Psychologists trying overcome barriers to work with hospice patients
The National Psychologist, Vol. 10, No. 4, p 12-13.
By Paula E. Hartman-Stein, Ph.D.
Small numbers of psychologists are the unsung workers in hospice care, going virtually unnoticed amid a collection of counselors, social workers, chaplains, nurses and volunteers.
Psychology is trying to change this slight.
In April 2001, the first meeting of the Ad Hoc Committee on End- of-Life Issues took place in Washington D.C. to strategize how psychologists can be increasingly recognized for their expertise in bereavement counseling, palliative care, training of other professionals, and research involving terminally ill patients.
The APA Council of Representatives allocated $26,000 in its 2001 budget to establish a new 5-person committee charged with implementing the recommendations of the original working group begun in 1997 on Assisted Suicide and End-of-Life Decisions.
The working group reported to APA in May 2000 that other professions do not see psychologists as essential team members in end-of-life decision- making. A notable exception is in Department of Veteran Affairs hospitals where staff psychologists and interns regularly provide clinical and consultation services to dying patients.
Hospice, an interdisciplinary team concept begun in 1967 in the U.S., with an annual new patient growth rate of nearly 17%, provides comprehensive medical and psychosocial care for dying patients. Supportive counseling is available for family members for at least a year after the death of the patient. Despite the holistic model of care, psychologists are excluded in the list of core service professionals. Psychologists are late to the table at end of life care, says John Anderson, Ph.D., APA staff liaison to the Ad hoc committee on End- of- Life issues.
Once a patient meets the medical criteria for hospice, that is, a person with life expectancy of less than 6 months, the hospice enrolls the patient and receives one of four per diem rates, depending upon the necessary level of service. According to John Millett, Media Relations Director of the National Hospice and Palliative Care Organization, Medicare covers 65% of patients, state Medicaid funds pay for 8%, with the rest of reimbursement extended through private insurance or charitable contributions.
The Balanced Budget Act of 1997 included a provision that enables medical directors and physicians to work under contract without being a hospice employee. Psychology is striving for the same prerogative.
Based upon an informal survey conducted by The National Psychologist using three list serves many psychologists expressed frustration when approaching hospices. One psychologist who requested anonymity noted, There was a social worker bias and there was a very complicated funding arrangement that seemed to confuse everyone with whom I spoke but was used to block further discussion. There was no money. It was a rather discouraging interaction but indicated how doctrinaire, insulated, and bureaucratic such places can be.
Many psychologists report involvement with hospice on a pro bono basis. For example, Betty Shull, Ph.D., retired faculty from the College of Wooster in Ohio, has worked with hospice volunteer training programs for at least 15 years, conducting workshops on listening skills. I have chosen to do it as a volunteer because I have felt that is something I can contribute to the important work which hospices do. It has given me immense satisfaction and has been very well received.
If a patient admitted to hospice has been treated for an emotional problem that predates the terminal diagnosis, the treating psychologist can be paid for continued clinical services as long as the therapy is unrelated to the patients adjustment to the terminal illness. In such cases the Medicare carrier has the discretion to continue to pay for therapy under part B of Medicare with the agreement of the hospice association.
In 1982 a special section of the American Psychologist outlined the potential roles of psychologists in hospice care. Since then psychologists appear to have made inroads at the research and training level, but have found it frustrating to try and get in the door at the practitioner level.
William Haley, Ph.D., member of the APA committee on End-of-Life Issues and current President of Division 12, section II, (Clinical Geropsychology) would like to see greater involvement for psychologists in assessment and treatment of hospice patients and families as well as researching empirically based practice in end of life care.
APA staffer Anderson noted that before specific advocacy plans are developed, APA must analyze the regulations involved with hospice reimbursement. Collaboration among the three directorates - Public Policy, Practice, and Public Interest has begun. We hope to have the analytic work done for the next meeting of the Ad Hoc committee in September, Anderson said.
Judith Gordon, Ph.D., current Chair of the Washington State Psychological Association End-of-Life Task Force, believes we have to start almost from scratch in both educating ourselves and networking on an interdisciplinary level, and this will take energy, time, and perseverance.
Paula Hartman-Stein, Ph.D. is a clinical psychologist specializing in geropsychology in Kent, Ohio. In 1998 she edited Innovative Behavioral Healthcare for Older Adults: A Guidebook for Changing Times. Her seminars are available in archive version through the Fielding Institute. She can be reached through her website, www.centerforhealthyaging.com.