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What Should Spiritual Care Be Accountable For?

Much has been made of the changes that are coming to our federal government with the advent of this new administration. And indeed drastic change is here and uncertainty is the watchword of the day. Despite that, most authorities are convinced that some initiatives will not change and this uncertainty also constitutes an opportunity to provide change to the system.

One of the fundamental changes is the conversion of the basic health care payment model from what has been known as fee for service to the one now most often called value-based purchasing. Fee for service is fairly simple. The health care provider delivers a service like a test or treatment and gets paid a set fee. The more service is provided, the more the provider is paid. Value-based purchasing pays for service to the extent it is deemed to be of high quality and, paradoxically, for saving money. This new system comes with many, many unknowns not the least of which is how does quality get defined, who gets to define it, and how is it measured?

The current centerpiece of this change is the Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act (MACRA) passed by Congress with overwhelmingly bipartisan support in 2015. (with now-Secretary Price voting for it). The regulations govern how providers are reimbursed by the federal government- mostly through Medicare Part B. MACRA replaces several value initiatives and payment models mainly with two alternative strategies for raising quality and lowering cost - the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Models (APM).

I have to admit that when I first heard about MACRA and what it involved, my conclusion was that this has to do with provider reimbursement and since chaplains don't get reimbursed, this has nothing to do with us. That conclusion has proved to be completely wrong. The explanation is complicated but basically involves the reality that, in this new system, the provider which could be the hospital or a doctor's group or other, gets paid for delivering quality care and/or an outcome which is cost savings. However, how the outcome is attained is, for the most part, up to the provider. The provider can provide the service any way they choose. Naturally, they will seek to use the most effective and efficient method available. Thus, if the particular service can be provided more effectively and efficiently (i.e. at less cost) by a chaplain, then a chaplain can be hired to provide the service.

A quick description of MIPS and APMs. In MIPS, the provider chooses a number of quality measures to report on from a very long overall list. Many of the measures like patient satisfaction, having advance directives and helping reduce pain, can easily be influenced by chaplaincy care. If chaplaincy care turns out to be the most effective and least costly way of attaining this outcome, the provider may use that method. 

APMs are plans for providing service in which the provider assumes accountability for providing a certain set of services at a certain cost. This set of services may be palliative care or oncology care or pretty much anything. The services are also supposed to be patient-centered. The plans are pre-approved by the government and then any provider can adopt them if they want to.  Various organizations are now submitting plans for approval. Again, as with MIPS, if the inclusion of chaplaincy adds to quality and cost savings, it can be included in the cost that the plan can charge and the services for which it is accountable.

The key to being included in MIPS and especially in an APM is (1) to be able to specify exactly what work your service will do and what outcomes your service will assume accountability for and (2) to be able to precisely price the cost of the work.

So what seems to be the bottom line?  After talking to many people who understand this much better than I do, this is what I understand.

There is an opportunity right now when quality, patient-centered care is the name of the game to demonstrate that chaplaincy adds to both of these goals and can be net cost saving in the process. The outcomes we have always claimed we deliver including patient satisfaction and cost savings are now taken very seriously. Further, a system is coming to a place that will pay for those outcomes.

BUT to take advantage of this opportunity we will have to:

-Rid ourselves of unsubstantiated statements. "We are the best" or "our program works" without data to measure the results against valued health outcomes simply exposes us as a discipline which doesn't understand the values under which the current health care system operates. We must have data to substantiate every claim we make.

-Agree on the outcomes we can be and want to be accountable for. A year ago HCCN put forward a set of evidence-based quality indicators for discussion within the field. To date, no individual or association within the field has engaged that discussion or tested the indicators although the list has been very widely applauded and adopted outside of chaplaincy.

-Be clear what activities we will be accountable for in the service of these indicators.  And we need to agree on how to price what we do. What kind of budget does a hospital need for a professional chaplaincy service and what does that money buy?

Already there is one proposed APM covering end of life care filed for federal consideration that has no mention of spiritual care or chaplaincy. There is another that HCCN is providing input to. However, there is no way of knowing how many others are in process. There will be public comment periods of course but there is real danger that the health care system will move ahead without us even in a time when we have maybe the most clear opportunity in our history to be firmly integrated and paid for.

