When taking care of patients in hospice, it’s important to understand the difference between over-the-counter (OTC) and prescription medications. Knowing how these medications work and what they’re used for can help you provide better care.
What Are Over-the-Counter Medications?
Over-the-counter (OTC) medications are medicines you can buy without a doctor’s prescription. These include things like pain relievers (like Tylenol or Advil), cold medicines, and allergy pills. People use OTC medications for common health problems like headaches, colds, or minor aches and pains. These medicines are generally safe when used as directed on the label. But it’s still important to be careful, especially when patients are taking other medications.
What Are Prescription Medications?
Prescription medications are medicines that a doctor or other healthcare provider must prescribe. These drugs are often stronger than OTC medicines and are used to treat more serious health conditions. Because they are stronger, they can have more side effects or cause harm if not taken exactly as prescribed. Patients in hospice care often take prescription medications to manage pain, control symptoms, or treat chronic conditions.
Key Differences Between OTC and Prescription Medications
Access: You can buy OTC medications at a store without a prescription, but you need a doctor’s order to get prescription medications.
Strength: Prescription medications are usually stronger and meant for more serious conditions.
Safety: Both types of medications are safe when used correctly, but prescription medications require more careful monitoring because of their strength and potential side effects.
What Hospice Aides Need to Know About Medications
Never Give Medications Without Approval: Always follow the care plan and never give a patient any medication, including OTC, without approval from a nurse or doctor.
Be Aware of Interactions: Some OTC medications can interact with prescription drugs and cause problems. For example, taking aspirin (an OTC pain reliever) with certain prescription blood thinners can increase the risk of bleeding.
Watch for Side Effects: Both OTC and prescription medications can have side effects. Be alert for any changes in the patient’s condition, and report anything unusual to the nurse or healthcare provider.
Follow State Guidelines: Each state has specific rules about what hospice aides can and cannot do when it comes to assisting with medications. In some states, aides may help with medication reminders, but they should not give medications directly. Always follow the guidelines in your state and the care plan for each patient.
Knowing how to provide support during times of hardship or crisis can make a significant difference in someone’s life. The Ring Theory, developed by clinical psychologist Susan Silk, offers a framework for offering support. Specifically, Ring Theory provides a framework for offering support that centers around the needs of the person experiencing the crisis. In this blog we will explore the key principles of this theory and its practical implications for providing effective support.
The Concept of the Ring Theory
At its core, the Ring Theory outlines a model for providing support during times of crisis. It is based on the idea of concentric circles. The person who is directly affected by the crisis is at the center of these concentric circles. Surrounding circles represent their closest relationships, with each circle representing a different level of connection to the individual in need.
Understanding the Circles
Center Circle: The innermost circle contains the person experiencing the crisis. This individual is at the heart of the support network and should be the primary focus of empathy and assistance.
Immediate Family and Closest Friends: The next circle consists of the individual’s immediate family members and closest friends. These individuals have the strongest emotional connection to the person in need. They play a crucial role in providing support.
Extended Family and Close Friends: The third circle includes extended family members, colleagues, and friends. They are also close to the individual but may not be directly involved in the individual’s day-to-day life.
Acquaintances and Casual Friends: The outer circles comprise acquaintances, colleagues, and distant friends who may have a connection to the person in need but are less emotionally involved.
According to the Ring Theory, each concentric circle is advised to “comfort in” and “dump out.” This means that individuals in the outer circles may talk about their stress to anyone in the larger circles but must provide comfort and support to those in smaller circles.
Practical Application of the Ring Theory
When applying the Ring Theory, it is important to prioritize the needs of the person at the center of the crisis. Instead of burdening that person with our own emotions or seeking validation for our feelings, we should focus on offering comfort, practical assistance, and a listening ear.
Offer Comfort, Not Complaints: Prioritize the needs and emotions of the person in crisis over your own. Offer words of comfort, empathy, and practical support.
Listen Without Judgment: Provide a safe space for the person to express their feelings without fear of judgment or criticism.
Respect Boundaries: Understand that everyone copes with crisis differently. Respect the person’s boundaries and preferences for receiving support.
