Hi everyone, small crowd so far. We're going to give it another minute or two and then we'll we'll get started and get this going. Okay, thanks for being here. Appreciate you being here. All right, we'll get started in just a moment here. Just want to give folks another minute or so to get here, and then we'll jump in. All right, well, we're not going to delay any longer. Good to see you all. It's again, small crowd today, but we'll get started here. And hopefully this will be very helpful for the group that's here today. I'm Bruce Hammond. I serve as HMDCB's Executive Director and it's great to see you all. Thank you for being here for our June Coffee Chat. So wanted to just, again, before we get started, like we always do, just a couple of quick announcements and then we'll turn it over to today's facilitator for the session. So there's a couple of events coming up by a partner group of ours, Weatherby Resources, that you can get some 10% discount by being an HMDCB Certificate to attend them. The Hospice Physician Documentation Clinic, which has three different dates, as well as the Hospice Physician Compliance Conference in August. If you've been to that, I think you probably would agree that it's a pretty comprehensive overview of compliance issues related to hospice. So that's a great event to attend. So you can learn more at the website on the screen or email Gina for the discount code if you'd like to attend those. Our July webinar is gonna be on the topics of substance use disorder and opioids in hospice. We have a great panel of providers who specialize in hospice and substance use disorders and addiction medicine. And so I encourage you to register for that today. That's gonna take place on July 20th at 1 p.m. Central Time. And then the remaining coffee chats are there on your screen in August, October, and December. So we have expanded the amount of coffee chats we're doing. We did four in the first year. We've jumped up to five and now we're doing six. So we're hearing from folks that these are very valuable to you all and we appreciate everyone participating and doing those. So again, three more to go after this one this year in August, October, and December. You can learn more on our website. And then if your credential expires in 23 or 24, you can recertify this year if you'd like. You can learn more and register at our website. Again, hmdcb.org slash CCP, which is Continuing Certification Program. So if you have questions about that, please feel free to let us know. But at this point, I am excited to turn it over to our facilitator for today's session, Dr. Albert Riddle. Dr. Riddle is the Chief Medical Officer at Hudson Valley Hospice in New York. He's a volunteer for HMDCB and just led the organization's two-part webinar series on dementia. And we're gonna spend a brief portion of today's session on following up to some questions that were asked during those webinars, just to kind of start the session there and then we'll open it up to everybody. So Dr. Riddle, I'm gonna turn it over to you. Thanks again for being here and for being our facilitator and good to see everybody. Thank you and good afternoon to everyone. So I'm gonna start off with a couple of questions as you just heard that came up during the dementia series that we just did. And the first of those is a question regarding what criteria are most helpful in determining a six-month terminal prognosis for a patient with either frontal temporal lobe dementia or Lewy body dementia. And I thought that with the group that we had, maybe I would just open this up and see if anybody wants to offer any recommendations around criteria off your experiences, things that you look for in those specific conditions. And so if anybody would like to jump in and make a comment, why don't we start that way for either frontal temporal lobe or Lewy body. And if actually, if no one has any comments, I'll make a few. So my first is that when you look at these two conditions, each one of them has their early, mid and late stages that you go through. And for both conditions, I think that toward the terminal stage, when you start to think about what would qualify for dementia, starts to look very much like Alzheimer's disease. And I think where these two conditions really separate themselves are in the early presentation. So for example, a patient with frontal temporal lobe dementia early on in their disease course, they really don't have the cognitive loss that we might see in other types of dementia. And instead, what they tend to see are either problems with language, either finding words or understanding words, or they might have specific behavioral issues where they start to act inappropriately in public and really can't put a cap on some of the things that they might do in public. As their disease progresses, it starts to look more and more like an Alzheimer's type dementia where they'll have the functional loss, they'll start to have some of the loss in cognition. And eventually, when you get to that very end stage, you're looking at the same types of issues where infections will become an issue, pneumonia, aspiration risks. So really those are the types of things that are gonna speak to a terminal prognosis so that in the end, you're really generally looking at those same criteria, using your FAST score, using your PPS score, using infections, hospitalizations, rapidity of decline, all of those things. When you look at a patient with Lewy body dementia, that's a little bit different, but again, the