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In May I wrote a post entitled Are Sales People Killing Hospice? that sparked an interesting discussion among members of the LinkedIn Hospice Group. A tangential discussion thread within the My.NHPCO Clinical and Operations Management Group on the use of admission representatives instead of nurses to make the initial visit prompted this post (if you are not an NHPCO member you probably won't be able to access the discussion). Specifically, NHPCO’s ethics guru (not an official title), Tim Kirk’s use of an ethical lens to think about the issue of informed consent reminded me of a perhaps underutilized NHPCO resource – the Ethical Marketing Statement.
I want to call your attention to several items within the document, starting with a reference to the American Marketing Association’s Statement of Ethics, which is a great read for any marketing professional and includes this:
“As marketers, we recognize that we not only serve our organizations but also act as stewards of society in creating, facilitating and executing the transactions that are part of the greater economy. In this role, marketers are expected to embrace the highest professional ethical norms and the ethical values implied by our responsibility toward multiple stakeholders (e.g., customers, employees, investors, peers, channel members, regulators and the host community).” American Marketing Association’s Statement of Ethics
I love the idea of marketers as “stewards of society” – more on that in a second.
The NHPCO Ethical Marketing Statement includes:
“…if competitive practices strive only to gain an advantage based on promises that go unfulfilled or overextension of services that in essence become inducements for referrals, this leads to inferior quality and reflects poorly on the hospice and palliative care industry.” NHPCO Ethical Marketing Statement
So here we are, hospice marketers and leaders, with a responsibility to be stewards of society with the ability to damage the reputation of the hospice and palliative care industry. This is a huge responsibility and one that is not thought about and emphasized enough. It is the crux of my concerns regarding sales people within hospice. Of course I do not think all hospice “sales” people are acting in an unethical manner. What worries me, and I hope it worries many of you too, is that hospice marketing happens outside the context of our values.
The NHPCO document goes on to state:
“NHPCO believes that hospices must accurately represent the capacity and services of their organization in all marketing, outreach and education.” NHPCO Ethical Marketing Statement
Staff who are representing your organization out in the community – specifically those who talk to seriously ill people and their family caregivers -- have an ethical responsibility and a moral imperative to accurately represent your hospice organization’s capacity to meet the individual needs of the patient and family. As hospice leaders, your responsibility is to ensure that what your sales staff is saying is accurate. We’ll come back to that in the section below.
Okay, let’s look at one more section of the NHPCO Ethics statement:
“The promise of services before an in-person assessment is conducted is a questionable practice that is not appropriate for hospice providers. Additionally, rewarding admission staff bonuses based on predetermined admission goals is not appropriate and must be discouraged. This practice can lead to rushed admission visits that result in a poor understanding on the part of patient and family members and/or questionable eligibility assessments. Informed consent can also come into question. If admission staff priorities become that of a sales force, critical clinical information and service will suffer.” NHPCO Ethical Marketing Statement
I bolded those two sections of the paragraph to highlight what I see as possibly perverse incentives for people who interact with potential patients and family caregivers. Those on the receiving end of a hospice intake/admission visit do not necessarily understand what hospice is, are frequently in desperate need of support and the services that hospice can offer, and may be emotionally exhausted. That combination of factors can make it hard for these often vulnerable people to take in new information and make what can be an incredibly difficult decision to elect hospice, let alone choose the best hospice to meet their needs. What these families often need is TIME to think through and process the information presented.
Wait, I can hear people already saying, "Kathy, we don’t have time – referrals are coming in to us too late as it is." And that is absolutely true, yet if this process is rushed, I believe more and more families will leave the hospice experience feeling as if the promise of hospice was unfulfilled.
Enough background, here’s what I think hospices (and any organization) can do to ensure they are using ethical marketing practices.
Having a set of values that you display in your office, post on your website or review in staff/volunteer orientation is not enough. Ethical marketing starts with the values of your organization, which means that your marketing plan must reflect those values. This is a rich topic and one deserving of a longer post, but here are a few action items to reinforce your values:
As leaders it’s our responsibility to know what our staff are saying when they represent the organization.
When my son was little, a teacher told us that every day our son was acting out and being taken to the office for a time out. As we talked more with the teacher, we learned that while in the office he was able to play with Legos, one of his favorite toys. Just as children cannot resist the temptation to act out when rewarded for bad behavior, neither will our staff.
Monetary rewards for intake or marketing staff cannot be tied to admissions or length of stay. Period.
