MEDICAL DIRECTOR

RESPONSIBILITIESTerri Hanlon M.D.

Medical Director

Creekside Hospice

Responsibilities of the

Medical Director

Patient Care

Development of treatment guidelines, protocols and standards

Hospice appropriateness, eligibility and recertification (intensive review of extended length of stay patients)

Oversight of Face to Face Encounters

Participate in interdisciplinary team care planning conferences

Assist in education and training of hospice staff

Develop medical education and palliative care research programs

Participate in clinical rotations and education of medical students and residents

Responsibilies (cont.)

Consultation with attending physician

Liaison with attending physician

Community professional education and liaison activities

Palliative Care Program

Quality assurance

Assume administrative and management roles within hospice

Supervise hospice team physicians

Pharmacy utilization management

Strategic and business planning

Survey and regulatory compliance

Budget issues

Physician Added Value

Leadership

Clinical Expertise

Quality

Compliance

Outreach

Research

Physician’s Role in Hospice“End of life care has changed marked in the past 25 yrs

and it is time to update our regulations to reflect advances in medicine and hospice industry practices as well as patient rights.” said Kerry Weems, acting CMS administrator.

“They (CMS) clearly intend for hospice physicians to be much more involved in the care of patients,” Porter S. Storey, MD, said. “In the past it was possible for a small hospice to just employ a doctor to come by once a week and sign papers. Those days are really over.”

“Most physicians will welcome this opportunity to become more involved in improving outcomes,” Dr. Storey said.

amednews.com 2008

HOSPICE ELIGIBILITY AND

RECERTIFICATIONTERRI HANLON M.D.

MEDICAL DIRECTOR

CREEKSIDE HOSPICE

Objectives

Identify eligible patients early

Knowledge of LCDs

Initial Certification Documentation

Prognosis prediction

Readiness for Recertification

Prognostic Accuracy

Initial certification based on physician or medical

director’s best clinical judgment regarding the usual

predicted course of the disease

“Individuals who present in the same way generally die

in 6 months.”

Several studies have indicated about an 85% accuracy in

physician’s 6 month prognosis

Eligibility Perspectives

Medicare Language: “ 6 months prognosis or less”

Medicare Reimbursement: “about 5 months”

Physicians: “Are they going to die tonight”

Hospice Nurse: “Do they NEED us?”

Marketer: “I am pretty sure I heard them cough”

Eligibility Myths

Eligibility vs. Compassion

Eligibility vs. Care needed or provided

Physician referral vs. other

Cancer = Eligibility

Local Coverage Determinations

LCD’s

1995, LMRP devised by NHO as “general guidelines”

LCD’s might not be up to date

Different states may have different fiscal

intermediaries, so LCD’s may not be uniform

Limited Prognosis is the only real eligibility criterion.

Some patients may not meet the criteria but still be

appropriate

Patient Must Meet 1 of 4 Criteria

(to guarantee Medicare payment)

Meets all LCD criteria

Meets most of LCD criteria and has a documented rapid

clinical decline

Meets most of LCD criteria and has significant

comorbities

A documented provider’s clinical assessment of limited

prognosis

General Guidelines for all

Diagnosis (Nondisease Specific)

• Clinical progression of disease

• Performance, functional status

• Nutritional status

• Severity of comorbitidites

Documenting Clinical Decline

OBTAIN AND REVIEW OLD RECORDS

Get names of all of patients physicians and hospitals

Serial physical findings and diagnostic studies

Multiple recent hospitalizations, ED visits or office visits

Changes in the MDS for nursing facilities

Deterioration while receiving home health services

Failure at rehabilitation

DISEASE PROGRESSION

Clinical Status

Symptoms

Signs

Laboratory

Clinical Status

Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract

Progressive inanition as documented by:

Weight loss and decreasing anthropomorphic measurements not due to *reversible causes such as depression or diuretics

Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreased portions eaten

Progressive stages 3-4 pressure ulcers in spite of optimal treatment

Symptoms

Dyspnea, tachypnea

Cough, intractable

Nausea/vomiting poorly responsive to treatment

Diarrhea, intractable

Pain, persistant, requiring increasing doses of

medication

Signs

Systolic BP <90 or progressive postural hypotension

Ascites

Venous, arterial or lymphatic obstruction

Edema

Pleural/pericardial effusion

Weakness

Changes in level of consciousness

Laboratory

Incr. pCO2, decr. pO2, or decr SaO2

Incr. calcium, BUN/Cr or LFTs

Increasing tumor markers (CEA, PSA)

