(1)The California Hospice Licensure Act of 1990 provides for the licensure and regulation by the State Department of Public Health of persons or agencies that provide hospice, which is a type of interdisciplinary health care that includes palliative care to individuals experiencing the last phases of life due to the existence of a terminal disease and supportive care to the primary caregivers and family of the hospice patient. A violation of the act is a misdemeanor.

The bill would authorize, until January 1, 2022, a licensee under the act to provide any of the authorized interdisciplinary hospice services, including palliative care, to a patient who has a serious illness. The bill would require a licensee that elects to provide palliative care pursuant to this temporary authorization to report additional specified information to the department, including the number of patients receiving palliative care. By modifying the scope of a crime for a violation of the act, this bill would impose a state-mandated local program. The bill would require the department, on or before June 1, 2021, to convene a stakeholder meeting to discuss the results of the information collected pursuant to these provisions.

(2)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

(1)The California Hospice Licensure Act of 1990 provides for the licensure and regulation by the State Department of Public Health of persons or agencies that provide hospice, which is a type of interdisciplinary health care that includes palliative care to individuals experiencing the last phases of life due to the existence of a terminal disease and supportive care to the primary caregivers and family of the hospice patient. A violation of the act is a misdemeanor.

The bill would authorize, until January 1, 2022, a licensee under the act to provide any of the authorized interdisciplinary hospice services, including palliative care, to a patient who has a serious illness. The bill would require a licensee that elects to provide palliative care pursuant to this temporary authorization to report additional specified information to the department, including the number of patients receiving palliative care. By modifying the scope of a crime for a violation of the act, this bill would impose a state-mandated local program. The bill would require the department, on or before June 1, 2021, to convene a stakeholder meeting to discuss the results of the information collected pursuant to these provisions.

(2)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

(1)The California Hospice Licensure Act of 1990 provides for the licensure and regulation by the State Department of Public Health of persons or agencies that provide hospice services, such as palliative care and skilled nursing services, to persons, and the families of persons, who are experiencing the last phases of life due to terminal disease. Existing law defines palliative care to mean patient and family-centered care that optimizes quality of life of a patient with a terminal illness by anticipating, preventing, and treating suffering, and defines skilled nursing services to mean nursing services provided by or under the supervision of a registered nurse, as specified, that pertain to the palliative, supportive services required by patients with a terminal illness. Existing law authorizes licensed hospices to provide, in addition to hospice services authorized under the act, specified preliminary services, including preliminary palliative care consultations, for any person in need of those services, as determined by the physician and surgeon, if any, in charge of the care of a patient. hospice, which is a type of interdisciplinary health care that includes palliative care to individuals experiencing the last phases of life due to the existence of a terminal disease and supportive care to the primary caregivers and family of the hospice patient. A violation of the act is a misdemeanor.

The bill would further authorize a licensed hospice authorize, until January 1, 2022, a licensee under the act to provide any of the same authorized interdisciplinary hospice services services, including palliative care, to a patient who is not a hospice patient, but has a serious illness, as specified, and authorize the hospice to provide services to the patient even if the patient is continuing to receive curative treatment from other licensed health care professionals. has a serious illness. The bill would require a licensee that elects to provide palliative care pursuant to this temporary authorization to report additional specified information to the department, including the number of patients receiving palliative care. By modifying the scope of a crime for a violation of the act, this bill would impose a state-mandated local program. The bill would require the department, on or before June 1, 2021, to convene a stakeholder meeting to discuss the results of the information collected pursuant to these provisions.

The California Hospice Licensure Act of 1990 provides for the licensure and regulation by the State Department of Public Health of persons or agencies that provide hospice services, such as palliative care and skilled nursing services, to persons, and the families of persons, who are experiencing the last phases of life due to terminal disease. Existing law defines palliative care to mean patient and family-centered care that optimizes quality of life of a patient with a terminal illness by anticipating, preventing, and treating suffering. suffering, and defines skilled nursing services to mean nursing services provided by or under the supervision of a registered nurse, as specified, that pertain to the palliative, supportive services required by patients with a terminal illness. Existing law authorizes licensed hospices to provide, in addition to hospice services authorized under the act, specified preliminary services, including preliminary palliative care consultations, for any person in need of those services, as determined by the physician and surgeon, if any, in charge of the care of a patient.

This bill would, among other things, expand the definition of palliative care to include relief of symptoms, pain, and stress of a serious, life threatening, or advanced illness, in addition to a terminal illness, without regard to the length of the patients remaining period of life. to mean patient and family centered care that optimizes quality of life of any patient. The bill would also expand the definition of skilled nursing services to include palliative, supportive services required by patients with a serious illness, and would define serious illness to mean a condition that may result in death, regardless of the estimated length of the individuals remaining period of life.

The bill would further authorize a licensed hospice to provide any of the same interdisciplinary hospice services authorized under the act to a patient who is not a hospice patient, but is in need of palliative care, has a serious illness, as specified, and authorize the hospice to provide services to the palliative care patient even if the patient is continuing to receive curative treatment from other licensed health care professionals.

The California Hospice Licensure Act of 1990, 1990 provides for the licensure and regulation by the State Department of Public Health of persons or agencies that provide hospice services, such as palliative care and skilled nursing services, to persons, and the families of persons, who are experiencing the last phases of life due to terminal disease. Existing law defines palliative care to mean patient and family-centered care that optimizes quality of life of a patient with a terminal illness by anticipating, preventing, and treating suffering. Existing law authorizes licensed hospices to provide, in addition to hospice services authorized under the act, specified preliminary services, including preliminary palliative care consultations, for any person in need of those services, as determined by the physician and surgeon, if any, in charge of the care of a patient.

This bill would additionally authorize a licensed hospice to provide palliative care services, as defined, for any person in need of those services as determined by the physician and surgeon in charge of the care of a patient, and would authorize these services to be provided concurrently with curative treatment to a person who does not have a terminal prognosis or who has not elected to receive hospice services only by licensed and certified hospices. would, among other things, expand the definition of palliative care to include relief of symptoms, pain, and stress of a serious, life threatening, or advanced illness, in addition to a terminal illness, without regard to the length of the patients remaining period of life.

The California Hospice Licensure Act of 1990, provides for the licensure and regulation by the State Department of Public Health of persons or agencies that provide hospice services, such as skilled nursing services, to persons, and the families of persons, who are experiencing the last phases of life due to terminal disease. Existing law authorizes licensed hospices to provide, in addition to hospice services authorized under the act, specified preliminary services, including preliminary palliative care consultations, for any person in need of those services, as determined by the physician and surgeon, if any, in charge of the care of a patient.

This bill would additionally authorize a licensed hospice to provide palliative care services, as defined, for any person in need of those services as determined by the physician and surgeon in charge of the care of a patient, and would authorize these services to be provided concurrently with curative treatment to a person who does not have a terminal prognosis or who has not elected to receive hospice services only by licensed and certified hospices.

 UNFINISHED BUSINESS  

Bill No: SB 294

Author:

Amended: 9/7/17

Vote:

SENATE HEALTH COMMITTEE: 9-0, 4/5/17

AYES: Hernandez, Nguyen, Atkins, Leyva, Mitchell, Monning, Newman, Nielsen, Roth

SENATE APPROPRIATIONS COMMITTEE: 6-0, 5/25/17

AYES: Lara, Beall, Bradford, Hill, Nielsen, Wiener

NO VOTE RECORDED: Bates

SENATE FLOOR: 37-0, 5/31/17

AYES: Allen, Anderson, Atkins, Bates, Beall, Berryhill, Bradford, Cannella, De León, Dodd, Fuller, Galgiani, Glazer, Hernandez, Hertzberg, Hill, Hueso, Jackson, Lara, Leyva, McGuire, Mendoza, Mitchell, Monning, Moorlach, Newman, Nguyen, Nielsen, Pan, Roth, Skinner, Stern, Stone, Vidak, Wieckowski, Wiener, Wilk

NO VOTE RECORDED: Gaines, Morrell, Portantino

ASSEMBLY FLOOR: 78-0, 9/11/17 - See last page for vote

SUBJECT: Hospice: services to seriously ill patients

SOURCE: California Hospice and Palliative Care Association

Coalition for Compassionate Care of California

DIGEST:

1. This bill permits a hospice agency to provide any interdisciplinary hospice services described in the Hospice Licensure Act of 1990, including but not limited to, palliative care, to a patient with a serious illness as determined by the physician and surgeon in charge of the care of the patient. This bill requires reporting by a hospice agency to the California Department of Public Health (CDPH) and sunsets this bill on January 1, 2022.