Posted by Kathy Brandt, MS, Principal of the kb group
Marketing audits identify areas to increase your census, ensure compliance with regulations, and strengthen your brand. To learn about marketing audits and other Survival Skills for Hospices, a collaboration of Weatherbee Resources and the kb group, visit our website or email firstname.lastname@example.org
On Old Olympus Towering Top*
Chef CMS did stir his pot
Relatedness, he was heard to say,
Must now begin and end the day
The hospice doc, with pen in hand
With the IDG must traverse the land
Of diagnosis, prognosis, services and meds
Armed with data, history,
Collaboration and regs
And tell us which of these cannot be said
To be a strand in the patient’s thread
Dear doctor, please do not despair
Because you most certainly do care
And through discussion, deliberation
Determination and grit
The salient points will surely hit
Documenting well each six month story
With details as rich as any cacciatore
Traversing this path, a trail you blaze
That will shine a light and dispel the haze
Unus pro omnibus, omnes pro uno**
From patient to staff, from Miami to Juneau
A clear, coherent tale emerges
That will stand the test of regulatory surges
Take heart, therefore, and do not fear
Be bold and write so all will hear
For CMS has given you the power
To determine the diagnosis/prognosis of the hour
So lead out, as you have been trained to do
Bidding confusion, stress and chaos adieu
May I be the first to acknowledge that I am certainly not a poet! Let me also be clear that this is written with the utmost of respect for the sacred responsibility that we elect in accepting the privilege of caring for those at the end of their lives. However, in the stressful times in which we are living, with increasing regulatory and public scrutiny, burdensome processes (e.g., The Hospice Item Set, CR 8358, etc.), and unclear guidance (e.g., Medicare Part D), my hope is that a small dose of humor might help in palliating some of the symptoms of confusion, frustration and disempowerment. And so yes, this blog post is ‘related’!
Heather Wilson, in her March blog on “Hospice and Part D,” thoroughly covered the ins and outs of the 2014 Final Guidance on Part D requirements, relatedness and the recommended prior authorization process. What this post attempts to do is highlight the physician role in this process.
I have always loved words and like to look at healthcare delivery through what I call the “4 Cs: Communication, Coordination, Collaboration and Continuum of Care.” It’s now time to move down the alphabet chain and I propose that we look at best practices for physician involvement in this arena through the lens of the “Four Ds: Discussion, Deliberation, Determination and Documentation.”
To recap the regulatory guidance as it pertains to the hospice physician/medical director:
Hospices are responsible for all care of the patient related to the terminal prognosis and its related conditions
Unless there is clear evidence that a condition is unrelated to the terminal prognosis, all services would be considered related
It is also the responsibility of the hospice physician to document why a patient’s medical need(s) would be unrelated to the terminal prognosis
Determination of what is related versus unrelated to the terminal prognosis remains within the clinical expertise and judgment of the hospice medical director in collaboration with the interdisciplinary group (IDG) (48 FR 56010- 56011)
Ensure that the admission team is able to give a report to the admitting/certifying physician that includes all available data necessary for determination of eligibility, choosing the hospice-qualifying diagnosis and making relatedness/unrelatedness decisions
Encourage the hospice physician to collaborate with the referring physician or the patient’s primary physician, as this collaboration can be a rich source of information impacting clinical decision-making. These conversations often reveal data not found in the patient’s clinical record or previously shared with the admission team
Involve hospice physicians, whenever possible, with the potentially “difficult” discussions with patients and families regarding unrelated medications/services
Collaboration is essential -- whether that be with the admission nurse/team and/or the IDG
To facilitate this stage, the hospice physician needs access to all the supporting documentation of the patient’s history to make the required determinations
Ensure that there are processes in place to expeditiously procure clinical records (including inpatient hospitalizations, diagnostic reports, laboratory reports, etc.) from the primary care/referring physician, or specialist consultations, when appropriate
The hospice physician must determine the hospice-qualifying diagnosis and then which additional diagnoses (comorbidities and/or secondary conditions) are related to the terminal prognosis and which are not
Coverage decisions are not always analogous to relatedness; one must also factor in the patient’s goals of care, the time to benefit for therapies, risk/benefits of therapies, etc.
Clinical pharmacists are a valuable resource in the determination process of which medications are related/not related to the patient’s terminal prognosis
The hospice physician must document in the clinical record all diagnoses, comorbidities, secondary conditions, therapies and medications that are determined to be unrelated to the terminal prognosis
This documentation needs to be clearly identifiable in the record
The hospice physician should complete this process at admission; with reassessment resulting in additions/changes in diagnoses; with changes in the patient’s condition, plan of care, level of care, or place of care; and at recertification
Establish a protocol for the location of documentation in each clinical record to ensure uniformity and enable quick access for clinical and auditing purposes
The hospice physician should document any communication s/he has regarding coverage determinations with patients/families, hospice team members, pharmacists, other physicians, and Part D sponsors
If there are medications/therapies that are determined to be unrelated to the terminal prognosis, the hospice physician must document the reason for the unrelated determination and communicate it to the Part D sponsor
The determination of relatedness is then used to capture and code the hospice-qualifying diagnosis and the related secondary conditions and comorbidities on the claim form. This is not a physician-specific responsibility and is best done by a professional coder or staff member trained in hospice coding
Work collaboratively with admission nurses to ensure that there are clear expectations of data/documentation needed for determination decisions
If possible, see new patients shortly after admission
Communicate clearly with team members about related/unrelated determinations
Make determination/coverage decisions at admission and as a part of IDG meetings when possible
Protocols/guides may be useful in the determination process but each decision must be based on patient-specific factors
Avoid “cookie-cutter” decisions
Be proactive in participating in the identification and resolution of any conflicts surrounding the appropriateness of certain interventions (e.g., parenteral antibiotics, specialist visits, transfusions, etc.) and DOCUMENT your determinations
Remember that relatedness refers to the terminal prognosis not solely the hospice-qualifying diagnosis; prognostication is a part of the practice of medicine
Posted by Suzanne Karefa-Johnson, MD, Physician Associate, Weatherbee Resources, Inc.
*A well-known mnemonic for cranial nerves
* *All for one, and one for all
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