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By LISA EISENHAUER

A proposal that the Centers for Medicare and Medicaid Services cover spiritual care for select groups of patients insured by both Medicare and Medicaid gets a thumbs up from spiritual care leaders in the Catholic health ministry.

A call for CMS to widen its coverage of spiritual care as an optional service for patients insured in capitated managed care plans for dual eligible populations was put forward in January in Health Affairs in the opinion piece "Requiring Integrated Care Plans To Offer Spiritual Care To Dually Eligible Individuals."

Currently, spiritual care is a covered service only for Medicare enrollees receiving hospice care and for patients at Department of Veterans Affairs facilities. CMS established three specific health care billing codes in 2020 so the VA could monitor and evaluate the spiritual care services it provides.

In the Health Affairs commentary, co-authors Dennis Heaphy and Sasha Shenk argue that spiritual care services "are an oft neglected but important part of comprehensive care." The patient advocates maintain that providing spiritual care to dual eligible clients would promote health, well-being and health justice for people with complex care needs.

"Spirituality at its core is about meaning-making amidst physical, psychological, and social challenges such as poverty and discrimination," the article says. "Evolving models of integrated care for dual eligibles, if they are to be person-centered and advance health equity, must, in the words of (psychiatrist and author) Viktor Frankl, address the 'unheard cry for meaning' among low-income people with disabilities and elders."

Heaphy and Shenk say spiritual care could be "seamlessly integrated" into capitated managed-care plans such as the Program of All-Inclusive Care for the Elderly, known as PACE. The Kaiser Family Foundation estimates the number of dual eligible clients in Medicaid managed care plans at 3.4 million.

Ministry-funded care
Teresa Galvin Anderson is mission leader for Trinity Health PACE and Trinity Health At Home. Anderson says she is in "absolute agreement" with Heaphy and Shenk that CMS should be reimbursing providers for spiritual care provided to PACE clients. Trinity Health already offers spiritual care to the about 3,200 clients in the 12 PACE programs it owns or manages at 21 centers across nine states.

Those programs all have chaplains, most of whom are full-time employees. Their services include conducting spiritual assessments, working with clinicians to develop interventions to improve clients' health outcomes, assessing goals of care, and assisting in advance care planning and in identifying surrogate decision makers.

Anderson says the chaplains are unofficial members of the interdisciplinary PACE care teams of clinicians, therapists, aides and social workers. Right now, chaplains' services come courtesy of Trinity Health as part of its Catholic mission.

If CMS integrated direct payment of chaplaincy care into federal health coverage for dual eligibles, Anderson says researchers could mine the related data to assess impacts on health outcomes.

"The chaplain often has the unique skills in communication and listening and assessing the values and the hopes and fears of each stakeholder," she points out, adding that stakeholders in PACE programs include participants, their families and members of their care teams.

Life-enhancing support
Trinity Health chaplains are from various faith traditions. If they haven't gone through formal clinical pastoral education on Catholic teachings and the Ethical and Religious Directives for Catholic Health Care Services, Anderson says the health system gives them orientation, mentoring and other help to ensure they are aware of Catholic spiritual and social traditions.

In their roles as spiritual caregivers, she says, Trinity Health chaplains don't proselytize but rather follow standards set by professional chaplaincy groups to give compassionate, respectful and appropriate care. "The goal is to provide the spiritual assessment interventions that are relevant and of support to meet people where they are, not to in any way push them towards us," Anderson says.

The 826 participants in Ascension Living's three PACE programs also have access to spiritual care services. The programs employ chaplains even though the services they provide are not billable, says Bob Smoot, chief mission integration officer, because Ascension Living considers spiritual care to be "an important service that enhances the lives of our PACE participants."

"We believe spiritually centered holistic care helps sustain and improve the health of individuals and communities," Smoot notes.

He adds that Ascension Living would back a CMS initiative to make spiritual care a covered service in PACE.

Search for meaning
CHA offers resources focused on the essential services for spiritual care at chausa.org/essentials. Those tools don't encourage religious rites or practices specific to Catholicism but rather call on spiritual care providers to "adequately provide for the spiritual needs of our patients, families and caregivers."

Tim Serban is a member of the CHA continuing care subcommittee that created resources on essential services for spiritual care in acute care and continuing care settings. As system executive director of spiritual health for home and community care at Providence St. Joseph Health, Serban supports more than 100 chaplains who offer spiritual care to people in PACE or under palliative, skilled nursing or hospice care in home and community settings.

Providence chaplains are required to have a graduate degree or equivalent in Catholic theology or their faith tradition. They must have 1,600 hours of clinical experience or have completed a yearlong clinical chaplaincy residency, be board certified by a chaplaincy organization and take part in continuing education.

