Okay, so welcome, everyone. Great to see you. Thanks for joining today. My name is Bruce Hammond. I serve as HMDCB's Executive Director. And before we start, I want to encourage everyone to ask questions, share comments during today's chat by either coming off mute or typing them in the chat box. If you're not speaking, we certainly do ask that you stay muted, if you would, so we can ensure that on the recording, there's not too much background noise and so everyone can hear. So we appreciate that very much. So today's chat will be facilitated by Dr. Alan Rosen, an HMDCB Certificant and Volunteer. Dr. Rosen will lead a discussion about valuable resources that have helped you this year in your hospice role, and we'll also have time for an open Q&A. So again, thanks for being with us today. One more slide here briefly before we get started, just a few housekeeping announcements. Some upcoming HMDCB events and community events are on the screen. Our first Coffee Chat in 2024 will take place on January 25th. We do have bi-monthly Coffee Chats starting in January. So just FYI, we're going to be doing those every other month. We also are doing bi-monthly webinars. So in the opposite months, we'll be hosting webinars throughout the year. So certainly hope you'll check your email for invites and registration links for those. We do continue to partner with Weatherby Resources in 2024. We will continue to do that to provide a discount for some of their hospice educational series and sessions. And so to learn more about HMDCB's community events, I encourage you to visit hmdcb.org slash community. And again, thanks so much to all of you for being here. We really appreciate it and hope the chat goes very well today. Thanks. Alan, I'll turn it over to you. Thanks Bruce. Welcome everyone. And by all means, feel free to have your cameras on. I understand if you're involved in something else, you need to have camera off. However, I hope people will participate and collaborate. I'm glad to see familiar names and faces. I also see the names of several people that were kind enough to submit questions in advance. Lastly, I want to let you know upfront that all of the resources we're going to discuss today and then some additional requests, we've been discussing how to collect, combine, and then share along with the recording of today's session. And going forward, I'd like to open it up and include any initial comments, questions people may have, or things to consider going forward before we jump in. I'm just wondering if people really have coffee right now. As always, excellent insight from Dr. Kai. I will also mention that among the resources and things, I do not have a direct conflict of interest for anything I'm going to share other than to say I am friends with several people whose websites, YouTube channels, and other things I am going to highlight. With Kai being someone I'm honored to call a friend and someone I'm honored to highlight as valuable resources. You may also know of Matt Tyler, who goes by the moniker Pally Dad and has a popular series on YouTube called How to Train Your Doctor. There are some others we will get into. I want to make sure as people sign on, if there are any particular burning issues, questions, we have had, as I look down the list, a number of things mentioned, and we will get to those. But I want to make sure anyone who's just joined, any topics, questions to address immediately. Okay, I don't want to waste everyone's time waiting. Let me go ahead. We had great question submitted by Joe Miller regarding buprenorphine and its use in hospice care. There can be an entire conference, literally multi-day conference on this topic. And what I will go ahead and put in the chat are a list of fast facts that we have mentioning best practice in terms of hospice and palliative care. But I want to remind people when utilizing the fast facts, this is for a broad population of palliative care providers. It may or may not be applicable within your individual hospice, whether organizational policy, state requirements, and some of them may be a bit outdated. For example, the initial fast fact makes reference to needing special training and a waiver at that time to utilize buprenorphine. That is no longer the case. And you may be aware of needing just additional CME within a particular category when you renew your DEA license after June of this year. That being said, rather than getting us bogged down in all the nuances of buprenorphine, I'm going to punt, we're going to punt, because I can tell you that we have a dedicated webinar on Bruce's prior slide showing upcoming webinars. One of them is dedicated exclusively to buprenorphine, but we also need your help. So while this question was raised by Joe, we appreciate it. One of the things to be aware of, there can be nuanced differences. Are we talking about buprenorphine for those with substance use disorder that come to hospice? Just last week, I had a colleague on a national call share that the emergency docs in his community are now utilizing buprenorphine for acute pain and that they're sending these patients to palliative to hospice on the buprenorphine