Abnormal electrolytes, Na+ or K+

Nutrition

10% weight loss in the elderly over ~6mo

BMI <22kg/m2 (BMI=703x (wt in lbs)/(ht in inches)2

Anthropomorphic measures

Arm, thigh and abdominal girth

Low serum albumin <2.5

Declines enteral or parenteral nutritional support

Function

Serial evaluations of ADL’s: bathing, dressing, feeding,

transfers, toileting, ambulation

IADL’s

ADL deficits are the most important predictor of 6 mo.

Mortality (at least 3/6)

KPS 50%, PPS 40%

Active symptoms

Comorbidities

Documenting other significant existing diseases

Document the severity and progression of these diseases

Supporting evidence for 6 mo prognosis:

Additional organ systems involved

Diseases that affect prognosis

Severity more important than the amount of comorbidities

Comorbid Conditions

COPD

CHF

CAD

DM

Neurologic disease

(CVA, ALS, MS,

Parkinson’s)

Dementia

Sepsis

Liver disease

AIDS

Debility

Declining Functional Status

Declining Nutritional Status, BMI <22kg/m2

Multiple hospitalizations over last several months

Comorbitidies

Desire for comfort care only

Cancer (simplified)

KPS/PPS may be initially >50%

Aggressive, recurrant or metastatic

Unresponsive to or not a candidate for disease remitting

therapy

Patient declines further therapy

Certain cancers have poor prognosis

SCLCA, brain CA, pancreatic cancer, malignant melanoma,

stage IV hepatobiliary and gallbladder CA, stage IV renal CA

Cancer

Cancers with higher probability of cure

Testicular, ALL, Hodgkin’s

Cancers that may have more favorable extended

prognosis with palliative treatment even after

metastasis

Prostate, breast, MDS, CML, CLL, multiple

myeloma

Non-Cancer Disease Specific

Criteria

ALS

Cardiac Disease

CAD, CHF, Cardiomyopathy

Pulmonary Disease

COPD, Emphysema,

Intersitial lung disease

Liver Disease

Renal Disease

HIV/AIDs

Dementia

Multi-infarct, Lewy Body,

NPH

Stroke/Coma

Parkinson’s Disease

Pulmonary Disease

1. **Severe chronic lung disease

Disabling dyspnea at rest (unresponsive to bronchodilators)

FEV1 < 30% predicted

Recurrent respiratory infections and or RF

Serial decrease of FEV1>40ml/yr

2. **Hypoxemia at rest on room air, pO2 <55mmHg, pCO2 >50% or O2sat<88%. Patient on chronic O2

3. RHF secondary to Cor pulmonale

4. Unintentional progressive wt loss >10% in last 6 mo

5. Resting tachycardia > 100/min

Pulmonary Disease-Assessment

H/o VDRF

pO2/pCO2, 50/50

SaO2 <88% on room air

Elderly

<90% ideal body wt

Continuous O2

Bed-chair existence

Cough and sputum

Hypotension, BP 100/80

Resting tachycardia >100

Tachypnea

Chest wall abnormalities

Use of accessory respiratory muscles

Cyanosis, clubbing

Edema

Wheezing, decr. BrS

Heart Disease

1. Patient has had maximal medical management or is not a surgical candidate

2. NYHA IV, significant symptoms at rest---CHF or angina

1. EF <20% or diasytolic disfunction

2. Inability to carry on any physical activity without pain/SOB

3. Supportive factors

1. Resistant symptomatic SVTs or ventricular arrythmias

2. H/o cardiac arrest or resuscitation

3. H/o unexplained syncope

4. Brain embolism of cardiac origin

5. HIV disease

Cardiac Assessment

NYHA IV

H/o cardiac arrest

AICD/pacer

H/o syncope

Optimal management with vasodilators or diuretics

Orthopnea and PND

Cachexia, fatique

Continuous oxygen

Hypotension

Tachycardia

“Gallop” S1/S2 + S3, S4

Crackles

Edema

Cyanosis

JVD

Diaphoresis

Renal disease: ARF

Table 1

*Refusal or withdrawal of dialysis

CrCl <10ml/min (<15ml/min for DM),

CrCl <15ml/min (<20ml/min for DM) with CHF

or Serum CrCl >8 (>6 for DM)