difference is more in the earlier stage where they're gonna have more movement disorder, they're actually gonna be more inclined to have visual hallucinations specifically. But again, as their disease progresses toward the end, they start to look a lot like your Alzheimer's type dementia. So again, it comes down to functional loss, it comes down to the impaired cognition being the issue and all of the things related to that. So once again, in the end, you're really not looking at anything that different, but what might be a differentiator with Lewy body dementia that you have to be careful about is the fact that even in the end stages of the disease, there can be a lot of fluctuation that occurs from one day to the next. So you might have a situation where the nurse doing the initial assessment will go in and see a person that looks absolutely awful and they'll report that to the physician who's admitting for the day and they might look like they meet criteria that day and then a few days or a week later when staff goes into follow-up, they might see a totally different person and wonder, hey, how is it that we accepted this patient based on what I'm seeing now? And then questions might come up in subsequent IDG meetings and I've seen that happen. So I frequently, as a reminder, have to bring up the fact that you can see a lot of waxing and waning and they can look horrible one day and very well the next day and you have to take that into account and factor it in when you're looking at their qualifying for having a six month prognosis. So does anybody wanna comment based on their experiences on anything that I just described? If not, the second question that came up was how do you diagnose depression in a dementia patient? So again, I'll open it up before I give my comments but does anyone wanna talk about how they handle depression or making that diagnosis or depressed mood in the patient with end-stage dementia? And again, if not, one of the things that I think is really important for us to remember is something that was mentioned in the second of the two webinars that we did, which looked at late life depression, which we'll often see in patients with dementia in the end stages and how that can look very different from a patient who has a major depressive disorder. All of the criteria may not be there for a major depressive disorder but that certainly doesn't exclude the fact that this can be a major issue with these patients. We know for patients with dementia, particularly in the later stages, that depression and comorbid anxiety can be very difficult issues and if not managed appropriately, can have a horrific impact on not just the quality of life of the patient but also on the quality of life of family members and other caregivers. So there's a couple of things I would recommend. First of all- Hi, it's Dr. G. Yes. I was trying to reach Zach. I think, oh, maybe that was someone who was talking in a microphone open. So anyway, what I was gonna start to bring up was a tool that I frequently use in this scenario with dementia. That is not a tool that's unfamiliar to us. It's actually the PHQ-9 or personal health questionnaire that has nine items. And the beauty of this tool is that even though it has a component that is based on being able to interview the patient and come up with symptoms of depression and give a score around severity, it also has a component that allows you to do the scale strictly by observation. And that comes in very handy for patients who have impaired cognition and can't report to you what they're feeling otherwise. So with this tool, it will help you pick out patients who are having substantial depressive symptoms and even give you a guide within the scoring system, let's say with a higher score, meaning more severe depressive symptoms with a minimal score being, let's say a five where above five, you would really need to consider using medication treatment. Below five means that symptoms are mild and you may not have gotten to the point yet where you would need medications. This kind of helps you to differentiate those very severe patients that need more help versus those where you might wanna try other interventions to help them with their mood. So this tool has been very handy. I actually, in addition to working in hospice, also work in a number of skilled nursing facilities. And with that population in particular, this PHQ-9 tool can be very valuable in helping you pick out those that have depressive symptoms where additional intervention might be warranted. The third question that came up is- Dr. Redding, can I stop you for one second? Dr. Downing, hands up. So I just wanna invite him to share. Yeah. Hi, how are you? Good. One of the tools that we ended up developing or I brought into our system was the Cornell Scale for Depression and Dementia, which is a two-factor test that you actually interview the caregiver and there's 19 different questions. So you get an idea of somebody who's seen the patient regularly over a period of time and then also interview the patient to see if it correlates with your impression of what you think about the patient. So you can use this as a screening tool to see about depression and then also to see if your drugs, if you've introduced any drugs or therapies, make any difference later on. So that's just another thing that's available for you. I have a question. Actually, I'm gonna bounce back to you. Have you found in terms of your interventions, any particular class of antidepressants that work