Hi, everyone. Thanks for being with us. We'll get started in just a moment or two. So thank you so much again for being with us. I'm not going to, I'm not going to, I'm not going to open my... All right, everyone. If you can make sure that you are on mute, we would appreciate it very much so we can get through this session. Thanks so much. Welcome. Good morning or good afternoon, depending on where you are in the country today. Happy holidays to everyone. I'm Bruce Hammond and I serve as HMDCB's Executive Director. And I'm really pleased that you're with us for today's final webinar of our 2022 series titled Supporting Hospice Program Vulnerabilities, General Inpatient and Continuous Home Care. So in a moment, I'm going to turn it over to our leader for today's session, Meena Chang, but I do have a brief, a couple of brief announcements that I'd like to make sure that you hear first before we get going. So first, we'd like to once again, thank our series sponsors for the year. We very much appreciate the generosity of Gentiva and Bluegrass Care Navigators who have supported HMDCB's webinar series both last year and this year. So thanks once again to those two companies for their continued support of our webinar series this year. I also wanted to just take a quick moment to provide a brief update about our upcoming 2023 events, which we're planning now in terms of our 2023 webinars. You'll see that the webinar dates and registration are going to open soon for 2023. Be sure to check out hmdcb.org slash webinars for those. We plan to do four webinars in 2023 as we go forward. In 2023, we also are going to do some additional coffee chats due to your feedback and the demand that our certificates have shared. We're planning to add two additional coffee chats in our 2023 schedule. We typically have done one per quarter, but that demand has increased and we're interested. We've heard our certificates are interested in us doing additional. So we are going to do six in 2023 in the months that are on your screen there. So please again be on the lookout for information about those exact dates. I also wanted to share that our 2023 initial application window is going to open on January 16th. So if you know any colleagues who are not certified but should be, please be sure to share information with them about the opening of the initial application window. They can certainly visit hmdcb.org slash apply to learn more information or email Gina on our staff at gparisi at hmdcb.org. And also if you're interested in receiving recordings for the past events for this year, Gina would be happy to send you a link to those. If you want to send her an email, she'd be again happy to send those to you if you missed anything from earlier in the year. So now with those announcements out of the way, I'd like to just take a quick moment to thank our three speakers for today's event and turn over the presentation to Mina Chang, who will be our facilitator and moderator for the session. Thank you. Good morning, everyone. I'm Mina Chang. Thank you for joining our session today. We welcome to the session entitled Supporting Hospice Program Vulnerabilities, General Inpatient and Continuous Home Care. My name is Mina Chang and I am Hospice Medical Director at Kaiser Permanente in Redwood City. I am joined with co-presenters Dr. Abby Katz, who is Vice President and Executive Medical Director at Emeticis Hospice, along with Dr. Stephanie Patel, Chief Executive Officer at Care Dimensions. Thank you for joining us today as we will discuss important hospice regulations and updates in the areas of general inpatient and continuous home care. We hope to support your practice and enhance your ability to implement these two levels of care within your agency. Next slide. In this session, we will review the impact that general inpatient, GIP, and continuous home care, CHC, has had on hospice agency in recent years. These two levels of care have been scrutinized by the Office of Inspector General, and we will review the role that CHC and GIP imparts on the Hospice Quality Reporting Program, including the two claims-based measures Hospice Care Index and Hospice Visits in the Last Days of Life, HVLDL. We will also describe which patients are eligible for GIP and CHC, and we will discuss documenting appropriately, and finally evaluate necessary conditions needed in an agency to support these two levels of care. Implementation can be a challenge, so we will review three models that can support CHC. Next slide. Now, why is this important? Well, the use of hospice care has increased among beneficiaries in the last 10 years, along with Medicare spending for hospice and the number of hospice agencies. And with the increase, the number of surveyed hospice agencies with deficiencies have increased as well. And the OIG noted various deficiencies, including underutilization of GIP and CHC, improper or lack of documentation, and improper conditions to support these two levels of care. For example, calling to question the use of a skilled nursing facility as opposed to a proper inpatient unit to justify GIP level of care. And this has also called into question whether hospices were providing patients with quality end-of-life care and comfort to families and caregivers at the end of the beneficiary's life. Next slide, please. For example, one hospice agency billed Medicare for 16 GIP days on a 101-year-old beneficiary with dementia who had uncontrolled pain but did not demonstrate GIP needs, since they did not change the pain medications until the 16th day and did not provide him with the mattress he needed for more than one week. And another agency billed Medicare for 17 days of GIP for a 70-year-old beneficiary but did not demonstrate GIP need. They never visited the patient but only called the family to inquire how he was doing. Next slide. More specifically, several reports from OIG, for example, in years 2013, 16, and 18, demonstrate improper documentation to support GIP, or hospice did not provide GIP when it would have benefited the patient, or hospice did not provide all of the required members in the care planning, or beneficiaries did not need GIP for all or part of their stay. As a result, in 2013, OIG recommended