Thanks so much for joining today. We'll go ahead and get started. We know others will join us throughout today's session. My name is Gina Parisi and I serve as the Executive Director for HMDCB. And I just wanna take a minute to thank you all for all of your support throughout 2024. We really appreciate it and we're proud of all that we were able to accomplish this year. And Ellen will spend some time today reflecting on 2024. And we just encourage you, if you have questions, please feel free to ask any hospice related questions, either by coming off mute or putting them in the chat box. And before we start today, I just wanna share a few quick HMDCB updates with everyone. So if your credential does expire in 2025, you'll be required to recertify through our longitudinal assessment, which will open on January 13th. So you could visit our website to learn more. And then of course our initial cycle will open January 27th. So we encourage you to encourage your non-certified colleagues to become certified next year. And then we will host our first webinar of 2025 on January 21st. And this will focus on medical aid in dying and hospice care. And we have a ton of other events that we are planning throughout 2025. So you can visit our website to check those out and you'll receive email updates about those sessions throughout the year. And a quick reminder that today's recording, as well as all of our coffee chat and webinar recordings are available in our new learning management system. So you can visit learn.hmdcb.org to create a free account. And then you'll have access to all of our sessions. And finally, I wanna introduce Dr. Alan Rosen, who is a volunteer with HMDCB and he will be leading today's coffee chat. So Dr. Rosen, thank you so much for being here with us today and facilitating this chat. And I'll now hand it over to you. Thank you, Gina. And before we begin, I also wanna acknowledge and appreciate all the efforts Gina has done, both what you see her name on, as well as all the activities behind the scenes to help increase the value and community of our HMDC peers. And not just within our own organization, but how we interact with others. And so a little bit of time to just dedicate and mention my personal appreciation and others for Gina, greatly appreciated. And with that said, thanks, Daniel. I see the other virtual hands. So a few different things for today. Number one, if you haven't been on a coffee chat before, welcome. This is community generated, community facilitated. I'm merely here to help with different people having enough opportunity to speak as well as exchange ideas. As we get going, let me introduce a prompt to think about particular cases or particular situations that may have been challenging that you consider a success. Often December, we look back on the year as well as looking forward. And I wanna take time to validate as someone who's been doing the hospice and palliative care for 25 years, this is something where, again, some things remain the same, but everything is changing. And how we handle it and what those challenges are. And because you're on this call, on this webinar, you yourself are a leader. You have gone above and beyond to help designate yourself, having the evidence basis, having the dedication to the field. And I wanna congratulate all of you for what you represent to our field, to our community. And I am personally grateful as I continue learning from all of you. Now, I'm going to share a couple slides. Don't worry, it's not going to be a lot. It's not going to be too pedantic here. And they're really just to help initiate some of the conversation. And as we go forward, please feel free to enter questions in the chat or please come off mute. The first thing I wanna do is highlight what HMDCB has accomplished. Oops, getting ahead of myself. And some of you may have seen the earlier emails, I believe in October from Gina, from David, who's on the call. And before I forget, let's also recognize the fantastic leadership David has provided as our president. And those of you that were able to see or watch the annual assembly, he received an award, a presidential citation for the work of this organization, which David, Gina, the board, and countless others behind the scenes helped bring to reality. And this slide highlights some of the successes. So again, new certified physicians, having a continuing certification program, you should have received emails about that. Those of us that have certified in the past and have an upcoming expiration, there is a new process consistent with many, if not all of the other board recognized designations. There's the learning management system Gina mentioned earlier. We also have had more activities. And again, there was an earlier survey that's not on this current slide, but I consider that an accomplishment to get more feedback from all of you. What would you like to hear more about? How can we structure things? When do we have meetings? In response to the survey, we've offered some evening educational opportunities, dialogues, other things, and we have even more planned for the coming year. The past year, we had webinars, which were more didactic and educational, as well as coffee chats like this one, because the sense of community and learning from each other is really critical. Speaking personally. And last but not least on this slide is also the recognition that there was a dedicated hospice forum. So again, a lot of news, a