Welcome everyone. So it is the 12 o'clock central time. So we'll go ahead and get started. Thank you all for joining the October Coffee Chat. My name is Gina Preecey and I serve on staff at HMDCB. And I just want to share with you before we get started today that we want to make this as interactive as possible. So we really encourage you to, if you have a question or a comment that you want to share, feel free to come off mute and share it with the group or type it in the chat box. We do ask though that you stay on mute unless you're speaking. So today's chat will be facilitated by HMDCB Certificate, Dr. Andy Arwari. And Dr. Arwari is a Hospice Palliative Medicine Board Certified Physician with the 20 years of experience in the field. He has completed a Master of Science in Palliative Care from the University of Maryland, Baltimore, and is presently working on a PhD in Palliative Care. Dr. Arwari serves as a faculty member for the Hospice and Palliative Medicine Fellowship Programs for the University of Miami and Larkin Community Hospitals. He's a Hospice Medical Director for VITAS and oversees Hospice and Palliative Care in Miami-Dade and Monroe Counties. So we're really grateful that Dr. Arwari will be facilitating today's coffee chat. And today's chat will be our typical open forum with attendees, so we encourage questions, but it will also serve as a follow-up to the September webinar that HMDCB co-hosted with AHPM, Caring for Patients Nearing Life's End, Managing Symptoms in the Final Week, Stays and Hours of Living. Dr. Arwari was a presenter at that webinar, so he'll be a great person to ask questions about that topic. So I wanna hand it over to my colleague, Leah Farfan from AHPM right now to share a little bit with you about AHPM Learn. Thank you so much, Gina. Hello, everyone. My name is Leah and I am the Education Coordinator on the AHPM staff. I just wanted to share with you all our exciting learning management system called AHPM Learn. We do offer several educational activities that involves interactive recordings and videos that are accessible on the platform. And we do offer CME and MOC opportunities with those educational activities. And some of the new activities offered in our platform, for example, is the continued access to pain management opioids. This is a repurposed recording from our live webinar that took place in April of 2023. And this activity is open access, meaning it is complimentary. And for anybody that is a member of AHPM or not a member, you also have access to this platform. So you're welcome to access these activities. And this also includes the top five highly attended 2023 annual assembly highlight sessions. And those include pediatrics, hospice, scientific research, and quality improvement. And our other new activity that we offer this year is the demystifying complex mechanical support, surgical equipment and devices in palliative care. Oh, Gina, you're on mute. Thanks so much, Leah, sorry about that. I threw in the chat a link to the AHPM Learn. So like Leah said, if you're a member or not a member, feel free to go on there and create a free account. We also have some upcoming HMDCB events. So the Weatherby Resources will once again present their hospice physician documentation clinic taking place November 3rd, 10th and 17th. If you'd like to receive a 10% discount code for this event, you can email me at gparisi at hmdcb.org. You can also register for our final webinar of 2023, strengthening the interdisciplinary group taking place November 13th at noon central time. Register for that on our website, hmdcb.org slash webinars. And this webinar will feature a panel of hospice and physicians and nurses discussing their unique IDG experiences and sharing how you can strengthen your own IDG. And our final coffee chat will take place December 5th at 2 p.m. central. So to register for that, visit hmdcb.org slash community. And finally, if your certification expires in 2023 or 2024, you're eligible to renew this year. So we encourage you to apply by November 1st at hmdcb.org slash CCP. So I wanna hand it over to Dr. Arwari right now to start our chat. Dr. Arwari. So thank you so much, Sheena, and welcome everyone. And wanna start off by asking if there are any follow-up questions to the webinar that anyone has specifically. I'll just say good job on it. It was good to see the representation and the good teaching. Thank you so much. So perhaps to get us started off, there were some questions that were posed, and I think these are pretty good questions and very interesting questions. And I'll start off with one that I think is important. And Naga Wutukuri asked about the new classes of medicines, specifically Nusinta or Tepentadol. Wanted to open it up to see if anyone had specific comments about this. Certainly would like to share my perspectives on it, but I'll open it up to the forum and see if anyone has any particular insights on this or comments they'd like to make about these novel pain medicines. This is Tom D. Gregory. Can you hear me? Yes. Yeah. Nusinta was the same company, I think, that had the fentanyl, but the duergegic patch. I've used it for years, off and on. When I first read the description of the drug, an NMDA inhibitor, it seemed to mimic methadone. The original studies that I remember, and it's been a long time, were done on bunion surgery post-op. And I used it. I think it was good. The side effects seemed to be minimal. I just got away from it for no real reason. And I do the long-term care full-time and hospice full-time. It's not on our hospice formulary. In my experience, it worked well in short acting, long acting. And I really can't tell you if I remember a problem with Nusinta. I know the drug rep. I've known him for years. They never talk about it. I guess it's generic now. But it's not a brand new drug. I bet it's been out at least 10 years, I think. And I remember when it came out and they pushed. That's when they used to discuss pain, until pain was criminalized. And it's very sad. And I do a lot of work with the