- Email: [email protected]
Hospice Medical Directors: A Survey of One State
JAMDA 13 (2012) 35e40
JAMDA journal homepage: www.jamda.com
Original Study
Hospice Medical Directors: A Survey of One State Debra Parker Oliver PhD, MSW a, *, Julie M. Kapp PhD a, Paul Tatum MD, CMD a, Audrey Wallace b a b
Curtis W. and Ann H. Long Department of Family and Community Medicine, University of Missouri, Columbia, MO University of Missouri School of Medicine, Columbia, MO
a b s t r a c t Keywords: Hospice medical director interdisciplinary team palliative care
Introduction: Little research exists regarding hospice medical directors (HMD). This project describes the HMD’s background and training, clinical roles, and current function within the hospice organization and their interdisciplinary groups. Methods: A survey was mailed to each licensed hospice that was also a member of the state hospice association in one state. Thirty-one HMDs from 31 hospice programs (40% response rate) in one state responded. Results: Findings show that the role of the HMD in this state is primarily part-time and filled by primary care physicians. Most HMDs report being satisfied with their positions. No more than one third belong to any one professional association and no physician in this survey was certified in palliative care by the American Board of Medical Specialties. The role for most of these HMDs centers around their clinical contribution to the team. Discussion: Despite the 2008 revisions in the regulations, the HMD roles still vary across hospices, and requirements regarding the specialty, training, and education for physicians are not specified. Professional associations for HMDs should target these part-time physicians in an effort to build a comprehensive organization represented by all types of HMDs. Conclusion: The part-time nature of HMDs has important implications for professional organizations and policy makers. Palliative care certification and continuing education opportunities need to be made available to these physicians. Additionally, new changes requiring face-to-face visits for recertification should consider the part-time nature of HMD work and the difficulties that the requirement will have in both cost for the hospice and access to primary care in rural areas. Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc.
The palliative medicine physician role has rapidly transformed from a dedicated volunteer to one of increased specialization and professionalism. In 1988, a small group of 250 hospice physicians gathered in a retreat in Colorado to form the first association for physicians working in hospice and palliative medicine. In 1996, the American Board of Hospice and Palliative Medicine emerged, and awarded the first physician certification in hospice and palliative care. This organization became the American Academy of Hospice and Palliative Medicine (AAHPM) and now currently has more than 3600 members.1 In 2006, hospice and palliative medicine was recognized as a formal board-certified specialty, achieving subspecialty status with the American Board of Medical Specialties.2 Formal fellowship programs now provide specialty training toward this board certification. This study was supported by a Health Sciences summer fellowship for a second year medical student, and an internal departmental grant for postage and supplies. * Address correspondence to Debra Parker Oliver, PhD, MSW, Curtis W. and Ann H. Long Department of Family and Community Medicine, University of Missouri, 709 Clark Hall, Columbia, MO 65203. E-mail address: [email protected] (D. Parker Oliver).
In 2008, numerous changes were made in the Hospice Medicare Conditions of Participation. Among those changes were updates clarifying the roles and responsibilities of hospice medical directors.3 These clarifications have brought increased attention to physicians on hospice teams. In the summer of 2010, additional federal regulations were published for comment that propose to require medical directors to make formal face-to-face visits before recertification of a hospice patient’s benefits after 6 months of hospice care.4 This proposal would dramatically change the roles and involvement of physicians in hospice agencies. Despite increased research in palliative medicine and hospice care, little research on the practice of hospice medical directors exists. One recent study reported that despite an extensive literature search, only 7 publications related to hospice medical directors were found, and 6 of those were review papers.5 Since that time, only 2 additional publications have explored the role of the hospice medical director and the experience of their team members.6,7 The only known survey of medical directors’ practice was published in 1999.8 Our study aims to update the 1999 survey and describe the Hospice Medical Directors’ (HMD) background and training, clinical
1525-8610/$ - see front matter Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc. doi:10.1016/j.jamda.2010.11.009
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D. Parker Oliver et al. / JAMDA 13 (2012) 35e40
roles, and current function within the hospice organization and their interdisciplinary groups.
acute settings, average daily census, length of stay over 6 months, and average length of stay; no differences were found (P > .05).
Methods
Results
Study Sample
Table 1 summarizes the sample demographics, training and certification characteristics. Responding HMDs were from hospices located in 23 (of 114) different counties in the state. The responding hospices varied in size, with an average daily census of 67 and an average of 331 admissions per year. The average length of stay was 81 days and most (84%) hospice respondents were not chainaffiliated. Slightly more than one half (58.0%) were not-for-profit. About half (54.8%) of responding hospices were located in a metropolitan statistical area as defined by the US Census Bureau.14 The average age for HMDs was 52.3 years (median: 51.0 years; range: 33e74 years). Eighty-four percent of HMDs were male, and 90% of respondents where Caucasian. One respondent was Native American and 1 was Hispanic. The average number of years in practice was 21.5 (median: 21.0 years; range: 5e49 years) with an average of 9.1 years working as a medical director for hospice (median: 5.5 years; range: 1e25 years) and 8.4 years working in the current hospice (median: 5.5 years; range 1e25 years). Forty-two percent were the only medical director, and an additional 45.2% reported having a total of 2 to 4 medical directors at their hospice with a range of responses between 1 and 8 HMDs.
