Welcome, everyone. Thanks for joining our coffee chat today. We're gonna go ahead and get started. So I just wanna take a minute to welcome everyone. My name is Gina Frazee and I serve on staff with HMDCB and we're really excited to host our first coffee chat of 2024 and today's chat will be led by Dr. Robin Turner, who is the assistant professor at Duke Palliative Care. She's also an HMDCB certificate and volunteer. So before we get started with our chat today, I just wanna share about a few upcoming events. So our education committee has been very busy planning events for 2024 and we'll continue to have bi-weekly or bi-monthly coffee chats and bi-monthly webinars this year. And we'll also continue our partnership with Weatherby Resources. So we'll work with them to help promote some of their educational events. And the first event is the Hospice Physician Compliance Conference, which is actually taking place tomorrow, January 26th. And so that is an eight hour long virtual conference and you can still register for it and you can use the discount code here on the screen to receive 10% off the registration fee. Our first HMDCB webinar will be hosted on February 20th at 11 a.m. Central. It will focus on hospice coding and billing and be taught by Dr. Christopher Jones. So you can register at hmdcb.org slash webinars. And then we'll have our March coffee chat on March 28th, 2024 at 12 p.m. Central. And this coffee chat will be led by Dr. Andy Arwari. And of course, we're gonna have our typical format where you can come, it will be an open Q&A, but we also wanna take some time and share about key takeaways that if you attend the annual assembly, just come ready to share about key takeaways that you learned. And finally, the 2024 Continuing Certification Program is open. So if your credential does expire this year, you can renew it now through October 31st. And we did launch the annual longitudinal assessment this year. So you can learn more about that at hmdcb.org slash CCP. And I'll put all of these links in the chat as well. And then finally, we just wanna share with everyone that HMDCB is really excited because we launched our new learning management system this month. An email was sent to all certificants yesterday with instructions on how to create account and navigate the system. And in the LMS, you will find the annual longitudinal assessment. So once you're ready to participate in that, you'll have access to that. But for now, you can access all of our webinars and coffee chat recordings as well as a discussion board. And so this is a place where you can post your hospice related questions, receive peer support and any questions that we don't have time to answer at today's coffee chat, we're gonna post in that discussion board. So in the follow-up email for today's chat, I'll include instructions on how to create an account and how to access the discussion board. And so I wanna hand it over to Dr. Robin Turner in a minute so she can facilitate today's chat. And of course, we really encourage you to go ahead and ask questions either by coming off mute or putting them in the chat box. Thanks everyone. Hi, welcome, everyone. Thanks for joining. We're gonna bring up a list of questions. I've been able and happy to lead this coffee chat a couple of times now, and I've actually never had this many questions pre the meeting. So I thought it would be good to put these questions up. We try to make it as short as possible we tried to group them in categories and maybe kind of focus on the questions within that category, but we really don't have to do it that way. We also left the names of the people who submitted these questions and are happy if you're on this call to kind of take the lead on the question, give us some context so that we can have discussion around it. In my view, I can't really see right now who is on the call, but I'm open for volunteers to jump in, bring up a question that's burning on their minds, if it's on here or not, and we can get the discussion going. Again, I'm sorry that I can't see people on my current view, but I did notice that a good number of people were asking questions around, you know, patient loads caseloads on call kind of the structure of a, you know, of medical director. Workloads is, is that a topic that people would like to discuss. So, Robin, I'm happy to, I'm happy to kick us off with kind of some discussion around that if that's okay. Can everyone hear me okay? Yes, I can hear you, Sarah. Okay. Yes, sorry, Sarah. I'm having technical issues, but I think Robin got bumped out, but if you want to go ahead and start us off, and Dr. Schaffer, maybe you can help lead that conversation as well, please feel free to do that. It looks like it's possible, Sarah, that the people who have generated this question may not yet be on the call, so that might be part of what's happening. Ah, okay, okay. So, I'm excited. This is actually my first coffee chat I've been able to join, so I'm excited. I'm Sarah Payne. I'm one of the new National Medical Directors for Genteva Hospice, and I'm kind of learning a whole new role here as I go, but a little bit about kind of what I've done in past roles. Typically for a 1.0 FTE physician, we've had them do quite a bit. They usually run a team, and again, it depends if you're talking HMD or hospice physician, but we kind of mirror the roles and kind of layer on responsibilities as we get the HMD duties, et