Good morning, everyone will be getting started in just a moment or two so folks get in. We can make sure to remain on mute that would be helpful for us as we record the session for folks who will be watching later thanks so much, and we'll get started in just a moment or two. Okay, well, at the risk of starting here as close to on time as possible, we're going to go ahead and do that. I'm Bruce Hammond. I serve as the executive director for HMDCB, and I wanted to take a moment to welcome you all to today's part one dementia prognostication webinar, which is the first of our series in 2023. So we appreciate you being with us, appreciate you sharing your time with us. I will be turning it over to our presenters in just a moment, but I do have a couple of announcements and reminders to share. So before turning it over to them, I wanted to share a thank you to our webinar sponsor for this season of webinars, Gentiva has generously sponsored the webinar series for the third year in a row. We appreciate their commitment to HMDCB and their commitment to providing education and opportunities for you all to get this education from your fellow certificates. So thanks to Gentiva for your generous sponsorship once again. I also wanted to take a moment on the screen here in a second, you'll see the upcoming webinars and coffee chats that we have coming up in the next couple of months. Part two of this webinar, dementia care and management will take place May 16th at 10 AM central time. And our next coffee chat will take place in April on the 20th. I also did want to mention that on the next Weatherby Resources Hospice Physician Compliance Conference will take place on April 21st. I think those of you who have attended that in the past can understand it's significant, there's significant value in that and HMDCB certificates receive 10% off the registration fee for that event. So make sure you reach out to Gina at the email address on the screen to get that discount code. And lastly, our 2023 initial application window is open right now through June 1st. So for those of you who obviously you are certified, if you have folks who you know who aren't certified yet but should be, please make sure to encourage them to apply for HMDCB's exam for this year through June 1st. So we appreciate your efforts in helping spread the word and we hope to get lots more folks certified with the HMDCB credential this year. So with all of that being said, without further delay, I'd like to make sure to introduce and welcome our two presenters for today, Dr. Albert Riddle and Dr. Peter Fish. We appreciate you both being with us and I'm going to turn it over to the two of you to get us started. Thanks so much. Thank you so much for that introduction. And let me just pull up the slides for today. Just give me one second. Okay, let's see here. Actually, Gina, perhaps you could pull up, I'm having trouble accessing this here. No problem. Just let me know when you guys can just tell me next slide. All right. Yeah, that's wonderful. Okay, great. So thank you so much. If we can just go right to the next slide. Today, we're going to be talking about dementia prognostication and the barriers that are in place right now for hospice eligibility for patients with dementia. In going over the importance of this topic, the United States population is aging. We're all well aware of that. And the proportion of Medicare decedents accessing hospice care due to end stage dementia is growing. But dementia remains a difficult diagnosis to apply prognostication to. And these patients, while on hospice, are likely to have prolonged lengths of stay. And CMS is very interested in how hospice as an industry is handling this situation. So going to the next slide, we see the important words that stick out of this. Older population, significant impact on numbers of hospice enrollees, the dementia, the progression, prolonged periods of decline, CMS interest. So going to the next slide, then, one of the things that I want to point out before we start to get into discussions about federal policy and CMS engagement is for us as practitioners to take a step back and look at what I think has been difficulty in making the diagnosis of dementia. And one of the things that our hospice, Hudson Valley Hospice in New York takes pride in is our ability to reach out to the community, reach out to our practitioners and colleagues in the community and talk to them about palliative care and also hospice care. And as we do that for this particular situation, just to mention that there's a lot of Alzheimer's right in front of us. We may be missing the diagnosis in some cases. And in other cases, we may be making the diagnosis but not sharing that information with our patients. And our reasons for not sharing that information might be for a couple of reasons. One, we don't want to cause stress in the patients or their families in saying that this diagnosis applies to them at this time. And the other is that with the time that we have available to spend with these patients, we may not have the luxury of spending time with these patients to go over the conversations that really should take place when this diagnosis is made. And obviously, this can have an impact on our ability to start to have appropriate plans in place for these patients as their disease process progresses. And that might set some unrealistic expectations, not just on our patients, but also on us. So let's make a commitment to make the diagnosis when it's there, use the tools to help us make the diagnosis, which we'll discuss in a few moments, and to open ourselves up to have these important discussions with our patients. Going to the next slide, we understand in this umbrella of terms covered by senile degeneration of the brain that we are seeing a growing population of patients on hospice with dementia. This comes about not only from the patients that actually have dementia, but also from the growing number of individuals who are coming on to hospice with this diagnosis who previously might have come under for a diagnosis of debility and failure to thrive. But because these terms are no longer accepted, now we're seeing more and more of this senile degeneration of the brain coming up as the diagnosis. So in this presentation, we'll speak more about why senile degeneration of the brain is important for us to at least consider as a diagnosis rather than the umbrella term of dementia. But before we get to that point, going to the next slide, let's just go through the five points that we're going to discuss today. We're going to look at coding and documentation, tools for determining prognosis, the clinical course of dementia, criteria for admission to hospice, and we're going to start off with going over federal policy changes. So as we get into the next slide, we're going to start looking at the CMS implemented