AG, and I'm in Pennsylvania. If you have pain, you're a criminal. So they rarely will come to me and discuss anything that has to do with pain, symptom management for pain, especially end of life, et cetera, et cetera, et cetera. Morphine's a bad, I don't want to get on a bandwagon, but I'm sure you hear the same thing. Everybody's on Tramadol, the APHM at the last board, he called it Tramadont. And everybody's on their SSRIs and nobody follows the directions. And they're all afraid to write morphine and Norco and God, I don't know. But I used a new scent of a lot before I just got away from it for not a real reason. But I think in the chemical structure and the way it works, I remember was similar to methadone. Do you remember that? I think it was an NMDA inhibitor. I just thought I would have to do that again. Yeah. So this one is very interesting because it actually is a mu receptor agonist and it works on the norepinephrine pathway. So it has a dual mechanism. But I was not able to find where this is comparatively a better opioid choice than any of the other opioids that we currently have. And I think for hospice physicians, one of the things that we really should be cognizant is the cost of these medicines compared to what we have. Right. And I absolutely understand what you're saying about the opiophobia that currently exists. However, looking at the price range for Nusenta, it can range anywhere from $300 at the lower dose to up to $600 for 30 pill supply. Whereas methadone, a 10 milligram tablet, it costs about $9 for 30 tablets. Yeah, much better. Right. So for hospice physicians, we also have a responsibility to be good stewards of the financial well-being of our hospice programs. How can we really justify spending that much more money for a opioid that perhaps does not really provide more analgesic or has less side effects than, for example, methadone? We do have to take those things into account, especially understanding that hospice is a capitated system where we're getting a certain, we get reimbursed for daily care at a certain rate and it doesn't vary. And in that medicines are included. So these are great medicines and I don't doubt that they have a place. I think for us where it really becomes a challenge is when patients are perhaps coming into hospice and have been seen by a palliative care service. And we're part of a insurance plan that covered these medicines. And all of a sudden now we have to start having the discussions with families about transitioning them to probably something that costs less for us and explaining, we're not going to give you something less effective, but we also have to realize that we can't afford to give you a $600 medicine. Again, if we can justify and say, this is so much better, we know that the effects of this are really going to improve the quality of life, then I think we make the argument for it. But if we can't justify it, I really don't see the reason to use these medicines. I totally agree. And perhaps, you know, that's the rub or the difficulty sometimes is, you know, not so much us starting these medicines, but perhaps the prescribed and that I wouldn't say the prescribing them, but changing the opioids when someone is on a chronic opioid to something that's less expensive and helping them understand why we're proposing the change and that it's a better option for them. And obviously, you know, I always think clinical care comes first. But then we again, we also have as hospice medical directors, hospice physicians, you know, being good stewards to our programs to make sure they stay financially viable, that that is part of what we do the value that we bring to the programs that we oversee. Just for chat sake, I'm gonna throw two thoughts just for my own fun. First, I want to say I really appreciate the comment, and I didn't catch who was speaking last, but thank you for the comment about kind of the criminalization of pain. I just want to share a perspective. I remember, I was in was doing training at at Texas Tech at the time when all of a sudden the fifth vital sign showed up. And I remember being a little alarmed that all of a sudden there was a vital sign that didn't make sense to me because that's not an objective finding. And I think I hope we are always from my perspective, what I try to always be at the balance in there. So I do feel like there was a time where opioids were being pushed without thoughts. And now they're being criminalized without thoughts. And I think our, our expertise is to be right in there with the correct assessment. We got a lot of great studies times when opioids are indicated and when they're not indicated, and I like being in that. I like being informed and, and, and thoughtful and working with our patients. I just want to kind of say I appreciate the criminalization statement. We've been on all extremes. And I think we should always be the smart ones. We can always be the smart ones and the listening ones. You know, we got that balance where we strike the balance between the science and the patient. And I like being in that role and, and making sure I know when and when not, you know, when to fold them and when to hold them. I like that. And then also on the part of the deprescribing, what's interesting for me now, and I know there's been lots of talk on buprenorphine, we just had our recent thing on buprenorphine. I'm a, I feel like I'm a beginner in buprenorphine, but I just want to say my early work using it now has been promising, including we found out on a patient that we were potentially going to use it on hospice that it didn't add a lot to our formulary. So now our medical director is very open to me considering buprenorphine as an alternative, as not as a, not a very expensive alternative to the, to opioid needs for patients, even on hospice. So I don't know if others are starting to use buprenorphine in hospice, we ended up not using it for this patient for other reasons, but I'm finding I'm getting a lot of encouragement with my use of buprenorphine outside of hospice for