everyone. Thank you for joining today. I know most people will start to come in, so we'll let them in. And my name is Gina Parisi, and I serve on staff at HMDCB, and I just want to welcome you all to today's coffee chat. Just a few reminders, if you aren't speaking, please stay muted. And we do really encourage you, though, to come off mute, to ask questions, to provide support, and you're welcome to use the chat box for that as well. So before we start today's chat, I just want to share a few HMDCB updates with everyone, and we also have the American Academy of Hospice and Palliative Medicine here with us today, and they'll share a few updates as well. So really quickly, just some upcoming HMDCB community events. We have the June webinar, which will provide an overview of medical aid in dying on June 13th. We're partnering with Weatherby Resources again to provide the Hospice Physician Compliance Conference on July 12th, and you can use the code on the screen to receive a 10% discount. We'll have our next coffee chat July 17th, and then, of course, if your credential expires this year, you can participate in the longitudinal assessment starting this year. Just make sure to get it done by October 31st. I'm going to hand it over to Julie Tanner from AHPM. Hello, everyone. I'm Julie Tanner. I'm the Director for Education and Learning for the Academy, and thank you, Gina and Emma, for this invitation to be here today, and we have definitely appreciated the support that we had with this pediatric presentation last month and the opportunity to keep the learning going forward. Just a couple of activities that we have. We've got a new addition for our AHPM Path. It's a really good interactive activity if you're interested in looking at clinical and regulatory types of questions that may be applicable, and then we have a new micro learning flight on home-based innovations in palliative care, and then we also have available our Grand Rounds Year of Reflection, so that's kind of what's happening in the enduring world of our learning activities, so if you want to go next, and then we've got an upcoming conference in person in Louisville at the Omni Hotel on August 8th through 10th, and just wanted to bring to your attention, one of this is an open access at no charge, two and a half hour core striking a balance for pain management opioids. This is made compliant, and there's no charge for attending this, so if you're interested, please, the information's on the website for the Academy, and then we have an intensive board review course following that, as well as the concurrent leadership skills course that'll be available, so thank you all very much, appreciate being here. Thanks, Julie, and now to introduce our facilitator for today. Today's chat will be facilitated by Dr. Emma Jones, and she is an HMDCB Certificant and is a board certified hospice and palliative medicine physician with over 15 years of clinical experience providing compassionate end-of-life care. She currently serves as a hospice and palliative care physician at several community organizations in Massachusetts, including Care Dimensions Hospice and Bay State Health. Dr. Jones' career has focused on pediatric and adult palliative care delivery across inpatient, outpatient, and home-based settings. She has worked both in community and academic settings and has had the privilege of training many students, residents, and fellows. As an advocate for quality and patient-centered care, Dr. Jones co-founded the Pediatric Palliative Improvement Network, the first national collaborative dedicated to pediatric palliative quality improvement. Dr. Jones holds a board certification in hospice and palliative medicine, clinical pharmacology, hematology, oncology, and pediatrics. She earned her medical degree from Louisiana State University Health Sciences Center and completed residency training at Vanderbilt University Medical Center. In her free time, Dr. Jones enjoys yoga and practicing mindfulness. Thank you, Dr. Jones, so much for leading today's Poppy Chat and for also hosting the webinar that we did last month focused on pediatric hospice, and I will now hand it over to you. Thank you, Dina, for that lovely introduction. It's always a little overwhelming when you hear all of your life put together in one minute or less, but yeah, I'm really, I am a pediatrician at heart. I now have made the shift over to hospice for all ages and have been in kind of the hospice setting full-time for a couple of years now, and so I think that this is really a topic that's near and dear to my heart in how do we do pediatric hospice better and how do we get more access for pediatric hospice so that every kid who needs it can have access to high-quality care, and so this education is part of that, and I'm happy to field all the questions that you guys have. Thanks, everybody who's here so far. So, let's see. To get started, if anybody wants to jump up and ask a question or post one in the chat, we can kind of go that way. We do have a couple that were submitted in advance. We'll kind of see what seems to be top of mind. Dr. Johns, this is Julie. I know that we had a question come across. If you could speak a bit towards pediatric concurrent care and the current landscape right now in that arena. Thank you, Julie. I know that's a very hot topic. Concurrent care, just to give, you know, sort of background just to make sure we're all talking about the same thing, concurrent care was the same thing. Concurrent care was the provision in the 2010 Affordable Care Act that basically said for patients less than 22 years, so up until the 22nd birthday, I believe, maybe 21st birthday, don't quote me on that. Anyway, children, as most people would understand it, can have hospice benefit while still having regular care, so we don't have to forego usual care or curative care in order to elect the hospice benefit. That's basically what the concurrent care provision says. Now, that is a Medicaid provision, which means that it's state by state, so this is really the problem and why 14 years on we don't have more clarity or more clear understanding or unified understanding about what that means and how that has shaped the care is because each state kind of interprets it differently. There were states that for years didn't even adopt that provision, so like it wasn't like it even didn't exist, so it just is kind of chaos because of the state by state issue. Even within the state, so like I practice in the state of Massachusetts, I have practiced in the state of Massachusetts for the past 11 years, you would think I understand it, but that it also because there isn't a lot of clarity on it, it still feels like every case we have to negotiate one by one in terms of are you paying for