federal policy changes in 2014 that looked at reducing hospice length of stay, particularly for dementia patients. According to National Hospice and Palliative Care Organization, the average length of stay for hospice patients is about 76 days, with a median stay of 24 days. This is different when you look specifically at the dementia population, where the average length of stay for patients with a primary diagnosis of dementia is closer to 112 days. That's close to 50% longer than the remainder of the hospice population. Within that, when we think about those patients who are in stage dementia, those who are at stage 7, we know that this stage can typically last for as long as two and a half years. So already there's a disconnect in terms of what the length of stay for these patients might be. Let's move to the next slide, then, and look at a study that we're going to review that discusses the federal policy changes to the hospice benefit and the impact that it's had on patients with Alzheimer's disease and related dementia. The question that comes about here is, did hospice access by persons with Alzheimer's disease and related dementia change between 2008 and 2019, in conjunction with Medicare policy changes that aimed to reduce prolonged hospice stays? Next slide. The study design was that it was an observational cross-sectional study that looked at Medicare hospice claims data from Medicare hospice episodes of care beginning in July 2008, running through to December of 2019. These were Medicare beneficiaries who were at least 65 years in age at time of enrollment in the hospice, with data analysis conducted between September 2019 and June 2021. The main measures that were looked at were new patient enrollees, patient census, and care days provided. All of this in patients with the ADRD code. Next slide. So what were the potential policy impacts that we were looking at specifically in this study? Well, there were actually two of them. The first was the 2014 Improving Medicare Post-Acute Care Transformation or Impact Act that basically looked at a systematized audit that would target hospices that had a high proportion of long lengths of stay, that being defined as a length of stay of 180 days or greater. And what we were hoping to do was to tighten the hospice survey frequency for these hospices that triggered. The second policy change came about in 2016 with the implementation of the two-tier payment system where there was a reduced daily routine home care reimbursement for patients who were on hospice for more than 60 days. Next slide. The patients that were looked at over this period of time included 11,100,000 plus with the mean age at 82, 40% were male, 7% were black, 1% Hispanic, and 86% white. The percentage of new enrollees with an ARD, ADRD code dropped significantly during the months of impact passage, but there were no significant changes that were observed at the time of the two-tier payment implementation. Let's look at that in a little greater detail, and actually I'm going to skip over this slide that just looks at some of the indicators that were looked at and go to the first of the three hospice level outcomes that was constructed from the study. This looks at monthly percentage of new enrollees with ADRD, and as you can see from this slide, the percentage of new enrollees increased immediately following the time where frailty and debility were put on the exclusion list. And then continued to rise during the following months with the rate of increase slowing down slightly after seven months. The percentage of new enrollees then dropped significantly during the month of the impact act passage, followed by a rise in enrollees that was nonlinear. Finally, there was no clear change in the percentage of new enrollees with ADRD at the time of the two-tier payment system implementation. And by 2019, the percentage of new enrollees with ADRD returned to a level similar to that that was observed before the passage of the impact act. We go to the next slide, and this simply breaks down how this compared between the for-profit and not-for-profit hospices. The for-profit in the black line on top and the not-for-profit with the blue line on the bottom. And you can see a very similar curve for both categories of hospices with lower numbers seen overall in the not-for-profits. We go to the next slide, and this looks at the percentage of total patients census with ADRD. And we can see that, again, when the frailty, debility exclusion came into place, there was a rise in the subsequent months in patients with dementia. And then the percentage of the total patient census dropped during the months of the impact act passage, again, followed by a gradual rise. And again, we see similar patterns between the for-profits and the not-for-profits, again, with generally higher numbers in the for-profit. And finally, the next slide shows the care days with ADRD from 2008 to 2019, again, broken down by hospice ownership status. And with a summary that in each of these three outcome categories, it was seen that trends differed across for-profit and not-for-profit hospices in terms of total number, that the share of patients with Alzheimer's disease and related dementias were consistently higher in the profit versus the non-profit, with faster rates of increase. The next slide, please. And again, we see similar patterns in the for-profit hospices prior to the frailty and debility exclusion notice. And in the months after the exclusion notice, but before impact passage, all outcomes continued to increase for the for-profit hospices, but exhibited no overall change in the not-for-profit hospices. So this does give us an indicator that these federal policy changes do have meaning in terms of access for patients to hospice, in this case, for patients with dementia and related conditions. So at this point, I'm going to turn it over to Dr. Fish, who's going to start to talk about criteria for admissions to hospice with a case study. Thank you very much, Dr. Riddle. I work with Dr. Riddle as one of his medical directors at Hudson Valley Hospice. I'm going to let you know that my voice is not in top form right now, and if it fails, Al will jump in. Gina, could you skip back eight slides? I'd like to show the QR code. So for this study that Dr. Riddle was referring to, you might want to look at the details specifically, and we put up this QR code. If you take a quick picture of that with your phone, you will be taken directly to the URL for this study. And we can leave that up for 15 seconds. I'm about to present a case study, which is very typical of the patients that we see. We'll present it, and then we'll discuss very briefly the salient points and how we would take a patient like this, pick out the salient points, and document why they are eligible for hospice. Gina, we can go back eight slides. All