration .

3. Providing inadequate information Your staff surely strives to provide adequate information to patients and families, yet can overlook the simplest of things that might contribute to a patient feeling informed and cared for. For example, during each visit do they confirm the next scheduled visit? Do they remember to describe clinical alternatives when recommending a course of action? Do they make a tuck-in call after changing medications or adding an item of HME? Consider this scenario:

The day after admission, the husband of a patient expresses some anxiety to the nurse about the choice to come onto hospice. He says, “I want to be able to take my wife to the emergency room when she needs it.” The nurse says that she wants to respect the husband’s wishes, and gets a revocation form signed.

The nurse listened to the husband’s concerns at one level, but failed to delve into ways to address his fears and provide reassurance .

It’s not uncommon for someone to “second guess” such an important decision as hospice election, but there is some critical information that might have helped the husband in this situation. First, he can always make the choice to go to the emergency room—we prefer that he call us rather than calling 911, but he retains the right to call 911. Second, it is natural to expect that he needs some time to build trust with the team—so he feels some assurance that the team will be responsive when he calls . In addition, many hospices have a process in place that tries to get management involved with patients at risk for revocation . Such a procedure might have helped address his concerns and, at the same time, might have helped mobilize other team resources to provide more reassurance .

4. Not understanding the patient’s perspective People in hospice and palliative care are among the most compassionate in the world . Yet there are times when even these most compassionate individuals fail to look at things from the patient’s perspective . Consider this scenario:

The nurse calls the pharmacy to order a refill of lasix at 2 p.m. She doesn’t tell the pharmacist that the patient has a two-day supply remaining. The medications are delivered at 11 p.m., after the family has gone to bed.

Just one small direction—“It’s okay to deliver this tomorrow”—could have prevented this inconvenience or upset to the family. The nurse, of course, would have to look at things from the perspective of the patient and family in order to give that one small direction—she would have had to know the delivery patterns of the pharmacy and the preferences of the family .

The authors

presented an audio

web seminar on this

topic. To purchase the

cD, see page 54.

Newsline 29

Forensic UR/QAHandling individual cases as outlined here is critical. It’s equally critical that we monitor these situations for trends. With each case, ask yourself whether this is an isolated incident, or whether there is a process within the organization that needs to be improved. Is there some coaching that should be done with an individual or the entire staff? Build in a feedback mechanism so that managers and staff are learning from service failures . And encourage staff to identify times when service wasn’t up to “world class” standards.

It’s also a good idea to involve the referral source or the attending physician and share your plan of correction with him or her—better that this individual hear about the situation from you than from the patient or family! You also may need to rebuild the trust of the referral source or attending physician . Focus on how you plan to prevent recurrence in this case, and of similar situations in the future.

Trending of service comments ought to be a part of your normal quality assurance process. For example, are you seeing more complaints regarding pharmacy? How does this compare to your family satisfaction survey questions related to pharmacy? Maybe these are indicators that this is an area ready for a performance improvement project? Don’t isolate this review to your quarterly quality assurance meeting—regularly talk about these situations in your management meetings so that you can assure appropriate follow-up and get on top of trends as quickly as possible.

your legacyHospice in this country has grown over the last three decades—from caring for a handful of patients to more than 1.3 million patients each year. That growth has resulted, in large part, from positive word-of-mouth advertising .

When one family has a good hospice experience (and the vast majority of hospice experiences indeed are good or even great), that family tells others, often lending a reassuring voice to another family about to embark on its own end-of-life journey. So when one hospice does well—every hospice benefits from the good will and positive word of mouth generated . And when one hospice does not handle service recovery well—every hospice suffers a ding to its reputation and its prospects for continued growth and success .

continued on next page

Newsline 30

That means we not only help our own patients and their families when we do service recovery well, but also help a hospice or palliative care organization on the other side of the state or one across the continent. You never know who might benefit a month or a year from now by your commitment today to service excellence .

stronger in the broken PlacesThe challenge before us is to do everything we can to anticipate and avoid service issues for our patients and families—like the very ones presented in this issue of Insights . The suggestions noted here can help you feel more confident in your ability to do so, and more confident in your ability to “do” service recovery well .

We can become stronger in these broken places, stronger because we’ve welcomed service comments and handled them well, and stronger because we’ve invested ourselves in identifying ways to improve our service .

Malene Davis is president/CEO of Capital Hospice (Falls Church, VA) and serves as chair of NHPCO’s board of directors.

Bob Miller is senior vice president for VITAS Innovative Hospice Care® (Miami, FL) and is the immediate past-chair of the National Council of Hospice and Palliative Professionals.

References:

Beckman H et al. 1994. The doctor-patient relationship and malpractice . Lessons from plaintiff depositions . Archives of Internal Medicine 154:1365-70.

Engel, Beverly. The Power of Apology. New York, New York: John Wiley & Sons, Inc., 2001.

Gallagher et al. 2003. Patients’ and Physicians’ attitudes Regarding the Disclosure of Medical Errors . JAMA 289:1001-1007.

Levinson, W. et al. 1997. Physician-Patient Communication . The Relationship with Malpractice Claims Among Primary Care Physicians and Surgeons . JAMA 277(7): 553-559.

Woods, Michael S. Healing Words. Oak Park, IL. Doctors In Touch. 2004.


Newsline 31

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Newsline 32

Are you a member of NCHPP? While we are now 20,000-members

strong, many people are still unfamiliar with NCHPP . The National Council of Hospice and Palliative Professionals is the individual membership within NHPCO which is open to staff and volunteers. When a provider (hospice or palliative

care) organization joins NHPCO, all of its staff and volunteers can join NCHPP free of charge—and benefit from a range of resources, education, and networking opportunities to help them in both their professional and personal development .

