for being here today. So we're gonna go ahead and get started and we'll keep letting people in as they enter. But before we do get started, I just wanna share that we really wanna make this as interactive as possible. And if you've attended one of these before, you kinda know how it goes. So please feel free to come off mute or talk in the chat box, either by asking a question or sharing comments with one another. We do ask though if you're not speaking just to stay on mute. And before we dive into our conversation, we do just wanna share a couple upcoming HMDCV events with everyone. So we will host our last webinar of 2022 on December 13th at noon central time. And the title of that session is Supporting Hospice Program Vulnerabilities, General Inpatient and Continuous Home Care. So you can register for that at hmdcv.org slash webinars. And then we just wanna share that our initial application will open on January 16th. So please encourage your non-certified colleagues to learn more about the credential, consider becoming certified. And then our 2023 community events, our webinars, our coffee chats, our other events that we partner with Weather Beyond, we're currently planning for those. So we'll have those posted at hmdcv.org slash community in the coming weeks. And also check your email because we'll have them post it, send out information and registration links that way. So I wanna introduce our facilitator for today, Dr. Todd Cote. Dr. Cote actually serves as our secretary treasurer for the HMDCB board. He is also the chief medical officer at Blue Grass Care Navigators in Lexington, Kentucky. So Dr. Cote, I will hand it over to you. Thank you, Gina. Can you all hear me okay, Gina? Is that all good? Yeah, I can hear you. Yeah, just wanna make sure. Nice to see everyone. And it's great to see people coming in and saying where they're from all over the country. Lots of colleagues, lots of friends. So great to see everybody. And good morning and good afternoon. So I'll say, as Gina said, I'm a chief medical officer at a large hospice and palliative care organization located in Kentucky. Our headquarters is in Central Kentucky in Lexington, Kentucky. So another reminder other than mute and unmute, which we all get caught in that, I know, is please, if you get on mic and talk, please share your name and where you're from, initially at least. And we'd appreciate that so we can kind of all feel like we kind of know each other a little bit better. But, well, I'd like to jump right into everything. Thank you for those of you that submitted some questions. We have about 12 questions, different areas. One of the roles I see as a moderator is to maintain and watch time, because one topic alone could probably consume the whole hour at times. And it's not a bad thing, but we just would certainly like to chat about many things that are on your mind. So I'll try to, if I interrupt, I don't mean to interrupt in any negative way versus just try to move forward so we can talk about it as much as we can. So again, thank you for calling in. So I'd like to just kind of ask as your moderator, before we jump to the pre-submitted questions, ask any of you, if there is something burning on your mind, something that happened today in your work and or that you really bit in the bit at and really want to get out, I'll just open to all of you, any questions, discussions to start, please. Dr. Coté. Hi, Ron Spencer, can you hear me? Hi, Ron, thanks, yes. Sure, yeah, you just perfectly described something that's been eating at me for a long time, not necessarily today, but I would like to get a survey of opinions about use of steroids, usually dexamethasone at end of life. I realize it's a bit controversial. There's a term going around called cytokine burden, which I think was born during the COVID crisis relative to cytokine storms and such. I'll try and summarize what my concern is. Most of our patients on hospice die of cardiovascular disease in one form or another. The biggest killer in the world and people have typically congestive heart failure and such. There's a notion going around that people accumulate too many deleterious cytokines in situations like that, also in neurodegenerative diseases and stroke and such. And people are liberally prescribing dexamethasone well-intended to reduce the cytokine burden. I recognize the utility of steroids for people with cancers, solid tumors primarily, myeloma, it helps. It helps with the traditional indication, specifically fatigue, perhaps wellbeing. But I'm not at all sure that somebody who's got maybe a month left of life with congestive heart failure and such is going to benefit from steroids and with the adverse effects that they come along with that we all know about too. So I just wanted to survey some opinions about what appears to be almost a universal utilization of dexamethasone near the end of life. Anybody have some thoughts on that? This is Tommy Farrell and Abilene. I don't mind jumping in. You just said something interesting there. You said the universal use. So I guess maybe I'm not seeing it used universally. So I do know that it's used at times and maybe that's where it's, maybe I'm just going off my own practice. I think there's, based