We acquired 2008 data from the state Hospice and Palliative Care Association of 107 state-licensed hospices in one Midwestern state.9 We also acquired 2009 membership rosters from the state organization Web site,10 representing 106 state hospice members. From the membership list we excluded 3 who did not meet our eligibility criteria because they were not hospices, for a sample of 103. From combining these lists, we excluded 32 state-licensed hospices that were not also members of the state organization, who had closed, or were a branch office. We also excluded a local HMD who assisted with survey development, for a final sampling frame of 71 state-licensed state associationemembered hospices. These 71 hospices were mailed a package to the hospice executive director. The package included the following: (1) a cover letter asking the executive director to give the survey envelope to one of the HMD to ensure one response per director; (2) a self-addressed postage paid return envelope; (3) a cover letter for the HMD; (4) a short 2-page/4-sided survey11; and (5) a $2 bill as an unconditional incentive.11 Survey responses were tracked via unique ID. Based on the literature, we handwrote addresses and used stamped postage in an effort to increase the response rate.11,12 We also handwrote “FOR MEDICAL DIRECTOR” on the survey envelope.11 After 4 weeks, we sent a second mailing (with no additional incentive). After approximately 8 additional weeks, we e-mailed the executive directors of the 45 remaining hospices with a reminder and opportunity to mail or fax completed surveys. We followed up with a final e-mail attempt after approximately 4 more weeks. A total of 31 respondents completed the survey, for a response rate of 43.7%. Survey Development The semistructured survey used closed- and open-ended questions modified from a similar assessment of chief medical officers in health care.13 We pilot tested the survey with a local geriatrician and an HMD, asking also for feedback on the length of time, the format, and general impressions. Revisions were made, for a goal of a 10-minute completion time. The final survey had 30 questions including 2 that were open ended. We collected follow-up information, including participants’ names and contact information. A follow-up interview was completed with 17 participants, and the data from those open-ended interviews is published elsewhere.7 The University of Missouri Health Sciences Institutional Review Board provided exempt approval for this study. Data Management and Analysis A Microsoft Access database v2007 was created for data entry of surveys. These data were imported into SAS v9.1 (SAS, Cary, NC) for management and analyses. We used all 31 respondents as the denominator for the “check all that apply” questions (yes/not yes). We classified the hospice county as metropolitan or non-metropolitan according to the 2003 rural urban continuation codes.14 We characterized the sample with descriptive statistics. We tested comparisons between categorical variables using chi-squared, and between continuous variables using nonparametric Wilcoxon tests. All tests were 2-tailed tests of significance at alpha ¼ 0.05. We compared responders with nonresponders by hospice county, tax status, ownership, total yearly admissions, total patient days in inpatient/
Training, Certification, and Employment Status Seventy-one percent of HMDs had a degree of Medical Doctor, whereas 29% were Doctors of Osteopathy. The overwhelming majority (90.3%) of HMDs were primary practice physicians (51.6% family physicians, 38.7% internal medicine) and 22.6% were additionally specialized in geriatric medicine. No one responded as having a medical specialty of anesthesia or pediatrics, or a subspecialty of pain, cardiology, nephrology, or pulmonology. Nearly one fourth (22.6%) were board certified (by the American Board of Hospice and Palliative Medicine process) and none reported being certified from the American Board of Medical Specialties. Additionally, none had completed a palliative medicine fellowship, although 41.9% had completed training from the American Medical Association’s Educating Physicians about End-of-life Care curriculum. HMDs belonged to a variety of physician and hospice organizations. The largest number, slightly more than a third (32.3%), reported belonging to the AAHPM. Additional memberships were reported in state hospice and end-of-life organizations (22.6%), the National Hospice and Palliative Care Organization (9.7%), and American Medical Directors Association (9.7%). Most medical directors were working part-time with 67.8% working 20 hours per week or less in this role. The range of phone calls reportedly received by the HMD from the hospice varied between 1 and 60 with 22.6% receiving 5 or fewer calls per week, 38.7% receiving between 6 and 15, 29.0% reporting they receive between 16 and 30 calls per week, and 9.7% reporting more than 30 per week. Likewise, reimbursement of HMDs varied. Thirty-two percent reported being paid by the hour; generally between $120 and $250. More than half (51.6%) were salaried. Interestingly, nearly 10% reported they were not receiving compensation. Most (71.0%) HMDs report to the local hospice administrator and nearly a third (32.3%) to a local case manager or supervisor. Medical Director Roles Table 2 summarizes the responses to questions on medical director roles, effectiveness, and satisfaction. More than half (58.1%) of HMDs reported not having done a home visit in the past month,
D. Parker Oliver et al. / JAMDA 13 (2012) 35e40
37
Table 1 Summary of Demographic, Training, and Certification Characteristics (n ¼ 31) Question Are you. Male Female Missing/no answer Which of the following best describes you? White Black Asian/Pacific Islander Native American Other (please specify) Missing/no answer Do you consider yourself to be of Hispanic origin? Yes No Missing/no answer What advanced degrees (ie, beyond baccalaureate) have you received? (circle all that apply) MD DO MPH,MHA,MBA Other (please specify) How many Medical Directors and Associate Medical Directors (total physicians including yourself) are in your hospice currently? 1 2e4 More than 4 Missing/no answer What is your medical specialty? (circle all that apply) Family Medicine Internal Medicine Oncology/Hematology Physical Medicine Rehab General Surgery Do you have a subspecialty? (circle all that apply) Geriatrics Hospice and Palliative Medicine Other (please specify): OB Are you board certified in palliative medicine? No Yes, by American Board of Hospice and Palliative Medicine, Yes, with the CAQ from American Board of Medical Specialties (after 2008) Missing/no answer Have you done a Palliative Medicine Fellowship? No Yes Missing/no answer What professional associations do you belong to? (circle all that apply) American Medical Directors Association: Certified Medical Director? Yes No American Academy of Hospice and Palliative Medicine National Hospice and Palliative Care Organization State Hospice and Palliative Care Organization/End of Life Coalition Other (AAFP, ACP, AGS, AMA, AOA, MAOPS, CMOA) Have you attended an EPEC (Education on Palliative and End of Life Care) Program? Yes No Missing/no answer In the last month, how many hours did you work with hospice? (please check one) Less than 5 hours 6e20 hours 21e30 hours 31e60 hours 61þ hours In an average week, how many phone calls do you receive from the hospice? 5 or less 6e15 16e30 More than 30 How are you paid for your hospice work? (circle and complete all that apply) Hourly rate Salary rate Other-volunteer Other- call
n
%
26 4 1
83.9 12.9 3.2
28 0 0 1 0 2
90.3 0 0 3.2 0 6.5
1 29 1
3.2 93.5 3.2
22 9 0 0
71.0 29.0 0 0
13 14 3 1
41.9 45.2 9.7 3.2
16 12 1 1 1
51.6 38.7 3.2 3.2 3.2
7 7 1
22.6 22.6 3.2
22 7 0 2
71.0 22.6 0 6.5
30 0 1
96.8 0 3.2
3 4 10 3 7 8
9.7 12.9 32.2 9.7 22.6 25.8
13 16 2
41.9 51.6 6.5
6 15 4 1 5
19.4 48.4 12.9 3.2 16.1
7 12 9 3
22.6 38.7 29.0 9.7
10 16 3 1
32.3 51.6 9.7 3.2
(continued on next page)
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D. Parker Oliver et al. / JAMDA 13 (2012) 35e40
Table 1 continued Question As (Associate) Medical Director, to whom do you report directly? (circle all that apply) The Local Hospice Administrator The Local Hospice Nursing Supervisor/Case Manager The Corporate Hospice Administrator A Corporate Hospice Medical Director Other (please specify) No one or unknown May we contact you for a follow-up study? Yes No