Assembly Amendments

add a sunset date and require hospice agencies to report to CDPH information about consumer complaints and staffing changes.

ANALYSIS:

Existing law:

1. Establishes the Hospice Licensure Act of 1990 (Act) which provides CDPH with the authority to license and regulate hospice agencies.
2. Defines “hospice” as a specialized form of interdisciplinary health care that is designed to provide palliative care, alleviate the physical, emotional, social, and spiritual discomforts of an individual who is experiencing the last phases of life due to the existence of a terminal disease, and provide supportive care to the primary caregiver and the family of the hospice patient, and that meets specified criteria including, but not limited to:
   1. Providing for the palliative medical treatment of pain and other symptoms associated with a terminal disease, but does not provide for efforts to cure the disease; and,
   2. Providing, to the extent appropriate, based on the medical needs of the patient, services in the patient’s home or primary place of residence.
3. Requires hospice agencies to provide the following basic services:
   1. Skilled nursing services;
   2. Social services/counseling services;
   3. Medical direction;
   4. Bereavement services;
   5. Volunteer services;
   6. Inpatient care arrangements; and,
   7. Home health aide services.
4. Permits, notwithstanding any provision of law to the contrary, licensed hospices to provide, in addition to authorized hospice services, any of the following preliminary services for any person in need of those services, as determined by the physician and surgeon, if any, in charge of the care of a patient, or at the request of the patient or family:
   1. Preliminary palliative care consultations;
   2. Preliminary counseling and care planning;
   3. Preliminary grief and bereavement services; and,
   4. Preliminary services may be provided concurrently with curative treatment to a person who does not have a terminal prognosis or who has not elected to receive hospice services only by licensed and certified hospices. Requires these services to be subject to the schedule of benefits under the Medi-Cal program, as specified.
5. Defines palliative care as patient and family-centered care that optimizes the quality of life of a patient with a terminal illness by anticipating, preventing, and treating suffering. Palliative care throughout the terminal illness involves addressing physical, intellectual, emotional, social and spiritual needs and to facilitate patient autonomy, access to information and choice.

This bill:

1. Permits, notwithstanding any other law, beginning January 1, 2018, a hospice agency to provide any interdisciplinary hospice services described in the Act, including but not limited to, palliative care, to a patient with a serious illness as determined by the physician and surgeon in charge of the care of the patient including, among other kinds of patients, a patient who continues to receive curative treatment from other licensed health care professionals.
2. Requires a hospice agency that elects to provide palliative care under this bill to provide CDPH with the date the agency intends to being providing the palliative care no less than 45 days before that date and relevant portions of specified forms.
3. Prohibits CDPH from requiring the documents submitted pursuant to 2) above to be approved prior to the agency providing services, and prohibits CDPH from charging an application fess to provide any care or services pursuant to this bill.
4. Requires hospice agencies that elect to provide palliative care pursuant to this bill to provide the following information on a form prescribed by CDPH on or before January 1, 2019, January 1, 2020, and January 1, 2021:
   1. The number of non-hospice patients who received palliative care;
   2. The number of patients enrolled in hospice;
   3. The primary diagnoses of the patients for which the licensee provided palliative care;
   4. The numbers and types of providers hired during the previous 12 months;
   5. The numbers and types of providers who left employment during the previous 12 months; and,
   6. Complaints received by the licensee during the previous 12 months, as specified.
5. Requires hospice agencies electing to provide palliative care pursuant to this bill to simultaneously submit to CDPH all information the hospice agency provides to the Office of Statewide Health Planning and Development during the period of time palliative care is provided.
6. Permits CDPH to implement, interpret, or make specific the provisions of this bill by means of all-facility letters, or similar instructions, without taking regulatory action.
7. Requires a hospice agency that ceases to provide palliative care pursuant to this bill on or before January 1, 2022, to submit the same documents described in 2) above.
8. Excludes a hospice facility, as specified, from the provisions of this bill.
9. Indicates that this bill does not modify the hospice care health insurance mandate, as specified.
10. Requires CDPH to convene a stakeholder meeting or webinar to discuss the results of the information collected pursuant to this bill on or before June 1, 2021.
11. Defines “serious illness” to mean a condition that may result in death, regardless of the estimated length of the patient’s remaining period of life.
12. Sunsets this bill on January 1, 2022.

Comments

Author’s statement. According to the author, palliative care is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment. Community-based palliative care models meet the needs of the sickest and costliest patients – who must otherwise resort to 911 calls, emergency department visits, and hospitalizations for problems that could and should have been addressed safely and effectively in the community. Hospice care is a well-known and comprehensive delivery model of palliative care, but it is limited to terminally ill patients, generally for patients when two doctors certify a prognosis of six months to live if the disease follows its usual course, and the patient agrees to forgo curative treatment. This bill is needed to clarify an ambiguity in existing law that may limit the ability of hospice providers to provide hospice services to a non-hospice, palliative care patient. The Act permits “preliminary” palliative care services that may be provided concurrently with curative treatment to a person who does not have a terminal prognosis or who has not elected to receive hospice services. Hospice agencies are concerned that current law is too limiting and unclear and does not authorize hospice providers to provide palliative care services beyond initial consultations.

Related/Prior Legislation

AB 1745 (Chan, Chapter 330, Statutes of 2006) required the Department of Health Services (DHS) (now DHCS) to develop, as a pilot project, a pediatric palliative care benefit covered under Medi-Cal, and required DHS to submit a waiver to the federal Centers for Medicare and Medicaid Services to implement the pilot project.

SB 1004 (Hernandez, Chapter 574, Statutes of 2014) required the DHCS to establish standards and provide technical assistance for Medi-Cal managed care plans to ensure delivery of palliative care services.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local: Yes

According to the Assembly Appropriations Committee, unknown, likely minor impact on hospice agency licensing and enforcement by CDPH (Licensing and Certification Fund). Any additional costs to process increased complaints or additional licenses would be supported through an existing fee, which may be readjusted annually. The 2017-18 licensure fee for a hospice is slightly less than $3,000.

SUPPORT: (Verified 9/11/17)

Alliance of Catholic Health Care

Alzheimer’s Association

American Cancer Society Cancer Action Network

Blue Shield of California

California Academy of Family Physicians

California Assisted Living Association

California Association for Health Services at Home

California Catholic Conference, Inc.

California Commission on Aging

California Hospice and Palliative Care Association

Coalition for Compassionate Care of California

National Association of Social Workers – California Chapter

Providence St. Joseph Health

Retired Public Employees Association

OPPOSITION: (Verified 9/11/17)

The California Right to Life Committee, Inc.

ARGUMENTS IN SUPPORT: The California Hospice and Palliative Care Association (CHAPCA) writes that this bill clarifies that licensed hospices may provide palliative care services to individuals and families who are not yet eligible for hospice, or who choose not to go on hospice. While the hospice licensing bill, originally passed in 1990, references hospices providing “preliminary services,” the language does not clearly state what palliative services are permissible under the license. CHAPCA states that the demand for palliative care is growing, as research demonstrates both significant patient satisfaction and cost avoidance. One study of Kaiser patients published in 2007, found that 36% of people receiving palliative care at home were hospitalized in their final months, compared with 59% of those getting standard care. The overall cost of care for those who participated in the program was a third less than for those who didn’t. Another study published in January 2017 showed that in the last three months of life, medical care for patients in a home-based palliative care program cost $12,000 less than for patients who were getting more typical treatment. CHAPCA points out that this bill is not mandating a new service. Rather, it clarifies this group of providers is legally authorized to offer palliative care services. According to the Coalition for Compassionate Care of California (CCCC), while palliative care has become well-established in the hospital-based setting, quality, community-based models must also be developed in order to meet increasing demand for services. Hospice programs, which have always offered palliative care to their hospice patients, have staff that are already trained and experienced in providing palliative care in the community setting. CCCC states that this bill is needed to clarify that hospices can provide palliative care service to non-hospice patients, beyond initial consultation. Blue Shield of California supports this bill because Blue Shield is working to enhance and expand existing benefits through the development of new models of palliative care delivery. Through collaborative partnerships with provider groups and Accountable Care Organizations, Blue Shield aims to bring a significant number of home-based palliative care programs into their network across the state.

ARGUMENTS IN OPPOSITION: The California Right to Life Committee, Inc. writes that this bill is trying to turn people with critical but non terminal lifelong medical needs into medically dependent patients who cannot function on their own.

