or early afternoon if you're on the East Coast, I guess. It's now afternoon for you. So I'm Bruce Hammond, serve as HMDCB's Executive Director. Thanks so much for being with us today. We really appreciate your interest in connecting with your fellow HMDCs and being here with us at our, I think this is maybe our third Coffee Chat. So very excited to be with you. Before we get started, I wanted to just give a very quick plug to have you consider registering for our October for HMDCs by HMDCs webinar town hall event, where we're gonna have a panel of leaders from a variety of the National Hospice Organizations, the American Academy of Hospice and Palliative Care, Palliative Medicine, excuse me, NHPCO, and the Family Medicine Organization as well. They're gonna be talking about their organizations, what's happening, and then answering any questions you might have. So that event is coming up. Gina is gonna post the link to register for that in the chat. So I encourage you to take a look at that, see if it works in your schedule and feel free to join us for that. So again, with that, we appreciate you being with us. Thanks so much. I'm gonna turn it over to our very able MC for this morning, Tommy Farrell, who's HMDCB's President. Tommy, feel free to take it away. Thank you. Thanks for all on the call, the Coffee Chat. We have, it's been wonderful to see the engagement and I can tell how much we enjoy getting to talk with each other. I see that there's some people on here that are even putting up with talking with each other for a second time in just a few days. So I see some doctors on here that were in our recent conversation for the nonprofit hospice providers of Texas. So we're not getting too sick of each other yet, it doesn't seem like. We had some questions that were sent in by participants. So last time when we did this, we had so many questions it felt like it was a marathon to get to them and we didn't get through all of them. But it's nice now as we got a more manageable list that we can also take other questions if these spur on questions from others. So I'm gonna bring up questions that the group wanna ask the group, and I like to, and that's really the theme of all these questions is kind of getting other people's inputs on how they do different things. I think I'll start with the ones that are, there's two that are COVID specific. So let's start with COVID specific ones. There's one on one person asked for us to discuss a clarification on GIP level of hospice care during COVID. And to me, I think the GIP level of hospice care during COVID would be the same, but they might be wanting to talk about something particular on how you do that when you have to take care. I don't know if we're wanting to look at how you take care of patients when they're with COVID and GIP or whatnot. So if someone would like to speak more to that question, let's hear more about GIP level of care during COVID. And if no one speaks up, then we get, I get to interpret it however I want to interpret it. I, I, uh, I agree with you, Tommy. I don't, I don't, I didn't ask the question, but I, I can, and I'm sure, you know, others had their own thing. It's, uh, as you said, I, I think it's basically the same, the one modification that we use sometimes depending on the situation, um, you know, the nurses are the front line. We, we may have done the daily rounding, um, the physician virtually while the, um, care manager was, um, kind of facilitating the visit, but otherwise I agree with you. I, I, it's basically the same as other diagnoses. I know that some states also might have different restrictions on visitation during that time. And so we had a modifier visitation, um, at the inpatient hospice for state regulations at the time. Someone else is speaking. I interrupted. Sorry. Uh, no, I, I'm Dr. Rajaram. I'm the external faculty director with the palliative program at UCI. And, uh, I'm retired as the senior medical director, um, uh, VITAS hospice in June, but we started the inpatient hospice at UCI two years ago, 2019. So we were right for COVID when last year, when COVID, a lot of the patients who were in respiratory failure was not, were not making progress. The inpatient hospice was used a lot for the palliative excavations. And even those who are not intubated, those who are on high flow nasal cannula and were not making progress. So there were definite criteria for inpatient hospice, GIP level of care during that time. And, uh, COVID now Delta has taken over there's about 20, 30 patients at UCI with COVID, but we get the usual run of the mill inpatient hospice for other reasons as well, respiratory distress or pain out of control. So I, I mean, there is a place for it because it's multi-organ failure. We are going to have multiple symptoms of higher level of care needed for inpatient hospice. I hope that answers some of the questions that I don't know who asked the question, but I just wanted to share some experiences. Very nice. Thank you. Another COVID related question that was up was just regarding the effect of the pandemic and nursing homes and hospice in nursing homes. And certainly there's, there's been some impact. I imagine that's also something that might vary from state to state, but for a while there, we had to fight to get our providers in the, in the nursing homes. What are their effects of people staying for their nursing home side of their care? I think the same thing happened in the nursing homes too, because there were patients who were either sent from the hospital to, you know, there were different levels in a nursing home or they gave different color codings at that time during the peak of COVID last year. And I think we did the same, just like we do inpatient hospital. The hospital is the same criteria for nursing home. And I think there were