But tell us that kind of went with Dr. Dr. Jim Valak, if that's how you say it and say the name correctly, is Dr. Valak on? Joe asked this question and we'll tie it in to Dr. Valak if he gets on or if not, we'll just kind of keep it in there. What have you found, asking to the group, what have you found works best when you try to support your staff on wellbeing and resiliency? I think this is a pertinent question when everyone's coming through COVID times and I got to see, we all got to see our staff's resiliency tried. So let's start with that as an open discussion point is how do you work on resiliency for your staff? And tying that into the other person, other doctor's question, it was kind of, was asking this question on how to separate work and personal time. So some of the, let's talk about some of these self-care topics before we jump into another point. So I'm opening it up. Here's our most resilient attendee right now. Well, this is Joe, I might just start by saying one of the reasons I was asking what works is a recognition that there are so many reasons that clinicians can be feeling stress or suffering. And it was certainly made worse by the pandemic, but also by some of the civil unrest, growing awareness of the systemic effects of racism and things like that, that as people get distressed, if your first thing to do is tell them, well, you need to learn to be more resilient. So here, I know you're exhausted and don't have any time, but come to this mandatory one hour training on how to be mindful or something. It almost feels like a blaming the victim kind of a thing. It's like, I'm not suffering because I'm not resilient. If I wasn't resilient, I never would have made it through medical school and my training. I mean, that's really a hard thing to get through. The problem isn't my resilience, the problem is all these systemic issues that are causing my moral distress and my exhaustion. So, we have to address the systemic issues somehow, but when it comes down to the individual clinician, they can only do what they can do. How do you, what have you found is actually palatable to an exhausted clinician? Something they can do, they can accept, doesn't add to their burden, but still somehow makes a difference. That's kind of what was behind my question. That includes a lot of insight. I appreciate that. Other thoughts? Yeah, hi, this is Dr. Chalat Rajaram. I'm from Southern California. A big thing that I've noticed is, and it's affecting the doctors, obviously, but thankfully I didn't lose any of my physicians, but we lost a whole bunch of team managers and nurses and other parts of the hospital industry, and it's so hard to get them back. And then going into the requirements that we have with all of the mandates and all the operation issues of running a hospital is also, how do you bring it all together? I go to the IDGs and I bring the morale up as much as I can. And yet, what can we do as an organization of the HMDC group here? How can we get some ideas from each other that might help programs across? And I do appreciate what Joe said earlier. I also agree with Joe and Chalat, and I'm in Missouri. And as anyone that knows me very well, I have plenty of criticisms and challenges to the organization I work for, but one of the things that I can say complimentary to our organization, to Joe's point, we've tried not to, and I agree with the shaming comment. We know this time's a tough, let's have you do this one hour workshop. So this is gonna sound a little trite, I think, but we've tried to give, if this makes sense, permission, maybe float out some options of things that might help you if you're struggling. And then when I say permission and the freedom, some flexibility with time to do that, rather than saying this is what you should do for your own resilience, or wherever you're at on the spectrum, it's just a more, I guess, a flexible approach, if that makes sense. What I like about the flexible approach is I think, I'm gonna say something I think's a truth that others may agree with or not, is I think a big part that helps us is when we have control, right? I think that's one of the hardest parts is when you feel out of control. And so when someone else is throwing solutions and mandates and shame at you, it makes it hard for you to think, well, I'm not getting much choice or not even getting a chance to do something here, versus whenever there's more flexibility and more just support for a person to seek their own path and places. I think that goes a long way. So I feel very grateful where I'm at, that we have a group that's kind of really forgiving and open to each other. And so like you brought up the, talked about how systemic racism has become such an important topic lately. I like, what feels good to me is that my team, we're working on this ourselves. You know, like we don't, we've been listening to some of the information that's out there, but instead of feeling like others are gonna kind of tell us how to do it, we're kind of doing some things in our own organization, talking to the, hopefully talking to the right people and patients and families, and we're doing something about it on our own. And so it feels good because we got the control of it, I guess is what I'm saying. So I think there's something about, and we all, as Joe was saying, since we have resilience, because we got through medical school, we know how to manage ourselves. So people give us a little bit of self-management and encouragement and openness and space for it. I think that goes a long ways. Other thoughts? Because we have- What about the Zoom thing that all the IDGs and all of the meetings have been for the last year and a half on Zoom and even their daily health visits and to get people back into live meetings and going in to see families and patients. And have you all found that to be kind of a slow progress back into