And he feels like his abdomen continues to decrease in size because he can bend over. Okay, well we're going to go ahead and get started. Thanks so much for you all joining us today. Really appreciate it. Great to see you all. I'm Bruce Hammond. I serve as HMDCB's executive director and I'm really pleased to be able to have the opportunity to talk to you a little bit here before we get started in our coffee chat, providing you with a few updates and then we'll get started with the with the chat and I'll introduce our moderator for today. So Gina if you want to go to the next slide that'd be great. Thank you. So just a couple of important upcoming events to be aware of our first webinar of the year that for the for certificates is taking place in March, March 28 at 10am Central time. It's on dementia prognostication, and we encourage you to sign up for that by visiting HMDCB.org slash webinars. This will be the first of six coffee chats in 2023 I think if you have attended a coffee chats in the past you may realize that we've had four in past years, we've heard from you all are certificates that you're interested in getting together a little bit more regularly for these events so we're doing six this year so pretty excited about that and this will be the first of those the remaining are on the screen here and again you can learn more about that on our website as well. Really excited to share that our initial application window is open so if you know physicians hospice physicians who are not yet certified, we'd encourage you to share with them that they can apply currently through May so we're excited to have the opportunity to have that open and again if you have questions or want to learn more, you can either visit HMDCB.org slash apply or email Gina at the email address on the screen so again I will now turn it over to our moderator for today, who will be leading us through She's the medical director of care dimensions in Massachusetts, and is a volunteer for HMDCB so I'm going to turn it over to Kristen and again thank you all for for being with us today. Thank you, Bruce. Hi everyone. How are you nice to see you. Yes, I'm Kristen Schaefer, I've been a certificate for since 2021. I come to hospice from primary palliative care and primary care for about nine years and then palliative care for about 12 years. And, and now I'm a medical director at care dimensions, which is a large nonprofit hospice in Massachusetts, Boston area, so very happy to have the opportunity to convene this group. Loving the power in numbers feeling of us all being together today so my goal is to just facilitate this time so people have a chance to ask questions and really just help each other out, think about things that are hard to solve or just questions we have that are coming up in our day to day. And I know one of our participants. Today on the call also has a case that he would like to share with us to think about and specific so and so we'll also look forward to doing that as well, but I thought I might just start by opening up to the group. If anyone would like to unmute themselves and form form a question to the group I think that would be wonderful some of you sent questions in ahead of time if you feel inspired to share them with the group and kind of share your question that would be great so I think I'll just start by opening it up to the group and see what's here today. Oh, and thank you for putting your names and where you're from in the chat that's a lovely way for us to efficiently kind of share with each other who's on the call and where we're from does anyone have a burning question, and they'd like to start us off with today. We had a kind of fun icebreaker question that Tommy Farrell sent in by email. So maybe I'll just throw that one out there to get people warmed up. Anything particularly fun you've done to show appreciation to nurses and NPs you work with? Said, I know the regular stuff, looking for any fun inspiration, how we've been able to show appreciation for nurses or NPs we're working with. If anyone wants to jump in on that as you're framing the question. I'm sorry, what was the question again? Hi, Vincent. The question is, what are we doing? Has anybody, Tommy Farrell posted, anyone have particularly fun ideas to share that we've done for our nurses or NPs for appreciation? Any particular ideas of showing appreciation to nurses and NPs? I don't personally, it comes more from our human resources people, but they do a really great job. If you wanted to work with them, I mean, we do free meal giveaways, like come take and bake meals, different gift options around the holidays. Like, you know, we did a Valentine's appreciation. And so just a lot of like goodies and food and that sort of thing for employees. Love it. And Laney, Lane, how do you say your name? Laney. Hi, Laney. And where are you? I meant to say when you speak also like let us know. Oh yeah, I'm with Four Seasons Hospice in Flat Rock, North Carolina. I'm the medical director there. Oh, wonderful. Thank you. Yeah. Yeah, it's a good reminder that we are in nurse-led organizations and of partnering with our nurse leadership. HR leadership is a really, really great reminder. Hello, this is Brenda Buzzard-Lowski. I'm in Philadelphia, Pennsylvania and new in the medical director position with Home Care and Hospice for our health system which spans Pennsylvania and New Jersey. My question is what pointers would the seasoned medical directors have for someone that's new to that position? And what are their tips for growth for a hospice? So I'll stop with that. Thank you, Brenda. So is your