this or am I paying for this because a lot of the treatments can kind of fall into that gray zone of, you know, is this curative therapy or is this comfort-directed care. When this provision was passed, I was practicing oncology, so it was great news to me as an oncologist. Great, I can still give my patients chemotherapy and transfusions and they can be enrolled on hospice. It was very clear for the oncology patient how this worked. For patients that have complex chronic conditions, neurologic impairment, a lot of the patients that are actually served by pediatric palliative care, pediatric hospice, it's very unclear, which is why it continues to come up as a question, you know, what's going on with concurrent care. There is unfortunately no policy that I am aware of pending to make this more of a federal regulation. This is still going to be state by state. I think NHPCO, AHPM, like all the different bodies are kind of doing the best they can to try to get everybody rolling in the same direction. But I think that that kind of siloed nature of it is what's making it hard. And then I see a lot of, you know, a lot of agencies, our agency has always taken a very restrictive view of it in terms of we're not going to overuse concurrent care. I think there's kind of like letter of the law and spirit of the law. And there may be things that you would say, oh, under the concurrent care, we can put this patient on hospice and they can still kind of have all their usual things. I have always taken the view that if there's a patient who's going into the hospital frequently, technology dependent and really goals of care are not to stay home or not what we would typically consider goals of care very aligned with the hospice care plan, I might leave that patient on palliative versus enrolling them on hospice. No, I have the luxury of having a home-based palliative care program. Not every state has that. And I know a lot of states have used the concurrent care provision to try to provide home-based palliative care for pediatric patients. So that was basically to tell you that it's as much of a mess and I don't have a whole lot of answers, but if it feels like a mess to you, it's probably a mess to everybody. It hasn't solved all our problems is I think the other thing, but I think there was a lot of hope hung on concurrent care, like, oh, if we can just allow people to still have curative therapy, we will solve the problem of pediatric hospice. Well, 14 years later, we still have not solved the problem of pediatric hospice because that wasn't the only problem. The patients have a lot more care needs that we need kind of more other kinds of policies to be able to address than just the concurrent care. So that's the other thing I'll say about concurrent care. Okay, let's see. I think we've got a few other questions coming in. How challenging would it be to add pediatric hospice to the community adult hospice program? Okay, let's see. Does the person who posted this question want to come on and tell me more about what you mean? Oh, hi, Kristen. Hi, it's me, Keyshawna. How are you? Thank you. Thank you for joining. Thank you for your question. Of course. Yeah. So previously, I've been a part of a community hospice program for adults and being in the hospice world for these, well, in HLUCB world for the past three years, I've seen there's a great need for pediatric hospice, you know, people, it's just nowhere. And so I, I asked the leadership, if we could add it, and they morally were just, you know, not able to even accept the idea. But I'm just wondering if an adult hospice can also add that to a program if that's even a thing, logistically. Yes, I love this question. And this is actually the question I have for this group is the inverse of this. What are the challenges to including pediatric patients in the services that your agency provides? Having pediatric program within an adult agency is the only way that this works. There is not enough pediatrics, thankfully, to have all like independent pediatric agencies. The place where I work, Care Dimensions, that's how it's set up. We're a large hospice, about, you know, 800 to 1000 patients a day on our census, just to give you an idea, we're a large hospice. And then we have pediatric programs within that our pediatric census is about five to 10 on any given day. But we have clinicians who, I'm a pediatrician. So I have that expertise. We have nurses who have specifically trained to be more comfortable with children and have pediatric expertise, but they do both they see adults and children, our social workers, chaplains, everybody kind of does both, but have self selected to be trained in the care of pediatric patients so that when our children come on service, they have that expertise. That is actually the model that I think is the best model. And so what it takes is a mission, dedication from the top to say we want to be able to take care of children. And so we're going to kind of figure out what that means in terms of training our people and dedicating the time because we do know that the time it takes to take care of pediatric patients is much more. So from a staffing perspective, leadership has to be on board as well with giving the clinicians who are caring for children more time and accommodating their caseloads properly. I'm interested to hear about the pushback that you got. Can you tell me more about it? Well, it was mostly because people can't emotionally handle that, the idea of children being terminally ill. That's what it was. It wasn't even focused on the health care and serving the family as we do in in hospice. It was more, oh, I can't stand to think about that. I cry every night again. So the conversation didn't go anywhere, even though I was willing to explore, hey, let's find a pediatrician, let's find a pediatric nurse, and I'll lead it and help. Because for me, it's about taking care of the family at the end of the day. Yeah, I love that. And I appreciate your dedication to it. I do think we hear that a lot from people who are not used to taking care of children and not accustomed just to children in general. Forget sick children, right? There's kind of both sides of it. And so I think meeting that with it, this is a strategy I take. I sort of meet that with compassion and say, like, I understand that this is hard and I understand that you're scared. I mean, I also understand you may not, you personally, this person, whoever I'm talking to may not be the person who's going to do it. But can we say that this is a mission that our organization has to make sure for, like, equitable care and for, like, doing the right thing for our community that we're able to care for the full age spectrum of patients? I think that is, like you said, that