Hey everyone, we're going to get started in just about one minute, 60 seconds or so, so please mute yourselves if you would and we'll get started in about 60 seconds. Thank you. Okay. Well, hello and welcome to HMDCB's second webinar of our 2022 for HMDCs by HMDCs webinar series of the year titled Symptom Management in Different Care Settings. I'd like to thank you for being with us. I'm Bruce Hammond and I serve as HMDCB's Executive Director and it's really a job I greatly enjoy, especially when I get the chance to connect with and hear from our certificants and we get the chance to do that today. So I appreciate you being here. Before we get started, I do look forward to introducing our three panelists here today, but before doing so, I do have a couple of announcements I wanted to share and updates to provide to you as we get going here. First, we'd like to thank our sponsors for this year's webinar series, who through their generous support have helped keep this webinar series complimentary for our certificants. So we appreciate them. Kindred at Home and Bluegrass Care Navigators, thanks so much for their ongoing support. So thanks very much for that. Second, I'd like to give a couple of updates and Gina, if you wouldn't mind moving to the next slide, that'd be great. We have some upcoming events that I wanted to share. First, for those of you who initially certified in 2016 or 2017, you're eligible to renew your certification this year. The application deadline is August 26th. The early bird deadline is August 5th. So make sure you get your applications in and we look forward to receiving those over the next month or two. Our next webinar and coffee chats are on the screen here. I'm looking forward to the next two webinar sessions. They're going to be great. The topics are very interesting and you can find more about those, both the webinars and the coffee chats right on our website there at those links. And I also wanted to just share briefly that we've been able to secure some discounts and free access to a couple of upcoming webinars and sessions through our friends at Weatherby Resources. Take a look and if you see something that interests you, please reach out to Gina as she just put in the chat at her email address to get those discount codes so you can participate. So now without further ado, I'd like to take a moment to introduce our speakers for today. First is Mark Corbett, MD FAHPM HMDC, who's going to serve as our moderator. Mark is the medical director for the Kate B. Reynolds Hospice Home in Winston-Salem, North Carolina, and we appreciate him being with us. We also have Keishonna Guidry, MD HMDC, who serves as a team physician for VITAS Healthcare in the San Francisco, California Bay Area, and Brian Michalosko, MD HMDC, who serves as a hospice medical director for Hope Hospice and Palliative Care in Rhode Island and serves on the faculty of the Brown University Hospice and Palliative Medicine Fellowship. So thank you so much to the three of you for being with us and doing this and I will turn it over now to Mark to get us going. Thanks so much. All right, we'll start out today with a case presentation and then just kind of go around. We're going to each kind of talk about some challenges with this case and talk about how we potentially navigated that and really just open it up for discussion. So I guess with that we'll launch right in and start with the case. So our case for today is a 78-year-old woman with breast cancer who's currently GFP at a hospice in rural New York. Her symptoms are best managed by a PCA pump without active titration. She has a history of methamphetamine and prescription drug use. Her husband, who is a retired nurse, is concerned about her receiving any pain medications. The hospital plans to discharge her, but they are unsure where to send her. Over the Fourth of July weekend, she begins experiencing pain that she rates as nine out of ten. When she presses her bolus button, her pain comes down to a four out of ten, which she finds tolerable. However, her improved level of pain lasts only about two to three hours and she has to take additional medication more frequently to maintain the desired level of pain control. She asks if anything else more can be done for her pain. Her husband insists that her PCA pump setting not be increased and expresses fervently that he can manage her care at home. The physician is concerned where to send the patient after discharge, how she will access medication over the holiday weekend, and worries the patient's husband will not provide her with the appropriate medication if she is discharged home. So with that, I'm going to pass the baton to Kay. Let her start it off here. Yes, good morning everyone. Can everyone hear me okay? Yeah, so I am going to focus on this hairy case, the component of it dealing with the family members and primary caregivers. So looking at this case, we can see that there's a loved one who has medical knowledge, and I know many of us have run into situations where, you know, we have to meet them where they are and kind of help them focus on the goals of care for the patient. When they may have fears of opioids, or I had a recent case where a family was stuck on needing steroids and wanted to use an old prescription they had because they figured the steroid was going to help with the edema that was actually a CHF exacerbation. So I just want to have a couple points about best practices for dealing with primary caregivers with varying degrees of medical knowledge. So my first point is saying, reminding us that our procedure is having this courageous communication in the difficult conversations, and that's what we do well. So number one, I like to meet them where they are with their medical knowledge and acknowledge it, separate their role as primary caregiver from their respective profession. I recently had a son who had been taking care of his mother for 12 years. I had a palliative care pharmacist who was taking care of a spouse. And so if you can imagine, they were very adamant about their routine and their knowledge of what they knew the patient needed. And so it was an opportunity for me to dismantle their fears