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Tuesday
Dec292015

New Year's Resolution- Being Able to Support What We Claim

I have never been much for New Year's resolutions. My take for myself at least has always been that I should make changes in my life when I decide I need to make them and when I'm so motivated, not because it is the new year. However, as I am taking some relative down time caused mainly by everyone I work with being on vacation and thinking about the projects I have coming up, one resolution does occur to me that I believe will help me and help advance professional chaplaincy.

My resolution was stimulated by a review article by Blinderman and Billings in the December 24th NEJM in which they make the point that the term, "comfort care", is sometimes used in a "misleading or imprecise manner". One example is when it seems to mean only that the patient has a DNR order while missing all the other implications and opportunities that true comfort care implies. This all too common issue reminds me how easy it is to misuse some very popular terms of the day so that we appear to make claims beyond what the claimant can really support or what is really true. Thus "comfort care" without attention to all the patient's symptoms is not comfort care.  Likewise, Betty Ferrell has reminded us that palliative care without attention to all eight domains of the NCP Guidelines is not palliative care.

My particular concern, both for myself and others, is that, in the current health care environment, many stakeholders assume that any claims one makes for one's profession are backed up by evidence and that evidence can be produced if asked for.  In other words, any claim is more and more often assumed to be "evidence-based" whether that modifier is used or not. Put another way, to make a claim for what we do or how effectively we do it without being able to provide evidence does not live up to the current standard for making these kinds of claims. Most importantly, it is the evidence-based claims that will advance our profession and the non-evidence claims that will mark us as a profession which cannot or even refuses to document how it contributes.

A pause to be clear what I mean by evidence.  It can be in the form of a quantitative research study, which is the form most people think about. However, the common categories of evidence in lists such as the one we used in our work for the US Navy also allows qualitative studies, case studies, consensus panels and even a category called "expert opinion".[i]  The latter are considered lower levels of evidence and should be identified as such but they do count as evidence.

The pitfalls for chaplaincy in this regard are many.  The late CPE Supervisor, Art Lucas, challenged his students years ago to provide concrete evidence for any outcomes they claimed for a patient visit rather than simply presenting assumptions or belief.[ii] I still hear and read claims for the efficacy of chaplaincy such as that we reduce law suits for which there is not a bit of evidence of any kind.

One temptation that I find myself succumbing to from time to time is to confuse what I believe to be true with what I know to be true. For instance, while I firmly believe that chaplaincy services properly targeted and integrated are cost savings to an institution and that some day the research will demonstrate that, there is no evidence yet to support that belief. To be clear, there is no problem with me making this claim as long as I am clear that this is only my opinion and not supported by any other evidence.

Along this same line, it is all too easy in the present environment to make the blanket claim that chaplaincy is "value added" or even that our training or certifications are demonstrably value-added. We as professional chaplains believe this of course (we worked too hard to be trained and certified not to) but the truth is that there is no evidence to support the contention that CPE or the BCC process reliably makes us "better" chaplains or adds value to the health care enterprise. The fact is we can't really even describe yet what "better" means in the context of health care.

So finally to the resolution.  I pledge that in my writing and speaking I will strive to support every claim I make with evidence including the level of evidence and to provide the specific citations for that evidence whenever the situation allows so that anyone who desires can verify my claim. If I make a claim that is only my opinion, I will strive to make that clear. These claims include claims for the value added of spiritual care and chaplaincy care, claims for what chaplains should be doing and producing, and claims for the efficacy of chaplaincy education and the competence of chaplains. I challenge my colleagues to strive to meet this same standard and I reserve the right to challenge anyone in the profession who makes claims that are not evidence-based. 

As a rabbi friend of mine likes to say, Happy Gregorian New Year!

 


[i] Hughes B, Handzo G. 2010. The Handbook on Best Practices for the Provision of Spiritual Care to Persons with Post Traumatic Stress Disorder and Traumatic Brain Injury. United States Department of the Navy, Bureau of Medicine and Surgery.

 

[ii] VandeCreek, L, Lucas, A. 2001.  The Discipline for Pastoral Care Giving: Foundations for Outcome Oriented Chaplaincy, J. of Health Care Chaplaincy, 10(2) and 11. 

Friday
Dec112015

Where Will This End?

I recently saw a play called "The Christians" by Lucas Hnath. While it does take place in a Protestant church and all the characters are Christians, the issues raised are universal and apply, not only to people of any faith, but to people of any kind of belief at all. Since everyone should see this play, I do not want to give away the plot. However, one of the important issues the play raised for me is how widespread and sometimes subtle intolerance can be.

In religious circles, many think of intolerance as a defining characteristic of conservative religiosity. Scriptural literalists and "fundamentalists". But what about the widespread intolerance of scriptural literalists by many "liberal" segments of our society? Is that intolerance and distain any less damaging to the fabric of our communities?  

Coming of age in the 1960s, I wanted at least to believe that our intolerance and our unwillingness to accept others as equals was declining if not coming to an end. The movements for "civil rights", "women’s rights", and "gay rights" all seemed to promise that we were growing more tolerate and mutually accepting as a society. However, many years later it is not safe to be black in the US. It is not safe to dress or act in a way that might lead others to suspect you are gay.  And now, it is clearly not safe to dress or act in a way that would lead others to suspect you are Muslim. It is definitely not safe to be in a Muslim house of worship.