is, there's mission in that too, even though there's fear. And that's kind of the way that I usually tend to try to motivate people. But I do think that is one of the drivers of why there aren't as many agencies that take on pediatric patients. It is financially challenging and it is emotionally challenging. So we have two things going against us, which is really tricky as we try to inspire people to want to add pediatrics to their service lines. Anybody have anything to add about that or share similar experiences? Okay, great. If you do think of something, please feel free to chime in. That's a big topic. I'll just throw out there that that's been our, that was our experience when we started pediatrics is that it's worked great, but I'm the only partner who will do it because the other partners struggle emotionally. And I don't know why, I guess I'm the only, I don't know what the right word is that makes me able to still do it and not be the, because I'm not non-emotional, but for whatever reason, I'm the only one that takes the pediatric cases, but that's how we had to do it is just figure out who's going to be available to do pediatrics emotionally. Yes, thank you for taking on the challenge. I think that I would say that different strokes for different folks is one thing. So there's not better or worse, like people who take care of kids aren't better or worse than people who don't. I think some of us feel particularly called to the work. And I, you know, I and other, my colleagues who are pediatricians actually find it easier to take care of children than to take care of older people. So I think there's that too. And I, but so then I think within your organization, and again, depending on the size of the organization and how big the pool is looking for those people where it may not be as hard, and then giving those people the resources to sort of skill up and develop, because there definitely are teachable skills as well about emotion management and boundarying and using your team. We work together as a team very, very much more tightly on the ped side than we do when we care for adult patients. Adult IDT is kind of more parallel play than like lockstep in holding each other up kind of thing, which is what I see a lot. It is. I mean, it's one of the skills that we have on PEDS and the teachable skills is how to kind of support each other as a team. And that that's needed because of the additional complexity that pediatric patients and families of children who are sick bring to the party, which is why it takes more time. And, you know, kind of all of the things that that also make it a challenge. But one of the, you know, hopes and goals that I have, too, is to also create some spaces where people can get more support for each other. So, for example, you know, Tommy thankfully spoke up and said, I'm willing to take care of kids. I don't know how many you take care of in in a year, but there are other there are people like myself who do it more. There are people who's that, you know, do do a few a few if we could sort of find each other. And then beyond the doctors, I really think the nurses and the social workers and the different therapists kind of need that support as well to kind of be able to if you don't have it within your own agency, at least have something in your state or your region or even nationally as a support network for boy, this was hard and I'm going to do it because it's my job and it's the right thing to do. But it's hard. And that's that is true. That's still true for us every day, even though it's what I love to do. I would say that, too, is that my experience has been because I'm a family medicine doctor, so I have a little bit of experience, but I consider myself more of an adult medicine doctor. But the I've not met any pediatricians yet that aren't willing to be super helpful on all the clinical parameters. If I'm willing to be the one that can make the home visits and take care of the emotional needs of the family with my team. And that's what I end up primarily doing is letting a pediatrician to do the bulk of the management, medical management, because I'm available to be the overall support structure for the family and the team. So that's and that's the other key thing I would say is if you're nervous because you're like, I don't know if I know enough medicine for condition X, there hasn't been a condition X has come to me yet, but I have not had extreme amount of support because I live in a smaller community in Abilene, Texas. It's Cook Children's Hospital in Fort Worth, who's given me all the clinician support I need because they have the doctors and all the palliative care doctors and specialists give you, no one's been, their pediatricians are nice people. They don't have, they don't seem to be able to recruit mean people to help. They all, they're extremely helpful. Thank you for saying that. I was, my experience as well, and that is also a model that I advocate for is a really strong partnership between the existing care teams. Those people don't want to give up their patients. Pediatricians are nice and pediatricians are protecting. And so we don't want to just turn our patients over to hospice. They want to be involved. And so it is good because they'll be supportive. It can also lead to some complexity because you have to kind of keep 12 different people up to date if they have a large care team. But I love that model and I'm glad that that's working well. I have some good friends down in Cook. So I'm glad to hear you're having good experiences with those teams as well. Okay, let's see if we have another question here. In Idaho, we generally make sure to get non-hospice covered meds approved by Medicaid before agreeing to take on pediatric hospice. More than one of those oncologic and seizure meds could bankrupt this. Yes. Okay, so it's kind of talking about this concurrent care and how do we decide what's covered by who? It is tricky. And I agree that a lot of the meds are very expensive and then we don't want to have to change them. I mean, that's part of the point is that we don't want to have to take you off all, particularly some of these neuro kids that are on five different seizure meds. Not the time to be rocking the boat with their very delicate seizure management. So I think ingenuity is definitely a good skill to have when you're trying to navigate concurrent care and getting things filled in advance before they elect the hospice benefit. At least gives you 30 days to sort it out, right? Versus having to decide on day one, am I going to pay for this or I'm going to kick it back and hope? So that's a great strategy. And let's see, how do we get pediatric referrals? We are a private agency and kids with terminal illnesses typically go to hospice