my cancer patients. And I think it will creep into our world, definitely on hospice and knowing that it's not super expensive based off how you do it. But I learned at least in my market, in my area, the sublingual tablets are cheaper than those strips. And those strips are cool because of the way you can titrate with them, but the tablets in our market is cheaper than the strips. So I'm being able to use those tablets. So there you go. That's, that's just a throat for discussion's sake. I don't have any big points other than just kind of bringing it up. No, I think that's an excellent point, Tommy, because so, so comparatively, the pills for us here cost less than methadone. And I don't think that we don't have a lot of patients on the, the Butrans, but, but you're right. We are going to start seeing them because there's a big push on the palliative side. And so a lot of palliative medicine programs here in the area are starting to use them. And I've seen them a lot in cancer patients who transition into hospice. And so we are having to learn about the Butrans and how to use them and how to manage them. So we, we, we are definitely not using it. I wouldn't say in a large scale, but, but we are finding that we are also using them for hospice patients. And so I think that's a good point. I do think that that is going to be an area that we will definitely need to continue to explore and to, to learn about and to become competent in treating patients with this, these novel medicines. Again, I, I'm always, if we can justify the cost and say equal cost, equal efficacy, safety profile, better patient care, then I would say, yes, that's what we should always, you know, choose. That's why I may, I think if you compare to the two, you know, for, for Lucinda, for example, I would say, no, I wouldn't, I wouldn't necessarily think that's my first go-to as, as a pain or opioid medicine. I have to agree with Thomas and Tommy about the criminalization, but I think it's creeped into the general public. I find that it's, it's now some patients, but mostly families, not wanting us to use morphine to get there because they're afraid of what it's going to do to them, that we're going to harm them in some way. I probably run into that much more than I run into anything from outside sources. It, it is so much in the public now that narcotics are bad, that they forget what they're actually good for. And I think that that's a unfortunate because it, even with a lot of educating, some patients, families are not willing to give into that. I don't know if anybody else has had that experience or not. That is definitely one of the biggest barriers to overcome, when we, especially when we are having the initial discussions with families about what we're gonna be doing and why we're doing certain things. And I think that highlights the importance of ongoing advanced care planning and goals of care discussions in hospice. And the fact that we are the educators for our hospice teams and on the importance of that, and we're the experts in pain management and opioid management. So that's the value I think hospice medical directors and hospice physicians bring to the interdisciplinary team. But there's, I agree, I mean, it's a big barrier. And my experience has been patients coming to our inpatient units where they're coming for pain crisis. And the first thing you hear is, well, the family doesn't want you to use any opioid whatsoever. One of the things I was gonna add is, in talking with families, sometimes putting it in context of something else they may be familiar with. So especially those with heart history or those with respiratory issues and helping them understand, well, think about, you've heard how people take for cardiac issues, sublingual nitroglycerin. Well, after taking your aspirin, after taking your nitroglycerin, if you're still having pain, what's the next thing they give in the ER? And it is morphine. And part of the reason is for the fluid dynamics, the O2 efficacy in being able to use what oxygen you have in the blood. And so in my experience, putting that in context, that just like when we use Roxanol for dyspnea, or we're using Decadron in other cases, that helping to make the communication and understanding across one thing which may be bothering them into a situation they may be either more familiar or accepting sometimes can be helpful. Then again, sometimes nothing is initially, and it just takes time and credibility. I think that's an excellent point. And I hadn't thought of it that way. And that's certainly something that we could use in our toolboxes, right? When having these discussions, because sometimes they are easy. There's a misperception. And when we clarify the benefits that we're gonna be providing, families will be open to it. Sometimes they're not. Be open to it. Sometimes it takes a lot, right? And I think that's an excellent way of framing it for families to help them understand why these medicines are gonna be beneficial or helpful for their loved ones. Thanks, Andy. The one other one that I find particularly helpful, especially in dementia or other disease pathologies and etiologies with the gut involvement, that people say, oh, we need to give nutrition or need to do things. And I say, why do you think the nerves in the gut are any younger than the nerves in their brain? And some of these challenges. And it might get a little smile and then follow that up with, I use an analogy and I compare our gut to the big tube of toothpaste that's mostly empty. And I point out, you know when you have that really big tube of toothpaste, if you're unorganized and squeezing it, you won't get toothpaste coming out. It has to be very coordinated. And these are examples people can relate to that when you say, well, if we're pushing in artificial and their body is not the organized symphony with the working conductor, then that's going to not move forward. Instead, perhaps move backwards. And just like we don't get toothpaste out of the tube. And so whether it's when they're brushing their