right, there will be QR codes, two more QR codes in the course of this presentation, one of which at the end will take you back, will take you to the site at the Hospice Medical Directors Organization so you can see this entire presentation. So here's the case study. C.G. is an 87-year-old female living in the community with a history of Alzheimer's. She also has breast cancer. She had a double mastectomy a decade ago. She has hypertension, heart failure, degenerative joint disease, and hypothyroidism. So she's very typical of many of the patients that we all deal with. Her family reports that she was doing well until three years ago. And then she started having difficulty breathing. She's been hospitalized three times. And with each hospitalization, she's declining. She's getting more and more confused. And now she's at the point where she is an elopement risk. She tries to escape, and she's also delusional, thinking that the staff is trying to poison her. And to that end, she's also stopped eating because she's paranoid, and she's losing weight rapidly. Her physician feels that comfort measures are appropriate at this time. And after discussion with her family, they referred her to hospice. Now, how do we quantify this? Before we move on to the next slide, let's look at some of the important points here. Certainly, an 87-year-old female should be looking at end-of-life types of decisions. But being 87 does not qualify her, as you know, nor does having Alzheimer's. So what you should be looking at is, in addition to Alzheimer's, the constellation of other medical issues. And if you look at the hypertension, the heart failure, those certainly would contribute, as could the double mastectomy if she's not been following up. But the real important details are indicating her rapid decline. And over the past three years, she's been to the hospital three times. She's more confused. She's paranoid, and she's losing weight. So these are all indicators of a rapid decline. And how do we quantify that decline? Let's go to the next slide. We have this scale called the FAST score, and you're probably all familiar with this, I would think. FAST score was originally written back in the 80s, but it has been, through the test of time, proven to be very effective. It is exclusively designed for Alzheimer's, and somebody asked a very astute question, what can we do if it's not Alzheimer's? But what we do is we use this tool in congruence with other tools, as you would with any tool in medicine. So are you going to rely on the FAST score entirely? Well, if a patient is entirely healthy and only has Alzheimer's, then this is what you lean on. But if a patient has any other history, and will, because most people at advanced stage with Alzheimer's do have other history, you use this score in addition to their other history. So as you can see, we range here from 6A down to 7F. These are the stages at which we start looking at a decline, and we start considering end-of-life considerations. Now, by no means is somebody who's incontinent necessarily approaching end-of-life. But if you start to get down into the 7 level, and particularly when you get to the red letters, the 7C through F, now there's a correlation with proximity to time. And when I see somebody who is 7A, I feel fairly confident that they're within six months. And at 7C, I feel very confident that they are within six months of demise. And that's why on every patient, I include a FAST score. Whether or not it is important yet, it certainly is a way to objectively document where they are now. So you can go on to the next slide. Now, what do you do to use with the FAST score? You want to support other conditions that, along with the FAST score, certainly suggest that a patient is declining. So what are these things? Recurrent fever after treatment with antibiotics suggests that the patient either has the lingering infection, which you would obviously pursue, but the more important point is that it suggests that perhaps they're beginning to have problems with their autonomic nervous system. Perhaps they're having other organ failure, and that is the real cause of the recurrent fever. Pyelonephritis or upper urinary tract infections that are recurrent. Certainly in a male, this is a very red flag sign. And in females as well, you're going to find that pyelonephritis certainly is an indicator because that should not be happening with any promptly treated urinary tract infection. Septicemia, of course, has, as you know, sepsis has a very high fatality mortality index. Decubitus ulcers by themselves are not necessarily fatal, but the decubitus ulcers strongly suggest that patients are immobile. And the immobility correlates directly to the degree of the ulcer. And that degree of the ulcer and the degree of immobility strongly correlates to decline. Aspiration of pneumonia, of course, correlates to dysphagia, which falls into the seven C through F criteria. Prior slide, please. Two slides back. There you go. And you can see inability to ambulate, inability to set up, no longer smile. And somewhere on here. No, dysphagia is correlating really to seven B and seven C is what I begin to correlate it to, although it's not specified on here. So you can go on. Difficulty swallowing food or refusal to eat in the patient scenario is very worrisome. And that correlates to one of the other criteria in hospice, which includes 10% total body weight loss within the past three months. So refusal to eat is almost certainly going to result in body weight loss. And that's another objective criteria you can use in combination with your FAST score. And then of course, the albumin being less than 2.5. Now by itself, low albumin is not meaningful by itself because it can come from other things, but you want to correlate it. Again, it's correlation of multiple symptoms that are a much stronger argument than simply leaning on one scale. Next slide, please. So now there are some other factors that you want to consider. Not only just those symptoms we discussed, but does this patient fit the criteria for Alzheimer's dementia, any dementia, or some other condition? So if you are not sure whether dementia is what you want to use as the main criteria for admission to hospice, but you feel that the patient does seem to be declining and certainly has indicators using some other scales, then you want to carefully examine all of the other medical conditions. So for example, do they fit criteria for end-stage COPD, CHF, cancer, things like that? And if they are on the line for meeting the criteria of one of the other conditions, if you combine them with dementia, is it going to make for a much worse outcome? Now, does the patient's observed or future anticipated rate of decline help her to meet criteria? So this patient may be just north of the criteria for whatever condition you are going