with the imminent death and also help them understand that I was not there to fight them. I'm there to work with them on meeting the goals of care. So it was an alignment of getting with them and helping them to focus on the goals of care and embracing their role as primary caregiver and giving that patient the love that I can't necessarily give them because I'm just their doctor. And so it's kind of like humbling myself with the medical knowledge and letting them see their role as the the loved one and knowing that we have roles that are common for a patient to help them get comfortable. Another point here is the medication. So if we have someone who has a high degree of knowledge with medications and they want to self titrate medications, or they think this one medication is the magic pill to a symptom when they don't realize there's another organ system affecting the symptom. Again, this is about advocating for the patient while educating that family member and just helping them see the difference. It takes time as we know, but that's why I picked this profession. I know so I'm not limited by 15 minutes with an encounter. So I can spend the time educating them and helping them understand what we're doing and how we're again meeting the goals of care. So those are my few points there. I'm open for questions. I'm not sure if we're doing it now or later. But those are the things I wanted to point out about this case. Any other points about dealing with family members? I see a question in the chat room. Gina, do you want to moderate that? Or would you like for us to no, go ahead. If you're if you see it come through, you can definitely present it to everyone and go ahead and answer it. All right. So Emily, do you have any tips for respectively helping to separate caregivers profession from the caregiver role? Yes. And it was like I said, I validate their profession, whether it's the caregiver for 12 years who hasn't gone to a medical program, or palliative care pharmacist that I had recently, I acknowledge it, but I also highlight and elevate their role as, you know, spouse or son or whatever it is, so that they can embrace the time that they have left with their loved one. And I educate them, or not, you know, sometimes I'll say, Oh, you learn this, you know how this is, just let us do it. Let's take let us take the team take the burden off of you. So you can focus on holding your your loved one's hand or whatever it is. So that's what I do just have the conversation. J. Joseph, I find it challenging to deal with family members who have consulted Dr. Google. Yeah, I'm sure we all have that mug. Don't confuse my medical degree with Google. But you know, I actually, I empower them with Google, I say, Well, did you look at this, you know, did you make sure you felt I'll direct them to particular websites, you know, Mayo has a good layman's website. And I'll tell them to always go to the images and, and I remind them about scientific integrity. They know a little bit, but but they don't have the big picture, and they may be missing something. And so I in my own way, you know, sometimes more aggressively than others, help them see all sides of the coin. And so they can. It's really they're really driven by fears, and panicking, you know, the life is slipping away. And so I help them kind of let that go and trust us with the care. So that's, that's what I try to do. Overall, sometimes I see it as wrestling with family members. And it works. Okay, that's all I see in the chat. I see Dr. Farrell has his hand up. Hi, good to see you. I was gonna say I think I think what I'm about to say is I feel like a kindred fellowship with most of y'all, but with all the words you said, and I was just going to say a few things, because I had this just last week sitting with a daughter, who's a nurse and infusion nurse. And no surprise, she wanted some infusions for her mom. And as we were discussing this, I think two things that you've kind of already said is one, I think it's also good to be very intentional, that we are emotionally aligned the same way. So letting them know that I so much understand that they want the very best care for their mom, and I want that too. So I just make sure I say that intentionally to them. And then I think what you said about time is very wise that I'm glad that I got to sit in that home for like about 45 minutes, because I needed, I needed at least 28 of those minutes to pass before I could say this, the I love your word courageous conversation. If I had started right off the bat of saying no, no, no, you're, you're not aligned with your mom's goals here. That would have not gone well. But about the 28 minute mark, I'm making that number up. But there's a point in there, where just having spent enough time looking at the mom and hearing what she was saying, and looking at the daughter and hearing what she was saying, that all of a sudden, there's a moment where I could finally crystallize it. And I said to him, because I had an argument that both sides could resonate with. And I, one of them was the daughters were going crazy that the mom wouldn't wake them up at night when she had problems, because she was being conscientious of them. And they were wanting these things for her mom that she was clearly not asking for. And after enough time of hearing this back and forth, I could say, you know, the moment we're in an interesting moment right now. And this is one that I've been in before with families where I can see that you love your daughter so much that you're not willing to wake them up at night, and they so much want to help you. And so now the daughters are like, Yes, thank you, doctor. And at that same moment, I was able to say, and I hear families who love their mom so much that they're not ready to let go of things that she's ready to let go of. And then they pause and like, Well, wait a second. And then I said, I'm about to ask your mom for the third time to offer her something that you want me to offer her that she's not commented on the fact that I'm having to ask this a third time to her directly lets me know she's not in the same place you're at. And just finally, that moment, I could