reality? Is that something that I'm seeing more here than other places? And I think you're saying that the human, getting back to the human and person connections, that's a helpful thing, right? Yeah. I feel that too. I think humans work better as pack animals. Go ahead. I absolutely agree with that. And it's great to get back to in-person. I think I would use the term flexibility again. I think I've been in lots of things. There are still advantages. It's not as good as in-person, but this is one example of, you know, we couldn't get together in this group on a regular basis as readily as we do here. And so kind of, I hate to use the term hybrid model because it's so overused now, but I do think it's important to the extent it allows to start to get back into the in-person and hang on to some of the positives. We may find anything to think positive since we've all been in so many Zoom meetings and other virtual meetings, but that would be my thought is, and I think that's part of the resilience. You know, if we say at this date, everybody's going to be back in person, that's kind of that mandate philosophy again with versus what works best. Now, I imagine if we left this topic open, there'd be much more discussion. I'm going to shift the topic for a second, but then if people say, no, we're going too fast, slow down, we can slow down. I'm interested in seeing about, there's a lot of different questions on here. So I'm going to go to a question that came from Dr. McNally. I also think I saw a message saying he was going to jump off at some point, but this one hits another theme that several people wrote about. He asked the question about, you know, hospice privileges for a non-boarded, hospital privileges for a non-boarded hospice physician. So there was a few questions that kind of get into this certification that, you know, I think most of y'all know, but if you don't know real quick, the history of this board came about because HPM started a group knowing that there were physicians out there that were doing the work of hospice that were mid-career physicians that didn't have a way of sitting for the HPM board because of the ABIM requirements. And they were saying, how do we recognize this group, this group that we're a part of? But we also see that it's a blessing to have the certification, but it doesn't really count officially for I think most hospitals. So that question was thrown out there, that topic was thrown out there. Some other questions that matched that were Dr. Cohen asking, finding academic positions in Boston without an ABMS HPM credential. Someone else asked, Dr. Song asked, can we ask ABIM to give HMBCB the opportunity for hospice and poly-admissive board certification? So there are several questions on certification. And so let's open up that topic for a little bit and hear people's thoughts on that. I feel like I'm guilty of talking to, I should let Dr. McNally, since you raised the question, you go ahead, I saw your mic come up. Just to make a quick comment, thank you, that this has recently come to a bit of a head in our system, I'm Intermountain Healthcare in Utah, because our hospitals have been a little more strict on credentialing providers only within their specialty board, whatever they may be. And so we've kind of gotten around this. We have several hospice providers that are board certified in hospice telemedicine. We have quite a few that aren't. We've circled around it within our system by having them get privileged within the specialty that they are boarded. So we have a lot of internal medicine docs that work with our hospice and some family medicine providers. And so we've kind of worked with our hospital partners to have them get boarded through internal medicine and then a little notation on their privileges or whatever that they're gonna be focusing on end of life care, supporting the Intermountain Hospice Service. So we've kind of got around it that way for now, but I'm curious as to what others have done or been working on. Thank you. So I would say great question. And as was indicated, there are a lot of questions about certifications. I would just say again, at the risk of talking too much in this group. So I don't, that's not my intent, but you're right. That's a growing issue and it's a challenge. I don't have any answers. I do want to shout out, as Tommy mentioned, double HPM and the whole evolution of the HMDCB because I was a part of a lot of those conversations. I've been doing hospice since the early nineties and I've been a member of the academy pretty much the whole time, back to when it had a different name. And so we had a lot of conversations and I applaud and appreciate the receptivity of the double HPM in saying, yeah, this is a real issue. We've got staffing shortages. We need to address this. The dilemma remains, as Dr. McNally said, is that within the hospital systems, I think Tommy said that too, that this is not terribly recognized. So I'm going to shut up and see if anybody actually has solutions here. I don't have a solution. This is Kim Zelke. I'm formerly with Henry Ford Hospice in Detroit. I've just moved to Savannah. I'm with Hospice Savannah here. I also have been doing hospice work since 93 and I was originally certified the old fashioned way. Then unfortunately I left hospice work for just a handful of years after a bad car accident. And so the notification saying that I had this small period of time to grandfather in before doing fellowship never came to my attention, must've come through to my hospice desk. So when I went back to hospice work with Henry Ford, of course it was too late to be grandfathered in. I went everywhere trying to find, I had missed the deadline by literally two months and tried to sit for these boards and have been unable. So I continue to be reboarded in internal medicine. That'll be coming up again when I turn 60. But