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Hospice Regulation Update Introduction

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					     The Role Of The Hospice
    Medical Director In an Era of
    Changing Hospice Regulation

                   Daniel Maison, MD FAAHPM
                   Palliative Medicine Specialist
                    Spectrum Health System

October 15, 2010          Oregon Hospice Association PPE
Faculty Information
Daniel Maison, MD FAAHPM

Palliative Care Physician
Spectrum Health System
Palliative Care/MC 120
145 Michigan Street NE, Suite #5120
Grand Rapids, MI 49503
dlmaison@yahoo.com
Objectives
    After attending this presentation, participants will
    be able to list 3 Medicare requirements for
    hospice physicians

    After attending this presentation, participants will
    be able to discuss 3 new challenges posed by
    these regulations

    After attending this presentation, participants will
    be able to discuss 3 strategies for overcoming
    these challenges
October 15, 2010    Oregon Hospice Association PPE
Introduction

• The Medicare regulatory landscape
  continues to evolve
• Many new rules
• Many of these new rules directly apply to
  hospice physicians



October 15, 2010
                   Oregon Hospice Association PPE
How can we know what to
do?
• We will spend time today exploring the
  new regulatory demands in detail
• No easy task keeping up with what is
  required
• If we don’t understand what is required,
  how can we prepare for the intense level
  of scrutiny that is taking place?

October 15, 2010   Oregon Hospice Association PPE
Some History

• The new Conditions of Participation
  (CoPs) are the first major changes since
  1983
• Hospice as a whole has changed
  tremendously (growth/patients served)
• The government is now looking at hospice
  in a different way

October 15, 2010   Oregon Hospice Association PPE
Changes in Hospice

• Hospice has grown tremendously
• Approximately a 500% increase in
  spending on hospice over the past few
  years
• Expected to continue growing rapidly
  (doubling again in the next 10 years)


October 15, 2010   Oregon Hospice Association PPE
The curse of hospice success

• We are now on the RADAR of the federal
  government
• Scrutiny has increased and will continue to
  do so
• RAC’s and other auditing tools are part of
  this new level of interest


October 15, 2010   Oregon Hospice Association PPE
What is driving hospice
growth?
•   Population changing (population aging)
•   More acceptance of hospice
•   More referrals, received earlier
•   Kinds of patients we serve
     – 40% in 2006 had non-cancer diagnoses
       versus a time when nearly all hospice patients
       had cancer


October 15, 2010   Oregon Hospice Association PPE
Growth Reasons (cont.)

• More hospices over all
• Increasing length of stay (CAP limits)
     – ALOS went from 62 to 82 days from 2000 to
       2006
• Physician billing piece
     – Big increase over the past 10 years
     – Focus of greatly increased scrutiny

October 15, 2010   Oregon Hospice Association PPE
How has Medicare reacted to
this growth?
•   Increased oversight (CMS, OIG)
•   Increasingly asking questions (MedPAC)
•   The RAC’s
•   Changing the rules of the game (the new
    CoPs)




October 15, 2010   Oregon Hospice Association PPE
So, what is MedPAC?

• Medicare Payment Advisory Commission
  (MedPAC)
• Independent government body set up in
  1997 by the Balanced Budget Act
• Advises Congress of how Medicare is run
• Hospice is on their RADAR of late

October 15, 2010   Oregon Hospice Association PPE
Some things MedPAC
recently recommended
• Changing the way we are paid to provide
  hospice services
• Increasing physician oversight (before 180
  days and every 60 days)
• Have a look at Hospice in SNF’s and the
  relationships between these two entities
• More data collection requirements
                   Oregon Hospice Association PPE
October 15, 2010
The New CoPs
• Went into effect December, 2008
• First major change to hospice rules since the
    MHB began in 1983
•   Goals are to make sure hospice care is “patient
    centered”, get more data (QAPI, outcomes
    driven)
•   Ensuring the attending physician is part of the
    picture
•   Continuity of care is ensured
October 15, 2010   Oregon Hospice Association PPE
Medical Director

• There can be only one per hospice
• Have to designate one person to be the
  medical director (not several people)
• Hospices have to be able to document that
  this person has the wherewithal to care for
  hospice patients (right skills, knowledge)


