Hospice Update. Annette T. Carron, D.O., CMD, FAAHPM, FACOI Director Geriatrics and Palliative Care Botsford Hospital Farmington Hills, MI

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1 Hospice Update Annette T. Carron, D.O., CMD, FAAHPM, FACOI Director Geriatrics and Palliative Care Botsford Hospital Farmington Hills, MI

2 Sudden death, unexpected cause < 10%, MI, accident, etc Health Status Death Time

3 Steady decline, short terminal phase

4 Slow decline, periodic crises, sudden death

5 Multivariable Models for Very Sick Patients Cannot Predict Time of Death Precisely 1.0 Median 2 Month Survival Estimate Lung Cancer Congestive Heart Failure Median of Predictions estimated from Data on Days before Death

6 Definition Prognosis: The foretelling of the probable course of a disease; a forecast of the outcome of the disease.

7 Why Talk About Prognosis? Recognize we are not good at it AMA Recs: Would I be surprised if my patient died in the next year? if no, re-assess current state and immediate future. Clinical Predictors Second Opinion Can get prediction based on patient data/information alone.

8 NHPCO Guidelines for Determining Prognosis: Non-Cancer Diagnoses General Guidelines Progression of primary disease Multiple ED visits or inpatient hospitalizations over prior six months Recent decline in functional status (PPS) Recent impaired nutritional status Unintentional, progressive weight loss of > than 10% over the prior six months Serum albumin <2.5 gm/dl.

9 Hospice in the US A place An organization or program An approach to or philosophy of care A system of reimbursement 1967, Dame Cicely Saunders opened St. Christopher Hospice in London, medical model for treatment of whole patient

10 Hospice in the US Hospice started in US in late 1970 s Initially volunteer until Medicare Hospice benefit 1983 Percentage of total US deaths in hospice 11% in % in % in 2006 Initially cancer diagnosis, 53% non-cancer in 2005

11 Curative / remissive therapy Presentation Death Palliative care Hospice

12 Hospice vs. Palliative Care HOSPICE 6months or less defined by medicare benefit forego live prolonging Rx levels of care goals same

13 Hospice vs. Palliative Care PALLIATIVE CARE Traditional medicare benefit anytime during illness, especially when symptoms begin no need to forego life-prolonging Rx goals same

14 Hospice vs. Palliative Care Goals Same Alleviate suffering patient and family Treat all aspects of pain physical, emotional, spiritual, and social Improve patient quality of life Help patient and family make transition from health and illness to death and bereavement Help patient develop goals of care

15 Hospital Stay with Serious Illness 98% of Medicare decedents spent at least some time in a hospital in the year before death 15-55% if decedents had at least one stay in an ICU in the 6 months before death 40% of MEDICARE payments in 1988 in last 30 days before death >50% patients die in hospital or nursing home thus palliative care most common in hospital

16 Barriers to Effective End-of-Life Care Physician Beliefs Nothing more to offer patients Failure Lack of understanding of what hospice and palliative care can offer Lack of training/trainers in hospice and palliative care ICU Goal is curative, prognosis uncertain, lack interdisciplinary, families overwhelmed

17 Medicare Hospice Benefit Eligibility Criteria Medicare beneficiary (of note most insurance have some sort of hospice benefit) Terminal condition with 2 physicians certifying prognosis less than 6 months if disease follows expected course (one doc must be hospice physician)- Only one physician needed for recertification (hospice physician) Patient chooses hospice care (forego life-prolonging tx) Care provided by a Medicare-Certified hospice program

18 Benefit Periods Two 90 day periods followed by unlimited 60 day periods Hospice physician responsible for recertifying that patient is terminally ill May revoke any time, if re-enrolled in hospice enrolled in next benefit period (no penalty)

19 Hospice Levels of Care General inpatient level (GIP) higher level of reimbursement (often hospital or hospice house) Must have uncontrolled symptoms or actively dying Routine home care (home, assisted living, nursing home, etc) Respite care 5 day break for family where room and board paid (usually nsg home or hospice facility) Continuous care minimum of 8 hours of care in 24 hour day (begins and ends at midnight) by RN or LPN

20 Services Covered by Hospice **Related to Terminal Illness only Medicines Durable medical equipment/medical supplies Lab, xray, XRT, etc Emergency services Ambulance/transport Inpatient care for symptom management Continuous nursing care Respite stay, max 5 consecutive days Bereavement/counseling for 13 months after patient death

21 Services Covered by Hospice Interdisciplinary Team Physician/medical supervision* Case management by RN with nursing visits* Social work* Pastoral counseling and spiritual support* Home-health aide and homemaker services Dietary counseling PT/OT/ST/Respiratory as appropriate Volunteer services min 5% of all patient care *Core team member

22 Physician s Role in Hospice Attending physician Patient can choose Can be hospice med director or hospice physician if pt chooses Hospice Medical Director or Team Physician Contract directly with hospice Oversees medical plan of care Certifies and recertifies patient s terminal illness Part of interdisciplinary team Works with attending physician as needed Cannot have requirement of referring pts to hospice Consultant physician treats pt as needed to manage symptoms of terminal illness

23 Physician Reimbursement in Bill only for patient care services, not administrative services (included in per diem) cannot bill for face to face but if sees pt for medical illness in addition can bill Part A Attending physician not hospice employees Bill part B with GV modifier Hospice Hospice employed physician bill hospice directly hospice bills Part A Consultant physician bills hospice directly hospice bills Part A Services related to terminal illness only Hospice physician and consultant services included in hospice cap but not attending physician services

24 Medicare Part B Modifiers GW-the service is unrelated to the hospice terminal diagnosis provided by any physician GV- the service is related to the hospice terminal diagnosis, the doctor is not the hospice medical director, and is the hospice attending physician 24

25 Hospice Length of Stay Average 59 days in 2006 Median 20.6 days Limited by late referrals Hospice Place of death 76% pts died in residence Help coordinate care, symptom mgmt, family support, psychological support, improve communication, physician home services

26 Why Not? Not something primary care can t do just might not have time?upset family not usually if presented objectively The earlier mentioned, less threatening If unsure, use palliative care or get hospice info visit to assess

27 What do you hate about Too much paperwork Too many calls/don t call Too much morphine, ativan, etc Refuse your patients Stop meds I want patient to get Upset families Hospice? Too hard/too long to have conversation

28 How can I benefit from Should reduce calls from tough patient/family Get help for patient/family, esp at home Face to Face visits -? Get paid? Career change Hospice? Hospice regulations getting much tougher

29 Hospice Board Certification No longer can grandfather into board certificatin for Hospice and Palliative Medicine Need to complete fellowship American Academy of Hospice and Palliative Medicine (AAHPM) now has Hospice medical director certification Requires clinical experience

30 The Death of Ivan Ilych - Tolstoy What tormented Ivan Ilych most was the deception, the lie... That he was not dying but was simply ill, and that he only need keep quiet and undergo treatment and then something very good would result.

31

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