cetera, but for a full-time hospice physician, they typically run a team. In my past role, it was about 80 to 100 per team. Sounds like that's kind of the going rate for a typical team load. Our call, we actually had contractual obligations for call in the last role I was in, so that was seven call shifts a month, whether that be an overnight shift, an evening shift, a weekend shift, or a holiday shift. Weekend days were 24 hours. Holidays were 24 hours, and then evening calls were usually 5P to 8A the next day. Contract models, I can't really answer too much about that one. I was employed by a health system. They had their standard contract models. Interestingly enough, at that time, it was through the medical group, which was an interesting structure in and of itself, and I think for community education and engagement around hospice services, one of the best ways I think all around is just getting out, getting in front of people, either in person or on Zoom, Teams, whatever way that might work. Anytime somebody refers a patient, and perhaps they're not eligible quite yet, or they are eligible, but there's some caveats, it's a great time to pick up the phone and call the referring provider and just kind of help educate, educate, educate. Then that usually gets their wheel spinning, and you take the opportunity, hey, I'd love to come out and talk to your group about just hospice 101 type things. So that's kind of in a nutshell what we've done. That's great, thank you Sarah. Does anyone else on the call have anything to share about their experiences contracting hospice medical directors? And also if anyone on the call has any burning questions they're bringing to the coffee chat hoping to get some input on. Hi, Dan Ray. Quick question. Hi, Dan. Hi. I'm a hospice physician up in New Hampshire working with Brookhaven Hospice currently. I guess the question I have is, what are the hot buttons right now for audits that are, you know, are they looking at length of stay? Are they looking at live discharge rates? And I think it goes along in line with someone had asked a question before is, how long can so many hospice visit an ineligible patient before getting audited? Can I link those two questions together? Yeah, I don't know if anyone on the call has had an audit recently. I wanted to share their experience. We've actually had a long pause. I work at Care Dimensions Hospice in Boston area, Massachusetts. We've actually had a long pause. So we're waiting for the other shoe to fall. I don't know what other people's experiences. Oh, there's Robin too. So she's back. Yes. But I don't, we were just kind of Robin approaching this question. And Dan was asking if people on the call were aware of hot button issues for audits. I had just wondered if anyone on the call and William, are you raising your hand, William? I was just asking if people had had any recent experiences or anything to share. So I've heard, so I'm Laney Honeycutt. I'm the hospice medical director at Four Seasons and Flat Rock, North Carolina. So that was recently announced that they're, we're expecting RAC audits. And I'm not sure exactly what they're going to be looking at, but they've said that they will go back three years, up to three years back. So we're kind of starting to prep for that. This is Chris Downey in Minnesota. And we've had audits last year, which were for length of stay longer than six months to a year. And so those are still in discussion at this point, despite all the documentation. And so that's that they're looking at that number. And then we just had a state audit a month ago and they were looking at visits as far as whether nurses are, you're documenting that the patients are being seen every two weeks and that the home health aid is being seen. Infection control is a big point. So those are, you know, not our usual stuff we think about, but you're hopefully your EMR and we're constructing things to help pull that information. Just recently added in a missed visits discussion in the IDT meeting because we've developed a method to look at that so that we can immediately get those covered before the two week period. So those are things that they're looking at and we didn't have anything major. It was these minor things. So, yeah. Thank you. That's so helpful. Yeah. I did a little digging and it looks like the RAC audits are going to focus on GIP and continuous home care, which we got a GIP audit not that long ago. So I guess we might be getting it again. Yeah. And is this the one that is the GIP within 72 hours of admissions or the very short, short length of stage GIPs, which was a little bit confusing as a focus. Yes. Right. Yeah. Our last GIP audit was, they looked, I think they were looking at anyone who was there longer than five days or something like that. Yeah. Yeah. So Kristen, you hear that they might be auditing shorter length of stage. Right. So the GIP in the hospital or hospice in place, I wonder if anyone knows how they're dealing with that because it's certainly, as we all know, popping up all over the country. I kind of worry about it at our hospital. So I guess we'll see. We have a program where a patient, I'm sure everyone does, but I feel like the part of the GIP program in the hospital, hospital GIP programs that make the most sense are when you start the process from the ED and have a direct, a process for more direct admissions, either to the inpatient unit, the