Centers for Medicare and Medicaid Services review long GIP stays or focus on hospices not providing any GIP care. And in 2016, OIG recommended CMS to increase its oversight of GIP claims, ensuring that a physician is involved in the decision to use GIP and hospices meet care planning requirements for GIP stays and review long length of GIP stays, for example, length of stays greater than seven days. And finally, in 2018, OIG continued its emphasis on recommending that beneficiaries receive the care that they need. Next slide. Similar concerns have occurred in CHC in the areas of improper or lack of documentation to support this level of care, improper conditions to provide CHC such as providing it in an assisted living facility, or too few beneficiaries were provided or offered CHC who could have benefited, or the opposite spectrum where hospice agencies provided a high percentage of CHC by forming a partnership with an outside entity, for example. Next slide. Cumulatively, these deficiencies, such as inadequate assessments, care planning and documentation or underutilization of GIP and CHC can impact quality measures within hospice agencies participating in the hospice quality reporting program. The updated hospice quality reporting includes two additional claims-based measures, hospice visits in the last day of life and hospice care index. This is in addition to a survey of family experiences with hospice care, the consumer assessment of healthcare providers and systems, the hospice survey, and the hospice item set comprehensive assessment. Next slide. These quality measures evaluate the processes or outcomes in the hospice care delivery. They measure whether patients receive the quality of care they needed, as well as supporting the family or caregivers at the end of life. This includes whether GIP or CHC was or was not adequately utilized in meeting the quality of care. I just want to highlight the two new claims-based measures, HVLDL, which looks at proportion of patients who received an in-person visit from a registered nurse or medical social worker in the final two of three days of a patient's life. And the hospice care index is a single measure comprising of 10 indicators calculated from Medicare claims data. Each indicator affects the single score. The metric one specifically looks at CHC and GIP provided. And these measures demonstrate whether patients received the quality of care they needed, which includes offering GIP and CHC if the patient and family caregivers will benefit. Next slide. Dr. Abby Katz will provide a deeper dive into continuous home care and she'll discuss how to assess and document CHC and she will review three models for CHC implementation. And following this section, Dr. Stephanie Patel will discuss GIP. She will review assessing patients' proper documentation and conditions for GIP eligibility. Great. Well, good afternoon and thank you, Mina, and thank you all for joining our session and thank you for allowing me to share my passion with keeping patients who want to stay at home so next slide, please. I'm going to start with the patient case. KW was a 29-year-old female with end-stage colon cancer. She was first diagnosed at age 27 after having given birth to her second child. Her condition progressed despite multiple aggressive treatments. She was admitted to hospice after hospitalization for acute bowel obstruction. So she came to us with a colostomy, a PEG tube, a left nephrostomy, a right PICC line, and was NPO. Her husband and her parents were very involved in her care and her goals of care were stated to be to have my life back and to never go back to the hospital. And ultimately, those goals evolved into simply spending as much time as possible with her children. Next slide, please. So her hospital course, over the first several days, her pain and nausea continued to progress and medications were titrated. And unfortunately, her symptoms continued to worsen to the point that the family was asking about sedation. And so the medical director did a home visit and discussed more aggressive symptom management up to and including the potential of the need for sedation. We initiated continuous home care and that included both nursing and a hospice aid, which was more time intensive at the beginning of the continuous care process and titrated down to two visits per day by the end of her time with us. And despite the challenges of obtaining IV medications, finding appropriate staff, having the team in place meant that we could respond quickly to changing conditions, even the condition of not having the medication we thought would work best. And the patient died comfortably at home with symptoms and control, but not fully sedated with the family at her side. The area vice president who helped operationalize getting this care into place reported that quote, it was truly a heartwarming experience for all. And we got to see our hospice team really pulled together and make a difference for this patient and family. The medical director reported it was validating to know that as a company, we have the resources to do difficult things. And although not required by CMS, he had done three home visits in 14 days. And I also wanted to just point out that we're discussing CMS Medicare regulations and this patient was a Medicaid patient, but in most States, the Medicaid regulations mirror the Medicare regulations. Okay. Now I'm ready for the next slide. So here is the regulation and we're going to emphasize some particular parts of it as we move forward. So continuous home care is provided for periods of crisis. Nursing care may be covered on a continuous basis for as much as 24 hours a day during periods of crisis as necessary to maintain an individual at home, either homemaker or home health aid, also known as hospice aid services, or both may be covered during periods of crisis, but care during these periods must be predominantly nursing care. A period of crisis is a period in which the individual requires continuous care to achieve palliation and management of acute medical symptoms. Next slide, please. Okay. So continuous home care is the CMS language, but it's a little bit of a misnomer. Many hospices call it some version of crisis care, and