28.5% reported 1 to 5, and 9.6% reported 6 or more. Nearly one fifth (19.4%) of HMDs reported visiting 6 or more patients in the nursing home in the past month, whereas 44.8% reported not visiting patients in the nursing home at all. About 16% of HMDs reported visiting hospice patients in an inpatient setting during the same month. In the role of HMD, 71.0% reported participating in quality assurance, nearly all (96.8%) reported participating as a primary attending for hospice patients, 96.8% reporting acting as a consultant with primary physicians, and 87.1% stated they make patient visits when necessary. It is also interesting to note the roles of the HMD not reported, specifically those required by the Medicare Conditions of Participation. Sixteen percent did not report they had responsibility for approving care plans, and nearly 10% did not report playing a role in reviewing certification. There was variance in the amount of participation in various administrative roles for HMDs. Although 93.6% reported acting as a medical liaison between hospice and the attending physicians and 93.6% participated in utilization and review of cases, only 64.5% reported providing education and training for hospice staff. Only 41.9% of HMDs reported being involved in the evaluation of clinical staff, and only one fourth (25.8%) reported participating in budgeting. Satisfaction and Effectiveness The excellence of the hospice interdisciplinary team was the most frequently reported factor for fostering medical director effectiveness (93.6% of respondents). Likewise, the personal history of the HMD and stature among the hospice staff were also frequently reported, by 80.7%. Nearly three fourths (74.2%) felt the commitment of the local hospice administrator contributed to their success and 71.0% identified having an excellent relationship with local physicians as fostering their effectiveness as an HMD. The commitment of corporate administrators (6.5%) and medical directors (16.1%) was indicated as a factor in fostering effectiveness. In contrast, the most frequently reported factors in limiting effectiveness included time (29.0%), challenging relationships with local physicians (22.6%), and a lack of clear role (12.9%). Finally, most (87.1%) respondents strongly agreed or agreed with the statement that they were satisfied with their current position. Similarly, 90.3% strongly agreed or agreed that their efforts had a significant impact on the quality of care in their hospice, and 93.3% strongly agreed or agreed that they had the necessary support to accomplish their responsibilities effectively. The HMDs identified key areas that would improve their effectiveness: increased understanding of hospice regulations (38.7%), peer support (29.0%), clinical experience (29.0%), leadership training (16.1%), and mentoring (12.9%). Discussion Our results show that the role of the HMD in this state is primarily part-time and filled by primary care physicians. Most
n
%
22 10 3 0 2 2
71.0 32.3 9.7 0 6.5 6.5
23 8
74.2 25.8
HMDs report being satisfied with their position. The role for most of these HMDs may center around their clinical contribution to the team, as inpatient/hospital visits were not frequently reported by these physicians. The clinical responsibilities primarily involve team meetings, including the approval of patient care plans and questions related to certification of the terminal illness. Only a few HMDs felt they had a direct line of reporting with a local leader of the hospice (eg, corporate hospice administrator or local nurse case manager) and some felt that the lack of a clear role for their position limited their effectiveness. A few did not report to anyone or were unsure. As noted by Vandenberg and Keller,5 there is not often an evaluation process for medical directors, leaving them to self-identify areas to improve and without an advocate for support. Further research should be done to understand the possible impact of the lack of role definitions and lack of evaluation and feedback on the HMDs’ ability to provide care. It is interesting to note that although most HMDs were primary care physicians, most palliative care research does not appear in primary careefocused journals.15,16 Related to this issue is that less than a third of our respondents reported belonging to a national palliative medicine or medical director association, potentially leaving them without subscriptions to many palliative care journals or journals that target their medical director role. This concern was supported by our follow-up interviews (reported previously7), in which both time and the lack of financial support for professional development were cited as barriers to the educational opportunities offered by hospice-related organizations. The HMDs have many years of experience as physicians, and yet none have completed fellowships and most are neither members of the AAHPM nor board-certified in hospice and palliative medicine. Despite their many years of hospice experience, a surprising number of HMDs did not identify duties required by regulation as part of their job. According to the conditions of participation, HMD responsibilities include approval of the care plan and reviewing recertification, yet not all respondents identified these as part of their role. From a quality standpoint, the lack of formal training and certification is concerning, although not surprising. Despite the 2008 revisions in the regulations,3 the HMD roles still vary across hospices, and requirements regarding the specialty, training, and education for physicians are not specified in the regulations. While board certification requires time and resources, which may be especially burdensome for practicing physicians or physicians in nonmetro areas, professional development and continuing education in palliative care would seem like minimal standards and potentially translate into improved patient care. For example, a study of long term care found that a medical director who has formal certification as a certified medical director appears to have a significant impact on the quality of the long term care program served.17 Future studies should consider the impact of the hospice medical director’s training on the overall hospice care quality and outcomes.
D. Parker Oliver et al. / JAMDA 13 (2012) 35e40
39
Table 2 Medical Director Roles, Effectiveness, and Satisfaction (n ¼ 31) Question In the last month, how many hospice patient visits did you do (circle all types that apply and include the number of visits for each)? Nursing home visits: 0 visits 1e5 6 or more Missing/no answer Home visits: 0 visits 1e5 6 or more Missing/no answer Inpatient/Hospital visits: 0 visits 1e5 6 or more Missing/no answer In your role as (Associate) Medical Director, which of the following do you actively participate in as a part of your role (circle all that apply)? Act as primary physician for patients as requested Consult with attending physicians as requested Participate in utilization and review of cases Acting as medical liaison between hospice and attending Review candidacy for hospice certification Assist team in generating care plan Make hospice visits as indicated Approving care plan Review and update care plan every 14 days Participate in quality assurance activities of the hospice Oversee or provide education and training for hospice staff Participate in evaluation of clinical staff Budget issues Other (please specify): (project development, attending for inpatient, hospital visits) What factors FOSTER your effectiveness as (Associate) Medical Director? (circle all that apply) Excellence of the Hospice Interdisciplinary Team Members My personal history and stature among our hospice staff Commitment of the Local Hospice Administrator Excellent relationship with local physicians Clear definition of the roles and responsibilities of my position Commitment of the Corporate Medical Director Commitment of the Corporate Hospice Administration Other (please specify) (personal passion, pride) What factors LIMIT your effectiveness as (Associate) Medical Director? (circle all that apply) Time Challenging relationships with local physicians Lack of clear definition of the roles and responsibilities of my position Lack of commitment of the Local Hospice Administrator Lack of training for the Hospice Interdisciplinary Team Members Lack of personal history and stature among our hospice staff Lack of commitment of the Corporate Hospice Administration Lack of commitment of the Corporate Medical Director Other (please specify): (nursing home relationships, regs) None I feel satisfied in my current position. Strongly agree/agree Neutral Disagree/Strongly disagree Missing/no answer My efforts have a significant impact on the quality of care in my hospice. Strongly agree/agree Neutral Disagree/Strongly disagree Missing/no answer I have the necessary support to accomplish my responsibilities effectively. Strongly agree/agree Neutral Disagree/Strongly disagree Identify resources that would help you be more effective as (Associate) Medical Director (check all that apply). a. Increased understanding of hospice regulations b. Clinical experience c. Peer support d. Leadership training e. Mentoring f. Other (please specify): (Clear roles, time, paid endorsement)