patients who were having so many either agitation or respiratory distress, respiratory failure, excessive separations, you name it. And they fell into the criteria because again, even though it was respiratory mostly, but there were other systems being involved with patients failing. And I think we had the same with intensive comfort care or continuous care at home with COVID as well. So I think the criteria for all three are the same inpatient or continuous care. We can't really change anything. It has to be symptoms that are out of control that you manage and then put them on that higher level for that period. So I think across the hospice, and we still do that even now for COVID and non-COVID, there are still COVID patients that we are admitting in the program. So. In the chat box, someone put in, how do you determine the prognosis for hospice eligibility for COVID patients? And I would say my quick thought on that is I consider it like I would with any other acute infectious illness that if I had a patient in the hospital with pneumonia, that triggers the consult for us to see the patient and take in the whole picture, take in the whole picture. And many of the people that are with pneumonia or with COVID in the hospital that are in a critical shape, they're in critical shape because of a lot of comorbids where they might've met hospice criteria even before the COVID diagnosis. But even if they didn't meet hospice criteria before the COVID diagnosis, if they are at a point where the attending feels like their prognosis is less than six months, the disease falls as natural progression, they'd be eligible for hospice. I don't know if others have comments about eligibility of COVID. I mean, you're absolutely right. I mean, the thing is when COVID becomes a diagnosis, of course, that becomes a primary terminal diagnosis, but there could have been at least four or five comorbid that could have been the primary before the COVID was diagnosed, but sometimes they don't refer to the very end anyway. And yeah, so that, I mean, I've seen that multiple times and they want to give COVID the primary because that's now the diagnosis, but there were multiple other things that the sepsis, for instance, sepsis with septic shock or, you know, multiple bacteremias and that went with it enough renal failure, they were on CRRT or whatever. So all these are, again, the system of multi-organ failure that comes and COVID was one of the things that showed up, not immediately when they were admitted to the hospital, but probably later. So I mean, we see this a lot. Any other comments anyone would like to make about COVID? Hi, Tommy, Alan Rosen from Florida. So you may understand my question that I put in where I asked out of curiosity, if anyone else is having challenges that patients' families do not want to see COVID-19 on the death certificate. And again, Florida's quite politicized and a variety of opinions. I'm curious how others have managed again, trying to help identify and clarify what is honest, what is appropriate and indicated and trying to make it more objective. I've talked with some other colleagues around the country and some, for example, in Pennsylvania have experienced this. There was even a story on NPR about it. I'm curious what people found here and what your experience and how you're dealing with it. Great question. I'm imagining someone has a thought on this. This is Mawia from Lorain. A thought on this. It's interesting what you said. Initially, I have like about three cases where the family upset and fighting, they don't want the COVID-19 diagnosis. This was in like early 2020. However, at the end of 2020, it's the family fighting to make the COVID-19 as a primary. And I'm not sure if it has to do with the potential reimbursement of this or something or something related to the COVID really. But it is strange initially, all the family fighting do not put the COVID on the death certificate. And subsequently, everybody now want the COVID and they don't want the COVID just on the death certificate. They want it as a primary, which sometimes is not primary. Let somebody went with the cancer and they find out he's COVID positive. I can't add it as like on the part three or part four of death certificate. But this is, I thought this is interesting. We went through that. I'm in Texas in Abilene with Tommy, actually. So we went through that transitional that I got a lot of angry phone calls about why did you put this on in the beginning, but I haven't received any of those in quite some time. Very much the other way of, you know, we get reimbursement for our funeral services if you place this on a death certificate. So I need it on there. So we're much transition to the other side of it now. And I would say on the approach, hopefully we have other conversations where families don't like what we're saying or having a document. And so I hope that most of us have that skill of one, accommodating what can be accommodated within the realms of truthfulness and correct pathophysiological process. But also knowing that there's other things that we have to say and do that people don't like, and we can do that still in a compassionate manner. There's other things that we have to do firmly, but compassionately. And that's the art of our job. That's why I think our jobs, I always say the medicine part of our jobs, the easiest is this stuff. It's knowing how to help families through this moment of wishing that the diagnosis were different when it is what it is. Other thoughts? Great topic. Just, I think that was well said, Tommy. I mean, we need to be, you know, compassionate and listening, but, you know, we still have to balance that with what, as you use the term, what was the pathophysiology of this patient's demise? And I personally, I had, the issue was always