Serban says chaplains are professionals trained in meeting a person's religious and spiritual needs, an important distinction. He refers to religious care as a formal way of practicing one's faith, whereas spiritual care is the search for meaning that may or may not involve religion.

Chaplains in health care settings, he says, have a special role in that they are offering spiritual care to people who are often in circumstances not of their choosing and in a vulnerable state.

"Chaplains are there to create a safe space to protect that vulnerability and to dive into how do people find meaning in the midst of this circumstance or situation," Serban says. "This is meeting a need of where people are as opposed to trying to impose something on them."

He considers the work of chaplains to be an enhancement and complement to the medical and mental health care provided by others on a patient's care team. Spiritual care, Serban says, has been vital during the COVID-19 pandemic when people have been overwhelmed by sickness, death, isolation and grief.

"Those are key areas where chaplains walk with people in the midst of their journey and do that in a professional way," he says.

Affirming an ongoing effort
While researchers assess the impact of the limited coverage of spiritual care that CMS has so far approved for reimbursement, Serban points out that studies already have found connections between spiritual care and improved health outcomes.

The piece in Health Affairs links to many such studies and analyses. One is a comprehensive literature review that found support for spirituality "as a coping method among individuals experiencing a variety of illnesses including hypertension, pulmonary disease, diabetes, chronic renal failure, surgery, rheumatoid arthritis, multiple sclerosis, HIV/AIDS, polio and addictive illnesses."

Serban says he felt proud on behalf of all chaplains when he read that a poll done by Gallup last year found one in four Americans have been served by chaplains. Most of those who had interacted with chaplains reported that they found the experience valuable.

In Serban's view, the expansion of spiritual care coverage that the Health Affairs piece urges aligns with policies he and others across Catholic health care have long championed. He says the expansion would be a move toward CMS acknowledging the link between spiritual health and overall well-being.

"I think that it's a great opportunity to affirm what we are already doing," he says.

Serban and Anderson both say that for health systems like theirs that already offer spiritual care, the biggest challenge to establishing it as a covered service might be logistical. For example, appropriate codes would need to be incorporated into electronic medical records systems.

Anderson says she is unsure of all the steps that might be necessary to get to where spiritual care is a reimbursable service, "but I think it needs to be taken seriously."

Chaplain's care guided grieving widower to 'a deep peace'

Teresa Galvin Anderson recalls how, over the course of 10 years, a chaplain helped a participant in one of Trinity Health's PACE programs cope with grief, estrangement from children and his complex medical condition to find what she calls "a deep peace" before the end of his life.

Anderson, mission leader for Trinity Health PACE and Trinity Health At Home, shared the details of the man's final decade to illustrate the impact spiritual care can have on quality of life and health outcomes for the frail elderly. She did not name the man or the chaplain out of concerns about federal health care privacy laws.

The African American widower was in assisted living when he joined Trinity Health PACE, at about age 70. A military veteran, he had supported himself and his three children as a short-order cook after the death of his wife when he was about 38. He had once been athletic and a coach but was using a wheelchair and largely immobile when he enrolled in PACE.

The chaplain worked with the man and his medical providers on interventions to address the unresolved grief he'd experienced since the death of his wife and the stress of his complex medical needs. The services the chaplain provided included grief counseling and support, assistance enrolling in a smoking cessation program and aid in crafting an exercise regimen the client could do in his wheelchair that helped restore some of his vigor.

The man had taken an "authoritarian approach" to parenting that, Anderson says, caused a rift with a daughter that had persisted into her adulthood. He also had become distant from a son who had contracted HIV/AIDS at a young age.

The chaplain helped the man become a regular at a Baptist church, where he restored a faith connection that he had let lapse amid his grief and anger.

Anderson says the chaplain provided encouragement and arranged supportive services such as transportation that led to the man reconnecting with his estranged children. The man was at the bedside when the son took his final breaths. The daughter was again part of her father's life when it ended. She even got grief support from the same chaplain who had cared for him.

"I think the care helped him die at peace and it helped her carry forth her grief afterwards to resolve that in a healthy way because it was complicated," Anderson says.

Trinity Health provides spiritual care to its PACE participants without outside reimbursement because the system recognizes that the care can have a major impact on their well-being, Anderson says. She supports a call for the Centers for Medicare and Medicaid Services to expand its very limited coverage of spiritual care so that more participants in PACE or other integrated care programs have the option for the services.

"If we can work out the right reimbursement, then programs can hire chaplains to do this important work in these integrated health settings," she says.

— LISA EISENHAUER