teeth the next day and they start to think about these things, if we can even pull together as a community, I want to learn from other people, particular tips, what stories, what articles, what approaches are effective for you and how can we help pass this along among colleagues or people new to the field? I got two thoughts from that on what Alan just said. Thanks for that. I was going to say one is, this is a total tangent, but it's the way my brain's working right now. He used the word need and I don't know if others, I want to give a shout out to those who listened to Jerry Powell, that Eric Widera and I'm, oh, I'm forgetting his partner. Anyway, those two guys in California that excellent Jerry Powell, there was just a series they did on communication and they talked about not using the words need or helping families when they use the words need. And that's not using the words need or want on medical care. And it's been making me think about it. And I have not used the word want, I think in this past week and a half, but it's been amazing how many times a day that that's the word that is wanting to come out of my mouth and instead of asking families, what would your dad want? Because of course I want to play for the Astros and I want to see them win tonight. And that part's not a fantasy, but the first part is. And so using the word want when what we really need to say is what would your dad instruct us to do in this situation or something like into that. So that's been interesting is paying attention to how often the words want and need are used. Because as you said, the body doesn't need that nutrition that way. It stays that someone else may don't say, well, we need to do this. And I've caught a lot of families saying, well, I understand we need to. And I say, well, actually you don't have to, there's not need to here. But on the part on analogies I use, something I say on the dementia too, on the dementia syndromes, I tell them, I just kind of grab them exactly where most people are at. I said, I understand most people think about dementia as a memory thing. And I want to tell you, it's not a memory thing, it's a nerve thing. It's a nerve conduction thing. And the most vulnerable nerve conduction in our body that we get to see early on is the memory part. But any nerve, and I'll say, if you remember back to our junior high science, nerves connect to, someone just posted that Jerry Powell podcast. That's good that you posted that link. It's an excellent podcast. The nerve, I say, just like we learned in junior high, the nerves have to connect things to tell them to move. And that's why they haven't been walking because that nerve connection is not gone. It's not like they forgot to walk. We often say that phrase, but it's not that they forgot to walk, how to walk, it's that the nerves no longer coordinate their walking movement. The nerves no longer coordinate their ability to chew. You've been softening their food for a while. And then usually the family's nodding yes. If these go in sequence and they're like, yeah, we've been softening the food. And then now it's hard as we've lost the swallow, we can't, as much as we love them, we can coordinate all the things that came beforehand with love. With love, we can help them remember to eat when they don't remember to eat. With love, we can bring the food up to their mouth when they weren't able to bring it up to the mouth themselves. With love, we can soften it so they can, when they can't chew it. All those things can be replaced with love. The one thing you can't replace with love as much as you'd like to, is telling the body to swallow down when those nerves are no longer letting it swallow down. And then using what Alan just said about, you can't, love can't replace the movement of peristalsis, the movement of the belly. And when the nerves aren't connected there, we're in a tough spot that you've done. And I think I use that love phrase as much to be able to say this next statement to them and say, you've done everything you can for a person that you love. You've done it all. And unfortunately now we're at the point where physiology doesn't let you do the next parts. So there's my storytelling or words that I use for that scenario for me. Thanks. No, those were excellent, great points. And I think for Alan and you Tommy, those are things that I was even thinking, those are things definitely to incorporate in discussions that I have with family members. And one of the things that I always feel that is important and is misunderstood by family members of everything you said is the concepts of starvation versus anorexia. So there's that fear, I'm starving or I'm allowing my loved one to be starved, right? And so having that conversation and explaining the difference between the two, for me has always been important. And I find that it is helpful to alleviate that fear that families have that they're allowing their loved ones to starve. So all the points that you and Alan made are absolutely valid. And those have to be included in that discussion. But that's the key thing that I want to always emphasize is like, we're not starving your loved one. There's a reason why they're no longer able to eat and the body is not able to process that food. So those analogies and those points are excellent to have the conversations with families. I wanted to follow up with, there was a question by Noella Stevens about using the buprenorphine patch as a single agent and using naloxone in certain circumstances. I don't know if anyone has any experience with that or like to comment on that. I already sent a reply on the chat, but I am actually not using naloxone on any of mine. I'm just using buprenorphine. The naloxone is what you need for substance use help. But since my patients, I have used it for that on a few hospital cases that they've been called in for when I'm, just because I'm using it and no one else in my hospital is using it, which makes me feel like I'm discussing that my town's too hick, but we are. So I've been called in for