n
%
13 10 6 2
41.9 32.3 19.4 6.5
18 8 3 2
58.1 25.8 9.7 6.5
20 6 3 2
64.5 19.4 9.7 6.5
30 30 29 29 28 27 27 26 24 22 20 13 8 3
96.8 96.8 93.6 93.6 90.3 87.1 87.1 83.9 77.4 71.0 64.5 41.9 25.8 9.7
29 25 23 22 17 5 2 2
93.6 80.7 74.2 71.0 54.8 16.1 6.5 6.5
9 7 4 2 2 1 1 0 3 6
29.0 22.6 12.9 6.5 6.5 3.2 3.2 0 9.7 19.4
27 2 0 2
87.1 6.5 0 6.5
28 1 0 2
90.3 3.5 0 6.5
28 0 2
93.3 0 3.5
12 9 9 5 4 3
38.7 29.0 29.0 16.1 12.9 9.7
40
D. Parker Oliver et al. / JAMDA 13 (2012) 35e40
Given the lack of HMDs’ board certification and low involvement with national professional palliative care organizations, perhaps there is a need for a formal process to foster board certification and advanced training for the experienced mid-career clinician. Although the new certification process for hospice and palliative medicine recognizes an experience pathway to achieve board certification, that pathway closes in 2012.2 For the midcareer physician in a nonmetro area with limited number of available colleagues to care for their patients, disrupting their practice for a year of fellowship does not seem feasible. A modified, part-time fellowship program that provides board certification may be a viable alternative. Currently, there seems to be little opportunity and even less support available for all HMDs to obtain continuing education, especially without membership to national palliative care organizations. Additionally, national policy leaders should be aware that membership surveys of the National Hospice and Palliative Care Organization or AAHPM may not be representative of all hospice medical directors, particularly those who practice in nonmetro hospice agencies. Policy makers might also note the part-time nature of HMDs’ practice needs when considering additional regulations in hospice. For example, the proposed rule for a mandatory physician visit for recertification at the 180 days on hospice has the potential to improve patient care and prognostic accuracy. However, for the part-time HMD working 4 hours a week, a visit to a single patient in a nonmetro hospice may theoretically involve 100 miles of travel from the physician office to the hospice patient home and back. The community’s only physician potentially driving an hour or more out of the area for a hospice visit may leave the community without physician coverage during that time. For a part time HMD the competing demands of the primary care role, reimbursement, and travel considerations become an even bigger challenge. Although larger hospices may be able to find the additional resources to pay for additional HMD time, smaller hospices with fewer resources may not be able to support a full-time HMD. Policy makers should consider the feasibility and potential offered by telehealth technology not only for the continuing professional development of these part-time HMDs, but also for expanding their role in direct patient care, especially in larger, less populated areas. To our knowledge, this is the first study that describes the role of the hospice medical director using a statewide survey of hospices. That we used a state hospice organization as a sampling frame to study the characteristics of HMDs may be especially useful for researchers investigating the HMD within hospice teams. Unlike surveys of the members of AAHPM and National Hospice and Palliative Care Organization, sampling state hospice organizations allows a larger sample of HMDs than sampling professional associations, given the limited number reportedly belonging to national associations. There are a number of limitations to our study that warrant mention. First, as self-reported survey data, we cannot validate the information provided against an objective gold standard, and so the potential for both recall and reporting bias should be considered when interpreting these results. Second, 56% of our target sample did not respond to our survey, therefore response bias needs to be considered. Although it is tempting to believe that fellowship-trained or board-certified medical directors would be more motivated to complete the survey and therefore possibly be overrepresented in these results, it is possible that the full-time or certified HMD is underrepresented if clinical duties prevented their response. Third, our sampling frame was limited to one Midwestern state. Similar methodological studies should be done in various regions so as to provide a diverse perspective of the role of the HMD. Finally, the lack of ethnic and gender diversity in the sample limits the ability to generalize these results to all HMDs.
Conclusions In one Midwestern state, the hospice medical director’s role appears to be primarily a part-time role filled by experienced primary care physicians. Formal board certification in hospice and palliative medicine is uncommon and none had completed fellowship training. Respondents reported that training, mentoring, and/or education were resources that could improve their effectiveness. Yet, targeting these medical directors for education and training is challenging given their lack of membership in palliative careerelated associations. State and national organizations should consider avenues to target education toward part-time hospice physicians. Regulators might consider supporting the need for hospice medical director training, and requiring that hospice programs support their medical directors with orientation and continuing education. Online training is becoming more readily available, which can assist in the expense and time requirement for continuing education in palliative care; however, without regulatory support it is not likely these options will become common practice in a competitive, capitated, resource-starved setting such as hospice. Acknowledgments We thank David E. Longnecker, MD, FRCA, for permission to use and modify questions from his “Roles and Responsibilities of Chief Medical Officers in Member Organizations of the Association of American Medical Colleges” survey (Academic Medicine, 2007). We thank Betty Kennedy for preparing and mailing the surveys. References 1. American Academy of Hospice and Palliative Medicine. About AAHPM. Available at: http://www.aahpm.org/about/history.html. Accessed September 10, 2010. 2. American Board of Medical Specialties. ABMS established new subspecialty certificate in hospice and palliative medicine. Available at: www.abms.org/ NewsandEvents/downloads/NewsubcertPalliativeMed.pdf. Accessed September 10, 2010. 3. Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs: Hospice Conditions of Participation. Federal Register v72 (October 1, 2007) (codified at 42 CFR 418). 4. Schumacher D. National Hospice and Palliative Care Organization; 2010. 5. Vandenberg E, Keller B. A guide to becoming a hospice medical director: Initial decisions and evaluations. J Am Med Dir Assoc 2009;10:298e303. 6. Parker Oliver D, Tatum P. The medical director as a member of the hospice team. J Am Med Dir Assoc 2009;10:92e94. 7. Parker Oliver D, Tatum P, Kapp J, Wallace A. Interdisciplinary collaboration: The voices of hospice medical directors. Am J Hosp Palliat Care 2010;27: 537e544. 8. Parker-Oliver D. Practice patterns of hospice medical directors in a Midwestern state. Am J Hosp Palliat Care 1999;16:633e638. 9. Missouri Hospice and Palliative Care Organization (MHPCO). 2008 Missouri Hospice Statistical Report. Lee’s Summit, Missouri: MHPCO; 2009. 10. Missouri Hospice and Palliative Care Association Membership Directory. Missouri Hospice and Palliative Care Organziation. Available at: www.mohospice. org. Accessed April 2010. 11. Edwards P, Roberts I, Clarke M, et al. Methods to increase response rates to postal questionnaires. Cochrane Database Syst Rev 2007;(2):MR000008. 12. Urban N, Anderson G, Tseng A. Effects on response rates and costs of stamps vs business reply in a mail survey of physicians. J Clin Epidemiol 1993;46: 455e459. 13. Longnecker DE, Patton M, Dickler R. Roles and responsibilities of chief medical officers in member organizations of the Association of American Medical Colleges. Acad Med 2007;82:258e263. 14. USDA. Rural-Urban Continuum Codes for Missouri. Economic Research Service; 2003. 15. Tiemann J, Sladek R, Currow D. Multiple sources: Mapping the literature of palliative care. Palliat Med 2009;23:425e431. 16. Tieman J, Sladek R, Currow DC. Changes in the quantity and level of evidence in palliative and hospcie care literature: The last century. J Clin Oncol 2008;26: 5679e5683. 17. Rowland F, Cowles M, Dickenstein C, Katz P. Impact of medical director certification on nursing home quality of care. J Am Med Dir Assoc 2009;10: 431e435.