hospital, if they're too unstable to transport or even directly into home hospice, depending on. So that has always seemed a little bit more robust and consistent with the goals of hospice, the cops to me, than converting these patients within the hospital. Although some people should be, we don't do high-flying, although some people should be, we don't do high-flow oxygen at our inpatient hospice. And so providing a place where patients can get what they need for their care, is a good argument for inpatient hospice, but mortality is not. So I guess that'll be interesting. Any other thoughts on that? Does everybody have a GIP? Oh, yes. I did think I, oh, thank you. Yes, Daniel, go ahead. I thought you might've had your hand up before as well. Sorry. I didn't have my hand up before. Dan Harris, I'm a medical director at Lumina Hospice in Corvallis, Oregon. We are disputing a UPIC audit currently. It was for extended length of care. And on the first round, they denied six of the eight charts that they reviewed. The initial reviewers were clearly not clinicians. They just said, well, you didn't meet the LCD guidelines. Well, no, they don't meet LCD guidelines. Those are guidelines. They have multiple disease processes that are interacting. They have, you know, et cetera, et cetera. We got half of those reversed on the first appeal, but are continuing with the second level appeal because still the first level appeal reviewers who were RNs are not acknowledging the medical facts that I am aware of. And, you know, I have very good documentation and medical judgment that these patients were absolutely hospice appropriate. And I will fight this all the way to, you know, if I have to testify in front of an administrative law judge, because I know these patients were appropriate for hospice. So it's really frustrating. But yes, it was for extended length of stay. I'm surprised you got that many overturned on the first appeal. Usually they don't even, the first appeal is nothing. It's like they just deny all of them. So good work. And I'll, you know, give a shout out to Weatherby. They are very helpful in this process. Can you say more about that, Dan, how that's been helpful? Weatherby? Weatherby services has helped us to compose the response letters, which then I have, you know, edited and added to myself. Oh, great. But also, you know, also giving us guidance, how to proceed with the different level appeals and what the next steps are. Right. Yeah, that's good to know, given that most of us do them internally and it's an awful lot of work. Your frustration is across the board. I mean, you look at the letters and it's like, who reviewed this chart? I mean, it's just so frustrating. Yeah. Are we seeing any audits on live discharge rates? Being triggered, you know, audits being triggered because of a very high live discharge rate at six months or at three months? Okay. That's not one I've seen myself. But maybe it goes back to the question that did ask about patients who were, oh, I can't remember the wording, inappropriate for hospice or ineligible for hospice. So it goes back to that question a little bit. I don't know how others feel, but it's so rare that it's obvious that somebody is ineligible for hospice, in my opinion. I mean, everybody deserves a benefit period. So, you know, if they're going to look at live discharges, but you're giving everybody a chance, I mean, we could all be in trouble from that standpoint, I think. Yeah, I just, I wonder if the trigger would be if there is a consistent discharge just under six months. You can see it's consistently discharging, live discharging, you know, at five and a half months, just kind of routinely in that high percentage is really high. I think someone might call into question, you know, what's really going on here. Yeah, we've been told that that's a red flag. Yeah, yeah. Yeah, there are also, Chris Downey, those people coming in at three months and then getting discharged right before three months is another red flag. So, and quite frankly, you know, I probably admit 96% of everybody, but there are times when, you know, you can't, the information you have doesn't give you enough evidence to say that they have a prognosis of six months or less. So, you know, I'm sure we all face that. Yeah. Gina is just putting something into the chat, just, you know, confirming what Dr. Harris shared, offered the consulting services to help with audits, and gave a link for those of you who might be interested in that. And then, of course, with those live discharge rates, you all should have access to the PEPR report, which we look at, and it shows where you are nationally in terms of live discharge rate, non-cancer length of stay, all those things. So, you can see if your hospice is an outlier at all. Well, certainly audits loom large for all of us. Dr. Downey, oh, the question to you, Dr. Downey, is do you admit 96% of evaluations presented to you? Is that what you mean? I guess they were just clarifying that. Yeah, I mean, that's just a poll. I mean, you know, there's not everybody gets admitted because, you know, but that's pretty much, almost everybody gets admitted, except there are a few that I don't have enough information or they have a longer prognosis based on what their choices are or what they're wanting to do. And you don't have a geriatric person coming back on the program. Well, how have they really changed in the last month