Archive for October, 2013

Final Rule in Regulatory Challenges—How are You Affected?

Larry Beresford

A dense, 49-page government document with a mouthful of a title, “Medicare Program; FY 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform” was published in the Federal Register on August 7—with huge implications for hospices and their medical directors.

This Final Rule does much more than update the annual Hospice Wage Index. It also covers changes in hospice quality reporting, looming reform of the hospice payment system, and a range of other regulatory issues. Appropriate eligibility for hospice care remains a major focus for the government. But hospices face new requirements in spelling out the primary diagnosis for this eligibility, all related comorbidities and secondary conditions, what is related or unrelated to the terminal prognosis, and how all of the above should be coded on claims forms, described in physician narrative statements and certified by two physicians in their best medical judgment. Some terminal prognoses, notably adult failure to thrive and debility unspecified, will no longer be permitted as primary diagnoses for hospice admissions.

All of this means the role and responsibilities of hospice medical directors are growing. Read much more about the regulatory challenges they now face in the Quarterly. You can also see how AAHPM’s comments on the proposed rule compare to the final regulations in this side-by-side prepared by the Academy’s lobbying and consulting firm, Hart Health Strategies.

Coming to Grips with Evidence-Based Medicine

Steven Prior, MD

I started All Things Palliative (ATP) in December 2012 as a way to cope with the vast amount of medical evidence for which I, as a front-line palliative care physician, felt responsible. Of the many things I’ve learned over the past 10 months, the most eye-opening has been just how enormous this body of medical evidence really is.

I operate within a rather small subset of healthcare – Hospice and Palliative Medicine (HPM). By its nature, HPM overlaps with all other medical specialties, from pediatrics to geriatrics, interventional radiology to general surgery. HPM is also interdisciplinary – the very definition of HPM outlines its incorporation of spiritual, psychological, social and physical care. So as a clinician educator at a major U.S. academic medical center, I often struggled to keep abreast of the medical literature as it pertained to HPM. Relevant studies would be published in the HPM journals, of course, but also in those of nursing, chaplaincy, mental health, ethics and social work, not to mention frequent publications among the surgical and medical subspecialty journals.

ATP has been, primarily, an attempt to pull these scattered bits of data together into one place. It has seemed a sensible way for me to start coming to terms with evidence-based medicine’s “Big Data” challenge in the field of HPM.

ATP has accumulated essentially all English-language HPM medical news and research released since the site’s inception. Every day I review titles of over a thousand articles from medical journals, medical news sites, professional organizations, advocacy groups, blogs and lay press outlets. From this 1,000+ daily set, I cull about sixty relevant articles. Roughly two-thirds is original research; one-third is news of various sorts.

Continued at All Things Palliative Blog

Bridging the Gap in Advanced Illness

Michael Paletta, MD FAAHPM

Many of us practicing hospice and palliative medicine have long struggled with the gap between persons coping with advancing illness and persons failing despite aggressive management. Patients seem to cross from the first group to the second quickly, almost without notice. Late referral to hospice is a natural result of this difficulty in identifying patients who are properly managed and compliant, yet whose disease is progressing, and whose final months often feature crisis care in emergency and intensive care settings. Palliative care offers interdisciplinary management, but trained providers are few, and services in many areas remain tied to hospitals and medical centers.

We at Hospice of Michigan, through our innovation division − The Maggie Allesee Center, sought to identify persons with serious illness earlier in their decline trajectory, before the suffering and the cost of multiple hospitalizations devastates their final months. Using Medicare claims data and a proprietary predictive model, we developed an integrative program, At Home SUPPORT ™, blending EMR access, telephone support, after hours visits, and family/caregiver training. The caregiver emphasis has been particularly effective for, after all, it is they who call 911 in a lonely panic, or encourage hospital admission as respite for their own exhaustion. Our partnerships with Accountable Care Organizations focus on the 5% of patients who generate 50% of costs and have yielded data supporting diminished ED use, fewer hospitalizations, increased and earlier referral to hospice, and diminished caregiver burden. As we expand our partnership database, we plan to further refine this model to a replicable program of advanced illness management.

Has your institution considered ways to reach patients and families earlier in the trajectory of serious illness? What can we learn from one another as we travel this road?

Dr. Paletta serves as Vice President of Medical Affairs for Hospice of Michigan. This post previews the latest installment of AAHPM’s Hospice and Palliative Medicine Profiles in Innovation.