without it having been initiated by a continuity provider or even pain specialists. And that was a new dynamic. When we talk about buprenorphine, another challenge some may have encountered is depending on the formulation. So if it's on your formulary or what criteria you have, if you're talking about the film, that can be a much higher cost. If you're talking about other formulations, that again has a challenge. And even if your hospice may allow it, as hospice medical directors, how are you credentialing or verifying competencies in your staff? And do you have the appropriate policies for that? So those are some questions, but we hope you will also contribute other aspects that are important to you. Are there other dimensions for buprenorphine use that you want to emphasize to make sure as we put together the resources in the upcoming webinar that you want to ensure are covered? This is Joe, and I have not used it, and when it got brought up last coffee chat, I was just interested to hear where people were coming from, whether it was getting used routinely, and I was way behind the times on that. And so I appreciate what you've said and what's coming up, and we'll continue to look into it. So thank you very much. No, excellent question, and I think this highlights one of the remarkable aspects about our hospice work. This is an evolving field. When I first started doing this 23 years ago, we never had patients on implantable pain pumps, or IV methadone, or some of these other more complicated interventions, neurostimulators for seizures, all types of things. And yet, as our patient needs in our populations, our vulnerable populations are evolving, we need to make sure our skills, our knowledge, our systems. Because as hospice leaders, we also are going to be responsible and accountable if you have associate medical directors, assistant medical directors working amongst your team or covering other teams, making sure care is standardized, treatment approaches are standardized, that you have policies. And how you cover that will be important. I'd be curious if anyone currently on the call is comfortable to share whether or not they currently have the option and utilize buprenorphine with their hospice patients. I see Kristen Schaefer raised her hand. I will tell you the last several hospices I've worked with, it was not something readily available. We could always do a one-off. However, that is something on a very individual case by case basis. Hey, David, thanks for raising your hand. Please join. David, I see you have your hand raised. Here I am, I'm unmuted now, I think. Yeah, I would say at any given time we've got a couple of patients using it, sometimes simply as an analgesic medication for people, and sometimes in people who have a history of opiate use disorder, but who really require opiate analgesia. So, you know, we definitely use it. Thank you, definitely appreciate that contribution because we, I have been at hospices where those patients coming to us already on it that later have, let's say, disease progression or something else that makes them medically appropriate for hospice. Those hospices have allowed and continued it, but as hospice medical directors we also know coordinating the care can be a challenge. Do you have, if it's a pain service or whomever, are they appropriately contracted with your hospice for any reimbursement, and how are they coding that? All of these issues are important. Any other thoughts or input before we move to another question submitted? We, Ms. Chris Downey, we at Alina Hospice, we use it regularly. We are getting more and more patients coming into our service because of it. We're a large 500 census hospice throughout the state of Minnesota, and so we get a lot of referrals from the university, which is putting a lot of patients, their palliative care uses a lot of bunorphine in the care of their patients. So, we get them coming in all over as well as substance use patients. So, it's a skill set that I'm starting to develop. I put in the chat, our medical director suggested this free program from Brown that was supposed to be good. I haven't looked that up yet, but anyway, that is one of the things. Excellent. Thanks, Chris. Greatly appreciate it, and we will make sure again any resource listed in the meeting chat for today is collected and will be part of what we disseminate with this recording. Any other questions come up before I address prior submitted issues? Okay. So, we had a question from looking to see which of the people are on first. So, I see that Noelle Stevens was on, and she had submitted a question that what are other hospices doing when their patients fall and fracture a hip? And require hospitalization for symptom management. There are questions about billing. There's also a question, the extent for surgical repair, and I've simplified the question because part of my personal experience and information may shock you on this. But before I do so, I'd like to open it up and hear if anyone else has initial comments, feedback, and resources to provide. I may be shown to raise the level and said some shocking news. Oh, I see. Do I pronounce