have that craziest conversation because I had time, time to listen and time to be with them. So thank you for saying those those things. That's great. Anyone else have any comments on case points at the moment? If not, we'll move on to Brian. Thanks, Mark. So good morning, everyone. And thanks for joining us. I just wanted to add some insight here in with my background, working with a lot of symptomatic patients. And what I think I love about this case is that it's very appropriate to our upcoming holiday this week and situations I found myself in before. And I think one of those things is certainly I've practiced in both very urban environments. So I'm thinking of New York City, where I was for a number of years, and then I've practiced in in the exact opposite environments, working in areas served by critical access hospitals on the West Coast. And one thing I always think about with holidays coming up is have I have I located every 24 hour pharmacy and identified them in my phone? Because inevitably, given that call on on in this case, the Fourth of July or Thanksgiving, or, you know, pick your holiday, it's going to be tough. And I think we, you know, we are used to the idea of, you know, as physicians that, okay, I'll order this medication, it'll magically be delivered to my patient, and they'll receive it, and that'll just be the end of it. And then you realize, oh, it's, it's, you know, winter, and it's snowing in the city, and I have an elderly homebound patient, and it's now a holiday weekend, how do I get their meds to them? And so one thing I always keep in mind is, is what are all my 24 hour pharmacies? I think a big part of it too, is, is the some of the foresight to think about, you know, if I have a panel of patients, who are some of my more symptomatic patients? And have they been calling in issues this past week, or the past couple weeks to some of my nurses that have been seeing them more frequently? Have they had a pain crisis recently? And, and should I, you know, give them a little more attention before the holiday to make sure that I'm not getting that call on, on, you know, on that day, looking at how I can get medication delivered. And a few tips, aside from, you know, knowing all the 24 hour pharmacies, that even if you know them, then the question becomes, well, how do you get it from point A to point B? And so I'm thinking of my time in New York City for some of our docs in the, on the webinar here that maybe work in a, in a bigger city environment, where I have a, an elderly patient homebound, and, and now I'm trying to figure out how I get them, even if I know the 24 hour pharmacy, how to get it from them to their house or their apartment. And that can be a big logistical effort. And so thinking about, is there family involved? Is there, do they have a delivery service? Or some other, other way of doing it? I know that in, where I was practicing in some of the more rural areas in California, it was not uncommon that we would just run out of medications because we were a small critical access hospital that was about four to five hours from any near city. And in those, we had to get creative in terms of how we would get medications. And so we would have to think about notifying, trying to stock up with our courier service days before the holidays and in emergencies, emergency situations, we actually contract with the highway patrol and they would actually bring medications from a nearby pharmacy that was about four hours away from one of the big cities that we work with. And so there, there are ways to do it, but you need to think ahead of these things is the biggest message I can, I can say today is anticipate these things because if something will go, something can go wrong, it will go wrong, especially on a holiday or early at night or some other time when it's not opportune. So that was one of the insights I wanted to share. The other part of this case that struck me is, I think there's some history of substance use here. And I think this is something that a lot of our, a lot of us run into when we're trying to really do a good job to address our patient symptoms. And, and how do we navigate that line? We're worried about having, you know, large doses of controlled substances in an area. And how do we treat our patients best in those cases? And I think there's a number of things we can do. We can work with, make sure there's safe access in the house. So if a loved one is dispensing the medications, make sure that they're appropriate for, they're stored in a safe place, that they're well-educated about what doses to give and how much to give, what symptoms to look for. I think making ourselves just very available to phone calls when we get inevitably called from family saying, what do I do in this situation? There's still plenty of pain or symptoms. How do I treat this? I myself have gone out and done some additional education in using medications like the buprenorphine or methadone. So that way I am familiar with those medications. And a lot of times, even when we're discharging patients from say the inpatient setting, home, I'll work with clinics like methadone clinics and say, you know, we're gonna, while the patients are here in the hospital, we're gonna make their doses TID rather than daily for their methadone. We'll titrate it up. And then when they go home, they'll go home on that consolidated dose of one daily dose at a much higher dose based on what their needs were in the hospital. Or we'll have our, even we'll have our prescribers who are in say one of our oncology clinics kind of embedded in there. We'll have them take over the prescribing and do frequent small prescriptions that are checked in every three to four days so that there's not a, you know, a 30 day supply at home or something if we're worried about that aspect of their care. So kind of a few points I brought up there, but I'll just kind of throw it back to the audience and if there's any questions or comments on some of those thoughts, and I'd love to hear any insights or questions. I see Dr. Rosen, I see a hand up. So Alan. Hi, excellent presentation, great insights as well, Brian. I agree with you on some of