Worse, it seems that many in our society of all backgrounds are of the belief that the way to defend ourselves against those who we refuse to tolerate or we perceive to not tolerate us is to shoot them thus creating a society which is not safe for any of us.

Clearly, finding ways out of this situation is everyone's responsibility. Yet, it seems to me that we as chaplains have a special responsibility. Values such as mutual respect and treating everyone with dignity have been cornerstones of our profession. We are supposedly experts in helping people listen to each other and hear each other rather than becoming adversarial. One of our professional mantras is "accepting people where they are" and we have never put any caveats on that statement.  Maybe even more importantly right now is that we are trained to recognize intolerance and disrespect when we see it and hear it and have the skills to bring attention to it in a way that can produce true listening and community.

At this point, these values and skills can be of a huge benefit to our whole society.  However, we need to be assertive and risk taking in calling attention to ideas and speech that separates us when we see it and hear it.  We need to be more aggressive in demonstrating good listening and acceptance in all of our encounters and modeling the behaviors we know will build community rather than tear it apart.  

None of this of course will reduce the prejudice and narrow-mindedness in our society over night. But it will help.

Wednesday
Nov182015

ICD-10 and Reimbursement for Spiritual Care

There has been much discussion and speculation recently among chaplains about the advent of ICD-10 and the fact that it contains codes for some spiritual interventions which chaplains do.

ICD-10[i] is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO).[ii] It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. It is widely considered the gold standard used for billing for any kind of medical services.  Chaplains have correctly noted that ICD-10 has codes for some spiritual interventions. They have also noted that the Centers for Medicare and Medicaid (CMS)[iii] will now start to pay for patients having end of life conversations. Lastly, it has been noted that social workers can bill.

All of this has led some chaplains to assume/hope that ICD-10 will allow chaplains in the United States to bill for spiritual interventions which now have codes and the CMS regulations will allow chaplains to bill for end of life conversations. Unfortunately, this is incorrect on all counts.

Social Work billing is limited to Licensed Clinical Social Workers (LCSW) who are functioning as psychotherapists, a level of functioning that most chaplains are not trained for or disposed to embrace.  The National Association of Social Workers (NASW)[iv] does not appear to promote any other reimbursement strategy at this time. The "end of life conversations” that are cited are reimbursement codes for physicians (and secondarily for Advanced Practice Nurses (APN) and Physician Assistants (PA) under the direction of the physicians). Those who were responsible for lobbying for these new codes agree that, eventually, chaplains and social workers need to be included. However, if that discussion is opened now, the whole proposal would at least be held up for a long time and probably scuttled altogether.

There is also a prior issue for chaplains.  In order to be reimbursed for medical services in the US as an individual provider, the provider needs to be able to bill under a billing code assigned by the National Uniform Billing Committee (NUBC)[v]. Chaplains do not have such a code.  The process is complicated. At least one attempt has been made to obtain such a code in the past and that request was denied.   The rationale was that there were no current payers for chaplaincy services, yet payers cannot be approached for reimbursement without a valid NUBC code.   Efforts continue to address this conundrum. However, the general opinion is that, politically in this time when cutting medical expenses is the goal, there is probably no support for adding a whole new class of providers to the payment mix even if the problem above can be addressed.

An alternative is to be part of a bundled service like hospice where chaplaincy and social work costs can be included in the bill for the bundle.  At least in that case, spiritual care is required but, as we all know, service provided is often minimal and sometimes skipped altogether.  And again, even a bundled strategy is not likely to succeed if it adds costs to the system. To qualify for CMS’s recognition as a billing party in Medicare reimbursement would require that we seriously redefine what chaplains do clinically in healthcare and redefine how chaplains are educated and trained to provide clinical services that are recognized as medical in nature.

So what’s to be done for chaplain reimbursement? Continued attempts to obtain an NUBC code are warranted and continue to be in process. Conversations need to be initiated with payers about reimbursement for chaplaincy services so that the documentation needed to apply for a NUBC code can be obtained.    Another road is regulatory such as the Joint Commission[vi] requiring a trained chaplain in order for a hospital to be certified in palliative care.

Chaplains can contribute to this effort by adding to the evidence-based literature of the work they do and the outcomes obtained for patients, staff, and the organization especially if that research shows cost savings to the institution.  Research isn’t simply a good thing to do; it is necessary to move the profession ahead, including in its goal to seek reimbursement for chaplains


[i] http://apps.who.int/classifications/icd10/browse/2010/en

[ii] http://www.who.int/en/

[iii] https://www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-CM-and-GEMs.html

[iv] http://socialworkers.org/

[v] http://www.nubc.org/

[vi] http://www.jointcommission.org

 

The Rev. George Handzo, M.Div, BCC, CSSBB

Director of Health Services Research & Quality

Health Care Chaplaincy Network

 

The Reverend Lerrill J. White, M.S., M.Div., BCC, ACPE Supervisor

Manager, the Center for CPE

Vidant Medical Center

Greenville, NC.” 