question about tips as you're starting the role? Was that your question? Just to- Yep, I'm new to the role. So my story is that, and I'll turn on my video so you see me. So I'm a second career physician and fell in love with palliative care and hospice in med school and pursued it with a passion and found myself in the position as the medical director for Home Care and Hospice. And so kind of new to that role, I've been the hospice medical director for one of our counties in New Jersey for the last six years, but new to the medical director role. And so any pointers that the group would have, I'd be appreciative. Wonderful. I'm gonna open that up to the group and people- I can jump in because I remember feeling this way several years ago when I started in this role. And I think two things that have been very helpful is that just from a regulatory standpoint, the AAHPM Hospice Medical Director Guide in terms of all the sort of regulatory issues, every once in a while I just kind of go back and peruse it, that's very helpful. But I think the other thing if you have the opportunity is at the annual AAHPM conference, usually the day before the formal conference starts, there's a hospice medical director, like one day conference. And I think that that's a great opportunity to kind of get together and people are sort of, somewhat like this where people are sort of getting together and reviewing updates and sharing with each other and talking about different cases and scenarios. I think those are both really helpful tips. Thank you. I agree with all that. And I would also say to find a mentor. There's a lot to learn. So I'd find a mentor or at least find colleagues that, I have other medical directors I might call up or email and say, hey, I've got this situation going on, what do you think about it? So just starting to get some contacts you can reach out to. I think that's such a good point. Both of you finding community and kind of peer mentorship in this work. Does anyone, so you're talking about the book, Beth, are you? The book, when you say the guide, yeah. Brenda, I don't know if, or if others are familiar with that book. It is, I believe, right? Beth, it's for sale on the HPM website. Yeah. So that's, that was a book I read before I took this role. And then I had to reread it about several months in because there was a lot of it that wasn't just going to be too relevant until I started doing it, I would say. Really helpful around documentation. I found that one of the early things from that book around specific examples of how to document certification notes in particular. I found there to be some really helpful, just templates in there around that. And then a helpful kind of plain language review of regulations around admissions and discharges that I find helpful in there too. Your mentor story. I had a friend who was a fellow of ours. I was associated with the fellowship program who reached out to me about a year ago and said, hey, someone connected us actually, said you guys should be talking to each other. And we just kind of, she's in a different state, but we just kind of set up a time to meet every couple of months and have lunch together on Zoom and just kind of share stories and challenges and questions about the work. So that's been a really nice thing too. Very good. Thank you all. And there's quite a bit of information in the chat just as an FYI. I'm sure you can't keep up with it all, Kristen, but Alan has put a few recommendations in there and so. Yeah, thank you. And Leslie Sutton mentioned the Weatherby conferences. How does, Leslie, how would someone get connected to invites for those Weatherby conferences? Do you have a specific idea around that? Yeah, I'm actually, yeah, I actually just completed the three Friday series. Great, how smart. Yeah, it's really more about the medical director role itself, you know, how do I corral seasoned hospice medical directors in various locations to focus now on a physician led IDT versus sitting there doing nothing while the nurses are talking about all the patients? And I really want to bring us up to a new level. So that's, and I like the idea of a mentor. So anybody out there, I'll give you my name. Yeah, I was kind of feeling, maybe others can speak to this too. I've been trying to meet with my physicians in person once a month. I figure they're driving all over the place to see patients. So I will once a month drive to try to coordinate wherever they are to just see them in person and kind of share my vision of what our physician and NP practice group is and who we are as a group. And that's been helpful. That's been helpful. Yeah, Alan. Sorry, hi, Alan Rosen. And for those that may have seen in the chat, I've gained a little weight since I had to eat my words. I'm now in Texas and today's actually first day as chief of palliative care for Texas Tech University and University Medical Center. All of that said, Brenda, I might offer a constructive consideration in that it may not be physician led, but physician engaged. And one of the reasons that, again, I've learned this the hard way, is that sometimes when you get doctors coming in that have not necessarily been within our multidisciplinary and interdisciplinary team meetings, they may come with a very directive approach rather than the collaborative one. And making sure that they are engaged, it also can be a time saver because when they're then having to complete the certificates of terminal illness or do face-to-face visits, if they have a mechanism and all of the resources mentioned up to now, identify ways to capture during IBG, IBT, those