NCHPP is NHPCO’s interdisciplinary-focused forum. It is comprised of 15 discipline-specific sections—from Allied Therapists and Bereavement Professionals to Social Workers and Volunteers/Volunteer Managers. Members of these sections strive to model and enhance interdisciplinary end-of-life care by lending their expertise to a variety of projects both within and across disciplines. For example, last year the Social Work Section published newly revised Guidelines for

Social Workers. The Development/PR/Marketing Section has launched a mentoring program to help support colleagues new to hospice . The Allied Therapist Section holds regular online chats to share information on the complementary therapies found to be effective at the end of life . All of the NCHPP sections collaborated on NHPCO’s Inclusion and Access Toolbox to help organizations increase access to care. And the list of benefits goes on.

Based on my personal experience, NCHPP membership has been invaluable . This year marks my first term as chair, but I have been an active member for many years—including six years as section leader for NCHPP’s Performance Improvement/Quality Assurance Section. Today, given the increasingly rigorous standards and regulations to which we all must adhere, I urge you—and your fellow staff and volunteers—to join . We have included the enrollment form on page 34 of this issue .

Sincerely,

Shareefah Sabur, MA, MNO, CDP

A Message from NcHPP’s chair

Direct benefits to staffDiscipline-Specific Benefits

When staff and volunteers join NCHPP, they are asked to sign up for one or two of NCHPP’s 15 professional sections—depending on their field and function:

Allied Therapist Bereavement Professional Certified Nursing Assistant CEO/Executive Director Clinical & Operations Management Development/Public Relations/Marketing Finance/Information Systems Nurse Performance Improvement/QA Pharmacist Physician Research/Academics/Education Spiritual Caregiver Social Worker Volunteer/Volunteer Management

Each professional section has a Section Leader and Steering Committee which, together, guide the work done on behalf of the discipline . Each section also has its own listserve and many hold regular online chats . These forums provide a perfect way for all staff and volunteers to network, share ideas, and develop their skills.

Education and Training Benefits

NCHPP members have full access to the NHPCO Web site—including the resources available through Quality Partners, InfoCenter, and NHPCO’s new Regulatory and Compliance Center. They also receive discounts on NHPCO’s educational offerings, including the newly launched distance learning program, End-of-Life OnLine. In addition, they have online access to NHPCO’s publications—NewsBriefs, NewsLine, Insights, and eNCHPP .

For details, visit nhpco .org > Professional Resources > NCHPP Home .

To join NCHPP, see page 34.

Joining NCHPP

Newsline 33

broader benefits to Advance the FieldPart of NCHPP’s broader mission is to enhance the integrity of the hospice and palliative care interdisciplinary team by providing recognition, leadership opportunities, and mutual support for professionals. Toward this end, NCHPP sponsors several awards which spotlight the exemplary contributions of individuals and organizations:

Heart of Hospice Award

This award recognizes NCHPP members who have attained repeated outstanding achievements in hospice—and made contributions with impact beyond hospice . They have shown creativity and courage to achieve a demonstrated difference in the areas of exceptional service, program creation, administrative development, innovative research, or educational advancement .

Volunteers are the Foundation of Hospice Award

This award, which is co-sponsored by the National Hospice Foundation, recognizes hospice volunteers who best reflect the universal concept of volunteerism in its truest sense—serving as inspiration to others .

Excellence in Teamwork Award

This award recognizes teamwork that makes a significant, innovative, and extraordinary contribution to hospice . The team’s contribution should be significant, in that it makes a major contribution to the community, patients and families, the organization, or a hospice at large; innovative, in that it is unique, creative, and inspirational; and extraordinary, in that the level of accomplishment far exceeds ordinary standards of excellence .

Awards of Excellence in Education

NCHPP sponsors three awards under this category. These awards recognize programs for outstanding achievement in the design, promotion and offering of educational programs: (1) for patients and families; (2) for staff and/or volunteers; and (3) to increase access.

Awards are presented each year at NHPCO’s national conferences . See page 44 for the 2008 honorees recognized at this year’s MLC, held April 10-12 in Washington DC .

NCHPP depends on members

in the field to nominate their

colleagues for these special

honors. Calls for nomination

are announced in NHPCO’s

e-newsletter, NewsBriefs, as

well as on the Breaking News

Section of the NHPCO Web

site (nhpco.org). For more

information, visit nhpco.org/

awards or contact NHPCO’s

Scott Vickers (svickers@

nhpco.org).

National Council of Hospice and Palliative Professionals

Become an

eNCHPP MemberIt’s easy to join. And it’s free!

What is eNCHPP?It is a complimentary membership in the National Council of Hospice and Palliative Professionals, the segment of NHPCO membership comprised of individual staff and volunteers.

Who is eligible for this free membership?You can join at no charge if you are an employee or volunteer of an organization which is currently an NHPCO member.

What benefits will I receive?A range of benefits are offered that can help you do your job better:

Full access to the NHPCO Web site, including the latest regulatory and 1. compliance updates.

The quarterly online newsletter, 2. eNCHPP, produced by the National Council of Hospice and Palliative Professionals.

NHPCO’s weekly e-newsletter, 3. NewsBriefs.

Online access to NHPCO’s membership magazines, 4. NewsLine and Insights.

The opportunity to enroll in any of NCHPP’s discipline-specific listserves — 5. a great way to share ideas and network with colleagues.

Discounts on NHPCO conference and educational offerings as well as items 6. in NHPCO’s Marketplace.

Plus—online access to the resources in NHPCO’s Quality Partners program 7. to help you prepare for compliance with the new hospice CoPs.

How do I enroll?Complete the form on the opposite page.1.

Return the form to NHPCO:2. • ByMail:NHPCO,P.O.Box34929,Alexandria,VA22334-0929 or • ByFax:703/837-1233

Upon receipt, NHPCO will send you confirmation of your eNCHPP membership, which will include your personal login ID number and your password. With this information, you have full access to eNCHPP benefits!

Questions?call

800/646-6460

Detach and Distribute to Your Staff & Volunteers–PutinStaffMailboxesor

Include With Their Paychecks

Your Name _______________________________________________________Degrees ____________________ Title ________________________________

Hospice/Company __________________________________________________________________________________________________________________ Be sure to provide your employer’s complete name for membership verification.

Email Address ___________________________________________________ @_________________________________________________________________ Please provide the email address where you would like to receive membership materials.