So what to do?

- Find the table in your institution (and there certainly is one) where these issues are being discussed. We know it is unlikely others will think of us for help here so we need to be there to raise our hand.

- Educate yourself on how your institution currently gets paid and for what and how do they plan to be paid in the future- MIPS vs. APM vs. Accountable Care Org vs. Medicare Advantage vs. Other.

- Think creatively with your chaplaincy colleagues about how you might volunteer chaplaincy to contribute to your institution's plans in this regard. What evidence-based case can you make for adding value to these activities?

There is an unprecedented opportunity here to integrate chaplaincy care and spiritual care into health care and have it reimbursed. However, no one is going to hand it to us. It will only happen if we do the work up front. This work can be done but it will not be easy because it ventures into territory we as a profession have never been in before. 


What Does The Election Mean for Chaplaincy in Health Care?

It is probably a fair assumption that very few people in the US do not have strong feelings about the recent presidential election spanning pretty much the whole spectrum of human emotion. However, whether we are in deep mourning or jubilant celebration, it behooves us to attend to business.

While the consensus I am hearing from people deeply involved in health care policy and funding is that the changes in health care are not apt to be as cataclysmic as both candidates predicted if the other was elected, there will be new changes in what already was a fast-changing health care industry. There will also be a continuation of some of the changes already in progress. These changes, both new and continuing, do not need to be negative for spiritual care. Like all times of turmoil, the situation provides both opportunities and dangers.  But the changes are all coming fast- some even before Mr. Trump takes office. 

The trick for everyone in health care, including chaplains, will be to negotiate this uncharted territory while simultaneously avoiding the grave dangers and taking advantage of opportunities. It won't always be obvious which is which.

While a lot is up in the air, a couple of issues seem to be clear to most experts. First, the new administration along with a Republican Congress is likely to double down on reducing the growth in health care costs, mostly by tightening Medicare reimbursement even further. The Advisory Board, maybe the most respected think tank in health care has said, "This means providers have to maintain a relentless focus on taking excess cost out of their systems, eliminating unwarranted clinical variation, and rationalizing their fixed cost footprints." Cost containment is not news.  However, it is clear that the pressure is only going to intensify. We should expect that no one is safe- including chaplaincy and Clinical Pastoral Education. The key word here I think is "excess".  How is a hospital going to determine what is excess? I think the answer is in what seems to be the next issue.

The Medicare Access and CHIP Reauthorization Act (MACRA) passed Congress with huge bipartisan majorities in 2015.  Because of the bipartisan support and because it supports many Republican positions (unlike the ACA), it is expected to survive and maybe largely intact.  The final rule implementing MACRA was recently released and is becoming generally known as the Quality Payment Program  (QPP).  The key word here is "quality".  QPP might well be translated as "we are only going to pay for quality." How is quality going to be defined? Most likely, quality will be that which serves cost reduction (i.e. reduction of excess costs) and/or better medical outcomes (i.e. reduction of clinical variation which also cuts costs). This is where the movement to payment for value and away from fee for service that is already in full swing meets the new administration agenda for cost reduction. This is why QPP largely stays.

So what about chaplaincy? Put simply, the pressure on clinical chaplaincy and chaplaincy training to demonstrate the value to the institution is likely to ramp up significantly as institutions delve into every corner of their operation to cut costs and increase value. Chaplaincy, along with all other programs and services that cannot show the data to demonstrate their value as defined above, will run an increasing risk of being deemed "excess cost". The good news is that many providers of all disciplines see opportunities in QPP for chaplaincy and social work to contribute value by documenting the cost saving of what we are often already doing in the service of certain quality metrics, and thus actually increase our footprint. In other words, inactivity on the value issue is a real threat, but proactivity can make this a significant opportunity.  