off the goals of the patient and the particular symptom burden we're having, I do use it at times, but probably not the majority of my patients. I remember, I'm going way back to medical school when I had a bad lecture where the lecturer, I didn't know it was a bad lecture at the time because I didn't know anything. The lecturer from internal medicine that taught us about death who didn't, but before palliative was the profession that it is now, just said everyone should die with a trough of IV fluids, IV fluids, oxygen, and steroids. And I said, you know what? I realized now that only two out of three of those are definitely not certain, but steroids is still on my list of something that I do. But it's not like an automatic, you're dying, let's try steroids. It's what I have going on. If I have symptom burden that I feel like may be relieved with a trough of steroids, and sometimes that's the physical symptom burden of the exact symptom, but that's when it's easier for all of us versus even kind of more of the theoretical. I had a lady who was dying of ovarian cancer and a big part of her narrative was she was very happy that she had not died from her breast cancer. She survived breast cancer three times, and that was just a very big part of her identity. And there was a cancer walk, and we were gonna go to that cancer walk with her in a wheelchair and a bunch of, we called them Anne's fans, because her name was Anne, and we were all gonna do the cancer walk with her because she survived breast cancer, a breast cancer walk. And that was very important to her. And then the nurse called me a week before this walk was happening, and she says, oh, I'm worried that Anne might die this week. She's going down. And we did do, based off her goals in an open discussion with her, a trough of steroids and a little bit of a fluid bolus, and we got her to that walk, and I think steroids were a part of the solution in that moment. But there you go, there's my fun. Yeah, that's fine. I understand that, and I'm sure that helped. It may have given her a bit of a boost, a bit of a lift. I understand that, and I didn't really mean universal. I meant liberal, where I just can't quite understand how patients have an increased cytokine burden, but cytokines are actually physiologic, but how someone might have a cytokine burden at the end of life that needs treatment with steroids. Ron, this is Alan Rosen. I'm currently in Nashville, 20-year hospice palliative care. I think there may be some conflation going on that sometimes there are kernels of truth, and it becomes the telephone game. As management gets relayed, it's taken out of context. What may work for one patient at one time? Unfortunately, by those without training trying to do primary palliative care, and I've seen this with methadone, I've seen it with dexamethasone, let me say- I'm in a meeting right now, so. Let me say in full disclosure, I am one of the ones that will liberally use dexamethasone, and I will actually say that I find there is resistance when it can be so helpful. So you name certain situations, I want to emphasize for everyone that there can be a GI benefit, there can be the respiratory benefit, there can be the energy benefit. If anyone has a head and neck cancer, I almost always, unless they're on some other contraindication, find it helps, because with head and neck, just a few millimeters can mean the difference in inflammation for swallowing versus coming out. The one other thing that I'd say on the side effects is sometimes it's less personalized dosing regimens and timing. So when I'm working with fellows, residents, and others, I have people front load the medication. So depending on what their intake is, if they're taking oral dex, then doing so when they're eating in the morning, but don't take it at 10 o'clock at night, especially if they're inpatient. So taking it earlier, and to quote Lynn McPherson, she calls it vitamin D. So I agree with you, it's not for everyone all the time, but I think the right dose at the right time, I'm not worried about. And I think some people may be conflating and justifying it out of an anecdotal experience. Yes, well, yeah, it's a feel good medicine. I think it to a certain extent allows us to feel like we're doing something. If ever anyone has been treated for influenza with steroids, they feel a lot better with the dose pack and such. And I want that for my patients, but I don't see it universally. Sure see it with the head and neck and the narrowing airways and superior vena cava syndrome and things like that. But I don't see it for stroke, simple stroke, ischemic stroke I don't see it for congestive heart failure. And yes, tumors and solid tumors. Can I push back one second on the stroke? Yes. And it may have been when I was a medical director in South Florida, we had a lot of drowning patients, other types of traumatic brain insults and strokes. And one of the cautionary things that I'd often see and this just may be my bias, but I'd see post-stroke edema and other symptoms that actually trying to help out in earlier utilize dexamethasone could be helpful. So I would not categorically say no in stroke. Again, I would personalize it, but I defer to others in