ASSEMBLY FLOOR: 78-0, 9/11/17

AYES: Acosta, Aguiar-Curry, Travis Allen, Arambula, Baker, Berman, Bigelow, Bloom, Bocanegra, Bonta, Brough, Burke, Caballero, Calderon, Cervantes, Chau, Chávez, Chen, Chiu, Choi, Chu, Cooley, Cooper, Cunningham, Dababneh, Dahle, Daly, Eggman, Flora, Fong, Frazier, Friedman, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez Fletcher, Gray, Grayson, Harper, Holden, Irwin, Jones-Sawyer, Kalra, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Quirk, Quirk-Silva, Reyes, Rodriguez, Rubio, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Voepel, Waldron, Weber, Wood, Rendon

NO VOTE RECORDED: Ridley-Thomas

Prepared by:

9/11/17 20:28:47

**** END ****

SENATE THIRD READING

STR Bill Id:SB 294

Author:(Hernandez)

As Amended Ver:September 7, 2017

Majority vote

SENATE VOTE: 37-0

SUMMARY: Authorizes a licensed hospice, Until January 1, 2022, to provide interdisciplinary hospice services to a patient with a serious illness authorized in the Hospice Licensure Act of 1990 (Act) as determined by the physician and surgeon in charge of the care of the patient, including if the patient is continuing to receive curative treatment from other licensed health care professionals.. Specifically, this bill:

1. Authorizes a licensed hospice to provide the same interdisciplinary hospice services to a patient with a serious illness authorized in the Hospice Licensure Act of 1990 (Act) as determined by the physician and surgeon in charge of the care of the patient, including if the patient is continuing to receive curative treatment from other licensed health care professionals.
2. Requires a licensed hospice that elects to provide palliative care to provide the Department of Public Health (DPH) with the date the licensee intends to begin providing palliative care no less than 45 days before that date, and to provide the following:
   1. Updated federally required licensing and certification forms; and,
   2. On January 1, 2019, January 1, 2020, and January 1, 2021, the following information on a form prescribed by DPH:
      1. The number of non-hospice patients who received palliative care pursuant to these provisions;
      2. The number of patients enrolled in hospice;
      3. The primary diagnosis of the patients for which the licensee provided palliative care;
      4. The numbers and types of providers hired during the previous 12 months;
      5. Complaints received by the licensee during the previous 12 months related to the following issues:
         1. An event that has caused, or is likely to cause serious injury, harm, impairment, or death;
         2. An event or incident that negatively impacts the individual's mental, physical, or psychosocial status and is of such consequence to the person's wellbeing that a rapid response is require;
         3. Delays in patient care for hospice and non-hospice patients who received palliative care; and,
         4. Qualifications of staff.
      6. Information from the licensee submitted to the Office of Statewide health Planning and Development (OSHPD) at the same time information is provided to OSHPD.
3. Authorizes DPH to implement, interpret, or make specific the provisions of this bill by means of all-facility letters, or similar instructions, without taking regulatory action.
4. Requires a licensee to inform DPH if it ceases to provide palliative care services by re-submitting the forms required in 2) e) above. Prohibits DPH from requiring the forms be approved prior to a licensee providing services, or from charging an application fee to participate in the pilot project.
5. Specifies that the provisions of this bill do not apply to inpatient hospice facilities with less than 24 beds.
6. Defines serious illness as a condition that may result in death, regardless of the estimated length of the individual's remaining period of life.
7. Requires DPH, on or before June 1, 2021, to convene a stakeholder meeting to discuss the results of the data collection during the pilot, and authorizes DPH to use electronic means such as a webinar.

FISCAL EFFECT: As amended, this bill has not been analyzed by a fiscal committee.

COMMENTS: According to the author, palliative care is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment. The author notes that community-based palliative care models meet the needs of the sickest and costliest patients – who must otherwise resort to 911 calls, emergency department visits, and hospitalizations for problems that could and should have been addressed safely and effectively in the community. Hospice care is a well-known and comprehensive delivery model of palliative care, but it is limited to terminally ill patients, generally for patients when two doctors certify a prognosis of six months to live if the disease follows its usual course, and the patient agrees to forgo curative treatment. The author states that this bill is needed to clarify an ambiguity in existing law that may limit the ability of hospice providers to provide hospice services to a non-hospice, palliative care patient. The Act permits "preliminary" palliative care services that may be provided concurrently with curative treatment to a person who does not have a terminal prognosis or who has not elected to receive hospice services. The author concludes that hospice agencies are concerned that current law is too limiting and unclear and does not authorize hospice providers to provide palliative care services beyond initial consultations.

1. Hospice care. At the center of hospice care is the belief that individuals have the right to die pain-free and with dignity, and that families will receive necessary support. Hospice care is available to patients who no longer wish treatment directed at curing their disease. Patients are usually referred to hospice by their personal physician, although they can be referred by their families or even by themselves. Initially, a physician certifies that the patient has a life expectancy of six months or less if the disease follows its normal course. Hospice usually begins within 48 hours after a referral, and can begin sooner based on the circumstances. A hospice nurse evaluates what the person and family needs and develops a plan of care. The plan addresses the entire family's needs: medical; emotional; psychological; spiritual; and, support services. The nurse then coordinates the care with a physician and the full team of health professionals.
2. Palliative care. Palliative care is patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care involves addressing physical, intellectual, emotional, social, and spiritual needs and, to facilitate patient autonomy, access to information and choice. Palliative care is provided and services are coordinated by an interdisciplinary team – patients, families, and palliative and non-palliative health care providers collaborate and communicate about care needs. Palliative care services are available concurrently with or independent of curative or life-prolonging care.
3. Legislative background. With the passage of AB 1745 (Chan), Chapter 330, Statutes of 2006, and SB 1004 (Hernandez), Chapter 574, Statutes of 2014, California has been promoting palliative care as an option for children and adults with advanced serious illnesses. AB 1745 resulted in the Pediatric Palliative Care for Children Waiver program, known as Partners for Children, which offers supportive services for children on Medi-Cal with life-limiting or life-threatening illnesses and their families in 11 counties. These services are provided by local participating hospice and home health agencies to eligible children and their families. SB 1004 requires the Department of Health Care Services (DHCS) to establish standards and provide technical assistance for Medi-Cal managed care plans (MCPs) to ensure delivery of palliative care services. DHCS has held five stakeholder meetings since February 2015 to help inform the preparation of an All Plan Letter (APL) specifying the palliative care eligibility criteria and services offered to Medi-Cal beneficiaries. DHCS released its palliative care policy document in September 2016 and a draft managed care APL in November 2016. The draft APL noted an effective date of April 1, 2017. The Governor's Budget proposes to delay implementation to no sooner than July 1, 2018.

In the DHCS policy paper, DHCS indicates that Medi-Cal palliative care may be provided in a variety of settings, including inpatient, outpatient, or community-based, and therefore providers may vary based on the setting and needs of the patient. DHCS proposes that Medi-Cal MCPs be provided flexibility in provider types, qualifications, and training requirements for palliative care, so long as the providers meet existing Medi-Cal regulations, Provider Bulletins, or APLs. Specifically, the paper indicates MCPs may contract with hospitals, long-term care facilities, clinics, hospice agencies, home health agencies, and other types of community-based providers that include licensed clinical staff. MCPs generally work with existing local providers, and may need to contract with several different types of providers depending on local provider qualifications and the need to reflect the diversity of provider types. However, palliative care services provided in a beneficiary's home must meet the applicable existing Medi-Cal requirements for in-home providers, services, and authorization, such as physician assessments, care plans, home health or hospice agency regulations.

The California Hospice and Palliative Care Association (CHAPCA) states that this bill clarifies that licensed hospices may provide palliative care services to individual and families who are not yet eligible for hospice, or who choose not to go on hospice. CHAPCA notes the demand for palliative care is growing, as research demonstrates both significant patient satisfaction and cost avoidance: a 2007 study of Kaiser patients found that 36% of people receiving palliative care at home were hospitalized in their final months, compared with 59% of those getting standard care.

The Coalition for Compassionate Care of California (CCCC) states that palliative care allows a patient flexibility to pursue disease directed treatment options while also receiving care for pain and symptom management, as well as assistance with coordinating care. CCCC notes that while palliative care has become well-established in the hospital-based setting, quality, community-based models must also be developed in order to meet increasing demand for services.