better in this population than others? You know, I, no. I usually go to Lexapro first. You know, although the geriatric letter talks about Zoloft, you know, I usually use the SRI first and just see where we go. And then if I'm not getting success, then I rotate around. Right, right. Yeah. Okay. I have a question about antidepressants in very late stage dementia, though. Like a lot of our patients come to us on them and I often wonder whether they're still appropriate at a certain time and when to deprescribe. Yeah, I actually- A lot of our patients are perhaps nonverbal or very few verbalizations, bed fast. And so you have to wonder what good is it doing now? I tend to, particularly for those patients that can't communicate, look a lot at their behaviors, specifically in terms of anything that might signal anxiety or restlessness per se. And I also look at other potential symptoms like caloric intake, weight loss, how well they're sleeping. I look at all these things individually and even with therapy, I try to look at antidepressants that might help with those individual symptoms. So Trazodone, for example, for someone who's showing insomnia might be helpful for a short period of time, probably not a prolonged period of time. As was just mentioned with the SSRIs, I use a lot of Lexapro in this population because I find it helps with the anxiety and the depression both. So I think that they're very useful agents to consider. And I also, in certain circumstances where the patient seems depressed and I think I might be able to boost their caloric intake a bit, would consider using low dose metazapine for a period of time to see how they respond to that. So I think there's many different ways that you can go about it. But I, in particular with this population, try to think about the individual symptoms and try to attack those with the medications as I can. And I think what you mentioned also about deprescribing is absolutely important. It's really important to continue to observe closely, recognize when you're not getting a response from these medications and withdraw them as appropriate and make sure that you're using the lowest possible dose at all times. This is Tom Browning. So just to follow up on that, I actually, as a hospice physician, I end up seeing patients and they're on an SSRI and they're on mortazapine and they're on trazodone and they're on, and I'm never quite, this deep tropic thing, I'm kind of in the same boat is where do you start and how do you get families on board? Because the, I don't know, how do you know the patients are really responding at that point? Sometimes you really don't. And I think that's where it's important to look at potential for slowly withdrawing some of the medications to see if there's any deterioration in symptoms. So, you know, setting up a schedule where you might cut a dose in half. I sometimes, by the way, also see a misalignment of doses. So for example, with mortazapine, I might typically look to see that they're getting a low dose, like a seven and a half milligram dose, for example, with having the experience that I've seen some patients come in on higher doses with the intent to stimulate their appetite. And so we know, or at least my understanding is that at higher doses, mortazapine can have the opposite effect and actually have a negative impact on caloric intake. So I just think you have to be really careful taking a hard look and have a schedule for dose reduction over time with these patients. Hi, Alan Rosen. I'll jump in a couple comments. One, I wanna support what Robin Turner put in the chat about Marilyn McPherson's videos and her advocacy on deprescribing. Also put a link in as Dr. Downey mentioned for the Cornell depression scale. The other couple things I'd like to just put out for this group as we're leading the field, also to keep in mind that we hope to see an evolution in the field. We hope people are referred more than three breaths before death. And so as we see people that may be at a different functional level or if their terminal prognosis is tied to cancer yet they may be higher functioning, we should also individualize some of our approaches that way. In the last part that I'll mention, sorry, two parts I'll mention. One, in terms of, if I'm looking at simplifying the medication regimen, I'll usually start to taper off, say the mirtazapine rather than the antidepressant. Again, you could see some confounding effects. The other thing is that while Lexapro can be easier because of the actual dosing strength, I find that especially people and families that are concerned for adverse reactions and new medication, especially if it's a new hospice diagnosis, I've found sertraline, Zoloft, better tolerated in the geriatric population and there's more flexibility in the dosing. So if that helps, food for thought. Okay, great. Any other comments? Hi, sorry I joined late. It sounds like it's been a good conversation. I think again, we have to also educate our colleagues upstream about when patients do come onto hospice, how you don't have to take a statin for life. You don't necessarily have to take Eliquis for life. Some people do, some people don't. So having some education about deprescribing in the elderly, even before they come onto hospice, I think is a real effort that we need to put forward. Let me ask a question related to that because I would be curious to hear about others' experiences. I know in my hospice, our ability to have direct patient contact for purposes of education isn't