 

The Rev. Susan Wintz, BCC

Director, Professional & Community Education

HealthCare Chaplaincy Network

 

.” 

Friday
Oct162015

There is Hope for Friendship Across What Divides Us

Like many, I am increasingly distressed by the overt hatred being expressed in many countries, including the US, by certain individuals and groups toward other groups because of that group’s ethnicity, culture, or religion. And it seems that this hatred results more and more often in violence and death. I guess I was one of those who at least wanted to believe that we as a country and maybe even as a human race were becoming more integrated and so moving past this kind of hatred and violence.

Even more disturbing is what seems like a lack of any will on the part of our leaders to implement laws and structures which aim to restrict this behavior at least to the point of making it as difficult as possible for anyone to intimidate or harm others simply because they are Muslim, African- American or gay. Yes, we are very fortunate to have the Bill of Rights in the US but many seem no longer to appreciate that none of those rights are without limit including when the right applies to them.

We who work with seriously ill persons and their loved ones in the health care system know well that the process of helping people get the care they want and is best for them relies heavily on trust and respect between those receiving care and those providing that care. To use a seemingly extreme but increasingly likely example, if as the relative of a seriously ill Christian patient you have been told again and again by those who hate that Muslims are only out to convert or kill Christians and so don’t belong in the US, even if you tell yourself that you don’t really believe that, might you not be at least a little hesitant and distrustful of the advice of a Muslim physician who suggests to you that it is time to disconnect your mother from the respirator and let her die? Very possibly. And in the process you might subject your mother to needless suffering.

And yet there are signs of hope. Recently, armed protests were promised in front of mosques all over the US by an organized group of people filled with hate. It seems not too many people showed up and, maybe more importantly, many were met by very peaceful people who wanted to engage them in respectful conversation about their beliefs.

On that same weekend, my family and I joined about 92,000 people to watch the US and Mexican national soccer teams play at the Rose Bowl in Los Angeles. Our tickets turned out to be at the boundary between all Mexican fans and all US fans- so a mix of both. These are people very passionate about this sport and their loyalty to their team is high so I wondered how this would go with the two groups mixed in the same section. Yes, there were lots of attempts to shout louder and longer than the other group but it soon became apparent to me that this was all done as part of the “game”. Shouting was followed by laughing and a number of times I saw a fan from one side ask a fan from the other to have their picture taken together wrapped in both flags. This request was always accepted.  

So there is hope.  Those of us who personally and or professionally understand how destructive hate and distrust can be to all of what we as people need to do in community should be motivated to redouble our efforts to promote respect and dignity in all of our relationships especially in the face of those who would convince us otherwise.

Monday
Oct052015

Get Palliative Care

Thanks to our colleagues at the Center to Advance Palliative Care, the latest figures are out on the penetration of palliative care services into the US health care system. The good news is that about two-thirds of hospitals offer palliative care. The bad news of course is that about one-third don’t. Further the rate of growth of palliative care seems to have slowed.

On top of this, I am certain that while the number of hospitals claiming to offer palliative care has hit the two-thirds mark, the number meeting all domains of the National Consensus Project for Quality Palliative Care is way below that number. I know this is true for Domain 5 (Spiritual, Religious and Existential Aspects of Care).  And finally, I am certain that even when the palliative care team has a chaplain included, that chaplain is not always fully trained in palliative care.

This latter point may need some explanation.  Dr. Diane Meier recently laid out four tactics for improving palliative care. The first two certainly apply to chaplains as well as others on the team.

1  Explicitly ask patients and their families what matters most to them, and ensure that this information is recorded, made available in the medical record, and actively used by all involved parties in decision making about care.

2. Require that all clinicians (doctors, nurses, social workers, and others) receive basic training and certification in pain and symptom management, communication, and coordination of care across time and settings.

My guess is that even many chaplains involved in palliative care do not routinely comply with #1 and very few have the training required in #2. I do trust that most chaplains know a lot about how to be the spiritual care specialist that is our primary role on the team. I suspect far fewer know how to be the physical care generalist and overall team player required by this standard. To be clear, individual chaplains are not primarily to blame here. I would be hard pressed to offer suggestions to a chaplain who wants this training at a level appropriate for chaplains. It is certainly not a regular part of CPE nor of the continuing education events chaplains regularly attend.

The research is now very clear about the desire of patients and their family caregivers to have what matters to them be a major determining factor in how their care is conducted and about the benefits of that inclusion for patient satisfaction and medical outcomes. While as Dr. Meier points out, asking patients about that is everyone’s responsibility, chaplains talk about these matters with patients all the time. The big change is making sure that they do it routinely and that those wishes are documented and remain front and center in the team’s care planning.

As to training, it would seem that the first goal is for chaplains and chaplain educators to appreciate that the knowledge base for working as a chaplain in the health care system includes much more than what has historically been included in delivering spiritual care. Once demand for this training is created, training opportunities will follow.

These two changes in practice and training will improve the care patients and caregivers receive and increase the value chaplains add to the health care system.