Balm for the Broken-Hearted: The Bereavement Program

Balm for the Broken-Hearted: The Bereavement Program
Jonathan C. Wretlind, M.Div
Chaplain and Bereavement Coordinator, Front Range Hospice

One of the great benefits of hospice care is the emotional support offered by chaplains, social workers, and the bereavement program. A well-organized bereavement program is crucial to providing the best care to hospice families. Hospice is not only about caring for the patient, but realizing that death of a loved-one impacts the entire family-system. Offering each family the opportunity to receive support for 13 months following a death, the bereavement coordinator “follows” family members by mail and phone in order to provide assistance to those who need it and are willing to receive help. It is a free benefit, and one that is often overlooked in presenting the benefits of hospice to family members considering hospice care for a loved-one.

One of the main goals of a bereavement program is to identify those individuals in a family that may need extra support, may experience “complicated grief”, and may need ongoing professional support through a referral to a local therapist or counselor. Complicated grief can be a serious psychological condition, and can mimic symptoms similar to Post-Traumatic Stress Disorder (PTSD), and is a form of secondary trauma itself. It may even lead to fully-developed PTSD, cause permanent brain damage, and even lead to suicide or homicide. Even “normal” grieving itself can result in depression, loss of productivity, or illness. It is because of this potential consequence of grief that Medicare requires the hospice program to provide bereavement services as part of the Conditions of Participation (CoP), even though it is non-reimbursed by Medicare/Medicaid.

The Bereavement Coordinator continually contacts family members who are in the bereavement program to “check-in” with them at predetermined intervals according to a plan-of-care based on an individuals’ risk for complicated grief. This is done through phone-calls, letters, or through support groups in order to continually assess which family members may need extra support in order to prevent complications due to grief. The plan-of-care may need to be altered depending on what is reported to the bereavement coordinator or bereavement program assistants or what other objective risk-factors (such as alcohol abuse, family dysfunction, lack of support system or suicidal ideation) are discovered through interaction with the bereaved individual. There are many factors which plays into an individual’s risk for complicated grief, and the bereavement coordinator along with hospice social-workers and chaplains record what is learned about the bereaved using a document called a Bereavement Assessment. This document is reviewed for each family member in the bereavement program on a regular basis by the psycho-social team, and modified if necessary.

Part of the bereavement program also includes grief counseling services through one-on-one counseling with a qualified counselor, or through group-sessions held throughout the year and conducted by the psycho-social team. Counseling may also be offered prior to the patient’s death if needed for family-members who are having difficulty with coping with “anticipated grief.” These are free benefits through our hospice program, and extremely beneficial to those willing to receive help. When a person is identified with a high-risk for complicated grieving and/or may be experiencing extremely poor coping, a referral may be made to a local counselor or therapist qualified to handle difficult cases of complicated grief. Also, family members who reside out of our service area may be referred to another grief program or counselor in their area.

I am proud to be part of Front Range Hospice’s bereavement program as both a chaplain and the bereavement coordinator, working with a team of top-notch bereavement assistants and volunteers. I have heard many stories and reports from our families of the legendary care that Front Range provides, and honored to be able to help the bereaved in their time of need.

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Speak Up

Speak Up

Front Range Hospice continues to maintain the highest standards of care set before us by the Joint Commission.. We would like to take this opportunity to introduce you the Joint Commissions Speak Up campaign. As a Joint Commission Accredited company Front Range Hospice supports this campaign and encourages everyone to familiarize themselves with the program. In an effort to help you understand this program Front Range Hospice is going to Speak Up about the program and get you started on the road of empowerment. When you finish reading this blog you will have a better understanding of the medications that may be used at Front Range hospice.

The Joint Commission has a hospice/palliative care education campaign as part of their award-winning Speak Up program. The Speak Up program urges people like you to take an active role in their own health care.

The basic framework of the Speak Up campaign urges patients and families to:
• Speak up if you have questions or concerns, and if you don’t understand, ask again. It’s your body and you have a right to know.
• Pay attention to the care you are receiving. Make sure you’re getting the right treatments and medications by the right health care professionals. Don’t assume anything.
• Educate yourself about your diagnosis, and your treatment plan.
• Ask a trusted family member or friend to be your advocate.
• Know what medications you take and why you take them. Medication errors are the most common health care errors.
• Use a hospice, hospital, clinic, or other type of health care organization that has undergone a rigorous on-site evaluation against established state-of-the-art quality and safety standards, such as that provided by The Joint Commission.
• Participate in all decisions about your treatment. You are the center of your health care team.