always as great as I'd like it to be. So there really is a reliance on staff, the nursing staff primarily, to do a lot of this education. So if that's the case with all of you, how much education do you do with the nursing staff to make sure that they're hitting all of the salient points that should be hit in that educating or education process? or do you set up schedules of training sessions with the staff where you go over these exact points? We've recently instituted, we're a large hospice and we have recently instituted each of the providers has even some of the nurse practitioners signed up. There's a monthly nursing in-service and each of us have taken 20 minutes of that time to do an educational process on different symptoms or problems that we wanna see or stress. And so that's how we operate. So, yep. Anyone else? We usually do, Dr. Laberge, we usually do a quarterly meetings and then during ITT, I do what's called a teaching point. So if something comes up and then every time I get a new staff member, I do those teaching points again with the whole staff at IDT, the big ones. How do you do PPS? How do you do KPS? What, how do you term the ADLs and stuff? So we're fortunate. I work full-time and we're a smaller hospice. So I go out a lot to the community too and do some teaching and go with the nurses to do visits. And that's a good time to teach too. So, but again, we're fortunate we have three docs and everybody loves to teach, so. All right. That's great. Anyone else? I put a comment, this is Alan. I put a comment in the chat. Some of our terminology could enable us to be more effective speaking with patients, families, allied staff, talking about simplifying the medication regimen or interventions, not we're discontinuing this, not that we're withdrawing this. And the other thing that I'll also put out there as food for thought is that sometimes we can be more effective in the communication with families and patients rather than requiring our referral sources to do the medication management and all of that. And I've had too many situations where others may be simplifying or thinking they're simplifying, yet the way they discuss it, present it, go about it is much differently than what we would recommend, especially if you have inpatient. So how many of us in ICUs might get a GIP referral and they're on drips, they're on other things, and I can tell you a number of docs that say, oh, just shut off all five pressers, just immediately do all of this when physically there may or may not be sequelae, but if family are at bedside and how we're looking to manage that situation, that's part of the art of medicine and how we can comfort staff involved and others. Okay, very good. So this is Tom Browning. So I actually like to link something that's happening with the patient with the medication. So magnesium supplements are huge pills, they're always prescribed for people with dysphagia. Statins are no longer helpful, it's just part of the toxic soup. Weight loss, people taking SSRIs or other medications, ARCEP that are associated with weight loss. So I try to get my nurse to link the constipation, the number of pills that get added on to manage the side effect. Mary Lynn has a great talk about that, the number of pills that we use to manage side effects of unnecessary medication. So I'll try to get the nurses to do a lot of linkage. Yeah, I've always looked at that whole medication cascade viewpoint as something we really need to pay a lot of attention to because so much of what we prescribe is looking at treating symptoms that are caused by some of the medications that they're already on. And my personal approach is always to look at that medication regimen with new symptoms and see what we can withdraw first before we start adding anything else. I think that's really important. Any other comments? All right. So then let's look at the next question that came up. This was around coding. What hospice diagnosis are you typically using for the typical nursing home patient that's referred for unspecified dementia? That was me. Oh, okay. Oh, okay. You know, it's always dementia unspecified or however dementia comma without behavioral symptoms unspecified, you know. So does that mean automatically now senile degeneration or do we say, well, we know Alzheimer's dementia. If we want to call it that then we can call it that and choose that. Yeah. What about at conferences? So the main issue around the coding comes back to what was brought up during the webinar that talked about those manifestation codes, right? So dementia, for example, without behavior disturbance or with behavior disturbance is still going to fall under that umbrella of being a manifestation code. So- But I feel, I'm sorry to interrupt. Go ahead. I feel that the nursing home doctors, we all go around calling things dementia. Very few people specify what the dementia is and no one takes the time to do that very rarely unless they've had a neurology consult or a psych consult and then they are the ones that are usually more specific as to the dementia. And it just carries on and carries on down the line. And then we get the referral for dementia. Right. When we might know it is actually Alzheimer's dementia but never has it been specified as such on paper up until now. Well, it might be Alzheimer's dementia. It also might, in many cases, be a vascular dementia where they've had a prior history of a CVA or some other neurologic event. Another one that I think you'll see is Parkinson's disease