it's one of the four levels of care required for a hospice to be Medicare certified. You must be able to provide all four levels of care, routine home care, respite care, continuous home care, and GIP, general inpatient care. So periods of crisis are times where skilled symptom management is needed in order to keep the patient at home. Up to 24 hours is a time period that starts at midnight and is a minimum of eight hours. It does not mean to need to be continuous. So it can be four hours in the morning and four hours in the afternoon or evening, but the minimum total must be 24 hours starting at midnight. So if you start at 2 p.m., you can get eight hours of care within a 24 hours before midnight. But if you started at 5 p.m., you won't get the eight hours in that 24 hour period, but once it comes over to passes midnight, then the rest of the time will be covered. That doesn't mean you don't provide that care. You just bill it routine home care for those first couple of hours. Predominantly nursing care means greater than 50% of the hours must be provided by a nurse, an RN, LPN, LVN. So that in an eight hour example, four and a half hours could be nursing and three and a half hours could be the aid. Or if you provide care for 15 out of 24 hours, 51% or seven hours and 45 minutes needs to be nursing and the remaining could be aid time. If fewer than eight hours of direct patient care are provided in that 24 hour period, services are billed as routine home care. It's also billed in 15 minute increments for that minimum of eight hours and includes only the nurse and the aid. Overlapping time between the two can be counted separately, but the specific reason that both are required at the same time must be documented. The whole team is expected to be involved in addressing the needs of the patient and family, but social work and chaplain visits are not counted in the hours calculation. Since it is for brief periods of crisis, it is important to be planning return to routine home care by providing education to the family about what to expect and how to manage the treatment. Continuous home care is where a patient lives and calls home. So a private residence or assisted living or long-term care that is not skilled nursing care. So they cannot be receiving skilled care. Next slide, please. Okay. So assessing the patient. So as we mentioned, continuous home care is for acute symptom management. So it's not for the convenience of the patient or it's not for convenience or for patient safety or imminently dying with no skilled needs. That's routine home care. It's also not for general caregiver breakdown without a skilled need. That's respite care. However, if a caregiver has been providing skilled care and is now unable or unwilling to continue, the skill of the nurse may be needed to provide care that was being provided by a caregiver to manage or avert a crisis. Next slide, please. Okay. Documentation is very important. So coverage of continuous home care for that minimum of eight hours is primarily nursing needed to manage acute crisis as necessary to maintain the person in their home and the documentation has to reflect that. So it must be able to support that the services provided were reasonable and necessary and in compliance with the plan of care. The most common denial is based on lack of documentation supporting the medical necessity. There is no specific frequency of documentation in continuous home care or even guidance, but the best practice is to document at least every hour and to maintain a medication administrative record and an opioid count. Okay. Next slide, please. The benefit to the patient is physical comfort and medication oversight so that the symptoms are controlled quickly. The benefit to the patient and the family is that rapid response to symptoms, especially as symptoms are escalating and evolving and the treatment plan becomes more complicated. It's also a relief to the family to not have to be that decision maker for every PRN dose when symptoms get out of hand and that they know that they're not alone in a difficult situation. It also helps in difficult transitions, for example, from the hospital to home when there are complex medical care needs. Next slide, please. The benefit to the hospital is that in addition to being required by Medicare, the satisfaction of being able to do the right thing, provide the right care at the right time in the right place is very satisfying. Most patients prefer to die at home and continuous home care helps hospices provide the care that's needed in critical situations. Employee satisfaction really has two sides. So for example, a nurse case manager walking into a situation where symptoms are out of control can find this an incredible dissatisfier because they think that it's going to take a long time with one patient and it's going to back up the rest of their day. However, when they know that their organization can support either that they can take all the time that they need to get the patient under control and the productivity burden is managed or that someone else with specialized continuous home care skills will be taking over and then they can go on with the rest of the day. That becomes a satisfier. Flexible scheduling is another satisfier. Moving away from the standardized staffing model of 40 hours a week for a nurse, it allows for swing shifts, PRN shifts, weekend and overnight shifts as needed and as desired by some clinicians who prefer to have that flexible scheduling. It also has an impact on quality scores, which we referred to earlier, but it specifically addresses communication with families, getting timely help, help for pain and symptoms and training families to care for the patient. Doing continuous home care well gives you a competitive edge to the community as well because we all know that when you help a hospital or a nursing home with a really difficult situation, they're more likely to think of your service in the future to help with other patients. Next slide, please. I wanted to just make a distinction between the service intensity add-on and continuous home care because it is expected that there are increased needs at the end of life and the service intensity add-on can