Lack of Staff, Guidelines Build Hurdles for Hospice Bereavement Care Programs

Hospices often lack the financial and staffing resources needed to fully support bereaved families.

As with nursing, the industry-wide labor shortage has impacted bereavement care, which is an underfunded service, according to Dr. Dawn Gross, palliative care physician at University of California, San Francisco (UCSF) Health. Gross is also a medical director at ANX Hospice Care.

“Hospices are not reimbursed enough to support grief care teams,” Gross told Hospice News. “These are usually chaplains or social workers providing bereavement services, and some hospices also have clinical psychologists or therapists as part of that team. But bereavement skills really need to be stretched so that all interdisciplinary team members, including clinicians, are involved and able to directly bill for these services. Look for those ways of overlapping skill sets, and share insight from patient and family assessments and interdisciplinary team meetings.”

Bereavement care staff often operate in silos outside of the interdisciplinary care team and have fewer opportunities to connect with patients and families, while physicians and nurses have more direct contact with patients and their families, she said. Having clinicians more involved in grief programs allows families’ continued interdisciplinary support after a loved ones’ through that direct connection, Gross explained.

But balancing clinical burnout, widespread workforce shortages and the pandemic has left hospices in even tighter financial and operational spots to adequately support bereavement services, Gross said.

“Whatever a hospice gets paid in their daily rate, there’s not much of anything leftover to try and pay for 13 months of bereavement – let alone cover the costs of staff providing care to loved ones” Gross said. “[The U.S. Centers for Medicare & Medicaid Services (CMS)] is not making it easy for anybody to make this a robust, sustainable business model.”

The pandemic’s impacts

The COVID-19 pandemic reshaped how hospices provide grief care, with many turning to the virtual setting — and implementing new technology platforms — to continue supporting families. This, and the need for staff training, represented additional costs for many hospices.

With the end of the public health emergency on May 11, hospices nationwide have expanded their grief programs, including summer camps, as the weather heats up — though a number are staying virtual.

Hospice of the Chesapeake’s has resumed its Camp Nabi for children this summer. The Maryland-based hospice suspended the program in 2018.

Chesapeake this year has extended the program to its affiliates Hospice of Charles County and Calvert Hospice, according to Chesapeake Life Center Director Brian Berger.

“We’ll have transportation to and from our Anne Arundel, Charles, Calvert and Prince George’s County offices,” Berger said in a statement. “These camps take a lot of support, both financially and through staff and volunteer participation. But this is something our community really supports and wants to be a part of.”

Bereavement staff lack guidelines

More robust regulatory guidelines would help providers shape their grief programs, according to Gross.

Federal rules do not contain specific standards on how that care should be provided or what it should include. CMS to date also has not developed quality measures to evaluate their effectiveness.

“There isn’t a guideline as to what would be considered best practice or appropriately fulfilling the Medicare requirements for bereavement,” Gross said.

Last year federal legislation was proposed that, if enacted, would have advanced the development of an evidence-based definition of “high-quality” bereavement care. The language appeared in the 2023 appropriations bill for the Departments of Labor, Health & Human Services, Education, and related agencies.

The bill included a recommendation to require the U.S. Agency for Health Research & Quality to develop consensus standards on what constitutes high-quality grief and bereavement care, in partnership with the National Quality Forum and hospice providers, among others. But Congress did not pass the legislation.

“Conditions of payment stipulate that hospices must provide bereavement care, but these don’t stipulate what that needs to look like,” Gross said. “So the offerings in that world are quite varied as far as services and products. That leaves a lot for hospices to not only define, but also raises a staffing issue of who will provide these services and how they’ll be made up. There’s no guideline in place for fulfilling this Medicare requirement in an economically feasible way.”