HMD Certification Exam: Hospice Regulation and Reimbursement

Elements of a NOE statement

"(1) Identification of the particular hospice and of the attending physician that will provide care to the individual. The individual ... must acknowledge that the identified attending physician was his or her choice. (2) The individual's ... acknowledgement that he or she has been given a full understanding of the palliative rather than curative nature of hospice care, as it relates to the individual's terminal illness. (3) Acknowledgement that certain Medicare services ... are waived by the election. (4) The effective date of the election.... (5) The signature of the individual or representative."

MD Considerations for Initial Certification of Terminal Illness

"(1) The primary terminal condition (2) Related diagnosis(es), if any (3) Current subjective and objective medical findings (4) Current medication and treatment orders (5) Information about the medical management of any of the patient's conditions unrelated to the terminal illness." https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1628.pdf

The Revised Declaration of Geneva (2017)

'Declaration of Geneva' the modern day successor to the 2500 year old Hippocratic Oath • Recognition of patient autonomy • Invoke standards of ethical and professional conduct • Incorporate the concept of physician well‐being • Mutual respect between students and teachers • Parsa‐Parsi RW (2017) JAMA 318:1971‐2

Non-core services

- PT / OT / ST - Hospice aide / homemaker services - Volunteers (5% of total patient care hours) - Drugs & biologicals

2 keys points about Revocation

-The decision to revoke the Medicare hospice benefit is a decision that can only be made by the patient or their representative, a hospice cannot "revoke" a patient. -When a patient or their representative opts to revoke their hospice benefit, they must document that decision in writing.

Regulations for transferring hospice

-no more than once per benefit period -this change in hospice providers is considered a transfer, not a revocation of services, so the patient remains in the current benefit period -the patient must notify the current and new hospice in writing of the desire to transfer hospices and the date on which the transfer will occur -the accepting hospice must file a new notice of election (NOE) even though the benefit period dates are unchanged -although the hospice must perform all of the required assessments of a new admission, a face-to-face (F2F) encounter is not required if the receiving hospice can verify that the originating hospice completed the encounter.

Additional Development Requests (ADR)

-require HMD to complete an eligibility summary for regulatory review by MAC

Medicare Requirements to reimburse at Continuous Home Care LOC

-symptom/medical crisis and 8 hours of registered nurse (RN) and hospice aide care are provided, with the majority (e.g. 5 of 8 hours) provided by the RN. -CHC may only be provided during a crisis in order to keep a patient at home, which includes a long-term care facility or an assisted living facility. -CHC may not be provided in a hospice inpatient unit, a hospital, or a skilled nursing facility. -As noted in the Medicare Benefit Policy Manual, for the purposes of CHC, a crisis is defined as "a period in which a patient requires continuous care which is predominantly nursing care to achieve palliation or management of acute medical symptoms."

Eastern Cooperative Oncology Group (ECOG)

0 - Fully active 1 - Restricted in physically strenuous activity and able to carry out work of a light or sedentary nature 2 - Ambulatory and capable of all selfcare but unable to carry out any work activities 3 - Capable of only limited selfcare, confined to a bed or chair more than 50% of waking hours 4 - Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair

Per Diem Reimbursement rates based on LOC (FY2019, from high to low)

1. Continuous Home Care (CHC) 2. General Inpatient (GIP) 3. Inpatient Respite Care 4. Routine Home Care (RHC) *Service Intensity Add-on (SIA) additional reimbursement; up to 4h/day in last 7d of life, based on CHC calculated hourly rate.

Top Medical Review Denial Reasons (2021)

1. Information provided does not support a terminal prognosis of six months or less. (27%) 2. The notice of election is invalid because it doesn't meet statutory/regulatory requirements. (21%) 3. Documentation indicates the general inpatient level of care was not reasonable and necessary. Therefore, payment will be adjusted to the respite care rate. (18%) 4. Requested documentation not received/received untimely (7%) 5. The physician narrative statement was not present or was not valid. (7%) https://cgsmedicare.com/hhh/medreview/hos_denial_reasons.html

Non-Medicare Hospice Eligibility

1. Medicare Advantage (MA) has no hospice coverage since the election of the MHB stops MA for related conditions 2. Medicaid coverage is set by the state with federal guidance. Pediatric Medicaid must cover concurrent disease‐directed care 3. Commercial insurances have variable coverage, ranging from: • Minimal or no coverage • Dollar delimited coverage (e.g. a dollar maximum for hospice) • Expanded coverage (e.g. a 12‐month life expectancy and/or ability to continue curative treatments) • Bottom line: must check the individual policy

