Welcome, everyone. Thank you so much for joining us today. We're going to go ahead and get started. I have a few HMDCB updates to share before we start today's session. So my name is Gina Prici, and I currently serve as the Executive Director for HMDCB. And before we start, I'll just share a few HMDCB updates with everyone. I first want to thank our webinar sponsor, Gentiva Hospice. Gentiva has been partnering with HMDCB for several years to help us provide these webinars for free for our certificates. So we thank Gentiva for their continued support. And if you're interested in learning more about them, you can visit their website at gentivahsp.com. We have several upcoming HMDCB community events. Our next webinar will take place on April 17th and focus on hospice pediatric care. We will co-host this session with AHPM, so CME will be provided. We'll also partner with Weatherby Resources to host the Hospice Physician Compliance Conference on April 18th, and that will be an all-day virtual event. And if you are a current certificate, you can email info at hmdcb.org to receive a 10% discount code. And then on May 7th, we'll host a free certificate coffee chat at 11 a.m. Central. And if your certification does expire this year, just a friendly reminder to make sure that you renew by October 31st. I want to take a moment and welcome all of our current HPM fellows. We're really excited to have you all here today, and this is the first session of a four-part educational series that HMDCB is hosting and inviting HPM fellows to as a way to provide you with access to free hospice education outside of fellowship. So our next session will take place on May 29th, and we'll focus on preparing and improving your career in hospice. So we encourage you to check out all of those sessions, and you can register for all of them right now, including the July session. Even though it takes place after fellowship, registration is now open, so you can register now and then still attend the session in July. And if you are interested in becoming HMDCB certified, our initial application is currently open, so you can visit hmdcb.org slash exam to learn more about the eligibility requirements and to apply online. And HMDCB certification is available and beneficial for all hospice physician, including those who are HPM board certified and fellowship trained. And if you are a current fellow, you can apply now and then take the exam after you complete your program. And finally, but certainly not least, I want to welcome our faculty for today, Dr. Ira Bayak. As many of you know, Dr. Bayak is a pillar in the hospice community, and we are honored that he is here with us today. And I want to read his bio just to give you some background and share some of the work that he has done, and then we'll start today's session. So Dr. Ira Bayak is a palliative care physician, author, and public advocate for improving care for people living with serious medical conditions. He has been involved in hospice and palliative care since 1978. His research has contributed to conceptual frameworks for the lived experience of illness, measures for subjective quality of life, and counseling methods for life completion and wellbeing. He is also a past president of the American Academy of Hospice and Palliative Medicine. From 1996 to 2006, Dr. Bayak directed a national grant project of the Robert Wood Johnson Foundation that developed prototypes for concurrent palliative care within mainstream healthcare. From 2003 to 2013, he led the palliative care program for the Dartmouth Health System, and he has spearheaded health service delivery models for concurrent life-extending and palliative care in acute inpatient, outpatient specialty clinics, academic, and community-based primary care, long-term, and chronic care settings. In 2014, Dr. Bayak founded the Institute for Human Caring, a component of Providence Health System. The Institute drives transformation in clinical systems and culture to make caring for whole persons the new normal. Dr. Bayak is an emeritus professor of medicine and community and family medicine at Dartmouth's Gazelle School of Medicine. He has authored numerous articles in academic journals and opinion essays in national newspapers. His books include Dying Well, The Four Things That Matter Most, and The Best Care Possible. Dr. Bayak, thank you so much for joining us today. We really appreciate you being here, and I'll now hand it over to you to start the session. Thank you. Thank you, Gina, very, very much. It is truly a pleasure to be with you. I've been looking forward to this for a long time. Thanks to HMDCB for asking me to do this, and for all of you for attending. I'm looking forward to this presentation. I'm particularly looking forward to a dialogue with you all. I've put together a slide deck, or we're making the slide deck or the PDF of it available to you, so that I can go pretty swiftly through the content. The article, the PDF of the article entitled Core Roles and Responsibilities of Physicians in Hospice Care is also available to you if you don't have it already. All of that to support a brief, relatively brief presentation didactically, and save time for dialogue. When we get into dialogue, I'm going to ask you to please consider putting your cameras on, so that it feels as much as we can in this Zoom world, like