Highlights of the October Issue of the Journal of Pain and Symptom Management (JPSM)

Listed below are a few articles from the most recent issue of the journal:

High Flow Oxygen and Bilevel Positive Airway Pressure for Persistent Dyspnea in Patients With Advanced Cancer: A Phase II Randomized Trial
David Hui, Margarita Morgado, Gary Chisholm, Laura Withers, Quan Nguyen, Clarence Finch, Susan Frisbee-Hume, and Eduardo Bruera

A Nationwide Analysis of Antibiotic Use in Hospice Care in the Final Week of Life
Jennifer S. Albrecht, Jessina C. McGregor, Erik K. Fromme, David T. Bearden, and Jon P. Furuno

Quality Indicators for Palliative Care: Update of a Systematic Review
Maaike L. De Roo, Kathleen Leemans, Susanne J.J. Claessen, Joachim Cohen, H. Roeline W. Pasman, Luc Deliens, PhD, Anneke L. Francke, on behalf of EURO IMPACT

To access the articles, you must subscribe to JPSM or be a member of the American Academy of Hospice and Palliative Medicine (AAHPM). For further information on the Academy, call 847.375.4712 or visit

Submitted by: David J. Casarett, MD, MA, Senior Associate Editor, JPSM

Hospice and Palliative Medicine Visionaries: How They Inspire Others

Submitted by Steve Smith, MS CAE, AAHPM CEO/Executive Director

Physicians, nurses, researchers, advocates and even a past president of the United States were voted the top 30 Visionaries in Hospice and Palliative Medicine, as the American Academy of Hospice and Palliative Medicine (AAHPM) celebrates 25 years of serving the profession.

In commemorating its founding, the Academy asked members to nominate individuals they considered to be the most influential leaders in hospice and palliative medicine, and then select their top 10 among the 111 nominated by the field. In the end, more than 6,500 votes were cast.

Several common themes emerged in praise of the nominees, such as – mentor, leader, big thinker. Some were cited for furthering research, communication or education; others for their expressions of kindness and compassion. Many have helped increase access to care within a region or community, while others shaped policy and practice on a national or international level. Among the 30 are early pioneers, some now gone, who inspired today’s leaders. Others represent the new generation of Visionaries taking the profession into the future.

So, here, in alphabetical order, are 30 hospice and palliative medicine Visionaries. In most other places, this list only includes names. I thought it would be interesting to share in this Blog post, some of the comments that were submitted anonymously in support of each Visionary.

Amy P. Abernethy, MD PhD FACP FAAHPM, Director, Duke University Medical Center, Durham, NC
“Amy has contributed invaluably to building the evidence base that informs our practice in palliative medicine by conducting rigorous clinical trials in a way that was previously not done in our field. She has also co-founded the first U.S. cooperative group in palliative care, and secured millions of dollars in funding for this from the National Institutes of Health (NIH).”

Robert M. Arnold, MD FAAHPM, Professor of Medicine, University of Pittsburgh, Pittsburg, PA
“There is not a part of the field that Bob has not touched. He should be considered a visionary because he has helped transform how we teach communications skills to practitioners both inside and outside of Palliative Medicine.”

Susan Block, MD FAAHPM, Chair, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
“Susan is committed to improving communications about end-of-life care, enhancing advance care planning and focusing on goal-consistent care, through research and professional and public education.”

Eduardo Bruera, MD FAAHPM, Professor and Chair, Department of Palliative Care, MD Anderson Cancer Center, Houston, TX
“Eduardo is dedicated not only to excellence through knowledge, but compassion in the use of that knowledge. He has contributed vastly to the advancement of quality palliative care internationally, in particular developing countries in Latin America through his work with the World Health Organization (WHO) Collaborating Center for Cancer Education, Training and Research.”

Janet Bull, MD FAAHPM, Medical Director, Four Seasons Hospice, Flat Rock, NC
“Janet was instrumental in starting the Palliative Care Program and founded the Clinical Research Department at Four Seasons. Trained in obstetrics and gynecology, she has witnessed as many births as deaths, and states, ‘A good birth and a good death are filled with the same ingredients – laughter, tears, peacefulness, joy, love, and an incredible sense of awe.’”

Ira Byock, MD FAAHPM, Professor of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH
“Ira is the voice and conscience of hospice and palliative care for our generation. He is a ‘big thinker’ offering a vision of how to move from hospice-focus to palliative care and maintains a laser focus on patient and family well-being and meaning.”

