Hospice and Palliative Care (07/09/2009)

Final
STAFF SUMMARY OF MEETING

HOSPICE AND PALLIATIVE CARE

Date:	07/09/2009	ATTENDANCE

Time:	09:03 AM to 03:05 PM	Balmer
		Cadman
Place:	HCR 0107	Kester
		Newell
This Meeting was called to order by		Roberts
	Representative Riesberg	Soper
		Tochtrop
This Report was prepared by		Tyler
	Kelly Stapleton	Williams
		Riesberg
		X = Present, E = Excused, A = Absent, * = Present after roll call

Bills Addressed:		Action Taken:
Introductory Remarks National Palliative Care Medicare Perspectives on Hospice Overview of Hospice Licensing and Reporting Pediatric Hospice and Palliative Care The Option to Die in Peace Concluding Remarks		- - - - - - -

09:03 AM -- Introductory Remarks

Representative Riesberg brought the meeting to order. He spoke to a handout provided by the Colorado Center for Hospice and Palliative Care regarding hospice cost savings (Attachment A).

09:06 AM -- Urban Hospice: Current Challenges and Potential Solutions

Cathy Wagner, Colorado Community Hospice, introduced herself and provided a handout to the committee (Attachment B). Ms. Wager provided information regarding the composition of the Colorado Community Hospice. She explained that some patients are not ready to discuss hospice and the implications of what it means. She stated that many physicians try to have conversations with their patients regarding end of life decisions, but many are hesitant to have those discussions. The committee discussed how to encourage more individuals to fill out some type of end of life directive. The committee discussed how to streamline end of life documents. Ms. Wagner stated that many people believe that filling out end of life directives is equivalent to acknowledging that they are dying. She stated that she would like to move the discussion towards having individuals understand that filling out advanced directive forms are helpful. Ms. Wagner spoke to patient's rights and advanced care directives.

09:33 AM

Ms. Wagner discussed the evolution of hospice care. She described the hospice approach to care. She spoke about long-term care providers and the need to coordinate care better between the two entities. Ms. Wagner spoke to the need for increasing surveys performed by the state. There was some discussion regarding the accreditation of hospice facilities. She stated that as of December 2008, new federal regulations for Medicare became effective. Ms. Wagner explained a scenario where a hospice patient may be in need of some type of general in-patient admittance. She explained that in order to admit the person to a hospital, a mental health diagnosis or a "PASR" or a pre-admission screening and resident review, must be ordered for the patient to be admitted. She explained that these patients are typically in crisis and are in need of a particular type of drug immediately. She stated that a PASR takes more time than is available due to the crisis situation. She stated that this regulation does not provide quality of care or take into consideration the safety of the patient.

09:59 AM

Ms. Wagner continued to respond to questions to the committee, with Representative Tyler inquiring about certification of hospice centers. Senator Tochtrop asked clarifying questions about what medications may be administered by hospice care employees.

10:01 AM -- The committee took a brief recess.

10:09 AM -- National Palliative Care

The committee reconvened. Porter Storey, Executive Vice-President, American Academy of Hospice and Palliative Medicine, Kaiser Permanente, introduced himself. Dr. Storey spoke to national palliative care issues. Dr. Storey provided a power point handout to the committee (Attachment C). He reiterated testimony from Dr. Cordt Kassner stating that most patients prefer to die at home, yet most people die in hospitals. He stated that he envisions that in the future a majority of hospitals will have a palliative care unit as palliative care improves the quality of life for the sickest and most vulnerable patients. He stated that nearly 1,100 hospitals nationwide have a palliative care program, a 63 percent increase since 2000. Dr. Storey stated that a study was conducted that showed there was a direct correlation regarding the number of people who die at home and the number of hospital beds in a given area stating that the study revealed that the higher the number of hospital beds related to the incidence of death at a hospital.

10:22 AM

Dr. Storey spoke about multi-disciplinary teams, clinic-based, inpatient, and home-based teams. He stated that the fragmented system does not allow all health care models to have these multi-disciplinary teams, but the model of multi-disciplinary teams works well for the patient. He spoke about various programs, such as Advanced Illness Care Coordination, which aims to address issues sooner rather than later for a person who may not be terminally ill, but has a chronic illness. He stated that these people typically are in need of care, but that the care can occur outside of a hospital. He spoke to the cost savings of these programs.