with the tutor, like 99% of the cases where the family protest on the diagnosis, it's two diagnosis always, and the tobacco contributing to the death. Like when you check tobacco, yes or no, somebody with cancer and they fight, it's not. The second one at the dementia, they don't want it as the first diagnosis, Alzheimer's, dementia. So those always my problematic diagnosis. So always if I put them on a death certificate, I really spent a little bit extra time so I would not have the headache subsequently to really revise it or do something or do something. But those two diagnosis always, it seems like mainly problematic. I agree with mine was, I agree with the dementia, that's a challenge for families when they've been having a hard time accepting the dementia. So that's been one. And alcohol, same thing with the, that's one of the angriest phone calls I ever got with someone that, why did you mention, I mean, why did you put down that this was alcoholic liver cirrhosis? To speak to that, Tommy, and do I pronounce it ma-wai? Maui-a, thank you. Maui-a, thank you. My apologies. The other thing I've tried to emphasize is the community health aspect, because with the statistics, that'll also allocate some of the public health funding and priorities. So in terms of COVID, accurately reflecting it may determine some of the community support. It might also impact whether it's schools or others that could be vulnerable. And looking at the broader picture, that they could be part of a community solution rather than hiding something. So I was just going to mention that. And then I put in the chat, oh, Emily responded, but Emily had a question about relatedness. And for example, on diabetes, her question, and I responded, it also depends on your MAC. So those of us that have dealt with palmetto will know they tend to be extremely diligent in identifying default being related until proven otherwise. And now we also have, as many people will know, within the 2022 final rule, that there is more emphasis as well on unrelated being rare, especially when it's involving anything contributing to a terminal prognosis. This is Lainey Honeycutt from Four Seasons Hospice. I agree with that, with Medicare saying that there should be very little that we're not paying for. I really make diabetes related, but it's really hard to parse that out from stroke and CHF and even with uncontrolled diabetes, or with controlled diabetes to say that that's unrelated. I've just really been covering most everything at this point. Yeah, I think, as you mentioned about final rule and talking about the clarifications on the addendum, before with the relatedness, it's been this emphasis that we see in the commentary, but as of last year, it was the addition to the election statement of hospice that the verbiage of this should be rare and unusual as part of you signing consents. So truly, talking about the litmus test of looking at our plans of care and what coding diagnosis we're including, we should be able to look at them and say that it's rare that there's a diagnosis there that's unrelated. So I think it's new. Well, and it's funny, CMS says it's not new. They keep telling us that since 1983, this is how we should have done it. So from their perspective, coming back at us, you know, on our PEPFAR reports, they now include Part D prescriptions. So you can see on average per each hospice patient, how many prescriptions they go to Part D for. That's now being, you know, publicly reported and you're compared to national data to see how many medications do your patients use that you're saying are unrelated compared to other hospices. And so that means audit is coming. So, I mean, that's 100% going to be the case. So you're either going to pay for it now and use formularies and navigate the financial risk or pay for it on the back end when it goes through, you know, the larger CVS or NetSmart where you haven't negotiated a financial cost of those medications. This relates to a question that was sent in too that I'll bring up here that, and I don't know if Joe will tell us on the call right now, because this would be a question I wonder if he knows something about, where it says, the question was, where are we in advocacy for patients on hemodialysis who could benefit from hospice, but not ready to stop hemodialysis? The reason why I lumped that in there, because that goes into that relatedness piece that it's hard to, most patients that are on hemodialysis, that's going to be related to the terminal, that's going to be related to their terminal diagnosis or contribute to it. So anyone have a thought? So it's asking where we are in advocacy. I don't know of any specific advocacy other than I think we all hate this and wish there was something there, but I don't know if there's specific measures going on in this realm with Medicare and hemodialysis. Anyone have any thoughts or knowledge on that? Alan's going to copy us a link about a pilot program out there on that. I can. Go ahead, I'm sorry. There was a story about it that was in Kaiser Health News, and they talked about this pilot program. Unfortunately, it's also given, and they were able to benefit under a Cambia grant. So not all of us may have access to that. It also depends on your own hospice. I know, for example, in South Florida, we would sometimes negotiate and have particular conversations around what specific goals were and looking at whether or not people are getting benefit, or I don't know if others have encountered this, but when I point out, I can tell you the number of patients who, forgive me if any of you are nephrologists, but I was calling it sham dialysis down here, because behind the scenes, the nephrologist would admit, yeah, we're just connecting them, but the patients couldn't tolerate any fluid coming off. They