it? Maui. Maui. Maui. Please. Well, I'm not suggesting anything, but whoever asked the question, I will just share what we do and what I do in our agency. So, the hip fracture, the first thing we'll meet with the patient, if it's appropriate, or the family, and verify goal of care first. So, if the goal of care, if they say regardless, if it's a fracture, we are not interested to do any surgical intervention. If it's a fracture, we are not interested to do any surgical intervention. If it's a fracture, we are not interested to do any surgical intervention. Then there's no point to send them to the hospital. There's no point to do an intervention. If the pain is significant, which is 99% of the time, it's a pain issue. I'll admit them to inpatient status to the hospice center and manage their pain symptomatically. If they decide to go to the ER anyway, and when they go to the ER, they don't have to revoke. In fact, you never ask the patient to revoke anyway. So, they'll go to the ER, and after they meet with the orthopedic, they'll decide if they want to go through the surgery or not. Even if they want to go through the surgery, I would not ask him to revoke. However, we will ask him to sign the advanced, the ABN advanced beneficiary and uncovered letters, simply because I will offer him symptomatic management for whatever condition for the fracture, but not necessarily, again, offer coverage for the surgical interventions. It's a family choice if they want to do the surgery and potentially have some financial responsibility, or they would forego the surgery and commit to symptomatic and comfort measure only. Okay, thank you for that. Anyone else willing, wanting to share? Tom? You're still on mute, Tom. How's that? Better? Thank you. So, it's pretty similar, although I have to admit, our patients end up in the ED, and my team is made aware, and they follow them to the ED, so they usually get the whole nine yards before we even are aware what's happening. But when they're identified as having a hip fracture, we do a similar thing, but we identify people who are non-ambulatory to begin with. People who are ambulatory, I think that most of them would say that they want an opportunity to walk again. So, those people, we do suggest that they pursue the surgery and revoke from hospice services so they can take advantage of the surgery and rehabilitation to become non-ambulatory. So, the two groups that are easy are those that are non-ambulatory and are going to be non-ambulatory after surgery, and we manage their pain, GIP status until we can get them someplace else if their care burden changes. It's the middle group that's pretty challenging, people who don't get symptom management with bed rest or who feel that they need to do it to begin with. We usually generally would offer them a revocation and repair and admission to short-term rehab and then identify them going out the door for readmission to hospice. Thank you. Anyone else? Okay. The reason I wanted to hear from other people is I want to share something with you, and Noel, this may shock you, but it depends where you are providing services because it depends on your fiscal intermediary, now known as your Medicare Administrative Contractor, your MAC. And you're saying, why does that matter? Anyone who was at an annual assembly and heard, I think it was 2010, maybe 2012, Dr. Harry Feliciano, he was medical director, chief medical officer for Palmetto, which covers many states, if not most, depending on circumstances. And back then, he was fairly adamant that any problem caused by someone's medical condition under hospice care should default to be the responsibility of the hospice. After 2009, the wording was changed in the conditions of participation. Instead of hospice eligibility and then looking at anything related to the terminal diagnosis, CMS changed three letters. And starting in 2010, they reinforced that their view was anything related to a terminal prognosis. If you look at the hospice guidelines, and again, I'll include the hospice payment system and resource at CMS, they say anything that is related to a terminal prognosis. And the example Dr. Feliciano gave when he gave a plenary address was that if you have someone on hospice services for cardiac disease, they're debilitated, they stand up, they get dizzy, they fall, they break their hip. Their diminished functional status is related to their hospice diagnosis, and therefore the sequelae that come from. Now, this can be quite a shock when you're hearing, it also depends on your own individual hospice philosophy, what's covered, what's not covered, a whole variety of things. Yet, I'll also mention the other dimension he provided was that if this is a pain issue, and there have been patients at some hospices I've been associated with where surgical intervention to pin it, not to do a whole hip replacement, but to pin a hip, that was viewed as what was necessary given the type of fracture for that person's pain relief. I included in the chat, and it's a little more focused than this broader conversation, but the fast facts, number 388, was looking at this dilemma when there is a patient with advanced dementia