we're actually together. Let me see if I can share my slides successfully. Are people seeing my slides? Not? Good. If that ever stops, I don't have the chat room open, but if technically we have problems, start waving at me or something, so that I don't make a fool of myself. Okay, so I want to get into this through the article and discuss the rationale of why we wrote this article and published it, and what it's intended to do, and how to make best use of it and the like, but I sort of have to start with that framework. As Gina said in that overly long, I think, introduction that I gave her, or bio that I gave her, I am really literally an OG in this field, and have got involved in the late 1970s. I'm aware of and have met most of the actual founders of the field, and I'm aware of our roots, so I want to just briefly ground us in kind of where we came from, our initial roots and purpose of the field. This book, Dying, by John Hinton, who was a physician and sociologist, was published by reporting his studies of how Britons were living and dying in the aftermath of World War II, and he described these assisted living or nursing facilities at the time as human warehouses, where people were maintained and existed rather than lived, and the quote that is often quoted and stands out for me is this one, we emerge deserving of little credit. We who are capable of ignoring the conditions which make muted people suffer. The dissatisfied dead cannot noise abroad the negligence they have experienced. It was in that context then that Kubler-Ross also, who was a Viennese, excuse me, a Swedish psychiatrist who came to this country and trained at the University of Colorado, further and taught there, and in Chicago, and she wrote this book on death and dying, which was groundbreaking for a number of reasons. It impacted the healthcare professions, but it was actually written for the general public, and it reported her experiences caring for people who were dying, who were being at that time, again in the 60s, early 70s, being kind of neglected, not out of ill intention, but just because for some reason it was kind of culturally uncomfortable within the environment of hospitals and the mainstream healthcare system to acknowledge dying people, and they were kind of put down the hall, ostensibly for their privacy, but in actuality also because it was awkward for the treating teams to see them. That's partly why this became nursing focused, that nurses didn't neglect these people, and even though they may have gotten less attention within that medical culture, the nurses attended to their needs and to their inherent dignity. At the same time, or relatively the same time, this book won the Pulitzer Prize, Ernest Becker's The Denial of Death, where he talked about and looked at evidence of death denial as being pervasive within western cultures, and the source, the root source of a lot of anxiety and depression and mental distress, particularly as people move toward the end of life, but actually within the culture at all stages of life. Dame Cicely, who is acknowledged to be the founder of hospice care in the modern world, and somebody who I'm proud to say that I knew and called a friend, famously said in the Oxford textbook, approaches to death and dying reveal much about the attitude of society as a whole to the individuals who compose it. She also talked about total pain and the importance of excellence of clinical care and symptom management and the importance of research, but notice I pulled out this quote because she also was aware of the impact of the larger society and culture. One of the earliest historians of hospice care in America, Sandal Stoddard, wrote a book about hospice care in America. I think that's what it was called, but she also wrote in the Journal of Palliative Care back in 1989, descriptors of hospice, that it conveyed a place or a type of care where people were cherished and refreshed, a place of welcome, special care and honor, a loving environment. She was particularly talking about the facility-based hospices like St. Christopher's and others in Britain. She said, hospice is not mere technique. It is a gift and an offering of the best that we have in our minds and in our hearts, an intimate transaction between human beings and community. I might say an intimate relationship, frankly, between human beings and community. While hospice was rooted in nursing and nurses were the driving profession for the evolution of hospice care, who taught many of us, many of my own mentors were nurses, physicians were intentionally part of the hospice model. In fact, when I was introduced to hospice, I recognized that the development of hospice programs was importantly one way that we could ensure that dying people, who kind of by definition are the sickest patients in our healthcare system, have access to physicians who are knowledgeable and skilled in caring for them. While again, nurses were predominant, hospice physicians had an irreducible role in providing excellent care, in diagnosing and treating people's symptoms, and supporting nurses in the work that they did at the bedside and in what has increasingly become independent nursing practice. We work today, we're meeting today in a difficult time and environment of healthcare. I want to acknowledge that before launching into the