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02/05/2010

Hospice E-News Volume 15, Issue 5 February 5, 2010

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ARTICLES ADDRESS FAMILY MEETINGS FOR PALLIATIVE CARE PROVIDERS

The current issue of Journal of Palliative Medicine's "Fast Facts and Concepts" series has two new articles: "Preparing for the Family Meeting #222," and "The Family Meeting: Starting the Conversation #223." Family meetings, says #222, are "a cornerstone procedure in palliative medicine." Healthcare professionals provide "leadership of family meetings to establish goals of care, typically completed at a time of patient change in status, where the value of current treatments need to be evaluate."

In article #222, authors David E. Weissman, MD, Timothy E. Quill, MD, and Robert M. Arnold, MD suggest having a pre-meeting "data review" of the current medical history and treatments, proposed treatment options, prognosis with and without treatment, physician and consultant consensus on a treatment plan, and patient/family psychosocial status and dynamics. If the consulting physicians do not agree on proposed treatment, "a plan should be developed for how to describe these differences to families." The meeting presenters should use the information from the data review to "make an independent determination of which current and potential tests/treatments will improve, worsen, or have no impact on the patient's function/quality of life (physical/cognitive) and time (longevity)." While it is useful for one person to orchestrate and coordinate the meeting, the core skills needed for a successful meeting can come from more than one person. Those core skills are "group facilitation skills, counseling skills, knowledge of medical and prognostic information, [and] willingness to provide leadership/guidance in decision making." Competent patients can be asked who they would like to have attend the meeting, and usually no limit on the number of attendees is needed. The medical team also decides who will represent it, but the authors caution: "It is important not to overwhelm a family with too many health professionals." Suggested healthcare attendees are a physician from the primary team, a nurse, a social worker, and if one exists, a physician with whom the patient has a long-term treatment history. Before the meeting, the healthcare members of the team should gather to determine "(1) the goals for the meeting (e.g., information sharing, specific decisions sought), (2) who will be the meeting leader to start the meeting, and (3) likely sources of conflict and initial management strategies." 

Article #223 provides suggestions on beginning the conversation during the meeting. Begin by introductions and setting goals for the meeting. Each person should introduce themselves, and the leader should summarize the goals and then ask if there are other agenda items. If the leader does not know the patient well, he or she can ask the patient or surrogate to describe the patient's life before he or she became ill. The next step is to determine what the patient and family already know, asking all members to speak. If the patient has been chronically declining, ask them to describe physical, functional and cognitive changes. Next, the leader should ask if the team can bring the patient and family up-to-date on the patient's status. In this process, healthcare providers should confirm the family's understanding where correct, and correct any misconceptions. The authors suggest not using medical jargon, but instead saying things like, "The worsening weakness and pain you describe is from the cancer, which is growing despite the chemotherapy." If death is likely soon, use of the work "dying" is ok. 

According to the article, "Both patients and surrogates find that saying the word dying, if done compassionately, is helpful in clearing what is often a confusing and frightening situation." Be prepared to allow and deal with silence.  Let the family respond, whether with factual questions or emotion. The leader's response should deal with any factual questions, but should also reach the underlying emotional content. If the patient and family accept that no further current treatments are needed, and that death is inevitable, then address prognosis "in terms of time, function, and symptoms, as best you can." Future "Fast Facts" will deal with ways to do this. (Journal of Palliative Medicine, 2010)
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ARTICLE FOCUSES ON SHIFTING FROM CURATIVE TO PALLIATIVE CARE IN THE NICU

"Dealing With Death in the NICU - A Conversation With Neonatal Palliative Care Expert Anita Catlin" uses the case of 24-week twins to illustrate the principles of palliative care in a unit where everything is done for the survival of the patients. The author, nurse Laura A. Stokowski, first notes that palliative care is not just about dying or giving up, but about quality of life, no matter how short. Catlin says that palliative care begins when "cure-oriented goals are replaced with comfort-oriented goals." Catlin says there is usually no seamless transition from one to the other. Curative care may go on longer than it should. She suggests remembering four facts to help make the decision to shift to palliative care:

  1. "All appropriate curative attempts that can be tried have been tried;
  2. Physiologic processes cannot be altered;
  3. Altering the physiology will not change the lethal prognosis;
  4. There are specific infants who are, in fact, going to die, and a dying infant is not a reflection of neonatal provider failure."