To learn more about this important topic, chaplains should listen to  the free webinar, Update on MACRA Quality Payment Program:  What Palliative Care Providers Should Do Now” sponsored by the National Coalition for Hospice and Palliative Care, the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, and Health Care Chaplaincy Network.   The webinar will be held on Tuesday, November 29 from 12:30 – 2:00 p.m. Eastern Time. Register for free at

So how does chaplaincy demonstrate its value? One course that is out of the question now is trying to get chaplaincy directly reimbursed for any service. Even in the current administration and certainly in the next any attempt to increase classes of providers or newly billable services will be seen as adding costs when all efforts are on reducing costs. Further, as we know, health care is increasingly a team game funded by bundled payments that are headed lower if anything.  In a team game, demonstrating the contribution of any single player becomes difficult.

However, there is a way. The paradigm is in research such as that done by Tracy Balboni and her team that has demonstrated that meeting spiritual needs at the end of life, which is what patients want, also reduces the use of aggressive care such as ICU stays and thus reduces costs. The next step is to demonstrate that this effect is larger and may be delivered more reliably when the team has a certified chaplain on board to lead the effort.

So what should chaplains be doing now?

Listen to the webinar on the 29th.

If you don't know already, educate yourself about how quality programs work. At least learn the language so you can participate in the conversation. Many institutions offer introductory courses for employees for free.

Get involved in the discussions in your institutions about what quality metrics your institution is going to report in the QPP. Many will need to start reporting in 2017. A good number of the options could be advanced by chaplain participation.

Investigate what quality initiatives are ongoing or anticipated in your institution and be creative and proactive in making the case for how what the chaplains do contributes to these. When those initiatives succeed, patients will likely be better served and the role for spiritual care will be enhanced. 

I firmly believe that, if we are aggressive and strategic, we can not only negotiate this new health care environment without serious damage, but we can  genuinely emerge with spiritual care and chaplaincy more firmly integrated than ever before into health care. I strongly believe we can do it without selling the soul of our profession and compromising our historic relationship to patients in the process.  However, there is no time to lose. 


New WHO Guidance on Planning & Implementing Palliative Care: What Should Chaplains Know?

As many know, in May 2014, the World Health Organization (WHO) adopted an extensive new document (WHA 67.19) on palliative care that among other landmarks included spiritual care for the first time. Now, as is customary for WHO, they have issued a guidance document for those in the 192 member countries of the WHO to help them roll out palliative care in their countries. (Planning and implementing palliative care services: a guide for programme managers. (http://

This is a hugely important document for all palliative care providers including spiritual care providers. It reaffirms WHO's stand that palliative care is not just a "nice to have" in health care but a human right. This means that all countries should provide it.

   "Ensuring the accessibility of palliative care is not just an ethical obligation of health systems;         it is also an obligation under international human rights law. The right to palliative care and pain     relief is recognized under the human right to health." (p.6)

For the chaplain reader in North American, it is necessary to understand something about the international context for palliative care in order to understand a lot of why the guide is written the way it is. Readers will notice a significant emphasis on the availability and use of pain relievers- especially opioids. While opioids are maybe too plentiful in the US, they are often very hard to get in many countries because of severe legal restrictions. At the same time in many countries where treatment for diseases like cancer are hard or impossible to obtain, pain relief is all that can be done. As the guide comments on page 6,  "Unfortunately, countries have paid far more attention to their obligation to prevent abuse than to their obligation to ensure access for medical purposes."

For anyone who is at home with the complexities of US health systems, the extensive step-by-step advice on how to set up palliative care in a variety of settings may seem simplistic.  However, in many countries, these models that we often are so used to are rare or unknown.

Finally, chaplain readers will notice that the word, "chaplain" is largely missing. In fact, it is only used once, incongruously, in the list of recommended staff for pediatric palliative staff. The point to remember is that, in most of the world, "chaplain" is far less known than even in North America and Europe. The term does not even have an equivalent in many languages. More importantly, providing trained chaplains is not a model that probably most countries in the WHO can aspire to. Maybe the major challenge for spiritual care providers is how to provide what we would call "specialist" spiritual care as part of palliative care in these contexts.

That all said, the guide makes very clear that spiritual care is to be a part of the palliative care that is required. "Spiritual" is used over thirty times. On page 12, the guide states" Spiritual distress and existential concerns should be treated with the same level of intensity and priority as psychosocial and physical distress or pain. Support may involve a spiritual carer." Spiritual care is not a second-class citizen.