All of us at Front Range Hospice want to help you speak up. As mentioned above, medication errors are the most common mistake in healthcare. What better way to minimize these errors then to talk about medications.

When becoming a patient at Front Range Hospice you may hear from the Liaison or Nurse that a comfort pack will be delivered to your home. Your now wondering what’s a comfort pack and what do I do with it once it arrives?

Answer: The hospice comfort pack – is a prescribed set of medications that are kept in a patient’s home in the event of an emergency or onset of new symptoms. Having the medications already in your home will help the hospice team treat any distressing symptoms as quickly as possible in your home. Front Range Hospice strives to get and keep you as comfortable as possible.
The hospice comfort pack may be ordered and delivered to your home at the start of hospice care or anytime the RN Case Manager sees a possible need. The Front Range Hospice comfort pack contains medications for pain, anxiety, nausea, constipation.
Other medications may be included depending on the hospice diagnosis. For example, a patient with a brain tumor who is at risk for seizures may have valium suppositories included in the comfort pack.
The Front Range Hospice RN Case Manager will explain each medication to you including the purpose and correct way to administer it. In most cases the RN Case Manager will instruct their patients and families not to start any of the medications till they have consulted the RN Case manager. At this time the RN Case Manager will review the medication, why it is being used, how to administer it and the frequency it can be given.
If you have a true allergy to these or any medications it is important to share that information with the RN Case Manager. A true allergy occurs when your immune system reacts abnormally to a medication. A number of drugs can cause a drug allergy, including prescription and over-the-counter medications. The most common signs of a drug allergy are hives, rash or fever. You can have an allergic reaction to a drug anytime you take it, even if it caused no reaction in the past.
Most drug-related symptoms are not a true drug allergy and don’t involve the immune system. Drug allergy and non-allergic drug reactions are often confused because they can cause similar symptoms. Either type is called an adverse drug event and needs to be reported to the RN Case Manager. Some allergic and non-allergic drug reactions can be severe or life-threatening.
Lastly please remember to report to the RN Case Manager any herbal remedies you are taking. Herbal remedies can have a negative impact on the medications being prescribed by your physician.
Remember to SPEAK UP! Excellent end of life care is your right and it is dependent on you Speaking up and communicating with your health care team.
Front Range Hospice
Legendary Care.

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As the Affordable Care Act shapes the future of patient care in the United States…

As the Affordable Care Act shapes the future of patient care in the United States, the issue of healthcare’s “revolving door,” or avoidable hospital readmissions, continues to take a front seat in the national conversation. Rehospitalization among Medicare beneficiaries has become a top priority for both policymakers and the Centers for Medicare and Medicaid Services (CMS) as hospitals feel added pressure to help patients remain at home.

Front Range Hospice is working hard at maintaining current relationships and developing strong relationships with the hospitals in our service territory. Front Range Hospice is the first hospice along the northern front range to track return to hospital rates along with other clinical data measures on patients receiving care through Front Range Hospice. Why do we track data you ask?
Nearly one in five Medicare beneficiaries is readmitted to the hospital within 30 days of release. As of this post Front Range Hospice has a zero percent return to hospital rate. Tracking this data allowed us to show our hospital partners how hard we work to support our patients and our hospital partners.

The CMS has taken on several initiatives to reduce readmissions – an important measure of patient care quality – from reporting hospital readmission rates and changing payment policies, to implementing shared savings programs in efforts to increase care coordination among post-acute care providers.

The biggest change, as part of the healthcare overhaul: Medicare began penalizing hospitals with high readmission rates for heart failure, heart attack, and pneumonia cases. In 2012 more than 2,000 hospitals received a reduction of up to one percent on their Medicare reimbursements. This penalty will increase to a maximum of two percent this year 2014, and three percent in 2015.
Because Front Range Hospice has developed chronic disease programs our staff is trained on how to manage chronic diseases like CHF and COPD in the home. Front Range Hospice nurses are able to better support the patient and family at home, reducing or eliminating the return to the hospital. Resulting in better family satisfaction and no penalties issued to the hospital.

Why Are Patients Returning to The Hospital?
There are some return trips to the hospital that are unavoidable – due to complications, new and unrelated problems, or anticipated steps of certain treatment plans. Some patients are also readmitted because they live in a region where hospitals are used more frequently as a place of care for illnesses.

Regardless of where patients reside, education and support are key factors in preventing readmissions to hospitals. We work hard to provide education to our patients and families with every interaction we have with them. The more education, the more comfortable the patient and family will feel, resulting in decreased or eliminating the trip to the ED or calling 911.