heroin withdrawals in the hospital and that's not even close to my expertise, but I'm using buprenorphine with naloxone for that. It's working great, by the way. It's done great for that. But when I'm using it for my cancer patients for pain, I'm not using naloxone because I don't need that expense and I don't need it tied together. I'm using just buprenorphine tablets. And currently, and again, I'm a beginner at this. There might be someone, pain management saying, oh, you're not using it right. But I'm starting on a two milligram buprenorphine dose every, I kind of started every four to six hours to see what they're doing. And then once I get a daily dose figured out, I'm starting it at that daily dose. Some of my patients, and again, my in on this right now for cancer patients, using it for pain is only three for my cancer patients. And one is taking two milligrams every here and there, like one or two a day. And that's managing all for pain and she's not getting the nausea she was getting with other opioids. That's why I tried her on it. Another guy's taking eight milligrams in the morning and four milligrams in the afternoon. And that seems to be the regimen that's just keeping his pain completely controlled. And my other person, I just started in on it. So I'm gonna see what his ends up being. That's my end of three for cancer patients. And none of them I have to know how I'm doing. It's cheaper for me to do the buprenorphine tablet myself. Tell me, do you know what the cost is on the buprenorphine compared to morphine concentrate or one of the other concentrates? I don't know. Remember the concentrate cost with the buprenorphine tablets that I'm giving patients. They're usually getting the, they're getting, I'm usually doing it at the start with two 10 packs of 20 tablets. And that 20 tablets is costing them like $28. So to get them started, it's costing like that. And then when I switched to the eight milligram, I don't know what the guy's paying for that because he's reached his out of pocket. So that's the nice thing for him is he's reached his out of pocket. So he's with his cancer. So everything's being paid for. So he said I could even go to Scripps with him if we wanted to, but he's liking the bills. But yeah, that's the two 10 packs that are costing $28 for the patients. I wanted to pose another question that was sent to us by Dr. Jerem Fayeza. And it has to do with GIP in the hospital setting. And I thought this was an interesting question. I don't know if there was really more specifics to it, but I had a recent discussion with a hospice group up in New Jersey. And what they were sharing was that patients, hospice patients admitted to the hospital and placed on the GIP. The rounding physicians were always billing level ones. And it was sort of like a flyby. I'm just gonna peek in my head. Yep, they're hospice, they're end of life. And that was the end of it. And my response to them, or at least what I was advising them is like, well, if you're placing a GIP patient, what's the crisis and what are you managing? And it's not just a flyby, right? And that doesn't necessarily mean that they're level ones. What's the expertise that you're bringing? What's the symptom management? I don't know if others want to comment on that or have thoughts on GIP in hospitals. I primarily work in a hospital setting, and so the folks who come to the GIP and patient setting at our hospital, I take care of, and I do tend to see them every day and document every day. And my comment is that in large part, because sometimes the medical doctors just say, come for care, fine, and there's no documentation. And I do try to emphasize to them, the whole reason they're here is because they need care, so you can't document that way. But I end up seeing those folks almost every day for that very reason. Just out of curiosity, do you specify why they're GIP? Like their symptoms, their crisis, the interventions you're providing, the outcomes of that intervention. I feel that that's usually what's missing. And again, I understand that in hospital settings specifically, a lot of hospice patients are followed by hospitalists who may not really be aware of a lot of the hospice regulations or the management or how we document. So having a hospice physician oversight is definitely important from my perspective. This is Clay Younger. I would agree. Oh, go ahead. I was just going to say, in our setting, that's definitely true. The only other thing I'd add is I also add documentation of the disposition plan, because I think that we have to show that we are moving toward a discharge, that we're trying everything we can. I'm going to echo those comments too. Our organization has created a lot of scrutiny around how we use GIP because of the concern about from an audit standpoint over the last year. So I would agree. If we have a GIP patient, basically the way we're approaching it is the hospice medical director or the attending hospice physician is seeing the patient every day and documenting the need for why this patient has to stay on GIP, that then that complements the nursing documentation for that level of care. Disposition is important. And we've kind of moved forward in the world of Epic to kind of looking at GIP on a day-to-day kind of basis, because it's easy to get to the point where a patient isn't having significant change and may kind of switch to routine. So what we're looking at on day-to-day is this patient meeting routine or GIP level of care. They're meeting GIP today, and we're going to reassess that tomorrow. At the point that we create a lot of stability, though, then we're having to have those conversations with family about routine level of care because of the concern about scrutiny. And if someone is in the same regimen for three days, there's no change, there's no intruded symptoms, can you really have somebody on GIP level of care for three days without any big change? Obviously, if you're doing something different, you should. But we've been using routine care a lot more this year, kind