couldn't tolerate a full cycle or other things. And so when you talk about transportation, when you talk about people, and again, I know many of you already realize this, if someone has dialysis and they feel great for the two days until they need it again, their marginal return is decreasing. We start talking about, okay, what are your priorities and how to go forward? Some of it is education that I find people think if you immediately stop dialysis, they're dead in five minutes, whatever. I've had people go several months and survive. Again, they're chronic, they're not in acute renal failure and they're compensated for it. So perhaps that may be relevant, but I'll copy the other link of that article. If I may comment on the subject, it's a very important subject, actually. I have two thing on the dialysis, hospice with dialysis. The first one, if it's really, truly, I do have a few patients where it ended up like five, six months after we stopped dialysis. This is not uncommon, chronic kidney disease, being dialysed and so on. But if it's true, like in this stage, renal disease and dialysis dependent, life expectancy, nine days minus a plus. So on those cases, like few cases where I did accept the patient on dialysis, our hospice agency paid for the dialysis for negotiated, limited short period of time. I do believe it was two weeks and this was due to a specific event, like the family waiting for somebody to come in overseas and so on and so forth. So we agreed to continue with dialysis and we paid for it. And this was not a problem, you paid for dialysis and we negotiated the rate with the dialysis people. Now, the other hand, from technical standpoint, can hospice patient be admitted, continue with hemodialysis, but as indecision and disease, not the primary diagnosis from technical standpoint? Yes, you can. You can have hospice patient, pancreatic cancer with lung metastasis, and they are in hemodialysis for 15 years. They don't have complication and they can stay another five years on dialysis. Can I admit this patient in this there, pancreatic cancer with lung and brain metastasis and dying in two months and continue with dialysis if the family choose? Yes, from technical standpoint, from regulatory standpoint, you can. However, it is a problematic. You don't wanna go this two years later, the Medicare come back to it, no one finding and so on and so forth. So in my career, I have two cases where I did not hear complication for it. I did explain to the family, listen, from technical standpoint, you can do that. However, basically they signed the advanced non-covered letters. They took, they agreed to take some financial responsibility in case Medicare declined paying for dialysis while they are on hospice. This happened about three years ago. I did not hear any audited for it. So I assume went through. We had one similar that the executive director for our organization called directly to the fiscal intermediary and they agreed to allow that circumstance of a cancer that we felt was not related to the chronic dialysis. And then going to what Alan was saying after a few, I think it was only a few months before the disease progressed enough that the family saw there was no more benefit of return on the dialysis. So the dialysis stopped as well. But I'll say I was the physician that ended up on call managing that Dr. Farrell and it was really messy and we're still getting bills as a hospice from that, but it's not clear how things can be unrelated when their documentation says short of breath, in pain, those types of things that align with palliative symptoms from, I think they were cancer. Tommy, if I remember correctly. Right, right, it was actually the pancreatic, or bowel duct, yeah. I think a lot of it has to do with risk. As you mentioned previously that it, they can still come back and bill you for all of those things if they determine that it's related, which is unfortunate. Yeah. Since Lauren just spoke, this is a question that sounds like her category, but I'm gonna mention someone said, how can we help case managers to improve their documentation and reporting of decline for recertification? So how do you make sure your nurses are always documenting to certification? And I think my quick answer on that is you do have to teach nurses that intentionally. This is not intuitive for nurses. So you have to be intentional in helping them do that. But any tips on how you help your nurses understand how important their documentation is for recertification? I just, hi everybody, I'm Keishonna Guidry. I just put together a little summary document, suggested template for the RN case managers because I was running into some QI resistance on my documentation. But as you guys know, we rely on theirs and I was new to this particular team. And so I just put together a suggested template for in-stage renal disease with those things that are in the LCD guidelines that they could use and the ADLs, their eating, their ambulation and other factors. And I just gave it to the DON and she gave it to them and we'll see how that works. So that's what I did to help. So you haven't had the feedback yet to see how well it's received? Well, initially I got a few comments. Oh, now that I have to do this, it's taking more time and I'm thinking, well, we should already be doing this. But I took the time to do it again because I want them to realize that we work together and I do rely on them, but that's a challenge as you guys know. Preaching to the choir. Changing words does help. Progress towards death is much better than decline. Progress towards death. I'll write that down. Thank you. I don't know if this family liked this terminology, progress towards death. I think this is- Nobody likes it, but it's hospice. It's part of the law. Yeah, I think that's not- Didn't