The California Right to Life Committee, Inc. (CRLC) is opposes this bill and states that the palliative care community appears to be improperly taking advantage of people who have a variety of critical but non terminal life-long medical needs and that this bill is trying to turn them into medically dependent patients who cannot function on their own. CRLC contends that it is not possible to have curative care and palliative at the same time, and that palliation, like abortion, was first sold to us as a kindness to help a few people and prevent unnecessary stress, pain, and embarrassment.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097 FN: 0001837

SENATE THIRD READING

STR Bill Id:SB 294

Author:(Hernandez)

As Amended Ver:May 26, 2017

Majority vote

SENATE VOTE: 37-0

SUMMARY: Authorizes a licensed hospice to provide interdisciplinary hospice services to a patient who is not a hospice patient, but has a serious illness, as defined, even if the patient is continuing to receive curative treatment. Specifically, this bill:

1. Revises the definition of palliative care and skilled nursing to include supportive services provided to a patient with a serious illness.
2. Authorizes a licensed hospice to provide the same interdisciplinary hospice services to a patient with a serious illness authorized in the Hospice Licensure Act of 1990 (Act) as determined by the physician and surgeon in charge of the care of the patient, including if the patient is continuing to receive curative treatment from other licensed health care professionals.
3. Defines serious illness as a condition that may result in death, regardless of the estimated length of the individual's remaining period of life.

FISCAL EFFECT: According to the Assembly Appropriations Committee, unknown, likely minor impact on hospice agency licensing and enforcement by the Department of Public Health (Licensing and Certification Fund). Any additional costs to process increased complaints or additional licenses would be supported through an existing fee, which may be readjusted annually. The 2017-18 licensure fee for a hospice is slightly less than $3,000.

COMMENTS: According to the author, palliative care is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment. The author notes that community-based palliative care models meet the needs of the sickest and costliest patients – who must otherwise resort to 911 calls, emergency department visits, and hospitalizations for problems that could and should have been addressed safely and effectively in the community. Hospice care is a well-known and comprehensive delivery model of palliative care, but it is limited to terminally ill patients, generally for patients when two doctors certify a prognosis of six months to live if the disease follows its usual course, and the patient agrees to forgo curative treatment. The author states that this bill is needed to clarify an ambiguity in existing law that may limit the ability of hospice providers to provide hospice services to a non-hospice, palliative care patient. The Act permits "preliminary" palliative care services that may be provided concurrently with curative treatment to a person who does not have a terminal prognosis or who has not elected to receive hospice services. The author concludes that hospice agencies are concerned that current law is too limiting and unclear and does not authorize hospice providers to provide palliative care services beyond initial consultations.

Hospice care. At the center of hospice care is the belief that individuals have the right to die pain-free and with dignity, and that families will receive necessary support. Hospice care is available to patients who no longer wish treatment directed at curing their disease. Patients are usually referred to hospice by their personal physician, although they can be referred by their families or even by themselves. Initially, a physician certifies that the patient has a life expectancy of six months or less if the disease follows its normal course. Hospice usually begins within 48 hours after a referral, and can begin sooner based on the circumstances. A hospice nurse evaluates what the person and family needs and develops a plan of care. The plan addresses the entire family's needs: medical; emotional; psychological; spiritual; and, support services. The nurse then coordinates the care with a physician and the full team of health professionals.

Palliative care. Palliative care is patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care involves addressing physical, intellectual, emotional, social, and spiritual needs and, to facilitate patient autonomy, access to information and choice. Palliative care is provided and services are coordinated by an interdisciplinary team – patients, families, and palliative and non-palliative health care providers collaborate and communicate about care needs. Palliative care services are available concurrently with or independent of curative or life-prolonging care.

Legislative background. With the passage of AB 1745 (Chan), Chapter 330, Statutes of 2006, and SB 1004 (Hernández), Chapter 574, Statutes of 2014, California has been promoting palliative care as an option for children and adults with advanced serious illnesses. AB 1745 resulted in the Pediatric Palliative Care for Children Waiver program, known as Partners for Children, which offers supportive services for children on Medi-Cal with life-limiting or life-threatening illnesses and their families in 11 counties. These services are provided by local participating hospice and home health agencies to eligible children and their families. SB 1004 requires the Department of Health Care Services (DHCS) to establish standards and provide technical assistance for Medi-Cal managed care plans (MCPs) to ensure delivery of palliative care services. DHCS has held five stakeholder meetings since February 2015 to help inform the preparation of an All Plan Letter (APL) specifying the palliative care eligibility criteria and services offered to Medi-Cal beneficiaries. DHCS released its palliative care policy document in September 2016 and a draft managed care APL in November 2016. The draft APL noted an effective date of April 1, 2017. The Governor's Budget proposes to delay implementation to no sooner than July 1, 2018.

In the DHCS policy paper, DHCS indicates that Medi-Cal palliative care may be provided in a variety of settings, including inpatient, outpatient, or community-based, and therefore providers may vary based on the setting and needs of the patient. DHCS proposes that Medi-Cal MCPs be provided flexibility in provider types, qualifications, and training requirements for palliative care, so long as the providers meet existing Medi-Cal regulations, Provider Bulletins, or APLs. Specifically, the paper indicates MCPs may contract with hospitals, long-term care facilities, clinics, hospice agencies, home health agencies, and other types of community-based providers that include licensed clinical staff. MCPs generally work with existing local providers, and may need to contract with several different types of providers depending on local provider qualifications and the need to reflect the diversity of provider types. However, palliative care services provided in a beneficiary's home must meet the applicable existing Medi-Cal requirements for in-home providers, services, and authorization, such as physician assessments, care plans, home health or hospice agency regulations.

The California Hospice and Palliative Care Association (CHAPCA) states that this bill clarifies that licensed hospices may provide palliative care services to individual and families who are not yet eligible for hospice, or who choose not to go on hospice. CHAPCA notes the demand for palliative care is growing, as research demonstrates both significant patient satisfaction and cost avoidance: a 2007 study of Kaiser patients found that 36% of people receiving palliative care at home were hospitalized in their final months, compared with 59% of those getting standard care.

The Coalition for Compassionate Care of California (CCCC) states that palliative care allows a patient flexibility to pursue disease directed treatment options while also receiving care for pain and symptom management, as well as assistance with coordinating care. CCCC notes that while palliative care has become well-established in the hospital-based setting, quality, community-based models must also be developed in order to meet increasing demand for services.

The California Right to Life Committee, Inc. (CRLC) is opposed to this bill and states that the palliative care community appears to be improperly taking advantage of people who have a variety of critical but non terminal life-long medical needs and that this bill is trying to turn them into medically dependent patients who cannot function on their own. CRLC contends that it is not possible to have curative care and palliative at the same time, and that palliation, like abortion, was first sold to us as a kindness to help a few people and prevent unnecessary stress, pain, and embarrassment.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097 FN: 0001213

Date of Hearing: June 28, 2017

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

SBPCA Bill Id:SB 294

Author:(Hernandez) – As Amended Ver:May 26, 2017

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill allows a licensed hospice to serve patients with serious illness who do not have a terminal diagnosis, including patients who are concurrently receiving curative treatment.

FISCAL EFFECT:

Unknown, likely minor impact on hospice agency licensing and enforcement by the Department of Public Health (Licensing and Certification Fund). Any additional costs to process increased complaints or additional licenses would be supported through an existing fee, which may be readjusted annually. The 2017-18 licensure fee for a hospice is slightly less than $3,000.

COMMENTS:

1. Purpose. According to the author, this bill is intended to allow a licensed hospice to provide palliative care. Current law permits “preliminary” palliative care services that may be provided concurrently with curative treatment to a person who does not have a terminal prognosis or who has not elected to receive hospice services. Hospice providers indicate current law does not clearly allow them to provide palliative care services beyond initial consultations, even though they may have expertise and ability to provide such care.
2. Background. Palliative care is specialized medical care for people with serious illnesses; it is commonly provided for cancer, heart and lung diseases, kidney failure, dementia, and other conditions. Palliative care is intended to provide patients with relief from the symptoms, pain, and stress of a serious illness, and to improve quality of life for the patient and family. It can be provided at any stage of a serious illness, and it can be provided along with curative treatment.

Hospice care is specialized care focused on the end of life. By law, licensed hospices must provide a number of services, including skilled nursing, social services, counseling services, medical direction, bereavement services, volunteer services, inpatient care arrangements, and home health aide services. Hospice care is patient-centered, emphasizing relief of suffering and quality of life for individuals who are dying. Licensed hospice agencies are restricted to serving patients who have a “terminal illness,” which is defined as a medical condition resulting in a prognosis of one year or less of life. This bill will allow a licensed hospice to expand to serve persons who do not have a terminal illness, as defined, but have a serious illness that may result in death.