clinical facts that will make your CTI process quicker, more accurate, and less vulnerable to regulatory recoupment. And so demonstrating that investment as well as it's not writing more, but writing better or more effectively. So again, those pearls can help validate that experience. Thank you, Alan. Very helpful. Wonderful. Any other comments? Oh, yes, please. I don't know how to, I put my email in chat, but I don't know if everybody sees it. Oh, Dr. Turner, how are you? I see she's on. Great, great. And I can add your email for everyone. It had come directly to me, but I'll share it in the chat if that's okay. Great, thanks. That would be great. Wonderful. Very good, thank you. Yeah, just to introduce myself, I'm Dr. Christine Schwartz-Peterson. I am a mid-career family physician that got grandfathered in to be certified in hospice and palliative about 12 years ago, and has been the medical director at JourneyCare in Illinois for eight, for three, worked for JourneyCare for eight, and now have a blended role in hospice and palliative at Ascension Resurrection in Chicago. So kind of the thing I would suggest, I'll leave you my email too if you have any questions, but I found just working really closely with the team manager as far as how we would like to be effective as far as education and support, and try to have fun with it, because I always found the nurses, nurse practitioners are so engaged in their, you know, in the field. They wanna learn, and if you're engaged, it's a win-win situation. Excellent, thank you. Can I offer a new question for discussion? I was about to ask, yes. Sorry, Leslie Sutton with Transitions Hospice from Raleigh, North Carolina, the medical director there. We have had a physician from another nonprofit hospice make the suggestion that the only physicians that should be writing the certification of terminal illness narratives are the physicians who are actually on that patient's specific interdisciplinary team. We have a blended company. We have half docs that do, or, you know, five docs that do palliative care, five that do hospice, but everybody takes call on the weekend. So if you're on call on the weekend, you write the CTI narrative for the patient that's admitted the weekend, whether it's, you know, whether you're a palliative care doc or a hospice doc, and we've been doing that for years, but we've recently been advised that, no, in fact, actually only the hospice doc or the medical director who is on that patient's IDT should be writing the certification of terminal illness narrative. And I wanted to know if others have been restricted like that or advised to that restriction, because that's gonna change our whole structure for admission CTI narrative. Yeah, I think that's a little aggressive of a statement. So if you were erring anywhere in the regulations, it will be, you would say that your hospice medical director is the only one who composes those, but we see very clearly that it can be their physician-designee. There is the regulatory requirement that the patient be assigned to an interdisciplinary group, but it's not reflective or limiting in terms of who can do the certification or recertification, provided that they've reviewed the medical record or evaluated the patient themselves. And then for the third benefit period and beyond, reviewed that face-to-face and integrated that information. So I would say what best serves your flow in terms of how we're efficient and how we're going to do quality care for our patients is how you would make that determination. Thank you. I agree with Lauren, we- Oh, sorry, let me just pause real quick. Oh, I'm sorry. No, just Lauren, can you introduce yourself? I wasn't sure you had a chance. Oh, sorry. Yeah. Thanks. Lauren Templeton. I actually work with Tommy Farrell, the crazy guy who did the icebreaker. He was my palliative care fellowship director at the program that Allen just joined. And so Tommy and I are in Texas too in Abilene and I work for Hendrick Hospice Care there. And then I do a lot of like regulatory teaching and auditing and record review and that kind of stuff. Wonderful. Thank you, Lauren. Yeah. So back to you, Lainey. I agree with Lauren that it's what works best for your organization. So we don't follow that model at all. Our physicians, we have a really heavy physician model where our physicians are out making visits all day. And so they don't have time to do their CTIs. So I'm doing, as medical director, I'm doing most of them but we also have other docs that step in and do CTIs. So yeah, we definitely don't have that, the model that you're talking about. I know it did come up when we were, I was with a bigger hospice with journey care that it seemed during one of one time that it was supposed to be only the medical director. And that was an impossibility, but it's got reinterpreted to being whoever the designee is as long as there is contact with the medical director as far as any questions and back and forth flow, back and forth flow of communication to be. But that never did fly after that recommendation that recommendation did come down our way. Now they did release appendix M, the interpretive guidelines for surveyors. And so you want to make sure that your policies include the physician designee for certification and recertification. So when they sit down and survey you, you need to make sure that that interpretation of the regulation, because technically right there, it says medical director, that you are implementing the rule or physician designee. Physician designee appears in every other spot. So it's very obvious, but you wanna make