of sometimes around GIP levels of care just because of the concern for the regulatory part of it. This is Brenda. I have a question. We run into this because we use a scatterbed model for our GIP patients, and oftentimes we get pushback when there's recommendations made for medicating patients within that GIP level of care with that mindset. But the hospitalists that are managing the patients for us say, no, they don't agree with that. And so then we're stuck with a patient that we've admitted, and they're not getting the level of care that we would want them to have. How do you all handle that? So, I hear you, Brenda, because we actually struggle with the same problem. We have an advantage down here in Miami, so my program has four inpatient units that are staffed by hospice and palliative care physicians, so we are always going to advocate as much as possible to have that patient move to the inpatient units when we can, because we know that we're going to meet the regulatory compliance issues and also the symptom management part, right? But it's not always easy, and sometimes the biggest barriers are family members who are reluctant to have the patient move from the hospital that they're presently at, and they just want to stay in that hospital. They may not understand the difference in the level of care that they're going to be provided. Daniel, you have a question. You raised your hand. So to follow, oh, go ahead, sorry. Sorry, this is Alan. While waiting for Daniel, whose hand was up, the other thing that I'll add on that is sometimes we need to also really educate our hospitalist colleagues that are not aware or refer to hospice and GIP, well, you can just stay here and you can stay till you die. And we need to help them understand, and I've done it in a way to also be collaborative and help them realize we wanna make sure you know the most current hospice regulations because we don't want you promising things that would create red flags or be problematic, but just like a family cannot prefer to stay in an ICU because they like the, you know, staffing ratio and the attention and all the monitors in the ICU. Unfortunately, regulations and even community need may not allow us to keep someone as long as we might otherwise wish. And so again, it's helping to correct things and emphasize best practice, hopefully in a more collaborative approach rather than what all of us sometimes experience as being dumped on and then having to pick up the pieces. I was trying to see if Daniel wanted to come off, but I think that you make an excellent point, Alan. And I think that that is definitely part of what we should be doing is educating and also working with hospital administrations to help them understand. It's amazing that hospital administrators don't understand the hospice Medicare benefit and they struggle with this and their perspective is sometimes warped towards patient satisfaction. So they're reluctant to have these conversations or to help us move, right, patients and families towards inpatient unit or helping them understand you can't stay in the hospital. We will continue to provide great care for you. That's exactly why we have you in their hospice, but this level of care is not appropriate for you to stay here in the hospital setting. One of our nurses, when she does the evaluation, she goes right to the family and explains it to them. And it's really great because they get it then. And we've had good success on just getting patients discharged to the home setting with family now willing to provide the care most of the time sometimes, of course, it's a facility, but so she of course tells the doctor, the hospitalist or the nurse at the bedside, but she really is informing the family. And so that there's no miscommunication of someone not being eligible for hospice when they're clearly dying or about to die, that would be confusing for someone to not understand why they wouldn't be eligible for hospice. It's the GIP part that they're not eligible for. And some hospitalists work at multiple different hospitals in different areas, for instance, in Pennsylvania where I work. And so some hospices serve some hospitals and they're a little more generous with the criteria than I might be. So the hospitalist is confused because this works up in such and so town, but doesn't work in my town. And so there's that too. Thank you. One other point to build on what Carolyn said and excellent information is sometimes reminding hospital administrators according to the conditions of participation, hospice eligibility and appropriateness, even including the level of care resides solely with the hospice, that's in the COPs. And I was in Miami, had a conversation with the VP of finance who was questioning, well, we put that patient there. I said, well, I wanna keep you and your doctors out of liability and other conflicts. I can provide, and I did provide the direct reference in the COPs where it says it. I said, if you look at our own service agreement, according to CMS, we have to have the language in that service agreement with hospitals. So depending on the audience involved, which tools we could bring to bear. I'm gonna just pivot. There was a great comment in the chat that Catherine posted. Number one, I wanna say welcome. She said it's her first coffee chat and welcome. So glad you're here with us. And she also brings up a really important point that as leaders, as those of us withstanding and diplomats of the hospice, medical director certification process and all those on the board, we need to take responsibility, accountability and ensure high quality in our organizations for processes. So I've talked enough so far. I wanna give others a chance, but I think this is an important issue we could help Catherine with. No, I think those are all valid points that you make, Alan, and it's absolutely that. That is, again, the value that we bring as hospice medical directors and hospice physicians. And that is one of the, I think, the important parts of our jobs, to be educators, not just