owned by one of the excellent specialty hospitals in our area. Okay, well, that's a really good question. I think that everything, in my experience, it is all about relationships. I think that we don't really have the problem, in our area, we don't have the problem that you have where there's competitiveness. We have gaps more often. But I think that a lot of how I try to advocate for patients to be referred to hospice at the appropriate time, or for people to even think about hospice for their patient, meaning they can go home instead of having to stay in the hospital, is to just keep those lots of relationships. The more people who know me and trust me, the more people who know our nurses and our social workers, they know our faces. They kind of say, oh, I would feel comfortable with those people taking care of my beloved little patient. Remember I told you they're very protective. So we have to nurture those relationships and you can do that through education. You can do it just through chit chats or answering their questions. But I mean, there's no substitute for it in my experience. And depending on the size of your town, that may be a few people or a lot of people that you have to talk to, depending on how insular your institutions are, it may be easy or hard to sort of get in. I have the luxury of coming from the large children's hospital. I worked there for many, many years before I came out into the community. So a lot of those relationships were already existing and people already knew me. So I've leveraged that. If you're starting from scratch, it is harder, but not impossible. I mean, I would take the intentionality and say, okay, I've just got to, I'm not, my only intention is to develop the relationships with these people, not for any reason, and then kind of let it develop from there. That is what I would recommend. And then you have a good answer. The story you have to tell is what kind of patient is hospice helpful with and case studies of like what kind of services your team can provide and tell the good news kind of thing. People love to hear that. All right, let's see. We get them because they're leaving the big city and coming back home, yes. And one of the smaller communities and we now have the reputation of working with cooks. Oh, that was from Tommy. Okay, fantastic. Yes, more good news. So that's just an example, right? Of relationships that you've built. So now people feel very comfortable when they know they're sending a patient to your neighborhood. They're probably actually really happy. Like, oh my goodness, great news. They're going to Abilene. We got Tommy there. I would. And I noticed Dr. Zlotowsky and Dr. Farrell both on and they both submitted questions. If you want to answer either of those, I can put Dr. Zlotowsky's in the chat. Thank you. Okay, so this was the question. We admit patients from the hospital after the pharmacies are closed. How do we get the medications? So this one might be a little bit, I would like to maybe want to understand a little bit more about what you're asking. Again, at our hospice, we have our own pharmacy that does provide medications whenever time. I don't know if this is pediatric specific formulations that we're having trouble getting or what exactly the issue is. Do you want to hop on? Yeah, the issue is we admit a patient and the patient is perhaps coming from the hospital. They're being discharged at 10 o'clock at night. They've been on say intravenous opiates in the hospital. There is no place in my area that I can obtain those medications at 11 o'clock at night, which means that the patient then has to suffer until they're available. And I didn't know what solutions other people were using. I have tried to talk my agency into keeping a small stock, but I've gotten nowhere. I don't know, I was wondering what other people do to solve this problem. Well, I will tell you that I solved that problem by telling them they can't come home until the next day. I wonder if you get pushback when you say that. Yes, tremendous amount of pushback when I say that because the hospital says, yeah, but we don't get paid if we keep them over midnight. Not that that matters to me, but it seems to very much matter to the hospital views. I know, I know. I think that, and I hear that that's a really tough negotiation. I mean, I think that I do see it as my duty to make sure that the patient gets good care. And sometimes the way that I do that is by being the bad guy that's saying, I'm sorry, no, you can't come home, or I can't admit you. I mean, if they choose to send the patient home, like they might decide to do that. I can't control their behavior, but that if I'm clear that we can do an admission and start IV opioids at 8 a.m. the next day or whatever time is reasonable based on what you can get from your pharmacy. I mean, this is not even taking into account when we have shortages. I mean, right now, right now, this is happening right this minute. There's a patient in the children's hospital they wanna send home. They said, can you put this patient on a morphine PCA? And my pharmacy is telling me we have no morphine cassettes because we're on a national shortage. The patient's refusing to be converted to dilaudid. So like, what am I supposed to do, right? I mean, to me, I feel like having a boundary and being very clear about what I can do in the home so that I'm not setting us up for a failure situation is the best that I can do, recognizing that sometimes that is going to make the hospital mad. That is not unique to the pediatric setting in any way. I mean, that's got to be happening all up and down. So I'm also looking to, you know, our higher, you know, other people in our organization to back me up on that as well. Because if I have to address that, I don't have anything more creative than that other than I think I've tried to kind of MacGyver things in the past and been like, well, what if we could float them by with some Roxanol until morning? And it just never works. So I have taken the stance, which I think is, I mean, thankfully, like I said, I have those relationships. And so people sort of give me the benefit of the doubt, but I do, this week in particular, I kind of feel like I'm getting a reputation as being obstructionary to patients coming home from the hospital because I keep saying, no, they're not ready yet. The level of care they're on and what I can do is not matching yet. So like we need to, it is our problem. This is what I say to the hospital doctors. It is our problem to solve. It's not my problem to solve this question. That's sort of my thoughts about it. I'd love to hear if other people have ways to think about that. I mean, the only, thank you. The only thing I've been, I'm trying to work with, and maybe