substance of this paper. American healthcare is complex. This is my own summary slide drawn from a lot of things. American healthcare is complex, confusing, and exceedingly expensive. American healthcare has world-class evidence-based treatments and technical expertise. In fact, people come from all over the world. If they have the money or are fortunate enough to come and have sophisticated treatments, surgeries and non-surgical treatments in American healthcare systems, particularly our academic healthcare systems, but access to primary and specialty care within the country can be difficult and is inequitable. The quality of services, patient experience and outcomes are highly variable. Profit motives are everywhere and exert pernicious influences on both access to services and quality of care. If you haven't read Don Berwick's article in JAMA, Salve Lucrum, I heartily recommend it to you. Salve Lucrum, published in January of 24, I believe. It may even have been of 23, where he talks about greed as being an organizing principle of American healthcare, not by intention, but by description. Medical practice often conflates disease treatments with medical practice and care. Medical practice is often so focused on disease treatments that we forget the larger frame of human care. Care of chronically ill patients is an area of high costs and low quality. It's with that and the notion that in hospice care, care has become highly variable. Thankfully, there are plenty of good hospice programs. It should be mentioned that there's a sampling bias that people, if you're working for a program and you're here today, you likely work for one of the better programs in the country. I'm so aware, for instance, just in the Denver meeting many of us were at of the Academy of Hospice and Valley of Medicine, that it was populated by clinicians from leading programs speaking to and teaching other clinicians from leading programs. That sampling bias creates sometimes an unwarranted confidence that the field is doing well, that our field is perhaps more healthy than it is. We're aware if you look at the data and you look at some of the exposés that have happened within the New Yorker and ProPublica and John Oliver's scathing piece, as well as the OIG, the Department of Health and Human Services Office of the Inspector General's reports. I'll mention the California State Auditor's Report of March 2022. All of that that's been discussed by myself and others realize that there is highly variation within the quality of hospice care as experienced by patients and families, and frankly, the programmatic structures and processes of care, of hospice care across the United States. We came together, 325 physicians came together to publish this document of core roles and responsibilities. It's a statement that is done independent of any of the associations that many of us belong to, and we stipulate within the article that we are signing this and endorsing it as individuals, not as representatives of our employers or our professional associations. There is nothing particularly novel in this. As the key drafter and first author of this piece, I want to tell you that I drew everything in it, basically, or darn near everything in it from these two documents. The hospice medical director manual of the Academy and Perry Fine et al.'s The Hospice Companion, and supplemented by a few things. There's a bibliography here of the references cited, but these were the two main resources. It starts, as we write, as individuals who are concerned about the troubling variability and access to and quality of hospice care. The statement arises from the need to protect the safety and well-being of vulnerable, seriously ill people with their families from low-quality care. The statement is primarily intended as a resource for hospice physicians in negotiating employment agreements, justifying staffing and their budgets and programmatic resources necessary to perform the hospice physician's job well. But this statement is also a resource and reference for patient advocacy groups, hospice industry leaders, health service oversight organizations like CHAP and the Joint Commission and the like, accountability agencies and legislatures in their efforts to ensure safety, quality, reliability of hospice care in the United States. We are moved to write first and foremost to protect the safety and well-being of families who are at risk of receiving substandard, low-quality or unsafe hospice care. We are also motivated to issue this statement out of concern for physician colleagues who may be asked to participate in hospice programs that are staffed, structured, and operated in ways that put patients and families at risk of poor care and concomitantly expose physicians to violations of clinical and ethical standards. Let me pause here. I hope there are people on on this call who are curious about this. I happen to know that physicians who are well-intended, who have been drawn into service in their very small non-profit local hospice program because how do you turn down a request from the local hospice program to work with them or support them? Some retired or partially retired physicians who have been general internists or primary care docs or even surgeons rise to this challenge and accept that responsibility. They don't realize some of them