Provide Practical Assistance: Offer tangible help such as running errands, preparing meals, or providing childcare to alleviate some of the person’s burdens.
Avoid Sharing Your Own Struggles: Refrain from sharing your own struggles unless explicitly invited to do so. Focus on validating the person’s feelings and experiences instead.
Additional Considerations
Beyond understanding the core principles of the Ring Theory, it’s important to recognize that providing support during a crisis can be complex and multifaceted. There are many considerations that one needs to keep in mind. Here we list some:
Cultural Sensitivity: Different cultures may have unique approaches to coping with crisis and seeking support. Be sensitive to cultural norms and preferences when offering assistance.
Self-Care for Caregivers: Supporting someone in crisis can take a toll on your own emotional well-being. Remember to prioritize self-care and seek support from your own network when needed.
Professional Resources: In some cases, the support needed may go beyond what friends and family can provide. Seek professional help or refer the individual to appropriate resources if necessary.
Where can you get more information
Ring Theory Helps Us Bring Comfort In – Psychology Today article discussing the principles of the Ring Theory and its application in supporting individuals in crisis.
The Comfort in, Dump Out Theory Explained – Psychology Today article providing an overview of the Comfort in, Dump Out Theory and its relevance in offering support during difficult times.
By understanding and applying the principles of the Ring Theory, we can provide meaningful support to those who need it most, fostering a culture of empathy, compassion, and understanding.
Caregivers play a critical role in hospice care, where the focus is on providing comfort and support to individuals nearing the end of life. These unsung heroes, often family members or close friends, offer physical, emotional, and spiritual support to their loved ones during one of life’s most challenging transitions. However, the demands of caregiving can take a toll, leading to burnout and reduced well-being. Recognizing and addressing caregiver burnout is essential for ensuring ongoing support for patients and their families.
Understanding Caregiver Burnout:
Caregiver burnout is a multifaceted phenomenon that is characterized by physical, emotional, and mental exhaustion. It can manifest as feelings of overwhelming stress, compassion fatigue, depression, and a sense of hopelessness. According to the Mayo Clinic, symptoms of burnout may include fatigue, irritability, withdrawal from social activities, and a lack of motivation or interest in caregiving tasks. If caregiver burnout is not addressed, it can have a negative impact on the quality of care provided to patients and negatively impact caregivers’ own health and well-being.
Research conducted by the Ann & Robert Lurie Children’s Hospital of Chicago and the University of Pittsburgh sheds light on the prevalence and impact of caregiver burnout in hospice settings. Dr. Michael Certo, assistant professor of pediatrics at Lurie, emphasizes the high risk of emotional, social, and financial consequences for caregivers. The study found that caregiver burnout is alarmingly common among those providing end-of-life care, underscoring the need for targeted interventions and support mechanisms.
Assessing Caregiver Distress:
To effectively address caregiver burnout, healthcare providers must first identify individuals at risk. The research team implemented a standardized method for assessing caregiver distress, recognizing the importance of early intervention in mitigating burnout. The caregiver self-assessment questionnaire, developed by the American Geriatric Society, emerged as a valuable tool for screening caregivers’ well-being. This brief yet comprehensive metric enables clinicians to identify signs of burnout and tailor support interventions accordingly.
Supporting Caregivers:
Once caregiver distress is identified, healthcare providers can offer a range of supportive measures to promote resilience and well-being. These may include encouraging caregivers to prioritize self-care, providing access to respite care services, facilitating peer support groups, and connecting caregivers with community resources. Additionally, caregivers may benefit from educational programs aimed at enhancing coping skills, stress management techniques, and communication strategies.
The Impact of Caregiver Burnout on Hospice Care:
Caregiver burnout not only affects individual caregivers but also has broader implications for hospice care delivery. Research has shown that patients who do not have adequate caregiver support may be less likely to choose hospice care, leading to delayed referrals and suboptimal end-of-life experiences. Moreover, caregiver burnout can strain healthcare resources and contribute to caregiver turnover, compromising the continuity and quality of care provided to patients and families.