                   Oregon Hospice Association PPE
October 15, 2010
What is the Medical Director
responsible for?
• Supervising all of the hospice physicians
• Be in compliance with all of the other rules
  (e.g. state laws)
• Has to step up coverage if the attending
  physician is not available
• There must be a hospice physician
  available at all times, 24/7

                   Oregon Hospice Association PPE
October 15, 2010
What are some of the other
elements of the new CoPs?
• We will go over some of the changes that
  apply to hospice in general
• We will also go into more detail about
  physician specific issues
• Remember that we are all in this together
  and that we are all responsible to help our
  organizations stay in compliance

October 15, 2010   Oregon Hospice Association PPE
What is every patient entitled
to according to Medicare?
• Pain and Symptom                 • Get info about the
    Management                         services you can
•   Be a participant in the            provide them
    the development of             •   Refuse any treatment
    their own POC
•   Choose their                   •   Their medical
    attending                          information will
•   Get information about              remain confidential
    the MHB

October 15, 2010   Oregon Hospice Association PPE
Huge Emphasis On The Initial
And Ongoing Assessment Of
The Patient
• There are specific requirements for:
     – Timeframes
     – Content
     – Who should complete it
     – How often it needs to be updated and who
       does the updating
     – Where else the assessment needs to have
       cross-talk with the rest of the organization
                   Oregon Hospice Association PPE
October 15, 2010
Initial and Comprehensive
Assessment: Who completes it?
• Everyone is in on the act
• Initial done by an RN
• Completed by the IDG (that also includes
    attending physician)




October 15, 2010   Oregon Hospice Association PPE
Other highlights to discuss in
brief
• Plan of Care specifics
• Coordination of Hospice Services
• QAPI




October 15, 2010   Oregon Hospice Association PPE
Plan of Care Specifics
Highlights
• Plan of care has to flow from initial and
  comprehensive assessments (what is
  identified is what is addressed and solved)
• Has to reflect the goals of care we are
  serving
• Has an intervention listed for every
  problem identified

October 15, 2010   Oregon Hospice Association PPE
Plan of Care Specifics
Highlights (cont.)
• Documents everything we need to be
  successful for meeting a patient’s needs
• Scope/Frequency of services we are to
  provide (how often will the patient get a
  visit from the hospice aide?)
• Medications/Treatments/Supplies
• Documented understanding of POC by
  patient and/or representative

October 15, 2010   Oregon Hospice Association PPE
Coordination of Hospice
Services
• Have to be able to demonstrate
  communication
• Have to be able to demonstrate IDT is in
  charge of a patient’s care (directing,
  coordinating, supervising)
• Plan of care is driving what we are doing

October 15, 2010   Oregon Hospice Association PPE
Coordination of Hospice
Services (cont.)
• Remember, it ALL has to flow and match up
• What is identified in the initial and
    comprehensive assessments is what is
    addressed in the plan of care
•   The patient/family goals of care are what we are
    attempting to accomplish
•   What is discussed in IDT is what is in the POC
    and that you are documenting that we are
    addressing those issues

October 15, 2010
                   Oregon Hospice Association PPE
Coordination of Hospice
Services (cont.)
• Don’t let the communication stop at the
  door
• Make sure that we are also documenting
  communication/coordination with our
  community partners
• Again, we are responsible for
  demonstrating that everything happening
  jives with our plan of care

October 15, 2010   Oregon Hospice Association PPE
QAPI

•   Big big role under the new CoPs
•   It’s all about data these days
•   Have to pick projects, track and document
•   Physicians are a big part of this process
•   Physicians nearly had an even bigger role
    in the proposed CoPs (did not come to
    pass)
                   Oregon Hospice Association PPE
October 15, 2010
QAPI (cont.)

• Projects should focus on areas of
  opportunity/challenge
• Have a significant impact on patient care
• Have to take action based on what is
  found
• Make sure that what you are doing is
  helping

October 15, 2010   Oregon Hospice Association PPE
The Physician Narrative

• New Requirement as of October 1st, 2009
• Must be done on EVERY patient on
  admission and at EVERY recertification
• Must be done by the physicians
  themselves



October 15, 2010   Oregon Hospice Association PPE
The Narrative (cont.)