dementia. Because many patients with Parkinson's go on to develop comorbid dementia. I think those are all valid codes that we could use, not just for the nursing home population but for the dementia population in general, community included. Well, the Parkinson's one is sort of easy because they're usually on some meds and they usually have Parkinson's disease as part of their profile of history. That it may- Same with the vascular. I feel like it's this large group of people that don't have any reason to have a vascular dementia. They don't have Parkinson's, things like that where it's just called dementia when the doctor truly meant Alzheimer's but they've never actually said it. And that's when I wonder, well, what do you specifically choose? What do you do? We specifically stick with the senile degeneration of the brain in those cases. Just for the safety concern of it with the coding and it being accepted by CMS. Are you worried it'll fall out of favor soon? I don't think it will. We've seen over the years an increase in the use of the senile degeneration of the brain code but when you take a hard look that coincided with us not using frailty and not using debility and failure to thrive any longer because many of these cases we're using those terms. So I hope it doesn't fall out of favor anyway in terms of it being accepted but we do tend to use that code way above other potential dementia codes that we could potentially use. Carolyn, could I just ask, so is your question mainly around patients where you don't have access to charts because if you can review the chart and see- No, no, I do. And honestly, I see it throughout the electronic medical record of a large local hospital system here in South Central Pennsylvania where doctors just continually to perhaps the same dropdowns just continue to populate and no one is choosing a dementia type. They're just calling it dementia and it defaults to that thing that makes me bonkers every time I see it. We're the ones that have to be specific but no one else has to be, right? When it comes to that. So- Yeah, that's what I was wondering because I agree with Leah. I think she put something. So at least I was told early on when the whole dementia you know, upheaval happened in hospice. If we can create the clinical scenario for ourselves and we just simply state that in the CTI based on my review of the medical record I believe that this fits the Alzheimer's category or whatever Alzheimer's diagnosis then it, you know- Right. We're doing our best to put together information from, you know, copy forwarded information that you've seen for 20 years. And so I think it's okay. And then finding other support of microvascular changes or, you know, anyone who is evaluated for hallucinations or, you know, things like that. You can put that together for yourself and just do your best. Nobody's gonna get mad at you for doing your best and doing a good clinical review of the chart. And then I guess if all else fails then use that senile degeneration, which I don't, I haven't, I really worry that it's gonna fall out of favor too. I kind of, I think Leah, I think she wrote in there too that she thinks it might fall out of favor because it's so nonspecific, I guess. It's a shame that Medicare won't let us use cognitive decline of unknowns because we all know that just dementia actually is associated with death. Right? And if the story is right- Whether we specify it or not specify it. Right. If your terminal trajectory scenario is compelling in a CTI, I've said this before, what difference does it make truly? Because we have to pay for all the meds basically. And, you know, I don't know. I just, I'm waiting for that Medicare, 2.0 coming up, right? Aren't we gonna have some changes coming down the line? Hopefully in favor of the patient. Careful what you wish for. I think one of the problems in addition to the coding issue is the extended lengths of stay that we tend to see with the dementia patients. And I think that's more of a concern to the payers than anything else that might make all of this more difficult for us to get appropriate patients on for whatever hospice code that we wanna use. I'll also add, and curious maybe for this or a different discussion, when bringing people on for dementia, for example, when I was in South Florida, it was very problematic that everyone would basically be looking to treat aspiration, put people on antibiotics, do automatic escalation and interventions, not based on symptoms, but rather just like whether it's a UTI or whether it is a aspiration that if you look at the different guidelines, it really says if the disease runs its normal course. And it got so bad in South Florida that anyone that had two prior revocations coming back needed to be reviewed at my level as the medical director, because if their goals are not aligned, that becomes problematic. And so I'm curious whether now or a future conversation to hear how others are handling that type of scenario. And again, it goes back to what are the goals? What are their priorities? How are we communicating it? But if you keep having patients revoke, readmit them, you know they're going to revoke, that also are grounds for having a red flag, but I'll defer to Lauren Templeton on the regulatory aspect. On that revocation point also, what I'm having difficulty with in my hospice are those patients who are going to the hospital for symptom management. And then when it gets to the point where they're going to being discharged, they get referred to