the clinical aspects to be clarified a little further in terms of what types of pain, and especially when we get involved, sometimes other providers may have started that pain pump without necessarily looking at what are the etiologies involved? Is this a bone pain? Is there a med? Is it a compressive? Is it a lymphatic issue? Is there another modality that could be helpful? Where is the pain? So if in this case, advanced breast cancer, and if there was a radical dissection or extensive lymph nodes, is there lymphedema? Because that type of pain, then using compression therapy as well as other things. And then I think you brought up a great point as well on the clinical aspects of prior opioid usage history, because then significant other, as a retired nurse coming at this, limiting the pain medicine to just be, it didn't even sound like it was a basal rate. It sounded like it was only bolus dosing. And so what is the rationale from his point of view, their point of view, because there may be a more effective regimen with a basal rate that gets to a lower total opioid use amount, especially if you have appropriate adjuncts and those come to mind as well. Yeah, a lot of good points there. And I'll just kind of throw some things that I thought about as you were making them. You know, one of the things I think about is just kind of the level of control that we have as clinicians in terms of how these medications are dispensed and so on one end, I would say would be, here would be a prescription, there's some number of pills or whatever it is, and it's up to the family's discretion to dispense them as they will. On the other end, I would say would be something like a PCA pump where the settings are kind of locked in and calculated and they can be controlled from the box and so there's not a lot of discretion for the family or the patient to change those settings. And we can control them by checking in, periodically with the family. So on those PCA pumps, you might even have where the solution of whatever it is you're infusing, dilaudid or fentanyl or whatever is, is in a locked canister. And so it's just kind of dispensing at a constant rate. So you have the ability to do the basal dosing, the demand dosing, but there's not a lot of leeway for that medication to be used otherwise. Other things I think about too are situations I've been in where patients are on very high doses of medications, and that's possibly related to a prior history of substance use or just very uncontrolled symptoms. And what I'm thinking about is someone who's on, say a couple hundred milligrams of methadone daily, and as their condition evolves, now they're becoming less responsive and less able to take oral medications. And so what do you do in that situation? And I think a lot about, you know, relying on the resources you have in the area. And so when I've been in those situations before, I try to rely on my local, if I'm fortunate enough to have an inpatient unit, hospital that is, and so I'll say, you know, we need to have a plan so that when the patient gets to a point where they can't take in their methadone or they can't take in their whatever, you know, oral medication they're being treated with, that's when we think about transitioning them to an inpatient setting. When I don't have that inpatient setting luxury, you know, it may have been boiled down to utilizing maybe a GIP level at the local hospital, which we've done before. And so when I was working in a critical access area where, you know, all we had was a 25 bed hospital, I think about similar patients who I would actually brought in, and we had them on a ketamine infusion for like three weeks and they were just inpatient there. I know it's not ideal for the hospital, but sometimes your hands are forced with terms of what you have with your local resources and how you can best with these patients. So a couple of points there, Alan, I hope I responded to some of them that you brought up. Ryan, can I ask a question quickly? I know that I'm not one of you all necessarily in terms of a physician or a hospice physician specifically, but I was very interested to hear you say how your hospice utilized the highway patrol to help with the... I mean, can you talk a little bit about that, how that worked? And I don't know if others have thought about that or utilize that in a situation where they have, you know, long distances between places to be able to get meds to the patient, but I thought that was somewhat interesting. So would you mind sharing a little bit more about that experience? Sure, I think it's a pretty unique situation that's, you know, really specific to the geography we're in and where I'm thinking of where I was practicing was kind of in the Eastern Sierras in California. And so we were about four hours from Los Angeles, four hours from Las Vegas and four hours from Reno. So there really wasn't any easily accessible place and you throw in the notoriously harsh winters that can take place out there. And you're talking about in winter time, even though the area does have a medevac, a pretty high functioning medevac system actually for getting patients to those cities, you could easily be down by hours when you're looking to get a patient out or trying to get something in. And so you have to be very creative. And so I think where this started from, Mark, to answer your question, or I'm sorry, Bruce, is when we had patients that needed blood products and so we'd say, okay, how do we get a patient a blood product? When they come in, they've got, you know, they're on an anticoagulant and then this was, there was some general medicine I was doing there as well. And so what would happen is the, I'm thinking of how we'd get it from a hostel in Reno would be the Nevada version of their highway patrol would get an ice chest, bring it to the state line, the California highway patrol, which then take that ice chest at the border, bring it down to us. And we'd have it in about maybe three to four hours, which was actually pretty good given the circumstances. And I don't know if anyone's ever driven from Reno down some of the Eastern Sierra highways, but they're pretty brutal, especially