10:41 AM

Dr. Storey spoke to the access of analgesics or specific types of pain medication. He stated that the federal Food and Drug Administration (FDA) sent a letter to manufacturers of certain opiate drugs that doctors will be required to have a Risk Evaluation and Mitigation Strategy (REMS) for the purpose of evaluating whether the drug prescribed outweighs the risk factors of prescribing that certain drug. He explained that the letter emphasized the FDA's concern that many teenagers were becoming addicted to these types of drugs. Dr. Storey stated that the REMS requires doctors to sign a registry and certify their training regarding dispensing these types of drugs. He stated that this could significantly affect patients that are in pain because not all physicians are certified and may not be able to prescribe the pain medication to patients. The committee discussed potential solutions to the issue. Dr. Storey stated that stakeholders are meeting with the FDA to formulate a plan in reaction to the proposed rules in the REMS. The committee also discussed the deposit of drugs that are not completely used.

11:00 AM

The committee took a brief recess.

11:06 AM -- Medicare Perspectives on Hospice

Cathy Claiser, Lead Hospice Liaison, Centers for Medicare and Medicaid (CMS), introduced herself and provided a power point presentation to the committee (Attachment D). Ms. Claiser explained her background to the committee. Ms. Claiser stated that the emphasis of the hospice program is to keep the patient in the home. Ms. Claiser discussed the types of services provided by hospice programs.

11:24 AM

Ms. Claiser spoke to the requirements one must meet in order to qualify for Medicare coverage for hospice care. She spoke to the settings in which hospice can be provided, such as in one's own home, a long-term care facility, or in-patient hospice facility. She also provided details regarding the type of services that Medicare provides for hospice care, such as routine home care, continuous care, respite care, and short-term inpatient care. Ms. Claiser spoke to various issues with regard to Medicare coverage of hospice, such as:

staffing;
payment for services; and
initial surveys for licensure and recertification.

11:36 AM

Ms. Claiser detailed how CMS approves and certifies hospice care programs. She spoke to the licensing procedures and briefly discussed the multiple location approval process. She outlined the requirements in how a patient chooses a program. She stated that patients must meet Medicare hospice eligibility criteria and that the patient does have the right to choose their own hospice, but there are certain requirements for that must be met in order for a patient to contract with a specific hospice care center.

11:50 AM

Committee members discussed reimbursement by Medicare for hospice care. Ms. Claiser provided concluding remarks on her presentation.

12:01 PM

The committee took a recess.

01:03 PM -- Overview of Hospice Licensing and Reporting

The committee reconvened. Howard Roitman, Division Director, and Judy Hughes, Division Section Chief, Health Facilities and Emergency Medical Services, Department of Public Health and Environment (DPHE), introduced themselves to the committee and provided a handout (Attachment E). Mr. Roitman stated that their presentation will address hospice licensure and reporting requirements of hospice care programs. He stated that the department licenses and inspects hospitals, ambulatory surgical centers, nursing homes, assisted living residences, hospices, and others health facilities. The department also performs state surveys for Medicare and Medicaid certification. Mr. Roitman stated that the department licenses approximately 50 hospice centers.

01:15 PM

Committee members discussed the three regulatory barriers that were raised during previous witness testimony, specifically whether a hospice care patient who is admitted into a hospital may return to an assisted living facility, the concern of physicians writing prescriptions for analgesics, and the issue regarding the PASR. Representative Roberts discussed with the department the assisted living facility issue. Senator Tochtrop described the concerns regarding the REMS and the PASR issue. Senator Tochtrop suggested the department obtain a waiver to address the PASR issue. Mr. Roitman noted the regulatory barriers and stated that he would evaluate each issue raised and get back to the committee.

01:17 PM

Mr. Roitman explained the process for certification and licensure of hospice care centers. He spoke to the process of occurrence reporting and investigation. He stated that there has been 28 occurrence reports over a period of approximately three years. Committee members discussed some of the statistics provided in the power point presentation.

01:30 PM

Committee members discussed with the department ways in which to address some of the regulatory boundaries presented to the committee.

01:41 PM

Mr. Roitman spoke to the procedure of how the department investigates complaints. He stated that the department maintains a hotline. He described the types of complaints that the department has looked into including quality of care, nursing services, patient rights, pharmaceutical services, and patient assessment. Mr. Roitman stated that because of the current funding situation, the initial inspections and surveys are not being conducted. Representative Riesberg asked if the Joint Commission (formerly the Joint Commission on Accreditation) could conduct the surveys. Mr. Roitman responded that it could be appropriate for the Joint Commission to conduct surveys. He stated that the department would like to work with stakeholders to develop a fee structure to conduct surveys to increased oversight of hospice programs.