to be admitting him or her, but have they declined towards that criteria rapidly? So that's similar to when you're looking at thrombocytopenia, and you don't look at just the pure number. You want to look at what is the rate of advancement of thrombocytopenia, or for that matter, for hemorrhage and HNH. You want to look at the rate of decline, and you take that into account and you document it. Now, is the disease, next bullet point, is the disease process interfering with the ability to regain or maintain stability? So in this particular case, we're talking about cognitive stability, not just postural stability. So for example, has the patient's dementia made it difficult for the patient to be compliant with the medications that are important to stabilize his or her other conditions? So is the patient no longer able to remember to take their diuretic, for example? Were they not remembering to take their anticoagulant? If that's the case, and you can document that, then that is clearly going to lead to an earlier demise. Has there been increased healthcare utilization? You'll notice that in the case study, we talked about the fact that the patient has been hospitalized three times. Now, that may or may not be a large number for you, but certainly if the patient has been hospitalized more than two or three times in the prior six months, that's worrisome. The more hospitalizations, the more recent hospitalizations, the more worrisome, and I certainly document those. Obviously, you want to correlate the hospitalizations to the hospice diagnosis or the constellation of hospice diagnoses. So if the patient has gone to the hospital because they had something minor, like a foreign body stuck in their ear, that's not going to be so relatable. But falls, changes in mentation, worsening of chronic diseases, all of these things certainly are going to correlate. Next bullet point, are there issues of stability of comorbidities? That sort of correlates to point number three. It may be, however, that even if the patient is taking their medications, their other conditions are declining. Take that into account. Falls, impact frequency and nature of the falls are very likely they're going to correlate to hospital visits. Sleep patterns. I always document whether a patient is sleeping more than the normal amount, normal being a somewhat flexible term. But if a patient is sleeping nine hours instead of eight hours, well, that's not so much of an issue. But if they are never sleeping, that's an issue. And if they're sleeping 20 hours a day, that's an issue. So it is a fairly subjective call on your part, but it is worth noting because if you're finding that the patient is sleeping 22 hours a day, when are they fitting in their ADLs? When are they eating? When are they taking their medications? And why are they sleeping that much? Is that a result of dementia or delirium? Or are they sedated because of medications? Or indeed, are they unconscious? So you take that into account. You can also use it as an indicator of rapid decline. What are the patient family goals of care? This, of course, is something that should be discussed. And if you find that the patient really, their goals of care is not to have any kinds of medical intervention in the face of a disease that you know has a very rapid decline without treatment, then you take into account those goals of care and you make sure you document them. And then finally, your clinical experience matters. And you'll note that in the definition, in the admission criteria, CMS takes into your account your opinion. So you put together your opinion about whether you think the patient is going to die. And you can take into account your experience. And even if you say, I cannot put my finger on why, but something tells me that this patient is going to have a demise in six months. That's obviously not ideal. But if that is your opinion, and you want to admit them, and then you conduct further research later, and you look at the progression of the patient's disease, and you want to add data later to indicate now I know why it is that I had a feeling about this patient. That is acceptable. Is it ideal? It's not ideal. But CMS includes your opinion for a reason. And I think you should use it. If you are somebody who's had a lot of experience, by all means, put your opinion in there. And then back it up with objective data as you collect it. Next slide, please. So again, I'm emphasizing the important points here. Does your patient fit the criteria? Look at the rate of decline? Look at whether their dementia is interfering with their ability to maintain the stability in their chronic diseases? Are they going to the hospital more? Do they have comorbidities that are going to add to the dementia issue? Are they falling? Are they sleeping too much or not enough? What are the goals of care? And how does your clinical experience and opinion speak to this admission? Next slide. So this graph here is showing that there is a correlation between amount of durable medical equipment and the prognosis of a patient. It's also showing that people who are hospitalized have a shorter prognosis often, and that patients who have home health care often have a shorter prognosis. The importance of this slide, however, is to show that people who do not have DME, people who have dementia, people who have dementia and are hospitalized, people who are at home with dementia, have very similar prognoses, and yet we are ignoring them. They are not being admitted to hospice as frequently as the people who do not have dementia. So the take-home point of this slide is that we are missing patients. We need to take into consideration that patients with dementia, even if they don't have these other factors, have a definite correlation to a shorter prognosis. Next slide. All right. So the summary of the international findings. Dementia patients are less likely to receive home health care and hospice care in the final months of their lives. So that is essentially what the slide was saying before, right? They are less likely to receive hospice care. That's very important. Despite appearing similar to those with terminally ill disease on a functional basis, dementia patients receive less home care because it's more difficult to identify whether they are within six months of death. That's the whole point of this talk. We're helping you to identify their short prognosis. Dementia patients had the same ADL score at 17 months prior to death as people without dementia. But it may be that people are finding it difficult to rate their ADLs when they have dementia because perhaps they can't ask questions, the caregivers can't ask questions, or it's harder to observe them. But hopefully at the end of this presentation, you will recognize that the ADL scores can be applied to dementia patients and that they do correlate