since they were there before? You know, there has to be good documentation about why now they meet criteria when we discharged them, you know, four months ago or a year ago. So, yeah. I know one of the things that I've always used is the rate of decline and making sure that that's documented in the narrative. Because some people can have a small amount of weight loss, but it's happened in a week and a half or I'm sure everyone on this call has seen that. So I know that is something that I focus on with our fellows and as new providers come into hospice, teach them or make sure that that's an important piece of information that they look at. Just going back to the reviews and one of the points that we're finding is a discrepancy between the nursing note and the face-to-face visit, what the nurse practitioner says, what the nurse says and what the healthcare aide says. And, you know, you have to make sure you're creating a language with everybody on the team so that people are saying, well, you know, they said three words today, you know, or that they had a really good day, they walked, you know. So you wanna make sure things are consistent across the disciplines. And that's another thing that we're stressing now, make sure, because that was called out a couple of times. How are you working on that? I'm going to be sure that all of us have seen that and it seems almost daunting. And one person is suggesting one way is that the face-to-face by the NP is done at the same time that the nurse's eligibility visit is done so that they do have consistency. But just wonder what maybe others are doing to- Yeah, that's the current formula that we're working on now and to have the nurse there at the same time. Plus also the physicians are going out now and documenting a nurse or a social worker with them at the same time. And so that's another way to make sure our documentation is consistent. And that's a function of Epic, you know, with a phrase that they can pull up and crack. Sorry, Steven, did you have a comment as well? Yeah, I have been doing face-to-faces and I actually get a much better, not all of them, but especially on patients that have been on for maybe a longer period of time. And I really get a much better feel for the patient. And it's oftentimes a different take than what the NP brings and I'm just reading. So I find it very helpful to do that. And my hospice will pay me for actually doing that. So I find that helpful not to still be with the NPs forever. Hmm. So Sarah brings up for long lengths of stay, alternating NP and doc for each face-to-face to lay new eyes has been helpful. No. Any other thoughts or comments on this particular? What more would be helpful in terms of the audit question? Just kind of keep ears out for what is coming down the pike. Is there something more that could be provided to this group or? I work in a relatively small hospice. We don't have a nurse practitioner. I do all the face-to-face visits myself. And maybe that's why I feel so strongly that my medical judgment on these patients that they were eligible for hospice is correct. Yeah. I think Dan, that also serves you well if you are in front of an administrative law judge. Right. You are the physician there defending your own decision-making. So that usually is very powerful and persuasive. It is. I guess the question would be, is there any notification or publication by RACS about the hospice? Is there any notification or publication by RACS about what audits are hot? What have they decided to look at during this next year or next quarter? Do we have any sense that that's out there or is it just kind of stealth? They show up and say, oh, by the way, we're going to do this time. Anybody know of any whisper down the lane kind of thing? I can put a link, you know, like Hospice News will send out things. And so that's where I heard about the RAC, the uptick in RAC audits. I think that was from this summer. Okay. Yeah, Laney put in the chat for everyone, the link to Hospice News. And so that's great. Thank you, Laney. And then Leah wants a clarification of RAC. I'll hand that over. What does that actually mean? Hi, this is Chalad Rajaram. RAC is Recovery Audit Contractor. So what it is is that the government actually finds, these are, they apply to Medicare. They'll say, we'll get back a certain amount of money to you. So the percentage of what the RAC keeps is based upon how much they're able to provide. How much they're able to pull back money from hospices. So the fact that there's a lot of these inappropriate kind of audits is because the RAC is not interested in the quality of this as opposed to how much money they can get back to the government, which means a percentage of money that they can keep. That's what I understood about RAC a while ago. Looks like the behavior is continuing. I hope I answered the question. Did that help, Leah? Yes. So it sounds like hospice news is a good resource for this. I think, you know, within the hospice, your leadership too, I'm sure there are other resources, NHPCO connections and all, I think probably would be helpful as well. But I don't know that, and maybe I'm wrong, I don't know that Medicare is gonna send us all a warning about what to expect. Did you have something more, Lainey? I was just gonna say, I really rely on my compliance people. Like they seem to have the, they kind of know before I do what's coming. That's where I hear about