inadvertently find themselves in situations of hospice programs that may be well-intended but are not sufficiently staffed or managed or resourced to take care of complex, seriously ill patients and their families. And then there are profit-motivated hospices and well-documented proliferation of those in Southern California and areas of Arizona, Texas, New Mexico that exist and are almost hospices in name only. They are so poorly staffed, managed, prepared, resourced. But they have physicians who may inadvertently or by intention lend their services to these programs. And those of you who are fellows and are going to be out looking for jobs, either full-time or part-time jobs, need to know that in the operating environment of American health care today, when you become a hospice physician, whether you're the medical director or not, you become responsible statutorily, frankly, but also ethically, for the quality of care that that program delivers. And that there may be structural or even contractual limitations that you inadvertently agree to or are imposed on you that limit your and the program's ability to provide the best care to patients and families. So in this statement, we explicitly delineate basic expectations and requirements of hospice physician practice. It is intended to serve as a resource, again, in negotiating contracts and deciding whether and which programs to work for and as a resource to providing consistently high-quality care. So you all have this both in the PDF we're giving you and in the article you've been given, but these are just the text boxes, summaries within the article of the basic roles and responsibilities broken down into patient care responsibilities and then administrative responsibilities, as well as team development and oversight responsibilities. So I don't feel I need to read these, but it's the work of reviewing, becoming knowledgeable about the patients who were admitted, participating in the IDT, doing a med-rec review, and looking for inadvertent drug-drug interactions or potentially adverse side effects. Being able to and being willing, available to make home visits or facility visits to patients, direct patient care when needed, both for the evaluation and ongoing clinical care, ensuring patient safety. I could talk for hours about the importance of explicit crisis prevention and early crisis management, symptom urgencies in the home and the like, being available in time-sensitive situations, and then being the liaison with the communities with the patients, attending physician or private physician, but also the community, medical community in general, and as not only a communicator with them, but also a teacher and ambassador to that community. Administratively, we all know physicians are the ones who certify medical eligibility for hospice care and confirm that eligibility at intervals. They provide medical expertise in this team-based or environment of health care, which we support so deeply, and just to shout out to the design of the interdisciplinary team, which is truly more than the sum of its parts. It's where magic happens. Care planning, that interdisciplinary team care planning, I've so often witnessed as being where the magic happens in solving difficult situations and supporting people in the best way. Physicians need to participate in quality monitoring and quality improvement, and when I say that, just to call out, they need to have that in their contracts or their employment agreement so that they're paid to do it. They have the time to do it because it's part of our role. Things like the completion of death certificates and responses to oversight concerns when a query comes in from a billing agency or accountability agency. Also, this field has recognized through some of the resources that I've quoted and the books I've shown you that there's a role for hospice physicians in ongoing team development and oversight. We practice collaboratively as a team, and while in no way diminishing the work of and importance of advanced practice providers, the highest functioning teams I know of have advanced practice providers being actively supported and being part of a medical practice with hospice physicians. Hospice physicians need to know that there are certain things that the program needs to provide in order to do our jobs well. We need to have within the formal scope of responsibilities, contractually or in employment agreements, the ability to review patient records and have a discussion with the case manager or admitting team prior to certification, to make visits for evaluation as needed and follow-up as clinically necessary, to have patient visits for continuous home care or GIP care, and sufficient time to fully participate in IDT. I think in the article we handed out or you have available to you on the resource page that's associated with this webinar, I published an article in STAT called Hospice Needs Saving, and I quote in their real case, of course, of a hospice nurse who wrote me in distress saying that her hospice team physician only attended about 50% of the IDT meetings and yet and wasn't available so often and and yet he was prescribing morphine and fentanyl and things based on her evaluation solely and she didn't want that sole responsibility. She wanted to practice as a real team and have that real support. It's