Addressing the Financial Burden:
In addition to the emotional and physical toll, caregiving often imposes a significant financial burden on families. According to AARP, unpaid family caregivers in the United States collectively spend billions of dollars annually on caregiving-related expenses. These costs may include medical bills, prescription medications, home modifications, and lost wages due to missed workdays. Recognizing the financial challenges faced by caregivers is essential for implementing policies and programs aimed at alleviating economic strain and promoting financial security.
In conclusion, caregiver burnout poses a significant challenge in hospice care, impacting both caregivers and the patients they serve. By implementing comprehensive assessment tools, providing targeted support interventions, and addressing the financial burdens associated with caregiving, healthcare providers can foster resilience and well-being among caregivers. Nurturing caregivers not only enhances the quality of care provided but also ensures that patients and families receive the compassionate support they need during life’s final journey.
Where Can you Get Additional Information:
Mayo Clinic. (n.d.). Job burnout: How to spot it and take action. Retrieved from Mayo Clinic
National Institute on Aging. (n.d.). Taking Care of Yourself as a Caregiver. Retrieved from National Institute on Aging
AARP Public Policy Institute. (2021). Family Caregiving and Out-of-Pocket Costs: 2016 Report. Retrieved from AARP Public Policy Institute
American Geriatrics Society. (n.d.). Caregiver Self-Assessment Questionnaire. Retrieved from American Geriatrics Society
Hospice Foundation of America. (n.d.). Caregiving at the End of Life: Finding Resilience. Retrieved from Hospice Foundation of America
Morrison, R.S. et al. (2009). Palliative Care Consultation Teams Cut Hospital Costs for Medicaid Beneficiaries. Health Affairs, 28(3), w450-w460. Retrieved from Health Affairs
Anticipatory grief, also referred to as anticipatory loss or preparatory loss, is a unique form of mourning that occurs before the actual loss takes place. It is the feeling of loss that is felt before the loss happens. While traditional grief typically follows a loss, anticipatory grief begins before the loss and can be triggered by the anticipation of impending death or significant life changes. In our minds it is the “beginning of the end.” Typically, in grief, one is focused on a loss in the past. But in anticipatory grief one is focused on the loss ahead.
What is anticipatory grief?
Anticipatory grief is the emotional response to an anticipated loss. It involves mourning the impending death of a loved one or preparing for other significant life changes, such as the end of a relationship, a terminal diagnosis, or a major life transition. Anticipatory grief allows individuals to begin processing their emotions before the loss occurs, which can help facilitate the grieving process later on.
What is the difference between conventional grief and anticipatory grief?
Conventional grief involves mourning a loss that has already occurred. Anticipatory grief is forward looking. It is grieving a loss that has not yet occurred but that one believes will occur. Anticipation of loss still leaves room for hope that the loss will not happen. This hope, however unrealistic it may be, often leaves anticipatory grievers “hanging on to possibilities” in unrealistic and non-helpful ways.
Who experiences anticipatory grief?
Anticipatory grief can be experienced by anyone who is facing an impending loss or significant life change. This may include family members and friends of terminally ill individuals, individuals facing their own terminal illness, caregivers, and those experiencing major life transitions such as divorce or retirement. Anticipatory grief is not limited by age, gender, or background, and can affect people from all walks of life. Younger caregivers and patients often experience more severe anticipatory grief.
When is anticipatory grief experienced?
Anticipatory grief can occur at any time when an individual is faced with the prospect of impending loss or significant life changes. It may begin as soon as a terminal diagnosis is received or when a major life transition is anticipated. The duration of anticipatory grief can vary widely, lasting anywhere from weeks to months or even years depending on the circumstances. Anticipatory grief may also continue after the loss has occurred, as individuals navigate the ongoing impact of their loss.
What are signs of anticipatory grief?
People experiencing anticipatory grief may show some of the following signs:
Feelings of sadness, anxiety, or depression
Preoccupation with thoughts of loss
Changes in appetite or sleep patterns
Withdrawal from social activities or relationships
Difficulty concentrating or making decisions
Increased irritability or anger
Physical symptoms such as fatigue, headaches, or stomach problems
What are the stages of anticipatory grief?