Mechanical ventillation

Malignancy

Chronic lung disease, advanced cardiac disease or liver disease

Sepsis

Immunosuppression/AIDs

Albumin <3.5

Cachexia

Plt <25,000

DIC or GIB

Renal Disease: CRF

Table 1 applies

Signs of RF

Oliguria <400ml/hr

Hyperkalemia >7,

refractory

Uremic pericarditis

Hepatorenal syndrome

Intractable fluid overload

Cachexia

Age > 75

Symptoms of Uremia

Confusion, obtundation

Intractable N/V

Pruritis

Edema

Liver Disease

1. Abnormal labs

1. PT>5 sec over control, INR>1.5

2. Serum albumin <2.5

2. Evidence of ESLD

1. Refractory ascites

2. SBP

3. HRS, oliguria <400ml/day and urine Na+ <10mEq/l

4. Hepatic encephalopathy

5. Recurrent varicealbleeding

Supporting factors

Malnutrition

Muscles wasting, weakness

Alcoholism >80gm EtOH/day

Hepatocellular CA

HBsAg

Hepatitis C refractory to interferon tx

Assessment of ESLD

Symptoms

Chg LOC

Sleep disturbance

Depression

Emotional lability

Somnlence

Obtundation

Slurred speech

Oliguria, anuria

Signs

Asterixis

Palmar erythema

Hepatomegaly

Distended abdomen, fluid

wave

Edema

Spider hemangioma

Jaundice, scleral icterus

Stupor

coma

Neurologic Disease

Dementias

CVA/Coma

ALS/ motor neuron disease

Dementia

FAST scale > 7

Unable to ambulate without assistance

Unable to dress without assistance

Unable to bathe without assistance

Urinary and fecal incontinence

No consistently meaningful verbal communication: stereotypical phrases or <6 intelligible words

Patients should have had one of the following in the past 12 mo

Aspiration pneumonia

Pyelonephritis

Septicemia

Decubitus ulcers, multiple stg3-4

Fever, recurrent after antibx

10% wt loss over 6 mo

Albumin <2.5

Acute Stroke and Coma

Has at least one of the following for 3 days:

Coma

PVS

Obtundation/myoclonus

Postanoxic stroke

High risk mortality after 3 days

Abnorm brainstem response

Absent verbal response

Absent withdrawal to pain

Cr >1.5

Supporting factors:

Aspiration pneumonia

Pyelonephritis

Sepsis

Refractory stage 3-4 decubitus ulcers

Recurrant fever after antibiotics

Poststroke or Multiinfarct Dementia

Fast >7

One of supporting conditions (last slide) in 3-6 months

Altered nutritional status

Dysphagia

Refusal to eat

Impaired nutritional status despite artificial nutrition

Poor porgnostic Factors:

Nontraumatic hemorrhagic stroke

Lg volume on CT

Ventricular extension

>30% cerebrum

Midline shift>1.5cm

Obstructive hydrocephalus

Thrombo/embolic stroke

Large ant. Infarcts

Large bihemispheric infarcts

Basilar artery occlusion

Bilateral vertebral art. occlusion

ALS and other Motor Neuron Disease

Rapid Neurological Progression over 12 mo

Loss of ambulation, speech, chewing

Progressive dependence

Critically Impaired Ventilatory Capacity

VC < 30%

Dyspnea at rest

Refusal of ventillatory support

Critical Nutritional Impairment

Dysphagia or refusal to eat

**artificial nutrition or ventillation will significantly alter prognosis

ALS and Motor Neuron Disease

Examination by a neurologist within 3 months to confirm

diagnosis

Supporting factors

Aspiration pneumonia

Pyelonephritis

Septicemia

Decubitus ulcers, multiple, stages III or IV

Recurrant fever after antibx

HIV Disease CD4 < 25 cell/ mcl (w/o acute illness)

HIV RNA viral load >100,000 persistant or

HIV RNA viral load <100,000 plus:

Refusal of antivirals or prophlactic meds

Declining functional status, KPS < 50

CNS lymphoma

PML

Cryptosporidiosis or toxoplasmosis

AIDs wasting or AIDs dementia

MAC bacteremia

Visceral Kaposi’s sarcoma

Renal failure

HIV disease

Supporting Factors:

