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Hospice News Nebraska, Sept. 7, 2017
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Sept. 18-21 (Mon-Thurs) - 2017 Nebraska Nursing Facility Association/Nebraska Assisted Living Association Fall Convention

Sept. 19 (Tues) - Nebraska End-of-Life Survey Press Conference

Sept. 28 (Thurs) - WEBINAR: Hospice Regulatory Update

Nebraska News


Each year, Medicare providers are required to recertify their Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) user access. It is important that you review the information under the "What You Need to Do" heading and take action now. Failure to recertify by Sept. 30, 2017, will result in the termination of FISS DDE/PPTN services. Read More

2018 ICD-10-CM CODES

The Centers for Medicare and Medicaid Services has released the 2018 ICD-10-CM files. The 2018 ICD-10-CM codes are to be used for discharges occurring Oct. 1, 2017-Sept. 30, 2018, and for patient encounters occurring Oct. 1, 2017-Sept. 30, 2018.

There are approximately 363 new codes, 142 deletions, and more than 250 code
revisions. Some of the updated code topics include:

  • New codes for enterocolitis due to Clostridium difficile.
  • New codes for Type 2 diabetes with ketoacidosis.
  • Expansion of codes in behavioral health related to use and abuse of
    psychoactive substances.
  • New codes in nervous system.
  • Changes in codes related to blindness and low vision.
  • New and changed codes in the circulatory system related to myocardial
    infarction and secondary pulmonary hypertension, and significant expansion in
    the heart failure codes including a new code for end-stage heart failure.
  • A revised code for pneumonia due to other aerobic Gram-negative bacteria.
  • Twenty new digestive system codes related to intestinal obstruction.
  • Seventy-two new codes related to nonpressure ulcer involving muscle and bone
    with the presence of necrosis.
  • Musculoskeletal options for coding dermatomyositis and spinal stenosis with and
    without neurogenic claudication.
  • Twelve new and 176 revised codes for a variety of injuries, poisonings and other
    consequences of external causes.

The CMS 2018 ICD-10-CM files include the following:

  • 2018 Code Descriptors in Tabular Order
  • 2018 Code Tables and Index
  • 2018 Addendum
  • 2018 Errata – update June 27, 2017
  • POA Exempt Codes
  • General Equivalence Mappings (GEMS)


In their final rule, the Centers for Medicare and Medicaid Services strongly encouraged providers to utilize the Technical Resources, Assistance Center, and Information Exchange (TRACIE) for emergency preparedness resources. TRACIE was developed by the U.S. Department of Health and Human Services’ Office of Assistant Secretary for Preparedness and Response (ASPR) and is designed to provide resources and technical assistance to healthcare system preparedness stakeholders in building a resilient healthcare system. ASPR TRACIE also provides a monthly newsletter, The Express. Read the August 2017 newsletter here.


The Participation Exemption for Size Form is now available to complete on the CAHPS Hospice Survey website until Dec. 31, 2017. Please note, exemptions on the basis of size are active for one year only.

The Participation Exemption for Size Form will need to include for calendar year 2016 the number of patients who were discharged alive, the number of patients who died while in hospice care and a count of patients who fell into the following categories:

  • Patients who were discharged alive
  • Decedents:
    • who were under the age of 18
    • who died within 48 hours of admission to hospice care
    • for whom there is no caregiver of record
    • for whom the caregiver is a non-familial legal guardian
    • for whom the caregiver has a foreign (non-U.S. or U.S. Territory) home address
    • whose caregiver requested that they not be contacted

The CAHPS Hospice Survey Project Team will confirm receipt of the Participation Exemption for Size Form. Confirmation of receipt of the Participation Exemption for Size Form does not constitute approval or denial of this request. CMS will determine the eligibility for size exemption in 2018 when CMS reviews all hospices' data to see if they met the fiscal year 2019 Annual Payment Update (APU). If your exemption is accepted, you will not face a two percent reduction. However, if CMS data indicates you have served 50 or more survey-eligible patients in 2016, you would not qualify for the exemption and in that instance, you would face the reduction. Therefore, it is the responsibility of the hospice submitting the Participation Exemption for Size Form to accurately portray that the hospice meets the fewer than 50 survey-eligible decedents/caregivers for calendar year 2016 and provide the number of patients who died while in hospice care and count of patients who fell into the categories listed on the form.