in winter. And so the thought came from, well, if that's one way that we were getting critical supplies, could this also be a way that if we need some kind of critical medication could be utilized as well? And so I wasn't involved in the actual setting it up. I was more on the end, on the kind of the receiving end of it, but I know our pharmacist did a great job and had a very good relationship where they kind of had some context, they can say, we had this emergency and we do this protocol and they would be able to get medications in fairly well from that system. And Brian, looks like Chris Downey has had some experience with the highway patrol as well. I don't know, Chris, do you wanna speak to that a little bit? I see your comment there, Chris, and thankfully it's- Yes, I had experienced the same thing. I was assisting in an operation and we needed more blood and the highway patrol had to bring it from 40 miles away over to us in an emergency setting. And then I went to a medical meeting that night and they said, well, we don't have a medical meeting for you, we don't have a medical meeting for you. And then I went to a medical meeting that night and I was speeding to get to the medical meeting because I was late for the other, I got pulled over by the highway patrol. I said, well, thank you for getting that blood to us, it really helped the patient. And he said, well, I'm gonna give you a warning, you better not drive any faster than 55 miles an hour. But anyway, that was our experience, but I think it's another avenue for those rural places, especially if you've been contracted, if you have that kind of need. So yeah, so no, that's true. And I think, and Chris, that's a great point. And I think one of the bigger things I would say to our group here would be just how important it is to be also familiar with some of the laws in your state or your city or even your local area, because we're now talking about controlled substances that are being moved in a hurry and those are things that typically aren't meant to move in a hurry. They're controlled, it's in the title for that reason. And so keep in mind about who can take custody of these things, who can account that there's no diversion or anything else. And so that was a big part of the protocol having it in. Thankfully, in some of the bigger cities, that's not a problem. But I think the other issue becomes, like I was saying earlier, you have someone who's homebound and they can't move their apartment. And now how do you get the medications from their pharmacy to them? And so thankfully, a lot of pharmacies will deliver in those areas. They have pretty, I know New York City is great. A lot of their pharmacies, you call them and they'll have someone either walk it over on a bike show up or whatever, but certainly controlled substances make it a whole nother level of complexity. So I think the message here is anticipate these things well in advance, think about them with your staff and contact your pharmacy early on to say, here's some things that we could run into. How do we work together to anticipate these and result in advance without running into a holiday weekend or a holiday situation with poor weather or something. I see your comments here about the submissions being open. So yeah, that certainly would be a fun one to submit. I have to get some pictures to put in the paper of the poster. Yeah, I think after a few times of doing it, I figured out what their accounts were on social media and I started sending out these kind of nice messages saying, oh, thank you to the local high patrol in this area for this great work. And I know they certainly appreciated it as we did because we were really in a pinch without their help. All right, that's some really good discussion. And thanks absolutely Alan for your comments there too. It's a great idea. Well, and I'll move into, you just, I guess, what kind of struck me about the case in particular was, we've had a few kind of similar instances here in our hospice home or IPU when folks are on PCA pumps and having challenges with discharge from the IPU or finding kind of a safe discharge plan from our IPU. Say, unfortunately in our area, one of the things that's challenging is to find a facility that's willing to contract with us and where we can send someone who's still on a PCA pump. So currently in similar situations, what we've done is if we're not actively titrating the pump, we haven't kept the patient GIP, but we'll make them routine home care while they continue to reside in the unit. And I'm just kind of curious what other people have done in similar circumstances. I mean, I don't know, people may keep them GIP as long as they're on a PCA pump or people may take them off or there may be folks who have facilities nearby that if they're not a safe discharge home, maybe they can send them to a facility, but we've met quite a bit of challenges with that here recently and then end up with folks kind of staying in our IPU for a fairly long period of time while we're working on this and usually not under a GIP level of care. So I guess it's kind of twofold. It's kind of, if you're not actively titrating the PCA, then is the patient still a GIP? And then if they're not and you're really needing to look at discharge, what other avenues might there be or what have other people done in similar circumstances? I'm just kind of curious. Thank you. So Marco, I'll jump in and respond to that and say definitely a tough situation because you're between a rock and a hard place where we wanna make sure that we're providing the best care to our patients and some of them may have an extended prognosis. And I think the question at some point becomes, like you mentioned, how do we ensure this patient is really GIP appropriate versus could they be managed in a different situation? And so I think part of that, I would say is very careful screening on the front end of make sure these patients are appropriate to begin with for being in, say, your IPU because I think the reality is we only have so many beds in our IPUs and that we only have one IPU in the entire state of Rhode Island. And so we were fortunate to expand recently and