in a facility who then falls. But again, when I was practicing under the jurisdictions within Palmetto, their view was if you're having people discharge or they initiate revocation, and then they're coming back on, that is a flag for them. When CMS updated their guidelines, and again, I'll include this in materials for Gina to share with everyone, they explicitly said you have to prove otherwise. The default should be that hospice covers. And to expand, this would include if someone comes on with cancer and they have cardiac challenges, if someone comes on hospice and they have diabetes, this is a lot of evolution for our field. CMS has said that they always intended this. They're just clarifying their language in order to raise awareness. Again, I'll put resources in that highlight this. You may have different MACs that are handling this differently, but under Palmetto, they've been particularly aggressive in looking at who is either put in GIP or who is discharge revoked for a hospitalization. Let me pause there. Let me see if people have reaction, comment. Kai, I think we need Ativan, not just caffeinated coffee. Is it okay if I add something? I actually have two of these that have come up fairly recently. One was a situation where our patient went out on a motorcycle as a passenger, remote, because that was his love. He is very active, physically active. They had a terrible accident. He required multiple surgeries and rehab. Then he did come back. He revoked. He wanted to revoke. I don't know who suggested it or how that went, but it didn't come from us. He revoked, but then he did come back on. I'm in New York State, by the way, if that also gives some context. Then the most recent one was a guy who has lung cancer. He always goes out into the yard to smoke because he doesn't want to smoke around his family. He fell on his way back in. He broke his hip. He did not want to revoke. This was a challenge for us. He did not voluntarily revoke. My administration sent a nurse in with revocation papers and said, you need to get him to revoke because we can't keep him on service if he's going to have surgery. He was obviously a mobile guy. I can't remember. I think it was Tom was saying, if they're mobile, he wanted to have surgery and he wants to go to rehab so he can remain as mobile as possible. I guess I felt obviously that is unethical at the very least. I think it's not permitted for us to encourage someone to revoke. The reason my administration did that is they said it's a billing nightmare. They didn't really comment on what our MAC would prefer or anything like that or any surveys. The reason was really because they felt like it was going to be a billing nightmare. This is the context of me trying to figure out what I should be recommending for folks who do have fractures. I also do palliative care in the hospital. I do those palliative care conversation schools of care and trying to help people with symptom management. I feel like I've got that. If they can be GIP, it's this other middle situation where they're very fuzzy. Thank you. I hear what you're saying. These are big challenges. I'm sorry. How do I pronounce it correctly? Please, thank you for your patience. Thank you. I have a thought because obviously the hip fracture has come on and on at least three or four times a year. This is my line of thinking. It could be totally off, but when we admit somebody with the cancer to the hospice, we declare that the patient is hospice-appropriate based on one, two, three. Even cancer, they forgo the disease-directed treatment. Their oncologist will tell them, you're appropriate for chemotherapy, you're appropriate for radiation therapy, but to sign for hospice, they have to, by the definition, by the instruction of CMS, forgo disease-directed treatment and focus on comfort and symptomatic measures only. They would not continue with the chemotherapy or radiation unless if it's for comfort symptomatic. We're talking about curative. Is it the same situation now? Somebody with a hip fracture, I'm not telling you you're going to die with agony pain. I'm going to focus on comfort and symptomatic management. If I need to give you continuous pump for pain management, I will. If I need to do anything to measure it, but I don't have to deliver this treatment, which is directly to the disease. I'm giving you symptomatic cover only, which is consistent with the definition of CMS when you are eligible for palliative care. Is this something we can utilize, or it's totally off? It's not totally off. There are risks for where this will be more highly scrutinized in which patient populations, and we haven't gotten into the differentiation sometimes in which where, and we haven't gotten into the differentiation sometimes in rural care, there are more limited treatment options available, accessible. And in terms of where you may be, it could be a challenge. But remember what I mentioned, I'm thinking of one patient in particular a number of years ago, the type of fracture that person had, that person would be in excruciating pain, regardless of the amount of methadone and other things that we did, that the pain intervention, now