There are four phases that one may feel while experiencing anticipatory grief. These may come in any order or simultaneously.
Accepting that death is inevitable. This phase often brings sadness and depression
Feelings of concern for the dying person. For family and friends, this phase often brings feelings of regret – regret over past actions, prior unresolved arguments, and the like. For the dying person this may be regret over missed opportunities or fear of dying.
Rehearsing the death. A person may become focused on planning for death including funeral arrangements, saying goodbyes, and what needs to be done in preparation for death.
Imagining the future. Family and friends may envision the future without the loved one. This may include imagining holidays and other special occasions with the loved one missing. The patient may imagine how the family and friends will experience life without him. The patient may also begin to imagine the afterlife.
How can anticipatory grief be treated?
While anticipatory grief can be challenging, there are strategies that can help individuals cope with their emotions and navigate the grieving process:
1. Seek support: Reach out to friends, family members, or a therapist for emotional support and guidance.
2. Practice self-care: Take care of your physical and emotional well-being by eating well, exercising regularly, and engaging in activities that bring joy and relaxation.
3. Communicate openly: Share your feelings and concerns with loved ones and healthcare providers. Talking about your emotions can help validate your experiences and provide comfort.
4. Create meaningful moments: Make time to create lasting memories with your loved one and engage in activities that bring you closer together.
5. Seek professional help: If you’re struggling to cope with anticipatory grief, consider seeking help from a mental health professional. Therapy or counseling can provide valuable support and coping strategies.
Is anticipatory grief beneficial?
Anticipatory grief is a natural response to impending loss or significant life changes. By understanding what anticipatory grief is, who experiences it, when it occurs, signs of anticipatory grief, and strategies for coping, individuals can better navigate this challenging emotional journey. The research is contradictory as to whether anticipatory grief is beneficial in helping cope after the loss has occurred. Some research suggests that anticipatory grief may help with coping with the loss. Other research suggests that it has no effect on post-death bereavement.
Seeking support from loved ones and mental health professionals, practicing self-care, and communicating openly about feelings are essential steps in coping with anticipatory grief.
Grief is the emotional, psychological, and physical response to loss. It is a natural process that helps individuals come to terms with the reality of their loss and adjust to life without the person or thing they’ve lost. Whether it’s the death of a loved one, the end of a relationship, or a major life change, grief can affect individuals of all ages and backgrounds. Grief can manifest in various ways, including sadness, anger, guilt, confusion, and physical symptoms such as fatigue or changes in appetite.
Who experiences grief?
Anyone can experience grief, regardless of age, gender, or background. Grief is a universal human experience that affects people of all cultures and walks of life. Common triggers for grief include the death of a loved one, divorce or separation, the loss of a job, a serious illness or injury, or a significant life transition such as moving to a new city or retiring.
When is grief experienced?
Grief can be experienced at any time following a loss, and there is no set timeline for the grieving process. While some individuals may begin to experience grief immediately after a loss, others may not fully process their emotions until weeks, months, or even years later. Grief can also be triggered by anniversaries, holidays, or other significant reminders of the loss.
What are signs of grief?
Signs of grief can vary widely from person to person, but common symptoms may include:
Intense sadness or depression
Feelings of numbness or disbelief
Anger or irritability
Guilt or self-blame
Difficulty concentrating or making decisions
Changes in appetite or sleep patterns
Physical symptoms such as fatigue, headaches, or stomach problems
How can grief be treated?
While grief is a natural and unavoidable part of life, there are strategies that can help individuals cope with their loss and navigate the grieving process:
1. Allow yourself to feel: It’s important to acknowledge and express emotions, even if they are painful or difficult to bear. A person who is grieving should give himself permission to grieve in his own way and at his own pace.
2. Seek support: : It is important that people who are grieving reach out to friends, family members, or a therapist for support. Talking about feelings with others who understand can provide comfort and validation.
3. Take care of yourself: Practicing self-care by eating well, exercising regularly, getting plenty of rest, and engaging in activities that bring joy and relaxation are important aspects to treating grief.