JAMDA journal homepage: www.jamda.com
Original Study
Hospice Medical Directors: A Survey of One State Debra Parker Oliver PhD, MSW a, *, Julie M. Kapp PhD a, Paul Tatum MD, CMD a, Audrey Wallace b a b
Curtis W. and Ann H. Long Department of Family and Community Medicine, University of Missouri, Columbia, MO University of Missouri School of Medicine, Columbia, MO
a b s t r a c t Keywords: Hospice medical director interdisciplinary team palliative care
Introduction: Little research exists regarding hospice medical directors (HMD). This project describes the HMD’s background and training, clinical roles, and current function within the hospice organization and their interdisciplinary groups. Methods: A survey was mailed to each licensed hospice that was also a member of the state hospice association in one state. Thirty-one HMDs from 31 hospice programs (40% response rate) in one state responded. Results: Findings show that the role of the HMD in this state is primarily part-time and filled by primary care physicians. Most HMDs report being satisfied with their positions. No more than one third belong to any one professional association and no physician in this survey was certified in palliative care by the American Board of Medical Specialties. The role for most of these HMDs centers around their clinical contribution to the team. Discussion: Despite the 2008 revisions in the regulations, the HMD roles still vary across hospices, and requirements regarding the specialty, training, and education for physicians are not specified. Professional associations for HMDs should target these part-time physicians in an effort to build a comprehensive organization represented by all types of HMDs. Conclusion: The part-time nature of HMDs has important implications for professional organizations and policy makers. Palliative care certification and continuing education opportunities need to be made available to these physicians. Additionally, new changes requiring face-to-face visits for recertification should consider the part-time nature of HMD work and the difficulties that the requirement will have in both cost for the hospice and access to primary care in rural areas. Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc.
The palliative medicine physician role has rapidly transformed from a dedicated volunteer to one of increased specialization and professionalism. In 1988, a small group of 250 hospice physicians gathered in a retreat in Colorado to form the first association for physicians working in hospice and palliative medicine. In 1996, the American Board of Hospice and Palliative Medicine emerged, and awarded the first physician certification in hospice and palliative care. This organization became the American Academy of Hospice and Palliative Medicine (AAHPM) and now currently has more than 3600 members.1 In 2006, hospice and palliative medicine was recognized as a formal board-certified specialty, achieving subspecialty status with the American Board of Medical Specialties.2 Formal fellowship programs now provide specialty training toward this board certification. This study was supported by a Health Sciences summer fellowship for a second year medical student, and an internal departmental grant for postage and supplies. * Address correspondence to Debra Parker Oliver, PhD, MSW, Curtis W. and Ann H. Long Department of Family and Community Medicine, University of Missouri, 709 Clark Hall, Columbia, MO 65203. E-mail address: [email protected] (D. Parker Oliver).
In 2008, numerous changes were made in the Hospice Medicare Conditions of Participation. Among those changes were updates clarifying the roles and responsibilities of hospice medical directors.3 These clarifications have brought increased attention to physicians on hospice teams. In the summer of 2010, additional federal regulations were published for comment that propose to require medical directors to make formal face-to-face visits before recertification of a hospice patient’s benefits after 6 months of hospice care.4 This proposal would dramatically change the roles and involvement of physicians in hospice agencies. Despite increased research in palliative medicine and hospice care, little research on the practice of hospice medical directors exists. One recent study reported that despite an extensive literature search, only 7 publications related to hospice medical directors were found, and 6 of those were review papers.5 Since that time, only 2 additional publications have explored the role of the hospice medical director and the experience of their team members.6,7 The only known survey of medical directors’ practice was published in 1999.8 Our study aims to update the 1999 survey and describe the Hospice Medical Directors’ (HMD) background and training, clinical
1525-8610/$ - see front matter Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc. doi:10.1016/j.jamda.2010.11.009
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D. Parker Oliver et al. / JAMDA 13 (2012) 35e40
roles, and current function within the hospice organization and their interdisciplinary groups.
acute settings, average daily census, length of stay over 6 months, and average length of stay; no differences were found (P > .05).
Methods
Results
Study Sample
Table 1 summarizes the sample demographics, training and certification characteristics. Responding HMDs were from hospices located in 23 (of 114) different counties in the state. The responding hospices varied in size, with an average daily census of 67 and an average of 331 admissions per year. The average length of stay was 81 days and most (84%) hospice respondents were not chainaffiliated. Slightly more than one half (58.0%) were not-for-profit. About half (54.8%) of responding hospices were located in a metropolitan statistical area as defined by the US Census Bureau.14 The average age for HMDs was 52.3 years (median: 51.0 years; range: 33e74 years). Eighty-four percent of HMDs were male, and 90% of respondents where Caucasian. One respondent was Native American and 1 was Hispanic. The average number of years in practice was 21.5 (median: 21.0 years; range: 5e49 years) with an average of 9.1 years working as a medical director for hospice (median: 5.5 years; range: 1e25 years) and 8.4 years working in the current hospice (median: 5.5 years; range 1e25 years). Forty-two percent were the only medical director, and an additional 45.2% reported having a total of 2 to 4 medical directors at their hospice with a range of responses between 1 and 8 HMDs.