this was a hospice that had again, back in the early 2000s, 800 ADC, 800, 900 ADC plus, and we were in the Palmetto jurisdiction. So that becomes a different nuance. This also ties into those of you in your hospice career that have seen the requirement to have ABNs, Advanced Beneficiary Notifications, given to patients, their families, that again, delineate what is covered, what is not covered, and how. So I want to include other people before I go on. Beth, please join. Feel free to jump in at any time. Beth, we're not able to hear you yet. If it was accidental that you raised your hand, by all means understand. But I will mention I put in the chat for those that aren't aware of the jurisdictions for the MACs, the Medicare Administrative Contractors. And specifically, there are different home health and hospice MAC jurisdictions. And if you've opened that link, you will see that Palmetto goes everywhere from New Mexico to North Carolina to Illinois and Ohio, essentially the Southeast and a couple Midwestern states. They are the fiscal intermediaries. One distinction might be if you're part of a health system that is based out of a different jurisdiction. And depending on how you're incorporated, there may be some differences. Lastly, remember MACs and the hospice Medicare benefit are specific to Medicare and CMS payers. If you're talking about commercial payers and others, there may be different factors involved. Any questions, comments so far? In the example that Noelle gave, part of what Dr. Feliciano from Palmetto said was, if you have someone on with pulmonary, and they trip over their O2, or if you have someone who has tripped over a carpet in the home, he made specific cases. Well, your social worker should be looking for home challenges. Your nursing staff should be looking at home safety. What else is going on? In the example that you provided, Noelle, you can make a case this was unrelated, unanticipated, whatever. Depending where you are, that may be a challenge for the hospice. MAC in New York is NGS. They've been involved in some of the LCD local coverage determination guidelines as well. Again, this is a bigger issue. I see Jigar, did I pronounce your name right, has a hand up. Jigar, hopefully you guys can hear me. Yes. Thanks, Jigar. Sorry. This is my second chat, and I appreciate you guys doing this. This is actually really fruitful for me to understand how everyone else thinks. I work out in California. I work out in California. There's a lot of scrutiny that's going on towards, especially LA County, a lot of hospices that are going on and utilization as well as revocation and all that. My concern that I run into is I have a lot of patients that go to the ER because family's afraid without notifying the hospice, and then they get admitted and things happen. How do you approach that, especially like a hip fracture or fall or something like that? Great question. This also ties in to some of the regulations because I want to make sure that all the hospice leaders on this call understand you cannot backdate or retroactively date different documentation. Part of how you handle that in the communication is to let people know. Likewise, if they call an ambulance themselves and they did not go through the hospice, they could technically be on the hook for that ambulance transportation. If it was not arranged by the hospice, many hospices have negotiated rates. Maybe it is a full service ambulance. Maybe it's medical transport without oxygen. There are different levels and different costs. To be aware, in the South Florida area, a hospital trip could run plus or minus $1,000. If you're just utilizing regular insurance and going and depending on who your fiscal intermediary is, what else is happening, is this related, unrelated, all of this can be then scrutinized. What we've informed patients and their families is that if they initiate care outside of hospice coordination, they could be personally responsible. That's why Medicare wanted that ABN form given in advance when you admit someone. Any other thoughts? Ellen, it looks like Beth was having technical difficulties and wrote her comment in the chat section. I don't know if you got to see that one. Yes. I was going to circle back to that. Thanks, Kristen. That's helpful. Before doing so, Jagat, did that address part of your concern so far? So it does, but I understand the ABN and we're giving notification. My whole thing is we're talking about this hip fracture. If, for example, you have within 24 hours to get this hip fixed and they go through with it and the hospice wasn't notified, what does NGS, Palmetto, any of these MACs think of who should be liable for that? Because that's what I'm looking at too. Technically or realistically, those are different scenarios. Number one, what Medicare has said for hospices, you're only responsible for covering what is in your plan of care. So if families and patients initiate something outside of the plan of care, that could be grounds that it is, even if it's deemed related, that could fall on patient-family responsibility. Now, if they try calling the hospice, the hospice doesn't answer after hours