lot of information and research really emphasizes palliative care. And as someone that's done palliative care for 25 years, that is fantastic. Yet, I also wanna make sure we give due attention to hospice. And many of us in our roles are seeing things change. When I was doing this 25 years ago, we didn't have people on cardiac drips or pumps at home. Or I've worked with hospices that personally I'm thankful they had philosophies and budgeting to support those that were on ventilators at home for their final days, et cetera. So a lot has changed in the field like I began at the beginning, yet things are constantly changing and we're gonna talk about that a little more. Before moving on, let me pause and let's hear some of the thoughts. The earlier prompt, remember, was what are you reflecting on as a challenge, as a success in the past year? Alan, I can jump on or should we be putting these? No, no, jump in. Welcome, Beth. And if you could introduce yourselves and mention where you are. Sure, I'm Beth Uliersik. I'm the Associate Medical Director of Helios Care. We are a small not-for-profit hospice in Central New York State. We serve primarily a rural area. I think one of the things, I guess I had two things that have come up this past year, but one of the challenges that we've faced, which I don't know if any of you have dealt with before, probably you have, but we have a pretty great policy for addressing substance use disorder when we have patients misusing opioids, for example, or other medications we prescribe. But we've recently had multiple patients who we've learned either before we've admitted them or long after we've admitted them that have been using other substances. So for example, when we have a patient misusing opioids, we have a really clear process for dealing with that, but we didn't have a clear process. And I'm not sure how we would go about it for dealing with patients who are using things like cocaine and amphetamines and whether we, do we need a policy for these things? What would that look like? And I did reach out to some people sort of working in that space, but I haven't been able to find specific policies. I've done a lot of reading and my thoughts on it have evolved, but I'm not sure if anyone else has specific policies in their organizations, whether this is just another thing that we sort of don't worry as much about at end of life because there's not much we can, maybe we can do or we should do, but I don't know if anyone has thoughts about that. Thank you for sharing that, Beth. And can you clarify in your question, are you seeking community input on the policies or what aspect would be most useful for you? I think we've found, and I think going to the hospice medical director conference or more than once at AAHPM, for example, it does seem like a policy is generally a good thing because then you have a uniform way of addressing situations and you can, I guess, defend yourself if issues arise. Yeah, so I think a policy would be most helpful. Does that answer your question, Alan? Sure. And there are a few different things. It also depends on what aspects of that substance use disorder are challenging your organization going forward. Sometimes, for example, in some communities, when someone is on ongoing methadone, the particular arrangements that they have with their monitoring, and in some cases, there's even been court direction and requirements, that is managed by an outside agency rather than necessarily the hospice. But those individual agreements or collaborations or multi-team involvement, those things are definitely important. And one of the things that I'd like to see as a member of our education committee for HMBCB is that we're developing more resources that might be available online, not that we have to reinvent the wheel, but how can we share particular policies, approaches, other things? Because as many of you have come to realize, knowing the medical management is just part of the challenge navigating community, organizational, and other dynamics are definitely important. And so let me open it up. I see Marie posted something. Marie, would you like to elaborate on your response for Beth? Yeah, sure. And Alan, it's good to see you. So Beth, I'm in Tennessee. Well, and everybody, I'm in Tennessee. I'm in Knoxville, Tennessee. I work for a small hospice that is in East Tennessee. We cover 13 counties, a lot of rural area. I'm in probably the biggest city, Knoxville, that we cover. But I have seen patients in multiple of our rural areas at different times. And I'm the medical director of our hospice. And we've had a lot of problems with opioid use disorder, drug diversion. So I have just, and more in the rural areas, it's really, truly like the Appalachia with the opioid crisis. I mean, it sounds very stereotypical, but that really is how I have experienced it. And I've done a lot of reading about kind of how things came to be the way they are. I grew up in this area and I had just really no idea how rampant some of these issues are. But what we have is we have kind of a standard drug contract and it says that the medications that you're prescribed should be in your system. Those that are not prescribed or anything that's in your system that is not prescribed, is grounds for dismissal. But that's just one of many of these kind of rules as part of the contract. And the way that I explain it when I discuss it with patients is I want to help you and I want you to be