Hospice Provider Preview Reports are now available from the Centers for Medicare and Medicaid Services. Hospice providers are encouraged to preview their quality measure results based on Quarter 1, 2016 to Quarter 4, 2016 data, prior to the November 2017 Hospice Compare refresh. Providers have 30 days to preview their quality measure results (Aug. 29, 2017-Sept. 28, 2017). For more information, visit the Hospice Quality Public Reporting web page and Preview Report Access Instructions.


NHPCA 2017-14 - Guidance on Changing Demographic Information on Hospice Compare
On Aug. 28, 2017, the Centers for Medicare and Medicaid Services provided guidance, in a Hospice Compare Update document, on how to update a provider’s demographic information such as address, telephone number and ownership with their state ASPEN coordinator.

NHPCA 2017-15 - Change Request 10131: Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2018

The effective date of Change Request 10131 is Oct. 1, 2017. Hospice payments for fiscal year 2018 will be increased by one percent. The fiscal year 2018 hospice payment rates are effective for care and services furnished on or after Oct. 1, 2017, through Sept. 30, 2018. Hospices that do not submit the required quality data will have their payment rates reduced by two percent.


NET Television will be airing the program "Now What?” on the following dates:

Now What? Eldercare and Dementia

  • Thursday, Sept. 7, 7:00 p.m. CST
  • Sunday, Sept. 10, 1:00 p.m. CST

Now What? Dementia, Down Syndrome and Other Disorders

  • Thursday, Sept. 28, 7:00 p.m. CST

NET's "Now What?" series addresses a variety of issues related to elder care and dementia. Providers are encouraged to share the program with residents, families, staff, and the community.

NET’s “Now What?” series is funded in part by the Nebraska Health Care Foundation. Previously aired programs can be viewed online.


The Nebraska Hospice and Palliative Care Association is accepting presentation proposals for the 2018 NHPCA "Living a Good the End of Life" Annual Conference.

Submit the call for presentations application to Pam Truscott, Vice President of Professional Development, at or fax to 402-475-6289.

The deadline to submit a proposal is Friday, Oct. 20, 2017.

View the application for additional details including conference dates, submission requirements, and topic suggestions.


The Centers for Medicare and Medicaid Services will begin mailing new Medicare cards with a new Medicare number (previously called the Medicare Claim Number on cards) to your patients in April 2018.

Beginning in October 2018, through the transition period, CMS will return your patient’s new Medicare number (Medicare Beneficiary Identifier, or MBI) on every remittance advice for claims you submit with their valid and active Health Insurance Claim Number (HICN). On electronic remittance advice transactions, the MBI will be in the same place you currently get the “changed HICN”: 835 Loop 2100, Segment NM1 (Corrected Patient/Insured Name), Field NM109 (Identification Code).

If the vendors you partner with to bill Medicare haven’t shared their MBI system changes with you, contact them to make sure you are both ready for the change; they can also tell you how they will pass the new Medicare number to you.

Visit the Provider web page for the latest information.


Hospice Notes

* Patients with acute myeloid leukemia (AML) enroll in hospice later, and at lower rates, than other patient groups. A study in the Journal of Clinical Oncology used Medicare claims to understand the patterns of treatment and hospice care. The authors say the “current hospice model itself may not be well-suited to handle the rapid clinical decline and medical complications” associated with the disease. In short, they say, the findings show, “We need to do a better job caring for these patients when they are near death.” (CureJournal of Clinical Oncology)

* Registration is open for the Medicare Learning Network event “Reporting Hospice Quality Data: Tips For Compliance Call.” During this call, learn more about Hospice Quality Reporting Program requirements. Find out how to be compliant and successfully submit Hospice Item Set data and the Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey in the next reporting year. A question-and-answer session follows the presentation. The event will take place Wednesday, Sept. 20, 12:30-2:00 p.m. CST, and registration is available online. (MLN)

* “Hospice providers score well on CMS' new compare site, but experts not impressed” is the headline of an article that discusses the CMS rating system and cites physician feedback to Hospice Compare. Physician Karl Steinberg says the report cards should be taken “‘with a grain of salt,’” and physician Joanne Lynn says the site is currently “of pretty limited value.” (McKnights)