is busy, other things, and then they feel they don't have a choice, that becomes a whole separate issue. But if they don't have a choice, in terms of the hip fracture, a few things. I would encourage you to have collaborations with your physician surgeons in the area. You may find some that are sympathetic and want to have a negotiated rate. If you are a not-for-profit organization or for-profit and you have a foundation, they may be able to donate their services. I'm much better on medical than the legal and philanthropic, so please check with your own experts in your local areas. But I've been at hospices where we've had general surgeons under contract, if we needed to do a ventinostomy, let's say a pancreatic cancer or malignant obstruction or something else, and that was very reasonable as a cost and other things. Just like you may negotiate with radiation and other things, well, perhaps you'll find an orthopedic surgeon who will. It depends in your area, what the costs, what the challenges are. The other thing we have not gotten to is where that patient is located. Because if you have a patient, even if they're a hospice patient in a nursing home, and they fall, the nursing home may be worried about their own medical legal risk. They're still supposed to collaborate with the hospice, but if they initiate things without including the hospice, that could be on the nursing home responsibility. Anyone else have anything else to add? If no one objects, there were a couple more questions, both things mentioned in the chat and that were submitted in advance, and I'd ask you to raise your hand again if there's something that comes up, but I want to acknowledge Beth's question from the chat that said, essentially, hospice patient, hip fracture, already very ill, into bed for surgery, and post-op complications, cannot come off, vent, et cetera, then what? Yes, these are very challenging circumstances, and I feel for everyone on this call, all of us will have challenges, and that's why this group is so important for peer support, ideas, how do we navigate this, whether it's regulatory, whether it's community, whether it's organization, and one of the things that I can tell you is that I don't know if you've checked whether your hospice can take someone who's currently on a vent. Many hospices do. I apologize in advance if anyone is a pulmonologist on the call. However, I personally do not make a distinction between nasal cannula oxygen or even an endotracheal tube and intubation. I can't tell you the numbers of pulmonary, cardiac and other patients that could not survive a matter of minutes if they were not on their nasal cannula O2, if they may not have been on BiPAP, if that were the case. However, if you have patients and families that are expecting daily, hourly respiratory therapy visits, active management of vent settings, then that goal of care in those intentions may not be compatible with your organization, either its capacity and the expertise. What I would tell people is that we would bring them on, essentially leave their settings. What is the pressure support? What is the P? What's going on? Basically, just like we may tweak the nasal cannula O2 flow rate, we may tweak a couple settings on, say, ventilation. But it is not the same scenario. Their loved one could be more comfortable, whether it was at home or if you have to have facility-based, whatever. But again, these are different dynamics depending on where you're located, where the patient's located, what's going on. Any comments so far or additions? I see Tom added his hand. You're muted, Tom, sorry. I have the flapping lip syndrome again. So that's interesting that you bring up the ventilators and whether your hospice has the capacity to manage ventilators. So I would say the same thing on any diagnosis because we do a lot of denting, gastrostomy, things like that, we keep them on hospice, GIP. Going back to the hip fracture question, though, is similar to the ventilator. It's a complicated process that is not isolated, that there are multiple specialties that are going to be involved. There's the surgeon, the anesthesiologist, there's the facility, there are the paraprofessionals, there's the post-op care, there's the nursing home. So I think that it's just, hospice is not meant for that. It does not have the capacity to perform that kind of service and it would be a disservice to the patient to think that we could do that. So I think it's the same question of the ventilator. Would we take the patient on the ventilator? And we've taken patients home. A close friend of mine, we brought him home from Boston. It's a 50-minute drive in an ambulance, got him home, got him in bed, got his family around and extubated him. So I think that there are things that we can do that we have the capacity to do, but to manage a daily ventilator is not something we can do regardless of whether they're a hospice or not. And a hip fracture, I would say the same thing. And other complicated surgeries, the question of the multiple trauma is similar. So sorry. No problem. I have the flapping gum syndrome, even when I'm not muted. So with bad humor aside, building on