able to be helped. And this is what allows me to do that in a way that keeps me legal and keeps our organization legal. And if I'm not legal, then I'm not going to be able to continue to help patients like you. And so this is an important thing for us as an organization to make sure we do appropriately. And so I try to say it in a way that kind of puts us on an even ground. Like I want to help you and I know you want to be helped. So this is how we can do this in a way that works. And when there are additional substances that are involved, I haven't had cases where I had those additional substances involved and really felt like they were benefiting the patient from the standpoint of pain control. That may have been your experience. And I think, I mean, just trying to think broadly what my response would be if that were the case, like, wow, Dr. Morrison, nothing works for me except this marijuana. Well, I don't have a problem if you smoke your marijuana, you know, that's fine. But that does obviously bring into play the fact that there's a loophole right there that I just said, you know, I don't care about the marijuana. Cocaine on the other hand, I might have more of a problem with because we have more potential systemic side effects, you know, that we could have from that. And I worry about safety. My biggest problems truly have been related to the safety of my staff with individuals who are diverting or trying to divert. We had one patient in a rural area that was on a Dilaudid drip and the infusion company got to the point where they refused to replace the pump anymore because three pumps had had to be replaced because they were the family members of the, and it was so sad. You know, it's not the patient who was doing this. He was like an 80 something year old man with head and neck cancer, desperately needed the medicine. But somebody was sticking a needle into the tubing and trying to draw it out. And so it interrupted the circuit, you know, and so then there was the problem. But I'll be quiet and let other people speak about their experiences, but I would be very happy to share our drug contract. I don't know that it's anything special, but I'm happy to share it. That is great. I wanna thank you, Marie, for adding that. And maybe if you could put your contact information in the chat or privately message Beth, another option if anyone ever needs to connect through HMDCB, and if you have any challenges, Gina can help facilitate. I also want to pick up on something Marie said that with regard to medical marijuana, that is a topic that is planned for an upcoming webinar in 2025. What resources are available? What might be different policies? There are a whole range of things to consider as leaders for yourselves, your patients, and your staff. How are you training staff on your policies? What policies do you have if you live in a state where it is legal, where maybe only medical marijuana is legal, recreational marijuana, or what happens if you're in a state where there is no legalization and yet we're encountering these weird situations? Stay tuned and keep an eye out. There are a couple other topics coming up, but anyone else who has feedback for Marie, Beth, or another question topic? Hello, my name is Dimitri Platis. I have another question, but I'll also like to comment on this question while we're at it. So I'm a hospice physician in a large hospice in New York. So the question or the comment I wanted to make about that particular situation is, you know, you don't only have legality in the state, but, you know, since Medicare is a federal program, food for thought, are those substances related? Should the hospice be coordinating them? And given its federal lack of clarity and differences in every state, really, you know, how, you know, how do we document it so that we're managing expected side effects complications, but, you know, still complying with local and federal regulation? So that was one thing that I wanted to just kind of throw out there. I did have another question. The question was related to hospice discharge. The question I have is, so there may be different practices everywhere, but we know in many physician practices outside of hospice, when you discharge a patient, there's ethical obligation to provide continuity of care. Many patients that come onto hospice may have their attending physician or they may not. Their attending physician may no longer follow a patient while they're on hospice. And while they're on hospice, the hospice team is really the only medical care they know for a good amount of time. So when that patient becomes eligible or appropriate for discharge in that situation, I'm just wondering how other groups are doing it in terms of, you know, how they're finding availability of community home-based providers to provide that continuity. Are they finding themselves required to somehow be very involved in the transition of care in terms of making sure they have the correct follow-up when there is or is not a provider to follow them in the community? And what are the regulatory requirements of that hospice discharging the patient for a safe discharge when there's not a physician in the community to follow the patient post-discharge? Thanks for the easy questions, Dimitri. Sorry. Dimitri, no, that's great. I'm just kidding. A couple of things. We'll get to your question one second. Before I forget, like you brought up on the substance use disorder and the collaboration