them. Yeah. And where are they hearing it from? Well, we have one compliance woman who's been doing this for decades and she's very well connected in North Carolina. So I think that part of it is just, we're lucky with her knowing, she knows the people at the MAC and yeah. Yeah, Anita. Annette Kaiser. Annette and Annette Kaiser, yeah, yeah. It looks like Chris put another link for the Medicare RAC. So that might be helpful for you all as well. It's actually RAC, not RAC-K. Mm-hmm, that's right. I think it's hard to remember all the acronyms, honestly, but whatever. Any other, are they different than the ADR? Yeah. Are they different than the ADRs? I'll hand that out there. But yes. Anybody want to take ADRs? Again, I always forget what they stand for, but they want more information on the patients that you've cared for, for the ADRs. And they are different. They are, well, and then there's another one which actually I'm not sure I can answer, the TPNE, does anybody want to? TPNE, I'm not sure I know that one. I think that's a targeted probe and educate. Right, probe and educate, yes, thank you. Leah can't come off mute. So yes, there are multiple different reviews, I guess, audits that can be performed for the different hospices. All right, any other comments on this? There are several resources now for those who ask for them. I'm not great at Zoom. If you can copy and paste them, that you can have access to them, I guess. Should we pull up the question list? Are there, can we do that? Sure, let me pull that up, Robin. And I apologize, everyone, I'm having some technical issues. So hopefully this will pull up. Let me know if you see this. And we can, if you put any resources or links in the chat, I'll be able to collect them and compile them and put them into a guide that we can share. Can you see that, Dr. Turner? Yeah. Okay. So we talked a little bit about the audits. There were some questions around revocation risk management. I'm not sure if the person who asked that question is on the phone, or the call, rather. I don't think Dr. Cohn is on, but if anyone wants to answer it, you can always review the recording. So that might be helpful. Yeah. Does anyone have any thoughts? I'm not entirely sure of the context around this. I'm not sure if anyone has any thoughts on this. Okay. Does anyone have an approach to assess patients prior to revocation, or try and prevent revocation at all costs? I can, we just had a discussion about this yesterday that we want, that revocation isn't necessarily always a bad thing. We want to make sure patients get the care that they want, and that it's appropriate care for them. So I would say most of our revocations would occur when a patient ends up admitted to the hospital for very aggressive measures. So we don't, I never, you know, if it turns out a patient wants to go to the ED and we send a nurse out and address their issues, I don't ask that they revoke before they go to the emergency department. So they go, we communicate with the provider there, you know, let them know that they're on hospice. And most of the time they end up just going back home. And it's not until, you know, we find out that they're being admitted to the ICU or something and, you know, the way we always phrase it, make sure we're very careful with the language and saying that, you know, not like to go get the revocation or go revoke the patient, but this is their decision. So phrasing it in a way of, you know, hospice will not pay for your aggressive ICU care, revoking your benefit will open up Medicare to pay for it. So just being careful in how we phrase and document a revocation. I think that is huge. That was a huge pet peeve. When you have your team members emailing back and forth, well, they went to the hospital, we need to get the revocation. Let's go get the revocation. No, no. So constant education, how to phrase that to the team members and, you know, if you're putting it in email, text, et cetera. So, I mean, oftentimes it's people who panic and go to the ED and then they get there and they kind of get a cursory workup and then they're like, you know, no, I don't want this. I just want to go home. So it doesn't make sense to have them revoke just to go to the ED because they end up back home so often. So Elaine, correct me if I'm wrong. My understanding is that if the reason the person's going to the hospital happens to be the hospice diagnosis, the primary diagnosis, the hospice agency is obligated to pay for that unless they revoke. Yes, yeah. Okay, all right. So a COPD patient who keeps wanting to go back in and be intubated, you know, it's like, okay, however, we can't ask you to revoke and we can't say we're not going to pay for it because technically we're required to. So how do you manage that? So repeated trips to the ED is a different beast. That's, you know, with one, someone panicking and going to the ED once and coming home, that's a whole, I mean, we'll often have to get like a complex case together. You know, are we going to issue an ABN saying if you want to stay, first of all, what are your goals? I mean, maybe what we find out is a couple of times we've had this conversation. I, you know what, I don't even want hospice. Like if I want to be hospitalized, I'm not, that's fine. But otherwise, when we've had repeated behaviors going to the ED, despite education, it's more, then we kind of have to gather together as a team and say, okay, are