you mention, Olga? Not the terminology you're using with a patient or family just as you're progressing. Then there are patients who don't decline, right? We have those sawtooth patients that might have periods of stability. And so what are you doing if you're only documenting towards decline? You have to document why a patient has a prognosis of less than six months. And so their PPS might be 50% from 30% at admission, but how is that patient still advancing towards death if they have a New York Heart Association of four congestive heart failure? Thanks for the shout out on the verbiage, Dr. Van Buskirk. That's my coin phrase that I've been using is how does the patient advance in their trajectory towards disease trajectory of how they're advancing towards death? It is helpful in framing how case managers write, especially, I think. We had a patient that was in that sawtooth pattern. It seemed like every few months, I was looking at the documentation from the nurses and I was like, dang, I'm uncertain this person qualified. But then I'd go make the visit to the home and more than just making the visit to the home, I'd also look back at the original cardiology notes and this guy's disease was so extensive that I kept in that. I'm just having to go back to my certifications and rewriting, almost taking big chunks of phrases from the original cardiology notes saying, I know this, so kind of documenting that despite evidence to find the patient's risk is still so high from this disease and this disease and this disease that I anticipate a sudden cardiac death at any time in the next six months as the disease follows its natural progression. And he did eventually pass, but he's one that had gone past the, definitely past the year mark and may have gotten even more past the year mark, but he was always appropriate for hospice despite not obvious decline, or at least to my estimation. And I guess I don't think we got audited unless Dr. Simpson knows we got audited on that patient. If it may be helpful for others, during part of my career, I was also a physician advisor and also did peer reviews and other things. One of the aspects of the language that may be helpful, and forgive me if this is common knowledge and I don't want to waste your time, but when you do your statement, not only specifics on identifying the patient, but after you identify name, gender, their hospice diagnosis, relevant comorbidities, when you say may, still qualifies for hospice or appropriate for admission and use the word because, that'll get you in the pattern, okay, I'm not saying they're appropriate since they have a label of class four CHF, there are millions of people class four CHF, what is different? And to speak to an earlier comment with nursing staff, admission staff, marketing staff in your own team docs, what is different? What are you seeing? Paint the story, convey the image and it doesn't have to be a novel. As a matter of fact, the shorter you make it, it can be more powerful if it's relevant. What is changed? What's happening? What are you concerned for? And be objective. Lauren had a great review and other comments that were built in, in another session, another event, but making sure things are specific. Don't just say eating less, how much less? How much time is taking? Not just sleeping more, but again, went from 16 hours a day, now it's 20 hours a day. What has changed? And for those moments where there may be a moment of improvement, also put it in context, that's not their baseline. And we sometimes see, again, a day before death, whatever, that people may start interacting, may have this last hurrah, if you will. And of course, as you're researching that they may be appropriate and you're wondering, put it in context, that may help. Yeah, I, like Alan, do that physician consulting review of documentation as well. I think one of the things I try to keep in mind is when I review documentation, I look at it from the lens of a hospice physician and can interpret what people are implying, but auditors are not going to give you that type of interpretive benefit of the doubt. And so we have to make sure our documentation is not open to interpretation. So, they have a prognosis of less than six months because of this. I think that statement, Alan, is very powerful, but it has to come with specifics to the patient. It can't just be words that we could use about me. When we talk about declining, I'm declining. My knees hurt more today than yesterday. I'm 38. That doesn't make me terminally ill. So, we just have to be, watch our documentation to be specifics. And to the point about nurses don't want to document more, I don't want them to document more either. I don't want more stuff to go through. I want them to document more efficiently and things that matter, not just the generic documentation that applies to every patient on service, make it specific to their patients that they know so well. I just want to respectfully caution you, Lauren. I can't even remember 38, so be careful there on those kinds of things. I'm going to take a question that's similar in that it's about our day-to-day wording. It's one asked, I'm curious about how other agencies involve and show that they involve the hospice attending of record. How do you involve the hospice attending of record and show that you're involving the hospice attending of record? My quick comment on this too, is it does have to be intentional as well, because nurses oftentimes, and I get their days are busy. It's real easy for them to call and use the medical directors and sometimes forget that there may be, or it should be a primary attending that should be getting the messages and calls. But how do you all do that in all the agencies? Make sure you're involving the attending and documenting that you're involved