4. Honor the loved one: Find ways to remember and honor the person who was lost. This could involve creating a memorial, participating in rituals or traditions, or finding meaningful ways to keep their memory alive.
5. Seek professional help: A grieving person who is struggling to cope with the grief or who is experiencing prolonged or severe symptoms should consider seeking help from a mental health professional. Therapy or counseling can provide valuable support and guidance during the grieving process.
Grief is a natural and universal response to loss that affects individuals in different ways. By understanding what grief is, who experiences it, when it occurs, signs of grief, and strategies for coping, individuals can navigate the grieving process with greater resilience and self-compassion. Seeking support is often beneficial to many who are grieving – whether through bereavement groups, friends, or professional help. And it is important to remember that patience is required during the grieving process as it may take time to heal and find peace after loss.
The False Claims Act (FCA) was established in 1863 during the Civil War to combat fraud and abuse perpetrated by suppliers of the federal government. At that time, the law was referred to as “Lincoln’s Law.”
The FCA has evolved significantly in recent years and is now one of the main tools used by the government to fight fraud. The FCA penalizes individuals or entities that submit fraudulent claims to the government, cause fraudulent claims to be submitted, or conspire to submit fraudulent claims.
One of the noteworthy provisions of the FCA is the qui tam provision, also known as the whistleblower provision. The qui tam provision allows private citizens, also referred to as “relators”, to report details of alleged fraud to the government. The whistleblower “stands in the shoes” of the government to prosecute the claim. This action benefits the government and the taxpayer as well as potentially the relator, who may receive a share of what is recovered.
How does the FCA relate to a hospice agency?
The False Claims Act allows hospice agency employees, patients, families of patients, or any individuals with alleged knowledge of fraud or abuse by the agency to report the behavior. Under the qui tam provision of the FCA, the relator may be entitled to a percentage of recovered funds.
What are different types of false claims?
A claim is a request for money made to the government. A false claim is money that is obtained from the government due to false or fraudulent claims. False claims include claims where the service
Has not been provided
Is already included as part of a different claim (i.e., double billing)
Is not coded correctly
Is not supported by the patient’s medical record
Claims may also be false and are covered under the FCA if they result from a referral made in violation of the Federal Anti-kickback statue (Stark Law).
The False Claims Act also includes payment from the government based upon false certification.
False claims include claims that the hospice agency should have known were false or fraudulent.
What is a claim that a hospice agency “should have known” is false?
The FCA expressly includes claims that a hospice agency “should have known” were false or fraudulent. “Should have known” means deliberate ignorance or reckless disregard of truth. As such, a hospice agency cannot avoid liability by simply ignoring inaccuracy in their claims. Examples of “should have known” include:
Ignorance of billing rules, i.e., lack of knowledge of the rules
Failure to act on consistent trends that are indicative of inaccurate billing
Failure to act on inaccuracies or system errors identified by outside or internal auditing teams
Failure to correct inaccurate billing (impacting either past or future claims)
A hospice agency must understand the rules and take proactive measures — such as conducting internal audits within the organization — to ensure compliance and accurate billing.
How can False Claims Act matters be initiated?
There are two ways that FCA matters can be initiated:
Initiated by the government: When a FCA matter is initiated by the government, this type of matter typically starts with an audit or an investigation by the government. The government would determine that there is a false claim made to it and would initiate a matter, usually by a subpoena or civil investigative demand (CID). The government would issue the CID directly to the hospice agency. CID is a form of subpoena that requires the hospice agency to engage in one-sided discovery. That is, the hospice agency is required to produce documents demanded, respond to interrogatories, and provide sworn oral testimony. However, the hospice agency may not conduct any discovery.
Qui tam matter: this type of matter is initiated by a whistleblower, also known as a “relator,” typically through the filing of a sealed lawsuit in a federal district court. The hospice agency does not know about the qui tam lawsuit since the lawsuit is initially served on the government. The case remains under seal while it is investigated by the government.
What is the qui tam process?