a skilled nursing facility because they're not quite ready to go home yet, they need a little tune up. And then the nursing home wants them to revoke so that they can put them through some torture rehab for days or weeks before they send them home. Judging by some of the looks I'm seeing, I guess I'm not the only one having that experience. I feel the burn on that too, but not recently. Oh, really? No, thankfully, but that has happened on a GIP where then the family decides they don't want to take them back home and the nursing home is offering a certain amount of respite, so to speak, at the skilled expense. But yeah. Right. Yeah. So any other comments around that or any other issues that anyone wants to bring up? There was a- Oh, go ahead. Dave Ledowski here in Southeast Pennsylvania. My hospice has had multiple ownerships in the last couple or three years. And we've had confusing direction in terms of which medications we are supposed to be covering ranging from only those that are directly related to the primary hospice diagnosis to anything that would affect the patient's potential trajectory to symptom management. So I'm wondering what other people are covering. Anyone want to comment on that? I know you- Oh, go ahead. Yeah, from Cedar Rapids, Iowa. I mean, our approach basically to this is if it's basically everything except for a few kind of outliers. So an example would be somebody who takes an osteoporosis medication that's really not going to be associated with a hospice diagnosis or some other medication somebody may take for chronic conditions that's not associated with it. But basically everything else is. The osteoporosis meds are the ones that are probably the easiest is an example that I can think of. We've had the same experience. The easiest example that comes to my mind are the glaucoma medications. We typically don't cover those, but very few others. Anyone else with comment? At the time of admission, however, if someone is coming to me with congestive heart failure and they're on Entresto, that will result in a conversation of if you want to stay on that medication, then you'll need to not be on hospice basically. And I know that Mary Lynn McPherson and her daughter and others on that really great conference that they gave supported us in that determination as a hospice medical director, because they said that really, there is no place for that at that moment when your prognosis is six months or less. And cardiologists really should agree with that, but sometimes they don't. So there are some medications and also for pulmonary fibrosis, some of those, Esbriette and others, that I would say, if it is your goal to continue with that medication, then we won't be able to admit you for hospice care. Right, so this is Tom Browning. We've been using the ABNs now for those kinds of things, like the IPF medications, the disease modifying. Those are pretty easy for me, because usually those drugs were approved based on a six-minute walk test. And I tell them, you're housebound now, so you're no longer part of that study, but we have them assign the ABN anyway, and Entresto is the same way. I agree, we just, and they often become hypotensive, so it's pretty easy just to tell them, I think they'll feel better without the Entresto. So we've just been more liberal using the ABNs. With some of the discussions around these issues, are you finding that some patients might be reluctant to pick up their hospice benefit at an earlier point in that six-month prognosis window? Any comments on that? I have not had that experience. Okay, no. We don't routinely cover Aspariva inhalers, because people with such advanced disease process, they can't manage it. And so we will substitute DuoNabs and other things. So we will replace those medications with a cheaper alternative, but also we know that they're at least getting some benefit from the drug. People with COPD really can't hold their breath for 15 to 20 seconds to get the effect, and so that's how we talk about simplifying their medical regime. The things that we are supposed to cover are biomedicines, pain medicines, psychiatric medicines, and I'm blocking on the fourth, but those classes that Medicare wants us to cover. And then everything else is kind of based on your hospice philosophy. And we'll cover Entresto, but we're large. We can do that. We do a lot of different things that we do blood transfusions. I mean, so each hospice has their own philosophy. That's what you wear two hats. You wear your fiscal hat and you wear your medical director hat. And that is a process. And so everybody can, it comes down to your philosophy of how you do things. And people can choose you or a different hospice. That's the choice. I agree, and that was actually one of the reasons I brought up the question I did, because we have a larger hospice also, and we do provide some of these treatments that a small hospice might not. And part of it was discussions around, we're trying to get people to understand that they can get more out of their hospice benefit if they get on earlier rather than later. And even with that, we still see so many referrals that are coming to us when they're more in the final days rather than the final six months. So is there another comment? Yes. I wish this would be the area where Medicare would review and reconsider that piece of the hospice benefit with regards to medication. I feel like it's a little bit of a fox mining the henhouse. We wanna do what's best for patients. We ought to be able to