and hospice pain, if I may make a parallel analogy when dealing with people in particular treatment programs, rehab, court mandated follow-up, other things like that, I often in the organizations would treat them similarly to how you might collaborate with the VA. Depending in your area and the central location, if you're in a more rural area, this may be less of an issue. But oftentimes, VAs have to, and even patients and their families prefer to continue that relationship, whether it's with their other meds, other things. So again, documentation, communication, and following your own policies really is helpful. In terms of your second question, before I chime in, anyone else able to contribute to the question on discharge and transition of care? Kai, wonderful seeing you here as well. And any comments you'd like to share to the group besides in the chat? Hello, everyone. Kaishana Guidry here. I am a hospice medical director for a few small agencies in California. You all know we have a ton here. So I have just made it my duty to support them and move on as they need. But I created Morning Dove Medical. It's a private mobile practice for the sake of those patients discharged for extended prognosis. So most of the time, a hospice agency will have a home health agency either within their own organization or another one in the community. And so we have facilitated that in that way, where I'm not carrying the full burden of taking care of them outside of hospice. Actually, just last week, a patient who's been on hospice for five years, on and off, she literally just passed away. But that's what we would do every time. She'd come off and go on home health. Whenever her family saw a decline, she'd go back on. In this particular time, she literally died the same day. So it's really simple in that aspect when you have other service lines within the community or within the organization. So hopefully that answers. As always, great insight feedback by Kai. And if you haven't caught her video series and other things, I highly recommend. It's also a resource you may find helpful. There are several out there. But one of the things particular with Kai is that not only is she a friend of mine, she puts out really useful information that I've had new physicians to hospice take a look at. And sometimes even for primary care and your referral sources saying, where can I provide information to this family, this entity, and definitely her morning activities fill that void. The other thing that this question brings up is, again, differentiating. If we're talking about discharge for inappropriate or aberrant practices with medications, treatment of staff, there can be a variety of things that lead someone to be discharged from hospice. And Demetrius, his question also has an answer that may be guided by what we're facing. If you think about what Beth mentioned earlier, or what Marie mentioned, that tampering with medications, or missing, unaccounted for medications, those types of things may have a different response. But it also brings up one of the opportunities we have as leaders to maintain those community connections. For example, is your team sending a copy of your IDG summary to the referring physician for that patient? Hey, here's an update. Just want you to be aware how so-and-so is doing and keeping them in the loop. That way, in advance of a discharge for extended prognosis, it may not surprise them. And you can even come into, hey, here's an early heads-up. We may be discharging your patient, you know, is doing X, Y, and Z. How does this look? What can we do to help facilitate transfer back to the community, i.e., hey, can we refer the patient back to your care? Anyone else have ideas and insight on this question? So just to simplify the question even more, if a patient is discharged for extended prognosis, the responsibility of the hospice, regulatorily, is the hospice required to make sure they have, let's say, an appointment with a community provider? Now, is it patient, if they cannot find the community provider, there's no one available. You know, is it, I hate to think of it that way, but is it patient abandonment to, you know, unless the hospice gets a continuity provider? I'm just curious, regulatory, what are the requirements and what are not the requirements of the hospice? I haven't seen anything in the conditions of participation about that, but just ethically, we're still physicians, right? So if we know that someone is leaving our service, then it's telling the interdisciplinary team, you know, when is their appointment? Do they need DME? That's just something that we created just so that we're handing them off. And we do have the social worker make them a follow-up appointment. If they're able to go to an appointment, most folks are not able to go, they're bedbound, they're homebound, and that's when we set up a home, you know, a mobile physician. So I think the obligation is on us, like any sign out we would do in a hospital or anything, just being, you know, just a part of our profession, but I'm open to other ideas. I think our hospice, this is Beth again, maybe faces some of the same issues that you're facing, Demetris, in terms of we always try to, I mean, we insist on a safe transfer of care in these settings, but it's hard to know exactly what that means, especially in communities where there's a shortage of providers. So, you know, and especially if a patient's homebound, you know, that makes