Four possible ways to document hospice eligibility

1. Perfect Fit Fully meets a disease‐category LCD guideline 2. Close Fit + Support* Almost meets a disease‐category LCD guideline + has significant comorbid diagnoses indicating terminality 3. Close Fit + Rapid Decline* Almost meets a disease‐category LCD guideline + has rapid decline indicating terminality 4. Clinical Judgment* There is not an applicable LCD guideline, but patient has a terminal prognosis * If using pathway 2, 3, or 4, documentation must adequately explain why the patie

3 situations in which a hospice is required to issue an advanced beneficiary notification (ABN) to the patient/ representative

1.) when the level of hospice care is determined not to be reasonable or medically necessary (eg, when a patient on general inpatient (GIP) care no longer qualifies for that level of care, but the patient/representative refuses to leave the hospice inpatient unit) 2.) when items or services not reasonable or necessary are billed separately from the Medicare hospice benefit 3.) when the beneficiary is determined not to be "terminally ill." In such situations, when the beneficiary is notified that the service is not covered by Medicare for the reason stated on the form, yet the beneficiary still desires the service(s), Use of the ABN transfers liability for the non-covered care to the beneficiary. If the patient/family agree to discharge with no further services from the hospice, the ABN is not necessary as there would be no liability to transfer financial responsibility.

Hospice Target Probe and Educate

20‐40 claims reviewed, if "compliant" no action for 12 months • Not "compliant", educate and allow at least 45 days to improve then 20‐40 claims reviewed, if "compliant" no action for 12 months • Still not "compliant", educate and allow at least 45 days to improve then 20‐40 claims reviewed, if "compliant" no action for 12 months • Still not "compliant", refer to CMS: extrapolation, UPIC/RAC

GIP SNF Findings in OIG Report of 2016

47.8% of GIP stays in SNFs were inappropriate 30.3 % of GIP stays in other settings that were inappropriate 38.9% of GIP stays in SNFs in which the beneficiary did not need GIP at all during the stay 8.8% of GIP stays in SNFs in which the beneficiary did not need GIP during part of the stay 36.3% of GIP Stays in SNFs in which the beneficiary was diagnosed with a mental disorder, ill‐defined condition, or Alzheimer's disease 22% of GIP Stays in other settings in which the beneficiary was diagnosed with a mental disorder, ill‐defined condition, or Alzheimer's disease

FAST 6

6a Dressing mechanics 6b Bathing mechanics 6c Toileting mechanics 6d Urinary incontinence 6e Fecal incontinence

PPS

70% Reduced walk. No normal work. Significant disease. Full self care. +/- intake. Full consciousness. 60% Reduced walk. No hobby/house work. Significant disease. Occasional assistance self care. +/- intake. Full or Confusion 50% Mainly Sit/Lie. No work. Extensive disease. Considerable assistance self care. +/- intake. Full or Confusion 40% Mainly in Bed. Minimal activities. Extensive disease. Mainly assistance self care. +/- intake. Full or Drowsy +/- Confusion 30% Totally Bed Bound. No activity. Extensive disease. Total self care. +/- intake. Full or Drowsy +/- Confusion 20% Totally Bed Bound. No activity. Extensive disease. Total self care. Minimal to sips. Full or Drowsy +/- Confusion 10% Totally Bed Bound. Unable to do any activity Extensive disease. Total Care. Mouth care only. Drowsy or Coma +/- Confusion

Which of these core services does not need to be a hospice employee? A. Nursing services B. Physician services C. Spiritual care counselor D. Dietary counselor

?nurse

CMS Attending of Record can be

A physician (MD or DO) • A nurse practitioner (NP) • A physician assistant (PA) [new for 2019]

FAST 7

A. speak only SIX words B. speak only ONE word C. Bedbound/Unable to WALK D. Loss of TRUNK strength/Unable to sit up E. Unable to SMILE F. Unable to hold HEAD up

Factors to consider for certification when not an exact fit for LCDs

According to Medicare, the hospice certification of terminal illness should be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness. Other information to be considered when determining whether a terminal illness is likely to have a prognosis of less than 6 months includes: secondary conditions; comorbidities; and the trajectory of decline in function, nutrition, and cognition.

Resources for Institutional Change to address burnout (NAM, 2017)

Action Collaborative on Clinician Well‐Being and Resilience" • https://nam.edu/initiatives/clinician‐resilience‐and‐well‐being/ • "Charter on Physician Well‐being" on behalf of the Collaborative for Healing and Renewal in Medicine • Dzau VJ (2018) To care is human—collectively confronting the clinician‐ burnout crisis. NEJM 378:312‐4 • Thomas LR (2018) Charter on physician well‐being. JAMA;319:1541‐2

Time calculations for CHC

CHC requires that at least 8 hours of predominantly nursing (RN, LPN, LVN, or NP functioning as an RN) care are needed to keep a patient at home during an acute medical crisis. -a minimum of 8 hours of nursing, hospice aide, and/or homemaker services must be provided during a 24-hour day, which runs from midnight to midnight. These hours do not need to be continuous within the 24-hour period.• -At least 50% of the care provided must be by an RN, licensed practical nurse (LPN), licensed vocational nurse (LVN), or nurse practitioner (NP) functioning as an RN.• -If the above criteria are not met, the day is billed as routine home care. -While all team members are encouraged to provide care during the crisis period, only nursing, aide, or homemaker services are counted toward the 8-hour minimum.