not uncommon. The time to accomplish the administrative responsibilities we went over just a moment ago, the quality and QI team participation, participating in ongoing CEU, CME, and team building like we're doing today, and provisions for their own continuing education and certification like HMDCB certification. This is maybe the most important text box. When hospice physicians should be concerned. When in the course of your practice you realize that you're actually responsible for more than 75 or 100 patients at any given time. These are seriously ill patients, some of the most complex patients in our health care system. It takes time. I'm pretty good at this stuff and when I was a hospice medical director for many years and I found that a bit over 50 average daily census and I was, you know, aware that I was being stretched. Physicians being responsible for 200 or 300 patients on any given day is no no longer uncommon and I think it should make all of us uncomfortable. Physicians hired and contracted primarily to, you know, certify and recertify. We should be worried when our, because this is an interdisciplinary team model of care, when nurse managers that we work with commonly are carrying caseloads of 14, over 14 patients. I think there's a general sense among senior longtime leaders in in hospice nursing that about 14 is as high as you really want to go for quality. Yes, you can make adjustments when there's no drive time and a nurse is seeing only patients in a given building, assisted living or whatever. You know, there are there are some wiggle room here but when a nurse is seeing 18 or 20 or more patients carrying that caseload, that nurse is not having an easy time, is likely stressed out him or herself, is likely charting well into the night and the like. This is not wholesome and I just would also say in so many programs I'm aware of these days, not only are the physicians over strict and there's simply not enough physicians and advanced practice providers, but there are not enough nurses and the nursing caseload is too high. You know, in a times of sudden illness or pregnancy and somebody's gone, yeah, paternity leave and the like and and everybody has to flex up and carry higher caseloads for a while, in a high-functioning team that's okay, you can get there's enough plasticity but when there's a baseline of under staffing and all the disciplines then there's no plasticity and things are likely to, crises are likely to happen or patient care crises are likely to be poorly met in those circumstances. I tell physicians, you know, I ask physicians who asked me for their, for my counsel, whether they're in a good hospice program or what do I think about their their job situation, you know, how much do you know about what happens after hours? A number of our colleagues now are told when they're hired that they don't have to worry about after hours call, they don't have to take call, the nurses have it managed, or there's some other system and some of my colleagues don't really have clarity even about what happens when calls come in in the wee hours of the morning or on a Sunday and and it's a symptom crisis. But as physicians we are responsible and if you're not involved you ought to know who, how these calls are managed and have a sense of confidence that they're managed well. We should worry when our hospice program does not provide access to continuous home care or general inpatient care. That's a red flag that this program has problems. These two high-level kind of intensive hospice levels of care are, first of all, they're conditions of participation in Medicare. They're not optional. They can be satisfied in various contractual arrangements with other programs, but if you're having to discharge patients or admit them to an acute care hospital to get their needs met in a symptom crisis, think somebody in crescendo pain, somebody in agitated delirium, somebody who's seizing. This is a reason to worry. The hospice programs are supposed to be able to manage these sorts of symptoms through continuous home care or general inpatient care. And then hospices that don't provide bereavement services. Okay, I'll close here in a moment. I didn't make up this 3S syndrome and it comes by a few different interpretations, but it's a cruel irony that, from my perspective as someone who was participating in hospice in America pretty near the beginning, that when I know that part of the rationale and purpose of developing hospice as a discipline was direct physician involvement, to now realize that in quite a few programs physicians are expected to show up, sit down, and sign, and otherwise not be particularly involved. And that in some places it's not rare that physicians are told it is not part of their job description to directly see patients, even patients in distress. A cruel irony that in the current American health care environment and hospice care environment, the hospice programs themselves may be the barriers to dying patients having access to physicians. This is in your handout and I don't know that we need to go over it, but I've started handing this out when I give talks to the public or do podcasts that are heard by the general public. I think patients and families ought to ask basic questions. Who owns the hospice program? Not that for-profits are always bad, but they are