as you can imagine, it's also very difficult in your internal medicine boards when you haven't been practicing straight up internal medicine for 30 years. So it's been a huge issue. Dr. Rosen, I see your hand up. So I agree with Kimberly, Jerry, Jeff, what a lot of the comments I've heard as someone who's been involved hospice palliative care and I started Moonline doing this over 20 years ago. And likewise, the prior certification and getting grandfathered in, the added challenge is that within family medicine, I've been doing hospice and palliative care for 20 years. And then American Board of Family Medicine would not let me renew. Out of the 10 subspecialty boards, only two of them, pediatrics and family med, still require primary care. And one of the things as we evolve, adapt and have flexibility, it's been mentioned, I think we can look going forward for the value. Some of the things I've proposed and I submitted some comments in writing already. Sorry if they were too many, Bruce. When you told me to reach out, I did. And Gina's been helpful, but some things that, when those of us get privileged at hospitals, there are specific criteria. And as someone, I think Jeff alluded earlier, differentiating for hospice and palliative and having those privileges aligned. And when I joined Hospital Privileges and actually one place where we had our largest consult service, we had 60 ICU beds. I was one of the co-leaders of our ICU interdisciplinary team. And someone then was asking about, well, what type of privileges are appropriate for that? I said, I'm not managing the vent. I have some thoughts and whatever else, but staying within our scope of practice and our excellence that not only transitions from inpatient, but across other settings. I think if anything, this pandemic has heightened the value in the need. And so some of the solutions, getting more residencies aware and involved. So we build that pipeline of acceptance. There was one job I applied for. I was glad to see they would require anyone joining to get the HDMC, I'm sorry, HMDC credential within three years of employment, like a new criteria. So if we can help build that up, that value for payers, for systems and for recruitment. One of the things that when I used to be medical director, director of palliative care for Seasons Hospice Palliative Care in South Florida would also recruit docs because I would promise them that I would mentor them to take the HMDC if they stayed with us. And so this became a recruiting option besides a validation. I'll stop there, but there are a lot more ideas and I'm happy to work with whomever's interested in figuring out solutions. Dr. Rajaram. Thank you. I'm one of those that did not, I mean, I got the FAHPM as a part of HPM recognizing my years and I got the fellowship, but I've always been an HMDC. And six, seven years ago, we worked with the University of California Irvine and I'm the external faculty director of the palliative fellowship program. The two months of the mandated hospice rotation is done at my hospice and we are graduating our eighth fellow this year actually on Friday. So I'm very proud that this HMDC has given us this ability and the hospital actually we started inpatient hospice at UCI 2019, A lot of work, a lot of work to do it, but the HCA, GME, everybody has agreed. And so two of my doctors, one was my own fellow that I recruited and hired. Of course, he passed, he also did HMDC and the HPM boards, but he's going to be the new medical director. I promoted him as I'm kind of finding my way out of this, but I'm also a CMD. And it's so funny that being recertified in HMDC, CMD last year allowed me to recertify for CMD because I'm already HMDC recertified. So two things, which is aside from this, but we are in four or five hospitals with inpatient hospice now. And most of my doctors, I have a mix of HPM boarded, either grandfathered or who went through the fellowship and some who are only CMD, I'm sorry, HMDC and five hospitals we have inpatient hospice now. And we are, we are creating the model. We are creating the way to do this. Sometimes it's not there, right? And we have, we are the ones who have to create this, this knowledge base as well as, because I'm thankful to my organization, VITAS for helping me to get there. But a lot of it comes from our own abilities to know what the community needs. And I just wanted to share that. So it is possible, I think with our HMDC to go further into, into hospice in hospitals and as well. So I just wanted to share that. Thank you. Yeah, I'm blessed to be our, our hospice and palliative care team in the hospital are so tied. I'm actually working with both. And so I'm actually on the credentials committee. So we just went through and I'm forgetting which position, but as one person already mentioned, we just made sure we worked through the criteria through their primary boards, but also making sure that we put in what we wanted to see in a person that would be working at our hospital. So we included that the HMDCB would be a way of showing this, showing this well. So we, we had a good, and so there's, there's ways with working with your hospitals and working with credentialing and you'll have the backing of HPM, you know, on this credential. So you can say our, our parent organization does recognize HMDCB and we are working on just so you know, where we are working in with HMDCB to have a new recognition there. We can't announce it yet. I don't think Bruce wants me to say anything yet. I'd have to look at his face on the screen, but I don't have a space on the screen, but he probably it's probably too soon for me to say, but just so you know, we do have hopefully a cool announcement to be making within this year on our relationship and, and, and recognition by groups that count. And so starting with one, one group that really counts and we'll move on from