Work Phone ______________________________________________WorkFax_________________________________________________________________

Work Address _________________________________________________ City____________________________State _________ Zip ___________________

Home Address ________________________________________________ City____________________________State _________ Zip ___________________

Home Phone ( ) ____________________________________________________________________

I am an employee: ❏ Full-Time ❏ Part-Time I am a volunteer: ❏ Full-Time ❏ Part-Time

Please indicate your preferred NCHPP Membership Section: Please check the two disciplines that you are interested in joining. Indicate primary and secondary by marking “1” and “2” after your choices.

❏ Allied Therapist ❏ Development/PublicRelations/Marketing ❏ Physician

❏ BereavementProfessional ❏ Finance/InformationSystems ❏ Research/Academics/Education

❏ CEO/ExecutiveDirector ❏ Nurse ❏ Social Worker

❏ Certified Nursing Assistant ❏ PerformanceImprovement/QualityAssurance ❏ Spiritual Caregiver

❏ Clinical & Operations Management ❏ Pharmacist ❏ Volunteer/VolunteerManagement

I agree to receive fax communications from NHPCO to the fax number listed above. Sign below:

X ___________________________________________________________________________________ Iunderstandthatwithoutmypermission,NHPCOwillnotbeabletosendmeanynotificationsviafax.

❏ Please do not list my name in the NCHPP Membership Directory. ❏ Please do not release my name to hospice-oriented vendors and educators.

NHPCO does not sell, rent or distribute your email address to any outside organization.

Please Return:

By Mail: NHPCO, P.O. Box 34929, Alexandria, VA 22334-0929 • Or Fax: 703/837-1233

I certify that I am an employee or volunteer with a NHPCO Provider member ingood standing. I amcommitted to thehospice and/or palliative care mission, vision and standards and programs of care. I understand that my e-membership is dependent upon my company remaining a dues-paying Provider member of NHPCO.

Should I no longer work or volunteer for the following program, I agree to contact NHPCO immediately. I understand it is my responsibility to update NHPCO of my current email address in order to receive benefits.

eNCHPP Membership Dues: FREE to employees and volunteers of current Provider members

Questions?call

800/646-6460

eNCHPPMembership Application

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Newsline 36

Newsline 37

June 2008

chronic kidney Disease:


challenging Hospices to Assure Accessby larry beresford

To Jane Duncan, hospice was a godsend. When she enrolled with Hospice Care Corporation (Arthurdale, WV), Duncan had been on three-times-a-week dialysis treatment for six years, following

a long struggle with complications from diabetes and heart disease that included the amputation of one leg . She was interviewed in her kitchen in 2006, as neighbors and friends dropped by for visits.

“For dialysis patients, hospice is the last best hope. It helps with the sores you get from head to toe, but the most important thing is the focus on you as a person,” she said. “They’re always so positive and uplifting.” But Duncan was apprehensive at first. “My thought of hospice was death. I found out differently. It’s so much more than that.”

Newsline 38


“There will be an end to dialysis,” Duncan said, noting that she had seen many of her peers on dialysis die, a few of them in their chair at the dialysis center. “But in the meantime, why shouldn’t we have the support that hospice offers? I would hate to think that we couldn’t get the same kind of spiritual and medical support, and the knowledge that our families will be comforted after we die.”

Duncan died in her daughter’s home a few months after the interview. For Malene Davis, then CEO of Hospice Care Corporation, her story epitomizes the challenge facing American hospices in serving patients with chronic kidney disease (commonly referred to as end-stage renal disease or ESRD). Today’s hospices must find ways to admit eligible patients with CKD, including those still receiving treatments at a Medicare-certified dialysis center and, in some cases, to pay for the dialysis. “Jane said to us, ‘Wait a minute, don’t I deserve hospice care, too?’”

Davis, now CEO of Capital Hospice (based in Falls Church, VA), has been a champion of the rights of eligible, terminally ill patients with CKD to receive access to hospice care . She chairs the hospice work group of the national Kidney End-of-Life Coalition,1 an organization that promotes dialogue about end-of-life care among dialysis centers, nephrologists, hospices and other health professionals .

While in West Virginia, Davis worked closely with Dr. Alvin (Woody) Moss. Moss, who is a nephrologist at the West Virginia University School of Medicine in Morgantown . chaired the ESRD Work Group convened by the Robert Wood Johnson Foundation’s project, Promoting

Excellence in End-of-Life Care. “Woody understands the nuances of CKD, and has studied the barriers,” Davis says. “He showed me the data and helped me to understand that there was a large population of patients who sorely needed hospice care and weren’t getting it.”

Nearly 100,000 dialysis patients die every year, and only about 15 percent of them receive hospice care. An estimated 20 million Americans have kidney disease . Most of them never even begin dialysis; many will die first from complications of the disease or co-morbidities. For patients on dialysis at the time of their death, only 3 percent receive hospice and for those who choose to stop dialysis, only 42 percent use hospice, even though 96 percent of them will be dead within a month .

However, if hospices are not establishing collaborative dialogues with the dialysis centers in their communities, it will be harder to bring up hospice as a care option when patients decide to stop dialysis. Twenty-five percent of patients who stop dialysis and get referred to hospice care, refuse the service, “which lets you know that there is a need for education,” Moss notes. However, this picture is gradually improving .2

“Hospices have a lot to offer to kidney patients,” he says. “They are familiar with advance directives and bereavement issues and could do in-services for dialysis center staff . They also understand pain management, and pain is a significant—and undertreated—symptom for dialysis patients.” Hospices can help nephrologists with their most difficult cases; however, first they need to demonstrate that they can be helpful .

Newsline 39

Nearly 100,000

dialysis patients

die every year,

and only about

15 percent of them

receive hospice

care.


Other Hospices confront ckDFor Hospice of Hope (Maysville, KY), it was an NHPCO educational session that inspired Pam Tribby, director of admissions, to reach out to the dialysis centers in her hospice’s service area . Her goal was to encourage hospice referrals of eligible patients and explore a possible contract for dialysis services for hospice patients. In the past, referrals were made when patients decided to stop the treatment and these referrals were rare, perhaps due to uneasiness by dialysis center staff. The hospice also cared for patients continuing to receive dialysis unrelated to their admitting diagnosis, although without a lot of collaboration between the two providers around the dialysis treatments .