I think we've been able to do a good job with getting all the patients in who need it. But certainly there are patients who will come in and have extended prognosis and they can certainly take up a lot of resources with staff and beds and things. And so I think screening them on the front end is very important. And we always try to have a good discharge plan in place should they have an extended prognosis. Where could they go that would be safe? So are there other long-term care facilities? Are there rehab facilities, nursing facilities, whatever it is, other family that can take care of them? And try to get that early on so that way inevitably at some point when you're into that you've got, I think, a plan and also resources to help you to navigate that. I think a part of it too is having conversations early on with families to set expectations about what can we provide here in our inpatient unit and what is appropriate and why do we have this service here, right? For patients that either have a decline or that are symptomatic or something. But like you mentioned, if they're kind of on a stable dose of a PCA for a long time those become really tough situations. And so I'd say a lot of education, a lot of screening on the front end and a lot of planning for contingencies will really help you in those cases. Thank you. There's a question in the chat about diversion and being absolutely certain that it's happening and how do we manage symptoms. Besides doing APS reports and things of that nature, all I can think of is placement for the patient, if we can get that done depending on the family dynamic, every situation is different. I'll keep it open to the panel as well. Yeah, I think going back to what I was kind of commenting on earlier in this situation is these can be kind of very labor intensive patients for your group. And I say group because really it needs to be managed by you and your staff. And so, whereas if you're the prescriber, you have your hospice nurses that are going to the home and checking those patients. It can be a lot of things, like I said, working with family, a lot of education. I think the prescribing really comes down to a few days at a time and checking in. So things like pill counts and making sure that the medication is handled safely by whoever it is that's in the house. And I always think about kind of safety being on a spectrum, right? And so if we're in the, you know, inpatient hospital side, I would say that, you know, of course, safety is important. And it's the utmost important. Those nurses in the inpatients that are checking that the patient's taking their, you know, they're swallowing the pills or they're getting the right doses. Everything is accounted for on the MAR. In the hospice environment, I think that we negotiate with symptoms as well. And so as much as we want this to be the safest environment possible, there's also a role to be said about how can we also make sure that we're managing symptoms and that we're not restricting medications too severely. And so I think the mix in between those two is to do short amounts of prescriptions for a couple of days, check in, send another script, and go from there. Other things I'll do at times is I'll utilize things like, if I can, patches, right? Things that I can put on for a couple of days at a time, and then, you know, let them taper off over three or four days, like a fentanyl patch. I've used a lot of buprenorphine patches in my practice. I love those because I can put them on and they last seven days. So they're great. And I think there's a lot, there's increasing willingness for people to prescribe them. But I will say it does take a lot of education if you're going to use the buprenorphine patches because a lot of docs in the community, if you have them prescribing for some of your hospice patients, will say, well, I can't prescribe this because I don't have a waiver. And with a lot of education, RNs say, no, you don't need a waiver if it's for pain or symptoms. What they're thinking about is more for if there's an addiction, you know, maintenance therapy for that. But in the pain and symptom setting, you don't need the waiver for that. And that needs to be, I think, doing a good job educating your colleagues on that. Even your pharmacists, I've had pharmacists call me and say, you know, I can't dispense this. The person's got a waiver. And I'll say, no, it's for pain. And then they've called me back. So, okay, we took it up if you're right. But it takes, you know, a day or so to get. So, again, kind of anticipating these things before they come up is a huge part of is make sure that the patient's able to have his medications. We have Chris with his hand up. Chris, if you want to share. Yeah. A PCA doesn't necessarily. I suppose if you're instituting it and adjusting it would be for a GIP stay. But I mean, we can do that in the home also. So, that by itself does not, to me, say you need, classifies as GIP care. We have, we know that Medicare is looking at GIP stays and belong GIP stays. So, that's a red flag to them if they're staying in a period of time. They want to make sure that you're documenting what nursing cares need to be undertaken to manage this patient on a daily basis. And we're now doing that. Some of our GIP stays are in our inpatient unit. Majority of them are, because we're big hospice, are in hospitals. And so, the team doctor is actually calling and talking to the hospitalist and documenting what's going on. So, that there is some level of care management with the provider. And then our nursing staff also goes in and sees the patient. Somebody from the team goes in. For those patients that are admitted on GIP, and then there's a problem placing them, we will put them on routine care. Now, those were large systems. So, those are our hospital-based system. And so, they're, it's uncomfortable for them, but they agree to continue doing that care, level of care. So, that's the GIP. For diversion, we're fortunate enough to have a pharmacist employed with us. And he or she will go out and have a conversation regarding diversion and draw up a pain contract at that time. And depending on what level is