sure your policies reflect that. So surveyors, when they interview your medical director, they really truly understand the intent there. Very helpful. Thank you. And Alan. They're gonna interview your medical director. Michael, sorry. Did you get to ask your question? What did you say? Oh, maybe lost internet. And Alan Rosen also left a comment in the chat, some additional information. I was trying to, Michael, or if you get you on the screen, but I think your internet may have frozen. So when you come back, just grab the mic and let us know. Okay, great. Is Dr. Riddle on the call right now? I don't see him, Kristen, but we can share his case or on the screen. Yeah, we can wait for him. That's okay. I think there's plenty of other, people have other questions. Who else has a question? And then, yeah, Dr. Riddle had brought a case he wanted to bring to the group to talk about. So let's see if we can wait a little while, Gina, for him to come. I do have a few questions, if you don't mind, guys. Yes, Vincent, please introduce yourself. Yes, the video. Okay, hi. I think some of you know me already. I did my fellowship in St. Louis in 2019, in St. Louis University. And then I moved back to Puerto Rico. I am the only post-medical director certified in Puerto Rico. I'm actually the only one with the training. Everybody else is GP. So I am also doing consult now for the medical insurance because nobody else, you know, I'm the only one with the specialty. So I have a couple of questions. Some of them might seem probably dumb, but to be honest, I don't know who else to ask. I've been waiting for this. So let me start quickly with two questions. They might be simple for you guys. I have a patient with severe pain, prostate cancer, with metatarsal bone, with severe, severe pain. He doesn't want to use methadone. I have him on fentanyl, 100 micrograms, morphine, hydromorphone, I try everything. So my question is, the morphine seems to be working initially. So the maximum that I can use right now that I know is 100 micrograms per patch. Do you guys combine the patch to go even higher than that or no? Can I use one part, I mean, one of 100, another one of 25? This is for the fentanyl patches, Vincent? Yes, you can, yeah, just add a second patch. Okay, perfect. And the other thing, just to mention, I don't know if you've tried this, but we've found that sometimes steroids have been helpful in these cases. We've tried. You've tried, okay. Yeah, I mean, now he's all blonde, like, so it's been hard to control him, but we're going to try our best. And the second question that I have is, recently in Puerto Rico, we don't do palliative extubation as in the States. I did that many times in San Luis, in Puerto Rico. There's a taboo, maybe, I don't know. I thought it was the law. I requested the lawyer and there's no law against doing it. It's just the protocol from the hospital, okay? So it's been hard for me to fight that, for example. Now, if somebody discharged from the hospital, they are intubated, in Puerto Rico, the hospice, they keep the patient intubated and they don't do anything. I mean, no matter what, how long, six months, seven months, I mean, they can live there. I know that's not the way that we do in the States. So my question is, when you accept somebody from the hospital, do you plan ahead? Like, we're going to do three days and then do the extubation at home. I know you can document, like, for example, we're going to wait two weeks until the daughter comes from Florida, for example, right? But is that not the case? How do you guys do it? Like, how do we come up with the time? And the same with the BiPAP. I also have same issues with the BiPAP. Like, do we continue the, I mean, there's two questions. So do we continue the BiPAP indefinitely, or do we plan ahead to transition the BiPAP to oxygen? I mean, I'm talking about in the home setting. Yeah, this is a really great question. Just to make sure we understand it. And then I would love for people in the group to share their own personal experiences they've had with this. But your question is about planning ahead for a terminal extubation or planning ahead for discontinuing BiPAP at home and kind of what strategies, how that's worked for people. Is that your question, Vincent? Okay, yeah. Can people share stories about that? So this is Brenda. When we do palliative care consults in the hospital, oftentimes what we will do is help to set expectations by time-limited trial and say, if we're not getting the effect that we want after X number of days, then let's regroup and talk about the next steps. So that's how we ease into that extubation or stop using the non-invasive positive pressure ventilation. Great, so this concept of- We can do that in Puerto Rico. I kind of said, we're going to try for two. I even called ICU doctor, clinical care physician, and there was a patient with liver failure, intubated. He was almost 90 something. I mean, no prognosis at all. When I called him, hey, doc, I want to help you out with the palliative extubation. He was like, what are you talking about? I said, you know, I can build a protocol. What are you talking about? We don't do that in Puerto Rico. He's going to stay intubated until, you know, let's call him, and that's it. There was no other option. And the patient ended up intubated for almost two weeks and a half. So that is not- I know in the state we do it easily, done it many, many, many times, but that's not an option that I have here. But your thought, Vincent, is to try to enroll people at home and do it there. Is that your vision? Yes, I actually had a family that