in the attending. One thing that I had done, and it also had a dual purpose for marketing, is sending copies of our IDT and IDG summaries. And that care plan, sometimes our marketing people would want to take it and personally deliver it. We'd find out some docs want to have it either physically given, faxed or whatever, but we let that be part of the relationship. Some said, we don't want it, it's just clutter, we trust you, we don't want to be involved, but it serves several purposes. It closes the loop. We also, if for example, there were consultants in the hospital and they can see what's happening, that helps to update them. And when we tell families, we have shared this with your team, so they're in the loop, that is helpful in appropriate circumstances. So it depends on the participants, but that may be a beneficial marketing advocacy for what we're doing and practice what we preach on collaboration. Other thoughts? Very good, thank you. Some thought about this one because actually, so involving the attending physician outside the media director in hospice, it's really the, we have to approach, but I like to share like three or four years ago, we got audited actually because of this aspect, was how the attending physicians was not exposed to the hospice plan of care. So the patient was nursing, the patient was nursing home patients and they have attending physician. Usually what we will do, the IDT note, we will fax it in or mail it to the attending physician. Even though we had record, like we did send the IDT to the attending physician, but we did not, by fax, we did not have, we could not confirm that he received it. So it's not really enough to mail it. You have to really, again, we get cited four years ago because we send the IDT note for the attending physician, but we could not produce that the attending physician received it. So it's sometime get- That's one picky surveyor right there. I'm sometimes I get like really picky on this. We sent it. We have page, like, you know, when you fax it, you have thing at the bottom, but we did not have the confirmation base. Like, you know, it went through this. I remember specifically she said, yes, I know it says like you sent it, but how do you know it's went through? That's what she said exactly. So it's, we have to be a little bit careful with it. So getting primary attendings to respond is really, really difficult because many of them, even though they say they want to be the primary physician, they never respond to us or the patient's family when they try to contact them. I think if you're in a situation where consultants or attendings want to participate, and we have some of those too, we really do, they become very easy, but the ones who don't just won't. You never get anything back from them. As I said, we hand deliver to the office and they have somebody who stands there until they sign it. And for those thoughts, here's a question from the chat that Dr. Fiessa shared, saying patient had a clear wish to die in her home state, but the airline's declined despite providing adequate documentation of okay to fly to maintain her wish achieved. What is your experience to giving permission for dying patients to travel? Anybody have any tips on getting a patient traveling? We just had this issue recently as well. The family was relocating from California, where I am, to Minnesota. The information was not conveyed to me, but the social worker of the skilled nursing facility was working with our social worker, and so there was an expectation of a clearance letter for travel. But after talking to administration, it was determined that we were discharging with giving them the support they need on the other end. So I actually don't know my role in that, and I'd like to know, because I figured if it's their choice to move and die in their home state, I don't have to say they're safe to travel. It's their choice to go. Am I wrong with that, or how does that work? This is Mike Tobin, I'm at Pathways Hospice in Brookholmes, Colorado. I've had to write letters for patients who want to get on airplanes to document whether or not they need oxygen, whether or not they need wheelchair transport. I think mainly what the airlines want to know is that they're not going to die in route, because that presents issues for them, they have to land at the closest airport or something like that. I've never been in a position of writing a letter for somebody who I think is going to die in the next day or two or three. To me, that seems like too high a risk, a situation, I haven't been through those, but maybe somebody else has other experiences like that. There's some going along in the chat for Dr. Piazza too. I held on to two questions because I thought they were ones that would be very nice if we were starting to lose steam, but we're not losing any steam. But let me bring out two questions that I think will probably get people's thoughts pretty strongly. One is someone states that their hospice nurse or administrator is suggesting that they keep writing opioids and controlled substances without paying attention to the, I don't recognize the first set of initials, but the other one's Physician Drug Monitoring Program. The first one was MAPS, and I'm just forgetting that acronym all of a sudden, but I get the PDMP. But my quick response on that, and I'm happy to hear others, is nurses and administrators aren't usually very good at helping me not keep regulations. They can talk me into other things, but I don't let them talk me into not keeping regulations. It's still important for us to make sure we're doing appropriate opioid management and again, with some compassionate considerations of how we try to manage a personal substance use disorder well, but still within the scope that shows that we are paying attention to