The Role of Hospice
Front Range Hospice is a leader in improving coordination of care between care settings and reducing avoidable hospital readmissions. Increasingly, hospitals are forming collaborative partnerships with hospice providers like Front Range Hospice, nursing homes and home care agencies to combat avoidable readmissions.

Front Range Hospice works closely with the hospitals, patients and families to identify care preferences, manage symptoms, and address clinical, emotional and spiritual needs through a team-oriented, interdisciplinary approach. This type of care allows patients to pick up the phone in a time of crisis and receive emergency medications at home, or a facility, without returning to the hospital.

Integrating hospice care services early in the hospital stay and making timely and appropriate hospice referrals can not only improve patient experiences, but address some of the most important issues faced by hospitals today: quality improvement, overcrowding in the ICU, increasing coordination of care, preventing complications, reducing costs – and ultimately, reducing return trips to the hospital in a patient’s final stages of life when comfort matters most.

-Victor Montour

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Honoring Veterans

As we celebrate the 4th of July Front Range Hospice asks that you pause to recognize the sacrifice from the millions of veterans in our Armed Forces. Since the Declaration of Independence was signed more than 200 years ago on July 4, 1776, our country has seen multiple wars – and called upon its sons, daughters, brothers, sisters, mothers and fathers to serve many times.

As our veterans age, they sometimes require special assistance beyond the typical senior citizen. Veterans may have physical wounds from battle injuries, or psychological wounds from being part of a war.

Even without service-specific wounds, veterans face the same diseases that we all do. World War II veterans are now all over 70, and many have cancer, dementia, chronic heart failure and other chronic or end of life diseases.


Like the rest of us, veterans need hospice care to guide them and their family through the end-of-life journey. These men and women deserve the best care available, and we are honored to serve them in their time of need.


It is never too late to honor and give a Veteran a hero’s welcome home. Front Range Hospice staff work hard to provide the last opportunity for Veterans to feel that their service was not in vain, and that they are appreciated. We do this with simple acts of gratitude at the end-of-life to make up for a lack of appreciation or recognition during the Veteran’s lifetime, especially for those Veterans who were never welcomed home or thanked for their service. Front Range Hospice will always, honor and recognize the Veterans we serve by providing;


Veterans with an opportunity to tell their stories.
Respecting Veterans’ service, their feelings, and any suggestions they might offer.
Thanking Veterans for their service to our country.
Providing a Veteran to Veteran volunteer program.
Showing our appreciation to the families of Veterans.
Always being sincere, caring, compassionate and ready and able to listen to what a Veteran or his or her family member has to share about the situation they are dealing with.
Being supportive and non-judgmental of our Veterans and always validating their feelings and concerns.
Being honest, sincere, caring and respectful.
Accept, without judgment, the Veteran as he/she is.
Being patient and listening.
Offering spiritual support for Veterans, family and friends.

Front Range Hospices asks that this 4th of July, stop and say THANK YOU to all of the service men and women who have made and continue to make the 4th of July possible. Without their sacrifice we wouldn’t be able to enjoy a day filled with family and friends or an evening filled with awesome fireworks.


Victor Montour
Hospice Liaison
Front Range Hospice
Providing Legendary End of Life Care
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Qualifying for Hospice: It used to be so easy, Or, The death of General Debility and Adult Failure to Thrive

Qualifying for Hospice: It used to be so easy,


The death of General Debility and Adult Failure to Thrive


In 2002 General Debility accounted for 6% of all Hospice claims and Adult Failure to Thrive was 3%. In 2012 there were a lot more hospices and General Debility accounted for 12% of all claims and was the number 1 code used on all hospice claims and Adult Failure to Thrive accounted for 7%. Why were there a lot more hospices? The American public is becoming more sophisticated in its choices for health care. They turn to the internet and look up diseases and their prognosis. They want to have more control over the end of their life and the Baby Boomers are entering retirement and caring for their parents and themselves.

Center for Medicare and Medicaid (CMS) thoughts

General Debility and Adult Failure to Thrive are: “non-specific, ill-defined diagnosis”

Since 2008 hospice has been required to do a comprehensive, individualized assessment and plan of care and if a non-specific, ill-defined diagnosis is used as primary this cannot be done (according to CMS). CMS says “these diagnoses are incongruous to the comprehensive nature of the hospice assessment”. They can be used as secondary or related diagnoses but not as primary diagnosis.

What all this means at Front Range Hospice

The Administrator and the DON are rapidly educating themselves on Coding for Hospice. All patients that were coded with a primary diagnosis of general debility or adult failure to thrive we have done the research and changed the primary diagnosis. Underlying the General Debility or the Adult Failure to Thrive is a primary disease that is creating this condition. We have done the research, found this disease and with the assistance of our Medical Director, we have changed the primary diagnosis.