1. Support. This bill is co-sponsored by California Hospice and Palliative Care Association and the Coalition for Compassionate Care of California, and supported by the Alliance of Catholic Health Care, American Cancer Society Cancer Action Network, Blue Shield of California, and others. Supporters state the clarification provided by the bill will assist in the development of community-based palliative care services that will help meet increasing demand.
2. Opposition. The California Right to Life Committee, Inc. opposes this bill, stating their belief that the palliative care community is taking advantage of people with serious illness and implying palliative care is abusive and profit-driven.
3. Related Legislation. SB 1004 (Hernández), Chapter 574, Statutes of 2014, required the Department of Health Care Services to establish standards and provide technical assistance for Medi-Cal managed care plans to ensure delivery of palliative care services.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: June 20, 2017

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

SBPCA Bill Id:SB 294

Author:(Hernandez) – As Amended Ver:May 26, 2017

SENATE VOTE: 37-0

SUBJECT: Hospices: palliative care.

SUMMARY: Authorizes a licensed hospice to provide interdisciplinary hospice services to a patient who is not a hospice patient, but has a serious illness, as defined, even if the patient is continuing to receive curative treatment. Specifically, this bill:

1. Revises the definition of palliative care and skilled nursing to include supportive services provided to a patient with a serious illness.
   
2. Authorizes a licensed hospice to provide the same interdisciplinary hospice services to a patient with a serious illness authorized in the Hospice Licensure Act of 1990 (Act) as determined by the physician and surgeon in charge of the care of the patient, including if the patient is continuing to receive curative treatment from other licensed health care professionals.
   
3. Defines serious illness as a condition that may result in death, regardless of the estimated length of the individual's remaining period of life.

EXISTING LAW:

1. Establishes the Act which provides the Department of Public Health (DPH) with the authority to license and regulate hospice agencies.
   
2. Defines hospice as a specialized form of interdisciplinary health care that is designed to provide palliative care, alleviate the physical, emotional, social, and spiritual discomforts of an individual who is experiencing the last phases of life due to the existence of a terminal disease, and provide supportive care to the primary caregiver and the family of the hospice patient, and that meets specified criteria including, but not limited to:
   1. Provides for the palliative medical treatment of pain and other symptoms associated with a terminal disease, but does not provide for efforts to cure the disease; and,
   2. To the extent appropriate, based on the medical needs of the patient, provides services in the patient’s home or primary place of residence.
      
3. Requires hospice agencies to provide the following basic services:
   1. Skilled nursing services;
   2. Social services/counseling services;
   3. Medical direction;
   4. Bereavement services;
   5. Volunteer services;
   6. Inpatient care arrangements; and,
   7. Home health aide services.
      
4. Permits licensed hospices to provide, in addition to authorized hospice services, any of the following preliminary services for any person in need of those services, as determined by the physician and surgeon, if any, in charge of the care of a patient, or at the request of the patient or family:
   1. Preliminary palliative care consultations;
   2. Preliminary counseling and care planning;
   3. Preliminary grief and bereavement services; and,
   4. Preliminary services may be provided concurrently with curative treatment to a person who does not have a terminal prognosis or who has not elected to receive hospice services only by licensed and certified hospices. Requires these services to be subject to the schedule of benefits under the Medi-Cal program, as specified.
      
5. Defines palliative care as patient and family-centered care that optimizes the quality of life of a patient with a terminal illness by anticipating, preventing, and treating suffering. Palliative care throughout the terminal illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.
   
6. Defines skilled nursing services as nursing services provided by or under the supervision of a registered nurse under a plan of care developed by the interdisciplinary team and the patient’s physician and surgeon to a patient and his or her family that pertain to the palliative, supportive services required by patients with a terminal illness. Skilled nursing services include, but are not limited to, patient assessment, evaluation and case management of the medical nursing needs of the patient, the performance of prescribed medical treatment for pain and symptom control, the provision of emotional support to both the patient and his or her family, and the instruction of caregivers in providing personal care to the patient. Requires skilled nursing services to provide for the continuity of services for the patient and his or her family. Requires skilled nursing services to be available on a 24-hour on-call basis.

FISCAL EFFECT: According to the Senate Appropriations Committee:

1. Minor costs to update existing regulations by DPH (Licensing and Certification Fund). DPH, which licenses hospice agencies, is currently in the process of updating its regulations for hospice agencies. DPH will be able to incorporate the changes in this bill into those revisions at minor cost.
2. Unknown impact on licensing and enforcement of hospice agencies by DPH (Licensing and Certification Fund). By expanding the universe of patients that can be treated by a licensed hospice agency, this bill may result in additional entities seeking licensure as a hospice agency to meet what may be a significant increase in demand for hospice services. To the extent that this does occur, DPH would incur additional licensing and enforcement workload.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, palliative care is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment. The author notes that community-based palliative care models meet the needs of the sickest and costliest patients – who must otherwise resort to 911 calls, emergency department visits, and hospitalizations for problems that could and should have been addressed safely and effectively in the community. Hospice care is a well-known and comprehensive delivery model of palliative care, but it is limited to terminally ill patients, generally for patients when two doctors certify a prognosis of six months to live if the disease follows its usual course, and the patient agrees to forgo curative treatment. The author states that this bill is needed to clarify an ambiguity in existing law that may limit the ability of hospice providers to provide hospice services to a non-hospice, palliative care patient. The Act permits “preliminary” palliative care services that may be provided concurrently with curative treatment to a person who does not have a terminal prognosis or who has not elected to receive hospice services. The author concludes that hospice agencies are concerned that current law is too limiting and unclear and does not authorize hospice providers to provide palliative care services beyond initial consultations.
2. BACKGROUND.
   
   1. Hospice care. At the center of hospice care is the belief that individuals have the right to die pain-free and with dignity, and that families will receive necessary support. Hospice care is available to patients who no longer wish treatment directed at curing their disease. Patients are usually referred to hospice by their personal physician, although they can be referred by their families or even by themselves. Initially, a physician certifies that the patient has a life expectancy of six months or less if the disease follows its normal course. Hospice usually begins within 48 hours after a referral, and can begin sooner based on the circumstances. A hospice nurse evaluates what the person and family needs and develops a plan of care. The plan addresses the entire family’s needs: medical; emotional; psychological; spiritual; and, support services. The nurse then coordinates the care with a physician and the full team of health professionals.
      
   2. Palliative care. Palliative care is patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care involves addressing physical, intellectual, emotional, social, and spiritual needs and, to facilitate patient autonomy, access to information and choice. Palliative care is provided and services are coordinated by an interdisciplinary team - patients, families, and palliative and non-palliative health care providers collaborate and communicate about care needs. Palliative care services are available concurrently with or independent of curative or life-prolonging care.
      
   3. Legislative background. With the passage of AB 1745 (Chan), Chapter 330, Statutes of 2006, and SB 1004 (Hernández), Chapter 574, Statutes of 2014, California has been promoting palliative care as an option for children and adults with advanced serious illnesses. AB 1745 resulted in the Pediatric Palliative Care for Children Waiver program, known as Partners for Children, which offers supportive services for children on Medi-Cal with life-limiting or life-threatening illnesses and their families in 11 counties. These services are provided by local participating hospice and home health agencies to eligible children and their families. SB 1004 requires the Department of Health Care Services (DHCS) to establish standards and provide technical assistance for Medi-Cal managed care plans (MCPs) to ensure delivery of palliative care services. DHCS has held five stakeholder meetings since February 2015 to help inform the preparation of an All Plan Letter (APL) specifying the palliative care eligibility criteria and services offered to Medi-Cal beneficiaries. DHCS released its palliative care policy document in September 2016 and a draft managed care APL in November 2016. The draft APL noted an effective date of April 1, 2017. The Governor’s Budget proposes to delay implementation to no sooner than July 1, 2018.

In the DHCS policy paper, DHCS indicates that Medi-Cal palliative care may be provided in a variety of settings, including inpatient, outpatient, or community-based, and therefore providers may vary based on the setting and needs of the patient. DHCS proposes that Medi-Cal MCPs be provided flexibility in provider types, qualifications, and training requirements for palliative care, so long as the providers meet existing Medi-Cal regulations, Provider Bulletins, or APLs. Specifically, the paper indicates MCPs may contract with hospitals, long-term care facilities, clinics, hospice agencies, home health agencies, and other types of community-based providers that include licensed clinical staff. MCPs generally work with existing local providers, and may need to contract with several different types of providers depending on local provider qualifications and the need to reflect the diversity of provider types. However, palliative care services provided in a beneficiary’s home must meet the applicable existing Medi-Cal requirements for in-home providers, services, and authorization, such as physician assessments, care plans, home health or hospice agency regulations.

1. SUPPORT. The California Hospice and Palliative Care Association (CHAPCA) states that this bill clarifies that licensed hospices may provide palliative care services to individual and families who are not yet eligible for hospice, or who choose not to go on hospice. CHAPCA notes the demand for palliative care is growing, as research demonstrates both significant patient satisfaction and cost avoidance: a 2007 study of Kaiser patients found that 36% of people receiving palliative care at home were hospitalized in their final months, compared with 59% of those getting standard care.
   