associated with lower staffing and higher caseloads and the like. Less physicians in general as a group. Ask how many patients our hospice nurse is concurrently caring for. Will a physician visit us at home? Who will see us if the hospice nurse is away or not available? Who do we call for urgent questions and problems? What happens if the medicines were given at home aren't working? Somebody's breaking through their pain or having seizures or puking or delirious. What happens? What is our crisis management plan? Is there a general inpatient facility? What is hospital levels of care available without being discharged from the hospice program? Will we receive bereavement support? That is my didactic presentation. Again, you're going to have all of this. I'm going to open a chat box and I would ask everybody to put on their cameras and let's have a dialogue. Thank you for attending. Gina, do you want to help manage this or you want me to? Yes, we have a question from and feel free if I read your question to join and Alan, I do see your hand. Let me just ask Dr. Sanders question. How do you suggest we approach and support our agencies when it comes to difficulty in role areas to go full time chaplains and even RNs? Nice try, Christy. I don't have solutions for any of this but I do think that there is a kind of dialectic of setting clear standards and promulgating those and then at times of budget development and fund development goals that these standards inform that planning and budget development. If we don't have this, we publish this statement as a resource to you to look at and bring to the leadership and the boards of directors and whatever so that the hospices know that they have full staffing and are delivering high-quality care. Dr. Sanders, I see your hand is up. Yeah, I think that the issue for us is not so much the budgeting but just trying to find workers. That's the issue right now for a lot of us and I almost feel like we either have to go to telehealth spiritual care or sharing with other small rural agencies. Yeah, I understand. I think whenever one does quality improvement and programmatic quality improvement, knowing that there's a gap is really helpful. You'd rather not have a gap, but at least naming the gap helps drive investment in problem solving. That's the most positive thing I can say there. This is hard. Alan, and then Dr. Jones, your question. Hi. Just wanted to also say for the person mentioning about spiritual care, Betty Farrell, Christina Pukowski, and myself are on the National Advisory Board for the Chaplaincy Innovation Lab out of Brandeis. And there are a lot of resources on chaplaincy. And one of the things that may be helpful is perhaps meeting with the spiritual leaders in a community. I can't recall the title of the article offhand, but 84% of spiritual leaders across religions were surveyed and felt uncomfortable and unprepared to deal with end of life spiritual support. And so this is another outreach opportunity with hospices across the interdisciplinary spectrum, just like there may be nursing, student rotations, other things that, again, may enrich your opportunities. Last thing I'll say on staffing, and this depends, again, on your population and even in rural areas, HMDCB could be a recruiting tool. And what I mean by that, there were communities that if we committed as an organization when I was CMO or that agency's hospice medical director, they could become certified after having a certain number of patients, having enough education. So one of the ways to help ease that transition into hospice, especially people later in their career, is if through that mentoring. I'll leave it at that. Thanks, Alan. And we have a question. And Dr. Kildore and Dr. Miller, I see your hands up as well. And I'll ask Dr. Griggi's question, and then we can address yours. So Dr. Griggi, she's a California lover, she's one of our California physicians. She's wonderful. Well-owned to me. As an OG in the field, where did we go wrong? What can we do to improve the pipeline of peer hospice physicians? Of peer hospice physicians, did you say? Well, I think because most people, if I could clarify, and I'm so glad to hear from you, I'm in California. And so there aren't enough people. There's not enough workforce even outside of the state. So I'm just curious, since you've seen everything from the beginning first, where did we go wrong in the field since you witnessed it happen? And then what can we do where there are actual physicians who will pick up the phone, respond to the nurses, and they're actually devoted to this and not just doing it as a side gig? OK, I'm not going to make this a soapbox rant. But I think we went wrong early on when we didn't promulgate clear programmatic standards and expectations and back them up with public-facing measures against those expectations or standards so that everybody could see where there was a gap, where there wasn't sufficient physicians and the like. I think I'm not, you know, I don't feel badly for the people who made those decisions. But I think the promulgation of board certification has not been open enough. There ought to be far more paths, alternative paths to certification for physicians in practice. I think that this organization, HMDC-B, is a critical solution to that very problem that you mentioned. And in one of