to short prognosis as much to dementia patients as they do to other patients. And finally, as you saw in the prior slide, dementia was associated with less durable medical equipment, less home health care, and fewer office visits for whatever reason, and yet their prognosis is just as short. So don't take the fact that they don't have DME, don't have home health care, and fewer office visits to mean that they are not going to have a six-month prognosis. Okay, next slide. Again, just emphasizes the points that I just made. Next slide. Okay, clinical course of the advanced dementia study, which was in the New England Journal of Medicine, and I believe there is a QR code for this on the next slide. In two slides, yes. So you can go back two slides. It was a study of 323 nursing home residents across 22 facilities with advanced dementia, and they followed them for a year and a half. The data collected emphasized survival complications during the final periods, the symptoms, and the treatments. And they found that over half of the residents that were being tracked in the year and a half died. And they found that the reasons that they died was pneumonia, fever, and lack of eating. And the lack of eating was the single highest correlation. And you'll note that we discussed on a prior slide that weight loss and lack of eating was highly correlated to short prognosis. So this study supports that. The pneumonia, of course, correlates very frequently not only to impaired immune system, but to dysphagia, and this is why pneumonia is on there. And that correlates also to the febrile episodes. By far and away, the most common cause of death in these patients is pneumonia, and often it is aspiration. And then finally, after adjustment for age, sex, disease, duration, the mortality rate for these residents who had pneumonia was 46.7% or almost 47%. Febrile episode was 45%, and eating problems was almost 40%. Okay, next slide. These graphs just correlate with that, just supports what I just said. Next slide. And we'll leave this up for 15 seconds so you can take a picture of the QR code if you're interested in looking at the primary study. So in the last three months of life, this is a classic course for advanced dementia study, for advanced dementia, according to the study. In the last three months of life, distressing symptoms such as dyspnea and pain, pressure wounds, aspiration, and agitation were common. So you could extrapolate from this that if you see patients who have these issues, they are very likely within three months. Certainly if they are in a nursing home, as were the people who were studied here, but you could also reason that if they're in the home setting, it's going to be true as well. 40% of these residents underwent at least one burdensome intervention such as hospitalization, emergency room assessment, parenteral therapy, or tube feeding, and yet it did not lengthen their life. If it did at all, it was certainly more miserable than had they not gone through these things. So you can use data like this in order to help and inform your discussions when you have those discussions with families about whether it's a good idea to have hospice and certainly to have a discussion about end-of-life emphases. Residents whose proxies had an understanding of the poor prognosis and clinical complications expected in advanced dementia were much less likely to have burdensome interventions in the last three months. In other words, these people who had had the discussion with their doctor or amongst themselves improved the quality of the patient's lives by not interfering with the natural process of death, by torturing them honestly with hospitalization, emergency room assessment, parenteral therapy, and tube feeding. Torture is a strong word, but having worked in the ICU quite a bit and having observed this, as I'm sure you have, I think it's pretty easy to say that an awful lot of these interventions are dramatically worsening the quality of people's life. And then there's the data, the stats at the bottom, which you can look up on your own. Next slide, please. Okay. This slide is another study which correlates dementia and cardiovascular disease. And essentially what it is saying is what I said in an earlier slide, which is that if you combine dementia with cardiovascular disease, then you're going to have a far higher prognostication power of whether these patients are going to die within six months. You combine your palliative care and with your hospice discussion, people who are not yet ready for hospice or feel they're not ready for hospice should be referred to palliative care. Because even if they are not ready or at ease with the concept of progression of their disease toward mortality, you can talk about the fact that they can continue whatever care they want while continuing palliative care. And I'm sure you've all had these discussions before. Next slide, please. Finally, this is a summary of the prior study. And essentially what it is doing is it's dividing care of the patients who have cardiovascular disease and dementia into three stages. And the first stage is screening people who have cardiovascular disease for dementia. The second stage is suggesting early integration of palliative care. But unfortunately, in hospice, we usually don't get these patients at these first two stages. We usually get these patients at the third stage. And the third stage is when you need to elicit preferences for medications, testing procedures, and hospitalizations, elicit document preferences for end-of-life care, monitor for changes in functional status, healthcare needs, and caregiver burden, and monitor for hospice eligibility. All of these things should have been prepared for in the prior two boxes. And they almost never are, unfortunately. So frequently, the burden falls on whoever is doing the hospice consult at the hospital or in the home. More and more, I am beginning to see that some primary care doctors are doing this. Unfortunately, there seem to be fewer and fewer primary care doctors. So this slide is not really telling you anything you don't already know. But what it is doing is it is reinforcing what your experience is. Next slide. This is just a slide that shows you what the PPS scale is. And this, like the Karanovsky scale, is simply another way of documenting how progressed the patient is in terms of taking care of themselves. Every patient that I do an admission on, I include a FAST score and a PPS. And again, I use it either as evidence for admitting the patient or I use it as a ways of documenting their progression. And I find that to be very helpful. And I feel very confident that if anybody decides to go and audit these charts, which I fully expect and think that they should be audited, when I have those objective numbers, it certainly supports the case. And it also reminds me