Chronic persistant diarrhea > 1yr

Alb <2.5

Substance abuse

Age >50

Symptomatic CHF at rest

Advanced liver disease

Age > 50yrs

Common Errors

Conclusions without objective evidence

Disease without documented symptoms

Conflicting documentation

Failure to tract S/S over time 6-12 mo

Not providing descriptive narratives

Burden of Illness

Age at disease onset, years of illness

Advanced age

Degree of frailty

Location/environment

CG ability

Access to healthcare providers

Secondary conditions and comorbid conditions

Documentation

Full head to toe assessments

Focused assessments on affected body systems

Vital signs, O2 sats q visit

Pain/symptom, PainAD scale q visit

ADL status q visit

Infections and treatment changes q visit

Weights, BMI, MAC or MTC q wk or mo.

Supporting Documentation

Description of patients general appearance

Skin changes: wounds, bruising, circulatory chgs, etc

Fatigue levels: DME, hours spent sleeping/napping, ADL

Cognition: behavior, examples of speech/communication

Changes in level of care needed

Psychospiritual needs

Greater involvement by IDT

Changes in diet

Medication changes

Scales for Documentation

Function: KPS, PPS, ECOG, ADLs, IADLs, Morse Fall scale

Nutrition: ht, wt, BMI, meal %, cal estimates

Mental Status: Ramsay sedation scale, FAST, MMSE

Cardiac: NYHA, BNP, ECHO

Respiratory: Functional dyspnea scale

Skin: skin turgor, edema, capillary refill, braden scale, pressure ulcer stages

Symptoms: pain scale, PAINAD scale, response to tx

BE PREPARED

Tape measure

Scale

Pulse oximiter

Review old records

Compare previous data and documentation

Think recertification criteria at every visit

Documentation flow chart

Paint a verbal picture

Certification

Written or oral certification of terminal illness within 2

days after the beginning of the election period

Must be signed by the hospice physician and the

patient’s attending physician

Written certification must be obtained before the claim

is sent for payment

If the patient is admitted in the 3rd benefit period or

beyond there must be a F2F encounter

The “Question”

(for certification)

“Would you be surprised if the patient

passed away in 6 months?”

Recertification

Documentation that the patient continues to meet criteria

Decline from admission is helpful but not required unless it is

part of initial certification

“Would you sign the patient on today?”

For 3rd certification and beyond, patients now require face to

face provider visit

Determined by the hospice medical director with input from

the IDG

Medicare benefit periods; 90, 90 and then 60 thereafter

Ineligibility

Decision of IDG, attending and medical director

Patient must be discharged when ineligibility is

determined, not end of cert period

Improvement---sustained, nonmalignant diseases wax

and wane

Remember, patients may get better

Admit often occurs after an acute event

Hospice care may improve symptoms

Case example #1 Mr. Jones is a 72 y/o male with multiple medical

problems including chronic renal disease due to

diabetes. His GFR ranges from 18-22%. He has had a

fistula put in one year ago but is “holding off on dialysis

until his GFR hits 16% as the “bottom limit” to have to

do dialysis. He was referred to hospice by his HMO care

case manager who states that they have seen a decline

in his condition over the last year. He has had two

recent hospitalizations. They were both for CHF with

severe scrotal edema and dyspnea. He is also a chronic

alcoholic, drinking a tall glass of scotch and vermooth

every night. On arrival to the ipu he had been without

alcohol for nearly two days and appeared completely

lucid and conversant. However when he began drinking

Case study (cont)

His usual nightly alcohol he became more confused and

agitated with repeated falls. His scrotal edema was

slow to resolve. The patient lives at home alone.

What other information would you like to find out?

His he hospice appropriate?

What would his hospice diagnosis be?

Can he still have dialysis?

Case example #2 Yvonne is a 52 y/o female with a mild mental disability

due to cerebral palsy. She had multiple hospitalizations

over the past 6-12 months for altered mental status and

seizures. She was on multidrug therapy for what

appeared to be atypical chronic seizures. With these

episodes she also had recurrent episodes of aspiration

and pneumonia. Before the most recent hospitalization

she was able to get around by a wheel chair and was

taking care of her elderly mother. She failed a swallow

study and did appear to have difficulty swallowing. She

was also very depressed because her mother was unable

to take care of her at home. She became mostly

bedbound after the last hospitalization, dependent on

5/6 ADL’s with KPS 30%.

Case Study (cont.)

Is this patient hospice eligible?

What further information do you want?