your perspective. Yes, I understand. And certainly hemorrhagic strokes, subarachnoid hemorrhage, anything that clearly causes massive edema like an anoxic event, a drowning. Yeah, absolutely. But for the more garden variety, middle cerebral arteries, such syndromes, the ischemic stroke, I couldn't find anything in the literature. And I've asked a couple of neurologists around here and they're kind of wishy-washy about it. I don't think there's a great deal beside of toxic edema that happens after an ischemic stroke, I don't think. So anyway, I'm just uncertain about things like that. I'd appreciate anybody else's opinions too. Thank you. Thanks, Ron. Fascinating question. And it goes to the point of maybe more research, but also following the research, as you just mentioned, I think that evidence-based approaches and all good points by Tom and others. So thank you so much for that. Any other burning questions or ideas, issues? And by the way, if anyone finds anything for Ron, please, we can connect and network through the HMDCB. Yes, and Alan, thank you. I think you mentioned Lynn McPherson. I looked through her textbook, which is now outdated a little bit, and I looked for something about vitamin D, I think she called it. And is that a thing? I mean, is that a thing within her pain management realm there? Okay, I will look again. And certainly there's a role for using inflammatory pain. I understand that. I've worked with her on a number of complex patients and conversions. And again, one of her first questions, but it goes back to what the etiology and what you're doing. I would not have it on standing orders automatic, but I do believe if you have symptom guided orders that you have to consider a number of other sets, whether it's respiratory, GI, contraindications, other things to consider, and then consider what you're doing and why. And going to Todd's point, what are your metrics? So if someone came in for a crisis, they're in your IPU, you're escalating this care to now include steroids, and what will be your metric and outcome for either scaling back? And is this a temporary measure or is this something their condition now needs ongoing? Which in turn may be determined by their estimate, their prognosis, how long they're gonna be around. The oncology literature suggests an improvement in pain and energy for two or three weeks. After that, the adverse reaction burden starts to accumulate a little bit. So what you said certainly makes sense. You pick out what you're going to use, how long, and how do you measure it? Yeah, finding a metric for that. Difficult to say in complex patients, but a good goal. Thanks again, Ron. Thank you for that. Let's jump to some administrative regulatory, all of our favorite, and I don't want to consume the rest of the time, but looking at the pre-submitted questions, there was a couple pretty straightforward from Vincent and Robert, if you're on the line. On the admission process, let's go through that real quick first. One question, do you guys require evidence before admitting the patient such as ejection fractions, echoes, MRIs, and any commentary what admission operational process you all have as hospice physicians? And then Robert dealt with another probably familiar concept of, hopefully not too familiar, how do you deal with challenges from non-clinical admissions managers pushing to admit a patient so that admission that's coming downstream to you that you need to admit that you already assessed and or didn't assess, so on and so forth. Any thoughts, comments on those two kind of perspectives on admissions operation, operational aspects of admission in hospice? Medical director at Four Seasons Hospice near Asheville. I also have seen a much bigger push to get people admitted quickly and without all the documentation. And I think it depends. I mean, sometimes I can clinically read about a patient or maybe they're at the hospital and I hear from the nurse that they sound hospice appropriate. Maybe I don't have all the records right away, but I'll go ahead and admit that patient and then ask our medical records people to follow up and get the documentation I need. So that I can write a strong initial certification. Other times I've heard of other hospices who just will basically admit anyone who's referred. And then the downside about that is that when you collect the records later, if you find out that they're not eligible, then you're having to proceed with discharging for extended prognosis. And that can create a lot of issues with the family and the patient. So anyway, I do agree I'm seeing a bigger push to get people admitted right away with less records. And so I just kind of try to do my best. The other thing I'll do sometimes if the records are really poor and I haven't been able to get records timely, we'll send a nurse out there to go see the patient and then they'll call me and say, this is what I'm seeing. And then sometimes it's really obvious that that patient needs to be admitted. So again, I'll just proceed with the admission and then ask for records to be, for them to work on getting records. This is Maria, I'm from Mercy, New Life Hospice, Lorain, Ohio. So for the first question, do I ask for really invasive