   The Coalition for Compassionate Care of California (CCCC) states that palliative care allows a patient flexibility to pursue disease directed treatment options while also receiving care for pain and symptom management, as well as assistance with coordinating care. CCCC notes that while palliative care has become well-established in the hospital-based setting, quality, community-based models must also be developed in order to meet increasing demand for services.
2. OPPOSITION. The California Right to Life Committee, Inc. (CRLC) is opposed to this bill and states that the palliative care community appears to be improperly taking advantage of people who have a variety of critical but non terminal life-long medical needs and that this bill is trying to turn them into medically dependent patients who cannot function on their own. CRLC contends that it is not possible to have curative care and palliative at the same time, and that palliation, like abortion, was first sold to us as a kindness to help a few people and prevent unnecessary stress, pain, and embarrassment.

REGISTERED SUPPORT / OPPOSITION:

Support

California Hospice and Palliative Care Association (cosponsor)

Coalition for Compassionate Care of California (cosponsor)

Alliance of Catholic Health Care

American Cancer Society Cancer Action Network

Blue Shield of California

California Academy of Family Physicians

California Assisted Living Association

Providence St. Joseph Health

Retired Public Employees Association

Opposition

California Right to Life Committee, Inc.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097

 THIRD READING  

Bill No: SB 294

Author:

:

Vote:

SENATE HEALTH COMMITTEE: 9-0, 4/5/17

AYES: Hernandez, Nguyen, Atkins, Leyva, Mitchell, Monning, Newman, Nielsen, Roth

SENATE APPROPRIATIONS COMMITTEE: 6-0, 5/25/17

AYES: Lara, Beall, Bradford, Hill, Nielsen, Wiener

NO VOTE RECORDED: Bates

SUBJECT:

SOURCE: California Hospice and Palliative Care Association

Coalition for Compassionate Care of California

DIGEST:

1. This bill allows hospice agencies to provide the same hospice services authorized in the Hospice Licensure Act of 1990 to a patient that has a serious illness even if the patient is continuing to receive curative treatment from other licensed health care professionals.

ANALYSIS:

Existing law:

1. Establishes the Hospice Licensure Act of 1990 (Act) which provides the Department of Public Health with the authority to license and regulate hospice agencies.
2. Defines “hospice” as a specialized form of interdisciplinary health care that is designed to provide palliative care, alleviate the physical, emotional, social, and spiritual discomforts of an individual who is experiencing the last phases of life due to the existence of a terminal disease, and provide supportive care to the primary caregiver and the family of the hospice patient, and that meets specified criteria including, but not limited to:
   1. Providing for the palliative medical treatment of pain and other symptoms associated with a terminal disease, but does not provide for efforts to cure the disease; and,
   2. Providing, to the extent appropriate, based on the medical needs of the patient, services in the patient’s home or primary place of residence.
3. Requires hospice agencies to provide the following basic services:
   1. Skilled nursing services;
   2. Social services/counseling services;
   3. Medical direction;
   4. Bereavement services;
   5. Volunteer services;
   6. Inpatient care arrangements; and,
   7. Home health aide services.
4. Permits, notwithstanding any provision of law to the contrary, licensed hospices to provide, in addition to authorized hospice services, any of the following preliminary services for any person in need of those services, as determined by the physician and surgeon, if any, in charge of the care of a patient, or at the request of the patient or family:
   1. Preliminary palliative care consultations;
   2. Preliminary counseling and care planning;
   3. Preliminary grief and bereavement services; and,
   4. Preliminary services may be provided concurrently with curative treatment to a person who does not have a terminal prognosis or who has not elected to receive hospice services only by licensed and certified hospices. Requires these services to be subject to the schedule of benefits under the Medi-Cal program, as specified.
5. Defines palliative care as patient and family-centered care that optimizes the quality of life of a patient with a terminal illness by anticipating, preventing, and treating suffering. Palliative care throughout the terminal illness involves addressing physical, intellectual, emotional, social and spiritual needs and to facilitate patient autonomy, access to information and choice.
6. Defines skilled nursing services as nursing services provided by or under the supervision of a registered nurse under a plan of care developed by the interdisciplinary team and the patient’s physician and surgeon to a patient and his or her family that pertain to the palliative, supportive services required by patients with a terminal illness. Skilled nursing services include, but are not limited to, patient assessment, evaluation and case management of the medical nursing needs of the patient, the performance of prescribed medical treatment for pain and symptom control, the provision of emotional support to both the patient and his or her family, and the instruction of caregivers in providing personal care to the patient. Requires skilled nursing services to provide for the continuity of services for the patient and his or her family. Requires skilled nursing services to be available on a 24-hour on-call basis.

This bill:

1. Revises the definition of palliative care by deleting “patient with a terminal illness.”
2. Clarifies in the definitions of home health care services and skilled nursing services that a patient can also have a serious illness.
3. Defines “serious illness” as a condition that may result in death, regardless of the estimated length of the individual’s remaining period of life.
4. Authorizes, further, notwithstanding any other law, a licensed hospice to provide any of the same interdisciplinary hospice services, as defined in the Act to a patient with a serious illness, as determined by the physician and surgeon in charge of the care of the patient, including a patient who continues to receive curative treatment from other licensed health care professionals.
5. States that 4) above is not intended to modify the provision of hospice care required to be provided by health care service plans.

Background

With the passage of AB 1745 (Chan, Chapter 330, Statutes of 2006) and SB 1004 (Hernandez, Chapter 574, Statutes of 2014), California has been promoting palliative care as an option for children and adults with advanced serious illnesses. AB 1745 resulted in the Pediatric Palliative Care for Children Waiver program, known as Partners for Children, which offers supportive services for children on Medi-Cal with life-limiting or life-threatening illnesses and their families in 11 counties. These services are provided by local participating hospice and home health agencies to eligible children and their families. SB 1004 requires the Department of Health Care Services (DHCS) to establish standards and provide technical assistance for Medi-Cal managed care plans (MCPs) to ensure delivery of palliative care services. DHCS has held five stakeholder meetings since February 2015 to help inform the preparation of an All Plan Letter (APL) specifying the palliative care eligibility criteria and services offered to Medi-Cal beneficiaries. DHCS released its palliative care policy document in September 2016 and a draft managed care APL in November 2016. The draft APL noted an effective date of April 1, 2017. The Governor’s Budget proposes to delay implementation to no sooner than July 1, 2018.

In the DHCS policy paper, DHCS indicates that Medi-Cal palliative care may be provided in a variety of settings, including inpatient, outpatient, or community-based, and therefore providers may vary based on the setting and needs of the patient. DHCS proposes that Medi-Cal MCPs be provided flexibility in provider types, qualifications, and training requirements for palliative care, so long as the providers meet existing Medi-Cal regulations, Provider Bulletins, or APLs. Specifically, the paper indicates MCPs may contract with hospitals, long-term care facilities, clinics, hospice agencies, home health agencies, and other types of community-based providers that include licensed clinical staff. MCPs generally work with existing local providers, and may need to contract with several different types of providers depending on local provider qualifications and the need to reflect the diversity of provider types. However, palliative care services provided in a beneficiary’s home must meet the applicable existing Medi-Cal requirements for in-home providers, services, and authorization, such as physician assessments, care plans, home health or hospice agency regulations.

Comments

1) Author’s statement. According to the author, palliative care is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment. Community-based palliative care models meet the needs of the sickest and costliest patients – who must otherwise resort to 911 calls, emergency department visits, and hospitalizations for problems that could and should have been addressed safely and effectively in the community. Hospice care is a well-known and comprehensive delivery model of palliative care, but it is limited to terminally ill patients, generally for patients when two doctors certify a prognosis of six months to live if the disease follows its usual course, and the patient agrees to forgo curative treatment. This bill is needed to clarify an ambiguity in existing law that may limit the ability of hospice providers to provide hospice services to a non-hospice, palliative care patient. The Act permits “preliminary” palliative care services that may be provided concurrently with curative treatment to a person who does not have a terminal prognosis or who has not elected to receive hospice services. Hospice agencies are concerned that current law is too limiting and unclear and does not authorize hospice providers to provide palliative care services beyond initial consultations.

Related/Prior Legislation

AB 1745 (Chan, Chapter 330, Statutes of 2006) required the Department of Health Services (DHS) (now DHCS) to develop, as a pilot project, a pediatric palliative care benefit covered under Medi-Cal, and required DHS to submit a waiver to the federal Centers for Medicare and Medicaid Services (CMS) to implement the pilot project.