Going forward, we will do the research and find a primary diagnosis that is not General Debility or Adult Failure to Thrive. It is important to Front Range Hospice that patients receive the hospice care that they are entitled to. This means that we must request more records and do more digging some times before our Medical Director is comfortable certifying what the terminal illness is.

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Happy CNA week!!!!

CNA Week is June 13 – June 20. Most people outside of healthcare have very little respect for CNA’s. When in fact, CNA’s are an intricate part of the nursing team and deserve the upmost respect.

The CNA provides a lot of the bedside care a patient may need. Assisting with activities of daily living like, brushing a patients teeth, giving bed baths, assisting patients with eating and many other tasks as directed by the RN or LPN.

Because of the amount of time a CNA spends with a patient they hear and observe the smallest changes in a patients condition. These changes are reported to the RN or LPN who facilitate obtaining the necessary treatment. CNA’s are the eyes and ears of the nurse when the nurse is not with the patient.

The CNA builds one of the strongest bonds with a patient. They learn the likes and dislike each patient has. They know just how to fold down the bed, fluff a patients pillow and if time allows they give a fabulous back rub to help their patients relax.

So the next time you see a CNA remember to thank them for caring about their patients. Thank them for bringing love and joy into the hearts of everyone they care for.

All of us at Front Range Hospice send a great big thank you to our CNA’s. We are fortunate to have each and every one of you on our team.

Happy CNA week!!!!

Victor Montour
Hospice Liaison
Front Range Hospice

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Hospice and Medicare D

Hospice and Medicare D

In 2003 Medicare developed an outpatient prescription benefit that is commonly referred to Medicare D. This has been beneficial to Medicare beneficiaries as it assists them in the cost of their maintenance prescription medications and any acute medications that they may need.  This program went into effect in Jan. of 2006.

Hospice is a managed care program covered under Medicare A. When an individual chooses hospice, the hospice becomes responsible for the cost of all medications related to their terminal diagnosis and related conditions that are designed for comfort and symptom control and all other medications related to symptom control as recommended by the hospice pharmacist and the hospice medical director.

The Office of Inspector General (OIG) published a report in June 2012 entitled “Medicare Could Be Paying Twice for Prescription Drugs for Beneficiaries in Hospice”. This is definitely a provocative title.  As you read the report it becomes evident that the OIG believes that there are certain categories of drugs that hospice should always pay for and should not be billed to Part D. These are: analgesics, Antinauseants, laxatives, and antianxiety drugs. Additionally they looked closely at two terminal diseases, COPD and ALS, and felt that all drugs related to these diseases should be covered by hospice.

What I have found in working with people is nothing is black and white. The response of Front Range Hospice to this entire issue has been very thoughtful and extremely aggressive and we believe that we are paying for every pill that we should be paying for. We are contracted with a Pharmacy Benefit Management Company that specializes in hospice and provides us an evidence based medicine approach to our drug formulary. Our formulary is a starting point. We do go outside of the formulary when we have documentation that a patient has tried what is on the formulary and has either had a negative reaction or poor results.

We will not be paying for all medications prescribed for pain or for the terminal illness if there is evidence that it does not work. For instance, if a 75 pound female whose healthy adult height was 5’7” comes on service with end stage dementia and she is bed bound, no longer continent, no longer speaks, and 100% dependent for all activities of daily living we will not be paying for a fentanyl patch, Namenda, or Aricept if ordered by her primary care physician.  Evidence based medicine tells us that a fentanyl patch needs fatty tissue to work and Namenda and Aricept are for early to mid-stages of dementia.  If the family choses to keep her on these drugs, they should be paying privately and not billing Medicare D. Hospice has no control over what the family does and all we can do is educate.

Front Range Hospice has reviewed all of its medication profiles (sheets), and primary and related diagnosis with our hospice pharmacy and our Medical Director. For those medications that we do not feel are hospice pay, we have sent in the proper form to the Medicare D provider for each of our patients. We have been appalled by the lack of response of some of the Medicare D providers. It is impossible to reach a human being and now the patient or family must make the decision to either go off the medicine or pay privately and fight the insurance company. In the meantime, the Medicare D provider continues to collect the premium.

Personally, I do anticipate a fix for this is coming. I still have faith in our federal government. We can all speculate what that will look like but at the very least the Medicare D provider will be required to respond within a short period of time and a clear appeal process will be laid out. I personally will do everything within my power to advocate that the subscriber not be held up in the pharmacy. I am only one voice. I will keep you informed.

-Pam Ware

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