it'll happen in a few months with one of the local hospitals where I can, I used to be ambulance director, I'm medical director for an ambulance company. And we had a relationship with a local hospital where the crews could go to the inpatient pharmacy if I wrote a script and get the meds from the inpatient pharmacy. I'm trying to set that up for the hospice, but it's months away. Yes. Sometimes if the IV meds is particularly challenging, sometimes if there are oral meds that I know may be a little challenging for us to get at home, I will ask that they fill them at the hospital pharmacy or if the family, if they have a long travel to get home, right, I want the meds in hand before they leave so that we don't have any gaps. I mean, I definitely will ask for that, but again, that's a little more like a daytime safeguard, not really solving the middle of the night problem necessarily, but we definitely have done that. Thank you. I was just looking for creative answers because I've been kind of at wit's end lately, but thank you. I know, it sounds like you're being as creative as possible. Sometimes less creativity is the right answer. Just give it all to them. I have learned, yes. Thank you. Thanks. Let's see. Oh, someone, yes, this person's agreeing. Wouldn't take them without the immune place. Great. Yeah, I do think that the relationships are really important. I mean, sometimes sorting out what's going on, I mean, as you all can imagine, there's lots of, if this is at the end of a long hospitalization, there were probably lots of back and forth conversations about even the decision-making to come home and what to do and what not to do and who's going to be driving the bus and all of these things. And then everybody in the children's hospital has all their different opinions. So you're, I mean, again, live cases, I've talked to three different teams and kind of gotten three different assessments about the same patient in terms of what's going on and what they think they need and what the next 24 hours might look like. So it is complicated. Again, that's not necessarily unique to pediatrics. I think that young patients who have high symptom burden, that may be 20-year-old, 30-year-old, 40-year-old patients also have a lot of these same challenges. They're just, it's much, it's almost universal in the pediatric population. It's not if they'll have complexity, it's how much complexity are they going to have? There really aren't any easy pediatric cases. But I do think that learning from the things we already know how to do, right? If your agency serves young adults, you probably know how to serve a little bit younger people, right, teens. Now, when we're getting into babies, they maybe have a very different care plan and they look different and they feed differently. And I mean, there's a lot of things that are different about babies, but teenagers, that's the low-hanging fruit. If we're trying to convince people to expand into pediatrics, I'd say, could you take a 15-year-old, 16, 17, 18, that's probably a relatively easy lift. Again, those are the patients that are gonna tend to have those cancers that are very symptomatic, that are gonna need high-dose medications, that if they're trying to send them out in the middle of the night, that's gonna be hard to solve. But from an emotional standpoint and from a logistical standpoint, it's gonna be more similar to some of the patients that you and your staff are accustomed to taking care of, perhaps. I know within our agency, young adults are very stressful to our people as well, because we don't have a young adult team. The young adults just get on whatever team they're on geographically. And so I do see that the emotional distress and the complexity and the care coordination and the time that it takes, all of those things kind of stress our teams as much as our pediatric patients do without the kind of extra support that we put in place when we know it's a pediatric patient or doesn't make it as a pediatric patient. Okay, let's see. Oh, yes, okay, we got a vote for just all the opioid stuff, right, pushing against the DEA for our stuff. All right, emergency hospice admission. Yes, Ronald, I agree with you that I have pretty clear rules. I think that when I worked at the Children's Hospital, we did do palliative transports and would transport patients home off of very high level support to then be discontinued in the home setting and that that was in collaboration with our community hospice partners. And that was a very clear protocol that we had in place from the Children's Hospital side, that we always said it takes at least three days for us to be able to arrange this. We have to have a hospice provider that agrees. So if we can't find one, that's a no-go. We have to be able to have the transport team available. So that's gonna be dependent on their staffing. And like, we have to get all the meds and we have to have like a good care plan in place, right, to know how we're gonna actually do good care for this patient when we discontinue their ventilator or whatever, that's the most common thing, ventilator. I don't think we've done an ECMO transport yet, but we talked about it. And so I think coming from knowing that that was the, those were the like very clear boundaries at the pediatric hospital side has empowered me a little bit from the home side to say, I don't need to rush. Like, it's okay, let me get everything in place so that we do a good job when this patient actually comes home. Whether it's that high level of support or even a lower level of support, if the patient couldn't be home without hospice, if the doctors at the hospital say we wouldn't feel comfortable with this patient being outside of our walls unless there was a hospice team there to catch them, then I feel like I get a little bit of a vote in when they're ready to go home. If they'd say, oh, this patient's on PO meds, they take one dose of morphine every three days, they can be home, you guys admit them, you know, when you get the pediatric nurse available two or three days from now, that's a really different story. Excuse me. Does the AAP still encourage returning to the hospital for pediatric patients who are at the end of life? I have always worried about that position statement, ultimately undermines hospices and attempts to create a good death at home. That's a really good question. I am not aware of a policy statement that recommends that. I think the position that pediatricians have taken is that we accept that good death can happen in a range of locations, including the hospital, and that the patient's preferred location of death is what we're targeting, which was a pushback against one of the sort of original metrics of high quality end of life care, which was