they were willing to take the patient at home and do the extubation outpatient, and that's fine. But then I didn't know how to do it. Like, as soon as he gets there, do we wait 24 hours? Do we wait two, three days? I mean, I had no- Yeah. I didn't have the answer for them. Yeah. So we, when we do them in the home, which we do occasionally, we usually do it shortly after they arrive home. And we have a physician in the home and the nurse and possibly like a chaplain if needed. And we have all the meds. We do a lot of pre-planning, but the expectation is that when the patient arrives in the home, we're gonna do the extubation. And usually there's a respiratory therapist that might be there too. So it's a lot of planning, but it happens pretty quickly once the patient arrives home. Okay. Thank you. Chris, Chris, did you have a comment? We typically do the same thing. There are- Oh, and Chris Downey. Chris. Chris Downey has a hand raised. And introduce yourself, Chris. Chris Downey from Minnesota. And we do, have done extubations in the home on hospice. We arrange it ahead of time if all works out. We've, taken people off also who have been on events for a while. And we also do a lot of pre-planning. There's a consult with the family, by the physician to discuss ethics. Also a group family meeting to talk about this so that everybody is on the same page. And then we need a respiratory therapist. If you're gonna do IVs, we have a team that will go out and drop a line in the home. And so we can have access to IV medications at home. Otherwise you have to do it with oral meds. And that's possible to do too. But it takes a lot of pre-planning, making sure everybody's on the same page. Have a respiratory therapist there. Make sure you turn off, you're able to get all the alarms off because that can be really frightening to the family members. But no, it's possible to do. Great. So I'm hearing advice about pre-planning who should be assembled in the home on both sides, both the clinical team and the patient family. Hearing also advice about taking the time to make sure goals of care are clear to the team that is doing this withdrawal. I think oftentimes if that has been accomplished in the hospital, those conversations, that's helpful. But taking the time to make sure that everyone's on the same page was a really nice comment, Chris. Alan? Couple of things, Vincent. I put my email in the chat. Happy to also connect you with Luis Padilla who's in South Florida. He's actually a physician from Puerto Rico and is board certified hospice palliatives. Still, I think I have to get him under HMDCP. But that aside, another thing that I'd also emphasize, two factors. One, making sure the expectations of the patient, the POA or the family are understood prior to admission and whether or not that plan of care aligns with your organization's abilities, capabilities and response. So those people coming out of the hospital that expect there'll be a respiratory therapist checking them on event every day at home, no. The other thing is I would also emphasize how we use some of the terminology to be most constructive in cultural considerations, geography, other things. So instead of withdrawal, we're going to simplify. We're going to prioritize. We're going to naturalize these interventions away from the artificial. Whereas that may help some that are concerned for religious reasons, because we see this, whether it's cultural, whether in some of the Orthodox Jewish populations, other ethnicities, that might be another way to find that middle ground. Benson, I'd like to add to that as well. You're definitely in a different position than probably most of us here on this call for sure. So I just want to make sure that you are safe in your practice and making sure that you have policies and procedures that and support from your organization. The other thing is, is that even with the acceptance that it has here in the States, when we started doing vent withdrawals in the home on patients actually with ALS, our nursing staff had a huge issue with this. So ensuring that they are also supported and we have emotional debriefings before and after these withdrawals, that's embedded in the policy and the procedure really. So I just want to make sure that you all are safe. And then finally, the last thing I would say about hospice here is that you can accept these patients as long as their goals are in line with hospice. And if they stay on a ventilator for three weeks, that can be okay with your organization because they're probably gonna die with or without the ventilator. But I think you have to make the determination on these patients like you would anyone else. Are their goals consistent with hospice and do they have a prognosis that's consistent with hospice? So I just wanted to add those three things. And thank you, Robin, for saying that. You know what? There's another hospice medical HPM, Paramedic Dr. Puerto Rico. She's an emergency doctor and then she's the fellow chief. She's working in the private hospital. The public hospital, the biggest one in Puerto Rico. So she was able to build the first kind of priority program and she started doing extubations in trauma patient with brain death. It was, I mean, she had to justify completely. And then once she started doing that, the nurses started complaining that she was killing patients and they shut down the program. That's it, by myself. Hmm, the one already, I don't know. Yeah, it sounds like a lot of work to be done and I don't, I wish you well. Thank you. For the sake of the patients and you. Yes, yes. And I like Robin, the comment