what Tom said, I also want to emphasize what you're hearing today is a variety of situations, but the unifying thing, especially for all of us on this call as leaders in hospice, being aware of what your organization process is. What happens when these cases come? How will you reach these decisions and outcomes? And these are very important things if your organization hasn't encountered it, that you could be that leader in helping to develop with your nursing leadership, with your administrative leadership, and then any of your clinical associates so you're all on the same page. I want to do a quick pivot. While we have a couple minutes left, there were questions, best review of new regulations submitted by John Hayward. I can also mention and refer back to Bruce Hammond's comment we're collaborating with Weatherby Resources. Also myself and others in this coffee chat are participating on HMDCB's education committee and new educational resources are being identified for the exam and other things. I hope to see that include regulations as well as resources that we can point people to. So we have some resources. Again, they'll go out after this. In another rapid question, there was a submission again by Beth. Is it okay to admit new patients under GIP status, hospital determinations of admission versus GIP? There's a related one that I'm going to, I apologize in advance, Malia about family requesting respite after acute hospitalization to arrange for placement. And I'm putting both of these in a similar answer that it may depend. It may depend how quickly there's a change. What I will tell you is that Medicare says out of convenience, that is not appropriate to utilize GIP. Now, there may be indications, where do you have respite stay? Is it until caregivers can be put in place and other things? The other caution that I want to put out there is to be aware and be careful that you're not using immediate respite, immediate GIP as a recruitment tool because that could be viewed by CMS as inducement. You come to us, we will put you in this level of care. We will provide support and that could be viewed as an improper technique for getting referrals. Lastly, I want to also highlight a great question Michael Gorby submitted, evolution of hospice medical directors toward a full-time effort. Many people start their career as part-time depending on your hospice ADC. Different organizations, and I've been with a number of them over the past 20, 30 years, have different levels of staffing based on their census or their trajectory. You may find some things within CAHPSI that may say, if you're looking at say 75, 80 patients, on a regular basis. However, I would say, if you have an average daily census of 50, yet your PPS score is 10% on average of admission, by definition, those patients likely are going to die within a matter of a day or two. That means you're churning a lot or turning over your census, a lot of admissions, discharges, admissions, discharges, that type of quick response, you may need higher medical engagement with that type of activity, if that makes sense. So, again, as a medical leader, knowing in your hospice, what are the median length of stay for your hospice? At time of admission, what is the PPS? And that also can have organizational implications, because if you're seeing an influx of, your Friday hospice admissions at a PPS of 10%, well, you know what? All of those people are likely to die over the weekend. Do you have enough after hours coverage? Do you have enough access? So, I wanted to highlight those things. Please feel free to email Gina as our time is winding up. And I wanna respect everyone's schedule. I'd also like to plant a seed. Please reach out to HMDCB. What types of questions and resources would be most helpful for you? I shared that there was one specifically on regulations. I'd also encourage us to think what we're doing for elevating the capability of our teams. Do all of your colleagues know about buprenorphine or about what we were discussing today? How are we designing in services? And what about management? I'm guessing everyone on the call, you're growing your programs. Instead of hiring an external community person, how are we going to train people currently with us to be able to increase their capabilities and capacity? I wanna improve all of your and our collective quality of life and figuring out how we might delegate and how we can train others. I'll stop flapping my gums there and turn it back to Gina. Thank you, Alan. I appreciate you leading today's chat. And thank you everyone for attending. We'll send out an email with the recording and a resource guide that will include direct links to all the resources people have submitted or that we discussed today. And just check your email for registration links for upcoming events. And we really appreciate you all being part of the HMDCB community. And we look forward to seeing you at events next year. Have a great holiday. Bye everyone.

Dr. Alan Rosen

hospice role

buprenorphine

hip fractures

GIP status

coordinating care

healthcare providers

regulatory guidelines

upcoming events

training for hospice professionals