certainly the drug monitoring program and other things that we should be doing for that patient. But anybody else have any other thoughts about how do you navigate the, and I'm assuming that this is probably from a compassionate nurse saying, why are we worried about their drug addiction when they're dying of cancer? I guess that's probably the phrase. I don't know if the person offering the question wants to say it differently, but I imagine that's the phrase you heard is, why are we worried about this? Someone want to answer that even better than I did? I'd like to make comment on this. It's really at least my professional experience with this. I'm not, I really, I'm worried about the addiction for those medication for the patient itself, but usually it's a drug divergence. It's the caregiver or somebody else or somebody else taking those medication. And I am practicing in Lorain, suburb of Cleveland. And I promise you just about 18 months ago, I have son of a patient. She was cancer patient in this stage, cancer patient with metastasis. He ended up in jail because he was stealing hair morphine and replace it with something else. Got caught, we called the DAA, investigated. So it's really the issue is the addiction of the patients for the medication, but rather diversion. At least this is what I'm experienced with it. So to control this, we are very clear on our opiate contract. We will not negotiate related to the missing dose and this and that. And any prescription being written by me before the nurses, before they tag me the prescription, I have to have the count from the previous prescription. And if the number is appropriate or not, if it's not appropriate, then we have like our procedure, what to do and what not to do basically. But this is very serious issue. And the last thing you wanna do, being the questions by law enforcement related to this issue as a hospice physician. One of my more heartbreaking cases was when we found out a adolescent wasn't getting all of his medicines because the mom was diverting them. And I was grateful for the nurse paying attention to all the right cues and us doing the right practices. Just throw it out there, choose some techniques as obviously, and hopefully, I hope this is, you're saying, oh, we already know this, but if you have someone with substance use disorder, consider making sure that you do the pill counts as mentioned, consider doing shorter prescription timeframes in between, doing shorter, only giving a week supply or three days supplies or whatever is a safe supply allow that person to have maximal treatment without going through their medicines too quickly. And I also offer, if we feel like we're getting really out of control, that that's a good use of our, if you have access to an inpatient unit, that's a good use for our inpatient unit. So we can have nurses administering the medicines to monitor exactly how much is needed to control pain adequately without delving into the problems that you get with the substance use part, the emotional coping part. And sometimes those are all techniques that hopefully can help. So I don't wanna just cut a person off of medications until I've done my best of managing the substance use disorder with the terminal illness. Other thoughts? We have a pharmacy bubble pack and three day supplies. So who delivered the medication to the patient? Is it delivering service or the family will pick up the medications? Pharmacy delivers to the house with bubble packs. Okay, so this is great. One of the other intervention, I have it in my region. In a few cases where before I write the prescription, we demand and request, we will not write the prescription without lockbox and assign one individual in a charge of those opioids to dispense those meds from the family member, especially if they have like too many family members, some of them abuser and so on and so forth. So we'll assign one person and they have the key. And this is, and we, of course, prescribe like limited amount and so on and so forth. And when it's always appropriate transition to methadone, I utilize methadone quite frequent in my region. Other thoughts? The other hold on question I had, I'm not in a state where this, I have any knowledge on this. So I'm gonna share this one for the states who do have this. Is it feasible for a hospice medical director to be the attending and prescribe a hospice patient's medication for medical aid in dying, the MAID? So I'd say Texas is not a state where we have this, but is it okay for a medical director to be the attending for a patient who's gonna be going through the option of medical aid in dying and prescribe, it said prescribe a hospice patient's medications. I'm not sure if they meant the medication specific, I'm assuming they mean just the hospice patient's medications, but also the medications for medical aid in dying. And so let's explore that subject for a while with me not having anything other than thought since it's not in our state, go ahead. Well, I'll speak to that. Emily Looney out of Albany, Oregon. And so it is feasible with my program. We just try to be really mindful of the fact that people already have misconceptions about hospice hastening death. And so just trying whenever possible to have another physician who knows the patient longer be in that role. But yes, it is feasible. There are no laws or restrictions against it. This is Dan Harris in Corrales, Oregon. I agree. While I try to get the subspecialist from the patient's disease process or their long-time primary care provider to be the other physician involved. But yes, it is quite possible for the hospice physician to be attending and to write the prescription. That's true in Colorado also. My hospice, however, is in affiliation with three other hospices on the front range of the Rocky