there. So just know that as HMCB, HMDCB board, we are working on official recognition from accreditation bodies. And that's on our, we know, we recognize that we need that, that that, so we're going to work on that. Also say, Dr. Rajaram, since you just spoke that I saw that you had a question about hospice updates at HMDC and HBM meetings. And I just want to make a quick announcement on that one to say, there is going to be a webinar coming up that you'll see for certificates. So we're going to have a webinar coming up about some hospice updates and another partnership that we'll be announcing soon. We have a group that's going to be providing hospice update information on regulations that we're going to be partnering with on an educational level. So there are some, I'm excited that there's things I, and I hate that I can't tell you about them. Again, I hate jumping around too much, but people holler real loud. If we're going too quick, I'm going to, I'm going to ask one more question off the list. And then I see someone on the, just the group I was given an announcement to ask for someone to have a question, but let me go to this one here. Dr. Gorby put in a question that kind of matched near another one too, where he says, how do you handle dissatisfaction and frustration that kind of is engendered by the competition in our hospice areas? You know, when you have multiple hospices covering the same area, something that is close to this is another question asked by Dr. Vance, that how do you cope when you have aggressive patient recruiting efforts going on by your administrative team? And that is also that pressure on you. And you have someone that they wanted to admit that you're not sure is actually eligible and, and knowing that there's a competition out there. So let's open up a discussion a little bit about the competition and the feelings that causes and the coping that we have to do with just the competitive nature of our field. If you happen to be in an area where there's competing hospices, thoughts on that topic. It's probably obvious to the group, but I have poor silence. So I just can't keep my mouth shut. And actually one of my questions was kind of a, I guess, heavily veiled because that's what, and that's a relevant issue. I said something about, I'd like to network about processes for admission and you have templates and forms. What that really meant is just to own it and be transparent. Our hospice is like so many others. I'm, as I said before, I've been doing it so long. I can remember the good old days where this was so much an issue, but what I think the dissatisfaction, I don't have an answer to, but I think what you mentioned, Dr. Farrell, it is very real. And I find myself, holy cow, we, because we're so concerned that a patient's going to be swooped up by another hospice, we are really bending, stretching. I would maybe even advocate breaking the ways it's supposed to work sometimes and sign people up when there hasn't been what I would call as a standard in all the years of hospice I've been in, appropriate, timely, but appropriate vetting process is this patient eligible for hospice? So again, I don't have any solutions, but the issue does resonate with me. Yeah, I knew this topic would resonate. We'll see if anyone has some other thoughts on that. Can you hear me or am I muted? Yes. You're heard. Well, yeah, so I'm in a small rural town and I did hospice like 30 years ago when it was like just cancer patients and, you know, it was a real, it was a real calling for the nurses and we had a huge volunteer group and it just, you know, there was no competition in that one town. But now it's just crazy. I think we have, I'm a director of a very small hospice, but I, I believe we're the, you know, we do it just, we don't, we, we do it right. But it's like, but these other hospices have arrangements, which I think are mainly in their nurse, in their nursing groups. Like I'll take care of somebody in the ICU that's dying and then they'll decide to go on hospice. But instead of calling me or giving them a real choice, they always go to these other hospices because the nurses or the discharge planners just have those relationships. And it's like, it's frustrating, you know, or if any, or if a patient becomes dissatisfied over any small aspect of your care, they just flip to a different hospice. And that, those things really, you know, take the, take the, you know, I don't know, the joy out of, out of doing it because, you know, because you've already established those relationships and, and, and they are difficult at times, but, but it used to be, you know, they stuck with you and you really had time to develop it. But that, that, I find that frustrating. And I went ahead and became certified this year and I want to increase the quality of it, but it's like, I mean, the numbers, the numbers drive a lot. And, you know, but we've done okay, but, but we, we definitely have the smallest numbers in the community. And I just wondered if other people had the same degree of competition or if it's just sort of a rural Texas thing. I think it depends too on if you're, sorry, this is Laney Honeycutt, Four Seasons Hospice in North Carolina. I think it depends too, whether you're, whether you're in a certificate of need state or not. You know, in North Carolina, we only have a couple, we are certificate of need. So we only have a couple competing hospices. And I can't imagine, you know, in South Carolina, they don't have that. So one city might have 50 hospice organizations or something. So I imagine that's a, it's a really different challenge there. Thank you. That's absolutely right. And you're absolutely right. I've, it's been a number of years now, but I live in Missouri and we have no certificate of need. And so just to give you a feel into Dr. Gorby's comment, the, I work out of two communities. The larger one