It Is About the Money
Sunday, May 14, 2017 at 09:22AM
George Handzo

I have devoted a lot of time and energy over the past several years to the development of the "evidence" for spiritual care and chaplaincy. That means mainly guidelines and studies with numbers. We have made some major gains over that time. The 3rd edition of the NCP guidelines[i] and the research of Tracy Balboni[ii] and colleagues and Deborah Marin and colleagues[iii] are major examples. The case for the inclusion of spiritual care and chaplaincy is much more compelling today than it was ten or even five years ago. And yet, despite the fact that spiritual care is named as a required service in virtually every model for palliative care, study after study continues to show that chaplaincy (and to a lesser degree, social work) lag behind and are the most often omitted members of palliative care teams[iv].  

In an interview discussing this study, Dr. Sean Morrison said:

We've seen really a tremendous growth in the number of advance practice nurses that are in the field. We've also seen a growth, you know, an accompanying growth in terms in of the number of physicians. But where we, as you said, we still have a lot of room for improvement is both in social work and in chaplaincy. And it's perhaps not surprising that those are the two disciplines where they can't bill for their services. And I think a large part of the lack of growth in those two areas is because of finances[v].

Recently I reviewed and submitted comments on two documents outlining guidelines for community palliative care.  In both, spiritual care was included. In one case, the document stated that spiritual care should be provided "when reasonable". In the other case, "availability" was all that was required. Further investigation convinced me that at least a part of the issue in each case was the presumed costs of chaplaincy. This will certainly amuse or anger many chaplains who know how little money most institutions invest in spiritual care and how cheap it is. While we should continue to develop "evidence" in all forms, we need to go after the money issue directly and aggressively.

Why is this happening? What is missing?

There is no silver bullet here of course but at least in part, I think we have not focused on making the business and financial case justifying the value of what we do. Years ago, the values of health care, the reimbursement structures and the lack of spiritual care research would have made that task impossible in a convincing way. I and others now believe that the situation has changed dramatically. It is now entirely possible and essential to the survival and growth of spiritual care that the case be made both in general terms and in terms that are customized to each institution.

What needs to happen for that case to be made in a convincing and widespread way?

1. We need to get over the attitude many chaplains still have that letting money drive our ministry is somehow beneath us or even unnecessary or something we can never build a case around.

2. We need to make common cause with social work. Neither chaplaincy nor social work can any longer afford to be engaged in turf wars over who does what in psychosocial-spiritual care. We need to get it straight, agree, and support each other. This will mean some swallowing of egos but it will benefit patients. Otherwise the game too often played by administrators of divide and conquer will continue.

3. Each of us needs to educate ourselves on the evidence for the cost effectiveness of spiritual care and chaplaincy at this time in health care. A paper recently produced by HealthCare Chaplaincy Network is a good place to start and a resource that can be passed on to administrators[vi].

4. Each of us needs to educate ourselves on what our individual institution is focused on in terms of cost savings and revenue generation, especially in light of the latest federal quality reporting options that have serious financial implications. Is it patient satisfaction? Is it care in the last month or 6 months of a patient's life? Is it increasing the percentage of patients with advance care plans? Whatever that is in our institution, we need to work at figuring out how chaplaincy can contribute and demonstrate that contribution in dollars made or saved.

5. We need to be pressuring our professional associations and certifying bodies to be involved both in resource development and direct advocacy. What resources and educational opportunities have your professional association offered membership on this topic? What direct advocacy are they doing both at the federal and state level? What support are they offering you directly to deal effectively with challenges in your institution? There are a dozen or so associations in the US that certify health care chaplains. How has your body collaborated with the other eleven in this cause?  (Hint: It is not true that all these bodies refuse to talk to each other.) Are we teaching aspiring chaplains the skills and knowledge they need to produce value added outcomes in health care chaplaincy and do our certification processes focus on making sure those skills and that knowledge are demonstrated- how to build a spiritual care service and do quality improvement for instance?

Again, this is not the time for turf wars or "we are the best" talk. We want to see all our associations grow and thrive.  What we should be caring about is how we are supporting each other in making a difference, not for our association, but for the patients we serve.




[i] The National Consensus Project for Quality Palliative Care Clinical Practice Guidelines for Quality Palliative Care 3rd edition 2013.

[ii] Balboni, T. A., Paulk, M. E., Balboni, M. J., Phelps, A. C., Loggers, E. T., Wright, A. A., ... & Prigerson, H. G. (2010). Provision of spiritual care to patients with advanced cancer: associations with medical care and quality of life near death. Journal of Clinical Oncology, 28(3), 445-452.

 [iii] Marin DB, Sharma V, Sosunov E, Egorova N, Goldstein R, Handzo G. 2015. The relationship between chaplain visits and patient satisfaction. Journal of Health Care Chaplaincy. 21 (1):14-24.

[iv] How We Work: Trends and Insights in Hospital Palliative Care

[v] "Sean Morrison and the Current State of Palliative Care",  GeriPal: Geriatrics and Palliative Care Blog, April 19, 2017.

[vi] Spiritual Care: What It Means, Why It Matters in Health Care. 

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