Ever-Changing Hospice Basics Hospice Medical Director 101 Update on What Every Hospice Medical Director Needs to Know To Lead the Hospice Team Lucius “Luke” Lampton, MD, FAAFP

The role of the physician is a centerpiece in the Medicare Hospice Conditions of Participation. The Medical Director oversees the medical component of the hospice patient care program. The hospice contracts with one Medical Director, and other Associate Medical Directors. The Hospice Medical Director

Admissions Certifications and Recertifications (including narratives) Face-to-Face Encounters (in person and overseen of NP) Related/Unrelated Determinations Medication Review and Clinical Expertise Medically Necessary Visits/Problem Solving Discharges Quality Program Medical Director Has an Important Role

The hospice medical director, and other members of the interdisciplinary team, collaborate with the patient’s attending physician, communicating the patient’s wishes and status. The medical director/associate medical director has responsibility for the medical component of the patient’s care. But also, melding the teamwork of all care in the patient’s best interest, in that we are a physician-driven and led hospice. The Hospice Medical Director

How this works: The admission nurse obtains information from the attending, the medical record, and the patient, and then communicates it to the medical director. At that time, the medical director reviews and provides recommendation to admit and gives verbal certification of terminal illness (CTI), if eligible. In the end, hospice admission is a patient-physician decision, not facility- patient or nurse-patient decision. It also requires recommendation of both attending physician and the medical director to admit. The MD Must Approve the Hospice Admission “The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient’s attending physician (if any).”

Benefit Periods Hospice care is provided in benefit periods. Benefit periods are: 90, 90, 60, 60, 60…. – Two initial 90-day periods – All subsequent are 60-day periods Every benefit period requires a certification of terminal illness (CTI) Physician narratives by Medical Directors critical in certification and recertification process.

1st – CTI from attending and medical director 2nd – CTI from medical director only 3rd and all subsequent – Face-to-face encounter, then CTI from medical director (in that order) Benefit Period CTIs (Certification of Terminal Illness)

Verbal Certification of Terminal Illness (CTI) A verbal CTI allows the hospice to begin providing hospice services. However – the written CTI must be completed before the hospice can begin submitting billing to Medicare. Verbal CTI is required from the attending and also the Medical Director.

Verbal CTI Verbal CTI may be obtained: – Not earlier than 15 days before the start of the benefit; and – Not later than 48 hours after the first day of the benefit period. Requires communication between the nurse and the physician Certification of Terminal Illness

Written CTI Requires signature and date of the certifying physician (plus a narrative from the certifying medical director) The signature confirms the medical opinion that the patient has a life expectance of 6 months or less, if the disease follows its normal course. Certification of Terminal Illness

Written CTI: Narrative The medical director must also write a brief, but specific, narrative that describes the patient’s clinical circumstances and factors that support a life expectancy of 6 months or less. Narratives associated with the third or > benefit period recertifications must include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of 6 months or less. (Document decline, etc.) An attestation that physician personally composed the narrative is part of the CTI document and is required by CMS. Certification of Terminal Illness

Face-to-Face Encounters Prior to the 3rd benefit period – and every benefit period thereafter – a hospice physician or hospice nurse practitioner must complete and document a face-to-face encounter. CTI must include an attestation of the F2F encounter, signed and dated by the person performing the F2F. The findings of the F2F are communicated to the certifying physician. Benefit Periods

Written CTI: Signatures/Dates All dates on signatures must be the actual day the physician signed the document (no backdating) – No stamped signature or stamped dates are allowed by CMS; but – Electronically affixed signatures and electronically affixed dates are allowed. Certification of Terminal Illness

Written CTI: Signatures Practice partners cannot sign for each other (per the Medicare Integrity Manual) The physician who gave the order must be the physician who signs the order. Certification of Terminal Illness

Interdisciplinary Team Meeting (IDT) An IDT meeting/updated plan of care is required at least every days: – 14 days (most states) – 15 days (federal) The medical director is a core team member and must participate to have a valid team meeting/ updated plan of care. (More than a signature!)

Leading the IDT Meeting It is the medical director’s role to help lead and facilitate the IDT meeting. Content includes: – Discussion of ongoing eligibility evidence for each patient discussed – Review of patient plan of care/problems and progress towards goal/revising plan of care as necessary

Leading the IDT Meeting IDT members are accountable for being prepared for the meeting. Inform members what you need to lead the meeting: data, med lists, etc. Members are responsible for giving a concise and objective report about the patient to the other core disciplines. Start on time if possible and keep meeting moving, focusing on work at hand.

Medical Diagnoses and Relatedness The medical director must provide brief documentation regarding diagnoses related and unrelated to the terminal diagnosis/prognosis. For those unrelated, must explain why it is unrelated. Staff often need this expertise of the physician of how certain diagnosis interrelate (or don’t) with the terminal diagnosis.