counsel them what we should do and shouldn't do. But I don't feel, if I were a patient, I would always have that idea. Well, of course you don't want me to be on Xarelto. It's expensive, it's hurting your bank. Of course you don't want me to be on Entresto. It's hurting your bank, whatever. I wish that we could have that teased out. And of course then we're not gonna be reimbursed as much on the daily. But I just really feel that we should, and we should still be advising and helping patients with decision-making on what's the best medical regimen for them at any point in time. But that's just me. Sorry, I just wanted to say that, can you guys hear me? Yeah. Yes. I don't know if this is right, but what I try to do is look at the relatedness first before I think of medications at all. And literally I'll have my list up of related and not related. And then anything related medication-wise, we'll cover if it's on our formulary, we might substitute something that's not related. We'll cover if it's on our formulary, we might substitute something that's cheaper. The place that I personally really struggle with is ventilators now. Everybody's getting a ventilator. I mean, you've got your, for us, it's a lot of COPD. That one to me is a little bit easier. But what's hard is the ALS patients. Often they're not using it really. They don't wanna use it. So there's some conversation and some things that can happen there. But, and sometimes they're using it more for their cough assist or whatever, but I'm kind of curious. I don't wanna change the subject if people are not ready, but I'm curious as to what people do with ventilators. Do you just do a cut and dry? Nope. Or do you look at it case by case? Or sometimes, or if it extends prognosis, we trend past six months, we won't. But what if it doesn't? Well, these people are gonna die anyway, ventilator or no ventilator. I assume you're talking about like a non-invasive. Yeah. Like a BiPAP, not the Trilogy. No, I'm talking about the Trilogy kind of stuff. Our community is, our pulmonologists are passing them out like candy these days. So the Trilogy most often at home is used really as a BiPAP and you can swap them out. That's what we do. They've got a Trilogy. We just swap it out with a BiPAP. And it's a little cheaper. Yeah, we've done that a couple of times. I was gonna say, we do cover the non-invasive ventilators just kind of with the caveat that we're not gonna be in there changing settings. Like we don't have a respiratory therapist on our staff. So, but if patients want to, we will cover the cost of them. I will add also, and I've done this over 15 years. Personally, I don't object if someone's already on a ventilator and way back when and in Chicago, the Les Turner Foundation gave VPAP machines to every ALS patient. It wasn't BiPAP. It wasn't BiPAP. That wasn't a typo. There was a chip in there if you didn't breathe a certain amount. And this again, I respect the different comments that have been made and everything given your patient population, your size, your organizational philosophy and all of that. However, if we also want to be, consistent with our integrity, there are so many of our patients who would not survive a day without their nasal cannula O2. And so I think it goes back to what are the expectations? If they're expecting that a respiratory therapist is gonna come every day, every week, even every month, that's non-appropriate alignment for what we typically can provide. Also, it is, if the machine fails other things, we would not necessarily support taking that person into an inpatient setting. These are different things that every protocol, you also have to consider how you have your protocols for after hours management. So there's more involved with it, but I just wanted to put that out there that we do see more nuance and that may be something to consider. Yeah, thanks. Are there any other topics that anyone would like to bring up? I'd just like to comment on discontinuing medications again. One of the approaches I take, again, I get to see a lot of the patients, is I discuss the difference between hospice and what a hospice doctor is going to want and what a specialist is going to want. So in the intresto, I tell them the cardiologist's goal is to prolong their life as long as they can, to make them as comfortable as they can, and that I can give them medications that will help their heart failure and tell them that I'm talking from a hospice perspective, with that you have six months to live. The cardiologist, when they told you you have to stay on this bed for the rest of your life, is looking at someone living longer than six months. And I do that with pretty much every disease state. So the inhalers, I demonstrate on it. I bring an inhaler with me. I demonstrate, okay, this is what you're doing to take a breath. This is what you need to do to take a breath. So sometimes educating the family on what the medications are doing and what they're doing for them. Same with bleeding. I always approach it with there's a higher risk, or at least as high a risk, for a bleed in the brain, especially if you fall or something, than what you're going to get for benefit from a fib. And we put them on an aspirin or Plavix or something, go back to the old school. And we didn't have these drugs that long ago. And a lot of people did very well without going on a $400, $1,000 medication. And I explain it that way. And we had pretty good success with our patients, the family listening to that. If we don't, then