happening, you know, whether it's going to be the pill count or feeding, I mean, it's pretty clear. And then, obviously, if there's a lot of diversion going on, you can discharge for cause. But because they're not following the treatment plan, and they're not following the contract, you have to document that pretty closely. So, those are my thoughts. Absolutely. Thanks for sharing, Chris. It's very helpful. Yeah, I mean, we do the same thing. Of course, here we have a freestanding inpatient unit. We don't have any current GIP beds with the hospital. But certainly, our practice has been once we, you know, no longer titrating, you know, actively titrating the PCA, and pain seems well controlled, we tend to change level of care as well, irrespective of kind of, you know, not having a discharge from discharge plan at that time, and then end up having people kind of here with us on routine home care for whatever period of time it takes us to find that safe discharge plan. Looks like there's some more comments here in the chat. Let's see. It says, Emily Looney says, also, if we can have effective courageous communication with the patient spouse to appropriately adjust the PCA, pain management may be significantly improved to make a home discharge plan more tenable. Absolutely. Yeah, I think that's a great idea. Being able to, you know, engage the spouse, you know, appropriately and compassionately and involving the patient in that hopefully would allow us to, you know, provide better pain control, you know, kind of figure out what the actual kind of barriers are to further titrating the PCA, allow us to achieve better pain control, and hopefully with that, a better discharge plan. So that's a great, great thought as well. Oh, looks like Beth is here. Also, they've written something in here regarding concerns for diversion. We have, unfortunately, had conversations with local law enforcement as well. And when we are concerned about diversion, we urge families to contact law enforcement or mention that we may call. We also ask for short supplies of meds to be sent, and at times have nurses present to open med deliveries, use regular med counts by our staff and other things. So, yeah, anyone else want to add to that? One thing I'd add, Mark, is I think about some times when I was practicing in New York City, and I remember that there were, you know, in addition to what Beth mentions here, there actually were pharmacies that would put pretty hard stops on how much they would dispense. And that was a tough for us because there were certain areas where patients were clearly in need of, you know, high doses of, you know, pick whatever opioid it is that they were sent home on. And the pharmacy would say, well, that's really kind of more than we would, you know, feel comfortable dispensing. We're going to limit it to only X number of pills or X number of milligrams per day or whatever. And so you really have to think about, I think, you know, that as well. But so, you know, in those cases, we'll work with our hospital pharmacy or work with our even a hospice pharmacy that we're contracted with to get the patients right medications. But I think, Beth, you make a great point about, you know, I think it's all about short supplies, frequent check-ins. You may need to have your nurse, you know, check on this patient every, you know, maybe day or two, depending on what your resources are. And but, yes, it can absolutely be tough in situations. And I've never had to have law enforcement involved, thankfully. But I think that, you know, just the amount of labor just with your staff can be quite a bit and could be quite challenging. So, yeah, opioid contracts, you know, and those are, remember, opioid contracts are they don't have any beneficial effects on patients. They're more for for us. Right. So we can say we talk into this agreement or whatever it is. And so I keep that in mind as well when I'm doing those. And also, you know, speaking with them, because I don't want them to feel they're punitive. Right. We have to be sensitive to the nature of our patients' conditions. And so I think we, you know, it's more of a strong understanding of, you know, we're only going to prescribe this number if your pain worsens and we cannot assess and it warrants a further increase will, you know, just at that point. But certainly, you know, having like I've been saying, having family involved, a lot of education, a lot of frequent check-ins, short prescriptions, all these things are very helpful. Thanks, Brian. It looks like there's some good conversation in the thread here, too, about, you know, just GIP contracts with various hospitals and duration of contracts with hospitals and some other things. Alan, do you want to just kind of share some of your thoughts on this? I'm sure others can have different experiences in terms of and I'm coming at this for those I have met, been a hospice palliative care provider over 20 years, a number of different states, and even within the same state, different cities and health organizations can have different dynamics. When I was in the Chicago area, Evanston Northwestern Hospital, for example, we could only really have GIP patients inpatient there for, say, 24 hours because the hospital census was so tight. There was another hospital, I will treat them kindly and not name them, but in the metro Chicago area, their hospital census was often below 70%. And they got upset if routine care was transferred out after GIP, and they wanted to have that as a census. Your hospice organization may also have concerns depending on the contract. Sometimes there's an entire pass-through of the GIP or the reimbursement. Sometimes it's becoming more common and appropriate to withhold, say, a 10% fee or set amount because you're still having administrative coverage and other things involved that aren't purely billable. And so that type of arrangement may impact the hospitals, how much money, what are their variable costs involved in this. So there are a variety of things, but I want to echo what Mark, Brian, Chris, Kai, others have said that if someone doesn't meet the criteria, don't do it just to keep them at a location. That location