  "Spiritual care should be provided to patients (page 9) families (page 13) and 'professionals             providing care (including self'" (page 10)

    "Palliative care services should, therefore, at a minimum: .... assess and reassess patients for        physical, emotional, social and spiritual distress and   (re)assess family members for emotional,      social, orspiritual distress; ..address spiritual, psychological and social needs;" (page 9)

    "Spiritual "understanding" is described as one of the core tasks of the palliative team (page 60       and discussion of "spiritual suffering" is part of the sample curriculum for training all staff."             (page 87)

Thus the mandate to include spiritual care is quite emphatic and all encompassing. What is beyond the scope of this guide and seems to be the challenge for us in professional chaplaincy to come up with answers to are issues like:

            If professional chaplains are largely not an option, who are these "spiritual    carers" on the team going     to be?

            Where are they going to come from?

            How are they going to be trained?

            How is this training going to be delivered often over vast distances?

Answering these questions presents a colossal challenge but also a colossal opportunity to impact spiritual care around the world.  The WHO has set the bar but much is left to be done.

We in chaplaincy and spiritual care are seriously indebted to a large number of those listed in the acknowledgments who have long championed the inclusion of spiritual care in palliative care and who have yet again carried this inclusion forward.  Those best known to the US audience would include Kathy Foley, Diane Meier and Christina Puchalski but I personally know a number of others in the group who undoubtedly supported this inclusion as well. 



Understaffing in Palliative Care

When the National Consensus Project for Quality Palliative Care released the third edition of its Clinical Practice Guidelines for Quality Palliative Care in 2013, Dr. Betty Ferrell who co-led the project said that any hospital that is not including all eight domains of the Guidelines is not doing palliative care. Note that the word “good” is missing here intentionally. Her meaning is that what you are doing should not be called palliative care if you do not include all eight domains- one of which covers spiritual, religious and existential concerns. The Guidelines call specifically for the inclusion of a "spiritual care professional" on the team. The Joint Commission's Standards for Advanced Certification for Palliative Care includes a chaplain as one of the four required members of the palliative care team.

However, a study just published in Health Affairs reports that using the Joint Commission staffing standards "only 25 percent of participating programs met that standard based on funded positions, and even when unfunded positions were included, only 39 percent of programs met the standard." [i]  The study points out that many programs do not have a physician assigned and rely on an advance practice nurse.

Another related issue is burnout among palliative care staff which Dr. Tony Back and colleagues have pointed out in their recent article appears to be higher among palliative care staff than among other medical disciplines.[ii] Part of the stress, of course, is from understaffing. This stressor can cause turnover, poor team functioning and, of course, substandard care.

In any case, this issue is important to chaplains because the part of palliative care that I see most often understaffed and underrepresented is spiritual care/chaplaincy. Many hospitals say they do palliative care which implies they take care of the spiritual dimension when, in fact, they do not or they do so only minimally. They have access to a chaplain but they do not have a chaplain integrated into the team, and certainly do not support a chaplain out of the palliative care budget.

So what to do?

1. We as chaplains should be supporting all efforts to increase palliative care staffing in all disciplines, and all efforts to increase training sites for palliative care physicians and nurses as championed by the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Care Nurses Association. More well educated palliative care doctors and nurses means more doctors and nurses who understand the role of spiritual care in palliative care- and better care for patients generally.

2. We need to be active in helping develop measures of quality for spiritual care in palliative care. Currently, as I've written elsewhere, the National Quality Forum (NQF)  has only one approved measure in spiritual care and that covers only hospice care, not the rest of palliative care. The NQF does not develop measures. It only evaluates measures submitted to it. Since chaplains are the spiritual care leads on the team, it is up to us to lead in developing more measures to demonstrate the importance and power of spiritual care in health care.

3. We need to be constant and aggressive in advocating for more palliative care staff in our institutions. This includes understanding the research that supports palliative care in general and spiritual care in particular.

