Medicare Hospice Benefits and More

Presented by: XXXXX

Introductions

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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

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

Local Project Hospice Lead(s)

• Insert from Speaker Notes 4

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

What is the Reality?

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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

Triggering Events for a Hospice Referral

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

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

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

Is Your Serious Illness the Elephant in Your Doctor ’s Examining Room? Here ’s the situation:

Patients and their families think that if they have a serious illness, their doctor will start the talk.

Doctors say that they will have these talks if their patients bring Doctors and their patients both think that having these talks are important.

Here ’s the problem:

Doctors and patients are each waiting for the other to start the conversation.

Because of this, these talks may not take place at all. Or, they may take place during a health crisis or emergency, when it ’s very stressful for everybody.

Is Your Serious

Patients and doctors can work

’s Examining Room?

the Patients and their families think “elephant” out their doctor will start the talk.

these talks if their patients bring think that having these talks are sure that everyone

Here ’s the problem:

involved can have Doctors and patients are each waiting for the other to start the these important Because of this, these talks may conversations

now .

may take place during a health crisis or emergency, when it ’s very stressful for everybody.

This is how to start. You can ask your doctor:

Do I have a serious or life-limiting illness?

Can my illness be cured?

Patients and there treatments that can slow doctors can work the “elephant” out If my illness keeps getting worse, of the examining sure that everyone Will you be the one to tell me when involved can have conversations

now .

Although your doctor doesn ’t know exactly how you are going to respond to a treatment, it is important to make sure you have enough information to make an informed choice about what you want.

This is how to start. You can ask your doctor:

Do I have a serious or life-limiting illness?

Can my illness be cured?

If my illness can ’t be cured, are there treatments that can slow down my illness?

What kind of care is available to focus on making me comfortable?

If my illness keeps getting worse, when is it a good time to think about getting supportive and comfort focused care? Will you be the one to tell me when to contact hospice?

Will you stay involved with my care even when I am no longer looking for treatment for my disease?

Although your doctor doesn ’t know exactly how you are going to respond to a treatment, it is important to make sure you have enough information to make an informed choice about what you want.

Communicating with Physicians & Providers

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

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

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

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

Hospice and the Hospice Medicare Benefit

Hospice

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

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

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

Hospice Today

• Over 5300 hospice programs nationwide 24

Holistic Needs-Holistic Care

• Physical • Spiritual • Emotional • Psychological 25

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

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

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

Primary Hospice Diagnosis 2012

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

Levels of Care

• In-home • Respite • Continuous Care • General Inpatient 30

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

Medications

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

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

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

Who Pays for Hospice Care?

• Medicare • Medical Assistance • Most Insurance Plans • Private Pay • Long Term Care Insurance 35

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

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

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

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

Questions

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Contact Information

XXXXXXX XXXXXX www.stratishealth.org

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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