we going to issue an ABN saying you can stay on hospice, but hospice is not going to cover your ED trips without you notifying us first and that type of, that's usually how we handle that. Right, thank you. Does anyone use, this is a concept that we've been talking about in our hospices, related but not necessary. So if it's a service or symptom management or our inpatient facility, if we can handle, like today, an example, we had a guy show up to our IPF thinking he was having a heart attack. So we're like, well, come on in, we'll treat all your symptoms, we'll keep you comfortable. But instead kind of chose to go to the ER and like a heart attack would be related. It's probably going to contribute to a prognosis of six months or less, but like, wouldn't it be necessary because we could manage symptoms, you know, with the hospice philosophy and all that stuff kind of here. And so anyway, is that something you guys ever use? I mean, the cost then falls on the patient and when that's explained, they oftentimes choose to revoke so that Medicare will cover that year admission for them. But that's something that we've been using. I don't know if anyone else does that, but that kind of not necessary piece. Yeah, definitely. I think that's, you know, if a patient is gonna go get a cardiac workup and potentially a calf, and that's not really in line with the palliative nature of hospice care. So I think, yeah, at some point you have to say, yes, it's related to your terminal diagnosis, but it's not part of palliation. It's more of an aggressive nature. Exactly. That's how I would put that as it's related, but not in line with hospice palliative goals. I'm curiously, how are patients and families accepting that language? Because I think that actually is quite nice unifying language and can help even as the nurses go out to discuss revocation with it in that situation. How's that going? I guess I can't speak to, it was more kind of out of the providers were getting called with the question of, is it related or is it not? Is it related or is it not? And so kind of empowering the physicians to kind of explain like, well, yes, it's related. However, not in line with, so I guess I can't say that it's maybe changed how the nurses are presenting the information. I do think they do a good job of talking about what are you hoping for? What are you worried about? Some of those goals questions. Always room for improvement. We've got new staff and all that stuff all the time, but that was more kind of why we've been delving into it as the providers are like, well, it is related, but it doesn't make sense. And so why would we be feeling like we have to pay for it or it covered in our hospice kind of thing? Well, I'm curious if I'm thinking, if it's a new diagnosis, so the patient's on service for X and they have something that is now Y, that clearly this new diagnosis is going to affect the terminal, the prognosis and will be added into their hospice diagnoses. But at the beginning when it happens, if it's not a preexisting condition on their problem list, how do you handle that then? Do you say, well, until we know what's going on, we're not going to say it's related or unrelated until we know definitely that this is going to be related and then add it. Splitting hairs. I don't know. That's what we do. Okay. It's a good question though, because it's a new thing is what you're saying. It's new. And Medicare does put the burden of relatedness on us. You know, and how far out is it? Six degrees of separation or what? And sometimes I'm sure hospice size depends on you know, will dictate maybe some of these practices because you can't have everybody go to the ED all the time. But I would imagine that maybe others who've been in this situation, I mean, sometimes you, you know, just accept that you're going to pay and it is what it is. And sometimes, you know, you have them revoke and they come back on with a new diagnosis. I think you can only do your best in the moment there. Makes sense. If anyone has any other thoughts on that. Well, coming back to the same case where Leigh was talking about this, say that there was cardiovascular disease already and now there is this new episode and they feel that it is related, but now we know how to manage this. You can provide your comfort. However, the patient ends up in the ER and says, look, they said that it is related to my hospice, but I'm here. And the ER physician is now calling you and now wanting to admit the patient to the hospital. Now you're having the conversation with the ER physician and saying, well, he's saying, will you take care of this patient if we admit this patient into the hospital, right? And now you're saying it's related, but there's an extent to which you can palliate this or go for aggressive management. That's where the decision has to be made, right? And I think earlier we were talking about this, or at least I was listening to you all talking about this as a part of who's paid for what, as to if they get admitted as a revocation to the hospital, now it becomes a new diagnosis and the hospital takes over the management of the cardiac disease, even though there was a preexisting cardiac disease. And we all struggle with this. I'm not saying that it's new to me, but how will you have this conversation so that we can have closure about this a little bit, at least I know there's so many different ways to approach this, but