studies sometime before like CAT scan or MRI, as you mentioned? The answer is almost never. I do ask sometime for certain tests, like complete metaprofile to evaluate the albumin, to evaluate the nutrition status. If they tell me there's weight loss and we cannot really objectively evaluate it, but to go further to CAT scan or something or something, I really go for that because most of the time it's usually it's a clinical presentation. You have to follow up and confirm it with the available medical record. This one for the second question, if we have push from the administrator. Yes and no, but if you have to, if you're not, okay, if the case is clearly as medical director, I know the patient is not appropriate, then he's not, he or she not appropriate, but if it's borderline, those most of the time when I utilize any testing, those when I utilize those testing to confirm or not confirm. And I have mechanism in my practice. If I find somebody not appropriate at the first initial evaluations, we'll ask if we can see the patient in one to two weeks. This is mostly related to not eating, nutrition and so on. If it's acute illness or just it's a chronic progression. So I try, if I decline patient to ask if we can re-evaluate in 15, in two week assembly, we don't wanna lose any potential hospice admission. Thank you. Ron Van Busker, home hospice of Grayson County, Sherman, Texas. When we get hospice referrals, my first question is, what is gonna cause the patient to die in the next six months? That's the first question I have to answer for myself. The second question is about, what am I gonna use for a terminal diagnosis? Those two questions are related, but not the same. I don't usually need exhaustive lab work or x-rays to tell me whether or not I think this patient is likely to die in the next six months. So when I hear about the patient, I get a pretty good idea about their clinical state. If I can't, I either go see the patient or we send one of our nurses to do an evaluation. The medical records, we need to establish diagnoses. And so we gotta get those, but that's not really what makes my mind up about hospice admission or not. Can I ask just a question for the previous two speakers? Said, if we decide we would send the nurse, in our practice, I never admit any patient before being evaluated of our hospice nurse. If there is any other practice where you can admit patient to hospice and then send your hospice nurse? According to the federal law, if a patient is diagnosed with a terminal condition, the patient can select hospice care. That's what the law says. So in our practice, we have what we call a start of care team that basically sends me a summary. So they look at all the admission records. They may even make a phone call to the referring provider or even the patient's family if the patient's not decisional. And they send me like a nice little summary of the referral and why the person is requesting hospice. Many times from that summary, I can say this patient is eligible for hospice. The admission nurse goes right out and admits and doesn't need to call me except for med needs. Other times when it's not so clear, that's when I'll ask the admission nurse to call me. When it's not clear from that start of care summary, we'll go out there, they'll see the patient and then they'll call me and let me know what they're seeing. In some circumstances, our social worker might do the initial signup, but they'll tell the family and client that the admission isn't real until the nurse assesses and calls me. And then it's a go. So there's that. And I just wanted to say where I've learned to be more careful is when other hospices are transferring their patient to my hospice. That's where I've had some issues in the past with some incomplete documentation, some, that person looks more custodial, why are you even on hospice? But you're moving from Florida to Pennsylvania to be with your kids, now I'm stuck. So I've told my admissions care, no transfers happen till I see documentation. Especially if they are in the six or seven or eight benefit period. Because it does have to be less. Or 20. Or revocation. Or revocations. Repeated revocations. So what do you all do about, we always have the transfers from Florida. And I mean, I'm hesitant to say no, even when they do appear custodial. It's like, well, this person's been on hospice and then they're moving up here and I'm gonna just tell them no, they can't do it. So a lot of times I just end up admitting them and then going from there. I really try not to do that because I feel like I get stuck in a pickle and I try to figure out a different service line that would meet their needs. Usually it's more of an in-home support type of thing. And if they're homebound and they have some sort of skilled need, then home care, maybe they need some physical therapy or maybe they, and of course, that's not gonna be the longterm solution, but at least it's a little bit of a wraparound service till they get situated in their new environment. That's where it'd be nice if one medical director could call another one and say, by the way, we're transferring this patient to your hospice and here's the story. You know, I think a lot of communication