Qui tam actions are initially filed under seal. That is, only the US Attorney and some members of the Department of Justice (DOJ) have knowledge of and access to documents related to the case. The relator serves the complaint on the government together with a written disclosure of all material evidence.
The purpose of the sealed qui tam action is to allow the DOJ time to evaluate the relator’s allegations and for the DOJ to decide whether it would like to take over primary responsibility for prosecuting the case. If the DOJ decides to take over primary responsibility for the case, the DOJ is said to “intervene.”
The complaint remains under seal for 60 days during which time the DOJ investigates the relator’s allegations. This 60-day period can be (and typically is) extended. In fact, the government may spend months – or even years – investigating the case.
While the DOJ conducts its investigation, it may issue a Civil Investigative Demand (CID). This form of subpoena requires the defendant (the hospice agency) to engage in one-sided discovery where the hospice agency must produce documents, respond to interrogatories, and provide sworn oral testimony, as demanded. The CID is “one-sided discovery” because the hospice agency may not conduct any discovery.
If the government decides to intervene, the government is then responsible for litigating the case and files its own complaint instead of the complaint that was filed by the relator. The relator remains a party to the complaint.
If the government declines to intervene, the relator may proceed in her own name subject to the government’s right to dismiss the claim or to intervene at a later date.
Whether or not the government decides to intervene, the government remains the real party of interest. (As a reminder, the relator is only “standing in the shoes” of the government.) As such, the government must agree to any decisions on the case. The relator may not agree to dismiss or settle the case without the government’s approval.
What are the key phases in a False Claims Act investigation?
Phase 1: FCA investigation is triggered. Triggers may include:
Qui tam (whistleblower) lawsuit
Call to OIG hotline
Information identified during audit or claim review
Complaints
Data mining
Phase 2: Formal investigation launches. Investigation may involve:
Review of corporate filings
Interview current or former employees
Review financial records
Electronic surveillance
Physical surveillance of employees or of company premises
DOJ civil investigative demand (CID), or the like
Government search warrant or raid
Phase 3: Litigation or resolution
Who are common whistleblowers?
Anyone can be a whistleblower and anyone may report alleged fraudulent activity to the government. The most common relators are:
Business partners
Current or former employees
Competitors
Patients
Individuals who mine CMS data to identify anomalies/FCA claims
How can a hospice agency reduce the chance of qui tam lawsuits?
Any complaints or concerns that are raised – by employees, vendors, patients, or competitors, or any other individuals should be investigated and treated with concern as these have the potential to reveal compliance issues that need to be resolved by the hospice agency.
Employee complaints – whether from departing or active employees – are often an excellent source of information on potential compliance issues. A hospice agency should have a clearly established method – that is clearly and often communicated to employees – for employees to raise concerns. It should also have an organized process to diligently investigate and address any concerns raised by employees.
Internal complaints:
There must be an organized process – that is communicated regularly to employees – for employees to raise concerns
All concerns must be investigated
Have a plan to address any issues that are identified
Take any necessary corrective actions
Follow up with the individual who raised the complaint
Provide training, as needed
Departing employees
Treat employees fairly as they leave
Conduct exit interviews to identify any potential compliance concerns – investigate any issues that may be identified
Potential releases (e.g., recovery from FCA claims)
Employees must feel that there is a process for raising concerns and that their concerns are heard. Employees should not fear retaliation for raising concerns. A hospice agency should be diligent and careful to respond to all employee complaints that are raised internally or to any complaints that are raised when employees leave the organization.
What are the financial benefits of avoiding FCA violations?
False claims act matters can be quite costly for a hospice organization. In addition to returning the payments associated with the false claims identified and incurring the costs associated with attorney fees to defend the matter, the hospice agency potentially faces the following significant costs:
Treble damages: The FCA has a treble damages provision which provides that a hospice agency that is found to have violated the FCA statute may be liable to pay three times the amount of the actual false claim amount
Penalty per claim: Under the FCA, a civil penalty may be assessed for each false claim that is submitted. The civil penalty dollar amount per claim has increased with inflation and currently may be as much as $23,000 per claim.