SB 1004 (Hernandez, Chapter 574, Statutes of 2014) required the DHCS to establish standards and provide technical assistance for Medi-Cal MCPs to ensure delivery of palliative care services.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

According to the Senate Appropriations Committee:

• Minor costs to update existing regulations by the Department of Public Health (Licensing and Certification Fund). The Department, which licenses hospice agencies, is currently in the process of updating its regulations for hospice agencies. The Department will be able to incorporate the changes in this bill into those revisions at minor cost.
• Unknown impact on licensing and enforcement of hospice agencies by the Department of Public Health (Licensing and Certification Fund). By expanding the universe of patients that can be treated by a licensed hospice agency, the bill may result in additional entities seeking licensure as a hospice agency to meet what may be a significant increase in demand for hospice services. To the extent that this does occur, the Department would incur additional licensing and enforcement workload.

SUPPORT: (Verified 5/25/17)

California Hospice and Palliative Care Association (co-source)

Coalition for Compassionate Care of California (co-source)

American Cancer Society Cancer Action Network

Alliance of Catholic Health Care

Blue Shield of California

California Catholic Conference

National Association of Social Workers, California Chapter

Providence St. Joseph Health

OPPOSITION: (Verified 5/25/17)

California Right to Life Committee, Inc.

ARGUMENTS IN SUPPORT: The California Hospice and Palliative Care Association (CHAPCA) writes that this bill clarifies that licensed hospices may provide palliative care services to individuals and families who are not yet eligible for hospice, or who choose not to go on hospice. While the hospice licensing bill, originally passed in 1990, references hospices providing “preliminary services,” the language does not clearly state what palliative services are permissible under the license. CHAPCA states that the demand for palliative care is growing, as research demonstrates both significant patient satisfaction and cost avoidance. One study of Kaiser patients published in 2007, found that 36% of people receiving palliative care at home were hospitalized in their final months, compared with 59% of those getting standard care. The overall cost of care for those who participated in the program was a third less than for those who didn’t. Another study published in January 2017 showed that in the last three months of life, medical care for patients in a home-based palliative care program cost $12,000 less than for patients who were getting more typical treatment. CHAPCA points out that this legislation is not mandating a new service. Rather, it clarifies this group of providers is legally authorized to offer palliative care services. According to the Coalition for Compassionate Care of California (CCCC), while palliative care has become well-established in the hospital-based setting, quality, community-based models must also be developed in order to meet increasing demand for services. Hospice programs, which have always offered palliative care to their hospice patients, have staff that are already trained and experienced in providing palliative care in the community setting. CCCC states that his bill is needed to clarify that hospices can provide palliative care service to non-hospice patients, beyond initial consultation. Blue Shield of California supports this bill because Blue Shield is working to enhance and expand existing benefits through the development of new models of palliative care delivery. Through collaborative partnerships with provider groups and Accountable Care Organizations, Blue Shield aims to bring a significant number of home-based palliative care programs into their network across the state.

ARGUMENTS IN OPPOSITION: The California Right to Life Committee, Inc. writes that this bill is trying to turn people with critical but non terminal lifelong medical needs into medically dependent patients who cannot function on their own.

Prepared by:

5/27/17 18:48:48

**** END ****

SENATE COMMITTEE ON

Senator Ricardo Lara, Chair

2017 - 2018 Regular Session

SB 294 (Hernandez) - Hospices: palliative care

*********** ANALYSIS ADDENDUM – SUSPENSE FILE ***********

The following information is revised to reflect amendments

adopted by the committee on May 25, 2017

Bill Summary:

SB 294 would authorize licensed hospice agencies to provide specified services to individuals who have a serious, life threatening, or advanced illness, even if the patient continues to receive curative treatment.

Fiscal Impact:

• Minor costs to update existing regulations by the Department of Public Health (Licensing and Certification Fund). The Department, which licenses hospice agencies, is currently in the process of updating its regulations for hospice agencies. The Department will be able to incorporate the changes in this bill into those revisions at minor cost.
• Unknown impact on licensing and enforcement of hospice agencies by the Department of Public Health (Licensing and Certification Fund). By expanding the universe of patients that can be treated by a licensed hospice agency, the bill may result in additional entities seeking licensure as a hospice agency to meet what may be a significant increase in demand for hospice services. To the extent that this does occur, the Department would incur additional licensing and enforcement workload.

Author Amendments:

make clarifying changes and specify that the changes in the bill are not intended to modify the current requirements for coverage of hospice services by health plans.

-- END --

SENATE COMMITTEE ON

Senator Ricardo Lara, Chair

2017 - 2018 Regular Session

SB 294 (Hernandez) - Hospices: palliative care

This bill meets the criteria for referral to the Suspense File.

Bill Summary:

SB 294 would authorize licensed hospice agencies to provide specified services to individuals who have a serious, life threatening, or advanced illness, even if the patient continues to receive curative treatment.

Fiscal Impact:

• Minor costs to update existing regulations by the Department of Public Health (Licensing and Certification Fund). The Department, which licenses hospice agencies, is currently in the process of updating its regulations for hospice agencies. The Department will be able to incorporate the changes in this bill into those revisions at minor cost.
• Unknown impact on licensing and enforcement of hospice agencies by the Department of Public Health (Licensing and Certification Fund). By expanding the universe of patients that can be treated by a licensed hospice agency, the bill may result in additional entities seeking licensure as a hospice agency to meet what may be a significant increase in demand for hospice services. To the extent that this does occur, the Department would incur additional licensing and enforcement workload.
• Uncertain impact on the costs of health care coverage, including the costs to CalPERS, due to the changes to the hospice licensing requirements (various funds). Under current law, health plans and health insurers are required to cover hospice services, and the law requiring such coverage relies on the definitions of hospice care used in the section of law that provides for licensure of hospice agencies. Therefore, a change to the licensing requirements for hospice agencies may be interpreted as changing the requirements for coverage of hospice services. Whether the expansion of hospice services under the bill would result in increased costs to health plans is uncertain, since many of the services provided under hospice care may be provided under other mandated health care benefits.
• No increased costs to the Medi-Cal program are anticipated. Current law requires hospice care to be provided as a Medi-Cal benefit. However, the law mandating coverage of hospice care in Medi-Cal does not rely on the definitions used in the section of law governing the licensure of hospice agencies.

Background:

Under current law, hospice agencies are licensed by the Department of Public Health. Hospice agencies are authorized in law to provide interdisciplinary care that includes palliative care for the treatment of pain and other symptoms associated with a terminal disease. Hospice agencies are authorized to provide skilled nursing services, social services, care arrangement, and other services. Current law limits hospice agencies to providing care for individuals with a terminal illness (defined as a medical condition with a prognosis of life of one year or less) and prohibits the provision of curative treatments.

Under current law, health plans and health insurers are required to provide coverage for hospice care. The laws mandating coverage for hospice care rely on the definition of hospice care included in the section of law governing the licensure of hospice agencies.

Under state and federal law, the Department of Health Care Services operates the Medi-Cal program, which provides health care coverage to low income individuals, families, and children. Medi-Cal provides coverage to childless adults and parents with household income up to 138% of the federal poverty level and to children with household income up to 266% of the federal poverty level. The federal government provides matching funds that vary from 50% to 90% of expenditures depending on the category of beneficiary.

Hospice care is a Medi-Cal benefit under current law. In contrast to the law governing commercial health care coverage, the law governing Medi-Cal coverage of hospice care does not rely on the definitions used in the sections of law governing licensure of hospice agencies.

Proposed Law:

SB 294 would authorize licensed hospice agencies to provide specified services to individuals who have a serious, life threatening, or advanced illness, even if the patient continues to receive curative treatment.

Staff Comments:

The bill would expand the universe of patients that could be served by hospice agencies, by allowing them to provide services to individuals with serious illnesses, but who are expected to live more one year. This has the potential to substantially increase the population of patients that could make use of palliative care from hospice agencies. To the extent that there is an increased demand form hospice agencies for palliative care, there could be an expansion of the number of licensed hospice agencies in the state. The size of that impact is unknown.

There are indications in published research that palliative care services improve patient satisfaction and lower health care spending. For example, an analysis of a Medi-Cal pilot program for pediatric palliative care patients indicates that monthly hospital spending declined by $1,700 per participant. Similarly, the analysis of a pilot project in New York State found substantially reduced hospital costs for palliative care patients.

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SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: SB 294

SUBJECT: Hospices: palliative care

SUMMARY:

1. This bill allows hospice agencies to provide the same hospice services authorized in the Hospice Licensure Act of 1990 to a patient that has a serious, life threatening, or advanced illness even if the patient is continuing to receive curative treatment from other licensed health care professionals.