is also part of our organization. It's kind of the home to it, but the actual community where I'm a hospice medical director, there's about 10,000 people in the community. And at last count, there were six hospices that said they were serving that area. It's just, it's insane is what it is. And everything that everyone else said about, Alan's comment in the chat about not only is it great challenges to doing it right, it's the hospice, if you're doing it right, you, you often get dumped on for the most challenging cases. I don't want that to sound negative. That's just a objective observation of experience. This is, this is Mawia from Lorain, Ohio. The same, I'm going to echo what the other colleague said. We have very competitive market and Lorain, Cleveland, like about 10 minutes, 15 minutes from Cleveland. And I do believe the competition now is not the issue about the quality, everybody thrive to deliver good quality of hospice, especially the medical aspect of it. But I think the competition has become at least for our agency challenges, especially in group home or nursing home, the other competitor, they are offering services, not necessarily as consistent with the plan of care, like somebody with restless agitation, they offer from their agency, somebody to sit with the patient, which the nursing home they love it. And now you are competing, no, we cannot provide one-on-one, we can treat it differently. And those type of competition become like really outside the medical management, it's almost like commercial competition, it come down to. Great. I was going to offer in response to Bruce's question, how to develop relationships and with the staff, two concrete ideas that I've used in South Florida, Illinois, that may be of interest, I call them guerrilla marketing, because for example, in South Florida, the hospitalist group was on the financial payroll, literally, some of it ceremonial with another hospice and would not refer to palliative care. I did an in-service with the nutritionist and speech and language pathology group with nutrition goals of care, their literature. And so when they would get consulted for severe dysphagia, other things, instead of just saying, NPO use alternative feeding, they also started to incorporate clarify goals of care, consider palliative care consult, patient centered preference, etc. Some of the things we sort of spoon fed them, that once it's in the medical record, either those attendings had to have those goals of care conversations, or consult us to help raise awareness, what the options are. The other concrete thing is that we found a lot of times the messaging in the ICUs was being undermined. And so we offered to bring lunch to the ICU nurse quarterly in-service and be part of their didactics and went over hospice and palliative care. So they would hear it from us. We had experienced nurses that would want to come in. And even though they didn't need the orientation, they heard about this. And it wasn't just for the free food, but because we brought the food, we were always invited. And it was at lunch. So that way, they heard the message from us, we built that rapport. And then we would hear on those interdisciplinary rounds, hey, Dr. R, you might want to talk with so and so. And they started to trust us. We wouldn't throw them under the bus, oh, nurse so and so thinks your patient's really uncomfortable. Instead, we hear we could be beneficial. The other thing, yeah, I have next to me part of the guerrilla marketing and feel free to share. I give out Lifesavers. And the irony involved, people go, wait, the hospice and palliative care directors giving out Lifesavers said, yes, we save quality of life. And if you're going to start doing that, let me give another suggestion, give two. Because the first one, especially wearing the mask all the time, they chew it up, and then they're disappointed. And they look down, and they have a second one. There are some docs who would never want to consult, and they come up and want this. I said, you know, I understand you have an interesting patient. He's like, all right, Alan, what's up? The other thing too, is extra strength hauls mental. The nurses especially like it when there's the code. Let's just say an aromatic room, and they're like, I gotta go in there. Can I have a few? Anyway, those are some guerrilla marketing ideas, if helpful. Thank you. I'm going to shift our topics again, unless too many holler. One thing I'll say on that last part, I don't know if this is helpful or not, but I think about just looking at always as you're kind of working, and we have to, I think most of us physicians don't like being a part of figuring out the competitive part of our jobs. But I go back to, I think I feel good about things, as long as I know my motives are good. You know, my job descriptions are very, I consider my job description to be very simple. My job is to relieve suffering. And that first focus is in the patient, then it's in the patient and family, and it's in the patient, family, and providers, and then it's in the patient, family, providers, and system. And so, as I approach people with the need for us to make sure we're being, you know, if I'm approaching someone to say, I need to work on marketing, that doesn't feel as good. But if I'm approaching someone to say, I want to make sure there's an opportunity, going back to what Dr. Gorby has said, going up to someone and say, I want to talk about how I keep taking care of a patient I developed a relationship with. That's a good moral high ground to be at. If you're there, I would like to be able to keep relationships with these families that I've been helping, and I'd like to keep being a part of their care. That's an appropriate place to come from, and that you can get into a direct conversation with that area. I'm going to say the name incorrectly. So, if this doctor