needs to accept what the right level of care is. So even if it's a hospital, if they don't meet hospice, and again, I'm saying through Medicare conditions of participation guidelines, then you need to do routine level of care. It doesn't matter that it's in a hospital. And your billing staff and others can help educate appropriate hospital personnel. Absolutely. No, thanks for sharing that, Alan. Yeah, it's interesting to me. It sounds like you've had some challenging situations surrounding that with some of the hospitals that you guys have partnered with at times. And I'm sure other people have too, and I know for sure with us, I mean, folks have gotten kind of, you know, just downright nasty at times about it. And since, if I may, just to put out there, as this session is talking about settings of care, the same as a corollary applies for continuous care. So making sure you are following appropriate practices and that your organization and your staff know what's involved. The other thing as a reminder, and again, since everyone is hospice MD certified, you'll know the regulations, I'm sure. But with that, making sure you also account for all of your staff time. So if the nurse went out, how long was that nurse there? How many other people were going to be there? Are you going to have that minimum of eight hours RN time? But doing the right thing, you know, just because someone has a crisis and it comes up and, you know, if it's after 4 p.m. during the day, regardless of the 12 o'clock midnight cutoff, do the right thing for the patients, families, and in your community and there are ways to try to address that. Absolutely. Thanks again, Alan. You know, I think about just how I've seen it in various hospital settings. I know that we just went through a change in our hospital here in terms of how some of our G.I.P. and hospice patients are managed once they get to that point. And so it used to be a few years ago that our hospital, you can only be in a hospice bed here if you were, I think, if you had Medicare insurance and you had an oncodiagnosis of some sort. And there was like, you know, a handful of beds on one floor that that was basically limited to. And I don't think I ever put anyone in those beds because it just was the restrictions were so many that we couldn't really do it. We renegotiated with the hospital and it's now been changed pretty dramatically where now really any patient can go on to G.I.P. hospice beds here. But the expectation is that there's a couple. And so if the patient is not stable for transfer to a different facility, they can stay there for a certain duration or if the patient's prognosis is very limited. We're talking, you know, on the order of say hours, then the hospital will be OK with that. But sometimes what happens is these patients, you know, they might look critical at some point and they may stabilize. And now we're on day, you know, 48 hours, 72 hours later, and we're asking, OK, we need to reassess here. And then the patient will end up getting transferred to, say, our inpatient unit or we'll start looking for a long term care or a SNF or some other facility they can go to. So I think it's been pretty dramatic with being able to provide hospice services and being able to provide hospice services to our patients that need them in the hospital. I think it's I think it is the right thing, as we talked about a second ago. And certainly it kind of aligns everyone's needs with the hospital wanting to provide good care, the patients wanting to get the hospice services and us wanting to get them to the right level and place of care. That's been pretty huge. One thing I do find that we run into in that situation is once the patient is, you know, transitioned to a hospice bed, they technically get discharged and readmitted. The patient never knows that because it's just basically a bed control issue. They just reassign a new number for the admission, whatever. But then what happens, I think a lot of our colleagues think, oh, they're now a hospice patient. And so the hospice and public care doctors will take care of them. And then I somehow my name will get into the chart. And at Sunday morning at 2 a.m., getting a frantic call saying there's no orders here. Who's who's the responding person to put these orders in and say, OK, we need to really make sure we educate about when they are in these hospice beds, who's actually taking care of them? It doesn't mean that the team that had them before is no longer taking care of them. In fact, it is that same team. We're just here to provide recommendations. Our nurses will visit them daily to check in as well as an extra layer of support within the hospital. Thanks so much, Brian. That's great. You know, unfortunately, this has been a great discussion. Unfortunately, I think we're going to have to go ahead and wrap it up. I just want to thank Bruce and Gina again for for inviting us all to participate. And I think Brian and Kay for their willingness to participate on the panel. So it's been a been a great discussion. And I just thank everyone for for for being involved today. Thanks, Mark. Thanks, Mark, Brian and Kay. Appreciate you doing this. Appreciate you being willing to to serve as panelists. And we're looking forward to continued conversations and and upcoming sessions like we talked about at the beginning. We've got a couple of additional webinars coming up later this year, as well as a couple of coffee chats, which we hope you'll attend. I know several of you. I see several names on here that regularly attend the coffee chats, and we appreciate you doing that. It's an opportunity for you to get your questions answered, get your issues that you're having answered by your colleagues. We encourage you to take advantage of that if you can. So, again, looking forward to seeing you all next time. Thank you so much to Mark, Brian and Kayshana. And we'll we'll see you all soon. Thanks so much. Thanks, everyone. Everyone. Thanks, everyone. Thank you.

Symptom Management

Different Care Settings

Webinar

HMDCB

Hospice and Palliative Care Certifying Board

Panel Discussion

Hospice and Palliative Care

Challenges in Care

Symptom Control