Time:09:02 AM to 12:27 PM
Place:HCR 0107
This Meeting was called to order by
Representative Riesberg
This Report was prepared by
Kelly Stapleton
X = Present, E = Excused, A = Absent, * = Present after roll call
Bills Addressed: Action Taken:
Introductory Comments
Hospital-provided Palliative Care
Statutory Template for Advance Directives
Findings and Recommendations
Federal Update
Proposed Draft Legislation

09:03 AM -- Introductory Comments

Representative Riesberg brought the committee to order. He stated that the committee would have an opportunity to propose draft legislation at the meeting. He provided information to the committee regarding the charge of the committee.

09:06 AM -- Hospital-provided Palliative Care

Sean Reed, Advance Practice Nurse, Centura Health, introduced himself and provided a handout to the committee (Attachment A). He stated that his presentation would address palliative care and intervention in the hospital setting, compare four different dying trajectories, evaluate recent palliative care hospital outcomes, and describe national social movement strategies to increase hospital-provided palliative care. Mr. Reed spoke to the four different dying trajectories. He stated that in palliative care, the most typical dying trajectory is a slow decline with a periodic crisis.

Attachment A.pdf

09:14 AM

The committee discussed issues surrounding how physicians approach conversations with patients about dying. He spoke to themes that are consistent throughout most of these conversation which include discussions about the process of dying, financial stress, the psychological aspect of dying, and spiritual needs. Mr. Reed described the palliative care team and how the team addresses the palliative care interventions appropriate for each patient.

09:22 AM

Mr. Reed stated that the top three referrals to palliative care provided in a hospital are from the intensive care unit, the medical/cardiac unit, and the oncology unit. He spoke to the financial outcomes of providing palliative care within a hospital setting and the average cost savings. He provided statistics on where patients "go" after they leave the palliative care setting. He stated that a majority go into hospice and home health care. He stated that 23 percent die in the hospital within the palliative care setting. Mr. Reed spoke to the End of Life Nursing Education Consortium that provides education for nurses regarding end of life care. He described the new unit at St. Anthony's Hospital that encompasses both a palliative care and hospice unit. He stated that this model is a benefit to the patient because they do not have to be moved to another facility. He explained that many times when patients are moved from palliative care to a hospice facility they may die in transit.

09:38 AM

Mr. Reed described the cultural shift and social movement towards palliative care. Mr. Reed responded to committee questions. He emphasized the need for education and more planning with regard to end of life issues. He also stated it would be beneficial if Medicare benefits included reimbursement for palliative care.

09:46 AM -- Statutory Template for Advance Directives

Kari Hershey, Colorado Medical Society, introduced herself and provided a handout to the committee (Attachment B). Ms. Hershey spoke to House Bill 08-1061 which authorized advanced practice nurses (APNs) to sign certain documents, like disabled parking permits. She stated that it was brought to the Medical Society's attention that APNs were given the authority, under House Bill 08-1061, to certify a terminal illness. Ms. Hershey stated that APNs consider determining or certifying death or terminal illness of a patient outside of the scope of their practice. She stated that the Colorado Nurses Association agrees. She explained that the bill's intent was not to add APNs to the list of individuals who may certify a terminal illness. Ms. Hershey clarified that the addition of the term APN in this part of the statute was an editing mistake. Ms. Hershey stated that APNs are able to enter an advance directive into the patient's medical chart.

Attachment B.pdf

09:50 AM

The committee took a brief recess.

09:58 AM -- Findings and Recommendations

The committee reconvened. Dr. Cordt Kassner introduced Bev Sloan, Denver Hospice, and Christy Whitney, Hospice and Palliative Care of Western Colorado. He stated that the panel will provide a wrap-up and its recommendations to the committee. Ms. Whitney spoke to the differences between the various hospices across the state. She stated that there is not one specific cultural perspective to hospice care; it is dependent on the community and environment. The committee discussed the cost saving aspect of hospice care.

10:11 AM

Dr. Kassner provided a handout to the committee which describes suggested legislation and committee recommendations (Attachment C). He spoke to the first recommendation and stated that there are four bullet points, but the overall goal of the first recommendation is to increase efficiencies for hospice. He stated that the first

recommendation would allow Medicaid to reimburse a long-term care hospice for a patient's room and board directly rather than paying a hospice facility which then reimburses the long-term facility. He stated this recommendation would eliminate the 'pass through' and reduce administrative burden. The committee and the panel discussed the recommendation.

Attachment C.pdf

Dr. Kassner stated that the second part of the first recommendation is to mandate long-term care to use selected medical diagnosis service (MDS) measures to trigger the offer of a hospice or palliative care consult. He stated that this will increase efficiencies. Ms. Sloan stated there are wide varieties between nursing homes and this recommendation goes to making this process more consistent. Senator Tochtrop stated that she thinks this recommendation can be done through rule making. She stated she is concerned that it could lead to micro-managing long-term care facilities and could have unintended consequences.

Dr. Kassner spoke to third part of the first recommendation which would allow Medicaid to reimburse hospice in-patient facilities for room and board costs when they provide residential level of care. Ms. Whitney stated that this recommendation would not impact a large number of people, maybe five or six individuals. Ms. Whitney stated that the Department of Health Care Policy and Financing is receptive to this recommendation.

