CMSHealthDisparitie

The Hispanic Health Services Research Grant Program
This is the 10th year for this grant program which is designed to:

1. Encourage heath services researchers to pursue research issues that impact Hispanic Medicare, Medicaid and State Children’s Health Insurance Program health disparities issues;
2. Conduct outreach activities to apprise Hispanic researchers of funding available for research into issues affecting Hispanic American communities and to expand the pool of applicants applying for such grants;
3. Assist CMS in implementing its mission focusing on heath care quality improvement for its Medicare beneficiaries;
4. Support extramural research in health care capacity development activities for the Hispanic American communities;
5. Promote research that will be aimed at developing a better understanding of health care services issues pertaining to Hispanic Americans, and
6. Foster a network for communication and collaboration regarding Hispanic health care issues.

Historically Black Colleges and Universities (HBCU) Grant Program
This is the 12th year for this grant program. The goals of the grant program are to:

1. Encourage HBCU health services researchers to explore research issues which impact the Medicare, Medicaid and SCHIP programs;
2. Support CMS in implementing its health disparity goals by focusing on health care quality and improvement for its Medicare beneficiaries;
3. Assist HBCU researchers by supporting extramural research in health care capacity development for African American communities;
4. Increase the number of HBCU researchers capable of implementing the research, demonstration, and evaluation of CMS activities; and
5. Assist in promoting inter-university communication and collaboration regarding African American health disparity issues.

The Office of Research, Development and Information Cancer Demonstration
Differential outcomes are prevalent in the areas of cancer diagnosis, treatment, and outcomes. CMS seeks to encourage quality of care in all facets of cancer treatment and care by encouraging best-practices. In 2005, CMS initiated a one-year demonstration project for cancer patients undergoing chemotherapy. The demonstration focused on measuring patient outcomes in three areas of concern often cited by patients undergoing chemotherapy: controlling pain, minimizing nausea and vomiting, and reducing fatigue. CMS continued the demonstration project in 2006. While the 2005 demonstration initiated the measurement outcomes for all cancer patients by tracking their symptoms while undergoing chemotherapy, the 2006 oncology demonstration provided a more comprehensive approach to supporting care. Such an approach has been shown to lead to better outcomes for patients. This initiative has now been expanded to include a focus on health disparities.

The Rural Hospice Demonstration Project

Section 409 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (Medicare Modernization Act) (Public Law 108-173) authorizes a five-year demonstration for rural Medicare beneficiaries.  The basics for the demonstration are as follows:

 Care models for patients without “appropriate caregivers” who reside in rural areas

• Provides care within a hospice facility at the appropriate level of care
• Routine Home
• Continuous Care
• General Inpatient
• NOT respite care because they lack an appropriate caregiver
• Majority Medicare patients
• Rural hospice facility must have 20 or fewer beds that offers, within its walls, the full range of hospice services
• Sites must undertake the Quality Assessment and Performance Improvement (QAPI) Program
• Report data on all patients (not just demonstration patients)
• Two waivers available
  • 20% inpatient cap
• Requirement to provide care in the community
• Sites agree to develop programs to increase care to priority populations
• Demonstration Timeframe:  October 1, 2005 through September 30, 2010
• The demonstration tests whether hospice services provided by a rural hospice that does not need to meet the cap on inpatient care days or provide hospice services outside of the facility results in wider access, improved hospice services, benefits to the rural community, and a sustainable pattern of care.
• The demonstrated was awarded to the Sanctuary Hospice House (SHH) located in Tupelo, Mississippi and Haven Hospice (formerly Hospice of North Central Florida) headquartered in Gainesville, Florida.

 Sanctuary Hospice House (SHH)

Operations

• Medicare Certification received Dec 2005
• One freestanding facility is located in Tupelo, Mississippi
• Originally organized and established to deliver hospice care only in its 16 bed facility

 Quality Program

• Just being established at start of the demonstration
• Falls tracking; some compliance auditing for charts

Waver status for demonstration

• Both waivers requested and granted
• To date has not used the 20% inpatient care waiver (March 10, 2009)

Goal to work with priority population even as a new hospice

Haven Hospice (HH)

Operations

• Established hospice more than 25 years ago
• Multiple locations in North-Central Florida; Based in Gainesville
• The Average Daily Census (average daily count of patients) is over 600
• Participating inpatient units Chiefland (16 beds) and Palatka (12 beds)

Quality Program

• Robust quality and compliance program
• Data collection via chart audits, and client surveys (e.g., families and physicians)
• Focused studies and performance improvement on areas of concern
• QAPI-ready

Waiver status for demonstration

• No waivers requested

Developing cultural understanding to work with priority populations.

Recognitions that Both Sites Independently Identified to Increase Care to Priority Populations

• Recognized that groups need to be approached differently based on cultural sensitivities
• Goal to engage in dialogue about hospice
• Need to develop rapport one-on-one
• Meet at places familiar to the group
• Church is an ideal setting
• As comfort level increases engage with the hospice in other settings – note early benchmark goal
• Recognized that it is a long-term project in order to see results

SHH’s Approach

Engaging the African American Community:

• Request to speak at churches with large black populations
• Attend church lunches
• Recruit volunteers from the African American community
• Chief Volunteer Chaplain is African American

Engaging the Hispanic Community:

• Attend Latino Mass
• Work with them on fundraising
• Note smaller community and slower process to make gains

HH’s Approach

• Have the church host information in their building:
• Health fairs
• Volunteer training for hospice services

• Rural areas require the need for word of mouth training:
• Literacy issues
• Access to information
• Train staff and volunteers on how to effectively conduct word of mouth campaigns

• Person to person:
• Civic clubs
• Community groups

Benchmarks to Date (March 10, 2009)

• Increasing minority volunteers appears to increase self-referrals to hospice

• Cultural Sensitivities:
• Discuss hospice services, such as pain management
• Do not discuss dying.  It is tantamount to giving up in these communities
• Engage the concept of family as it relates to hospice
• Hospice staff cannot be perceived as taking the place of family since family is there to provide care
• Trust must be earned. 

• Families that have been served are their best referral sources
• Word of mouth is key
• Multi-prong approach is required

Contact Information:

Cindy Massuda
Project Officer
Centers for Medicare & Medicaid Services
Office of Research, Development and Information
Rural Hospice Demonstration, 410-786-0652
Cindy.massuda@cms.hhs.gov