The article says that professionals may feel trapped into continuing aggressive treatments once they have begun. "Without palliative care to ‘take over,' so to speak, the decision to end curative care becomes almost impossible to make." The clinical staff may have difficulty in dealing with parents who are unrealistic about their baby's condition. Catlin cites an article by Ralph Baergen, "How Hopeful is Too Hopeful? Responding to Unreasonably Optimistic Parents." 

Baergen lists the following clues that parents are having difficulty taking a realistic view of their child's future:

  1. Believing that less than full-out efforts to cure make them bad parents;
  2. Viewing cessation of treatment as abandonment of the baby;
  3. Thinking that withdrawing treatment is the cause of death rather than the underlying medical problem;
  4. Believing that only God can determine the time of death;
  5. Believing that where there is doubt or medical uncertainty, there is hope;
  6. Thinking that limiting care means they question their faith; and
  7. Plain old denial.

There are many barriers to communication with parents, but one cited in the article is the tendency of the clinical teams to refer to their work as "care." Thus when treatment stops, parents may believe that care will stop, rather than that their child will be supported to a comfortable death. Another critical issue is to maintain the focus on the infant's needs. While the family has legitimate needs, the clinical team should watch for parents attempting to meet their own needs (to have children, say) rather than on those of the child. Withholding hydration and nutrition are difficult and complex subjects, especially where infants are concerned. 

The Committee on Bioethics of the American Academy of Pediatrics has summarized those issues, and "there is consensus that it is ethically permissible to withdraw medically provided fluids and nutrition from infants in selected circumstances." When discussing palliative care with parents, Catlin offers several suggestions:

  1. Have the parents bring someone for support;
  2. Meet in a comfortable room;
  3. Offer to record the discussion;
  4. Assure the family that their child will not be abandoned;
  5. Call the baby by name, and avoid medical jargon; and
  6. Don't present palliative care as a choice between cure and comfort, but focus on establishing goals for the baby's support, and on what the parents may now do (hold, cuddle, breast feed, etc.).

The article concludes, "Death seems so much worse for the young, who haven't yet lived. It can be very difficult for parents, and sometimes even caregivers, to recognize the fork in the road. If palliative care is begun at birth or when a potentially life-limiting condition is recognized, it will be easier to make the transition to purely palliative care when the appropriate time comes."  (Medscape Today, 1/29)
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RESEARCH & RESOURCE NOTES

  • The American Pain Foundation has announced a new initiative to raise awareness about cancer pain. Their online guide to breakthrough cancer pain includes fact sheets, information about breakthrough pain, common questions and answers, and other resources. The APF's quarterly newsletter, Pain Community News, will feature articles on breakthrough cancer pain, and a "dedicated online chat and interactive webinar, When Cancer Pain Breaks Through, will offer more insight on breakthrough cancer pain for patients and providers." (American Pain Foundation Press Release, 1/29) 
  • When physicians delay talking about end-of-life issues with patients until treatments have been exhausted, it may mean that patients do not have the right to "truly informed choices" early in their treatments. Authors of this study, from Brigham and Women's Hospital and Harvard Medical School, call for more research to "understand physicians' reasons for timing of discussions and how their propensity to aggressively treat metastatic disease influences timing, as well as how the timing of discussions influences patient and family experiences at the end of life." (Cancer, 2010; The Baltimore Sun, 1/25; Medline Plus Website, 1/12)