Gail Austin Cooney, MD FAAHPM, Vice President of Access, Hospice of Palm Beach County, Palm Beach, FL
“Gail is a tireless advocate and hospice and palliative medicine champion. Under her watch we developed an open access policy that allowed terminally ill patients who were still ‘fighting’ to continue to receive complex therapies. She saw the value of teaching and encouraged relationships with the different training programs in our community to conduct lectures on end-of-life care issues.”

Nessa Coyle, NP PhD, Memorial Sloan-Kettering Cancer Center, New York, NY
“Nessa is responsible for the one-year nurse practitioner fellowship program in pain and palliative care and is co-editor of The Oxford Textbook of Palliative Care Nursing and The Nature of Suffering and the Goals of Nursing.”

Patrick Coyne, MSN APRN ACHPN FAAN, Clinical Director, Thomas Palliative Care Service, Virginia Commonwealth University Medical Center, Richmond, VA
“Throughout his stellar career in hospice and palliative medicine, Patrick has established a phenomenal track record as a clinician, researcher, author, teacher, activist, trailblazer, and human being. His tireless work at VCU led to the establishment of a palliative care consult service followed by one of the first inpatient palliative care units in the U.S.”

Betty Ferrell, PhD MA RN CHPN FAAN FPCN, Research Scientist, City of Hope National Medical Center, Duarte, CA
“Betty has tirelessly championed holistic quality interdisciplinary palliative care and mentored a generation of clinicians, educators, and researchers. She has been in oncology nursing for 35 years and has focused her clinical expertise and research in pain management, quality of life, and palliative care.”

Kathleen Foley, MD, Chair, the Society of Memorial Sloan-Kettering Cancer Center, New York, NY
“Kathy helped establish Memorial Sloan-Kettering’s Pain and Palliative Care Service in the early 1980s and served as its chief. Her research in the assessment and treatment of pain in cancer patients led to the development of standards of care for pain and palliative care worldwide that are still used today. ”

Atul Gawande, MD, Associate Professor, Brigham and Women’s Hospital, Boston, MA
“A surgeon, writer and public health researcher, Atul is well-known for his writings in the New Yorker, including the article “Letting Go – What Should Medicine Do When It Can’t Save Your Life” and was named one of the world’s hundred most influential thinkers by TIME magazine. His writings have generated significant interest in palliative medicine in recent years.”

Sister Mary Giovanni, RN, Founder and President/CEO, Angela Hospice, Livonia, MI
“A registered nurse, Sr. Giovanni attended a seminar by Dame Cicely Saunders and spent the next decade researching pain control, alternative comfort measures and the daily needs of dying patients. She opened Angela Hospice in 1985 and today the hospice has more than 200 employees and 400 volunteers serving 1,700 adults and children a year.”

Nancy Hinds, RN, Founder, Hines Hospice, Fresno, CA
“With a deep personal faith and conviction, Nancy founded her hospice within her own home while she was a new widow with three babies. Since then, her spirit of selflessness has stretched around the world through her conferences for international organizations. Her spiritual and physical holistic care has brought peace to many.”

Elisabeth Kübler-Ross, MD, author of the ground-breaking book, On Death and Dying (deceased)
“With the 1969 publication of On Death and Dying, Elisabeth started the national discussion about death and dying, and the care and treatment of terminally ill patients. Her teachings transformed education and understanding of the Five Stages of Grief. She taught death and dying courses in colleges, seminaries, medical schools, hospitals and social-work institutions, where she impacted more than 125,000 students.”

David McGrew, MD FAAHPM, Chief of Medical Services, Hernando Pasco Hospice, Hudson, FL
“A founding member of AAHPM, Dave served as an Advisory Board member to the Florida Legislature’s Panel for the Study of End of Life Care, helping change laws regarding advance directives, DNRs and professional education.”

Diane E. Meier, MD FACP FAAHPM, Professor, Mount Sinai School of Medicine, New York, NY
“Diane leads the development of hospital-based palliative care in the U.S. and mentors a generation of clinicians, researchers, educators and leaders. She is the most visible central figure in the national palliative care movement over the last 10 years.”

R. Sean Morrison, MD FAAHPM, Professor, Mount Sinai School of Medicine, New York, NY
“Sean leads the drive for research in hospice and palliative care, mentors dozens of researchers, and works tirelessly to develop infrastructure to support research in hospice and palliative care.”

Balfour Mount, MD, Emeritus Professor, McGill University, Montreal, QC, Canada
“Balfour is the father of palliative care in North America and coined the term ‘palliative care’.”