will correct me, Dr. Tayade, T-A-Y-A-D-E, had a question they wanted to throw out. So, I'm going to scrape from the list and see if that physician will speak up and correct me on their name. Yeah, good morning. And you were close to correction. So, I think that's perfectly okay. And sorry, my video isn't working, ever since I was driving. But my question is, and I'm from the VA, which is a whole different world. Also, I was a community, I started a community hospice program. And we started with a very Jewish hospice program. And we have grown as a big program. And now I just had to basically, two years ago, I left that one just to become the full-time VA. And I have actually started having a little bit of more, and I was one of the first few ones in Washington State to do the HMDC. So, I'm proud of that. And I was actually able to sort of basically educate others to become certified in this, because we had hospice medical directors in VA who have never heard of this and never tried to become the good medical directors for the hospice program. They were kind of grown into as a medical director without having a lot of regulatory knowledge of it. So, one of my questions is, how do we raise awareness in the VA about this? And are there any VA sort of representatives that are sort of educating others that this certification has necessity or it has a value? As I also started an advanced hospice medical student program in the University of Washington, and I'm a site director for that at the VA. But this is something that I have interest in raising awareness of this in the VA system, and as well as making that more recognized in the VA to be part of the credential that, as we have for the nursing homes as a CMD, I also wanna become more of an advocate for getting this more popular in the VA and get recognized in the VA. Well, I'll jump in. Do we have any other VA physicians? Oh, go ahead. Go ahead, no, go ahead, Tommy, that's fine. Well, I was curious first to see if we have any other VA physicians on this call right now. Go ahead. So I'll just say, I think this is an area where we could absolutely use some help. So this is a great thought. And we will, as someone who raises their hand and asks the question, we're gonna reach out to you because we need your help. We're gonna need your help in terms of better understanding how to do that and how to get connected there. And you may be our first person who can help us raise awareness in the VA. So I love the idea. I think it's great. Let us follow up with you after the call, if that's okay, and kind of talk through this with you. I think it's a great idea and a way that we could certainly get some more visibility. That'd be fantastic. And it looks like Dr. Klassen has her mute off, so. Well, I live in Pennsylvania, and I know that Scott Shreve at the Lebanon VA is a wonderful contact. And Alan Fishler down in Martinsburg, West Virginia would be two VA docs. Thank you. I have been in contact with Dr. Shreve, but we're absolutely happy to sort of form a VA group and get this more noticeable and more recognizable. Also, it has a value in our trainings programs. The palliative care program at the Martinsburg VA is truly outstanding. So, yeah. Thank you. Because we're near three quarters, Mark, I'm gonna make a, we'll make one announcement is we saw that several of the questions had to do, and we talked a little bit about some of it with the HMDCB specifically in areas that we can be working on. Again, I'm excited about some announcements that we'll eventually be making when we're allowed to. But I will say that Gina and Bruce have prepared some answers to those, but instead of taking any of this time, so I'm enjoying the way the discussions are going without them, no offense, Gina and Bruce. I'm gonna let them, they're gonna send an email out to everybody who's participated to give some of the answers that they prepared later. Also, I just wanna say one of the questions that was brought up in the chat room had to do with the fact that, something to the nature, I'm gonna mess it up, but something to the nature that we should be doing, oh, there it is, does HMDCB and certificates have a distribution list or a discussion group? Well, obviously, because of the myriad of questions that I'm seeing on this and the great discussion we're having and how much more time we could spend on these topics, we obviously need one. So, just so you know, we've taken that comment. It was actually on a list of things we were considering talking about the board about, but y'all just helped, today's helped make the point that we really do need more than just these coffee chats and we need to continue these coffee chats. So, y'all have contributed to the bigger value of HMDCB. So, I appreciate that. I'm gonna switch to a question that also had two certificates putting in. Dr. Hutchinson asked about billing routine home care for patient and hospital who no longer meets the criteria for GIP, but has nowhere to go. And I think we've had that situation if you have any GIP services. And then this fits in with Dr. Pizzullo's question of the issue regarding GIP slash home care level payments for end of life care. So, who has thoughts about how do you manage that patient that you brought on GIP with all the right criteria, they are not passing away, they don't have a place to go and you don't have, you're not managing symptoms that make you feel like you have a GIP level of care. What do you do with that situation? No, there is- That's why I'm asking the question. Okay, I have the, okay. This is Maui again from Lorain, Ohio. I manage a GIP unit we have done. We are the only unit, the only GIP unit in Lorain County, basically. So those patients, we do re-agent in three ways. First of all, if, of course, if they have Medicare, Medicaid, you cannot, okay, I retreat back. There's such thing, rooming board. Okay, previously