about emotional debriefing. Is that what you said before and after? And even in these cases, I think when my, we just had a terminal extubation in our inpatient unit two weeks ago, and there was actually difference of opinion between the nurses and the clinical team about whether the patient needed to be sedated with a continuous infusion or not. That was the particular debate that happened. And actually the answer to the question, it was, you could do that lots of different ways. What we really learned is that our nurses did not feel heard in their opinions and they had quite strong attitudes about the patient promising the patient that they would not wake up and feeling that the only way they could do that was with the particular approach they were asking for. But it's really those attitudes around what are we promising patients that we realized we have a lot of work to do as an interdisciplinary team to be able to hold different attitudes around that. It's emotional briefing and it came, but it came to us through this kind of technical question that people were somewhat at odds with each other ahead of time. And honestly, with this particular team, we have some new people on that team. We realized we have a lot of work to do to be able to do extubations safely, honestly, to Robin's point, right? Like if there's any kind of dissonance in the group, it starts to feel like there are limits to what you can do with the team that you have kind of as you're building a team. So I wanted to say that also. Vincent, did you have another question? I do have a last one and it's a quick one. We have also a palliative program in our hospice. How long do you guys keep the patients in the palliative program? For example, I'm also doing, again, I'm doing the consulting for the medical insurance and they're also asking me how long do they gonna keep paying for that patient in the home-based palliative program? So I know technically, by definition, you have to have a symptoms, conditions. So once you fix the, you can control the symptoms, you can probably rely the patient to the PCP. But do you guys have any experience on how long you're gonna keep the patients in the program? If you have a program like that, a combined program. I'll just comment. I mean, there's a lot of different models of palliative and some are kind of one and done with one consult and then you move on. Some will do continued pain management, symptom management. Sometimes you need a transition that you think they're gonna be hospice eligible in a matter of time. So it's kind of what your resources are and what you feel is gonna be most beneficial that you can provide quality consults and support. So it is, the couple of models I've been, have kind of been shifting to more of a limited number of visits and trying to see, are they heading more towards hospice? Are they heading towards curative and home care and maybe can graduate as well too? But kind of is, I think it's important to keep it individualized. Thank you, Kristen. I would agree and add one other wordsmithing opportunity that instead of saying you discharge someone, whether from your palliative program or your hospice, you graduate them. So again, if things happen or symptoms change, likewise for those that don't have symptoms changing and they're on the same opioid regimen, whatever, you can refer that back to their primary team and be able to say, if something new comes up, re-consult, reconnect, but that may free up your own bandwidth to handle more acute cases. Thank you. Hey, so thanks a lot for those questions. Really appreciate and it underscores that we are all working in different micro environments with different limitations and different resources. And I just really appreciate the questions. Hope this group can be in the spirit of answering these questions together. So I noticed Thomas is on the call and submitted a question about the role of hospice kits. Thomas, was that something that you wanted to share with the group? I see you're on the call. The question you had. I didn't know if you wanted to elaborate on your question that you submitted. Kristen, I think he said he was multitasking, so he may not be hearing us right now. So maybe we just share the question and maybe we see if there's interest. Definitely. So the question Thomas submitted was the role of hospice kits as compared to specific medications per case and recommendations related to medication destruction or repurposing. So a kind of shift gears, a somewhat more technical question about prescribing our comfort kits at home and strategies for medication destruction or repurposing was the question Thomas asked. Is this something that others on the call have thought about or strategized about in your own practice? This has come up recently and we don't do comfort kits and haven't for a long time. We try to make sure that any comfort meds put in the home at admission are really individualized. And actually I'm interested to know if anyone is still doing comfort kits. I know do hospices, but we have the same question. One of our challenges is that local, we're using Clara, which of course is a male. So getting medications quickly has been a challenge. So I don't know if other places that use mail order, so to speak, VBMs that have the same issue around care kits versus individualizing, which was always my recommendation to do hospice. I'm sorry, where I was before it was very individualized. We didn't do a symptom release, but where I'm at currently, it's something that I will be working on to individualize because they are still doing SRKs. Yeah, I think the role