Medications The medical director must provide brief documentation regarding medications related and unrelated to the terminal diagnosis/prognosis. Relieve the pill burden of terminal patients whenever possible, i.e. discontinue medicines unnecessary for patients with a less than 6 month expected lifespan (statins, bisphosphonates, acetylcholinesterase inhibitors) and be aware of those no longer needed (some diabetic and hypertensive meds). This often requires education of patient, family, and nurse.

Medication Review and Management The medical director has a primary responsibility (can be with the attending) to review each patient’s medications for: Make recommendations and give orders as needed to discontinue, add new, or make adjustments to patient medications. Have nurses review and recommend changes at each IDT. - Therapeutic effectiveness- Duplications - Side effects- Needed lab monitoring - Interactions

Medical Director Role in Quality The medical director’s engagement and ownership of quality is crucial to the success of each hospice program. This is a physician-driven and led hospice, and physicians must keep it that way with their leadership of the hospice team. Leadership is action!

Medical Director Role in Quality The medical director must participate at each quality meeting and take an active role in promoting quality outcomes: – Educating the team, as needed – Asking the right questions to find out what happened when an outcome is not good – Applying expertise and engagement at QAPI

Levels of Care There are 4 levels of care: 1.Routine home care 2.Respite 3.General inpatient care 4.Continuous care

The 4 Levels of Care 1.Routine Home Care: – Performed wherever the patient calls home: Personal home Assisted living facility Long-term care facility

The 4 Levels of Care 2.Respite: – Custodial care performed in a contracted facility, for not longer than 5 consecutive days. – Relieves exhausted family members are exhausted or when family is temporarily unable to continue care. – The frequency hospice can perform respite is “occasionally” and must always be accompanied by clear documentation of family circumstances requiring this level of care.

The 4 Levels of Care 3.General Inpatient (GIP) Care: – Brief inpatient care to provide skilled care that cannot be provided in the patient’s home. – Requires order from medical director for admission into and discharge out of GIP. – Must be accompanied by explicit documentation of ongoing need and interventions every day in GIP. – Dying without crisis symptoms does not qualify for GIP.

The 4 Levels of Care 4.Continuous Care (CC): – Brief periods of skilled care provided in the patient’s place of residence. – CC is in response to a physical crisis requiring this level of skilled care to maintain the patient in his or her home. – Must be accompanied by explicit documentation of ongoing crisis need and interventions, hourly. – There are specific rules about the required time that can be billed to CMS for this level of care.

Discharges Very limited number of reasons a patient can be discharged from hospice: Death RevocationPatient makes the decision to revoke the hospice services and hospice benefit (Docs can help with this, with a visit or other medical intervention) Patient out of service area This includes inpatient in non-contracted facility. (The patient may temporarily leave the service and the hospice contracts with another hospice to provide hospice services on our behalf without discharge.)

Discharges Very limited number of reasons a patient can be discharged from hospice: Condition improved The patient’s condition improves such that he or she is no longer considered eligible for hospice. For causeIncludes situations where patient safety or hospice staff safety is compromised. The patient (or other persons in the patient’s home) behavior is disruptive, abusive or uncooperative to the extent that delivery of care to the patient of the ability of the hospice to operate.

FAQs Must a patient be discharged if he or she exceeds 6 months on service? Patients may stay on hospice as long as they meet medical eligibility with a continued expectation of prognosis 6 months or less, if the disease runs its normal course. This must be accompanied by objective and reasonable data to support that prognosis. Evidence of decline usually supports continued eligibility.

FAQs Are there a limited number of diagnoses for which hospice can provide care? Hospice sees a lot of the same kinds of terminal illnesses, but there is not a limited number of diagnoses that may be causing the patient’s terminal status. Whatever the diagnosis, the documentation must support a hospice prognosis.

FAQs Does the hospice medical director always become the attending physician? No. Patients determine who will be the attending, if any. It may be a physician or an NP. In cases in which there is no attending, or when the attending does not wish to continue in the role of attending, the patient may request that the medical director become the attending. The medical director is responsible to over see the medical component of the patient’s care.

FAQs What does hospice provide? All visits, medications, supplies, and DME related to the terminal prognosis. All of those should be billed to the hospice, rather than Medicare or Medicaid. The only things that are billed outside of the hospice benefit are things that are clearly unrelated to the terminal illness/prognosis.

The hospice rules are subject to relatively frequent changes or reinterpretations by CMS, Medicaid and state licensing agencies. Compassus will keep you and your program informed of those changes. The importance of the Medical Director in each program cannot be overstated. WE APPRECIATE YOU! Conclusion