* A new study published in Journal of Palliative Medicine recommends hospice care providers implement alcohol and substance use screenings for patients and family in order to combat opioid misuse. Authors of “Screening and Assessment of Substance Use in Hospice Care: Examining Content from a National Sample of Psychosocial Assessments” reviewed a sample of Medicare-certified hospices. The study found that 68 percent of agencies assessed such abuse, that assessments were typically broad, and that assessments focused on whether substance misuse was a current problem. “No assessment directly addressed potential diversion of pain medications.” (JPM)

* John Tagtmier, a Fort Myers man whose loss of Medicare hospice benefits and live-discharge made national news, has died. An article summarizes previous reports and quotes his daughter Krissy, his caretaker, as saying, “He fought a good fight.” (News-Press)

* Hospice professionals don’t have the authority to dispose of patient medication, a Washington Post opinion piece points out. Edo Banach, NHPCO’s president and chief executive, argues that a recent Washington Post Health & Science article “unfairly pointed to the hospice community’s role in exacerbating” the opioid crisis. Banach’s piece notes NHPCO’s support of a national policy and a set of practices that would allow hospice professionals to dispose of drugs. “Hospices work to do the right thing for patients and families, to address the pain and suffering of patients and to support their loved ones.” (The Washington Post)

* In a retrospective, Robert J. Tilley, MD, MBA, offers a candid look at his career and promotes hospice experience for doctors. An unexpected joy of his work has been associated to hospice service, a role he feels thankful for being asked to fill. “Ultimately the root of medicine is the elimination of suffering, a goal that can be easily lost in filling out pre-authorizations, meeting HgA1c goals, completing the proper ICD-10 list for billing, and the myriad concerns that plague modern practice. Going to hospice weekly is like a breath of fresh air.” He urges other practitioners to engage with hospice providers and experience the “care and compassion they provide.” (KevinMD)

* Karen Purze discusses her experience in encouraging her father to start hospice care “early” for his untreatable cancer. She shares the influence the 2010 New Yorker article “Letting Go” by Atul Gawande made on her decision. Gawande’s article makes the case that medical advances in treatment are changing the way people die, and that’s “not always for the better.” (Life Matters Media

* The Franklin family of Tennessee visited family member Uldine Bisagno, who was starting hospice care just as the flooding began in Houston. As the water rose, they faced complicated questions: “Was Uldine in the health to board one of the boats? Was it even safe to stay?” The family boarded rescue boats and aided Uldine in dangerous territory. The event was captured on a cell phone video. “It was a beautiful bonding time of humans helping humans,” a family member said. “It does give you an appreciation for strangers. If people would only look deeper, that would be amazing.” (WSMV)

* The Centers for Medicare and Medicaid Services has issued updates in “Emergency-related policies and procedures.” Section L, beginning on page 17, discusses hospice services. The document answers 12 questions including: “What is a hospice agency’s responsibility in the event of a disaster?”; “If a hospice provider cannot provide care for its patients, can these patients transfer to another hospice provider?”; and “Will the hospice inpatient and aggregate payment caps be waived?” (CMS)

* U.S. correctional facilities face increasing needs in palliative care services. But this population faces unique barriers to care. A JAMA article highlights models for hospice care in prisons and examines the challenges faced by consulting physicians. The article covers “issues specific to palliative care and hospice in prison include palliative care standards, inmate-physician and inmate-family relationships, confidentiality, interdisciplinary care, do-not-resuscitate orders and advance medical directives, medical parole, and the use of inmate volunteers in prison hospice programs.” (JAMA)

* On Sept. 11, 2001, Andrea “Andie” Raynor, a Harvard Divinity School graduate and hospice chaplain, was in New York. She made her way to Ground Zero where she “prayed over body parts” and comforted first responders. This article reflects on that traumatic experience, noting how hard it still is to grieve. “We have to allow ourselves to feel what the human heart can feel.” (

* A writer describes missing the chance to say goodbye to his dying father. “I'm finding that there really is no universal road map to guide us through the grieving process,” he says, but offers up lessons on how to navigate the “new normal.” He provides ideas from his own strategies and suggestions from Diana Sebzda, director of bereavement at Karen Ann Quinalan Hospice. (New Jersey Herald)