We acquired 2008 data from the state Hospice and Palliative Care Association of 107 state-licensed hospices in one Midwestern state.9 We also acquired 2009 membership rosters from the state organization Web site,10 representing 106 state hospice members. From the membership list we excluded 3 who did not meet our eligibility criteria because they were not hospices, for a sample of 103. From combining these lists, we excluded 32 state-licensed hospices that were not also members of the state organization, who had closed, or were a branch office. We also excluded a local HMD who assisted with survey development, for a final sampling frame of 71 state-licensed state associationemembered hospices. These 71 hospices were mailed a package to the hospice executive director. The package included the following: (1) a cover letter asking the executive director to give the survey envelope to one of the HMD to ensure one response per director; (2) a self-addressed postage paid return envelope; (3) a cover letter for the HMD; (4) a short 2-page/4-sided survey11; and (5) a $2 bill as an unconditional incentive.11 Survey responses were tracked via unique ID. Based on the literature, we handwrote addresses and used stamped postage in an effort to increase the response rate.11,12 We also handwrote “FOR MEDICAL DIRECTOR” on the survey envelope.11 After 4 weeks, we sent a second mailing (with no additional incentive). After approximately 8 additional weeks, we e-mailed the executive directors of the 45 remaining hospices with a reminder and opportunity to mail or fax completed surveys. We followed up with a final e-mail attempt after approximately 4 more weeks. A total of 31 respondents completed the survey, for a response rate of 43.7%. Survey Development The semistructured survey used closed- and open-ended questions modified from a similar assessment of chief medical officers in health care.13 We pilot tested the survey with a local geriatrician and an HMD, asking also for feedback on the length of time, the format, and general impressions. Revisions were made, for a goal of a 10-minute completion time. The final survey had 30 questions including 2 that were open ended. We collected follow-up information, including participants’ names and contact information. A follow-up interview was completed with 17 participants, and the data from those open-ended interviews is published elsewhere.7 The University of Missouri Health Sciences Institutional Review Board provided exempt approval for this study. Data Management and Analysis A Microsoft Access database v2007 was created for data entry of surveys. These data were imported into SAS v9.1 (SAS, Cary, NC) for management and analyses. We used all 31 respondents as the denominator for the “check all that apply” questions (yes/not yes). We classified the hospice county as metropolitan or non-metropolitan according to the 2003 rural urban continuation codes.14 We characterized the sample with descriptive statistics. We tested comparisons between categorical variables using chi-squared, and between continuous variables using nonparametric Wilcoxon tests. All tests were 2-tailed tests of significance at alpha ¼ 0.05. We compared responders with nonresponders by hospice county, tax status, ownership, total yearly admissions, total patient days in inpatient/
Training, Certification, and Employment Status Seventy-one percent of HMDs had a degree of Medical Doctor, whereas 29% were Doctors of Osteopathy. The overwhelming majority (90.3%) of HMDs were primary practice physicians (51.6% family physicians, 38.7% internal medicine) and 22.6% were additionally specialized in geriatric medicine. No one responded as having a medical specialty of anesthesia or pediatrics, or a subspecialty of pain, cardiology, nephrology, or pulmonology. Nearly one fourth (22.6%) were board certified (by the American Board of Hospice and Palliative Medicine process) and none reported being certified from the American Board of Medical Specialties. Additionally, none had completed a palliative medicine fellowship, although 41.9% had completed training from the American Medical Association’s Educating Physicians about End-of-life Care curriculum. HMDs belonged to a variety of physician and hospice organizations. The largest number, slightly more than a third (32.3%), reported belonging to the AAHPM. Additional memberships were reported in state hospice and end-of-life organizations (22.6%), the National Hospice and Palliative Care Organization (9.7%), and American Medical Directors Association (9.7%). Most medical directors were working part-time with 67.8% working 20 hours per week or less in this role. The range of phone calls reportedly received by the HMD from the hospice varied between 1 and 60 with 22.6% receiving 5 or fewer calls per week, 38.7% receiving between 6 and 15, 29.0% reporting they receive between 16 and 30 calls per week, and 9.7% reporting more than 30 per week. Likewise, reimbursement of HMDs varied. Thirty-two percent reported being paid by the hour; generally between $120 and $250. More than half (51.6%) were salaried. Interestingly, nearly 10% reported they were not receiving compensation. Most (71.0%) HMDs report to the local hospice administrator and nearly a third (32.3%) to a local case manager or supervisor. Medical Director Roles Table 2 summarizes the responses to questions on medical director roles, effectiveness, and satisfaction. More than half (58.1%) of HMDs reported not having done a home visit in the past month,
D. Parker Oliver et al. / JAMDA 13 (2012) 35e40
37
Table 1 Summary of Demographic, Training, and Certification Characteristics (n ¼ 31) Question Are you. Male Female Missing/no answer Which of the following best describes you? White Black Asian/Pacific Islander Native American Other (please specify) Missing/no answer Do you consider yourself to be of Hispanic origin? Yes No Missing/no answer What advanced degrees (ie, beyond baccalaureate) have you received? (circle all that apply) MD DO MPH,MHA,MBA Other (please specify) How many Medical Directors and Associate Medical Directors (total physicians including yourself) are in your hospice currently? 1 2e4 More than 4 Missing/no answer What is your medical specialty? (circle all that apply) Family Medicine Internal Medicine Oncology/Hematology Physical Medicine Rehab General Surgery Do you have a subspecialty? (circle all that apply) Geriatrics Hospice and Palliative Medicine Other (please specify): OB Are you board certified in palliative medicine? No Yes, by American Board of Hospice and Palliative Medicine, Yes, with the CAQ from American Board of Medical Specialties (after 2008) Missing/no answer Have you done a Palliative Medicine Fellowship? No Yes Missing/no answer What professional associations do you belong to? (circle all that apply) American Medical Directors Association: Certified Medical Director? Yes No American Academy of Hospice and Palliative Medicine National Hospice and Palliative Care Organization State Hospice and Palliative Care Organization/End of Life Coalition Other (AAFP, ACP, AGS, AMA, AOA, MAOPS, CMOA) Have you attended an EPEC (Education on Palliative and End of Life Care) Program? Yes No Missing/no answer In the last month, how many hours did you work with hospice? (please check one) Less than 5 hours 6e20 hours 21e30 hours 31e60 hours 61þ hours In an average week, how many phone calls do you receive from the hospice? 5 or less 6e15 16e30 More than 30 How are you paid for your hospice work? (circle and complete all that apply) Hourly rate Salary rate Other-volunteer Other- call
n
%
26 4 1
83.9 12.9 3.2
28 0 0 1 0 2
90.3 0 0 3.2 0 6.5
1 29 1
3.2 93.5 3.2
22 9 0 0
71.0 29.0 0 0
13 14 3 1
41.9 45.2 9.7 3.2
16 12 1 1 1
51.6 38.7 3.2 3.2 3.2
7 7 1
22.6 22.6 3.2
22 7 0 2
71.0 22.6 0 6.5
30 0 1
96.8 0 3.2
3 4 10 3 7 8
9.7 12.9 32.2 9.7 22.6 25.8
13 16 2
41.9 51.6 6.5
6 15 4 1 5
19.4 48.4 12.9 3.2 16.1
7 12 9 3
22.6 38.7 29.0 9.7
10 16 3 1
32.3 51.6 9.7 3.2
(continued on next page)
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D. Parker Oliver et al. / JAMDA 13 (2012) 35e40
Table 1 continued Question As (Associate) Medical Director, to whom do you report directly? (circle all that apply) The Local Hospice Administrator The Local Hospice Nursing Supervisor/Case Manager The Corporate Hospice Administrator A Corporate Hospice Medical Director Other (please specify) No one or unknown May we contact you for a follow-up study? Yes No