CMS definition of unrelated diagnosis

Centers for Medicare & Medicaid Services considers unrelated conditions rare and thus requires documentation of which conditions are unrelated and the clinical reasoning behind these judgments. Hospices are responsible for the treatment of medical conditions related to or arising from the patient's terminal condition or its treatment. This includes covering the costs of related medications and supplies. Hospices are not responsible for the treatment of conditions unrelated to the patient's terminal condition or prognosis.

2 CoPs

Conditions of Participation: Rules governing the eligibility of someone or of an entity to be involved in a particular activity or organization • Failure to comply can result in sanctions, increased reporting requirements, and eventually, exclusion from participation in the program • Failure to comply may also trigger False Claims Act violations • Conditions of Payment: • Other rules for which failure to comply can result in the denial of the claim for payment • Repeated failures to comply with conditions of payment may trigger additional sanctions

NHPCO Determination of Medication Coverage

Depends in part on the relatedness question: yes or no • Yes - depends on whether is medically necessary or within the hospice plan of care • No - is generally not covered, but then must determine who pays. Potential payors include: Hospice, Non‐hospice payor (e.g. Medicare Part D), and Patient Remember that this is only for Medicare • Medicaid is usually similar, as determined by the state • Commercial insurance is often different

Painting the picture/key elements in the narrative: Symptoms and Burdens of disease

Disease specific and/or disabling symptoms • Dyspnea at rest, NYHA Class, refractory angina, etc. • Refer to applicable guidelines Burden of disease • Onset / duration / response to therapy / location of care / time‐to‐task completion / degree of frailty / asleep ≥12h/d • Describe these serially, documenting trajectory of disease with absolute values over a time period

Medicare does allow some deviation from this time frame for the following exceptional circumstances:

Emergency weekend admissions when it is impossible for a hospice physician or nurse practitioner to see the patient until the following Monday or When CMS data systems are unavailable and the hospice is unaware that the patient is in their third or later BP.

Individual Coping Strategies

External resources • Social supports outside medicine (eg. church groups) • Professional peer support Internal resources • Personal traits (eg. grit, optimism, sense of humor) • Processes of adaptation (eg. coping styles, mindfulness) • Learned skills (eg. goal‐setting, stress‐management, cognitive reframing, intentional efforts to achieve work/life balance) Existential resources • Practices such as meaning‐making and finding gratitude • Perez GK (2015) Promoting resiliency among palliative care clinicians. J Palliat Med: 18:332‐7 • Rosenberg AR (2018) Seeking Professional Resilience. Pediatrics;141:(3) • Montross‐Thomas LP (2016) Personally meaningful rituals: a way to increase compassion and decrease burnout among hospice staff and volunteers. JPM 19:1043‐50 • Hotchkiss JT (2018) Mindful self‐care and secondary traumatic stress mediate a relationship between compassion and burnout risk among hospice care professionals. AmJHospPalliatMed;35:1099‐1108

Alzheimer's LCD

FAST 7, AND At least one of the following in the last 12 months -aspiration PNA -Pyelonephritis -septicemia -multiple decub ulcers or Stage 3-4 -fever, recurrent after antibiotics -10% weight loss in 6 months or serum albumin less than 2.5 -in absence of 1+ of these findings, rapid decline or co-morbidities may also support eligibility

NP Role

FTF visits (as long as they are a W-2 employee) Change a level of care based on symptoms and needs. To bill for HSV, NP must be the patient's designated hospice AOR.

When and how does hospice cover PT/OT/SLP?

For "symptom control or to enable the individual to maintain activities of daily living (ADLs) and basic functional skills." These services are covered by the hospice per diem rate.

pre-existing schizophrenia - how does the psychiatrist bill?

For professional services rendered by a nonhospice-affiliated provider that are unrelated to the terminal condition or prognosis, physicians or NPs can bill Medicare Part B directly using a GW modifier and be reimbursed at the Medicare allowable rate.

Attending of Record (AOR) sees patient for non-hospice diagnosis related issue

For professional services rendered by a nonhospice-affiliated provider that are unrelated to the terminal condition or prognosis, physicians or NPs can bill Medicare Part B directly using a GW modifier and be reimbursed at the Medicare allowable rate. Conditions not related to the terminal condition or prognosis can be billed to and reimbursed directly by Medicare Part B. The GW modifier should be used when billing in these circumstances. A contract between the hospice and the nonhospice-affiliated provider is not needed.