obviously we would still cover it. Is there a point where, oh, I'm sorry, go ahead. I was just going to say, you know, that's great. And I think our nurses here at hospice try and do that as well. You know, sometimes when I get involved with the family, you see the patient who has heart failure on Entresto, and they can't move because they're so short of breath. And they're on Entresto. And, you know, you try and say in a very palliative care way, well, I really don't think it's working anymore, is the other thing. I think people think that it's just working. And if they're declining through the medications, then obviously at that, well, to us, it's obvious, you know, I'm presenting it to the patient and the family in a different way, but the risks, you know, outweigh the benefits at that point in time. And so, you know, having that conversation too, I find to be very helpful is that, you know, it's a constant balance of weighing the risks and the benefits. And up until now, the benefits have way outweighed the risks. And now we're at the point where the risks of the medicines are too high. But, you know, sometimes I just kind of look at that picture and I think, do they see what I'm saying? But whatever, families have a hard time giving these things up for sure. Do you ever in a circumstance look to have conversations with the prescriber, let's say the cardiologist, in addition to the discussion that you're having with the family? I definitely do. And, you know, kind of what I was saying before, I think it's really important to have those conversations with the team before the patient even comes on so they can help us. But I'm curious what other people do about that. Yeah. I talk with the referrals from, well, first off, we have a palliative care nurse that works with the heart failure clinic. And so that helps set the groundwork for somebody coming into hospice. But I also call the cardiologist. Some referrals that come in, you know, they have cardiomems in and they've been managing that. And, you know, we, you know, going into the ER and getting IV diuretics, you know, and they're very happy to get, let go of the patient and have us manage them. But then the discussion is that we need your help to, you know, transition them to our service to get out of this fast fix, mind fix. So that's, that's, so that helps. Yeah. Yeah. We we've been more aggressive in my hospice about opening up those lines of communications. And I think in addition to the fact that the, these doctors are happy to pass the patient off to us. I think they're happy to have the opportunity for that warm handoff and have some interactions and help with the, with the transitions that the patients have to make. I think it improves relations with the community and hospice tremendously. The problem I have is sometimes getting a hold of the doctor. A lot of times we get a lot of patients on these medications that the cardiologists will see once in the hospital. And even though, you know, so they may go home for a week and then they're going on hospice. So they have, they don't want anything to do with it. They don't because they saw the patient only in the hospital. They don't want to make that decision and they don't want that phone call. So I don't know if anybody else runs into that or not, but I run in Lansing. And I run into that quite a bit, you know, they don't want to discuss it because again, a lot of our patients haven't seen their cardiologist for a year or two and to go back and try and, well, I haven't seen that patient for two years. So again, I use my other approach. The other comment I'll draw people's attention to, I put in the chat, consider having regular interactions with your marketing staff, your liaisons. We would do, you know, every other month and sometimes more frequently a session. What is coming up when you're meeting with a referral source, what are they saying and helping to coach our staff on the front lines? Well, when they say X, how are you responding or how can we be effective in this? And doing some of those role plays, some of those opportunities as well as you know what, if there are certain types of things, either that person is uncomfortable with whatever, refer them, have them talk with me. I'd be more than happy to interact. And that type of communication can help avoid, you know, especially your Friday admissions and whatever other conversations to then be a smoother process. Anyway, just want to put that out there that the hospice medical director has a lot of different opportunities besides just with nursing. Absolutely. We are coming close to the top of the hour. Do we have any other points or items that anyone would like to bring up? If not, Gina, do you think we should look to start to wrap up at this point? I think that sounds good. If there are no more questions, we can definitely end today's session. Thank you all so much for joining and we'll send out a recording of today's session either later today or tomorrow morning. And then I'll put a link in the chat if you want to register for all of our upcoming webinars and coffee chats or some of our partner events with Weatherby Resources. And Dr. Riddle, thank you so much for facilitating today's chat, really appreciate it. Thank you. Thanks everyone, we'll see you next time. Thank you. Bye.

hospice care

Alber Riddle

dementia patients

medication regimens

ventilators in end-of-life care

tailoring medication regimens

education and communication

prescribing physicians

managing patient expectations