help offset some of that cost, but it doesn't replace the need for continuous home care when CHC is appropriate. So SIA is for actively dying. Every patient needs those extra visits. A nurse and a social worker are supported with up to 12 hours, sorry, not 12 hours, up to four hours per day in the last seven days of life. This is calculated automatically and it's not billed separately. Continuous home care is for crisis. It's not necessarily for active dying, but it could be for symptomatic active dying. And it's supported as with a minimum of eight hours, predominantly nursing, social work does not count here and needs to be specifically billed with specific codes. Next slide, please. Okay, so staffing and monitoring are the two biggest challenges. So staffing has always been an issue, but in a time of COVID with caregivers leaving healthcare altogether, it's a particularly challenging concern. Hospice core services also must be provided by hospice employees. So hospices are not allowed to routinely contract with nurses to provide continuous home care, although there are exceptions for short-term unanticipated need. Monitoring includes managing the model, the documentation, the compliance, and also the related process improvement components. And I'm gonna talk about those in just a moment. So next slide, please. So I have three example models. The first is a regional model, and this is good for both rural locations where GIP is not easily available and also in metro areas where the demand for both GIP and continuous home care is sufficient. The model is mostly an LPN model where LPNs are hired specifically for this role. There's a hundred mile radius. So drive time is paid and is counted as the cost of providing care. It provides flexible scheduling, but with the understanding that there's generally enough work in that radius to keep the staff busy. Patients are identified using internal assessment tools or the nurse who is the clinical manager identifies a case that has need, then the RN will go and do the assessment, creates the plan of care for the LPN to follow. And then an RN visits every eight hours to assess and update the plan of care. Financially, this model carries its own P&L sheet to confirm that it will break even or be profitable. And charts are put on bill hold until they're monitored and reviewed for compliance and billing at the correct level of care. For example, you bill routine home care if the times or the clinical necessity is not borne out in the documentation. Also at this model, it's helpful in the quality improvement process to review all deaths, to confirm that all appropriate cases had been identified and to do a root cause analysis for potentially missed opportunities. Next slide, please. Okay, another model is a just-in-time model. In this context, again, it's staffing challenges. There needs to be shared company resources. For example, between a parent and a branch relationship to be able to stand up a case quickly and can use just-in-time type model to do that. In this model, the hospice would utilize the regular care teams and the staff with optimizing workflow. Patient cases are identified in the field in real time and potentially in the office by a clinical manager working with a broader view of the patient's conditions and or with innovative EMR tools that assist in identifying patients in crisis. Staff need to be trained to recognize early in the visit that there might be a need or to anticipate that the coming days their need might escalate. Staff also need to be trained to manage very complex care. Clinical managers assist with patient selection and garnering resources to support and often need regional management level support to move the pieces around. Again, in order to maintain compliance, it's recommended to put the billing on hold until it's completely reviewed to confirm medical necessity and the hours of care were met. And quality processes involving reviewing deaths to confirm the appropriate level of usage. Next slide. Okay, finally, this is an innovative model in the setting of shared resources. And the shared resources here are with the palliative care and the hospice. So the medical director oversees both programs. The palliative care nurse practitioner provides as often the person who recognizes the need for continuous home care as part of the transition plan from palliative to hospice care. The shared social worker and nurse navigator help within the hospital for identification. And then the specialized home team, the LPN and aid are shared resources between multiple locations within a large metropolitan area. And in that sense, it's like the regional model. The patients identified are part of the palliative program and referred to hospice or as identified in the field from the hospice team into the crisis care model. Administrative management and clinical oversight on the hospice side is similar to the regional model dedicated staff that would go where needed and be monitored for compliance. And that's the end of my discussion. And so with that, we'll hand over to Dr. Stephanie Patel to discuss GIP. She'll be reviewing, assessing patients, proper documentation and conditions for GIP eligibility, as well as some lessons learned. So thank you very much. And Stephanie, I'll hand to you. Thank you, Abby. Thank you all for coming today and allowing me to participate in this webinar. I am gonna talk about general inpatient care, which in my mind is not as difficult as Abby's discussion of continuous care, which I find a bit more confusing. I am also gonna start with a case. Next slide. J.W. is a 68-year-old female with metastatic ovarian cancer with mets to the liver, peritoneum and bone. She was diagnosed two years ago and has had extensive treatment for which she has had disease progression. And she's admitted to home hospice. On admission to home hospice, she has a venting G-tube and J-tube, which she is able to manage on her own quite effectively. And she also has a very large tumor mass in her left, that should say left groin, with copious amounts of drainage that require her to do a dressing change at least two times a day, sometimes three times a day, but she's able to manage this on her own. Next slide. She's