of what the presentation of the patient was and how they progressed. So I find this to be very useful. There are other scales, of course. Next slide. You can also use the CATS scale. And I find that while it's not the one that I use, it's just as valid. And next slide. You can also use RUGS, which is the Resource Utilization Guidelines. The RUGS are the ones that are used by either the nursing homes or the post-acute care rehab facilities. And they use them for billing purposes. However, they do correlate to ADLs. And if you prefer to use the RUGS, that's certainly something that you can. And that is required by CMS. So you're, in this case, using a scale that CMS uses. Next. There are even more scales, like the Mitchell Mortality Risk Scale. Now, how are you going to sort out all these scales? Furthermore, how are you going to remember them and look for them? What I find is the most useful, and I didn't remember to include it in here, is there's a website that was put together at UC San Francisco. And it is called eprognosis.com. One word, eprognosis.com. And it is a very simple plug-and-play website that utilizes all of these different scales. And it asks you simple questions, like, is the patient in the hospital? Are they in the nursing home? Or are they at home? And then they ask you yes or no questions and take you through the most appropriate scale. And then it gives you a prognosis. It actually asks you what your estimate is first, so that they can gather data. And then it gives you what the prognosis is according to whatever scale you've been shunted into. And then it gives you the scale and the information so that you can go and check it if you want to. And I have found this to be a very useful scale and a very useful tool to give to nurses who are doing the assessments initially in deciding whether people need to be admitted. And they can use that. And they can call me up. And they can tell me what the number is on a scale. And then we can correlate it to what they have observed. So I find, and I also find it very useful when I'm having a discussion with family, because whenever you get the dreaded question, how long does he have? All of us are going to say, well, we can't predict. Because of course you're going to say that. We cannot predict. However, when you have a tool such as this, you can say, there is a study, however. And it is called this study. And they looked at 1,000 patients or 5,000 patients who look just like your dad, and patients who look just like your dad, on average, lived to this period of time. A lot of people didn't, or this number of people didn't, this number of people did, but this is what that study says. And this is very likely what the chances are for your father as well. So I find that to be extremely useful, and I find most people are receptive to that. They're certainly more receptive than that to, well, I can't tell you. Who would be receptive to that? Next. All right, cognitive assessment tools. Now, it said in the first box a couple of slides back, how are you going to assess dementia? And obviously, assessing dementia is gonna be very important if you're going to get an idea of how bad their dementia is, how progressed their dementia is. If somebody has mild cognitive impairments, in other words, if they're like many of us who can't remember where we parked our car, you're not gonna immediately refer me, I hope, to hospice. If, however, the old joke goes, I can't remember whether I have a car, that's a little bit more progressed, and then you wanna start thinking about doing an assessment. How do you do that assessment? Well, there's a number of them. There are three main assessments. They're all scored on a 30-point scale, and they all look at different areas of cognition because, of course, it's not just a question of remembering things. There are different areas of cognition that they have to test, time and space orientation, ability to concentrate, short-term memory, visual-spatial skills, ability to memorize and do abstract reasoning and abstract calculations and comprehension of directions. These things, all these different areas, are tested using these different scores. And can you determine that somebody, again, is going to necessarily have a short prognosis when you look at this? No, but you can look at what area is affected, and then you can decide, is that area putting that patient at risk? And what are the things that can be done that can help mitigate those issues? So let's look at a couple of these scores. There's the MOCA versus the mini mental status exam. So the mini mental status exam is the one that we all learn in medical school. It is very convenient and very easy. It is almost entirely verbal. You can get away with just doing it very quickly, and a lot of medical students do it. The problem with the mini mental status score is that it's not particularly comprehensive. And by the way, it's still copyrighted, and you're supposed to actually pay the author every time you use it, which I'm obviously opposed to. I think that's academically unethical at this point, but that's just my opinion. And fortunately, it is, in my opinion also, an inferior score, so I never feel compelled to use it. What I prefer instead is the Montreal cognitive assessment score, which is free, and it is written and validated in a multiple of languages, and it is very easy to administer. It also scores on a 30-point scale. It takes just a few minutes more. It includes tasks, and it tests for executive function, which is not done in the MMSE, and it is free. So I believe the next slide shows what the MOCA looks like, and the, oh, it does not, but it looks very similar to the SLUMS, which is the St. Louis examination, the St. Louis medical score. SLUMS is a quite unfortunate abbreviation, in my opinion, again, but it is what it is. SLUMS was designed by the VA in St. Louis, and it is also a perfectly valid, and I use this one as well. I tend to use the SLUMS for people of perhaps a slightly lower educational level, simply because I find the questions are easier. And the MOCA is a little bit more difficult, but again, that is entirely up to your opinion. They are both fully validated. So you'll see that it is broken down into multiple different areas of cognition. Includes the clock draw. It includes orientation, the first three. It includes visual spatial organization, ability to concentrate, et cetera. So you can use that in order to do your initial evaluation of dementia, and you can also repeat it in order to show progress of dementia. All right, next. So that is the last of my slides, and I'm gonna hand it back to Dr. Riddle, and thank you very much for your time. Thank you. So let's pick up with the ADEPT tool, the Advanced Dementia Prognostic Tool. This is off of a study that was conducted in all nursing homes in 2002, with residents who were