• The form has to indicate where the
    physician got the information:
     – A review of the medical record
     – Direct examination of the patient
     – Combination of a review of the medical record
       and direct examination of the patient



October 15, 2010   Oregon Hospice Association PPE
The Narrative (cont.)

• The narrative must contain enough
    information on its own to make the case
    why the specific patient qualifies for
    hospice services with a prognosis of 6
    months or less if their disease runs its
    normal course



October 15, 2010   Oregon Hospice Association PPE
What else do you need on the
narrative
• The physician’s signature has to
  immediately follow the narrative statement
• If you separate the Certificate of Terminal
  Illness and the narrative on 2 different
  pages, the physician has to sign BOTH



October 15, 2010   Oregon Hospice Association PPE
What won’t pass muster

• Another hospice team member (e.g.
  nurse) completing the narrative and then
  having the physician sign off on it
• Check boxes
• Statements like:
     – “As Above”
     – “Hospice appropriate”
     – “Terminal” or “Patient Died”
October 15, 2010   Oregon Hospice Association PPE
Remember . . .

• The narrative should be able to stand on
  its own to make the case for hospice
  eligibility
• Has to make the case vis á vis the LCD’s
  to prove eligibility
• Make sure you write enough to prove your
  point

October 15, 2010   Oregon Hospice Association PPE
Surveyors are zeroing in on
narrative
• If they pull a chart and the narrative is
  either missing, incomplete, or does not
  make the case, a hospice can receive a
  technical denial
• Same as if you do not have a valid CTI or
  NOE
• Expect scrutiny to increase not decrease
October 15, 2010   Oregon Hospice Association PPE
    What we are trying to do
• We are painting a picture as to why someone
    is eligible for hospice services
•   Why are we saying that this particular patient
    has a prognosis of 6 months or less to live?
•   Burden of proof is on us to demonstrate with
    supporting evidence why someone is eligible
•   Be comfortable that you have the data you need
    to support the eligibility of every patient you
    admit should her chart be requested for review
Sample Physician Narrative
• Mrs. X has a PMH of Alzheimer’s X 10 yrs; secondary
  DX: dysphagia, and non-healing Stage IV decubitus on
  sacrum; co-morbid DX: CVA and CHF; KPS 40%; FAST
  7d; dependent in 5:6 ADL’s; and “tremendous weight
  loss” per nursing home staff. Based on the above, I
  believe that the patient has a prognosis of 6 months or
  less if her disease runs its normal course.
• Remember to document the source of your information
  (chart review/examination of the patient/both)
What you write depends on
what you are trying to prove
• Very different narrative for a patient with
  Metastatic Pancreatic Cancer versus a
  patient with Dementia
• Try to hit the key elements of the LCD for
  a patient’s hospice diagnosis
• Summarize criteria in paragraph form


October 15, 2010   Oregon Hospice Association PPE
For cardiopulmonary disease

• Utilize NYHA classification scale
• “Maximal medical management?”
• Document:
   – O2 utilization and liter flow; pulse oximetry
   – Respiratory and pulse rates at rest and after any
     exertion;
   – Blood pressure;
   – Edema levels, if any
   – Hospitalizations, ER visits
COPD

• Dyspnea at Rest
• Frequent/Increasing ER and/or
    Hospitalizations
•   Hypoxemia at rest on room air
•   Right Sided Heart Failure
•   Resting Tachycardia
•   Weight Loss
October 15, 2010   Oregon Hospice Association PPE
Dementia
• Utilize FAST scale (7A or worse)
• Utilize non-verbal pain and symptom
    assessment scales and/or caregiver reports; and
•   Weight loss
•   Serious Infections
•   Skin Breakdown
•   ADL dependence
•   KPS/PPS
How about recertification?