End-of-Life Notes

* Teenagers’ health may be impacted by their experience of the end-of-life care provided to their parents. A study published in the Journal of Clinical Oncology focused on teens whose parents died from cancer. They found 18 percent of the teens had “little or no trust” in the final weeks of care. The youth in this dissatisfied group are twice as likely to suffer from depression, anxiety and eating disorders. Dr. Amos Bailey says, “What is at stake for bereaved families is the potential for lifelong mental health problems that are probably more socially significant for a teenager (who) will live with this grief for 60 or more years as opposed to a widow who may outlive her husband by three to five years.” (Reuters)

* A new study, “Epidemiology and Patterns of Care at the End of Life: Rising Complexity, Shifts in Care Patterns and Sites of Death,” identifies three trends in end-of-life care. The trends are “increasing diversity in the primary diagnoses of decedents, increases in multimorbidity and illness complexity among people with terminal illnesses, and shifts in patterns of care at the end of life and in sites of death.” (Health Affairs)

* Listen to a recent conversation with Dr. Ira Byock, Fellow of the American Academy of Hospice and Palliative Medicine and author of "Dying Well." Byock speaks with physician Karen Wyatt. The two discuss “the changes that have taken place in end-of-life care over the past 20 years and what still needs to be done to ensure everyone in this country has the opportunity to ‘die well.’” Audio is available at the link below. (Iteleseminar)

* A study conducted on the End-of-Life Transfer Tool found “an inversely, statistically significant correlation … [indicating] a relationship between the score on the tool and the time to death.” The tool, which assesses six objective elements, was piloted on 30 patients over a 10-month period in a Midwestern teaching hospital. The authors claim the research will help further development, ultimately supporting “the decision-making of the bedside nurse.” (JHPN)

* Social worker Scott Janssen discusses the challenges faced by terminally ill patients with PTSD. Aside from the Veterans Administration, few professions have training in both PTSD and end-of-life care. He describes physical and psychological symptoms and advocates for guidelines developed by The National Center for Trauma-Informed Care to assist hospices, hospitals and caregivers. “These include an enhanced awareness and understanding of the potential impact of trauma on patients and their loved one, and developing the professional skills and training needed to recognize the signs and symptoms of trauma in patients, families as well as professional staff who may be at risk for vicarious trauma; and incorporating knowledge about psychological trauma into policies, procedures and organizational culture.” (KevinMD)

* Caretaking provides a kind of stress paradox, explains Rick Nauert, PhD. Research shows that helping behaviors relieve stress, yet caretaking is “among the most stressful, emotionally burdensome, and physically demanding roles a person can take on.” Nauert discusses studies of spousal communication and appreciation. “Spending time attempting to provide help can be beneficial for a caregiver’s mental and physical well-being, but only during those times when the caregiver sees their help has made a difference and that difference is noticed and recognized by their partner.” (PsychCentral)

* The American Academy of Pediatricians (AAP) has issued new guidance on end-of-life decision-making for children, and the ideas are based on ethical considerations and scientific evidence. AAP proposes a range of recommendations on forging life-sustaining medical treatment. Topics include “open and honest” discussion practices with age-appropriate information, physicians' religious or moral concerns, developmental disabilities, infants, and other topics. (Healio)

Palliative Care Notes

* A new study of Medicare patients found that patients given “palliative care earlier in the course of disease had decreased rates of hospitalization (risk ratio 0.53), fewer invasive procedures (RR 0.52), and chemotherapy (RR 0.46). They also had longer hospice stays (P<0.001) compared with patients who received palliative care closer to the end of life.” The authors write, “Palliative care represents an inflection point in patient care, with higher use of health care services before palliative care consultation and lower use after.” (Medpage)

* The Center to Advance Palliative Care posted a number of quality standards “to ensure that the care delivered to seriously ill individuals is evidence-based, person-centered, and high-quality.” The CAPC page links to seven guidelines and quality standards developed by national organizations. (CAPC)

* CAPC and NCHPC have announced the “Mapping Community Palliative Care” initiative with the goal of developing an inventory of community palliative care programs. The three-year project is funded by the Gordon and Betty Moore Foundation and will seek to determine the prevalence of such care programs nationally and allow them to be put “on the map.” Interested participants can visit (CAPC)