identified using MDS assessments, and basically picking out those who were over 65 years of age, and had variables that indicated that they had pretty advanced dementia. Mortality rate or mortality data was taken from Medicare files, and basically used to determine 12-month survival of patients in the sample. Independent variables were selected from the MDS, and when the data was looked at over 12 months, 40.6% of the patients had died. But 12 variables, if we could move ahead to the next slide, were pointed out and identified as predictors of mortality. So that included lengths of stay, age, male sex, dyspnea, pressure wounds, total functional dependence, being bed-fast, having insufficient intake, having bowel incontinence, having low body mass index, weight loss, and heart failure. There was a risk score that was put together that ranged from one to 32.5, with higher scores indicating worse survival. And when we looked at the data, if we can go to the next slide, what is striking is that despite the fact that over 41% of these patients died, when you looked at predictors, and looked at those who met qualifications for a hospice, simulating the qualifiers using MDS data, it found that only 15.9% of the subjects had both a FASTV7C and had met at least one of the preexisting conditions that we look for to qualify for hospice, such as a urinary tract infection, or insufficient oral intake, or fever, or any of the other indicators that you see that are there. And what was even more stunning was that looking at mortality data, matching it to who would have qualified for hospice with 7C, and having one of those other preexisting conditions, it was basically left to chance whether or not those criteria would have predicted death in a 12 month period of time. So this really points to the fact that our criteria that we have available to us in terms of the FAST and list of preexisting conditions doesn't do a good job of identifying patients with dementia who should qualify for hospice. If we can look now at the following slide. So when we look at the ADEPT tool, you can see how characteristics are set up, looking at age, looking at sex, and a number of other conditions with the risk score that would be assigned to those, and how that can be used in combination with, not to replace, but used in combination with the FAST scale to help us in terms of our prognostication for dementia. If we can move to the next slide. And we can see how these scores bear out. Just looking at, for example, a risk score that would get you up around a point, or between an 18 and a 19, for example, would give you a 12 month death probability that exceeds 75%. And you can see how all of these various scores would tie into a death probability. We can go to the next slide. So I'm gonna give you an example in a few minutes of an actual case where that data can be used to predict death probability. But before I get into that, let me just go back and have you think about all of the tools that we just mentioned, whether they were tools that measured function, or tools that measured cognition, or tools such as the ADEPT tool that pull everything together. All of these are very important for us to consider, not just in our admission of patients, but also at the end of certification periods when we're making decisions about recertification. Remember, two important factors about dementia patients in hospice. First is that they have extended lengths of stay in usual cases. And second is that with those extended lengths of stay, there might be quite a bit of stability that we see within those recertification periods that may lead us to question whether or not that person continues to qualify for subsequent benefit periods. So the recertification points that we really wanna focus on are the impact of hospice care on the stability of those conditions, revisiting factors that we discussed earlier about the stability of other diagnoses, weight stability, certain lab parameters, the medication changes that have been made, the ability to take those medications and be in compliance and the impact of those changes, also changes that we see in endurance and fatigue over time, and keeping very much in mind that improvement that we might see in any period of time doesn't necessarily mean that that patient should be discharged from hospice, because there's so much variability that we can see in short periods of time. Move on to the next slide. It shows us in comparing dementia to non-dementia cases, how much stability we can actually see in a short period of time, even toward the end of death in those last six months, and how different the slope of this curve looks for dementia patients versus those that do not have dementia. So we can't be fooled by the stability that we might see and have that lead to a premature or inappropriate discharge. Again, looking at the next slide, we can see when we compare dementia with the prolonged dwindling to what we might see in other disease trajectories related to heart failure exacerbations, for example, or cancer patients, that we might see extended periods of stability and even improvement, and that should not lead to us recommending discharge when it comes to recertification. I'm gonna skip because we're running short on time at this point. I had several slides. Gina, if we can move to slide number 49, the one that says the physician of certification of terminal illness, and let's go back further, a little bit further, one more, here we go. So that's the slide. So this is looking at a physician certification of terminal illness. This is a patient who is 86 years old with a primary diagnosis of advanced dementia whose condition has seen gradual decline with increased confusion, not wanting to get out of bed, sleeping 14 hours a day, mostly sleeping during the daytime, but still alert and oriented times too, but with non-meaningful conversation. Otherwise, high risk for wandering outside, needing close supervision, incontinent, increased difficulty with ambulation with the recent fall, increased dependence for ADLs, decreased appetite, recent episodes of hematemesis that led to a discontinuation of aspirin, fast score of only 6E, PPS of 40%, a MAC of 23.5, now weighing 156 pounds, down 24 pounds over the past year. And when you look at whether or not this person might meet criteria for dementia, you might automatically say, I don't think so because of that fast score of 6E. And you might say, maybe this is a person that should be referred for palliative care referral, and then maybe reassess for hospice down the road. But let's take a look at the key points here. Increased confusion, gradual decline, sleeping 14 hours, high risk for wandering, difficulty ambulating, recent fall, not eating, weight loss. Let's move to the next slide. If we use the mortality risk index score by Mitchell and applied that to this