Conversations regarding mutual education, advance care planning and a hospice contract proceeded very slowly, Tribby says. Because the hospice was establishing a home-based palliative care service in the spring of 2007, offering palliative care consultations to help with symptom management for patients receiving dialysis seemed a feasible interim step .

But obtaining privileges from the dialysis centers for Kathy Egan, the hospice program’s palliative care nurse practitioner, took months. Now Egan has privileges to provide consultations in two local dialysis centers, billing Medicare Part B for this service. The palliative care consultations require a physician’s consent and are most often ordered for pain management. “It’s a small program,” Egan says. “We’re taking baby steps. I went to meet with the centers wearing a new hat—explaining that I’m employed by hospice but providing palliative care consultations.”

Managing the complex casesHospice of Dayton, a community-based provider in Ohio with a census of approximately 600 patients, approaches these questions on a case-by-case basis. The goal is to assure access, regardless of diagnosis, for patients who are certified as terminally ill, who want hospice, and who live within the agency’s service area, says CEO Deborah Dailey.

If appropriate management of these patients includes dialysis, Dailey notes, we’re going to pay for it under a contract with a local dialysis center, detailing the medical management and payment mechanism. Dialysis is not inexpensive, Dailey adds, “and it is not a cheery thing for the patient to go through.” It requires discussion with the patient and physician regarding goals of care .

The other approach used by Hospice of Dayton is to follow

Newsline 40


hospice patients on dialysis with “complex care review,” along with other high-risk patients, those receiving chemotherapy, coumadin or dobutamine, or those with complex psychosocial needs . Complex patients are seen more frequently by the hospice’s medical directors

and advanced practice nurses (APNs), receiving special review every two weeks in recognition of the fact that they fall outside of the norm of hospice patients .

“We want to make sure they’re getting what they need,” Dailey explains. “What is their quality of life? Is the treatment helping or causing pain? Are we doing what is necessary to alleviate suffering caused by the treatment? What are the desired outcomes, and are we achieving them? And is this still what the patient wants?”

Hospice of Dayton emphasizes disease management, outcomes-based care, and the demonstration of clinical competencies by staff. It employs a focused care team of APNs and other specialists to provide education and consultation to clinical staff on complex cases .

“The bottom line: in order to effectively care for complex patients, we need to have specialized resources,” Dailey says. “It’s like pediatrics. If you don’t do enough of it, it’s hard to keep your skills up.”

Larry Beresford is a freelance writer who has authored numerous articles on end-of-life care.

References:

1 See www .kidneyeol .org for information on this group and a variety of professional resources .

2 Moss AH . Personal communication . ESRD Network #1 Study, submitted for publication.

NHPCO Targets Access and Quality of Care

for CKDChronic Kidney Disease (often referred to as End Stage Renal Disease) is the next non-cancer diagnosis being addressed by NHPCO as part of its Inclusion and Access initiative . The goal of this initiative is to de-velop resources, tools and recommenda-tions that encourage hospices to increase access for eligible patients in a high-quality manner .

Dr. Alvin Moss, a nephrologist at the West Virginia University School of Medicine, and other researchers are currently at work on better prognostic criteria for CKD. NHPCO, in turn, is in dialog with the fiscal inter-mediaries of the Centers for Medicare and Medicaid Services to clarify hospice eligi-bility criteria for this population .

While this work is an important step toward increasing access for CKD patients, it is but one step. Malene Davis, CEO of Capital Hos-pice (based in Falls Church, VA) and chair of NHPCO’s board of directors, frequently presents at educational programs spon-sored by regional networks of dialysis cen-ters. “I tell them, if your local hospice isn’t calling you, you should be calling them,” she says. “Everywhere I’ve gone, people have said to me, ‘Oh my gosh, we’re doing this wrong. We’ve got to get the message out that hospices can care for these pa-tients.” But, according to Davis, it isn’t easy because there isn’t a single solution to the needs of CKD patients . Hospices will need to examine their philosophy of care and ad-mission practices, and reconcile those with the eligibility criteria promulgated by their regional fiscal intermediary.

Check in regularly at nhpco.org/access to view the ever-expanding list of resources for non-cancer diagnoses. Materials on CKD should be posted later this summer .

Given the challenges the hospice and palliative care community are facing this year, NHPCO and its lobbying affiliate, The Alliance for Care at the End of Life, have launched a Legislative Action Center—with a sophisticated and powerful web-based tool to help members make their voices heard on Capitol Hill .

Sending a Letter to Your Elected Officials is Easy

With this new tool, your staff, volunteers and friends—as well as patients and family members— can send personalized, targeted letters to members of Congress in a matter of minutes . They can build their letter online, by selecting from prepared comments, and send it to their local elected officials with the click of a mouse.

Joining the Action Network Keeps You in the Loop

Members can also join the NHPCO Action Network to keep up to date on those issues affecting the field that require help at the local level.

Visit the new Center today: capwiz.com/nhpco/home:

Newsline 41

short Takes

A New legislative Action center for Members

using this tool,

nearly 6,000

members have now

urged their members

of congress to

oppose the proposed

Hospice Medicare

benefit rate cuts.

Join the effort today.

Cheryl Arenella, David Casarett, Sarah Friebert, and Howard Tuch have joined NHPCO as consulting medical directors. Each will provide specialized expertise on a range of projects relating to quality, regulatory/compliance, palliative care, pediatrics, and public policy:

cheryl Arenella, MD, MPHDr . Arenella received her medical degree from Georgetown University School of Medicine and her master’s degree in public health from George Washington University. She is board certified in family medicine, geriatrics and hospice and palliative medicine, and

served as a trustee of the American Board of Hospice and Palliative Medicine (1996-2004), where she was instrumental in developing a certifying examination and maintenance of certification program. Currently, Arenella works as a contracted cancer education program specialist in the Office of Communication and Education of the National Cancer Institute. She is also a health consultant for hospice and palliative care programs in the areas of compliance, quality and medical staff development . Arenella currently serves on NHPCO’s Quality and Standards Committee . She retired from Capital Hospice in 2005 after 25 years of service as medical director.