Mountains. And our affiliation as a group has agreed that we wouldn't write the prescriptions or even be the consulting physician. Which I personally think is unfortunate because who better than a hospice physician or medical director to make those determinations but something to continue to work on with my group. Are you all still caring for patients that are taking the option for medical aid in dying? Are you still caring for them otherwise? Yes, but our affiliation has agreed that we can't aid in the process. So for instance, if the medication needs to be mixed, I think the current cocktail is a powder that needs to be mixed with a diluent and then drunk, about six ounces, four to six ounces. Like our nurses aren't allowed to mix it up for them. And if they spill it, they can't help them pick it up. Those kinds of things, but they can be there and they're expected to be there for support for the patient, the family and for symptom management. Thanks for the resources you just sent in the link, Alan. I think we need to have a coffee chat. That's just resources by Dr. Rosene. Any other comments on the medical aid in dying? Bruce, I went through all the questions on the list. Do you want to pick out a particular question, your favorite last question from the chats that I haven't been able to pay attention to all the chats? Do you have a question in there that you think is worth bringing into the group, especially, Bruce? Yeah, there was actually two, but I'll ask the one first. It was a question from, I think it was Dr. Looney who asked this question about, it was from earlier on. So we have to kind of go back and remember what was being talked about exactly. But it was, how many of you on the call have a point person contact within your MAC to review questions like one that was posed earlier by Mauya, is it wise and feasible to have this direct contact with the MAC? So I'm interested, I thought that was an interesting- And that's probably in relation specifically for the question about like dialysis, being able to do dialysis at the same time. And as Dr. Tempton pointed out, we had a direct contact with the MAC and it still didn't mean that because you had a verbal conversation approving something that it didn't mean later on you had headaches. But anyone else have thoughts about having a direct contact with your MAC? Oh, you didn't pick an interesting enough question. Apparently not. Bruce, I'm sorry. I'm sorry. Apparently not, wow, okay. Does anybody else, does any, oh, there's someone that said we have a compliance officer coming up that last chat. Oh, go ahead. Can I have like one question unless if somebody else is- Nope, I think you got it, let's do it. Okay, anybody, okay. Anybody can update us on the exemption for face- Okay, the visual face-to-face for hospice physician. We have the exemption from last year. Anybody knows if any plan to remove it or expire it or still effective as far as we know? I can comment to that. Oh yeah, go ahead, yeah. Yeah, so in California and Texas specific to Medicaid, they've given orders regarding the timeframe for Texas we have until November something. And we have to change for Medicaid only recipients back to in-person in the order itself. They specify that if someone is dually eligible for Medicaid and Medicare, that the Medicare face-to-face regulations are compliant. There is a lot of talk about this on the forums. And so I reached out to the NHPCL about national clarification because it seems like a lot of this information is being disseminated to other states and what does it really mean? The NHPCL is getting legal guidance themselves and they'll be releasing a statement tomorrow is what I heard from Ms. Lund, which is she's part of the regulatory committee. So we should know more tomorrow. But for now we have a state order in Texas that you have to stop, I apologize. It's like November 6th or something on or before that and have to do Medicaid patients in person. But from Medicare standpoint, it remains in place as long as the public health emergency remains in place from the CARES Act. Yeah, on the Medicare part, it's all about whether we're still in a state and as long as they're declaring the state of emergency, it stays in effect, but that gets renewed. I think that gets renewed every 90 days. The other thing, if people aren't aware, the Federation of State Medical Boards, fsmb.org, has an entire section on what states have made whatever accommodations, whether it's credentialing, whether it is waivers, and it links for each state. I'll type the general site in. It's Federation of State Medical Boards. I think it's .org. And there was, I was looking for something else and happened across it. I'm like, wow, I didn't even realize this existed. So that may be a helpful reference. Thank you so much. Thank you for y'all's participation. We're at noon. On the way home from work today, I'm gonna be listening to At the Heart of Healthcare with Dr. G for the first time. I'm looking forward to seeing that podcast that I saw on the link. Thank you everyone for attending. Any last statements you need to make, Bruce? No, that's it. Gina just put a link in the chat. And Dr. Rosen, you're correct. It is fsmb.org. That is the correct link. So if anybody is interested in that. But thank you all so much again for attending. Really appreciate it, Tommy. Thanks for MCing. Appreciate it very much. Sounds like we can have a coffee chat almost every day on topics. There's a lot of good information we're sharing with each other. Thank you for y'all's engagement. Thank you so much. Thanks, everyone. Thanks, everybody. Have a good one. Hey, Gina, thank you for everything.

hospice care

palliative care

COVID-19

nursing homes

attending physician

prognosis

documenting decline

medical aid in dying

opioids

exemption