that we, well, that frustrates me is that we want good communication but yet even us as hospice medical directors, we're not really sometimes nice to our colleagues about doing that sort of thing. Yeah, I had a case where someone was transferring from Georgia and I didn't understand what was going on. So I called and asked to talk to the medical director and whoever I was talking to said, oh, the medical director won't take any phone calls. Oh my God. That raises more red flags. Can you hear me? Hi, I'm Ann Marie Moshloff. I'm from Iowa City Hospice in Iowa. And being in Iowa, we do get transfers from other areas. And I have, our access team is trained to make sure with those transfers, they have documentation, particularly we're interested in the last time they were recertified, we're interested in what the medical director documentation was, making sure we've got ADLs and PPS. And then if I can't speak with the physician who's been caring for the patient, I usually am pretty successful with getting the primary RN to advocate for a safe and successful transfer. So I will ask that they contact me. I didn't, you know, years ago, 16 years ago, we did get a number of people that came on our service and I was like, oh my gosh, we promised these people we would do this. And yeah, I think it's really important to make sure. We just had someone come in that was like three weeks prior to meeting a recertification discussion. So they came to us needing a face-to-face visit. And I just wanted to make sure that when we did all of that, that we didn't tell them no. So it does take a little bit of extra coordination, but we are theoretically tasked with being the best communicators in the medical care system. And so we coach our teams to take care of that process. Yeah, Laney and Carolyn, I'll remind us all of collegiality. Do you remember that? With having, there's nothing more valuable. I agree, Carolyn and Laney, with hospice medical directors, particularly in the trenches, being able to talk, particularly when there's transfers. I don't think we do that enough. It's extremely valuable. Sometimes it takes five minutes, so on and so forth. So I'll remind all of us. So thank you for reminding us all that. Go ahead, one more comment on that. Thank you. The speaker, I did not catch the name. So, I mean, everybody knows the, to admit any patient to hospice, you need Medicare Part B and life expectancy, six months or less. The speaker who mentioned just patient referral and medical director, it is a little bit risky always to have just the patient self-referring and admitted as medical director. Can anybody comment on those? Because, I mean, yes, we know we need two physicians, but medical director can do the signing for attending and the other, but to admit patient based on the patient referral and the medical director opinion, this is where the flag for me. Can anybody comment or can you expand on your commonplace? Since I brought that up to start with, I was only quoting what the federal law says. The federal law says, if a patient has a terminal diagnosis, the patient can elect hospice care for the treatment of that diagnosis. That's how the law is written. Now, so my goal is to be sure they have a terminal diagnosis. That's not the full story though, Ronald. This is Alan Rosen. What, just the wording yourself, and I stopped looking up, I'll put in the chat. I encourage people to take a look at the Medicare Learning Network and the MLN series. They've revamped and have a lot of excellent clarifications. We need to be careful who the payer source is. When we're talking about CMS, there are specific conditions of participation. You also get to eligibility. You also have from the side of an agency in terms of the responsibility, regulatory responsibility for an admission. So the word can does not mean will, and it also depends what their goals of care are, their other plan, the size of the hospice. And if they have commercial insurance, it may default to the state definition of terminal prognosis. Remember 1982, many states had 12 months, federal government had zero, and politicians compromised when they created the formal hospice Medicare benefit. If someone has commercial insurance, they may default to the state definition, which might be 12 months. And that'd be wonderful if it was 12 months across the board. I agree with that. But we so rarely see anybody with commercial insurance, I would fall over. Thank you all for that discussion. I'd like to move forward and we'll jump back to a clinical question, very specific. Jay, I think you're on the line. How are others handling referrals for non-invasive vent-dependent patients? Is this palliative, life-extending treatment, so on and so forth? Any thoughts? Or Jay, you may be on, if you'd like to elaborate. Or anyone else's experience. I can share our experience, but go ahead. You said non-invasive vents? He's up. Yes, Lainey, I suspect I know what you're going to say, but go ahead. We take those patients on hospice. If they have a six-month prognosis or less, definitely. We haven't had any issues with it. It's actually, at least where I'm in North Carolina, it's not expensive. So it's, yeah, but we always take those patients. And