we did not initiate the rooming board, but now, like past like two years probably, we asked the family, even we asked the family, they are responsible about the rooming board, which is actually deferred from agency to agency. In our center, we ask for $250 for rooming board. And this is also, if you send the patient for inpatient, for a routine for the, for a routine for the nursing home, they do ask for rooming board if they are not, if they are not Medicaid. So if this is rooming board, it help a little bit, it's not much. If the social worker has to find long-term replacement for those. And usually we, I evaluate those patient every like about one to two weeks. If they are really actively dying, the life expectancy weeks, they can stay until they die. If they are filling the financial equipment, if they are requirement, if they don't have the money to pay for the rooming board, then like any hospital struggle with patient, they are not able to discharge them somewhere. You're gonna look for a nursing home, you're gonna look for a group home, you're gonna use your magic. Now, for those inpatients, if they don't have the money, but they are able to, they are in a process to go to the nursing home and they have Medicare pending, you can switch those patient to five days respite. If they are, if the level of care to change it from the previous inpatient admission and the family asks for five days respite, you can, if the family asks, you can use five days respite. And during those five days respite, you are preparing to find appropriate place, accommodate the new level of care the patient need. And sometimes you get stuck with patient, you have no way unless if the patient die or you have some place to go, basically. Thank you. Other thoughts? You use your respite in the hospital, like in our hospice, if they're already home care level, sometimes a respite might be at a local nursing home, which actually ends up to be a little difficult with the planning process and getting those people in there. But my question stemmed from a patient who's in the hospital being referred to hospice with a hope for home care, but the level of need allows them to be GIP, but then there's never really a plan for home care. They just stay. And now day 11, we still have to quote, unquote, justify constant nursing changes, constant medication evaluation, et cetera, to keep them at GIP. So I didn't realize we can do a respite in the hospital. Is that just unique to you or? I'm sorry, my inpatient, no, rest. Okay, my inpatient unit is separate from the hospital. It's independent GIP unit. It's not in the hospital. So yes, I can use this. In fact, because the GIP number is a little bit low and we are the only unit in the county, we are, of course, because of the census is low and the financial challenges and so on and so forth, we are even able to use the GIP unit we are even in the process of leasing those inpatient rooms for other hospice agency. They can inpatient their hospice patient in our room because we don't want the room to just stay empty. Simply, and just, I'm not sure if this is important or not, this GIP unit, although it is the only unit in the whole county, it's always at last. It's always at last at about 400,000 a year, 300 to 400,000 a year. Compensate with the whole agency make money. Like, let me say a hand at 1.5, you take 400,000. So this unit, it support the extended care of our agency, but by itself, it's almost impossible to survive. Your licensing is different than the hospital. So you can do that. And that's good. Sure. But our GIP is in a hospital. So what we would have to do is build routine level of care. And then the hospital just doesn't get what they were getting when it was GIP. And we essentially give them all the money. Sure. In fact, you, okay, you usually lose money when you have a GIP. We always lose money. You lose, even sometimes with the GIP. And so do they. So does the hospital. But they lose more when we can set up a routine. And then all of a sudden the nursing home bed does become available. True. Yeah, when you have the GIP, it's a separate from the hospital. You have the privileges to do the respite after five days looking for, this is five days. We'll give you just a little time to look around. Then you, we will have to term, at least in my agency had term of extended routine care, which means the family of the paying for the rooming board. So you will have like $250 for rooming board and whatever routine care is about $180. You ended up with $500. It's reasonable versus, I mean, you get stuck with the patient without any payment. This is better than nothing, but I think it's doable. Yeah. Well, the saving grace from a financial point of view, the percentage of GIP patients are very, very small compared to the rest of our census. So that helps, but. We're hearing a low on the conversation. Is there one more, is there one more comment on this before I, so that I only jipped seven people instead of eight. I'm going to ask this next question from Dr. Matthew Kwong. Patient not terminally ill, but wishes to voluntarily stop eating and drinking hospice eligible question mark. If so, hospice primary diagnosis. So there was a great presentation on VSED at the last academy meeting that if you, I don't know if those recordings, I guess those recordings aren't available, but I heard a great session on VSED at the academy. But anyway, let's hear thoughts on, what do you do if a person's got an illness or a situation where they're going to do, be a voluntarily stop of eating and drinking? We bring that patient on hospice. Go ahead. Literally just had a case about three months ago. Local neurologist referred a patient to our community hospice with a history of Huntington's chorea. And his perception was he had a very poor quality of life and was ready for VSED. And she referred to hospice for that extra