say this particular case ends up in the ED. Now the ER physician wants to admit and he's calling the medical director. How will you now approach this? I didn't ask anybody in particular, yes. I think it depends what are the goals. If it's a hospital where we have a GIP contract, maybe they're wanting to admit them GIP for pain control and that's fine. If they're saying, well, we think they might need a cath and so we're gonna do all these things. And I would say, well, hospice won't cover that. So let me send a nurse out to discuss options with the hospital. Let me send a nurse out to discuss options with the patient. Okay. So there's a possibility that the nurse now tells the patient, the patient says, I want everything done. So I will come off of hospice now and then we'll be happy to come back and reevaluate after the cardiac procedures are done if you're still interested, depending upon how you're going to do. But coming back to what Leigh was saying, that so if you have a GIP, that is the slam dunk because then you don't need to even go to the ED. You can directly say, I can admit you to a GIP unit at the hospital. So you can have a direct transfer to the GIP unit from hospice if they agree to that without any further aggressive management, maybe the cardiologist can come and see the patient there, but you're not doing anything more aggressive. So I think that part was answered, but you are now adding more specific to saying that you'll send the nurse from the hospice now to talk to the patient or the family for goals of care. Now you have a decision whether to keep the patient or discharge the patient. And that's where we are, how liable are we if we discharge that patient? That's a question that everyone has in their mind about related and palliative and related non-palliative. Mm-hmm, I think, Chris, were you gonna jump in with something or? Well, it was just, you can't discharge them going to the hospital. Only if they die, move out of the area, are unable to be managed and block in in the fourth. But anyway, and we would do GIP. And then at our hospitals, we also have palliative care. And so one of those providers would come in and help manage that patient in the hospital setting, plus having the palliative care team there and the nursing team staff member coming in on a daily basis. And then our doctors on our GIP, even though we're not in the hospital, are documenting and talking with the hospitalist on a daily basis, because we're still theoretically responsible for that patient. And so why they still meet criteria for GIP. So that's another level that we do as far as our documentation for GIP patients. In order to be eligible for the Medicare Hospice Benefit, you have to have a prognosis of six months or less. You have to have Medicare and you have to choose a palliative approach. So if the patient is not choosing a palliative approach, then they are deciding that they are no longer eligible for hospice. It always sounds a little easier than it is, but it sounds like everyone is in agreement that the dividing line really is goals of care. And I guess to Lee's point as well, not medically necessary to achieve comfort. So I don't know if that helps a bit, Chalotte. It is very hard to talk with the ED docs around this. It's very hard. And you're trying to do some of this over the phone. So it's very challenging. Yeah, they're dealing with both sides. One is someone like this, and then sometimes they're just tired of hospice patients showing up in the ED. So we don't have a good relationship only because they just want to get the patient out. Why is this patient showing up in my ED? So, no, I agree. It's not easy. So I'm glad you all brought up something really difficult for all of us, but how do you wade through these waters? Thank you. If it's okay, we could talk about this for hours, I'm sure. But I do think it's a good, I think it's a good summary, Gina, for the person who asked the question. So hopefully they can review this and hear what everyone else had to say. David Zokolowski joined, and he had an interesting question because it said it was too big to fill the space given to write it out. So, David, I just thought it might be interesting or good to give you an opportunity if everyone else is ready to move on to state your question and see if we can have some conversation around it. And to sound like a complete idiot, now I don't remember what it was I was going to say. No. That's okay. I totally get it. It was probably in the moment. Well, yeah, it was in the moment. I was typing it in, but the box would only let me put in so many characters. Okay. All right. Are there any other burning questions? I'm curious about the Pax Livid question because this has come up recently for us as well. I'm wondering about what you all are doing about covering the cost of Pax Livid. We have tended to, especially if it's one of those situations where patients at home, family notices, they've kind of declined or there's been COVID in the home, we catch it early so that we can start the Pax Livid early. We tend to do that. There are times where we maybe don't as much as when it's a nursing home patient, they're getting screened regularly, they just pop positive, they're not necessarily symptomatic or things aren't changing, then I won't even order it. And if a nursing home, like we've had nursing homes ask us to cover the cost of screens and Pax Livid, and it's kind