the slides, I think what hospice physicians need from the program to do their job well, we explicitly said that the job should support ongoing continuous education toward either specialty certification or hospice medical director board certification. That needs to become an expectation within the business community of hospice care. And again, this paper is there to support all of us saying, look, this is what the field thinks is essential. This is what the field thinks a contract, a physician's contract with the hospice program should look like. I want to just make a pitch for this paper being part of hospice palliative medicine fellowship training curriculum, so that we're teaching how to ensure that as an independent contractor or as an employee, you're fostering best practices. But we went wrong a long time ago and have been kind of inadvertently mostly supporting the industry in doing what it will. I would just say we're not, all of this is not self-serving, by the way, as hospice physicians. Because at the end of the day, we don't serve ourselves. We serve the most seriously ill patients and families in our communities. And so advocating for scope of practice, the scope of work within a contract, and adequate compensation to have the time to do that is how we foster population health in this realm, frankly. That was a little bit of a rant, wasn't it? Sorry. You're in a safe space. Rant on. Thanks, Dr. G. Thanks, Ira. And Dr. Kaldor, I see your hand is up. Do you have a question you'd like to ask? You're muted. OK, did I unmute? Yes, we can hear you now. OK, great. Thank you. Very much appreciate the information here. In terms of the physician caseload, and I see the 75 to 100 patients kind of as a cutoff to start thinking about too much census. Our hospice, we try to do and do a lot of home visits as possible. In terms of forming a balance, at one point we wanted to really try to reach out. And obviously, a number of the folks who come out of service pass within a short period of time. And those folks are hard to see up front. But in terms of a reasonable balance, in terms of staffing the hospice with physicians and nurse practitioners, when you think about doing home visits for symptom management, or especially, we were trying to start a program where we do what we call welcome visits, try to see people within the first week and a half or so of coming on. Anyone else out there with experience in doing this in terms of what's a reasonable staffing ratio? We do have support from a nurse practitioner here as well. But between the mandatory face-to-face visits, what is the reasonable expectation in terms of balance for an FTE in seeing these patient symptom visits when you have a certain caseload already? Can I start? And then I don't want to dominate that. I want others to answer that. But I think it's going to be highly variable. And there's a number of different staffing models that might support high-quality care and high-quality physician practice. Some programs may have one physician and three advanced practice providers, but they're in a genuine collaborative practice. They meet frequently. They take call. They share call sequentially. They are constantly in dialogue and collaborative interaction. And in that way, you can diminish the need for physicians as a discipline within a medical practice that discharges the physician responsibility. So I think it varies. I know of some current hospice programs, good ones, by the way, very good ones, that are frankly based in a medical practice of physicians with very few nurse practitioners. That's actually unusual these days. But they still exist. So it's going to vary, I think. I'm going to stop talking. Others, please respond to Dr. Caldor's. As I said before, I found it hard after 50. Sorry, I just found it when I was a hospice medical director and there was no advanced practice nurses at that time weren't as active in the field. I thought for me, after 50, I felt like I wanted a little help. I think this is where we actually do need to strategize in the business of hospice and sit down and create a pro forma and get very strategic about what we feel. What is our time and death certificate on average based off of our admissions and deaths per month? Because that is going to vary on how many death certificates you do. If your median length of stay is 10, your death certificate time and initial certification time is huge versus someone whose average length of stay is 90 days like other aspects of the country. Look at exactly what your goals are, how much time you'd spend in IDG, how much time you actually spend in nursing phone calls and be a business for yourself and see what time you have left over and then go from there. I think that hospice as a business is such a bad rap, but we have to be business people in order to be successful and require what we, what I was speaking to, which is the appropriate requirements. Give ourselves administrative time, give ourselves phone call time, give ourselves prescription signing time, death certificate time, and then see what you have left over. Then you're going to have to strategize on time it takes to get to the visit. If you're a rural provider or urban provider who it still takes just as much time, I think that's where the business of hospice has to rise up that we set ourselves up for