Dr. Kassner spoke to the final part of the first recommendation which would allow Medicaid to reimburse advanced practice nurses for visits made outside of a clinic setting.

10:29 AM

Dr. Kassner stated that the second recommendation would allow registered nurses to pronounce death. The was discussion among the committee members regarding where advance practice nurses (APNs) stand regarding this recommendation. Representative Riesberg stated that one of the concerns is that there are not enough physicians in rural communities to sign death certificates. He stated that numbers have been provided to him that show that there are more physicians than APNs in rural communities. Representative Roberts stated that there may be more physicians than APNs, but it is also a matter of whether the physician wants to sign death certificates. Ms. Sloan stated that APNs are already pronouncing death when they call a physician and say, 'the patient does not have any vital signs, he or she is deceased.' She stated that many physicians do not appreciate being called in the middle of the night, even though that is what the law requires.

10:42 AM

Dr. Kassner spoke to recommendation number three which would clarify and update the living will statue.

10:43 AM

Dr. Kassner described recommendation number four which includes three parts. He described the first part which is to implement the Colorado Advance Directive Consortium recommendations regarding the Medical Orders for Scope of Treatment (MOST) form. The second topic includes language edits to the Colorado Department of Public Health and Environment CPR directive and the last topic comes from the Colorado Medical Society and goes to Ms. Hershey's testimony regarding edits to House Bill 08-1061 to revert to the original language stating that only physicians may certify terminal illness rather than physicians or APNs.

10:48 AM

Dr. Kassner highlighted several recommendations from the panel that would not require statutory changes, but could be regulatory changes. He stated a lot of the suggestions have to do with education and outreach. There was discussion between the panel and the committee regarding the timing of implementing the recommendations.

11:04 AM -- Federal Update

Betty Sweeney, Community Liaison, Office of U.S. Senator Michael Bennet, introduced herself and stated that Senator Bennet sits on the Special Committee on Aging. She described some of the issues that Senator Bennet supports including increasing education regarding palliative care services. She stated that Medicare pays for six months of hospice care. She indicated that Senator Bennet has signed a letter addressed to the Obama administration which states that he does not support any cuts to hospice care. Ms. Sweeney indicated that funding for hospice and palliative care will be protected under any health care reform legislation.

11:11 AM -- Proposed Draft Legislation

Representative Roberts suggested that a bill be drafted that would update the living will statute (Recommendation number three from the Colorado Center for Hospice and Palliative Care. See Attachment C for a list of all the recommendations from the Colorado Center for Hospice and Palliative Care).

Representative Tyler suggested that a bill be drafted using the Statewide Internet Portal Authority (SIPA) to establish a central registry for living wills and other advance care directives. He spoke to the funding mechanism of SIPA. There was committee discussion regarding any bills that drive a fiscal note.

Dr. Kassner returned to the table to speak to recommendation number four from the Colorado Center for Hospice and Palliative Care which goes to adopting the recommendation from the Colorado Advance Directive Consortium regarding the MOST form. Representative Roberts spoke to the need for statutory recognition of the MOST form, especially in legal settings. Carl Bladstein, attorney in Denver practicing elder law, commented on the issues that were brought forth with House Bill 09-1232 concerning advanced care directives. He spoke to the difference between 'what a patient wants' versus a medical order signed by a physician. He emphasized that the MOST form is a medical order that can be portable across various medical providers. He stated that it is important to acknowledge the patient's wishes.

Representative Roberts suggested a bill be drafted that would increase the time frame for Medicaid eligibility for hospice care from six months to nine months. Dr. Kassner spoke to the eligibility renewal period for hospice care. He stated that eligibility can be extended six months at a time after the initial approval. He stated that the bill is focused on the initial eligibility prognosis. He stated that this recommendation will be a cost saver.

Senator Tochtrop suggested that a bill be drafted that would improve efficiencies in hospice care. She spoke to the recommendation from the Colorado Center for Hospice and Palliative Care describing eliminating the 'pass through' and allowing long-term facilities to be reimbursed directly for room and board costs rather than paying the hospice which then in turn pays the long-term facility. See Recommendations 1a and 1c from the Colorado Center for Hospice and Palliative Care (Attachment C). There was discussion regarding whether this would need to be two bills. Christy Chase, Office of Legislative Legal Services, stated she did not know at this time.

Attachment C.pdf

11:49 AM

Senator Tochtrop also suggested that a bill be drafted that would address the pre-admssion screening and resident review (PASRR) issue that was discussed in committee at the July 9, 2009, meeting. She stated she would like to seek a waiver for the current requirement that patients must first receive a PASARR prior to be admitted to a hospital.

Representative Riesberg asked that a bill be drafted that would address the Colorado Medical Society's concern with House Bill 08-1061. The bill would amend current statute to state that physicians only, rather than physicians and advance practice nurses, may certify terminal illnesses.

Senator Tochtrop suggested that a bill be drafted that would allow advanced practice nurses the authority to pronounce death.

12:05 PM

The committee discussed various issues raised throughout the committee meetings.

12:17 PM

Christy Chase, Office of Legislative Legal Services, recapped the bill draft requests.

12:26 PM

The committee adjourned.