28.5% reported 1 to 5, and 9.6% reported 6 or more. Nearly one fifth (19.4%) of HMDs reported visiting 6 or more patients in the nursing home in the past month, whereas 44.8% reported not visiting patients in the nursing home at all. About 16% of HMDs reported visiting hospice patients in an inpatient setting during the same month. In the role of HMD, 71.0% reported participating in quality assurance, nearly all (96.8%) reported participating as a primary attending for hospice patients, 96.8% reporting acting as a consultant with primary physicians, and 87.1% stated they make patient visits when necessary. It is also interesting to note the roles of the HMD not reported, specifically those required by the Medicare Conditions of Participation. Sixteen percent did not report they had responsibility for approving care plans, and nearly 10% did not report playing a role in reviewing certification. There was variance in the amount of participation in various administrative roles for HMDs. Although 93.6% reported acting as a medical liaison between hospice and the attending physicians and 93.6% participated in utilization and review of cases, only 64.5% reported providing education and training for hospice staff. Only 41.9% of HMDs reported being involved in the evaluation of clinical staff, and only one fourth (25.8%) reported participating in budgeting. Satisfaction and Effectiveness The excellence of the hospice interdisciplinary team was the most frequently reported factor for fostering medical director effectiveness (93.6% of respondents). Likewise, the personal history of the HMD and stature among the hospice staff were also frequently reported, by 80.7%. Nearly three fourths (74.2%) felt the commitment of the local hospice administrator contributed to their success and 71.0% identified having an excellent relationship with local physicians as fostering their effectiveness as an HMD. The commitment of corporate administrators (6.5%) and medical directors (16.1%) was indicated as a factor in fostering effectiveness. In contrast, the most frequently reported factors in limiting effectiveness included time (29.0%), challenging relationships with local physicians (22.6%), and a lack of clear role (12.9%). Finally, most (87.1%) respondents strongly agreed or agreed with the statement that they were satisfied with their current position. Similarly, 90.3% strongly agreed or agreed that their efforts had a significant impact on the quality of care in their hospice, and 93.3% strongly agreed or agreed that they had the necessary support to accomplish their responsibilities effectively. The HMDs identified key areas that would improve their effectiveness: increased understanding of hospice regulations (38.7%), peer support (29.0%), clinical experience (29.0%), leadership training (16.1%), and mentoring (12.9%). Discussion Our results show that the role of the HMD in this state is primarily part-time and filled by primary care physicians. Most
n
%
22 10 3 0 2 2
71.0 32.3 9.7 0 6.5 6.5
23 8
74.2 25.8
HMDs report being satisfied with their position. The role for most of these HMDs may center around their clinical contribution to the team, as inpatient/hospital visits were not frequently reported by these physicians. The clinical responsibilities primarily involve team meetings, including the approval of patient care plans and questions related to certification of the terminal illness. Only a few HMDs felt they had a direct line of reporting with a local leader of the hospice (eg, corporate hospice administrator or local nurse case manager) and some felt that the lack of a clear role for their position limited their effectiveness. A few did not report to anyone or were unsure. As noted by Vandenberg and Keller,5 there is not often an evaluation process for medical directors, leaving them to self-identify areas to improve and without an advocate for support. Further research should be done to understand the possible impact of the lack of role definitions and lack of evaluation and feedback on the HMDs’ ability to provide care. It is interesting to note that although most HMDs were primary care physicians, most palliative care research does not appear in primary careefocused journals.15,16 Related to this issue is that less than a third of our respondents reported belonging to a national palliative medicine or medical director association, potentially leaving them without subscriptions to many palliative care journals or journals that target their medical director role. This concern was supported by our follow-up interviews (reported previously7), in which both time and the lack of financial support for professional development were cited as barriers to the educational opportunities offered by hospice-related organizations. The HMDs have many years of experience as physicians, and yet none have completed fellowships and most are neither members of the AAHPM nor board-certified in hospice and palliative medicine. Despite their many years of hospice experience, a surprising number of HMDs did not identify duties required by regulation as part of their job. According to the conditions of participation, HMD responsibilities include approval of the care plan and reviewing recertification, yet not all respondents identified these as part of their role. From a quality standpoint, the lack of formal training and certification is concerning, although not surprising. Despite the 2008 revisions in the regulations,3 the HMD roles still vary across hospices, and requirements regarding the specialty, training, and education for physicians are not specified in the regulations. While board certification requires time and resources, which may be especially burdensome for practicing physicians or physicians in nonmetro areas, professional development and continuing education in palliative care would seem like minimal standards and potentially translate into improved patient care. For example, a study of long term care found that a medical director who has formal certification as a certified medical director appears to have a significant impact on the quality of the long term care program served.17 Future studies should consider the impact of the hospice medical director’s training on the overall hospice care quality and outcomes.
D. Parker Oliver et al. / JAMDA 13 (2012) 35e40
39
Table 2 Medical Director Roles, Effectiveness, and Satisfaction (n ¼ 31) Question In the last month, how many hospice patient visits did you do (circle all types that apply and include the number of visits for each)? Nursing home visits: 0 visits 1e5 6 or more Missing/no answer Home visits: 0 visits 1e5 6 or more Missing/no answer Inpatient/Hospital visits: 0 visits 1e5 6 or more Missing/no answer In your role as (Associate) Medical Director, which of the following do you actively participate in as a part of your role (circle all that apply)? Act as primary physician for patients as requested Consult with attending physicians as requested Participate in utilization and review of cases Acting as medical liaison between hospice and attending Review candidacy for hospice certification Assist team in generating care plan Make hospice visits as indicated Approving care plan Review and update care plan every 14 days Participate in quality assurance activities of the hospice Oversee or provide education and training for hospice staff Participate in evaluation of clinical staff Budget issues Other (please specify): (project development, attending for inpatient, hospital visits) What factors FOSTER your effectiveness as (Associate) Medical Director? (circle all that apply) Excellence of the Hospice Interdisciplinary Team Members My personal history and stature among our hospice staff Commitment of the Local Hospice Administrator Excellent relationship with local physicians Clear definition of the roles and responsibilities of my position Commitment of the Corporate Medical Director Commitment of the Corporate Hospice Administration Other (please specify) (personal passion, pride) What factors LIMIT your effectiveness as (Associate) Medical Director? (circle all that apply) Time Challenging relationships with local physicians Lack of clear definition of the roles and responsibilities of my position Lack of commitment of the Local Hospice Administrator Lack of training for the Hospice Interdisciplinary Team Members Lack of personal history and stature among our hospice staff Lack of commitment of the Corporate Hospice Administration Lack of commitment of the Corporate Medical Director Other (please specify): (nursing home relationships, regs) None I feel satisfied in my current position. Strongly agree/agree Neutral Disagree/Strongly disagree Missing/no answer My efforts have a significant impact on the quality of care in my hospice. Strongly agree/agree Neutral Disagree/Strongly disagree Missing/no answer I have the necessary support to accomplish my responsibilities effectively. Strongly agree/agree Neutral Disagree/Strongly disagree Identify resources that would help you be more effective as (Associate) Medical Director (check all that apply). a. Increased understanding of hospice regulations b. Clinical experience c. Peer support d. Leadership training e. Mentoring f. Other (please specify): (Clear roles, time, paid endorsement)