Painting the picture/key elements in the narrative: Function, Nutrition, Cognition

Functional impairments: • PPS, ADL dependence, etc. - reported serially Nutritional impairments: • Weight, BMI, MAC, albumin, changes in oral intake, etc. Cognitive impairments: • FAST for dementia • presence & severity of delirium, etc.

2016 most common diagnoses

Hospice Wage Index 2018 • Alzheimer's Disease , unspecified 11% • Congestive Heart Failure, unspecified 6% • COPD 5% • Lung Cancer 4% • Senile Degeneration of the Brain 4% (Alzheimer's Disease late onset, 2%)

How are bereavement services paid for?

Hospice covers the cost for 1 year. Family members are not to be charged for bereavement support, and it is not separately reimbursable by Medicare.

If a hospice claim is requested for a pre-payment review, HMD must write an additional development request (ADR). What is the next step if claim is denied?

Hospice has 120 days to submit a request for Redetermination by the MAC after the initial denial is received. If denied, 180 days to request Reconsideration by a Qualified Independent Contractor (QIC) If denied, only 60 days to request an ALJ hearing.

Inpatient cap

Hospice inpatient days are not to exceed 20% of the total hospice patient days in a given fiscal year. The inpatient days include GIP and respite days. When the inpatient cap is exceeded, the hospice is required to repay any reimbursement in excess of the cap.

Billing for a hospice pre-election visit

Hospice pre-election services include an evaluation of an individual's need for pain and symptom management and counseling regarding hospice and other care options. In addition, the services may include advising the patient about advance care planning. Patients must be diagnosed with a terminal illness without yet having elected hospice care and services. These services can be provided at the request of the Medicare beneficiary or their physician, but they may not be initiated by the hospice. Since this service is not a provision within the Medicare hospice benefit, payment is not included in the hospice cap. These services can be provided by the medical director or an employed physician of the hospice that will be billing for the service (not an advance practice nurse, registered nurse, or social worker). Hospice pre-election evaluation and counseling service visits are billable under Medicare if done for terminally ill patients prior to electing hospice services by a physician who is an employee of or is serving as the medical director of the hospice agency, assuming the patient's physician does not have the requisite skills to provide the service.

Rationale for GIP LOC after an acute hospitalization

Hospices must provide short-term GIP care for pain and symptom management that cannot be provided in other settings. GIP care is allowable immediately following a hospital stay as long as the patient has uncontrolled symptoms that cannot feasibly be managed at home upon discharge from the hospital.

Once a patient is no longer considered to have a life expectancy of 6 months or less if the disease runs its normal course, Medicare coverage and payment for hospice care should cease. Medicare does not expect that a discharge would happen immediately and allows time for post-discharge planning. Key elements of discharge plan include:

It would be expected that the hospice's interdisciplinary group is following the patient and if there are indications of improvement in the individual's condition such that the patient may not qualify for hospice services in the foreseeable future, discharge planning should begin. If the patient seems to be stabilizing and the disease progression has halted, it is important to begin preparing the patient for alternative care. Discharge planning should be a process, and planning should begin before the date of discharge. A notice of Medicare non-coverage (NOMNC) form must be presented to the patient or patient's representative at least 2 days before Medicare-covered services end. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c30.pdf

Improving Medicare Post‐Acute Care Transformation Act of 2014

Mandates that all Medicare certified hospices be surveyed every 3 years beginning April 6, 2015 and ending September 30, 2025

4 categories of medications requiring prior authorization (PA) when hospice patients attempt to obtain using Part D rather than through the hospice benefit (these four classes of medications should almost always be covered by the hospice benefit)

Medicare Part D requires PAs when hospice patients attempt to obtain analgesics, antiemetics, laxatives, and anxiolytics

Hospice Medical Errors and Patient Safety

Medication errors, particularly opioid toxicity • Right patient, right medication, right dose, right route, right time Patient safety • Falls, pressure ulcers, delirium, constipation • Communication errors Prognostic errors • Death shortly after live discharge Dy SM (2016) Patient safety and end‐of‐life care. Am J of Hosp & Palliat Med 33;791‐6 • Smucker DR (2014) Patient safety incidents in home hospice care. JPM 17:540‐4 • HPNA Position Statement (2011) Medication error reporting in the home setting. J Hosp & Palliat Nursing 13:268‐9 • Dietz I (2010) Medical errors and patient safety in palliative care. JPM 13:1469‐74