it extra tricky. We've so far had pretty good luck with some of our major referral sources in terms of being able to find nurse practitioners or physician's assistants who will sort of take over, take back the care, but for some of the smaller practices where people have retired and things like that, it's not always easy. I guess I'm just, I don't have the answer for you, but I'm just saying that I can relate. One thing that we've done in our hospice is, and I agree with everything that everyone said so far, I have not seen a regulatory guideline that says that we have to set up an appointment, but we have found two different, well, a lot of times it's only one, but we have two different companies that have nurse practitioners that do homebound patient visits and they bill for those visits. It's not the best care sometimes, but it's, they are very well integrated with us as in they see something that's happening, like the patient's going downhill, you know, from the standpoint of their function or their, you know, their weight, cognition, whatever it is, then they'll refer them back to us. And so we have, usually that's a nice warm handoff that we can say, hey, these individuals will come to your home. We get the appointment set up. Our social worker does that. She sets up the appointment. That works much better. We used to have the primary case manager, the RN do it. And that was just very difficult because they already have so much on them. The social worker, not that she doesn't have a lot on her, but that ended up being better allocated as a task for her. And then making sure that I have some kind of a discharge note, which I'm not really, there's not really a place in like the Medicare structure to have that, you know, cause it's not necessarily a face-to-face, maybe they're not due for a face-to-face, but I'll do something that's like a PRN visit or something like that. That's kind of a little bit of a summary to say, you know, they're doing well, this is blah, blah, blah. And I will say I have gone up against an administrative law judge or not up against them, but, you know, testified in front of an administrative law judge regarding a patient that we took care of for about five years. And he, we had a lot of trouble with handoff because he was on benzos and opioids and the VA did not want to take him back. He was part of the veterans administration home-based primary care program. And so, and they have a home-based palliative program also. So it seemed like it would be like a, like a really quick and seamless thing to get them back into their care, but then they didn't want to take him with both opioids and benzos. So we ended up having to do a very long process of weaning and, and we won that case. So it's, it is appropriate. I mean, just as Beth said, we're still physicians. It is appropriate to, to stand our ground and say, this is what's going to be best for this patient. If you get into some kind of a complicated thing, I was grateful we won that because I wasn't really sure if we would, but we felt like that was the right thing to do with that patient. Marie, can I ask a question? What, what kind of, in that situation where you have a patient that you're working to discharge, but there is something that needs to happen, what kind of language are you using in your certification note where you, you know, you don't want to say he meets hospice criteria, but you need to say that they need more time. We are continuing to evaluate for ongoing hospice eligibility. That's our little kind of buzzword phrase. Yeah. We had to come up with it carefully. Mm-hmm. Another one is appropriate community support beyond the scope of this organization. Something again, that is collaborating, communicating. Go ahead, Asha, were you wanting to add something? Oh no, sorry. That was a mistake, but I do need, I do have a question after we're done with this topic. Okay. We'll get to that in one sec. I also want to highlight something important that Marie reminded all of us, and that is what's in the regulation versus what is best practice and doing a discharge note, whether it's from the actual medical director, your team physician, or as hospice medical director, you're looking at, okay, has everything gone together? Is there a community plan? What's going on? These are things that again, unfortunate for Marie having to deal with the ALJ, but that documentation and those communication points, that really makes a difference. That's an investment in your organization, yourself, and the community. One other thing to add to Demetris' situation is if any of you have experienced patients and families not wanting to graduate from hospice, one of the things I try to say is we're not discharging, we're graduating. You had to meet certain criteria. Congratulations, you've met this. Well, not everyone wants to leave. And so the other thing, just like any other medical practice, if you identify here are resources in the community, or here is the health department, some other things, that also can help in bridging. I want to give a pause for any other follow-up comments, and then let's have Afshan, if I pronounce that correctly, ask her question too. I will just say in follow-up about that, about graduating, most of the time our patients don't want to graduate. They are not excited about it. And so we actually have developed a very, it's not a robust program, but we have a palliative program where we will follow patients with