at home for about two weeks. During that time, she started on some methadone for pain and she's had several visits from the wound nurse for management of that wound. But suddenly over a three-day period, the wound seems to be getting worse and starts draining a lot of copious amounts of fluids and her dressing changes are increased to three days a week. And then she develops severe abdominal pain, pelvic pain, and starts to require morphine quite frequently, getting up to about every three hours. So her methadone is actually titrated. Next slide. But the next day after the titration, the nurse is called and the patient's now complaining of nausea, vomiting, and severe pain. So when the nurse arrives, she sees that the patient is in 10 out of 10 pain and she's confused and no longer seems to be managing her venting G-tube very well because she's left it clamped even after all her meds, after she gave herself all her meds. And then she finds that even the bed linens or her clothes are all soaked with drainage from the wound drain because she has not changed the dressing as frequently as she's supposed to. So the nurse calls the hospice physician for the team and the social worker, and they talk with the patient and family and decide to transfer this patient to the inpatient facility for uncontrolled pain, nausea, vomiting, and a complex wound, as well as her confusion that may or may not have been caused by her increased requirement for pain meds. She is given for the ride up to an additional 30 milligrams of morphine. Next slide. But when she arrives at the hospice house, she is still in 10 out of 10 pain. So she is given IV morphine and some IV Haldol and continued on her methadone. The wound nurse comes in to address all of the drainage. So on the next day, her pain is somewhat better. It's about an eight out of 10 with the IV morphine, but her wound is still draining large amounts requiring extensive dressing changes three times a day. And she started on a morphine PCA. By the next day, her pain's definitely improving on the morphine PCA, pain's five out of 10. The wound is also improving with the new dressing changes. They do titrate her methadone again, and her Haldol has been DC because she's no longer not eating or vomiting. Next slide. Two days later, her pain rates at a two out of 10. She's on the methadone and her morphine PCA. She's much more alert and oriented and is again trained on her new dressing changes, which she is able to show the nurses that she can manage again at home with her G-tube and her J-tube. And she has subsequently transferred home on routine hospice now that her symptoms are managed. Next slide, thanks. So general inpatient is another one of the four levels that is required for a certified hospice. And if a hospice cannot provide GIP itself, it needs to have at least one contract that GIP can be provided for. And we'll talk about the requirements for those contracts. The purpose of GIP is actually to palliate and manage or manage acute symptoms or other medical situations as in this case, the copious wound dressings and complicated wound dressings that can't be managed in another setting. And it really is only intended to be short-term. There's no definition of short-term, but it's not meant to be a long-term intervention. It's really should be initiated when other options to control those symptoms or medical issues have been ineffective. So we'll talk about the documentation of that in a little bit. The interdisciplinary group, which include the physician, the nurse, social worker, and spiritual counselor are all required to be involved in the discussion and they should all document on the decision to change someone to GIP. And just so that you are aware, GIP under the hospice benefit is not considered the equivalent to a hospital level of care. So sometimes that comes up during audits. So just so that you're aware, they do not quantify it as being equivalent to a hospital level of care. Next slide. Location of GIP. So it can be provided at a hospital, a skilled nursing facility, or a hospice owned inpatient facility. And we'll get into the requirements for each of those in just a bit. Where it can't be provided is at home or an assisted living or at a long-term care facility. So it can be at a skilled nursing facility, but not at a long-term care facility. GIP can be provided at the end of a hospital stay. So you can go right from a hospital stay into GIP when there's a need for symptom management that can't be managed in another setting. This is scrutinized. So you need to make sure that your documentation documents why those symptoms can't be in another setting, but you can go from the hospital stay directly to a GIP stay. And hospices must have a written contract with any facility, whether it's a hospital or a skilled nursing facility that they are going to provide GIP services in. So make sure that you definitely have a contract. If you're getting CHAP surveys or other surveys, they will look for those contracts. Next slide. So essentially here is the requirements or the regulation talking about short-term inpatient for if you're going to contract with a hospital or a skilled nursing facility, know that they have to have 24-hour nursing services with at least one RN on each shift that is providing direct patient care. They cannot be an LPN. It must be an RN, and they must be in the building every shift. This is probably the biggest reason why, at least in our area, we're unable to find some skilled nursing facilities that can provide GIP. Patient areas at those hospitals and skilled nursing facilities must accommodate private accommodations, but they also must let the family remain overnight and allow for visitors at any hour of the day. They can't just exclude them to their visiting hours. So the hospital has to understand that if you're going to have a contract with them. Next slide. Requirements for a GIP that's hospice-owned, it's very much the same. It must be a Medicare-certified hospice, and they must have that 24-hour nursing with at least one RN on each shift who's providing direct patient care. They have to provide private areas as well as accommodations for families to remain overnight and allow for visitors