* Palliative care consultations reduce aggressive end-of-life care, according to a study published in the Journal of Oncology Practice. Further, retrospective data suggests that earlier consultations result in a reduction of health care use. The authors note a “disturbing trend” of consultations conducted very late, with a median time of 12 days before death. The authors say this study “complements the findings of other studies that providing palliative care to patients earlier translates into less intensive care, improved quality outcomes, and cost savings at the end of life for patients with cancer.” (Medscape)

* Hawaii has the lowest rate of opioids dispensed, according to CDC figures. Demographics may play a large role. According to Claudio Nigg, a professor at the University of Hawaii's Office of Public Health Studies, with Hawaii’s “large Asian population, its residents are more likely to embrace alternative medicine therapies including acupuncture and chiropractic manipulation.” Data also shows rates of filling prescriptions fall well below national averages. The article concludes with Medicare data on opioids, antibiotics, and prescription costs. (NPR)

* Patients are often said to “fight cancer,” and the language of war is common among discussions of cancer patients. A USA Today article discusses this rhetoric, using John McCain’s cancer diagnosis and treatment to argue that “invoking war, battle and the fighting spirit” is “understandable.” But, says the article, this often misses the question of our goals and values. “It’s not that you're a fighter that's important,” the author writes, “It’s what you are fighting for.” Not every illness is curable. People face diseases “that will almost certainly claim their lives and could result in loss of critical abilities before that. Up against a threat of that nature, it is vital we help people choose with great intention what they will fight for.” (USA Today)

Advance Care Planning Notes

* Aid-in-dying laws are prompting more end-of-life conversations, says an article from the Los Angeles Times. It focuses around the work of Anne Coscarelli, a clinical psychologist at UCLA, who heads a team of health workers. These workers ask patients questions like, “What scares them, how they’re feeling, what they’re worried about, what defines their quality of life.” In 2015, Kaiser Family Foundation found that while 89 percent of people believed doctors should discuss end-of-life care, only 17 percent had that conversation. Coscarelli says, “There’s a lot of need for talk, and talk is something that’s bigger and broader than the actual aid in dying itself.” (Los Angeles Times)

* In dealing with progressive heart failure, clinicians traditionally discuss pathophysiology and treatment options with patients. However, a new study says, “Patients and families wish to engage with their cardiologists in advance care planning and, when appropriate, end-of-life decision-making.” The review describes communication strategies that focus on patient and family support when coping with heart disease. (Springer Link)

Other Notes

* A study finds that emergency department visits were 23 percent higher among disabled patients who are cared for by fatigued and unhealthy caregivers. The findings were published in Journal of the American Geriatrics Society. Researchers examined Medicare payments and emergency department visits in the case of couples over 65 years old where one spouse acted as a caregiver for the other. The study discusses burnout and stress for daily care providers, noting, “Medicare does not offer payment or formal respite coverage for family or friends who take regular care of older adults, and only covers home care by certified agencies under certain circumstances.” (News Medical)

* Condolences are an important part of a physician’s care routine, says Dr. Yul Ejnes. He advocates for the practice on the grounds that it helps doctors realize what they’ve done for the patient or family, and to experience closure. “Whether it's writing letters, making phone calls, or expressing it in person, show your patients’ survivors that you care. Show yourself that you care.” (Medpage Today)

* A study finds that caregivers provide two-and-a-half times the weekly hours “to dying individuals than to those not at the end of life.” The study, conducted by Dr. Katherine Ornstein, draws from two national surveys about caregiving to help quantify what was already suspected about the strain of caregiving at the end of life. “We need to think about expanding access to palliative care services,” she says, and “provide more paid family leave so families can provide the support we're pretty much expecting them to provide.” (U.S. News)

* Experts worry that Express Scripts, a new program by pharmacy-benefits manager (PBM), might mean well, but limits individual physician judgment about patient needs. The program limits new opioid patients to a seven-day supply, regardless of injury or chronic illness. Steve Miller, M.D., Express Script’s chief medical officer, points to 33,000 opioid deaths in 2015 as an indication that “the approach that's been taken is not working.” Express Scripts says the CDC’s 2016 opioid prescription guidelines proved a “strong foundation” for its work, and they will unveil an Advanced Opioid Management program on Sept. 1. It is unclear how many members the new program will impact. (Medscape)