David casarett, MDDr . Casarett is associate professor of medicine at the University of Pennsylvania, director of research for Wissahickon Hospice, and a staff physician at the Philadelphia VA Medical Center. He is board certified in palliative medicine and a fellow of the

American Academy of Hospice and Palliative Medicine. Casarett’s research on decision-making and quality of care near the end of life has won numerous awards, including the Outstanding Clinical Investigator Award, presented by the American Geriatrics Society, and the Presidential Early Career Award for Scientists and Engineers, presented by the White House.

sarah Friebert, MDDr . Friebert received her medical training at Case Western Reserve University School of Medicine . She completed her residency in pediatrics at the Children’s Hospital of Philadelphia, and her fellowship in pediatric hematology/oncology at Rainbow

Babies and Children’s Hospital in Cleveland, Ohio. She is board certified in pediatrics, pediatric hematology/oncology, and hospice and palliative medicine. Currently, Friebert directs the Haslinger Family Pediatric Palliative Care Division of Akron Children’s Hospital Medical Center, which she established in July 2002. She also serves as consulting pediatric medical director to Hospice of the Western Reserve, and is an associate professor in pediatrics at Northeast Ohio University College of Medicine .

Howard Tuch, MD, cMDDr . Tuch received his medical training as an internist and geriatrician at the University of North Carolina and the Johns Hopkins School of Medicine . He is board certified in internal medicine, geriatric medicine, and hospice and palliative medicine, and has worked as a hospice

physician since 1992. In 2006, he was awarded a Robert Wood Johnson Health Policy Fellowship and worked as a policy advisor on the Senate Finance Committee and the House Committee on Ways and Means. Currently, he is employed by The Hospice of Florida Suncoast, where he continues his work on several state and national health policy matters related to hospice care . He also serves on the Public Policy committees of NHPCO and the American Academy of Hospice and Palliative Medicine .

Newsline 42

leading Medical Professionals lend expertise to NHPcO

Newsline 43

The Circle of Life Awards are presented annually to celebrate innovation in palliative and end-of-life care. In 2009, up to three organizations will be honored with this prestigious award for their work to improve care to patients, while other organizations may also be recognized with Citations of Honor .

All organizations or groups in the United States that provide palliative and/or end-of-life care are eligible, including but not restricted to hospitals and healthcare systems. The organization being nominated should have been in existence for at least three years .

To nominate an organization (either your own or another), visit the Web site of the American Hospital Association, (aha .org > News Center > Awards and Recognition). If you have questions, contact the American Hospital Association Office of the Secretary at 312/422-2704 or email [email protected].

The application is also posted on the AHA Web site, and the deadline for submission is August 8, 2008. The awards and citations will be presented at the American Hospital Association Health Forum Summit, July 23-25, 2009, in San Francisco.

The Circle of Life Awards are funded in part by a grant from the Archstone Foundation. Major sponsors of the awards are the American Hospital Association, the American Association of Homes and Services for the Aging, Catholic Health Association, NHPCO, and the National Hospice Foundation. The American Academy of Hospice and Palliative Medicine is a Circle of Life cosponsor.

circle of life Awards: call for Nominations

Correction:In the Short Take, “Portraits of HOPE: Educating Through Pictures” (NewsLine, 4/08), the wrong photograph was featured. The photograph shown was actually from the traveling exhibit, “Portraits of Healing: Celebrating the Gift of Hospice,” developed by Providence Hospice of Seattle. Our apologies for the error .

leaders in Hospice and Palliative care Honored at Mlc

Newsline 44

During NHPCO’s 23nd annual Management and Leadership Conference in Washington, DC this past April, nine individuals and organizations were honored for their contributions to the field.

Becky McDonald (right), with NHPCO’s board chair, Malene

Davis.

Karen York (center) with Don Schumacher and NCHPP’s vice

chair, Kathleen Roble.

Heart of Hospice AwardThis award was created on behalf of NHPCO’s professional member division, the National Council of Hospice and Palliative Professionals, to acknowledge those people who have attained repeated outstanding achievements in hospice . This year’s honorees were:

Senior Executive Category: Becky McDonald, RN Executive Vice President The Hospice of the Florida Suncoast Clearwater, FL

Management Category: Karen York, MA, CPMSM, CPHQ Executive Vice President of Organizational Excellence and Mission Alive Hospice, Nashville, TN

Founders AwardThis award honors individuals and/or organizations of national or international stature which have demonstrated a pioneering spirit in opening the frontiers of hospice and palliative care . This year’s honorees were:

Tom Koutsoumpas Corporate Vice President of Federal Affairs UnitedHealth Group, Washington, DC

African Palliative Care Association (APCA) Kampala, Uganda

Tom Koutsoumpas (left) with Don Schumacher, president/

CEO of NHPCO.

Faith Mwangi-Powell, executive director of APCA,

with Don Schumacher.

volunteers are the Foundation of Hospice AwardThis award recognizes hospice volunteers who best reflect the universal concept of volunteerism in its truest sense—serving as an inspiration to others. This year’s honorees were recognized for their demonstrated strength in fundraising, board, and administrative support:

Sam and Joyce Goldenberg Volunteers/supporters of Covenant Hospice Pensacola, FL

Newsline 45

excellence in education AwardThis award, also presented on behalf of NCHPP, recognizes programs for outstanding achievement in the design, promotion and offering of educational programs. This year’s honorees were recognized for achievements under two categories:

Educational Program for Staff and Volunteers: Covenant Hospice (Pensacola, FL) for its “Leadership Development Institute”

Educational Program for Patients and Families: The Hospice of the Florida Suncoast (Clearwater, FL) for its “A Plan for Life: Your Personal Journal and Resource Guide”

Amy Bajjaly from Covenant Hospice (center) with Malene Davis and Kathleen Roble.

Louise Cleary (left) and Judy Crown (right) from The Hospice of the Florida Suncoast

with Malene Davis.