support. Well, our local hospice is run by a Catholic health agency and it actually went to the ethics and legal and they would not accept the patient because it was going to be considered soliciting his suicide. So we ended up doing an outpatient palliative care consultation. And with that being done, we found there was probably some unmet psychological needs. We ended up changing his depression medicine. And for six weeks, it improved his mood and he had a better quality of life, but he was still determined that he did not want to live any longer. And the family was not interested in moving to another state where aid in dying was available and subsequently went to Switzerland and with their euthanasia program there. He actually was going to do VSED, but unfortunately he did like to drink his water and beer and he didn't think he'd be able to stop drinking. This is something that we've not had, but have had come up as a possible, would we do this? And I think that VSED is so hard because you've got to stop that water entirely. But I think what we had decided in the past was we would wait and see that they were sort of successfully doing that, but not just, hey, I wanna. I did the same, what you did, this is Mawia. I did the same, what you did. So we set up, follow up the agents. Okay, when we saw that, when the hospice nurse evaluate the patient, I declare him, he is not hospice appropriate at this time, because it's really just decide they wanna stop. There is no indication that's in the, so I sent the nurse again in five to seven days to reevaluate. We went to see the patient twice and patient, unfortunately after 10 days, 12 days, successfully stopped eating, drinking. Then we admit him. At that point, he was really actively declining and he passed probably in about like six weeks after the total. So we did not- The second part of that question, what was the diagnosis that you listed? When he died? Well, okay. When he went, like after the 12 days, he said he cannot even swallow and I'm not sure if he dry or not. So I put the dysphagia, the unintentional weight loss and the list of the other diagnosis he had. They already have like coronary artery disease, but was not met the criteria for hospice. He has like touch of CUPD, but was not like an oxygen dependent. So I put all the diagnosis, the chronic medical illness that he has. But in the beginning, I did put the dysphagia and unintentional weight loss. Of course, subsequently he become a little bit confused and so on. When he's dehydrated, I add metabolic encephalopathy to it. Others? Could you put malnutrition as your primary terminal diagnosis in that where you admitted him? Because I think dysphagia with unintentional weight loss has already got two things in it. The primary terminal diagnosis. I just wondered as a question, because you knew already at this time, he was going to decline, he had already declined and then you brought him under. Could malnutrition be used as a primary terminal diagnosis? You're talking about the beginning or after two weeks? You're muted. When you brought him, when you finally stopped eating and drinking and at the time that you admitted him to hospice, you knew there was a few weeks left and actually he lasted about six weeks, you said. Could you have put primary as malnutrition? Yeah, yeah. You can put malnutrition, but you cannot use unintentional weight loss with it. This is peer coding, ICD-10 coding. Try to code malnutrition with the unintentional weight loss. You cannot. No, you cannot, yeah. You have to, does not even go to now see ICD-10. You cannot go just malnutrition. You have to specify mild, moderate or severe and you have to remember. So I did not draw blood really to see his albumin or his prealbumin or whatever. So it's really generic acceptable to have unintentional weight loss because it's easy. We weighted him initially versus the malnutrition. It's a little bit more objective and you have to have the number. And you cannot, again, I repeat, you cannot put both malnutrition and unintentional weight loss in the diagnosis. You're gonna choose either one. So the tie in for our whole thing here, thank you for everyone for making this what I feel like was a very successful coffee chat. I didn't have to talk very much. This is really good. And just like the difficulty of VSED of a person needing to actually not drink, but you always have to drink some, is I feel like we wet our thirst on many topics just enough to keep things going, but not have anyone truly satisfied on their appetite. So I think that we definitely need more of this. So we're gonna stay in contact. We definitely need ongoing communication because what we just did here today was a really a good thing. And I sense, or maybe it's just in within myself that we want even more. So we will keep working on engaging and giving opportunities for us to have these chats, listserv service, whatever we need to be doing. So thank you, thank you to everybody. Any closing comments that you need to make Bruce or Gina? Very quickly, we did have a couple of questions come in right here in the chat near the end. So we'll grab those and we will maybe have Tommy give some answers to those and send those back out, or we'll figure out a way to get back with everybody to answer those. And like we talked about, there were some questions specific to HMDCB that we'll provide some answers to to everybody too. So just wanted you to be aware of that. Thanks so much for being with us and participating. We appreciate it. You're one of the seven people who said my question didn't even come up. We know that, I know that. Thanks everyone. Thank you.

supporting staff well-being

work-life balance

competition among hospices

billing and reimbursement

levels of care in hospice

eligibility criteria for hospice care

HMDC certification

raising awareness

hospice and palliative care