• Same process, but hopefully will be even
  more straightforward
• You have had this patient under your care
  for several months
• Should be able to make your case or
  decision to discharge easily if you have
  tools in place

                   Oregon Hospice Association PPE
October 15, 2010
Do not wait until the recert date

• Use every IDG as an opportunity to
  discuss eligibility
• Don’t make a decision the night before the
  benefit period is over
• No recertification decision should ever be
  a surprise


October 15, 2010   Oregon Hospice Association PPE
FI/RHHI nuance

• The LCD’s are FI/RHHI (Regional Home
  Health and Hospice Intermediary) specific
• Become intimately familiar with your local
  areas requirements
• Much in common across the country, but
  make sure you know your specific ones
  well

October 15, 2010   Oregon Hospice Association PPE
Make it easy for them to say
“Yes”
• Remember auditors are busy too
• They are reviewing many charts and have
  to wade through a lot of data
• Help them glean what they need to make
  their decision
• Make every chart reviewed a “no-brainer”

October 15, 2010   Oregon Hospice Association PPE
Example Summary

• Mr. Jones is an 82 year old gentleman
    with a history of end stage, oxygen-
    dependent COPD. He has been
    hospitalized 3 times in the last six months,
    has lost more than 10% of his body weight
    in the last 6 months, and has a bed to
    chair existence.


October 15, 2010   Oregon Hospice Association PPE
Sample Summary (cont.)

• He has evidence of right-sided heart
  failure as evidenced by JVD and
  intractable lower extremity edema. His
  heart rate is 104 at rest.
• Based on the all of the above, this patient
  clearly has a prognosis of 6 months or less
  to live if his disease runs its normal
  course.
October 15, 2010   Oregon Hospice Association PPE
“As evidenced by”

•   Again make it easy
•   Can’t just say “The patient is declining”
•   Define “decline”
•   “The patient continues to decline as
    evidenced by progressive symptoms,
    increased weakness, and continued
    weight loss.”

October 15, 2010   Oregon Hospice Association PPE
For those patients that have
been on longer than 6 months
• What is coming January 1st, 2010
• Have to have a face to face meeting with
  every patient 15 days or less prior to end
  of 2nd 90 day certification period
• NHPCO released commentary via email
  regarding rule on September 14th, 2010


October 15, 2010   Oregon Hospice Association PPE
Some tools to consider

• What forms do you use to gather data on
  the hospice patients evaluated for
  admission?
• Make it easy for the nurses to gather what
  is needed for hospice physician to make a
  decision
• A little up front work will go along way
October 15, 2010   Oregon Hospice Association PPE
As an example

• Develop worksheets that capture the key
  points of your Local Coverage
  Determinations
• This will prompt your admissions and
  clinical team members to ask the right
  questions
• They will have everything needed when
  they call you with a new patient
October 15, 2010   Oregon Hospice Association PPE
Another question to ask

• How well does EVERYONE know the
  criteria for admission?
• Do all the physicians have a clear
  understanding of the LCD’s?
• Do all of your physicians have the same
  understanding of why someone is or is not
  eligible?

October 15, 2010   Oregon Hospice Association PPE
Appropriateness should
never be a surprise
• Don’t wait until the day before
  recertification to think appropriateness
  through
• If everyone is on board with this, should be
  a constant process
• Avoids stress and allows for much better
  coordination of services

October 15, 2010
                   Oregon Hospice Association PPE
Is there a silver lining in all of
these new regulations?
• At their roots, these regulations are meant
  to help us take better care of patients
• The hospice physician’s importance has
  never been more fully recognized
• Medicare is acknowledging the very
  important role physicians play in the
  provision of hospice care

October 15, 2010   Oregon Hospice Association PPE
Silver Linings (cont.)

• We need data!
• There is a tremendous lack of data about
  the benefit of hospice services to patients,
  their family, and the system as a whole
• We can now prove what we all believe to
  be the truth


October 15, 2010
                   Oregon Hospice Association PPE
Conclusions

• The first big change in hospice regulations
  occurred December of 2008
• More big changes are coming
• As the national debate over the future of
  healthcare continues expect hospice’s role
  in reform to be extremely significant and
  increasing

October 15, 2010   Oregon Hospice Association PPE
Conclusions (cont.)
• The new CoP’s identify physicians as an
  essential component of hospice care
• The new CoP’s give all hospice
  professionals a chance to prove the worth
  of Hospice with the context healthcare as
  a whole
• Make the most of these changes and see
  them for the opportunity they are

October 15, 2010   Oregon Hospice Association PPE
                     Thank You

                   QUESTIONS?



October 15, 2010     Oregon Hospice Association PPE

				
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