Public Policy AwardNHPCO presents this award to a federal or state legislator or government employee who has made a noteworthy contribution to the advancement of appropriate end-of-life care . This year’s award was presented posthumously to Bonnie Brown, a long-time supporter of hospice and palliative care throughout her tenure on Capitol Hill:

Bonnie Brown Legislative assistant to former Congressman Bill Gradison (R-Ohio)

Daughters Debbie Bruegge and Beckie Toney, accepting the award on behalf of Bonnie

Brown from Jay Mahoney, former president/CEO of NHPCO (then NHO)

Are There Colleagues

Who You Believe Deserve

Recognition?

Calls for nominations are

announced in NHPCO’s

e-newsletter, NewsBriefs,

as well as on the Breaking

News Section of the NHPCO

Web site (nhpco.org). For

more information, visit

nhpco.org/awards or contact

NHPCO’s Scott Vickers

([email protected]).

Newsline 46

The National Consensus Project for Quality Palliative Care (NCP) has established the NCP Quality in Palliative Care Award. The award is designed to recognize organizations which perform superior work incorporating the NCP’s Clinical Practice Guidelines for Quality Palliative Care and the National Quality Forum’s Preferred Practices into their palliative care services .

Up to eight NCP Quality in Palliative Care Award winners will be selected next fall—with the winners announced on October 1. All organizations or

groups in the United States that provide palliative care are eligible for the award, including (but not restricted to) hospices, hospitals, long-term care facilities, and other healthcare providers.

Additional information regarding criteria, application materials, and related information can be found on the NCP Web site (nationalconsensusproject.org/Awards.asp) or by calling Ken Zuroski, project coordinator, at 412/787-1002. Applications are due by September 1, 2008.

inaugural NcP Palliative care Award: Applications Due by september 1

Hospice Medical Director

Hospital employed Medical Director position with brand new 30-bed inpatient Hospice House in desirable 400,000 multi university South Carolina metro area associated with growing 319-bed health system.Palliative care experience.

$180K salary, bonus and benefits.

P: 800-831-5475F: 314-984-8246Email: [email protected]

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Thank YouNHPCO extends special thanks to the following

organizations for their educational grant to the 23rd

Management and Leadership Conference, held in

Washington, DC during April 2008:

Hospice Pharmacia

Hospice and Community Care Insurance Services

VITASInnovativeHospiceCare®

Misys

Odyssey Healthcare

VistaCare

Goodway Graphics

For a closer look at NHPCO’s upcoming conferences,

visit nhpco.org/conferences.

Newsline 47

People and Places

NHPCP Honors End-of-Life Professionals The Nebraska Hospice and Palliative Care Partnership honored several end-of-life professionals at its annual banquet this past spring. Aloha Schmid from Hospice of Tabitha-York received the state association’s highest honor, the State Impact Award, for her contributions to the work of NHPCP and end-of-life care over the last year .

In addition: Carol Schroeder of Valley County Hospice and Lisa Weber-Kohler of Hospice of Columbus Community Hospital received the Shining Star Award for their work in raising awareness of end-of-life issues; Kelly Keller of AseraCare Hospice-Omaha and the team at Saint Elizabeth Hospice and Palliative Care in Lincoln received the Spirit of Hospice Award for their dedication to the hospice philosophy of care; and 23 hospice volunteers, from programs throughout Nebraska, were recognized as Outstanding Nebraska Hospice Volunteers.

Saint Elizabeth Team

AlohaSchmid

Lisa Weber-Kohler

Carol Schroeder

KellyKeller

Newsline 48

community Hospice employee Named social Worker of the yearRoxanne Clemens, LCSW, bereavement and community grief manager for Community Hospice of Northeast Florida (Jacksonville), was named Social Worker of the Year by the Northeast Florida Unit of the National Association of Social Workers. Clemens joined Community Hospice in 2002. In her current role, she oversees the daily operations of the program’s bereavement department, supervising a team of nine employees .

center For Hope Opens New Residential Facility

The Center For Hope Hospice & Palliative Care (based in Scotch Plains, NJ) celebrated the opening of Peggy Coloney’s House at Hope Village, during a ribbon-cutting ceremony held earlier this year. The new 30-bed facility was named in memory of Peggy Coloney, RN, who co-founded The Center of Hope in the 1970s. Construction of the facility cost $11.2 million dollars and was completed in just less than two years. It includes 30 patient rooms, 3 guest rooms, a library, a children’s playroom, sun rooms, sun porches, a chapel, dining facilities, and numerous common space lounges .

Delaware Hospice Patient’s Dream comes True

While we all strive to educate the public about hospice care’s emphasis on quality of life, having control and honoring the patient’s choices, Brett Santangelo demonstrated these messages with one giant step from a plane at 14,000 feet. The 42

year-old Delaware Hospice patient loved skydiving, wanted to do it again, and Delaware Hospice supported him all the way .

An experienced skydiver himself, Delaware Hospice nurse, Todd Karrick, noticed a photo of Brett skydiving, and the two of them started discussing their mutual interest. Brett told Todd that he had always wanted to jump again, and Todd said, “Why not?” Three months later, Brett’s dream came true and his story captured local media attention. In an article published by the Cape Gazette, Brett said, “I’m so grateful to Delaware Hospice people for making this possible and for all that they do… . They give me the help I need.” Pictured above: Brett and his mother on the morning of the big day .

Does your program have similar stories that have gotten local press? NHPCO’s weekly e-newsletter, NewsBriefs, features clips of interest. Send your news to [email protected] .

Runners can designate

one-half of their dollars

raised to a local hospice

of choice. If your hospice

would like to recruit

runners and participate,

call vice president,

Pam Bouchard, at

703/837-3157.

Newsline 49

Run to Remember®: Advancing Hospice care One step at a Time

Run to Remember® is the National Hospice Foundation’s marathon training and fundraising program that is dedicated to advancing the cause of hospice care—at both the national and local-community levels.

The program helps train and support runners and walkers who are preparing for a marathon or half-marathon. In turn, the runners and walkers dedicate their run to a loved one while collecting pledges for the National Hospice Foundation and a local hospice program of their choice .