success. Thanks. That's a good segue because our webinar next month, is it next month or in May? But we are going to talk about the business that we are the business as a hospice physician. Right Gina? And to that point, what I wanted to point out also is, I think when you asked, how did we get here? Like so much of it is what the hospices are willing to pay for. They are willing to pay for nurses, but they don't want to pay for a physician's time. And so they say, oh, it'll only take you a few minutes, only an hour every two weeks. And they pay for that. That's what their expectation is to pay because they're asking physicians only to sign. But I think as physicians, we're the ones who need to push back and say, no, if I'm going to be providing care for your patients, then I need to do it the right way. And I think using this article, Dr. Bayek, that you've written and other resources that are out there and also using HMDCB resources, we can go back and say, look, this is what we need to do to provide adequate and good quality hospice care. This is where our time is going to go. And if this is what you want, then that's what I'm going to provide. And that's how you compensate me. And either hospices will go along with that or they won't. The other thing is I've also been, I've practiced in Atlanta area and I've been involved as a hospice medical director. I've been involved as a program director for hospice fellowship programs. I've taught residents, I've taught nurse practitioners. And one of the things when it comes to HMDCB, even though I've taught hospice fellows, practices hospice and palliative care physicians, not everybody has access to that. Not everybody has the ability to take a year out of their schedule to train and get the actual fellowship. But there's so many more hospice positions needed out there. So many more hospices that require physician involvement. And so our residents that were out graduating in internal medicine and going out to private practice or residents who are in family practice who are going to go out and practice out there, we actually, one of the things I would talk to them about is the HMDCB certification and say, get the hours that you need to work with the hospice, but go ahead and get certified and use that, the resources to actually negotiate with the hospice to say, this is what I'm told I need to be doing to be a good doctor. So I think teaching the new generation and making sure that they follow along with a model that requires more physician input and more physician involvement and engagement and expectation, setting that sort of expectation, I think is what's going to take to make that sea change happen for the future of hospice and palliative medicine. Thank you. Thank you for that. Yeah, that's a great discussion. Thanks everyone. And Dr. Miller, I know you've been waiting patiently. Well, maybe this is helpful. And that is number one, will this recording be available so that I can share it with my administration? And also I have a 25 plus year pain doc who is an anesthesiologist to start with, who has now become my partner, who's been working about 15 months. He's got another nine months to go before he can sit for the exam, but very interested in doing this, lots of experience. I'm a 40 plus year family practice, family physician, and I, just a second. A busy clinician. Yeah, yeah, and that's a hospice question that I'll call him here in a second. But for me, this has been an ideal practice in semi-retirement, but, and they seem to listen to me, but I really want to be able to build what we're doing here. Right now we're doing everything I feel in the right way. When I read the article, I passed it on to administration and nursing and said, this is why we do things the way we do them. But this recording, I think is very good. And I guess I would ask, can we share it? Because I think that it shows your concerns, it shows my concerns and it shows the way things should be done. And so I would say, can we do that? And then I put in the chat about the telehealth. As I understand, it's been extended. I found that out today to September 30th. Hopefully it'll go permanently, but it has been extended to September 30th. So I think that probably is beneficial to all of us. I know we're coming down to the end. Any final comments before we close? Our recordings are casual. I don't know if this should be public, but I'm sure there are some podcasts that Dr. Bajek have been on to pass along and I'll put it in the chat. You certainly can, you certainly can share the PDF of the article, Core Roles and Responsibilities that we handed out. You're welcome to share the stat article that are in the resource page that I published a year or more ago. And as we close, I just wanna say thank you again. I really do think HMDCB is critically important in helping us maintain the safety and quality of hospice care in America. And I hope this article can help you in again, your employment agreements, in program development and budget planning and all of that. So let me lastly say thank you all for the work that you do day in and day out. And it's a privilege to be with you.

Hospice Medical Director Certification Board

Gina Prici

Gentiva Hospice

pediatric care

Ira Bayak

hospice staffing

patient care standards

hospice physician training

hospice care advocacy