1. Medicare Hospice Benefits and More Presented by: XXXXX

2. Introductions 1

3. Objectives Overview of the TRUE project Explore triggering events for a hospice referral Explore strategies for communication with primary physician about a hospice referral Describe the Medicare hospice benefit and services 2

4. Stratis Project Team Stratis Health Staff Janelle Shearer, RN, MA, CPHQ, Program Manager Laura Grangaard, MPH, Research Analyst Subject Matter Experts Barry Baines, MD Lores Vlaminck, RN, BSN, MA, CHPN 3

5. Local Project Hospice Lead(s) Insert from Speaker Notes 4

6. Targeting Resource Use Effectively (TRUE) Goal:Optimize hospice use –Increase appropriate referrals to hospice –Increase the length of stay of hospice patients (days of care) How:By forming multidisciplinary community based teams to implement strategies to address barriers to optimal hospice use in the XXXXX community 5

8. What is the Reality? 7

9. The Medicare Hospice Benefit is Widely Underutilized The median (50 th percentile) length of stay in hospice was 18.7 days in 2012 30% of all Medicare Beneficiaries enrolled in hospice died within three days or less 35-40% of patients enrolled in hospice died in seven days or less –NHPCO 2012 Data 8

10. Triggering Events for a Hospice Referral

11. Triggering Events for Hospice Referral Recurrent infections Recurrent hospitalizations/clinic visits Repeated home care admissions Declining health Weight loss Decrease in independence in ADL’s 10

12. Triggering Events for Hospice Referral cont’d Increase in pain/interventions Unexplained weight loss Patient/family request Change in goals of care Provider referral Other 11

13. Opportunities for Conversation Expressions of spiritual/social distress affecting daily life Quality of life/patient stated goals for care/interventions in conflict Expressed desire for advance care planning or revision of current plan Lack in clarity of goals Conflict among family members and/or patient 12

16. Communicating with Physicians & Providers

17. Suggestions… Gather the facts –Assessments (Demonstrating comparison and contrasts) –Observations of client Recount expressed feelings, behavior, emotions –Patient complaints Pain, fatigue, weight loss, depression, etc 16

18. Suggestions… cont’d –History of ER visits, clinic visits, home care readmissions –Patient/family stated questions/comments (if any) –Caregiver observations –Advance Care Directives –Other 17

19. Phrasing…. Frame the conversation: –I am calling you about ______________. –During the past _________(time) I have noted the following of our mutual patient. Share your assessments/observations Patient/family quotes Concerns 18

20. Shared Decision-Making Between Physician and Patient: Physician’s Responsibility: –Inform and recommend best treatment option(s) Patient’s Responsibility: –To choose or refuse treatment option(s) 19

21. Hospice and the Hospice Medicare Benefit

22. Hospice Definition-philosophy and services Benefits Eligibility Guidelines Level of Care/Reimbursement Transfers/Revocation/Discharge 21

23. Hospice Philosophy Hospice is based on a Philosophy which embraces six significant concepts: Death is a natural part of life. When death is inevitable, hospice will neither seek to hasten or postpone it. Hospice care establishes pain and symptom control as an appropriate clinical goal. Hospice recognizes death as a spiritual and emotional as well as physical experience. 22

24. Hospice Philosophy Patients and their families are a unit of care. Bereavement care is critical to supporting family members and their friends. Hospice care is made available by most hospices regardless of the ability to pay. 23

25. Hospice Today Over 5300 hospice programs nationwide 24

26. Holistic Needs-Holistic Care Physical Spiritual Emotional Psychological 25

27. Hospice Team Members Medical Director/Attending Physician Nurses (RN on-call 24/7) Social Worker Chaplain/Counselor Volunteers (Active and Bereavement) Hospice Aide Therapies (PT/OT/ST) Registered Dietician Pharmacist –Pet Therapy –Massage/Music –Other 26

28. Who Qualifies for Hospice Care? Terminally ill persons whose life expectancy is six months or less given the current progression of their disease process (any age-any diagnosis) –Minnesota Medical Assistance ≤ 12 months Patient is seeking palliative care rather than curative treatment 27

29. Local Coverage Determination Guidelines for Hospice CMS Provides guidelines for hospice admission –Alzheimer's and related dementia –Cardiac disease –Lung disease –Liver disease –Acute and chronic renal disease –Stroke and coma –AIDs –ALS –Cancer –General decline in status 28

30. Primary Hospice Diagnosis 2012 Cancer 36.9% Non-Cancer Diagnoses 63.1% –Debility Unspecified 14.2% –Dementia 12.8% –Heart Disease 11.2% –Lung Disease 8.2% –Other 5.2% –Stroke or Coma 4.3% –Kidney Disease (ESRD) 2.7% –Liver Disease 2.1% –Non-ALS Motor Neuron 1.6% –(ALS) 0.4% –HIV / AIDS 0.2% NHPCO published 2013 29

31. Levels of Care In-home Respite Continuous Care General Inpatient 30

32. Medical Supplies Per diem includes all supplies to terminal illness and related conditions Wheelchair Walker Oxygen Wound care Incontinent products Dressings Ostomy supplies Other 31

33. Medications Per diem includes all medications related to the “terminal and related conditions Hospice may charge $5.00 co- pay for medications 32

34. Palliative Care Treatment Measures This may include:  Chemotherapy  Radiation  Blood products  Enteral feedings  IV fluids  Dialysis  Surgery  Other “Palliative” care measures as approved by the IDG team related to the alleviation of pain and suffering 33

35. Transportation Emergency transportation by ambulance is covered by hospice if approved by Hospice Team and deemed the mode of transportation needed for transfer Non-emergency transport not mandatory- individual agency decision 34

36. Who Pays for Hospice Care? Medicare Medical Assistance Most Insurance Plans Private Pay Long Term Care Insurance 35

37. Revocation Patient and/or family initiated Requests revocation of the hospice No penalty to patient to re-enroll Patient signs statement of revocation on effective date 36

38. Discharge Hospice provider may initiate if: –Patient moves out of service area –Patient is no longer deemed terminally ill –Chooses facility in which hospice does not have a contract –Behavior is disruptive, abusive, or is uncooperative 37

39. The Reality Again – Expressed by Patient and Family “I wish I had enrolled in hospice sooner” “I didn’t realize all the support hospice offered” “Why didn’t my doctor tell me about hospice?” “Why didn’t I know about hospice?” 38

40. Average Length of Stay in Hospice in Days 2012 - 35.5% died/discharged in ≤ 7 days 2012 - 71.8 average length of stay 2012 - 18.7 median length of stay NHPCO Data 2013 39

41. Questions 40

42. Contact Information XXXXXXX XXXXXX www.stratishealth.org 41

43. Stratis Health is a nonprofit organization based in Minnesota that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities. This templatewas prepared by Stratis Health, the Quality Improvement Organization for Minnesota, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-MN-SIP TRUE HOSPICE-14-68 050214