Incidence of Burnout in MDs

Meta-analysis: >182 studies involving 109K physicians in 45 countries published between 1991 and 2018, of which 85.7% used some version of the Maslach Burnout Inventory to assess burnout One systematic review found that: • 67% of physicians reported burnout (range 0‐80.5%) 2 studies within HPM specialty • Estimate of 62% using 3 components of MBI • Estimate of 23% in study using a single component of MBI • Rotenstein LS (2018) Prevalence of burnout among physicians: a systematic review. JAMA;320:1131‐50 • Dyrbye LN (2018) Association of clinical specialty with symptoms of burnout and career choice regret among US resident physicians. JAMA;320:1114‐30 • Kavalieratos D (2017) It is like heart failure....a qualitative analysis of burnout among hospice and palliative care clinicians. JPSM;53:901‐10 • Yoon JD (2016) Physician burnout and the calling to care for the dying. AmJHospPalliatMed;34:931‐7

Hospice growth 2006-2018 years

OIG Report July 2018 • Medicare paid $16.7 billion dollars for hospice in 2016. Since 2006 this represents: • 81% Increase in spending for hospice care • 43% Increase in the number of hospices • 53% Increase in the number of hospice beneficiaries • OIG recommended 15 changes • CMS agreed with 6, declined 8, and will consider 1

Original Medicare vs. a Medicare Advantage Plan (Medicare Parts A-D)

Part A (hospital care) Part B (doctor visits, lab tests and other outpatient services) Part D (prescription drugs) If you decide to go with Part C, a Medicare Advantage plan, a private insurer has already bundled together parts A and B and almost always D into one comprehensive plan **Medicare Advantage (MA) has no hospice coverage since the election of the MHB stops MA for related conditions

MHB definition of palliative care

Patient and family‐centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social and spiritual needs and to facilitate patient autonomy, access to information, and choice."

Liver transplant patients on hospice?

Patients listed for liver transplant can be admitted to hospice services and then elect to revoke their hospice benefit should an organ become available. It is best to confirm this with your Medicare administrative contractor's (MAC's) LCDs, as this may vary according to MAC.

Single most important factor in cancer prognosis

Performance status PPS < 40 or ECOG 3 - median survival is 8 to 50 days (1 month) •PPS < 20 or ECOG 4 - median survival is 7 to 16 days (1 week) Goldstein NE, Morrison RS. Evidence‐Based Practice of Palliative Medicine. Philadelphia, PA: Elsevier/Saunders; 2013

Institutional Influences on Burnout

Physician well‐being requires collaboration between individual physicians and their organizations Important factors for physician well‐being • Meaningful work • Strong relationships with patients • Positive team structures • Social connection at work • Thomas LR (2018) Charter on physician well‐being. JAMA;319:1541‐2 • Wenzel RP (2019) RVU medicine, technology, and physician loneliness. NEJM;380:305‐7 • Kulkarni A (2019) Navigating loneliness in the era of virtual care. NEJM;380:307‐8

LCD for Heart Disease

Poor response to (or pt's decision not to take) optimal treatments OR Angina at rest resistant to nitrates, PLUS NYHA class IV with significant sx at rest and inability to carryout even minimal activity without dyspnea/angina Supporting evidence: -ejection fraction of 20% or less -rx resistant dysrhythmias, hx of cardiac syncope, CVA secondary to cardiac embolism, hx of cardiac arrest or resuscitation

Liver Disease LCD

Prolonged PTT (>5 sec over control), OR INR (>1.5) AND Serum albumin <2.5gm/dl AND End-Stage liver disease with at least one of the following: -Ascites, refractory to treatment or pt declines or is noncompliant -History of SBP -Hepatorenal syndrome (elevated creat and oliguria <400ml/day) -Hepatic encephalopathy, refractory to rx or pt noncompliant -History of recurrent variceal bleeding despite intensive therapy or patient declines therapy Supporting evidence: -progressive malnutrition -muscle wasting with reduced strength -ongoing alcoholism (>80gm etoh/day) -HCC -Hep B surface antigen positive -Hep C refractory to interferon OR rapid decline or comorbidities may also support eligibility

Medicare regulations re Respite LOC

Provided on an occasional basis with limits of no more than 5 consecutive days per respite period. The 5-day respite period includes the day of admission but not the day of discharge because the day of discharge is billed at the routine home care level. More than one respite period is allowable in a single billing period. Respite care can only be provided in a Medicare participating hospital or hospice inpatient facility or a Medicare or Medicaid participating nursing facility. Respite care cannot be provided to hospice patients who reside in a long-term care or skilled nursing facility.

For professional services rendered by a nonhospice-affiliated provider that are related to the patient's terminal condition but the clinician is not the AOR

Provider must look to the hospice for reimbursement.

Service intensity add-on (SIA) reimbursement

RN or SW visits in the last week of life. NOT aide or chaplain. Billable in 15 minute increments (based on the continuous care home rate) for up to 4 hours/day during the last week of life. Patient must be routine LOC and discharge status must be death.