What Participants Receive:

The honor of dedicating their training and efforts to the memory of • loved ones .

The personal satisfaction of training for and completing a distance race .•

The opportunity to support hospice care .•

What the Program Provides:

Training Support: Run to Remember• ® provides details on all aspects of preparation for a distance event—from treatment of common injuries and the elements of proper nutrition to training schedules for increased endurance and contact with other trainers .

Online Fundraising Resources: Powered by Active Giving, the Run • to Remember® Web site allows participants to customize their own fundraising page . They can then email the link to family and friends around the country to collect support and raise awareness .

A Run to Remember• ® Jersey: The program provides participants with a special shirt for race day, with space to designate the name of their loved one .

This is a perfect opportunity to challenge yourself, have an experience of a lifetime, and raise vital dollars for hospice. To learn more, visit runtoremember .org .

Above: Run to Remember® founder, Stuart Lazarus (kneeling, center), with one of several teams that ran the Columbus Marathon in 2007—raising more than $30,000.

Master of CeremoniesBob Schieffer

HonoreesGlobal Vision AwardMary Fisher

Artist, Author and InternationalChampion for Hospice andPalliative Care in Sub-SaharanAfrica

Humanitarian Leadership AwardMelissa Gilbert

Actor, Advocate and President,Board of Directors, Children’sHospice and Palliative CareCoalition

CBS News Chief Washington Correspondent and Moderator, Face the Nation

Buchwald Spirit Award for Public AwarenessSteve Stockman

Producer, Writer/DirectorTwo Weeks

Julianne Nicholson

Actor, Two Weeks

Special GuestBishop Kevin Dowling

Director of the TapologoHospice and HIV/AIDSProgramme, South Africa

Gala Director

Official HotelOfficial Airline

David and Sandra Lee

Gala Stars

Thank you to the lead supporters of the 2008 National Hospice Foundation Gala

It was a

Fabulous Affair

Friday, April 11, 2008 • Omni Shoreham Hotel • Washington, DC

1.2vertical.qxk 4/22/08 1:38 PM Page 1

THE SOURCE of local market data for home health agencies

and hospices

Know your Market . . .

. . . Surpass your Competition!

HealthcareMarketResources

Growing Bottom Lines with Information

www.HealthMR.com 215-657-7373 [email protected]

Healthcare Market Resources,INC. A

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HOSPICE PHYSICIANS NEEDED Hospice of Chattanooga, Inc.(c) is currently seeking medically licensed physicians (preferably in internal medicine). Today we are the oldest, largest and only non-profit hospice in the area. We are also accredited by the Community Health Accreditation Program (CHAP). We employ over 250 employees. We desire physicians interested in full-time employment but would consider part-time work as well. Physicians are assigned to an interdisciplinary clinical team that consists of nurses, social workers, nurse aides, a chaplain, a bereavement counselor and a nurse manager that serves hospice care to patients in a particular geographical area. Our physicians meet weekly with the interdisciplinary teams and make home or nursing home visits to the patients. The physicians are responsive and available to the nurses who may call them throughout the day regarding patient care. We provide office space, lap top, cell phone, company benefit package, clerical support, and working hours are Monday - Friday from 8:00 a.m. to 5:00 p.m. with all MD’s on a rotation for weekend call, which is one weekend about every 6 weeks.

Hospice of Chattanooga, Inc. Attn: Human Resource Department 4411 Oakwood Drive PO Box 19269 Chattanooga, TN 37416 Fax: (423) 892-8985 Phone: (423) 892-4289 x 111

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Newsline 50

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exceptional care.

You are sensitive to

your patients’ needs.

You can’t imagine

doing anything different

with your life.

Neither can we.

putting patients and families first

Suncoast Solutions provides world-class computer software to hospice organizations.

With Suncoast Solutions, you'll havea comprehensive software tool --your one source to help improve thequality of life of each patient.

(800) 334-0505 • www.sncoast.com

Let Optimum Hospice Solutions help you achieve measurable outcomes and become the number one choice for end-of-life-care. OHS provides comprehensive solutions exclusively for hospice because we know the “business.”

Inpatient/Residential Feasibility StudiesCertificate of Need ApplicationsFull Range of Capital Campaign Services from Feasibility Studies to CompletionStrategic AuditsThe Watchman™ Program — The First Hospice Specific Faith-Based Marketing Strategy.

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Do You Want to Be theNumber One Provider in

Your Service Area?

VITAS is about life, some of themost important moments of life.

I’m not a nurse. But my wife’s failing heart and lungs turned meinto one.

Before we called VITAS, it felt like I was all by myself. I wasoverwhelmed ... I was a cop for 35 years—I’d never felt so helpless.

Then, there was VITAS.

The pain medication was delivered. The medical equipment camewhen they said it would. Never a check to write.

Nurses, nurses aides, social workers, chaplains … even their doctorcame to the house.

When things got tough, VITAS was there around the clock.

VITAS calls continuous care “Intensive Comfort Care SM”.I call it a lifesaver, a friend.

Wouldn't you choose America's hospice leader?

Please call 305.350.6957 www.VITAS.com

Newsline 51

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The California Hospice & Palliative Care Association (CHAPCA) is seekinga President/CEO to manage all of its activities as well as those of itssister organization, the California Hospice Foundation (CHF).

President/CEO

The President/CEO provides inspired leadership to ensure that the missions of CHAPCA andCHF are successfully carried out. The President/CEO works closely with the Boards ofDirectors of both organizations on setting strategic directions for the future. He/she is thechief spokesperson for both organizations and is responsible for representing the Associationand the Foundation on a state and national level.

The President/CEO has overall responsibility for day-to-day operations supervising staff andoverseeing legislative and regulatory activities, as well as the programmatic, financial andmanagement operations of each.

We offer a competitive compensation and benefits package. For acomplete position description, including qualifications and require-ments, please see: http://www.calhospice.org.Send resumes by July 15, 2008 to:

Search CommitteeP.O. Box 160087

Sacramento, CA 95816-0087

Making Community Outreach Easier All Year Long

Each year, NHPCO develops a range of

educational and promotional materials—

specifically for members—to make it easier and

more affordable to educate the local community

about end-of-life care. Among these materials are

a series of display ads, plus other time- and cost-

saving tools and templates.