02:00 PM

Representative Balmer asked Mr. Roitman about governmental regulation, particularly if there are any hospice associations that do not want further regulation. Mr. Roitman replied that a comprehensive discussion on this topic has not occurred, but that he has spoken with association officials. He further noted that he is conscious of the business climate under which hospice providers operate. Representative Balmer replied that a combination of self-regulation and government regulation could be preferable. Mr. Roitman responded to Representative Balmer's comments regarding regulation.

02:08 PM -- Pediatric Hospice and Palliative Care

Dr. Brian Greffe, The Children's Hospital, introduced himself and provided a handout to the committee (Attachment F). Dr. Greffe provided an overview of pediatric hospice and palliative care. He provided data regarding the death of children in the United States. He described pediatric palliative care which is a comprehensive approach to the needs of children with life-threatening illness. He spoke to the four types of diseases in children that require palliative care, these categories include diseases which are curative but the cure may fail, diseases in which premature death is anticipated but with intense treatment may prolong good quality of life, progressive diseases, and conditions with severe neurological disabilities. He stated that his presentation will include an overview of the Butterfly Program, models of pediatric palliative and hospice care, and the Colorado Medicaid Waiver for Pediatric Palliative and Hospice Care.

02:16 PM

Dr. Greffe described the Butterfly Program which provides medical and home care, as well as emotional support, for families and children with life-threatening illness. He stated that the model for pediatric palliative care is quite different from the adult model for palliative care. One example of the differences in the pediatric model is that children are eligible who have a 12-month expectancy, versus in the adult model, a physician must certify that an adult has a 6-month expectancy. He stated that children do not need to have a DNR form in place as adults are required and that children are not disenrolled from the program if they surpass the 12-month expectancy.

02:25 PM

Dr. Greffe spoke to the educational outreach efforts of the Children's Hospital. Committee members asked questions of Dr. Greffe regarding the specifics of the program.

02:40 PM

Dr. Greffe described the Cocoon program. He stated that the program helps families and children make their hospital room look like a home. He showed a picture of a typical room with a 'cocoon' or a large cabinet that had a tv, games, and other objects in it to create a more friendly environment. He spoke to some of the challenges and successes regarding pediatric hospice and palliative care. He briefly reviewed other models of pediatric palliative and hospice care, including programs at Children's Mercy Hospital, Harriett Lane Compassionate Care - John Hopkins University, St. Mary's Health Care System for Children, and Seattle Children's Hospital Palliative Care Consulting Service.

02:48 PM

Dr. Greffe provided an overview of the state's Children's Medicaid Waiver for Pediatric Palliative and Hospice Care. He stated that the waiver provides pediatric palliative care services to Medicaid eligible participants from the time of diagnosis. He stated that the program was implemented in April 2008. He stated that it took over 7 years to obtain approved for the waiver from the Centers of Medicare and Medicaid. He stated that services include nursing, counseling, spiritual support, respite, complementary therapies such as art and music therapy, and anticipatory grief therapy.

02:57 PM

The committee took a brief recess.

03:05 PM -- The Option to Die in PEACE (Patient Ethical Alternative Care Elective)

Bart Windrum, author of Notes from the Waiting Room, introduced himself and provided a handout to the committee (Attachment G). Mr. Windrum described his personal experience with end of life decisions that he had to make regarding his mother and father. Mr. Windrum stated that the outcome of both his parents' deaths in the hospital have led him to suggest a paradigm shift regarding death and hospice care. He stated that he would like to see a new clinical evaluation that somehow identifies when an individual begins to die and at that point, the individual would become eligible for hospice. He stated that this shift would give patients and families more time to have important conversations around death and to make the necessary decisions regarding end of life directives. Members asked questions to Mr. Windrum.

03:48 PM -- Concluding Remarks

Representative Riesberg asked if anyone in the audience wanted to testify. There were no public testimony requests. He stated that future meetings will provide further discussion of specific issues regarding palliative and hospice care. The Five Wishes form was provided to the committee (Attachment H).

03:55 PM

The committee adjourned.