visits that we don't bill for, but just kind of to keep them on the radar, and so they don't feel dropped. It's not providing their care because I cannot write for their opioids unless I'm their physician. And they do understand that, but having that close connection of being seen, we use our chaplains actually to do monthly visits with those patients. And then we are very quick to get them back in to our, you know, under our care as a hospice patient, if there's a change clinically, and they're going to have one. I mean, the family knows they'll have another, you know, change too, because we're all going to die at some point. But we just kind of have that kind of a, like a protective umbrella of watching them during that time. And that has helped with patients feeling a lot better about that transition time. And we do something similar just with phone calls, because we don't have the staff to do visits. But that did remind me of that, Marie, where we'll check in periodically, you know, depending on the situation, every few weeks, every few months, just make a phone call to just make sure things are going okay. And, you know, again, it helps with having the patient re-referred, you know, hopefully weeks before death as opposed to hours, for example. Thank you all. Afshan, please share your question. And where are you currently located? So I'm in Cleveland, Ohio. And I was a medical director. It was unclear if I was associate versus main. Actually, this is part of my question. You know, to be honest, I don't really have questions per se. It's mostly kind of just telling you the experience I had working with a small hospice here. And I'm not sure, I'm still kind of processing everything. So just kind of getting people's thoughts on what, you know, on this experience, because I'm not really sure what to do with the information I have. So I just resigned and I was working with a small hospice for a year, no, a little less than two years. And I came on when there was a main medical director. So I was kind of, I was the associate medical director, but then the main one had left. And the main one had left maybe like six months in, and it was unclear. I was the only remaining medical director and it was unclear what my status was, okay. And there was a couple, I think there was like six months where I'm like the only medical director and that was fine because our census was not that great, you know, it was not that high. But I did jump from, when I came on our census was like 20 and then it went to a hundred and a hundred within months. And so they did hire another one. I'm a hospitalist. My part time gig is a hospitalist, so I don't have an outpatient practice. I do hospitals medicine part time. And so the one, the medical director they hired, they kind of hired without me knowing like kind of being part of that process in hiring this person. This person had no hospice experience coming in. He was a busy doctor running multiple out, like, you know, he was a medical director of many nursing homes. He had an outpatient clinic. I mean, this guy was just, he had NPs working for him. He was all over the place. And it sounded like, you know, it wasn't really him kind of making decisions for, you know, when it came time to orders and stuff, he, it was very clear that he did not have the expertise to do hospice medicine. And so there were certain things that were really concerning about how things were operating. Like eventually my call was cut in half, given to him, which I actually appreciated. Like finally I had some time that I didn't have to be glued to my phone. But then, you know, things were concerning when I would come on, like everyone was just given Ativan, like all the people with delirium with behaviors, like people who were not terminal had Ativan written for them. And it just kind of, it just didn't seem very conscious and very thorough medicine. And I thought that was a liability to be working with someone who didn't have hospice medicine experience, but also didn't seem like there was an effort to learn it. And there was no kind of relationship that was built between us. I mean, it seemed like how the manager was doing it. Like she wanted us to kind of remain separate, not really want to engage with each other. And it was unclear like who was kind of controlling the show, who's actually had the last word on a patient's management. It was unclear. And I was having issues with that because I was not very comfortable with some of the medicine that was happening. I'm sorry, I'm talking a lot. Please cut me if I'm like, you know, taking up a lot of the time, but I'll try to make the rest quicker. And you know, I was kind of being a little critical about some of the management, you know, for patient safety purposes. And then the other thing was like certifications, like people were kept on way longer than they should have when it was very clear that they were making some really great gains. There was absolutely no decline going on over certification periods. And I would say like, okay, well, I need like, what are we missing? Because we can't keep this patient on. And so the manager would say, okay, well, I'm going to be talking to corporate about it. And kind of, it was clear that things were being purposely delayed. And I was kind of just being told to like, okay, yes, we're getting the info, we're getting the info, even though it was time for certification, it was past the time for certification. And I had