BiPAP, of course, also, but it's just so prevalent now. I just, it was a good question by Jay I wanted to throw out there. Anybody else? I definitely would take those patients. In fact, in my agency, as of October 1st, we start like second step where we, I am taking patient on complete vent, actually, from the hospital to the hospice center, which is adjacent. It's not the same hospital, it's the same. And we will compassionately wean in the hospice center within a 24 hour. So sometimes those compassion wean, they ended up with BiPAP or CPAP, but the non-invasive we're taking regardless, but as initial initiative, as of October 1st, we take even the hospice patient, the vented patient, and we try to, when that we try, we will have agreed with the family to compassionately wean them within a 24 hour. And they will be admitted under GIP when I take them on a vent for respiratory management. So most of our patients on non-invasive ventilation are at home and not GIP. And it's always a problem and an issue. But yes, we admit those patients. Sometimes it's easy and sometimes it's difficult because sometimes you, and I know you all know this, you end up with people who are sedated to control their symptoms and on non-invasive ventilation. And that reaches a point where I am very uncomfortable keeping patients in that state. They're awake and alert, that's a whole different and that's different. But when I've pushed the pain medicines and the sedation, that's the problem. So this is Jay, I submitted that question. I appreciate everyone commenting on it. Two follow-up questions. Dr. Honeycutt, you mentioned if the prognosis is six months or less despite the ventilatory support. I think sometimes that can be a little hard to know if someone is chronically vent dependent, are they now, is that a life-sustaining therapy? So wonder if the group has thoughts about that. The second is, so we've now had two ALS patients, one who is trach vent dependent, one just today who was BiPAP and IV dependent who decided to have a terminal weaning at home with cooperation from one of our intensivists. We've developed, are developing an ability to perform that service at home. Curious if others are doing home terminal weaning and what your experience has been, thanks. We have, we do continuous care. Dr. Joseph. Hey, Dr. Joseph. Carlos in Athora Care in Greensboro, North Carolina. We have done about two to three home vent weaning patients. The learnings that we had was that to make sure that you have a good IV access. We decided to medicate the ALS cases that we manage with subcu drips and they were not that great. And we have a intensivist, we have a respiratory tech, two nurses and myself and other nurses. And we did continuous care as well. So our learning was to really suggest to bring into the IPUs to do the weaning if possible. Otherwise have a big line or very good one or two IVs access. We had some challenges managing the symptoms and we have to back off several times from the weaning process. And despite combining medication subcu and escalating for some reason they were not as effective as utilizing IV. So just that's my experience with home vent, you know, the escalation of weaning. So thank you. Thanks Juan. Thank you. This is Todd. I just wanted to comment because there's one of you is from Massachusetts but back in 2001, the state hospice and palliative network did a white paper publication. It was brilliant. It's still brilliant. I have it on paper. So I'd send it right now if I could on home extubation ventilated patients. And Juan, even more from what you described which is the middle part, the actual doing the procedure which is the easiest part of even home ventil, you know, extubation is the pre and then middle and then post part. And they outlined the documents so well outlined and well thought out. So when I'm hearing all you talk, I go way back now to my experience and it talks what the social worker's role is in home extubation. It talks what the chaplain's role is. And those things that we've learned time and time again which, you know, you can't expediate, you know, quite often the family wants you to come over and extubate their ALS father patient who's been on the vent, you know, so on and so forth. It just requires a lot of time. So I think it's something hopefully we don't have to deal with a lot, but something that has been dealt with a lot. I was going to mention with some reluctance but we own our own pharmacy. We're in a big hospice, of course. So we have our own BiPAP and Trilogy, you know, 30 to 40. Quite often we have to rent them is what I wanted to say because we have so many in the field in patients that are appropriately, I think eligible in hospice that are declining and so on and so forth. Pulmonary hypertension, COPD, lung cancer, the whole work. So it is something that we need to think more about. I think particularly as things are moving from hospital to home, just wanted to comment on that. Anybody else on that topic? I may just add another thing. And again, it's being specific to the person, the dynamic, the setting, the timing, also your organizational capacity and whether it's medical leadership, nursing, other interdisciplinary teams, support and