Five sequential steps of the Medicare appeals process

Redetermination by the Medicare administrative contractor (MAC) Reconsideration by a Qualified Independent Contractor (QIC) Administrative Law Judge (ALJ) hearing Medicare Appeals Council review Federal District Court review https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c30.pdf

HMD and HP Roles and Responsibilities

Regulation mandated: • Medical component of the patient care program* • Prognosis determination and eligibility certification/recertification • Relatedness determination • 24/7 availability for care related to terminal illness plus other care not provided by attending • Involvement in QAPI program* Additional: •Work as part of hospice program leadership • Hospice & Palliative Medicine expertise & teaching • Patient care, including in‐person patient visits • Pharmacy utilization management • etc *Indicates items specific to the HMD

Entering 3rd period, no FTF, first day of 3rd period in on Sunday

Schedule a face-to-face (FTF) encounter with the patient on or before Sunday, because it fulfills the FTF requirement no more than 30 days before and no later than the first day of the third (or subsequent) benefit period (BP). Note: CMS clarified that the FTF visit can be completed on the first day of a new BP.

RHC U‐shaped payment (the 'back‐end')

Service Intensity Add‐on (SIA) payment • Additional payment for direct nursing or social worker visits provided in the last 7 days of life • Up to 4 hours per day • Nursing care must be by Registered Nurse (RN) • Regardless of location • Amount paid is same as Continuous Home Care (CHC) rate • Calculated & applied by CMS

Medicare Care Choices Model (MCCM)

Sometimes known as the hospice concurrent care demonstration project • Hospice‐like support services to be provided concurrently with usual care for hospice‐eligible patients • MCCM is designed to: • Increase access to supportive care services provided by hospice • Improve quality of life and patient/family satisfaction • Inform new payment systems for Medicare and Medicaid programs • MCCM has diagnosis and other restrictions regarding who can enroll. Hospice provider participation is currently limited

7 Items of the Hospice Item Set

The HIS is a component of the hospice quality reporting program (HQRP) and incorporates seven items. Increased focus on quality as measured by Hospice Compare, which includes the HIS, can result in substantial benefits for a hospice program, eg improved scores on the Medicare Hospice Compare website The 7 items reported are the following: At the beginning of hospice care: 1. Asked about treatment preferences like hospitalization and resuscitation 2. Asked about pt/family beliefs and values 3. Screen for pain 4. Screen for shortness of breath Patient care: -timely and thorough pain assessment -timely treatment for shortness of breath• -constipation care for patients on opioid medication

when patients travel

The Medicare Modernization Act of 2003 clarified that hospice patients are not required to be homebound, and hospice agencies can contract with another hospice agency to continue services while a patient travels. Although duration is not specified in the Medicare regulations, most agree a traveling arrangement should be for less than 14 days since an update to the comprehensive assessment would then be required if more than 14 days elapses.

Aggregate cap

The average aggregate payment is adjusted annually based on the consumer price index, and is $29,205 per patient for fiscal year 2019. Unlike the daily payment rates for hospice services, the aggregate cap is not adjusted based on geographic cost differences.

Reasons for Respite LOC

The caregiver feels if he or she had relief from caregiving responsibilities for a short time, the caregiver could resume or continue caring for the beneficiary at home again.• The caregiver is temporarily unable to provide care to the beneficiary because of personal illness.• The caregiver needs to go out of town.

Notice of Election (NOE) Statement

The hospice chosen by the eligible individual (or his or her representative) must file the (NOE) with its Medicare contractor within 5 calendar days after the effective date of the election statement. Consequences of failure to submit a timely notice of election: Medicare will not cover and pay for days of hospice care from the effective date of election to the date of filing of the notice of election.... Exceptions include "Fires, floods, earthquakes, or similar unusual events..."

Goleman 6 Leadership Styles

Visionary Coaching Affiliative Democratic Pacesetting Commanding *Interplay between relationship and task behavior Goleman D (2013) "Primal leadership: unleashing the power of emotional intelligence" Harvard Business Review Press https://www.wsj.com/articles/BL-HOWTOMB-23

MHB definition of terminal illness

a medical prognosis that his or her life expectancy is 6 months of less if the illness runs its normal course

Medicare appeals process: required documentation and the financial minimum required for each level.

minimum $ amount to request an ALJ hearing is https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c30.pdf

A hospice newly admits a patient on a Friday who is in their third or later BP, and the first day of the next period is Sunday. What to do?

schedule a face-to-face (FTF) encounter with the patient on or before Sunday, because it fulfills the FTF requirement no more than 30 days before and no later than the first day of the third (or subsequent) benefit period (BP).

Attending of Record (AOR) sees patient for hospice diagnosis related issue

the provider may bill Medicare Part B directly using the GV modifier

If another physician covers for a hospice patient's AOR

the services of the substitute physician are billed by the designated AOR under either the reciprocal billing or fee-for-time compensation arrangement (formerly referred to as locum tenens arrangements) instructions. In such instances, the attending physician bills using the GV modifier in conjunction with either the Q5 or Q6 modifier.