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PUBLIC POLICY NOTES

  • In 2006, Medicare spent $2.5 billion for "home" hospice care received by patients who lived in nursing homes. Those patients represent 31% of all Medicare recipients who receive hospice. A news update in the Journal of Palliative Medicine says that there is "essentially a single payer for health care over the age of 65: Medicare," and that much of nursing home care is paid through Medicaid.  According to the note, the government "often pays twice for patients enrolled in hospice programs living in nursing homes. It should be no surprise that the OIG is looking to see if the federal government is getting its money's worth, or if it is being double-billed for the same services."  (Journal of Palliative Medicine, 2010)

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PEDIATRIC CARE NOTES

  • The Pediatric Palliative Care Network Operational Program Standards of the Massachusetts Department of Public Health have been posted.  The contents include eligibility for services, providers, information about program access, and provider responsibilities. (Massachusetts Department of Public Health, 11/24)
  • "Measuring quality of life in pediatric palliative care" says that the health-related quality of life (HRQOL) of children with life-limiting illnesses could be improved.  A recent study of the HRQOL tool, the Pediatric Quality of Life 4.0, found that it "does not have valid psychometric properties for measuring HRQOL within this population."  The study notes several challenges in using the instrument, and suggests "future directions to refine or develop HRQOL instruments for this population of vulnerable children." (PubMed, 2010)
  • "Pediatricians' Management Practices for Chronic Pain" reports that a survey of  pediatricians revealed that only 32.3% of responders thought it was their responsibility to treat chronic pain.  Roughly 19% "never or rarely" prescribe intermittent opiates. (Journal of Palliative Medicine, 2010)

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OTHER NOTES

  • An article in The New York Times relates the difficulties faced by loved ones when terminally-ill patients insist on aggressive treatment. (The New York Times, 1/25)
  • An interview with Dr. Joan Teno, professor of community health at Brown University and associate medical director of Home and Hospice Care of Rhode Island, is available for download from the WRNI website. In the program, which is part of the "This I Believe Rhode Island" series, Teno speaks positively of hospice. (WRNI Radio, 1/27)
  • A press release from Stanford Hospital & Clinics profiles the work of the palliative care team.  For Georgia Sue Huston, team members were the first persons to answer her questions about her end-stage lung disease.  Huston's daughter said, "My mom said, ‘I've been wanting to bring this up for a long time, I've been wanting to talk about this, but I didn't know what to say.'  Once Judy [Judy Passaglia, palliative care program director] and Dr. Bouvier [Denis Bouvier, palliative care attending physician] talked with her, she looked relieved.  She went from, ‘Oh, my God, I can't do this,' to being at peace." (Earthtimes, 1/26)
  • A Cleveland physician, concerned about the low rate of organ donations, suggests that having a conversation about organ donation before a patient is critically ill or the family is coping with grief could raise the donation rates. A study encourages primary care physicians to discuss the issue with their patients. (The Plain Dealer, 1/26; Journal of the National Medical Association, 2010;102:59-60)
  • A Penn State press release says that the university has received a $1.27 million grant to develop an end-of-life intervention toolkit for use in the state's prisons. The purpose of the project is to improve delivery of end-of-life care in prisons. (EurekAlert!, 1/26)

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NHPCO COMPLIANCE REGULATORY AND ADVOCACY UPDATES

Associating Hospice Visits to the Level of Care on the Claim Form
CMS, on 1/19/10, issued Transmittal 1897, CR 6791which will require hospice providers to report separate line items for the level of care each time the level of care changes. Click here to read the MedLearn article. CMS Issues Caution: Should providers not adhere to this policy the Centers for Medicare & Medicaid Services (CMS) may consider implementing a line item date of service billing requirement for hospice level of care revenue codes.This would require reporting a separate line for the level of care for each day billed on the hospice claim.  (NHPCO, 2/3/10)