of comfort kits is to fill the need of the hospice, not to fill the need of the patient. And so like if you're taking care of patients that are a hundred miles away, and it's something that like there may be some barrier in terms of mileage, or if you have a male in PBM that you're struggling with, and this is something that you need to bridge a gap, that's great. But then the individualization of the care, I think is the current modern hospice, or that's what our goal in my opinion should be. And can alleviate a lot of the medication disposal issues when you don't have a comfort kit on thousands of patients all the time. They hate when we're wasting Lorazepam and nursing facilities, thanks to the mega rule too. Thomas, welcome back. We were addressing your question. I didn't know if you wanted to introduce yourself and reframe other pieces of the question that you're not hearing answers to. I will confess that I don't even remember the question. I just read it, so to the group. But it was about people using comfort kits versus individual prescriptions, and also question about medication disposal versus repurpose. Yeah, I think the challenge for me through many years of doing hospice work at Medicare Aurora, and right now I'm in Chicago, but we're based out of Oakland, but it's a big region and big group at this point. But a patient has hypertension, chronic disease, no active pain, but you expect they're gonna die of albumin, I don't know, 0.5, something like that. And the next thing you know is there's a morphine there, and there is Halval there. So I think that kit approach where all of the medication gets shipped out to someone that cannot be reused as far as I know, is it a huge waste? I think it serves the purpose of on-call, and there's an emergency and various things, but it's always been a kind of a open loop for me. The other thing that I'm worried about is that staff having access to controlled substances, and more or less I take the word they're gonna dispose it, and I don't believe that we do urine toxics or anything like that. So really it's another open loop. So I'm just curious about best practices, and I'm not looking for policies or procedures, but also pharmacies, as long as they dispense it, they're kind of neutral. Other thing with kits is kits go to subacute rehab, but they never come back. And it's, again, where did those narcotics go? And I don't think anyone's accountable. So those are my thoughts. And from the discussion, any pearls or what does everybody think? I know where we practice, there's no 24-hour pharmacies, just, I think it depends on, if you're in Chicago, you probably have a lot more access to emergency medication when you need it. Where I am, if somebody has terminal agitation or acute pulmonary edema in the middle of the night, if we don't have Haldol or morphine there, we're kind of in trouble, and the patient ends up having to go to the hospital, which is not what we want. But I think, and obviously our comfort kits are personalized. So if somebody has renal failure, we don't put in morphine, for example, or if somebody has Parkinson's, we don't put in Haldol, we sort of use other medications. But in terms of disposal, what we've been advised, at least in New York State, is that the care kit is the, or any controlled substances, any medications are the property of the family, and our nurses are not allowed to take medication out of the home. What they do at the death visit is advise the family on safe disposal, and hopefully that happens. And sometimes there's take back days or whatever at police departments or different pharmacies, but it's a complicated issue. I'm always very uneasy about leaving these meds anywhere. I guess, I don't wanna interrupt your question, Thomas, but I had a related question for anyone who is using these care kits or anybody, I guess, many of the patients will have some of these medications, maybe even with individualized kits, but are people who are using these kits or when patients come on to hospice, are those meds coming, are any of the medical directors prescribing them or everybody's deferring to the referring physician or the community physician? In my case, it's the community. It's usually the medical director. Yeah, the medical director. Talk about as part of the admission process, Beth? Yeah, because I think, we haven't seen the patient, and so a lot of these, my sense is if you haven't seen a patient, it gets risky to buy some controlled substances. So we generally put that on the referring provider, but it seems like different places do it differently. So I was sort of curious about that. Yeah. So what do you do though, if you don't have a referring provider or no attending a record? Then what we normally do is we make sure that there's an acute, we sort of say like, what is the acute or anticipated symptom that's going to arise? And we send five-day emergency, four or five-day emergency supplies. And then we don't, and then we kind of keep doing that or see the patient ourselves. So I know that sometimes even locally, we'll sort of say, oh, the medical director is supposed to order the care kits. And again, just this sense that like, well, we haven't seen the patient, so that seems maybe not quite what we wanna do. Yeah, I think you can only speak to what you're comfortable doing as a physician, but the industry standard would be that hospice physicians prescribe without evaluating a patient. Otherwise it will be a barrier to hospice to all of these patients who don't have a referring physician, don't have an attending. And at the end of the day, we're charged with the 