Key elements in disclosing an error

• An explicit statement that an error occurred • What the error was and the error's clinical implications • Why the error happened • How recurrences will be prevented • An apology Gallagher TH (2007) Disclosing harmful medical errors to patients. NEJM 356:2713‐9 • Pronovost PJ (2015) From shame to guilt to love. JAMA 314:2507‐8 • Disclosing medical error. https://www.mypcnow.org/blank‐furhl

Malnutrition Universal Screening Tool (MUST)

• Body Mass Index ( <18.5 kg/m2) • Unintentional weight loss in past 3 - 6 months ( > 10#) • Acute disease effect score (is it likely that patient will not be able to get nourishment for 5 days) • Risk stratify into low, medium and high malnutrition risk Ellia M, editor. Screening for Malnutrition. A multidisciplinary Responsibility. Development and use of the 'Malnutrition Universal Screening Tool' ('MUST') for Adults. British Association of Parenteral and Enteral Nutrition; 2003.

Addressing Burnout

• Dzau VJ (2018) To care is human—collectively confronting the clinician‐ burnout crisis. NEJM 378:312‐4 • Aspinwall LG (2010) The value of positive psychology for health psychology. Ann Behav Med:39;4‐15 • Schwenk TL (2018) Physician well‐being and the regenerative power of caring. JAMA;319:1543‐4 • Back AL (2016) Building resilience for palliative care clinicians: an approach to burnout prevention based on individual skills and workplace factors. JPSM 52:284‐ 91 • Montross‐Thomas LP (2016) Personally meaningful rituals: a way to increase compassion and decrease burnout among hospice staff and volunteers. JPM 19:1043‐50 • Hotchkiss JT (2018) Mindful self‐care and secondary traumatic stress mediate a relationship between compassion and burnout risk among hospice care professionals. AmJHospPalliatMed;35:1099‐1108

Definition of Burnout

• Emotional exhaustion • Cynicism (depersonalization) • Feelings of ineffectiveness (low personal accomplishment) Wright AA (2018) Beyond burnout—redesigning care to restore meaning and sanity for physicians. NEJM 378:309‐311 Maslach C (1993) Professional burnout. Taylor & Francis:1‐16

'H‐E‐A‐R‐T' for Service Recovery after a medical error

• Hear the concern • Empathize with the way the person is feeling • Apologize for the experience the person is having • Respond with action to the problem • Thank the person for the opportunity to make things right https://vimeo.com/51700947

Routine Home Care (RHC) U‐shaped payment (the 'front‐end')

• Higher rate for days 1‐60 of an episode of care • Base FY2019 rate: $196.25* • Lower rate for days 61+ of an episode of care • Base FY2019 rate: $154.21* • Episode of care resets if readmission occurs more than 60 calendar days after hospice discharge • These reimbursement rates are independent of the benefit period days

Malnutrition Independent Risk Factor for Mortality

• Hip fracture in the elderly - higher 6 month mortality • Stroke - 40% 6 month mortality • Hospitalized elderly patient - Increased 1 year mortality Ann Rehab Med 2017;41(6):1005‐1012 Journal of Stroke and Cerebrovascular Diseases, Vol. 25, No. 4 (April), 2016: pp 799-806 The Journals of Gerontology: Series A, Volume 57, Issue 11, 1 November 2002, Pages M741-M746

NHPCO Relatedness Process Flow

• Identify the Principal (terminal) Hospice DX • Are there other diagnoses, conditions or symptoms caused by or exacerbated by Principal Hospice DX? • Are there additional diagnoses, conditions or symptoms that contribute to the 6 month or less prognosis? • Are there additional diagnoses, conditions or symptoms caused or exacerbated by treatment of the related conditions? • If "yes" to any of the above, the diagnosis, condition or symptom is related • If "no" to all the above, and documented in the record, then the diagnosis is considered unrelated https://www.nhpco.org/wp-content/uploads/NHPCO-Relatedness-Process-Flow_Revised-Version-2.0-2020vFINAL.pdf https://www.nhpco.org/wp-content/uploads/NHPCO-Medication-Flow-Chart-_Apr-2020vFinal.pdf https://www.nhpco.org/regulatory-and-quality/regulatory/determining-terminal-prognosis/terminal-prognosis-articles/

I-PASS system for sign-out

• Illness severity • Patient summary • Action items • Situation awareness and contingency plans • Synthesis by receiver *Decreased errors/adverse events by 30%; 2.5 minutes/patient Starmer AJ et al (2014) Changes in medical errors after implementation of a handoff program. NEJM 371:1803‐12 • http://www.nejm.org/doi/suppl/10.1056/NEJMsa1405556/suppl_file/nejmsa14055 56_appendix.pdf