Implications for Hospice in Proposed 2011 National Budget
The Obama administration submitted its proposed budget for fiscal year (FY) 2011 to Congress on Monday. The proposed budget assumes health care reform legislation will pass in 2010 and some revenue will be generated through "Medicare savings." This would likely mean Medicare payment reform and continued threats of rate cuts to hospice over a ten-year period. The President's budget also forecasts increased provider oversight to include mandatory on-site surveys for some providers every one to two years, but only every 11.5 years for hospice. NHPCO will continue to work toward assuring hospice quality and compliance be documented by federal agencies by advocating that surveys of hospice programs are conducted as often as other provider groups. Additionally, the budget calls for over $1 billion to address fraud and abuse, calling for greater resources to identify and reduce improper payments in the Medicare, Medicaid and CHIP programs. Stay tuned for more details.  (NHPCO, 2/4/10)

CMS Revises Voluntary Uses of Advance Beneficiary Notices of Noncoverage (ABNs)
CMS revised CR6563, which was originally issued on October 29, 2009, to reflect a new CR release date, transmittal number, and Web address for accessing CR 6563. All other information remains the same. (NHPCO, 2/4/10)

CMS Revises CR 6721: Implementation of HIPAA Version 5010 276/277 Claim Status
CMS recently rescinded and replaced CR 6721, Implementation of the HIPAA Version 5010 276/277 Claim Status Second Phase. There was an error in the 276/277 CMS defined flat file. The definition of SVC07 in the 277 should be S9(07)v999. This also changes the length of SVC07-1 to 5 bytes. All other information remains the same. (NHPCO, 1/27/10)
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CMS NEWS AND CHANGES

Summary PS&R Reports
The September 30, 2009 cost report is due March 1, 2010, or 30 days from the receipt of the Summary PS&R reports, whichever is later. CMS has advised RHHI's/MAC's to send the PS&R reports to providers with a September 30, 2009 cost reporting period due to issues providers are encountering with obtaining these reports through the CMS online PS&R system. As explained in the MLN Article, providers are required to register for access to the Redesigned PS&R system and obtain your own reports. PS&R reports will not be sent again, and it is your responsibility to obtain future reports you require directly from the PS&R system. Please refer to the PS&R website, to obtain more information pertaining to the PS&R and registration. requirements. (CMS, 1/27/09)

Revised Medicare Physician Fee Schedule Fact Sheet
The Medicare Physician Fee Schedule Fact Sheet (February 2010) has been revised to include information about the two month zero percent (0%) update to the 2010 Medicare Physician Fee Schedule (MPFS) effective only for dates of service January 1, 2010 through February 28, 2010. (CMS, 2/1/10)

Fourth National Medicare Fee-For-Service (FFS) Education Call on HIPAA Version 5010
CMS will be hosting its fourth national provider call, HIPAA Version 5010 National Provider Call: CMS' approach for new error handling transactions: 999 and 277CA, on February 11 from 2:00-3:30pm EST. There will be a brief presentation given by CMS followed by a Q&A session with CMS subject matter experts. Please note that this call is geared towards vendors, clearinghouses, and providers who are performing their own development of 5010.

In order to receive the call-in information, you must register for the call. Registration will close at 2:00 p.m. ET on February 10, 2010, or when available space has been filled. No exceptions will be made, so please be sure to register prior to this time. To register for the call, click here. (CMS, 2/3/10)
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NAHC NEWS & UPDATES

FDA Announces Class I Recall of Certain Huber Infusion Set Needles
The U.S. Food and Drug Administration (FDA) announced a Class I recall of Exel/Exelint Huber needles, Exel/Exelint Huber Infusion Sets, and Exel/Exelint "Securetouch+" Safety Huber Infusion Sets manufactured by Nipro Medical Corp. for Exelint International Corp. (NAHC, 1/28/10)