Existing law:

1. Establishes the Hospice Licensure Act of 1990 (Act) which provides the Department of Public Health with the authority to license and regulate hospice agencies.
   
2. Defines hospice as a specialized form of interdisciplinary health care that is designed to provide palliative care, alleviate the physical, emotional, social, and spiritual discomforts of an individual who is experiencing the last phases of life due to the existence of a terminal disease, and provide supportive care to the primary caregiver and the family of the hospice patient, and that meets specified criteria including, but not limited to:
   1. Provides for the palliative medical treatment of pain and other symptoms associated with a terminal disease, but does not provide for efforts to cure the disease; and,
   2. To the extent appropriate, based on the medical needs of the patient, provides services in the patient’s home or primary place of residence.
      
3. Requires hospice agencies to provide the following basic services:
   1. Skilled nursing services;
   2. Social services/counseling services;
   3. Medical direction;
   4. Bereavement services;
   5. Volunteer services;
   6. Inpatient care arrangements; and,
   7. Home health aide services.
      
4. Permits, notwithstanding any provision of law to the contrary, licensed hospices to provide, in addition to authorized hospice services, any of the following preliminary services for any person in need of those services, as determined by the physician and surgeon, if any, in charge of the care of a patient, or at the request of the patient or family:
   1. Preliminary palliative care consultations;
   2. Preliminary counseling and care planning;
   3. Preliminary grief and bereavement services; and,
   4. Preliminary services may be provided concurrently with curative treatment to a person who does not have a terminal prognosis or who has not elected to receive hospice services only by licensed and certified hospices. Requires these services to be subject to the schedule of benefits under the Medi-Cal program, as specified.
      
5. Defines palliative care as patient and family-centered care that optimizes the quality of life of a patient with a terminal illness by anticipating, preventing, and treating suffering. Palliative care throughout the terminal illness involves addressing physical, intellectual, emotional, social and spiritual needs and to facilitate patient autonomy, access to information and choice.
   
6. Defines skilled nursing services as nursing services provided by or under the supervision of a registered nurse under a plan of care developed by the interdisciplinary team and the patient’s physician and surgeon to a patient and his or her family that pertain to the palliative, supportive services required by patients with a terminal illness. Skilled nursing services include, but are not limited to, patient assessment, evaluation and case management of the medical nursing needs of the patient, the performance of prescribed medical treatment for pain and symptom control, the provision of emotional support to both the patient and his or her family, and the instruction of caregivers in providing personal care to the patient. Requires skilled nursing services to provide for the continuity of services for the patient and his or her family. Requires skilled nursing services to be available on a 24-hour on-call basis.

This bill:

1. Adds to the definition of palliative care, that palliative care includes relief of symptoms, pain, and stress of a serious, life threatening, advanced, or terminal illness without regard to the length of the patient’s remaining period of life.
   
2. Clarifies in the definitions of palliative care and skilled nursing services that a patient can also have a serious, life threatening, or advanced illness.
   
3. Authorizes, notwithstanding any other law, a licensed hospice to provide the same hospice services authorized in the Act to a patient in need of palliative care, as determined by the physician and surgeon in charge of the care of the patient, including if the patient is continuing to receive curative treatment from other licensed health care professionals.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, palliative care is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment. Community-based palliative care models meet the needs of the sickest and costliest patients – who must otherwise resort to 911 calls, emergency department visits, and hospitalizations for problems that could and should have been addressed safely and effectively in the community. Hospice care is a well-known and comprehensive delivery model of palliative care, but it is limited to terminally ill patients, generally for patients when two doctors certify a prognosis of six months to live if the disease follows its usual course, and the patient agrees to forgo curative treatment. This bill is needed to clarify an ambiguity in existing law that may limit the ability of hospice providers to provide hospice services to a non-hospice, palliative care patient. The Act permits “preliminary” palliative care services that may be provided concurrently with curative treatment to a person who does not have a terminal prognosis or who has not elected to receive hospice services. Hospice agencies are concerned that current law is too limiting and unclear and does not authorize hospice providers to provide palliative care services beyond initial consultations.
   
2. Background. With the passage of AB 1745 (Chan, Chapter 330, Statutes of 2006) and SB 1004 (Hernandez, Chapter 574, Statutes of 2014), California has been promoting palliative care as an option for children and adults with advanced serious illnesses. AB 1745 resulted in the Pediatric Palliative Care for Children Waiver program, known as Partners for Children, which offers supportive services for children on Medi-Cal with life-limiting or life-threatening illnesses and their families in 11 counties. These services are provided by local participating hospice and home health agencies to eligible children and their families. SB 1004 requires the Department of Health Care Services (DHCS) to establish standards and provide technical assistance for Medi-Cal managed care plans (MCPs) to ensure delivery of palliative care services. DHCS has held five stakeholder meetings since February 2015 to help inform the preparation of an All Plan Letter (APL) specifying the palliative care eligibility criteria and services offered to Medi-Cal beneficiaries. DHCS released its palliative care policy document in September 2016 and a draft managed care APL in November 2016. The draft APL noted an effective date of April 1, 2017. The Governor’s Budget proposes to delay implementation to no sooner than July 1, 2018.
   
   In the DHCS policy paper, DHCS indicates that Medi-Cal palliative care may be provided in a variety of settings, including inpatient, outpatient, or community-based, and therefore providers may vary based on the setting and needs of the patient. DHCS proposes that Medi-Cal MCPs be provided flexibility in provider types, qualifications, and training requirements for palliative care, so long as the providers meet existing Medi-Cal regulations, Provider Bulletins, or APLs. Specifically, the paper indicates MCPs may contract with hospitals, long-term care facilities, clinics, hospice agencies, home health agencies, and other types of community-based providers that include licensed clinical staff. MCPs generally work with existing local providers, and may need to contract with several different types of providers depending on local provider qualifications and the need to reflect the diversity of provider types. However, palliative care services provided in a beneficiary’s home must meet the applicable existing Medi-Cal requirements for in-home providers, services, and authorization, such as physician assessments, care plans, home health or hospice agency regulations.
3. Prior legislation. AB 1745 required the Department of Health Services (DHS) (now DHCS) to develop, as a pilot project, a pediatric palliative care benefit covered under Medi-Cal, and required DHS to submit a waiver to the federal Centers for Medicare and Medicaid Services (CMS) to implement the pilot project.

SB 1004 requires the DHCS to establish standards and provide technical assistance for Medi-Cal MCPs to ensure delivery of palliative care services.

1. Support. The California Hospice & Palliative Care Association (CHPCA) writes that this bill clarifies that licensed hospices may provide palliative care services to individuals and families who are not yet eligible for hospice, or who choose not to go on hospice. While the hospice licensing bill, originally passed in 1990, references hospices providing “preliminary services,” the language does not clearly state what palliative services are permissible under the license. CHAPCA states that the demand for palliative care is growing, as research demonstrates both significant patient satisfaction and cost avoidance. One study of Kaiser patients, published in 2007, found that 36% of people receiving palliative care at home were hospitalized in their final months, compared with 59% of those getting standard care. The overall cost of care for those who participated in the program was a third less than for those who didn’t. Another study published in January 2017 showed that in the last three months of life, medical care for patients in a home-based palliative care program cost $12,000 less than for patients who were getting more typical treatment. CHAPCA points out that this legislation is not mandating a new service. Rather, it clarifies this group of providers is legally authorized to offer palliative care services. According to the Coalition for Compassionate Care of California (CCCC), while palliative care has become well-established in the hospital-based setting, quality, community-based models must also be developed in order to meet increasing demand for services. Hospice programs, which have always offered palliative care to their hospice patients, have staff that are already trained and experienced in providing palliative care in the community setting. CCCC states that his bill is needed to clarify that hospices can provide palliative care service to non-hospice patients, beyond initial consultation. Blue Shield of California supports this bill because Blue Shield is working to enhance and expand existing benefits through the development of new models of palliative care delivery. Through collaborative partnerships with provider groups and Accountable Care Organizations, Blue Shield aims to bring a significant number of home-based palliative care programs into their network across the state.
   
2. Oppose. The California Right to Life Committee, Inc. writes that this bill is trying to turn people with critical but non terminal lifelong medical needs into medically dependent patients who cannot function on their own.

SUPPORT AND OPPOSITION:

Support: California Hospice and Palliative Care Association (cosponsor)

Coalition for Compassionate Care of California (cosponsor)

American Cancer Society Cancer Action Network

Blue Shield of California

Providence St. Joseph Health

Oppose: California Right to Life Committee, Inc.

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