that you should die at home. So I think we kind of said, well, you should die where you want to die. That's a harder metric to capture because it means we have to ask you where you wanted to die and then we have to see if you actually died in the place where you wanted to die. So I don't necessarily think that, I've seen that as opposed, but I guess it could come out that way. I don't know if you want to say more about that or if anybody else has thoughts about that. This is Tommy again. I was just gonna say, I try to make sure I find that these families, especially with younger children, are very, very vulnerable to some of the clinician guidance. So I really try to emphasize with my team and what I appreciate about, again, those partnerships that I had, at least the palliative care doctors that are at Cooke's and not always the primary, but definitely the palliative, is helping these families feel empowered to do what's right by them. Because we tell them, we got three options. We got your house. We got our inpatient hospice unit and Cooke's children will take you back. And families go all sorts of directions. Some of them, it's very important to have that child in their home. Others are very worried about what that's gonna impact their other children and themselves. And so they like to be back at Cooke's where they know, because that team has become their surrogate family in a lot of ways, that they've had to spend a lot of time in that hospital. And then some of them kind of hit that in-between spot where they wanna be in an inpatient setting with nurse's care, but not having to travel back to, Cooke's is about two hours from us. And so they wanna be at our inpatient unit. And the big thing I try to really emphasize with our team is no emotional manipulation here. No, you really, you make them feel good about whatever they want. Don't make, really don't make this about us at all. And I find that it works out great. I love that. What a lovely reflection. It's not about us, right? We have expertise and we need to create the conditions where if they choose home or hospice facility, we provide an excellent experience for them. But if that's not what they choose, or if either one of those doesn't work for some reason, cause there are patients for whom those levels of care may be insufficient. I do believe that. Then that's okay, right? Like everybody can accept that that's the case. Now, I think what we, the piece that we have to say about it is that we do the absolute best that we can. I think that what I don't want is somebody has to go back to the hospital because they don't have a hospice provider who serves their area. Or the nurse that walks in and says, oh my God, I'm so scared with this baby, just go back to the hospital. Like that feels like a miss. But to say we showed up and we did good work and we did everything that would, anybody would recognize as good hospice. and a result was that the family decided to go back to the hospital or the care required the hospital then I think I don't I don't lose any sleep about that personally. And the hospice did provide a service because they got those days or weeks at home free hospitalization so I make it's not a miss at all if you gave good care and the settings just had a change during phases of the illness. Yes I do think about it the same way too we have many we have several patients whom the preferred location of death is actually the hospital and they say that kind of right away we know that going in that when they start getting sick they're gonna go back but that there's a lot of opportunity for hospice level support while they're home they're having medication titration they're certainly having the psychosocial support the anticipatory grief work the sibling work the legacy work everything that our team is doing is great work even if the end result is and then catching it right anticipatory guidance oh I think we might be changing death might be coming here in the next day or two if you don't want to die at home we probably should leave home now this is the time that's it that's an incredibly important piece of work for our team to be doing if that is the goals of the family and we do have families that have that for many reasons two of which you kind of alluded to one they don't want the child to die in the home where they're going to continue to live and raise their other children that just that's that kind of memory or mark that they can't tolerate and we try to work to overcome that or see if it's malleable but for some people it isn't and so that's just sort of a hard line like I can't have my child die in a house that I'm going to continue to live in so then we figure out the options but I mean again we have to be able to give them good guidance based on the physiologic data that we're getting and then the other is that they really feel a lot of comfort at the Children's Hospital that has come to become a second home and that is true for a lot of the patients that I take care of and that when they're at their most vulnerable and that their highest need they want to be surrounded by the clinicians that have cared for their child possibly for their child's entire life or very intense couple of years and so we do see that a lot as well and again it's not about us they're like we love you guys but that's where we want to be is back in the is back in the arms of our oncology unit or cardiology or whichever team has been kind of their second family for so many years and then we get lots of people who say I never want to go back to that place ever again thank God you're here and I say thank God we're here too because if we weren't then you'd have to go back and so to me that's sort of where this mission to increase access and make sure that there aren't gaps in coverage is so important for the people who really want that and there aren't other ways to accomplish their goals great let's see did I miss anything okay good we got caught up on the AAP guidelines thank you all for posting the most recent thing oh hi Keith how you doing nice to see your name and I can look at dr. Farrell's question he submitted in the chat since he's on or if anyone has any other questions but I'll put that in there okay yes I remember seeing this one I'm gonna ask you for a little clarification on what you mean by it so we can talk about that interesting question it wasn't necessarily specific I just I know that nurse practitioners can be attendings on hospice and I've heard mixed feelings people have on that on doing that I guess I was one of the hospices the hospital I'm now working with the most I said why isn't our nurse practitioner made available to be in attending for some of the patients and they had some reasons why they didn't like that and it threw