UPICS - Unified Program Integrity Contractors

• Investigate Medicare fraud • Conduct audits • Suspend payments • Look at contracts, licenses, medical records • Refer provider for exclusion to Medicare program • Able to extrapolate • Can find thousands in denials and extrapolate to millions • Call your lawyer if they show up

Common narrative trip‐ups

• Lack of sentence format • Composed by someone else • Copy‐and‐pasted narratives • Illegible handwritten narratives • Never addresses terminal prognosis • Failure to include BP dates • Trying to use a guideline that does not apply • Using the word "decline" instead of using comparative data • Listing unrelated diagnoses https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1628.pdf

Leadership Principles

• Leadership involves self‐discovery and self‐development • Establish clarity around a set of core values • Communicate a clear sense of purpose and vision • Build a culture of excellence and accountability • Create a culture that emphasizes leadership as an organizational capacity Kirkland KB (2017) Walking the shoreline. JAMA 318:2297‐8 • Souba W (2004) Building our future: a plea for leadership. World J Surg 28:445‐50 • Byyny RL (2017) Being a leader. The Pharos. Summer 2‐6

Payment for MHB services

• Paid through Part A Medicare Administrative Contractor • Paid at a per diem rate, depending on level of care • Inclusive of all care related to the terminal illness* *Physician services are paid differently • Administrative services are included in the per diem • Attending physician directly bills Part B with GV‐modifier • Other physicians (including HMD and HP) must bill hospice for professional services related to the terminal illness, and the hospice may be able to add those claims to the hospice's per diem claim

Children's Understanding of Death: School‐age children (6‐12)

• Problem solvers/concrete thinkers • Develop social groups • Concerns about body image • Understand death and that they could die • Interested in what happens to bodies and spirits after death

MACs - Medicare Administration Contractors

• Process and pay claims • Medical record review to determine if payments appropriate • Educate providers • First level of claim appeals • Pay claims for Part A and B • Use LCD guidelines • KNOW your MAC and what they look for

Vocabulary for Certification

• Prognosis: Likely course of disease, medical practice • Life expectancy: Historically, to project mortality into the future; Make estimates • Eligibility: requirements to receive the MHB - prognosis involved, rubric and local guidelines to follow

CERT - Comprehensive Error Rate Testing

• Randomly select claims • Usually single chart pulled • Calculates error rate for MACs • Can request charts to see if overpayment occurred • Usually cannot see billing patterns that indicate fraud

RACs - Recovery Audit Contractors

• Recoup overpayments • Pilot demonstration program - lead to permanent program ‐ Jan 2010 by doing post pay reviews • Incentivized to make money (9 ‐12.5%)

What goes in the F2F documentation?

• Should be clinical data pertinent to prognosis and eligibility -History -Physical findings • Remember: this is not 'the narrative' • So no requirement to document any conclusions ((no prognostic determinations within the F2F documentation without input from the IDG) • The certification narrative is a different document with a different attestation, done for a different purpose, even if done the same day

SBAR pass-off tool

• Situation: Concise statement of the problem • Background: Pertinent and brief information related to the situation • Assessment: Analysis and consideration of options • Recommendation: Action requested or recommended http://www.ihi.org/resources/Pages/Tools/sbartoolkit.aspx • Haig KM et al (2006) SBAR: a shared mental model for improving communication between clinicians. J on Quality and Patient Safety 32:167‐75 • Thomas CM et al (2009) The SBAR communication technique: teaching nursing students professional communication skills. Nurse Educator 34:16‐80

Children's Understanding of Death: Infants and Toddlers

• Totally dependent • Fear of separation and abandonment • Unaware of difference between separation and death • At end of period, recognize death as immobility

Children's Understanding of Death: Preschoolers (3‐6)

• Understand lack of body function after death • Do not understand permanence, universality or causality of death • May see death as punishment • Egocentric with magical thinking

Children's Understanding of Death: Teenagers (12‐20)

• Understand loss of future • Aware of genetic and familial implications of death • Developing an existential construct • Increasing connection with peers and independence from family

Required minimum frequency of hospice RN visit

• on-site visit every 14 days • To assess hospice aide care • To determine if services ordered by IDG are meeting patient's needs

Changes to document for eligibility

• vital signs • diagnostic lab results • pain/symptoms • responsiveness • lucidity • strength • dependence for ADLs • intake / output • weight • anthropomorphic measurements • skin condition • increasing ER visits or hospitalizations

Painting the picture/key elements in the narrative: Diagnoses' that impact prognosis

•Use sentence format • State patient's age • State patient's principal and related medical conditions • Describe how these impact prognosis; including a description of their severity • Try not to include unrelated diagnoses