for patients and families, but for our fellow colleague physicians who are not familiar with hospice, and also for non-clinicians, especially the administrators of hospitals, nursing homes, ALFs, to help them understand. Because it is complex. It's not that easy. We talk about conditions of participation, we're all familiar with them, but you mentioned conditions of participation, and people look at you like, what's that? I have no idea what you're talking about. Unwinding Medicare is itself complex, so to help them understand how hospice is part of Medicare and how that works, it's not an easy task, but that's where we come in, and that's where we can provide that expertise and be able to educate the role that we have as educators. And I think that's an important role that we should never underscore as hospice physicians. Catherine, thank you and welcome, and she actually posed a question in the chat. I want to help her address this, and she has a question about if any of us have ever experienced detecting an RN calling in controlled medication prescriptions refill without being notified or consenting to these. I don't know if anyone wants to comment on that, I'll share personally that that's not possible where I'm at, because we use an electronic prescription app where the nurse does enter the medicine, especially if it's a controlled substance, and we have to sign off on it, and it actually requires a two-factor authentication, so especially if it's a controlled substance, we have to use a little fodder key that we enter the code, and we have our own identifier, so the reason that's done is that you can never state, well, I just signed off on this, I clicked the button, right? You actually have to put some thought, so it's your responsibility to review what they're putting in to make sure it's correct, correct patient, correct dose, correct medicine, and then you are signing off on that electronically. The other thing, I think those are excellent points, Andy, and another aspect, Catherine, in different organizations, understanding what the culture is, and that might also direct how to intervene. Number one, we have to do the right thing, but where you start in this, is this a single nurse, was it a single location, in which case it is helping to educate constructively. That is different if you've joined an organization, and this is a common practice, then that becomes a leadership issue, education, compliance, quality, risk, and so there's a bit of nuance, what might be the most appropriate response in your specific situation. The other thing is if you are the medical director, and yet this is something you found with one of your team doctors, and with one of the staff on that team, that might also require a slightly more nuanced, different approach, and so how you might best handle it would depend on more information, and if you're comfortable sharing with the group, please feel free. Hi, all, I'm not, usually we use Teams, so I'm a little out of my league in Zoom, but I, so I've been with this agency for 12 years, I have served in a variety of roles, mainly hospice physician, or associate medical director, I was medical director for two years, and two years, and I was serving in that role while I found this out, and it involves more than one nurse. However, when we started e-prescribing a couple years ago, I felt that it was pretty clear cut, and we used to even fax our benzo prescriptions and whatnot, preceding that, but definitely when we were educating the staff with the e-scribe, that all controlled medications were supposed to be entered through e-scribe, so I'm not really sure where the disconnect is, or why they elected to do this, but it, I mean, regardless, it was concerning when we detected it, so I was just curious if anybody else has went through this process, and what, because I, you know, I feel like there's the company's duty to check on this, and they had actually contracted with an attorney to review the, you know, internal processes, but I felt like they wanted to handle it internally, but I felt also as a physician, I mean, was there a reason that I needed to contact, you know, the board of nursing, or anyone else outside of the agency about these, I mean, because it's almost like someone practicing medicine with your license, unbeknownst to you, you know, what was going on, so just curious if anybody else had had anything like this come up. So I think Alan made some excellent points. And one of the things that we should not forget is that you can and do find drug diversion in hospice. And so, you know, as much as we want to believe that we're all in this and we're trying to do the best we can, you're always going to have, unfortunately, some people who operate outside the norms. And that's important. And I hear what you're saying. And at the end of the day, you know, it is your medical license and your DEA number that's being used to prescribe it. The nurses don't have prescription authority or capability. So there has to be some level of oversight and scrutiny and mechanisms to try to prevent any mishaps or maluse of these substances. It's always interesting to me, right, if you do the comparison of a hospital setting where, you know, medicines are in the pixies, you need to have electronic signatures as a pharmacist who might be overlooking this, as opposed to hospice where, you know, we are sometimes even verbally prescribing medicines for patients. There is a lot more need to have that level of supervision. That's my belief. I agree with what Andy also just added. What I will also put out there for Catherine and others is that while I haven't encountered this exact situation, and perhaps even discussing with the chief nursing officer and or your compliance officer, what might be most appropriate in getting the correct facts and enhancing the process to be compliant and of highest quality. One other thing that is a corollary that I have encountered is some of the doctors for my various hospice teams sometimes were a little too willing to just automatically