of like, we're not going to because if they're not symptomatic from it, then we wouldn't be testing them. And it's kind of the nursing home that wants to do it. So if we feel it's going to help them feel better or it might help them feel better, we do it. But there are instances where we don't, if they're not symptomatic, it's kind of how we do it. Now, I'll add a comment here. So yeah, we've been doing the same thing. We occasionally cover it. My understanding of what I've read about Pax Livid is that it's mostly useful in decreasing the chances of hospitalization of people who have COVID, which of course is a different consideration in hospice patients where we can typically manage that symptom burden at home. So I, although we've done it, I sort of questioned whether it's really appropriate for us to do so. You know, what symptom would come up that we couldn't manage in the home or, you know, nursing home setting, you know, in terms of if it's dyspnea, we certainly can manage that. So, and our goal is not to keep people out of the hospital, obviously. Well, except for the discussion we just had. But so, yes, I'm not sure if we really should be covering it. But what about if it is the nursing home? The nursing home is screening all residents and you have say three or four patients who are on hospice and now you have a couple of them who are symptomatic and the facility wants to decrease that burden because now others who are on Pax Livid, non-hospice patients who are on Pax Livid, now they want you to cover for the two hospice patients out of the four that you have. How can you say no if that burden of disease is going up in the nursing home? Because when the state is going to come in and audit on your infection control and management and say, these two hospice patients were not provided, will we ask for that? So is that a tricky situation? How would you deal with that? My understanding, and I'm not an expert on infectious disease, but my understanding is that Pax Livid does not decrease transmissibility of the virus. So it's not protecting the other patients is my understanding. You're right about that. But when they're talking about the burden, this patient is infectious now and that you can actually mitigate it by early starting of the Pax Livid. That's what I was talking about. I would say, no, I don't know that you can. And of course, there's this issue about rebound off Pax Livid and some thought that maybe these patients are actually contagious for a longer period of time if they're on Pax Livid. Yeah. Well, thanks for the answer. I liked the way you said that. But I've struggled sometimes in the nursing home, even though I don't have the hospice patients now, they're mostly community patients in the nursing home. But it's a good thought to have. Thank you. Cost of Pax Livid, since it's off now, not being covered, is about $1,300. Whoa. Primaries, no wonder they're advertising. Yeah. And so we do not, we just had this discussion and we're not, we used to cover it, but now we're not covering it at this point. So that's kind of where they're at with this. And the nursing home question came up and you could say, it's not part of our formula now and you do an ABN and then Medicare would pick it up then. But that's- I mean, I don't know if there's a right or wrong answer, but this is, we had this conversation because I felt like, oh, we should cover it. And then the compliance people and other people like, no, we should not be paying for this. Just like we don't pay for Tamiflu. This is an endemic virus. And so we just, we aren't covering paying for it. So I was just curious to hear what you all were doing. It seems to fit within the same question, maybe not entirely, but the Jardians and Entresto question, which is standard of care to prevent re-hospitalization and mortality. But we can do that in other ways within the hospice. So I'm not sure. Dr. Jones has asked, I'm assuming the Paxlovid is related to the terminal diagnosis. That's the approach we take. I mean, since COVID is just endemic and most of the time it's, I mean, sometimes it does cause our patients to accelerate faster towards death, but most of the time it's just an endemic disease that they picked up from a family member. And yeah, that's how we're looking. Yeah, I agree. And hopefully with immunizations, et cetera, vaccines. Excuse me one second. I think, so sorry. It is the top of the hour and this has been a great discussion. There were a lot of questions that of course we didn't get to. Gina, I think you are going to post some of these on the new chat board. So you're welcome to start taking a look at that, contribute, and we can have conversations in between these coffee chats. Certainly this face-to-face or call-to-call conversation is more robust than the chat. So we hope that these questions in between will also feed these coffee chats in the future. Yes, thank you, Dr. Turner. Appreciate you facilitating today and everyone joining us. And I will post the questions that we didn't have time for today on the discussion board. And like Dr. Turner said, if you have a chance to go in there and contribute to them, it's just a great way to keep that conversation going. But we'll go ahead and end the chat today. And thank you all so much for joining and we'll see you next month for our webinar or at the March coffee chat. Bye everyone. Bye.

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