tale of vanishing hospice chaplain

Wednesday, August 27, 2008

The Tale of the Vanishing Hospice Chaplain

I have been writing lately about the changes our industry is going to have to deal with in the future, and what needs to happen now. In this post, I want to deal with the scary future of hospice if these changes are not made.

Currently, hospice as a business is at a crossroads. Where it will end up is anybody’s guess. My guess (or prayer) is that we end up being what hospice was created to be. We have become so much more than any of the original hospice pioneers ever dreamed we would become. It is not an overstatement to say that we are reaching the goal of changing the way our nation views and faces the end of life. Even more, we have become a driving force behind the national movements to increase awareness and access to pain management and grief counseling. What the hospice movement has become is nothing short of awesome. Unfortunately, as I’ve been saying in the last few posts, I believe the federal government is going to force us to downsize our ambitions. I won’t rehash why I believe these changes are coming in this post. My great fear is that, when something drastic happens, the good hospices will become extinct and the only thing left is the hospice that has allowed the business side to “suck the life out of” hospice care.

This blog was created in response to those hospices out there who see hospice as nothing more than a business. There is something special and sacred about hospice, but not every hospice actually seems to understand that. Although hospice is special and sacred, hospice has become a business, but not every hospice actually seems to understand that. Some hospices are nothing but business and that results in care which is significantly lower than I believe is acceptable. Other hospices are nothing but care which results in business practices that are significantly lower than Medicare believes is acceptable. When my beliefs about minimum standards of care are forced to do battle with Medicare’s beliefs about minimum standards of business practice, Medicare will win every time. They are Medicare. Thus, we, as an industry, can’t put ourselves in a position to fight that losing battle. The battle we must choose is to find a way to provide excellent care within the guidelines of the financial reality of the future. As I have said, I believe that means that we must refocus our efforts on those things that are at the core of hospice care and leave behind some of our “added services”.

Let me paint a small picture of what the future looks like if hospice is left to businesses with no heart. This picture will focus on only one area of care, because I believe it is the easiest example of where our industry is headed if the hospices with heart disappear. This tale is one of the Vanishing Hospice Chaplain.

The new hospice Condition’s of Participation talk about spiritual care in many places, the biggest section says:
Spiritual counseling. The hospice must:

(i) Provide an assessment of the patient’s and family’s spiritual needs.

(ii) Provide spiritual counseling to meet these needs in accordance with

the patient’s and family’s acceptance of this service, and in a manner

consistent with patient and family beliefs and desires.

(iii) Make all reasonable efforts to facilitate visits by local clergy, pastoral

counselors, or other individuals who can support the patient’s

spiritual needs to the best of its ability.

(iv) Advise the patient and family of this service.

There are two ways to interpret this:

  1. The patient focused hospice reads this to say that we are required to send a well trained hospice chaplain with knowledge of spiritual issues and a background in grief and family counseling to do an assessment on every patient and their family. This chaplain will communicate with local pastors, rabbis, etc. and make regular visits to the family to ensure that, as the disease progresses, the patient and family’s spiritual issues are cared for.
  2. The business focused hospice reads this to say that we are required to have a member of the team inquire with the patient and their family about their spiritual background and any spiritual needs. If they say they have spiritual needs, then the hospice is required to find someone in the community who can help. If they don’t say they have spiritual needs, then they should be informed that, if needs arise, they can call the hospice.

It is important to note that interpretation number two is an honest, logical, and acceptable interpretation of the regulations and that it does not include the word chaplain. This means that it is legal and acceptable for a hospice to completely “outsource” spiritual care. The RN or the Social Worker (which are both specifically required by Medicare) can do the “spiritual assessment” and then contact someone in the patient’s chosen religious community and ask them to provide spiritual care. That approach is legal and, shall we say, “cost effective”. Is it quality hospice care? I would say no. If patient focused hospices can’t survive in the future financial climate, then the hospice chaplain will be a dying breed.

I tell the story of the Vanishing Hospice Chaplain because it shows that it is acceptable in the eyes of Medicare to provide care that most in the hospice community would deem below acceptable standards. This type of issue is not isolated to spiritual care, and should be a wake up call. Hospices have always done more than the Medicare standard, but now that some of those standards have changed, we are doing excessively more than the standard. Medicare wants to know what it costs to meet their standards and may soon stop paying us enough to provide much more than their standard. We must begin to focus our business practices on the core of hospice care or the entire industry could be turned over to those who see the Vanishing Hospice Chaplain as a fairy tale.


Christian Sinclair, MD

The New York Times says that chaplain services are on the rise so hopefully the business model does not overwhelm what is a real need. I linked to this post in the comments at NYT.

Hospice Oak Park

I Was surfing and found your blog on net and blog very interesting i would like to have more information about it so can you please give me some more details.

Hospice CA

It is really a good post has really very good articles.Good issue are discussed in this blog.