Hospices must show diminished patient access and failed attempts to hire
Hospices that can prove they are forced to turn patients away because the current nursing shortage has left them without adequate staffing can now hire contract nurses to fill the gap without running afoul of Medicare regulations.
The Centers for Medicare & Medicaid Services (CMS) has issued a temporary measure that bends the core services requirement to allow hospices to contract for nursing services, rather than providing them directly as current regulations require.
The temporary measure will be in effect until Sept. 30, 2004, at which time CMS will re-evaluate the current nursing shortage to determine whether it should be extended.
The memo was issued on Sept. 12 by Steven Pelovitz, director of the survey and certification at the Center for Medicaid and State Operations. It came after the California Hospice and Palliative Care Association (CHAPCA) asked CMS to clarify the "extraordinary circumstances" clause in the core services provision, which describes the minimum services a hospice must directly provide its patients, such as nursing services. The provision includes language that allows hospices to bend the core services requirements. Specifically, CHAPCA sought guidance on whether the current nursing shortage can be considered "extraordinary circumstances."
"The regulations allow a hospice to use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patients during periods of peak patient loads or under extraordinary circumstances," the memo states. "If contracting is used, the hospice must maintain professional, financial, and administrative responsibility for services."
In short, CMS has granted a qualified exception to the requirement that calls for hospices to provide nursing services using its own employees. However, CMS’ sympathy for the plight of hospices doesn’t come without its share of red tape.
To qualify for the exemption to the core services provision, a hospice is required to provide written notification to its state survey agency when the nursing shortage has become so severe that the hospice is unable to hire its own nurses. In addition, the hospice must estimate the number of nurses it believes it will need to employ under contract. This notification should do the following:
- Give an estimate of the number of patients that the hospice has not been able to admit during the past three months due to the nursing shortage and the current and desired patient/ nurse ratio for the agency.
- Provide evidence that the hospice has made a good-faith effort to hire and retain nurses, including:
— copies of advertisements in local newspapers that demonstrate recruitment efforts;
— copies of reports of telephone contacts with potential hires, professional schools and organizations, recruiting services, etc.;
— evidence that salary and benefits are competitive for the area;
— evidence of any other recruiting activities (e.g., recruiting efforts at health fairs, educational institutions, health care facilities, and contacts with nurses at other providers in the area);
— an ongoing self-analysis of the hospice’s trends in hiring and retaining qualified staff.
- Demonstrate that it has a training program in place to assure that contracted staff are trained in the hospice philosophy and the provision of palliative care prior to patient contact.
- Provide assurance that contracted staff are providing care that is consistent with the hospice philosophy and the patient’s plan of care.
- Show that contracted nurses are used to supplement the hospice nurses employed directly. Contracted nurses should not be used solely to provide the continuous nursing level of care or on-call service.
- Show that the hospice is expected to continue its recruitment efforts during the period that it is contracting nurses.
"We commend the Department of Health and Human Services for being flexible and responsive to our concerns," says Margaret Clausen, CAE, executive director of CHAPCA, which is based in Sacramento.
Last year, CHAPCA asked CMS for clarification on contract nursing rules and gave the agency data from a survey of its membership. The survey showed that although 88% of California hospices had increased their salaries, nursing vacancy rates averaged 14% over a six-month period.
More telling, says Clausen, are the statistics on patient access to hospice. More than one-third of hospices surveyed reported having to turn patients away because they did not have the staff to handle the added caseload. That translated to between three and four patients per hospice who were placed on waiting lists each week.
The National Hospice and Palliative Care Organization (NHPCO) applauded CMS, as well. The temporary measure will help ensure access to hospice as the industry tries to find solutions to the long-term nursing shortage problem, says Judi Lund Person, MPH, vice president for state and regulatory affairs for NHPCO in Alexandria, VA.
The temporary solution will likely not have an effect on hospices’ nursing shortage. While contract workers will fill a void, the task of filling open hospice nursing positions with full-time employees will still be difficult due to stiff competition from hospitals, physician offices, and other settings where the pay is better and the work often is less demanding. While the health care industry and nursing associations are attempting to make fundamental changes to attract more nurses to the profession, Clausen sees the nursing shortage continuing beyond 2004, especially for hospices.
"I don’t think the nursing shortage will be solved in two years," Clausen says. "What is being proposed are institutional changes, and institutional changes take time."
One example of institutional change that is already under way includes a group of more than 60 nursing organizations that released a broad strategic plan in April addressing the root causes of the growing nursing shortage.
"Nursing’s Agenda for the Future" identified a number of domains in which nursing leaders envisioned change, along with a strategy to achieve their vision. The domains are: leadership and planning, economic value, delivery systems/ nursing models, work environment, legislation/ regulation/policy, public relations, communication, professional/nursing culture, education, recruitment/retention, and diversity.
The plan is as much an industry statement as it is a strategic tool. It offers a picture of where the nursing industry sees itself being by the year 2010. Rather than allow the current trend to continue where demand for nurses will exceed the supply by 2010, the industry hopes to set into motion changes that would make nursing more attractive and fulfilling.
While hospices use contract nurses, the supply of nurses will continue to work against them, making it important for hospices to continue their efforts to make hospice nursing attractive, particularly to new nursing school graduates and veterans who long to reconnect with hands-on nursing.
"[CMS’ temporary measure] is not a reason to stop recruiting," says Lund.
Just how NHPCO thinks hospices should recruit nurses and retain current ones can be gleaned from its recent monograph, "Finding Answers to the Nursing Shortage." In it, the NHPCO advocates creative recruitment and retention efforts, as well as increasing salaries to become competitive with other providers.
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