Russell K. Portenoy, MD, Chairman and Friedman Chair in Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, NY
“Russ is committed to improving patients’ quality of life through research in assessment and management of pain and other symptoms. He is editor in chief of Journal of Pain and Symptom Management and has written, co-authored, or edited more than 20 books and 450 papers and book chapters on topics in pain and symptom management, opioid pharmacotherapy, and symptom assessment.”

Timothy E. Quill, MD FACP FAAHPM, Professor, University of Rochester Center for Experiential Learning, Rochester, NY
“An early and continuing strong advocate for compassionate care of the dying, Tim was the lead physician plaintiff in a case that eventually reached the U.S. Supreme Court. He has lectured widely about various aspects of the doctor-patient relationship, with special focus on end-of-life decision making and has authored numerous books and articles that have appeared in major medical journals, including the New England Journal of Medicine.”

Ronald Reagan, 40th President of the United States (deceased)
“President Reagan signed legislation in 1982 adding hospice care to the Medicare benefit. The number of hospice programs and patients served continues to grow, with more than 1.5 million patients receiving services from hospice annually.”

Cicely Saunders, OM DBE FRCS FRCP FRCN, Founder, St. Christopher’s Hospice, South London, England, (deceased)
“Dame Cicely was a physician, nurse and social worker who lectured widely on caring for patients with terminal illness, wrote many articles and contributed to numerous books. She is credited with founding the modern hospice movement and was an inspiration to countless others, including many of her fellow Visionaries.”

Rae Seitz, MD, Medical Director, Hawaii Medical Service Association, Honolulu, Hawaii
“Rae has helped improve quality of life for thousands of Hawaiians by extending hospice services through the creation of a supportive care model allowing patients to receive disease- directed therapy along with support from Medicare-certified hospice agencies.”

C. Porter Storey, Jr., MD FACP FAAHPM, Executive Vice President, American Academy of Hospice and Palliative Medicine, Boulder, CO
“As the Academy’s first and only executive vice-president, Porter continues to be a vocal advocate for seriously ill patients and their families as he represents AAHPM on Capitol Hill and to the media. His extensive list of publications includes the popular UNIPAC books – the resource for hospice and palliative care professionals.”

Martha L. Twaddle, MD FACP FAAHPM, Chief Medical Officer, Midwest Palliative and Hospice Care Center, Glenview, IL
“Few people have contributed to the hospice and palliative care movement on so any levels as Martha – from collaborating with other pioneers to make palliative care a medical subspecialty, to improving patient care and setting quality standards, to increasing industry awareness and shaping national public policy, and to ongoing education and mentoring.”

Charles F. von Gunten, MD PhD FACP FAAHPM, Vice President, Medical Affairs, Hospice and Palliative Medicine, Kobacker House, Columbus, OH
“Charles developed a model for palliative care that is the basis for most of the nation’s hospital-based programs and played a leading role in gaining formal recognition of palliative medicine as a medical sub-specialty. He serves as editor-in-chief of the Journal of Palliative Medicine.”

Declan Walsh, MD MSC, Professor and Director, The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic, Cleveland, Ohio
“Declan became the first director of the Palliative Care Program created at the Cleveland Clinic, which was designated a national and international demonstration project by the World Health Organization. A frequent invited speaker at international meetings on palliative medicine, he has published more than 250 articles, 26 chapters and four books, including Palliative Medicine.”

David E. Weissman, MD FAAHPM, Director, Medical College of Wisconsin Palliative Care Center, Milwaukee, WI
“David’s passion for teaching and mentoring has left a remarkable legacy across the country – for example, his leadership in stimulating end-of-life care curricula for all residency training programs and partnering in the development of the Center to Advance Palliative Care (CAPC). Practically any topic within palliative medicine that you research will lead you to an article with his name on it.”

Warren Wheeler, MD, Senior Director of Palliative Medicine, Nathan Adelson Hospice, Las Vegas, NV
“Warren is a visionary who has dedicated his entire professional career to people who need care when they are the most vulnerable. He founded two hospice programs in Columbus, Ohio, volunteering his time and raising private donations; founded a palliative care program for patients suffering acute pain but not ready for hospice; and helped secure passage of two laws making it easier for physicians to relieve suffering and treat intractable pain.”

On behalf of the AAHPM staff, we extend our congratulations to all of the nominees and thank them for their continued commitment to improving the care of seriously ill patients and their families.