at any hour. They also have to meet compliance for fire protection and building safety. There's a lot of codes for this that you have to go through, and they have to meet infection control standards. So obviously most skilled nursing facilities and hospitals do that on their own standards, so that's why it's not repeated in the hospice benefit. Next slide. So assessing the patient, when you're assessing a patient for GIP, again, key is that the pain or symptom cannot be managed by changes that have already occurred if you are in getting audits, or even if you haven't, be aware that they will look for those changes and the documentation of those changes in the previous setting. So they're really looking for why it could not occur in a setting other than GIP. So examples of that are often intractable nausea, go back, intractable nausea and vomiting, complex wounds, unmanaged respiratory status, obviously severe pain, delirium, often terminal delirium, acute seizures, ongoing seizures that aren't controlled well with medications, pathologic fractures, which can be very painful, especially with any kind of movement. What it's not for, as Abby described in continuous care, is those with imminently dying with no symptoms or well-managed symptoms. It's also not for when a patient's acute symptoms have resolved, And just because they're in an inpatient facility, and are managed with their current regimen, it's not necessarily that that's an automatic that you meet that level of care. So if they no longer need that further intensity of care, they would need to go back to the routine level of care. This is always a tough one patients who families who refuse to leave inpatient care, it happens more often than you think. And in most instances, what you need to do is share with the family, obviously the regulations around inpatient, give them an ABN, an advanced beneficiary notice saying that Medicare won't cover their general inpatient stay as they're not meeting the requirements. And you can let them know that they're basically they're responsible for the difference between the Medicare GIP rate and the routine level of care rate, but that they're back on the routine level of care. Again, you can't use it for caregiver breakdown or when there is no caregiver available those, you know, you have to use respite, respite rates for the other thing that comes up quite quite a bit. And that confuses some people safety concerns in the home. You can't use that as a reason for GIP. At this point, Medicare doesn't accept that. Next slide. So documentation is probably just going to be the most important thing you can do for for GIP. So you need to, you need to definitely document what the uncontrolled symptom was, what precipitated that symptom, what you try to do for that symptom and all of those that failed prior to GIP. So you know, if you're not documenting that, and or you can't see it in your record that it tells a story, you should do it at least when the patient gets to GIP. But ideally, you need to do it throughout that course. Describe what the patient needs, including if it's medications, frequent medication adjustments, wound care, ongoing observation by nursing and physicians for the outcome. It's key here to to try to explain why a caregiver giving that observation is not the same as a nurse that it needs the skill of a nurse or a physician, a physician order to change the level of care, it's not necessary by the federal regulations. But all auditors and surveyors are usually looking for those. So I would go ahead and document a physician order for that. The documentation during GIP ongoing observation for the severity of symptoms should occur q shift. So you want to document every shift, how severe the symptoms are, or what interventions they're requiring every shift or what observations the nurses are seeing are requiring to do. The outcome of all your interventions should be documented, as well of the as the plan of care directed towards controlling symptoms so the patient can return to a lower level of care. This is the same that Abby talked about in continuous care and GIP. The goal is that it's short term. So they're always looking for that you're trying to get them back down to that lower level of care and document each day why the patient is GIP by all by all members of the IDG. So I would actually tell you that you should just add in somewhere that that's a that's a requirements that each discipline document why they feel that patient is GIP. And then from the onset, you should document the plan for transition once GIP is no longer needed. So what is your plan whether they'll go home whether they'll go to a nursing home, whatever that plan is. Next slide. So as hospices, when you're documenting, you need to document that you're aggressively working on a safe discharge plan. So sometimes this is very difficult. I'm sure other people have run into where there's just really no place for the patient to go. But you have to document everything thoroughly and that you're very much looking for a safe discharge plan. You should also document on honestly, if symptoms continue to require active interventions, if they're requiring frequent adjustments, or the need the new symptoms have arised that are requiring a new treatment or a frequent, new frequent assessment. So anything like that definitely wants to be documented. And preferably in all disciplines notes, if you can. Next slide. Obviously, the benefit to to GIP in my mind to the patient is pretty clear patients get improved comfort and aggressive symptom management that can be difficult to do not outside of GIP. There's also that key to the immediate availability of medications. I know for me, that's that's one of the reasons why GIP is so, so heavily utilized in those patients that have a lot of symptoms. There's also increased availability to our the full interdisciplinary team, most GIP units have staff there, eight to 10 hours a day. So the family and patients get more access throughout the day to improve their psychosocial symptoms. It does provide relief for caregivers who are often been medicating every two to four hours, which can be really difficult and exhausting, especially when it's not meeting the