The literature supporting the effect of palliative care on satisfaction, QOL and use of health care resources is robust and growing.  All models supporting it also support the inclusion of spiritual care. However, as this study demonstrates, just having a study or a guideline does not make something happen. It happens when people who believe in palliative care take this evidence and use it to advocate for better care.


[i] Spetz, J., Dudley, N., Trupin, L., Rogers, M., Meier, D. E., & Dumanovsky, T. (2016). Few Hospital Palliative Care Programs Meet National Staffing Recommendations. Health Affairs, 35(9), 1690-1697.

 [ii] Back, A., Steinhauser, K., Kamal, A., & Jackson, V., (2016). Building Resilience for Palliative Care Clinicians: An Approach to Burnout Prevention Based on Individual Skills and Workplace Factors. J of Pain & Symptom Management, 52(2), 284-291.




Implications for Spiritual Care from Recent National Quality Forum Meeting

The National Quality Forum (NQF) is a not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in healthcare. One of NQF's activities is to convene multistakeholder Standing Committees in topical areas that are charged to review and recommend submitted quality measures for endorsement to NQF’s Consensus Standards Approval Committee (CSAC). NQF endorsement is often a stepping-stone to inclusion on federally required data sets for various levels of health care providers.  These data sets are often tied to reimbursement for those providers. So this endorsement is a big deal.

Recently, Chaplain Margie Atkinson, the current President of the Association of Professional Chaplains (APC) and I were appointed to the End of Life and Palliative Care Standing Committee. It is important to note that while we were nominated by APC and HCCN respectively through both organizations’ membership on the National Coalition for Hospice and Palliative Care, we serve because the NQF staff judged that each of us is qualified to sit on the committee. We do not represent our nominating organizations nor do any organizations have any allocated seats on any standing committee.

Over the years, I have occasionally heard several questions raised within chaplaincy about NQF and why spiritual care and chaplaincy were not represented in its membership or in the measures it endorses.

The membership question is fairly simple. Only NQF member organizations can nominate people to the committees and being a member is very expensive. HCCN and APC get to nominate because both organizations are members of the Coalition that in turn is a member of NQF.  The Coalition submitted a number of nominations in this round many of which were accepted, but some were not.

The question of why there are not NQF endorsed spiritual care measures is also simple in a way. NQF does not itself develop measures. It only considers measures for endorsement that are submitted to it. Further, to be endorsed, measures must satisfy a number of very extensive and very rigidly applied criteria including (1) evidence that the measure improves some specific health care outcomes (2) evidence that the measure measures what it claims to measure and (3) evidence that the measure reliably measures what it claims to measure the same way for everyone, every time. Exceptions to (1) are possible at least at the beginning of the measure's use. The one spiritual care measure of the 35 currently endorsed in EOL and Palliative Care is, in fact, endorsed as an exception and it was not submitted by chaplains but by a research group at Univ. of North Carolina. One result of this gap is that spiritual need and spiritual care are not measured in most required data sets. Thus, one of the major motivators for organizations to integrate spiritual care is missing.

So what do chaplains need to do to remedy this situation? The place that most measurement efforts start is with screening measures that are then paired with treatment measures. By example, one endorsed measure reports the percentage of people admitted to hospice who are screened for pain. The paired measure reports the percentage of people admitted to hospice who screen positive for pain who then are treated for their pain.

Using a chaplaincy example, it might be reasonable to start by proposing the Rush spiritual screening protocol that has some validity testing already done. What would be needed in addition is (1) significantly more validity and reliability testing and (2) research evidence that using the Rush improves some particular health outcomes. It is important to note here that demonstrating that treating spiritual distress improves health outcomes is a contribution and some of that evidence does exist but this evidence is not sufficient for NQF endorsement. The evidence must demonstrate that doing the screening itself leads to improved outcomes.  

It is certainly true that few chaplains have the ability or resources on their own to do this kind of research. However, many have the ability to advocate for this kind of research in their institutions and lend their expertise to the projects. The reality is that unless and until this kind of effort occurs in our field, except in a very few instances, spiritual care quality measures will not take the place they need to occupy to help move spiritual care integration in health care forward.