philosophy. But I'd like to put something out there that was a humbling experience I had when I was in Illinois in Joliet where the Les Turner Foundation was providing every one of their patients a VPAP. It basically was a BiPAP with a chip that gave automated breathing. It essentially was a ventilator. And one of the challenges I had organizationally, again, this is 15 years ago, they didn't want to do the simplification of care, withdrawal of life support in their eyes. I wanna remind people, we have gazillion patients who, whether it's their insulin intervention, whether it's for oxygen, COPD, cardiac disease, other things, that in many cases, we are supporting their quality of life and comfort. And no offense to anyone who's a pulmonologist, but I've had pulmonologists agree with me when I say, you know what? I equated a bit like nasal pannula oxygen in that I'm not going to keep dialing things or there's not gonna be a respiratory therapist coming every day. However, we can manage their symptoms. And so when we talk about the heroics or the interventions, it depends, what are the goals of care? What are the expectations? Because how many of our patients would not survive their COPD, their other conditions, even on nasal pannula oxygen? If I may add for the compassion training at home, the biggest challenges for us as, for my institution was, it's basically medication access in home for the IV medication access, opioid ad events. So it's really probably one of the biggest challenges if you try to compassionately wean anybody after you do all the logistic, the availability of the IV medication, of course, the same like subacute, but those medication, if your institution does not permit it or if you don't have your own pharmacy, it's gonna be a big challenge for you at home. So that's why, because of the limited availability of those IV medication, currently, we're just doing it in the GIP unit. Yes, thank you, this Todd again, and thank you all for that important discussion. I will try to get the Massachusetts white paper out to you all also. Thank you. Todd, you went on mute. Thank you. My last comment real quick before we move is speaking of administration, we talked about administrators, non-clinical. If you're doing these kinds of things in the home, please make sure that your leadership knows you're doing these kinds of things. There is precedent for this. There's even precedent for neighbors finding out you're doing this kind of thing and calling the police department. So I get all these experiences over the years of just trying to get your checks and balances in place versus kind of going forth really aggressively and, oh yeah, we can do it in the home sort of thing. And it is true, but I think it requires really quite a lot of operation and process. So all in there, and we'll kind of, let's swing back. We have about 12 more minutes or less to a topic. I always am a little reluctant because it probably requires a couple hour discussion on levels of care, particularly GIP. I think Monica, you alluded to it a little bit in the hospital setting that you found out your academic university hospital was doing some routine hospice care within the hospital. And then Pam did have a question. Is there a trend towards three day GIP limit? Of course, we've thrown up our arms for five day, but now three day, three to five day. Any thoughts, comments on all of that? Pamela, if you're on, you're more than welcome and Monica to comment. Are you talking about in the hospital or just in general in an inpatient unit? In the hospital setting, I think. And then I guess the more, Lainey, the more direct question is the three day GIP, which could of course be anywhere in the hospital, anywhere in a health facility, as we described possibly. I've just seen, I've personally seen hospitals where we have GIP contracts. Like if someone, if we have a patient, they're GIP more than three days, they're like pushing to get them out. So I don't know if anyone, I don't know if that was part of the question, but we certainly don't have that kind of limit at our IPU. Smaller hospices like the one I work for, all of our inpatient care is done on a contractual basis with the hospital. And we give them everything we get from Medicare for GIP goes to the hospital. So if we say, what we've been told is that if the patient is no longer eligible for GIP care and not looking at a number of days, but just we decide GIP is no longer appropriate, right at that point, we notify the hospital that we are only gonna give them what we get for routine hospice care. The hospital, of course, at that point does not want the patient in the hospital. So the number of days, yes, has become a real issue. We've actually been asked to provide medical records by reviewers before the patient was even discharged after five days. Day six, we get a letter before we've even been paid or filed for payment. So yeah, it is coming. Anyone else comment? Yeah, Ronald, I agree. To note, of course, way back in 82, statutory law suggested that a hospice can negotiate, by the way, with a hospital on terms of the agreement, basically the per diem, period. So there is flexibility. Todd, you're on mute. Thank you, Gina. It keeps clicking. Sorry, sorry