Authors’ call for spiritual care coverage springs from personal experience

By LISA EISENHAUER

Dennis Heaphy finds it egregious that, even with evidence linking spiritual wellness to overall well-being, there is very limited support for designating spiritual care as a health care service.

“We know that spiritual wellness is key to self-perception of one’s health outcomes and yet we don’t address it in the health care system,” says Heaphy, a health justice advocate and researcher at the Disability Policy Consortium, a Massachusetts-based disability rights advocacy organization.

Heaphy is the co-author with Sasha Shenk of an opinion piece published online Jan. 31 by Health Affairs that urges an expansion of the Centers for Medicare and Medicaid Services’ direct reimbursement for spiritual care provided to patients insured in capitated managed care plans for people eligible for Medicare and Medicaid. Shenk is a senior research technician at the Jonathan Garlick Lab and Center for Integrated Tissue Engineering at Tufts University.

The article is part of the Health Affairs Forefront series intended to “inform policies on the state and federal levels to advance integrated care for those dually eligible for Medicare and Medicaid.”

In their piece, Heaphy and Shenk maintain that CMS could require providers in Fully Integrated Dual Eligible Special Needs Plans, known as FIDE SNPs, and Programs of All-Inclusive Care for the Elderly “to provide enrollees with spiritual assessments and spiritual care as optional services.”

Even though adding spiritual care to the blanket of services the programs provide wouldn’t necessarily increase the amount of public funding they get, the authors say such a step by CMS would confirm the value of spiritual care and, through the related codes, create valuable data for research purposes.

Personal, professional insight

Heaphy is a person with a disability and is enrolled in the Massachusetts One Care plan. The integrated care program for people ages 21-64 with disabilities will be transitioning into a FIDE SNP. He is a member of the Medicaid and CHIP Payment and Access Commission. As chairman of the Massachusetts Implementation Council set up to ensure that One Care met enrollees’ needs, Heaphy testified last year before the U.S. Senate Special Committee on Aging about the value of integrated care.

While the authors extoll the benefits of spiritual care as a component of primary care, in a recent interview, Heaphy says he first saw the value of spiritual care during a hospital stay. The chaplains who came to his bedside, he says, addressed a need for understanding and meaning that would have otherwise gone unmet.

“When I sustained a spinal cord injury in 1985, chaplains were vital to my journey toward wholeness,” Heaphy says. He later became a chaplain certified through the Association of Professional Chaplains and worked in spiritual care in a number of settings. Heaphy, who is Catholic, has a master of divinity and a doctorate of ministry in transformational leadership from Boston University and master’s degrees in public health and education.

Shenk says her appreciation for the importance of spiritual care stems in part from her work in a research lab focused on scleroderma, a group of rare autoimmune diseases that can cause hardening of skin and connective tissue. Systemic scleroderma can cause problems in the blood vessels, internal organs and digestive tract. Because there is so far limited treatment for the disease, Shenk says she has seen scleroderma patients struggling to cope and relying on support groups for hope.

“It goes to show that people are creating this in their own way, because it’s not offered as a service, to even just connect with other human beings to really talk about what they’re going through,” she says.

Justice and racial dimensions

In their commentary, Heaphy and Shenk call out access to spiritual care as a health justice issue. They maintain that the care is especially important to people with disabilities, who experience disproportionate levels of isolation and loneliness compared to the general population and make up an estimated one-third of the dual eligible population.

Heaphy says faith traditions have too often linked lack of faith and sin with dis- ability and notes there are examples of this in Judeo-Christian Scripture. He says faith communities can also convey this message in their preaching or in how they engage with persons with disabilities. Spiritual care from trained chaplains, he says, may provide an opportunity to bring healing to those who have had negative experiences with organized religion or have internalized a feeling of sinfulness.

The authors also assert that spiritual care can be of particular importance to African Americans and other minority populations.

Heaphy, who is white, explains that the literature on spiritual care shows that for many African Americans, their spiritual, religious or faith community can serve as a source of resiliency in the midst of systemic racism. He describes how systemic racism is evident in the level of health disparities and inequities experienced by African Americans and how integration of spiritual care may be a means of countering inequities.

Heaphy says insurance coverage of spiritual care is a touchy subject for many reasons, starting with the health care system’s discomfort with spirituality and all things that cannot be empirically measured. There are also concerns and confusion among some about spiritual care being government support for religion, he says. Another issue is whether adding another benefit would drive medical costs even higher.

“Health care advocates have an obligation to challenge the current barriers to spiritual care to ensure people have access to person-centered care that values people as mind, body and spirit,” Heaphy says. “It is imperative that this need be met among persons with disabilities who already face systems that deny their personhood.” leisenhauer@chausa.org include participants, their families and members of their care teams.

Life-enhancing support

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

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

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

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

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

Search for meaning

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

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

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

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

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

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

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

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

Affirming an ongoing effort

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

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

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

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

“I think that it’s a great opportunity to affirm what we are already doing,” he says.

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

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