n
%
13 10 6 2
41.9 32.3 19.4 6.5
18 8 3 2
58.1 25.8 9.7 6.5
20 6 3 2
64.5 19.4 9.7 6.5
30 30 29 29 28 27 27 26 24 22 20 13 8 3
96.8 96.8 93.6 93.6 90.3 87.1 87.1 83.9 77.4 71.0 64.5 41.9 25.8 9.7
29 25 23 22 17 5 2 2
93.6 80.7 74.2 71.0 54.8 16.1 6.5 6.5
9 7 4 2 2 1 1 0 3 6
29.0 22.6 12.9 6.5 6.5 3.2 3.2 0 9.7 19.4
27 2 0 2
87.1 6.5 0 6.5
28 1 0 2
90.3 3.5 0 6.5
28 0 2
93.3 0 3.5
12 9 9 5 4 3
38.7 29.0 29.0 16.1 12.9 9.7
40
D. Parker Oliver et al. / JAMDA 13 (2012) 35e40
Given the lack of HMDs’ board certification and low involvement with national professional palliative care organizations, perhaps there is a need for a formal process to foster board certification and advanced training for the experienced mid-career clinician. Although the new certification process for hospice and palliative medicine recognizes an experience pathway to achieve board certification, that pathway closes in 2012.2 For the midcareer physician in a nonmetro area with limited number of available colleagues to care for their patients, disrupting their practice for a year of fellowship does not seem feasible. A modified, part-time fellowship program that provides board certification may be a viable alternative. Currently, there seems to be little opportunity and even less support available for all HMDs to obtain continuing education, especially without membership to national palliative care organizations. Additionally, national policy leaders should be aware that membership surveys of the National Hospice and Palliative Care Organization or AAHPM may not be representative of all hospice medical directors, particularly those who practice in nonmetro hospice agencies. Policy makers might also note the part-time nature of HMDs’ practice needs when considering additional regulations in hospice. For example, the proposed rule for a mandatory physician visit for recertification at the 180 days on hospice has the potential to improve patient care and prognostic accuracy. However, for the part-time HMD working 4 hours a week, a visit to a single patient in a nonmetro hospice may theoretically involve 100 miles of travel from the physician office to the hospice patient home and back. The community’s only physician potentially driving an hour or more out of the area for a hospice visit may leave the community without physician coverage during that time. For a part time HMD the competing demands of the primary care role, reimbursement, and travel considerations become an even bigger challenge. Although larger hospices may be able to find the additional resources to pay for additional HMD time, smaller hospices with fewer resources may not be able to support a full-time HMD. Policy makers should consider the feasibility and potential offered by telehealth technology not only for the continuing professional development of these part-time HMDs, but also for expanding their role in direct patient care, especially in larger, less populated areas. To our knowledge, this is the first study that describes the role of the hospice medical director using a statewide survey of hospices. That we used a state hospice organization as a sampling frame to study the characteristics of HMDs may be especially useful for researchers investigating the HMD within hospice teams. Unlike surveys of the members of AAHPM and National Hospice and Palliative Care Organization, sampling state hospice organizations allows a larger sample of HMDs than sampling professional associations, given the limited number reportedly belonging to national associations. There are a number of limitations to our study that warrant mention. First, as self-reported survey data, we cannot validate the information provided against an objective gold standard, and so the potential for both recall and reporting bias should be considered when interpreting these results. Second, 56% of our target sample did not respond to our survey, therefore response bias needs to be considered. Although it is tempting to believe that fellowship-trained or board-certified medical directors would be more motivated to complete the survey and therefore possibly be overrepresented in these results, it is possible that the full-time or certified HMD is underrepresented if clinical duties prevented their response. Third, our sampling frame was limited to one Midwestern state. Similar methodological studies should be done in various regions so as to provide a diverse perspective of the role of the HMD. Finally, the lack of ethnic and gender diversity in the sample limits the ability to generalize these results to all HMDs.
Conclusions In one Midwestern state, the hospice medical director’s role appears to be primarily a part-time role filled by experienced primary care physicians. Formal board certification in hospice and palliative medicine is uncommon and none had completed fellowship training. Respondents reported that training, mentoring, and/or education were resources that could improve their effectiveness. Yet, targeting these medical directors for education and training is challenging given their lack of membership in palliative careerelated associations. State and national organizations should consider avenues to target education toward part-time hospice physicians. Regulators might consider supporting the need for hospice medical director training, and requiring that hospice programs support their medical directors with orientation and continuing education. Online training is becoming more readily available, which can assist in the expense and time requirement for continuing education in palliative care; however, without regulatory support it is not likely these options will become common practice in a competitive, capitated, resource-starved setting such as hospice. Acknowledgments We thank David E. Longnecker, MD, FRCA, for permission to use and modify questions from his “Roles and Responsibilities of Chief Medical Officers in Member Organizations of the Association of American Medical Colleges” survey (Academic Medicine, 2007). We thank Betty Kennedy for preparing and mailing the surveys. References 1. American Academy of Hospice and Palliative Medicine. About AAHPM. Available at: http://www.aahpm.org/about/history.html. Accessed September 10, 2010. 2. American Board of Medical Specialties. ABMS established new subspecialty certificate in hospice and palliative medicine. Available at: www.abms.org/ NewsandEvents/downloads/NewsubcertPalliativeMed.pdf. Accessed September 10, 2010. 3. Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs: Hospice Conditions of Participation. Federal Register v72 (October 1, 2007) (codified at 42 CFR 418). 4. Schumacher D. National Hospice and Palliative Care Organization; 2010. 5. Vandenberg E, Keller B. A guide to becoming a hospice medical director: Initial decisions and evaluations. J Am Med Dir Assoc 2009;10:298e303. 6. Parker Oliver D, Tatum P. The medical director as a member of the hospice team. J Am Med Dir Assoc 2009;10:92e94. 7. Parker Oliver D, Tatum P, Kapp J, Wallace A. Interdisciplinary collaboration: The voices of hospice medical directors. Am J Hosp Palliat Care 2010;27: 537e544. 8. Parker-Oliver D. Practice patterns of hospice medical directors in a Midwestern state. Am J Hosp Palliat Care 1999;16:633e638. 9. Missouri Hospice and Palliative Care Organization (MHPCO). 2008 Missouri Hospice Statistical Report. Lee’s Summit, Missouri: MHPCO; 2009. 10. Missouri Hospice and Palliative Care Association Membership Directory. Missouri Hospice and Palliative Care Organziation. Available at: www.mohospice. org. Accessed April 2010. 11. Edwards P, Roberts I, Clarke M, et al. Methods to increase response rates to postal questionnaires. Cochrane Database Syst Rev 2007;(2):MR000008. 12. Urban N, Anderson G, Tseng A. Effects on response rates and costs of stamps vs business reply in a mail survey of physicians. J Clin Epidemiol 1993;46: 455e459. 13. Longnecker DE, Patton M, Dickler R. Roles and responsibilities of chief medical officers in member organizations of the Association of American Medical Colleges. Acad Med 2007;82:258e263. 14. USDA. Rural-Urban Continuum Codes for Missouri. Economic Research Service; 2003. 15. Tiemann J, Sladek R, Currow D. Multiple sources: Mapping the literature of palliative care. Palliat Med 2009;23:425e431. 16. Tieman J, Sladek R, Currow DC. Changes in the quantity and level of evidence in palliative and hospcie care literature: The last century. J Clin Oncol 2008;26: 5679e5683. 17. Rowland F, Cowles M, Dickenstein C, Katz P. Impact of medical director certification on nursing home quality of care. J Am Med Dir Assoc 2009;10: 431e435.