these notes that needed to be written. And I'm like, I can't write, I can't certify these patients. I don't have the data to do this. So there were some, I was very concerned about, I don't know what to call this. Like is this like, you know, keeping patients on without any certifying issue, no certification, no criteria, nor is there a concern for discharge. I know we just had a whole discussion on like, that was not made clear to me as a reason to keep them on. So the totality of all this made me resign recently. And I'm just wondering if I should be doing anything to like a postmortem reflection, like, as part of like, what thoughts should I have and like, future ways of kind of avoiding these kind of issues. And also, like, you know, whether or not this hospice is, you know, I hate to say the word fraud, but like, you know, keeping patients on and without having good reasons and having this medical director, they eventually had this medical director sign off on these patients. And it's like, the notes are not very well written. They're all over the place. They're putting in criteria from the last certification. It doesn't even apply to the certification. So I'm not sure what I do with the information I have. Afshan, I want to thank you for sharing. Hopefully you've seen in the chat, you have resonated with many people, I'll add myself, who have left organizations for doing things that were not consistent with the COP's common practice. And I also want to thank you for sharing in this group. If you've seen Brooke, Anna, Kai, Daniel, Beth, many others, all of us have empathy for what you're going through. And I'm so sorry for what you've experienced. I want to, again, celebrate your excellence, because you knew where that boundary was. And you are not being part of the problem. Some of you on earlier webinars have often heard me say, you can be part of a problem or part of the solution. If you know of a problem and you're not working to change it, then you become part of that problem. And so one of the things for community that HMDCB offers are these spaces for the debrief and connections. And whether myself or others on this webinar, more than happy to follow up offline, Afshan, if that would be helpful. I think you did the right thing. As Kai mentioned, there are some big red flags for how this physician was brought in. As someone who's been with multiple organizations over many states and have hired, collaborated with hundreds of hospice physicians, my number one thing when recruiting, I want to make sure they have a heart for hospice and are willing to learn and collaborate, whatever the discipline. I don't care how many patients they can refer or what else. It also has to be appropriate care and be a team player. And in terms of others' comments, I'd like to open it up and see, Gina beat me to it. I was going to mention that this Friday, look on AHPM's website, Friday the 13th is a virtual career fair, and there may be more opportunities and options. Gina beat me to it. And as always, she's on the ball. Anyone else have comments, feedback, input for Afshan? At the risk of speaking again, yes. I'm in a small hospice. It's run for profit. Very, very similar circumstances. Actually, we were asked to give a question to discuss today. And when I registered for this coffee chat, and mine was how do I, well, I can't remember exactly how I worded it, but basically guidance about oversight of other physicians and hospice who are part-time without much hospice experience. I wrote it down because I knew I would forget. But that's an issue that we're having right now. And I've actually kind of run off two doctors that we had hired, one of whom was unable to work with the nurses. She was very adept at following hospice guidelines, but was horrible as a team worker and left nurses crying. And then another doctor who was just not, she wasn't following guidelines. And so, and now we have a third doctor who's trying to fill the same position. And I'm not in a position of, I've been given a position of leadership. I moved up within the company from an associate medical director to the medical director. And you, every hospice should have a very clear delineation because there can be only one medical director associated with that NPI number. But I haven't been given the leadership role to really train those physicians or have oversight of them. So we did get a really nice, and I've been with the company now seven years, coming up on eight years. And we just now in January are going to have some physician training. So I'm hopeful that's going to change a little, but I think you were put in a really, really hard spot and having sat in front of the administrative law judge and having had to argue what was done before by a colleague who did not follow guidelines. All I could say when I was in that position was I didn't see that patient, but I can tell you what frequently happens. Is that blah, blah, blah. You know, so I'm not trying to throw somebody under the bus or my company under the bus, but it led to a very difficult situation. So it's hard and my heart. Thank you. No, that was great. And I'd be happy to discuss with people, just so you know, a few things. One, the education committee of HMDCB in a survey, the program directors found that a hospice curriculum was something that they were interested in for their fellows. There's going to be a new blueprint for the HMDCB exam that'll be coming in the next year or so. And