* The Patient-Centered Outcomes Research Institute (PCORI) will invest $10 million in two studies comparing strategies to reduce unsafe opioid prescribing habits, including electronic health records. “These studies are the latest in a growing portfolio of PCORI-funded research, which represents $150 million in funding for 50 comparative clinical effectiveness research (CER) projects related to pain treatment, as well as opioid overuse and misuse.” (Healthcare Informatics)

* President Trump announced plans to declare a “national emergency” regarding the opioid crisis. Opioid overdose deaths increased 156 percent between 2010 and 2015, and 180,000 more are predicted by 2020. The president’s Commission on Combating Drug Addiction and the Opioid Crisis proposes reform that leads to “better Medicaid coverage for substance use treatment; expanded funding for integrated medication-assisted treatments; medical training in appropriate pain management; and waivers of health information privacy regulations that impede access to complete data on fraudulent prescription practices and those who misuse opioids.” The JAMA article describes concerns, including increased incarceration or patient rights to drugs, but ultimately argues for a “well-targeted” approach. (JAMA)


In recent years, the public has become increasingly aware of the problems associated with opioid abuse. Melissa Bailey is a writer for Kaiser Health News and author of “Dying at Home in an Opioid Crisis: Hospices Grapple with Stolen Meds.” The article describes a pattern of misfortune and abuse across the country, and has garnered significant media coverage. Read More


The ability of hospice to adapt to the individual needs of terminally ill patients has cemented its value. Yet it’s that same degree of variation and variety of services that make the services hard to provide and regulate. An article in Health Affairs discusses the challenges and opportunities that come with this provision of services, and explore possibilities for accountable care organizations’ (ACO) action in providing end-of-life care. Read More


Hospices across the country have taken criticism from media accounts of live discharges. By hospice’s nature, patients enter with the expectation—certified by two physicians—they will die within six months. When they are discharged and told services can no longer be provided, some patients feel angry, overlooked or unduly burdened. In his article “Hospice Live Discharges: Some Perspective,” published in the The National Law Review, attorney Brian M. Daucher aims to provide context for the complexities surrounding live discharges. Read More


In June 2017, the National Coalition for Hospice and Palliative Care held an invitation-only summit that gathered national stakeholder organizations to define “essential elements quality primary and specialty palliative care services.” The organization produced a summary of the event, and shared plans for 2018. The event, supported by a two-year grant from the Gordon and Betty Moore Foundation, leads now to work on the fourth edition of guidelines, slated for release in July 2018. The National Consensus Project last issued those guidelines in 2013. The new summary report of that summit gives insights into the perspectives offered by provider organizations, individual professionals, caregivers, and various health care organizations. Read More


The National Hospice and Palliative Care Organization’s regulatory committee has submitted legislative recommendations to the U.S. House of Representatives Ways and Means Committee. Support and passage of these bills, says the committee, would provide regulatory relief to hospice providers. Read More

Thanks to Don Pendley, Jeannette Koijane and Brenda Clarkson for contributions.

Hospice Analytics is the national sponsor of Hospice News Network for 2017. Hospice Analytics is an information-sharing research organization whose mission is to improve hospice utilization and access to quality end-of- life care. For additional information, please call Dr. Cordt Kassner, CEO, at 719-209- 1237 or see

Hospice News Network is published 45-47 times a year.  Copyright, 2017.  All rights reserved to HNN subscribers, who may distribute HNN, in whole or part, to provider members of the subscribers’ state organizations.  If readers need further information, they should consult the original source or call their state association office.  HNN exists to provide summaries of local, state and national news coverage of issues that are of interest to hospice leaders.  HNN disclaims all liability for validity of the information.  The information in HNN is compiled from numerous sources and people who access information from HNN should also research original sources.  The information in HNN is not exhaustive and HNN makes no warranty as to the reliability, accuracy, timeliness, usefulness or completeness of the information.  HNN does not and cannot research the communications and materials shared and is not responsible for the content.  If any reader feels that the original source is not accurate, HNN welcomes letters to the editor that may be shared with HNN readers. The views and opinions expressed by HNN articles and notes are not intended to and do not necessarily reflect views and opinions of HNN, the editor, or contributors.  Only subscribing state hospice organizations have rights to distribute HNN and all subscribers understand and agree to the terms stated here.