24-7 provision of care and cannot be delay. So, I mean, ultimately it's your decision. Yeah, I'm just curious. I mean, obviously you have so much knowledge of all the regulatory things in terms of all the new sort of opioid prescribing different guidance or different regulations coming out. That still seems to make sense to everyone in terms of the medical director. Yeah, and it's a federal requirement that we're able to meet the need emergently of our patients. So, and hospice is still a provision that allows this appropriate prescribing of opioids. I feel very confident in it is what I'll say. And I'm in Texas. I would just, this is Jerry Wilma. Sorry to interrupt or interject, but I've been doing hospice for 30 years and vast majority of it with SSM Health and I'm currently transitioning now to the other, but the whole, it's an age old issue of comfort kits. And I would agree certainly with Dr. Templeton. I do agree with what you said, Beth. And without speaking too much, my concern, I've been in experiences where we do comfort kits, but we don't, like you said, customize it. Somebody with renal failure or liver failure, they get the same list of medicines and I've bought that tooth and nail because one size doesn't fit all. But overall, yes, the patients, both from the standard of care, but regulation and the health care, from the standard of care, but regulations, as Dr. Templeton said, is that that is our responsibility. I've found that most, honestly, most referring physicians don't want anything to do with prescribing comfort meds. And when they do, they prescribe weird concentrations of morphine that get confusing or like, I honestly, I'd rather have our docs doing it. We serve a really rural Appalachian area and we still don't do comfort kits. The expectation is that the admission nurse calls the doctor. So either like that's me during the day or the team doctor or at night, the on-call doctor. And we go through what symptom issues there are. And then we prescribe meds based on that. That can get tricky, like you said, we don't have a lot of 24-hour pharmacies too. So certainly there's times when it's been hard for families to get medications, but overall we're pretty quick about prescribing medications, comfort meds, personalized right at admission. And just a comment, we usually, whether it's a symptom relief or individualized, it's always a minimum amount to get them through within the first couple of days until the case manager is able to assess them and can have a bigger conversation as far as what the symptom should be. Though just, I know we're running out of time, but in Illinois, we have a regulatory issue where that anyone that prescribes more than 25 prescriptions of C2s is obligated to be telling the patients that you may become addicted to this medication and offer them Narcan. I'm just wondering if that's come up at any of the states that you're practicing in and how you're dealing with it, because in Illinois, there's no exceptions for hospice or palliative. Yeah, I was gonna say Massachusetts, there are exceptions for hospice and palliative, and ask, I imagine there's great variety on that around the country. Yeah, we're working with our prescribing vendors to see how to do the language with the consents to cover that. Chris, you had a comment? No, it's just how we, Minnesota does have exceptions. The same exception for hospice and palliativeness, and yeah. I don't have a problem with Narcan. I mean, I think it should be in the home. I mean, our comfort kit, and it might be interesting when we have more time to figure out what everybody's comfort kit is, but we give 15 to 30 mLs of concentrated morphine, 20 to one, Roxanol, that's 600 milligrams of morphine in the home. And the prescription for the comfort kit is five milligrams Q3 hours PRN, or some variation of that. And most of these people are on higher doses of opioids anyway, when they walk through our door. So that's not even very effective. So you're giving them 600 milligrams of liquid morphine and no Narcan. So I think Narcan is really important. And I just heard today, maybe you all have also seen it, but it's recommended to the FDA to consider making Narcan over the counter now. So that brings in a whole host of other problems and other concerns, but we don't have to guide people that maybe they'll become addicted, but Narcan, I think is an important consideration. Thank you. This is a really rich conversation. We are out of time. I just so much appreciate people's discussion. So Gina, I don't know if there's anything you wanna say to close. I really, I learned a lot today. Thank you, everyone. Thanks, Kristen. We appreciate you facilitating. You did a great job and thank you all for attending. We will keep the chat open for 10 to 15 minutes. If anyone wants to continue the conversation, you're welcome to stay on. We'll stop the recording, but you're welcome to stay on for the remaining 10 to 15 minutes just to carry on the conversation. If not, we'll host our next coffee chat in April. So you'll see some emails about that or you can register on our website. Yeah, I have to jump off. So I'm glad you're staying open. Thanks so much. Everyone. Thank you. Thanks, Kristen. You folks have stuck around, it looks like, or are signing off. Not sure what's going to happen here, Gina, so we'll see. Ron's here. How are you doing, Ron? Good to see you. I'm fine. Yes, I just wanted to make a quick comment about Narcan. Oh, yeah.

Narcan

prescribing opioids

hospice patients

overdose risk

adverse reactions

addiction risk

home availability

FDA recommendation

patient safety