me off because I thought it would be a good thing to let families choose an NP that's as attending if they wanted so I just didn't know if more people were using in pieces attendings it ultimately comes down to a billing thing in the end you know if that NP is not named as attending which of course needs to be family's choice not in any other contrived ways but they can't bill for their clinical visits if they're employed by the hospice if they're not the attending and so I'm sure that other people allow in peas to be attending when families ask for them to be the attending yeah I will admit that I don't have a lot of knowledge about kind of how that works from a maybe more systemic type of thought process I will say from the lens of thinking about leveraging pediatric expertise it could be I mean it's definitely something to explore because if there were a nurse practitioner who was pediatric trained or had pediatric expertise we would want to sort of find a way for that patient to be meaningfully engaged in the care of children if there were particularly if there wasn't a doctor who felt comfortable with children right like that's a nice partnership at our agency we don't really do that very much or I don't think at all we have had patients have I have had some patients on my team where that their NP is listed as their PCP but I am listed as the hospice doctor and I don't know if anybody else has or if I'm misunderstanding the question or if anybody has anything else to add about that and I can read yes that's one of the non-pediatrics coffee chat to you I'm just curious if any others are using MPs anybody else in the group using MPs in the role or where they have MPs as attending for a patient and it's okay if there's not an answer to that right now today I'm patient you know this is how this is my way can I add just like one more question to this because I was going to actually submit this question so for the attending I never use okay I am physician I have one nurse practitioner help me in the hospice never sign her at the attending physician because this is gonna complicate thing well for us from billing and so on however if the family choose to continue with the attending physician with the nurse practitioner at attending physician I don't think there is any problem accepted during this certification even when I have a patient they I have nurse practitioner she has really large chances as a family medicine nurse practitioner what if she wanna if she wanna have any hospice referral always she has to look for attending physician use what he had collaborating physician to admit the patient to hospice then she will find herself as attending physician because she cannot really be the second physician for hospice admission if I did not decide to do the post signature now my question is the probably is related to nurse practitioner I am a physician I'm hospice physician I have nurse practitioner and she covered me some time but how much she can cover can she admit patient to hospice if she's covered me for uncalled usually she covered me for prescription and triage but can she also do the admission when she covered me she is not the attending physician for those hospitalization my understanding is that the certification is only a physician that only a physician can do a certification determination right certification of terminal illness that is a physician specific function but in terms of 14 days after the patient admitted to be able to write the Cody so what we have done in the past if I wasn't here is this because I am the only one who does it for pediatric patients I know about this are the rest of our organization has a very well-oiled machine how we kind of keep this going but for pediatric patients which may be the case for smaller organizations overall if a nurse practitioner covers me they can write the prescriptions they can make the care plan they can support the RN case managers and then I can write the Cody when I get back as long as it's within a 14-day window but that's the only that is a piece that can't be done and then recertification ongoing is also physician specific otherwise I think however it makes sense clinically whoever you feel comfortable to delegate your coverage to there's nothing in the eggs that would say you couldn't do that so for the new admission she can give the diagnosis and sign at the new admission and I will give the verbal certificate within 72 hour or 48 hours that's what you say like my expertise nothing everything everyone's saying including in the chat sounds correct to me from all our I mean yeah the nurse practitioner can do anything clinically you need them to do that is in their scope practice for you but the certification processes all have to be done by physicians and as was said in the chat by dr. Gallagher I think was you have to have they have to be attending though if they're going to bill for a clinical visit so anything that that nurse practitioner is doing while you're while covering for you is not going to be billed it's not gonna be billed to Medicare and so that's why that's why I'm interested in because I have a great nurse practitioner that some of our patients come to want to make sure there's always a person being asked questions now why why not let them choose to let her be the attending so that she can bill for clinical visits when which she's making often anyway but that's like I say it because it's not a common practice and it's in this small little group showing that it's not a common practice still I seem to be thinking maybe a little bit either either I'm ahead or I'm not or I'm off course and that's what I'm trying to figure out I'm ahead of the curve or I'm off course because there's not a lot of people doing this and this is this group's confirming that and that's okay that's kind of feel like the Wild West sometimes it certainly does in pediatrics where you know it's always good to kind of test the waters and say hey does anybody think this is a really bad idea but then other than that you know sometimes you have to try stuff and see what happens and Abilene Texas does have a Wild West Museum with all the vintage riflery that you can never find so I live in a part of the country where I can really own that statement there you go family medicine occasionally get pediatric patients who are co-managed with pediatric bridges hmm internal medicine colleagues say that their malpractice coverage does not cover them well I don't know if that's true I think that it's probably a question for the insurer you know what's the scope of practice I am a pediatrician and I see lots of adult patients so I'll say at least going the other direction this seems to be okay and the hospice and palliative medicine boards are for all ages so