While a CD of the 2007/08 materials was mailed

to each member organization last August, the

materials are also posted on the NHPCO Web site so

staff and volunteers can access them all year long.

Visit nhpco.org/communications.

Newsline 52

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Are you sure?

Are you protected if he falls?

It can easily happen. The days are long, and patients are frail and oftenheavy. With just a little miscommunication or dizziness or movement in the wrong direction, the patient can end up on the floor instead of on his feet. Patient transfers are a cause of many lawsuits againsthospices and home health care agencies.

Lawsuits are expensive to defend, and some result in very high-dollar losses. That’s why liability insurance coverage is so important. Hospiceand Community Care Insurance Services is administered by GlatfelterInsurance Group, a national agency. We work closely with your insurance agent to provide competitive proposals and friendly

service for special businesses like yours.

Remember, before you can take care of others, you have to

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For more information, call 800-233-1957 • www.hccis.com

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Newsline 53

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Dates to Remember

MarketplacePicks

This month we spotlight a range of items related to topics addressed in this issue .

End–Stage Renal Disease: When Is It Time for Hospice (AWS CD) Presented by Perry Fine, Harry Feliciano, and Malene Davis Item: 821042, Member Price: $29.99

Stronger in the Broken Places: The Power of Apology to Strengthen Relationships (AWS CD) Presented by Bob Miller and Malene Davis Item: 820620, Member: $29.99

Coaching for Success (AWS CD) Presented by Pam Barrett and Janet Fortner Item: 820638, Member: $29.99

Hardwiring Excellence By Quint Studer Item: 820995, Member: $17.00

Built To Last: Successful Habits of Visionary Companies

By Jim Collins and Jerry Porras Item: 820953, Member: $15.45

Performance Measurement: Accelerating Improvement By the Institute of Medicine Item: 821036, Member: $52.95

To order, visit Marketplace (nhpco.org/marketplace) or call 800/646-6460. Source Code: NL01.

NHPcO’s Audio Web seminarsInterdisciplinary Topics:

2:00 – 3:30 p.m. (EDT)

06/12/08: Conditions of Participation for Clinical Staff

07/10/08: Hospice in Long-Term Care Facilities: Doing it the Right Way

08/07/08: Improving Comfort and Quality of Life: Complementary Therapies in End-of-Life Care

Leadership Topics:

2:00 – 3:30 p.m. (EDT)

06/24/08: Conditions of Participation for Managers and Leaders

07/22/08: Quality Measurement - Ensuring Your Program is “Stepping Up” Instead of Falling Behind

08/26/08: Ready? Set? Survey! Preparation and Readiness

NHPcO’s National conferences08/18 – 08/20/08: 2nd National Conference on Access to Hospice and Palliative Care, Obstacles, Options and Opportunities Minneapolis, MN

10/23 - 10/25/08: 9th Clinical Team Conference, New Frontiers: Expanding Quality End-of-Life Care Dallas, TX

Hospice MDP Two-Day Foundational courses08/16 - 08/17/08 in Minneapolis, MN: In conjunction with NHPCO’s 2nd National Conference on Access

10/2 – 10/3/08 in Hot Springs, AK: Hosted by the Arkansas State Hospice and Palliative Care Association

10/21 - 10/22/08 in Dallas, TX: In conjunction with NHPCO’s 9th Clinical Team Conference

For details and for additional MDP foundational courses and modules, visit nhpco.org/mdp.

Newsline 54

Newsline 55

NHPCO has redesigned the Regulatory section of its Web site to give members quick and easy access to timely information—from materials to help you understand and comply with the new Hospice CoPs… to the latest news on relevant CMS change requests…to guidance on billing and clinical care.

First, click on “Regulatory Center” in the bottom left corner of the NHPCO homepage (nhpco .org)—or use the shortcut www.nhpco.org/regulatory . This brings you to the new Center’s landing page .

On the Center’s landing page, you’ll find:

Links to the key NHPCO materials containing • information on regulatory and compliance issues. For example, click on Regulatory Alerts and you’ll advance to a web page with links to all Alerts listed by issue date .

NHPCO resources organized by topic and • displayed as square buttons. There are sections on:

New Hospice CoPs•

Regulatory & Compliance—containing • information on CMS change requests, Hospice Cap, links to federal and state web sites, and more.

Hospice Wage Index•

Hospice Billing and Reimbursement•

Hospice Operations•

Clinical Care•

Plus discipline-specific tip sheets, FAQs, • and other resources that will be posted throughout the summer .

More News of Note

On May 8, NHPCO’s Regulatory team released analysis and tools regarding the proposed FY 2009 Wage Index, including:

Charts showing its one-year and three-year impact on each state and each county;•

Wage Index calculator to help members determine its impact on their program; and•

Related material, including NHPCO’s response to the proposed rule.•

Visit: nhpco.org /regulatory .

A closer look at NHPcO’s New Regulatory & compliance center

Take a moment now to explore this new “members-only” section: nhpco.org/regulatory .

Na

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1700 Diagonal R

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Alexandria, VA

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Please visit our W

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.

Do you have

artists and writers

in your midst w

ho have captured the unique aspects of end-of-life care?

Each year, N

HPC

O holds

a Photography, W

riting and Film

contest to show

case the talent of staff,

volunteers and supporters who have

produced creative work on behalf of an

NH

PCO

mem

ber program . S

ubmissions for

the 2008 contest are being accepted now

through July 31. Winners w

ill be announced at C

TC next O

ctober, and their work w

ill be featured in D

ecember N

ewsLine (the cover

from last year’s special section is show

n here). For details, visit nhpco.org/aw

ards .

2007

Photo, Film, Essay &

Poetry Awards

“Golden Companions” by Cassie Umberger

National H

ospice and Palliative CareO

rganization

Documents

Finding N Direction - National Hospice and Palliative Care ... · Direction When Things ... comprehensive article on service recovery—how . Newsline 5 ... This should prompt a review