California Hospice among Those That Have Challenged Hospice Cap Regulation
If your hospice has recently received, or anticipates receiving, a hospice cap repayment demand from Medicare, this issue may be of significant interest to you. A number of hospices across the country have challenged hospice cap repayment demands on the grounds that the Medicare regulation used to calculate the demands (42 C.F.R. 418.309) is invalid, in that it fails to follow the statutory requirement to allocated cap allowances for each patient across years of services. In August 2009, Medicare hospice provider Los Angeles Haven Hospice won its court challenge to the hospice cap regulation. Federal Judge George Wu (C.D. Cal.) held that the cap regulation fails to follow the statutory instruction on how to calculate the aggregate hospice cap. As a result, he entered judgment against the U.S. Department of Health & Human Services (HHS), finding the hospice cap regulation invalid and setting aside the 2006 cap demand to Haven Hospice. HHS must now either return funds previously paid by Haven Hospice or apply those funds (including interest) to a new demand. A copy of this final judgment is available here. If you are interested in more detail concerning the group appeal, you may contact the National Association for Home Care & Hospice's Vice President for Law Bill Dombi at (202) 547-7424 or wad@nahc.org, or counsel for the group appeal Brian Daucher at (714) 424 2843 or bdaucher@smrh.com. In addition, more information is available HERE. (NAHC, 2/4/10)
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PALMETTO GBA UPDATES AND CHANGES

February 2010 Medicare Advisory (2010-02)
February 2010 North Carolina Part A Intermediary, South Carolina Part A Intermediary and Regional Home Health and Hospice Intermediary (RHHI) Medicare Advisory (2010-02) is now available. (PGBA, 1/28/10)

BNAF Adjustments
The Budget Neutrality Adjustment Factor adjustments (also known as the Stimulus payments) listed on our Claims Processing Issues Log as the Reason Code 31949 adjustments have all been resolved. (Ed Greenleaf, PGBA, 2/5/10)

Provider Contact Centers Will Close on Monday, February 15, 2010, for Washington's Birthday (President's Day)
Although Palmetto GBA's offices will be open on Monday, February 15, 2010, for Washington's Birthday (President's Day), the Provider Contact Centers (PCCs) will be closed. This is a holiday observed by the federal government and much of the business community. PGBA will use this day to conduct training of the PCC representatives. (PGBA, 2/1/10)
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STATE NEWS

State Revenues Now Running Below Estimates
After months of squeaking by making revenue forecasts, a preliminary look at January revenue shows it $108.4 million below estimate for the month and approximately $99.6 million or 1.1 percent below estimates for the year. (Hannah Report, 2/4/10)

Governor Pushes for More Federal Aid
The Columbus Dispatch reports that Gov. Ted Strickland met with President Barack Obama and other senior administration officials in Washington D.C. Wednesday in an effort to push for more federal money. (Hannah Report, 2/4/10)

Sheriffs, Pharmacy Board Target Rogue Prescriptions
Ohio sheriffs have joined the state pharmacy board in legislation that would compel doctors to more closely track prescription "doctor-shopping," reports Gannett Newspaper Network. (Hannah Report, 2/4/10)
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Glatfelter Insurance Group is the national sponsor of Hospice News Network for 2010.  Glatfelter Insurance Group provides property and liability insurance for hospices and home healthcare agencies through their Hospice and Community Care Insurance Services division.  Ask your insurance agent to visit their website at www.hccis.com. Hospice News Network is published 45-47 times a year by a consortium of state hospice organizations.  Copyright, 2010.  All rights reserved to HNN subscribers, who may distribute HNN, in whole or part, to provider members of the subscribers' state organizations.  If readers need further information, they should consult the original source or call their state association office.  HNN exists to provide summaries of local, state and national news coverage of issues that are of interest to hospice leaders.  HNN disclaims all liability for validity of the information.  The information in HNN is compiled from numerous sources and people who access information from HNN should also research original sources.  The information in HNN is not exhaustive and HNN makes no warranty as to the reliability, accuracy, timeliness, usefulness or completeness of the information.  HNN does not and cannot research the communications and materials shared and is not responsible for the content.  If any reader feels that the original source is not accurate, HNN welcomes letters to the editor that may be shared with HNN readers. The views and opinions expressed by HNN articles and notes are not intended to and do not necessarily reflect views and opinions of HNN, the editor, or contributors.  Only subscribing state hospice organizations have rights to distribute HNN and all subscribers understand and agree to the terms stated here. (Volume 14, Number 5, February 2, 2010)


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