patient's needs. There's also the ability to quickly palliate a new symptom that comes on. So I'm sure most of you have seen you got one symptom, and then that leads to another and another. But also, we've seen patients like in our example, where you can quickly palliate a symptom, and this allows a patient to go home, and improved patient and family satisfaction. The benefit to hospice organizations really, for many of us, it can help you avoid hospitalizations, increases our collaboration with hospitals and community partners. If you're having trouble staffing continuous care, it's an alternative to continuous care. It also makes the quality of care a little easier and relieves some of the stress on field RNs and on call staff, as these patients usually require frequent visits throughout the day, increased revenue with a higher reimbursement rate. And it's often if you have your own hospice facility, it's often a philanthropy or development opportunity for the organization. Next slide. There are a lot of challenges. Sometimes I think the challenges outweigh the benefits, the location of where you're, you are located as a hospice is a big challenge. Financially, it's not feasible for everybody to own their own hospice unit. And if you if you're doing it in a hospital or skilled nursing facility, they often don't remember or they don't understand the regulations. So you spend a lot of time explaining those and trying to meet make sure you're meeting all the regulations with the care plan and the visits needed. As I said, many, many skilled nursing facilities in our location don't have 24 hour care. And for rural areas, it's very difficult. Compliance wise, it's very highly scrutinized. This is one of the biggest requests for audits. So if you're if you have your own unit and you're not getting GIP audits, lucky you. And documentation requirements, as I said, not understood by hospital and skilled nursing facility staff. So if those charts get audited, it's often much more difficult to substantiate what the care was that was provided. It's very difficult to manage them in outside cases. And you have to they have to often remember that you're in charge of the care and the responsibility for that patient's management, despite the fact that they're not in your own facility. I want to make sure we have time for questions, but that I get to my next slide. So I'm going to move on to I'm going to skip this one. So we have time for questions. But this is our sample of how we work in a contracted facility. So I wanted to give you guys some lessons that I've learned over the years, I've been in a lot of GIP audits, we own two of our own facilities. And I learn every time what we can add to try to, to get these approved earlier and earlier, I would say, I want to see this is up a shot. I had gotten. So often you'll see in GIPs that you'll get one day approved and not the next. It sounds kind of crazy. And if this happens, I would definitely tell you that you need to appeal it. There's nothing more frustrating than seeing that they want you to instantaneously discharge someone as soon as they have one day of stabilization. But if it's documented, well, and you explain that you can't, that's in your documentation that why you're waiting, even though the patient is stable today, here's the reasons they could get this, this and this, they'll often get approved that way. timing for your discharge from GIP to routine is very ambiguous. One auditor says one thing and one auditor says next, the best thing that you can do again is explain any delay from that instantaneous discharge that the routine reviewers are looking at, because remember that these routine reviewers are non clinical, very, very unoften have I gotten a clinical person doing a first line review or even a second line review of charts. So I have heard that they do, do agree. They really are looking for medications to be altered. So if you're not altering a medication per day, it's best that you can explain why they don't often look at the complexity of the regimen. But if you write it in there, they will, they will often pay attention to that, that they're not again, so much on IV, make it very clear that IV, they're on IV meds, they're on multiple meds. And these are often these are things that can't be do at home, it's too difficult. Often documenting about the safety of transport, if they're looking to transport someone to a different facility, because they're no longer GIP, documenting that is sometimes helpful. Documenting things why less skilled providers wouldn't know how or when to provide PRN medications. This is really going towards somebody who may have stabilized a little bit for a day, but they're so tenuous that a family cannot really judge, oh, this patient is now going to go into CHF again, or is now going to have respiratory failure again. So it's same thing and emphasizing why a family or another caregiver these days have been helpful. Their recommendations that, you know, have come through meetings with the auditors as well as things that judges have pointed out. And I think physician visits that are narrative and individualized are really key to success. So these are just some of my findings, I'm giving that other people probably have had others. So next slide. And I'm going to hand it back to Meena. Thank you. So just in the last seven minutes, we have left just some, thank you, Stephanie and Abby for your expertise. And just some quick pearls and takeaways. CHC and GIP continue to be an area of scrutiny. CHC is for brief acute symptom management in the home sitting setting minimum of at least eight out of 24 hours starting at midnight, predominantly nursing care, as Abby said, 51%, at least. And there's multiple models of care that Abby shared. And GIP is a short term intervention to provide pain and symptom management that cannot be provided in their current level of care. And documentation of daily eligibility are important before returning to their routine home care. Next slide. We just want to thank Dr. Ron Cosno. I think I saw him in the audience. And then Dr. Edward Martin and Mark Corbett for also contributing to the slides. And these are some references that we used for our presentation. Thank