refill opioids when they were on call or a habitual, you know, this medication got lost or this or other things. And that became then a responsibility on my part to educate a colleague with perhaps less experience and insight on what to look for and how to go over that. So, again, those might be things if you're in leadership, consider looking at certain patterns and where, again, it's easier to avoid problems than having to react and get subpoenaed, get charges, other things. And all of those, again, an ounce of prevention. Yeah, I totally agree. Thank you for your comments. I just, I, as a protection measure for, you know, my physicians and myself and, yeah, I do feel that obviously we have some sort of breakdown with our education department as far as, you know, the nurses entering the prescriptions for review. You know, it was just a handful when I looked at what was reviewed after it was discovered, because I had pulled like my, through the state monitoring database, like my prescription history, and we actually work in two states, so it's double the fun because we're on a border town. But, yes, it's been concerning, but hopefully we can get improved processes for sure. If I could piggyback a little bit, just it's a little bit of a separate comment, but just to acknowledge for folks who are entering as a newer hospice physician or a new role as the director, is that what I find is when I started with my community hospice several years ago, I worked pretty hard to understand the guidelines, the regulations, and to institute those, which was not the culture at that particular hospice. Basically, they just, if somebody had the sense that someone would die in six months, they could get on to hospice. And so, there were, people weren't following like the criteria for admissions. Currently, I'm trying to help educate everyone about how to write an addendum. There's a culture to just say non-formulary on the addendum instead of expanding on that, and it takes a lot of education and patience, but also I feel this sense, like Catherine does, of this strong sense of responsibility to my organization, and in the event of an audit or whatnot, I want us to be able to succeed, but you can run into a lot of challenges. I'm sorry, you actually had posed that question, and I just want to make a brief comment, and I don't know what other people's experience may be, but we are seeing a definite uptick in audits from our MACs. And so, that's one of the biggest pushes that we have is documentation, and again, it's educating our team physicians, our teams about the importance of being precise and explicit in their documentation, because they are, we're finding, we're getting audits, and unfortunately, we are the ones, the medical directors are the ones that have to respond and construct the response to the MAC. I can't do that if there's a lack of documentation. I can't document what's not there. I can't say, well, I think that this is probably what happened, so that's the point I always make to the team physicians. I say, or the admission department, or whoever that might be, if you don't document, and I have to then respond, if it's not there, it didn't happen, right? So, I think it's very important to continue to bring this forward as, and to help them understand the why, right, we're asking them to be compliant with the conditions of participation, the things that need to be documented, because we will not be able to defend that if we are, we're asked to construct a narrative or response. One thing I did, what I wanted to add about the opioid prescribing refills, I always ask my nurses to, when they're calling me about the request, to send it in writing, in an email, and that way, I, it protects all of us. It's making sure, like you said, the right patient, the right medicine, dose, pharmacy, and then that gives me an opportunity when I'm looking in my, I prescribe app, that's how I do my electronic prescribing, when was the last time that I did that, and then I can also kind of cross-check for a discrepancy, like, wait a minute, why do you need this now? We just did this X amount of days ago, and you shouldn't need it yet, and so that's actually been really helpful in, not often, but the occasional time when there was some diversion going on, but, and then also in the email, if I'm busy or if I'm on the road when they're calling, I know that I won't forget to do it, because I'll cross-reference my emails when I get where I'm going, or at the end of the day, make sure I've done everything that needed to be done, didn't forget about it. Yes, Dr. Klassen, I agree, that's how I prefer to, because you can track it easier that way by email, and I agree. And I like it both ways, I want them to call me, so they're all well-trained, so that I know it's going to be in an email, especially on a weekend, if I happen to look at two o'clock that you wanted something, and the pharmacy closes at three, I kind of growl a little, so don't do that to me, you know. I growl to myself, not to the nurse, but instead I'm thinking, you really thought I was going to look at this on a Saturday at two o'clock, but somehow I did. That's pretty much a nightly occurrence with the evening call, before the pharmacies close at six o'clock. I think we're out of time, this was great, I hope everyone found this useful, and I certainly did, and I certainly look forward to the next one, and so hope to all see you at the December coffee chat, and with that I'll turn it over back to Gina, and I don't know if you have any final closing remarks, Gina. Thanks Andy, no, I just want to thank you for facilitating today's chat, you did a great job, and thanks everyone for participating, and proposing such great questions, and we'll send out a recording of today's chat, along with some information about the other upcoming events. Have a great day, bye everyone. Thank you, bye-bye. Thank you.

video chat

Dr. Andy Arwari

hospice

palliative care

symptom management

pain medicines

buprenorphine

GIP

criminalization of pain

education