I am board certified to see patients of all ages in that capacity but I think that is a question that should be clarified my sense is that that's probably just an excuse because they don't want to see kids and not that that's actually a restriction of their licensure or malpractice coverage I agree I carry my own hospice and palliative malpractice insurance for the things that I do in a community and it's it's fine so they would have to carry their own it's not typically a part of whatever hospital system or whatever job they have and so it they probably don't want the additional cost yeah I think we did when I when I came on here at care dimensions we did have an intentional process of training all of our staff so that they could cross-cover me when I wasn't I take call during the week but not on the weekend or if I'm on vacation so there was time where people who weren't pediatricians were going to have to cover my patients and we did some training so that people could feel like they had enough competency and we have some processes in place so they know about the patients and kind of know how to answer but our understanding as an organization is that your competency as a hospice physician covers the full age spectrum including zero and 106 and everything in between there's that's a hundred and thirteen years in Massachusetts I just saw we had a birthday party for her at one of the hospitals yesterday can you believe that 113 she's not on hospice she looked great you to add to the coverage you mentioned if I may add our medical license you know is for being a generalist so I just wanted to add that yes it's unrestricted medical license but I do think the malpractice is malpractice insurance is um I have come to learn very situational and it's always good to ask lots of questions about what's covered what kinds of things are covered what locations are covered so that you you know that before you have problems definitely don't want to mess around with that but I think that I mean then it's a problem to be solved right it's like you have five positions in your organization and you want to have a pediatrics program in which all five of you are gonna have to cover the pediatrics patients and then somebody says I don't think my coverage includes that the answer is like well how can we fix that problem not like oh well can't see kids so I think you know it I don't want to say there's nothing to it but it's a resolvable problem I believe it really does come back to the mission this is not an easy thing to do I know that it's not an easy thing to do for all the reasons that we've discussed policy emotion financial all of these things but if the intention is there and people say we we really do believe we need to be taking care of children because it's on mission to provide high quality care for patients end-of-life care for patients across the age spectrum then you figure it out right and you kind of like cross the barriers as they come and learn from people who know what they're doing or at least a step ahead of you I'm not sure I want to claim I know what I'm doing but I'm a few steps ahead at least and and then we you know and then I think those networks where we can kind of learn from each other are really important to me too I'm trying to sort of right now I'm at the agitating phase where I'm just trying to get people motivated that this is a problem in the big children's hospitals have to kind of buy into right because they have power so they don't really think there's any problem with the community we're we're kind of missing some of the advocacy so I'm agitating a little bit to like nope you can't send your patient home because they asked me to go out of service area and cover that patient and I said no because actually I need to let that fall through the hole so that they can see that they have a they have a problem because their patient can't go home because there's no agency that serves them if I kind of like you know stick my arms out and cover all the gaps then nobody knows there's gaps and we never actually solve the problems my boss is here so she's happy that I'm putting boundaries up by the way I'm putting I'm putting on my best boundary show we are lucky to have Emma Jones obviously in our organization and I will say I wanted to add one thing about kind of Tommy I was feeling for you being the only person there Emma does set boundaries when she's on vacation we don't do admissions for hospice when she's on vacation if I'm on call and she's given me clear sign out of the primary physicians and teams at the hospital usually who we instruct you know our nurses know to call them directly or I can call them directly so we do have a really close partnership to with our network of community physicians so that it doesn't have to be all Emma all the time no I'm protected too we're good but thank you for that thank you for thank you for saying that I think that to the boundary setting it is really an important piece of engaging in PD like taking on pediatrics as a service line being able to say that we can do this much we can't do all the things is actually really important so like no we can't admit people in the middle of the night like but we do take really good care of children that meet the criteria that we feel like we can meet that would still be a huge stride forward from where we are now well I know we're coming to the end of time I don't know if anybody has any other questions or comments or Gina if there's anything else you want to say to wrap us up I know we are in about three minutes left so if anyone does have it does anyone have a question that they would like quickly answered if not we can end today's chat I'm just seeing some thank yous dr. Jones so I think it's safe to say we know in today's chat and thank you so much dr. Jones for facilitating today and finding us such great information and thank you everyone for attending we'll have our next coffee chat in July and can't wait to see you there that's the last words reach out to me by email I think my emails in the somewhere it's just e Jones at care dimensions we'll make sure that everybody has it I'm very happy to partner with anybody who's trying to increase their pediatrics at their organization or or just want to commiserate happy to work together I just put your email in the chat so now everyone questions thanks everyone see you next time thanks for coming

pediatric hospice care

palliative care

relationships in pediatric referrals

medication management for pediatric patients

nurse practitioners in hospice care

clear boundaries in healthcare

communication in healthcare teams

end-of-life care for pediatric patients

malpractice insurance for pediatric care providers

collaboration in expanding pediatric services