you all for joining our session today. I believe there's a couple of questions in the chat. So I know I saw that Abby had answered one of the questions regarding the continuous home care regarding at least eight hours. I'm not sure Bruce or Gina, if you want to facilitate the questions or if you would like me to or if you want to, you know, Stephanie and Abby to answer in the chat considering the time we have left. Yeah, so there's just a couple of minutes left. So I thought I would just jump into one. There's one that seems like it might be a maybe an easier answer than others, but I'm not sure. There's a question here that says, is there a standard of care expectation that a physician sees hospice patient while on GIP? If so, how frequently? Maybe, Stephanie, would you be able to take that? Sure, I can probably answer a couple of these quickly as I read them. Sorry. There is no standard or expectation. It's not in the regs that a physician needs to see a patient when they're on GIP. It's going to be if you get audited, they're going to look for it. So to them, it's going to be difficult to say a patient is GIP appropriate if they don't need to see a doctor at least, I would say a couple of times, but you're going to be able to substantiate it better if they're seen every day. There was another about dropping a patient from GIP to routine while in the hospital. It's interesting, you can do that. What I will tell you is that I've met with regulatory people and some attorneys, you have to be able to have a contract for routine level of care so that you can be providing all of that, which includes medications. We don't do it because we don't have any of those kind of contracts with our hospitals. The contract is just for GIP. So just make sure it's one that's come up several times. And so I've met with several people about it. And then somebody else asked, oh, if you're not, the hospice is not staffed. They're actually not. The hospital is not billing for their bed. The hospital is billing hospice for the GIP rate. The doctor at the hospital can bill for his visits. But that's it. I think that's why you're asking if it's double dipping. The hospital is actually not able to bill for the bed or anything. In fact, your contract should say that you're covering all of those things, except the hospice, the hospitalists say visit and that that you can bill through that they can bill for and get paid because they're the attending of record. Okay, let me see if I can read some of these any more quickly in three minutes. Stephanie, there's a comment here that says I don't fully understand the comment that GIP does not equal hospital level care. So they don't see it the same way. So if people put it, if you put it in your records that the patient is getting hospital level of care, because GIP is at the hospital, they don't see that as hospital level of care. It's just a different, it's different terminology. So you just don't want to use it as your reason just because they're in the hospital getting GIP. You shouldn't get paid a different rate. That's they, they want people to fully understand that. Now, some of these we all struggle with view on vent withdrawals and GIP. Um, that can be. Yes, you can. I mean, I think you could support it as long as your documentation can support it. I think you could. Because it's going to obviously, if you have a physician there, it's going to require a lot of intensity and interventions and nursing assessments. So I mean, I think you could definitely, I don't know if they were in the hospital, though they are scrutinizing more these hospital stays that jump right to GIP in the hospital. So, you know, we're being careful about those and making sure it makes sense. That's where they might. They might say, Well, why didn't they just withdraw the vent in the hospital? It's a good, I don't have an answer for that one. When we've I mean, obviously, you can take them to your inpatient unit and do it. And I think we've never gotten a question about that. But now that there's the scrutiny with GIP in the hospital facility jumping from inpatient hospital to inpatient hospice, they could say, Well, they should have just done it on the hospital's course. I'll have to research that one. Allen's Allen's points here at the end in the chat. I'd encourage folks to read those, if you can, before we jump off. auditors will look to see if you're following whatever your own policy says you'll perform. So that's certainly that's very true. Yeah. And then emphasizing the availability of necessary PRN meds for managing vent withdrawal for for for those situations. You definitely could after the vent is withdrawn, you could say yes, definitely, there's potential for this and that and you need that. I just don't know if they question the whole, you put them on before the event was withdrawal, but I don't know that it would come to that. Because it depends on your auditor. Exactly. Some of them are stricter than others. I was also going to mention, remember your own fiscal intermediary, because some of the geographies and some of the settings can also determine what expectation or scrutiny you have. Also, for what types of cases, pain management may be most common, but don't overlook your other patients in need. CHF, pulmonary edema, other things. Again, those are things to be careful of. And if you're using your inpatient unit for doing procedures, that is something that again, would not normally be an automatic coverage, like doing a parasitesis, plurisentesis. So it depends on the symptoms and document appropriately. So everyone, thanks so much, Alan. Thanks for those final comments. Stephanie and Abby and Mina, thank you all so much for joining. We have hit our time here. And we're actually a minute over. So we appreciate everyone spending your time with us. Thanks again so much and be on the lookout for our 2023 events will be coming up as we go forward here. So thanks again. Have a great holiday season. And we'll see you again in 2023. Thanks so much.

Supporting Hospice Program Vulnerabilities

General Inpatient Care

Continuous Home Care

Hospice Regulations

Eligibility Criteria

Documentation Requirements

GIP

CHC

Models of Care

Medical Necessity