what I've done at other organizations is use that as not only a training outline, but even a recruiting one. And for example, I've told physicians when I was recruiting that I would make a commitment to them if they didn't have any hospice experience. You had to have two years before saying for HMDCB and a sufficient number of patients. I told them I would personally mentor them and help them get to that point if they didn't work for other hospices. So that was one of the ways that, again, helped in recruiting. It also sets the standard. Again, Afshan, I'm willing to wager that doctor you described did not have an HMDCB certification. If so, that's a whole other conversation. I also want to make sure to touch, there was a question in the chat about a safe census for one hospice medical director. It really depends on your location and geography. When I was a hospice medical director in Chattanooga, there are mountains in Chattanooga. You have to drive around a mountain to get someplace. From our service area, on the map, it doesn't look much. But if you put into the maps, we had to have separate medication, comfort kits, other things because they were so rural. Think about Asheville. Think about other places that, again, we've heard how logistics can play a role. So that census may vary. Also, as many of you know, if you have a predominantly facility-based nursing home site of care, you can have much higher census than if every patient is at home and rural. There are some hospices that have cookie cutters and say, this is our plan. We are having this number. And I'll throw out, you'll often see some say an average daily census. You should be having a full-time medical director by the time you get to 50. Some say 80 per team. But that is an average where you may have to go up consistently to 120 or otherwise. The other thing, are you looking at not just your average length of stay, but your median length of stay? As a reminder, that's when 50% of patients die. That matters because if you're an organization that has a median length of stay really short, then what that is saying is you're bringing on people with a low PPS initially. Are you tracking your PPS at admission? Because the way to think about it, if you're getting 90% of hospice referrals, they're at PPS at 10%, you're going to have a very short median length of stay. Your average may be thrown off by a few of those longer stays. And so your staffing will be impacted because if you're doing admission visits and death visits, which take the most time, that is taking limited staff available for your other services. And so those are considerations. There is not necessarily a set number on that, but happy to elaborate. I know we're approaching the end of time. I am more than happy to stay on for a few minutes. I do want to also try to properly share my screen. I missed the announcement earlier that I did not have the right screen selected. And this is what I was trying to show people earlier. A thumbs up if you can see the highlights and all. Marie, are you able to see that? Okay. So then the next thing I wanted to share before we end, I've always had this in my office for years. And if you can't read it behind me, I put it here in the chat. And I've had people say, wait a minute, you're the hospice medical director. You know, this is talking about living. And one of the things that I would also emphasize is we also need to live, connect, and be human. And there's a great thing I saw years ago on social media, humankind, be both. And for some of you that may have seen on my prior social media, I shared this. And I thought to close us out today, I wanted to remind all of you, and as you've heard in today's conversations, this organization, this group, each and every one of you, is what's helping to not only maintain our own humanity, our stamina, and our connections, and you all make me excited for our field. I'm going to stop sharing so we can see each other. Gina, before I turn over to you, any closing comments, other things? I appreciate Anna's addition on the physician training webinar. For those that know, there are modules at AHPM. They used to be called the UNIPAC series. Those have tests in them. And I've used that to show surveyors, when I've had physicians complete it, that, okay, here's evidence-based. Also, it's a great tool when you might get some cocky physicians, not that any of you have ever encountered that. Oh, I'm a hospital. I had a hospitalist tell me, I have 40 patients. I know pain management, had an oncologist, same orientation. Tell me, no, no, I know all this. I said, great. Well, here are three questions on med conversions and things, and this way we can let the surveyors know you are well-prepared. They got zero out of three correct and justified that, yes, they had to attend the pain management training. Anyway, let me open up any final comments. Thank you all. I've enjoyed this immensely. Gina, take it away. Thanks, everyone, so much for joining today. We appreciate you being here, and I just want to thank you again for all of your support this year, especially our board, our volunteers, all of our certificants. So we'll send out the recording either today or tomorrow, and then we'll see you all in 2025. Have a great holiday.

HMDCB session

Gina Parisi

certification renewal

longitudinal assessment

hospice care

substance use disorders

safe discharge practices

ethical standards

community support

physician training