about that. I don't know how much you heard about it. It was brilliant when I was saying, no. Ron, to your point, again, the mandates dictate that a hospice and a hospital or a health facility, which a hospital is part of, can negotiate that rate. Most, I agree, it's never been, I haven't seen a lot of data on, because it's proprietary information, what you negotiate, right? As far as a hospital hospice contract, but you can negotiate. And I do think there's certainly our organization, along with many others I know, are pushing that threshold a little bit, particularly with the ask from hospitals, can you help us with hospice in our building, so to speak? And usually it's a one-way education from those of us that do hospice to the hospital leadership, particularly the hospital administration. And I guarantee you that masters and health administration programs do not teach hospice very well. It's pretty, the model's pretty easy to teach, but they might've had one lecture on it because you really have to find yourself backtracking. And what happens is hospital leadership have heard from other hospital leaders about how they're dealing with their hospice. So there is flexibility in negotiation. And I think that's really important, particularly for big and small hospices to be able to integrate into a hospital setting, which is very difficult. So all kinds of trends back and forth over the years, there probably is a little more trend of, can you come and do a GIP or hospice in our hospital? I do think the rules and regs need to be followed very clearly. Tons of education typically to the hospital leadership, and then a lot of planning and organization versus just kind of jumping right in. In competitive environments, there's struggles because people say different things. You all probably have experienced some of that. And this, Monica, to go to the routine care, it's rare, we do that rarely, but I do think that needs to be part of this organized discussion and contractual agreement with hospitals, between hospitals and hospices. I'll stop there for anybody else. Go ahead. I think it's time for CMS to overhaul their levels of care. We're trying to fit things that didn't exist in 1982 by and large with our hospice patients into a 2022 problem. And along with some other things that I wanted to, if we had time, but I see we're running out, it had to do with the addendum and things that should not be on the addendum, but we need to find a way to tell patients right up front, other than saying to you, I'm not going to cover ESBRI yet for your pulmonary fibrosis. It's not appropriate. You're on 10 liters of oxygen plus eight additional when you move your hand. So where do you fit that? That's an aside. But I think that we really have to look at what was the spirit of GIP when it was first concocted? It was really for, this is how I'm interpreting it after all these years. My patient is in the home setting in a lot of pain or delirious or vomiting, and we're doing everything that we can. We've been working on it for days. It's not getting better. Let's go to the hospital, see if it can be better managed. And now it's this other thing. So-and-so exhausted all their days. They were on antibiotics for their pneumonia. They're not improving. The family doesn't want to take them home. They don't want them to go to a nursing home, but they are dying. Can you do GIP? So I just wish there was some other level of care or some, we just need to overhaul it. Thank you, Caroline. I don't think that'll happen in my lifetime though, right? Well, it's going to be already over. It's already happened. And that's a whole nother coffee chat, I think. I'm not sure if it's me, but I can't hear you, Todd. Sorry. Can you hear me now? It's just a little better. And I don't know. Yeah. I'm at my office and sometimes we get. Okay. Anyone. Any other comments? We have three minutes left. It's probably hard to start a new topic. I'm so sorry for. A few other topics that we couldn't get to, but I do know that. Even next year, we're going to do these every two months instead of quarterly. So I think we'll have some more sessions coming. Gina, I think we can go ahead and end with respect to everyone's questions. Thank you so much for leading today's chat and thank you everybody for attending. I know there were a lot of questions submitted. We didn't get a chance to answer, but like Todd said, we'll host the coffee chats in 2023. Every other month started in February. So we'll send out registration links soon for that, but we really encourage you guys to, I know a lot of you left in your email in the chat, which is great to reach out to each other. Or please feel free to reach out to me. I'll include my email in the chat and I can always connect you with some other hospice physicians who are also certified. We just did that this week. So we're happy to make those connections where we can or on the age PM and their connect board as well. So thank you all for being here today. We'll see you next time. Thank you all. Bye.

admissions processes

steroids at end of life

non-invasive vent-dependent patients

hospice

clinical judgment

evidence-based admissions

controversies

personalized dosing

levels of care