particular case, we would see that they would get 1.9 points for the ADL dependence, 1.9 points for male gender, 1.6 for congestive heart failure, 1.5 for less than 25% of food eaten, 1.5 points for bowel incontinence, 1.4 points for age over 83, and 1.4 points for not being awake most of the day. That adds up to a score of 11.2, which puts this person at a 57% risk, estimated risk of death within six months. And I can go further to say that you might, because of the description I gave you, add in that they have unstable medical conditions that would add another 1.5 points that would put this person over 12, giving them a risk index of 70%. So a very different picture can be painted when we start to use these additional tools that we're talking about. So in summary, if we can go forward a couple of slides to the action points. Just to close out, and then I'll leave time for questions here. The action points that we really need to summarize taking here, if we go to the next slide, are that we need to talk to our colleagues, as we mentioned in the beginning, about making the diagnosis of dementia, sharing that with their patients and their families, giving them an opportunity to start the plan for what is inevitably going to be consideration for hospice down the road. So that we can get them appropriately on hospice as soon as possible, so that they can get the maximum from their hospice benefit. Educate our local chronic care facilities, especially those with memory care units, about the importance of recognizing patients who are appropriate for hospice, perhaps getting involved in their medical staff meetings and doing nursing and services so that we can keep them educated on the things that they should be looking for. Use the validated supplemental tools that we have brought to you in this presentation to assist you with the FAST tool to help you in your dementia prognostication, making the link between common coexistence of dementia and cardiovascular disease so that we don't miss opportunities with these patients, and increasing our understanding of the dementia coding complications, which unfortunately, I don't think we're going to have time to cover today, but what I think we're going to do is carry that over into the presentation that was going to follow this in May so that I can give you a really good understanding of how dementia should be coded, why we tend to use senile degeneration of the brain and not dementia or other codes so that we can successfully code for the work that we're doing and be properly reimbursed. So Gina, I'm going to stop at this point and turn this over for any questions that anyone might have. Thank you, Dr. Riddle, and thank you, Dr. Fish, so much for preparing this presentation, and we will send a recording to everyone, and I appreciate everyone staying on. I know we're past time, but Dr. Riddle has agreed to stay on if anyone has any questions, so please feel free to put those in the chat. And Dr. Riddle, I know something came through right now. Oh, Dr. Rosen is reminding everyone, if you're on Twitter, there is an HAPC chat. It's always the last Wednesday of the month at 9 p.m. Eastern, so get on your Twitter and you can join your colleagues in a great discussion on there. And I know there were a couple questions I saw come through the chat, Dr. Riddle. Dr. Honeycutt had put something about being surprised that fast scale was used for unspecified dementia. She says she uses it for documented Alzheimer's disease, even if she finds that many clinicians, although she does find many clinicians use it incorrectly. Do you want to speak to that? I know we've seen some other questions around that in the past as well. Yeah, and as Peter mentioned earlier so well, that fast score is going to be appropriate if you have someone who has Alzheimer's without other conditions. But when you start to look at other forms of dementia, such as dementia with Lewy bodies, for example, or frontotemporal dementia, those can be associated with very inconsistent presentations for that patient from day to day. And you might catch that person on a very good day, for example, where their cognition may look pretty good. And you might say, oh, this person looks like a stage six to me today. Whereas tomorrow with a very different picture of a decline cognition and function, they might look like an advanced seven the following day. So we need to be very careful in situations like that and understand the limitations of that tool outside of strict Alzheimer's dementia and start to use some of the other tools that we mentioned in the presentation. Thanks, Dr. Riddle. And I know earlier Dr. Guidry shared something in the chat. I just put it in so everyone could see. And she said that in her practice, it seems like senile degeneration of the brain went as quickly as it arrives. So her hospice agency had us clarify all of those charts. We now use cerebral, and I'm going to not get this word correct, atherosclerosis. Yes, thank you. She was wondering if you have any information on that. I do. And we'll cover more of this in the subsequent presentation. But basically when you're coding, what you have to be careful about is that dementia and even vascular dementia will be looked at as basically the result of an overlying physiologic condition. And what CMS is looking for us to do is to code the overlying physiologic condition rather than the resulting condition. So in the example of a vascular dementia, it's going to be the atherosclerosis or atherosclerotic disease or the cerebrovascular accident that is going to be the overriding cause that led to the vascular dementia. So they'll look for us to code that atherosclerotic process or that CVA rather than to code the result, which was the vascular dementia. And that's why we have to be very careful with the more general term of dementia versus senile degeneration of the brain. Senile degeneration of the brain is seen by CMS as a primary physiologic condition, as opposed to dementia, which would be the cause that came about from some overriding physiologic process. So they wouldn't want us to code the dementia per se, because that was a result rather than a condition. Thank you, Dr. Riddle. And there's one more message now. Oh, just Alan saying, great presentation. So thank you again. And I think we can end it here since we're past time and we look forward to the next presentation that Dr. Riddle and Dr. Fish will present on May 16th on dementia care and management. So again, thank you so much for sharing all this valuable information and we'll send out a recording later today. Bye everyone. Thank you.

dementia prognostication

accurate diagnosis

documentation

conversations with patients

tools for prognosis

hospice eligibility

ongoing assessment

coding dementia-related conditions

action points for healthcare professionals

validated tools