Well, hello, everyone. Welcome to the third and final 4 HMDCs by HMDCs webinar series event for 2021. I'm Bruce Hammond. And I serve as HMDCB's executive director. And it's great to have you with us. Before we get to the session today, I'd like to just take a few moments to give you a couple of updates and housekeeping items before we get to our fantastic speakers on the topic of the changing requirements of HMDs. So I'd like to first take a moment to thank our series sponsors who for 2021 have helped make it possible for us to host this series complimentary to our certificates. Those two companies are on the screen here, Kindred at Home and Bluegrass Care Navigators. Just wanted to take a quick moment to say thank you to them. Thank you for their investment in making these happen. And we really appreciate their connection and their ongoing support. I'd like to also just take a quick moment before we get started to make you aware of a few upcoming events that we're going to be having here in early 2022 and throughout the year actually in 2022. So as you can see on the slide, our initial application window will be opening on January 11th. So we really encourage you to help us spread the word to those physicians you know who aren't yet certified, but should be certified. Because as I think you're aware, the more high quality physicians who become HMDCB certified, the more value of your, the credential of your value increases. And we certainly hope you'll help us spread the word as that launches in early January. I also wanted to share that we are planning to host quarterly webinars once again in 2022, as well as quarterly coffee chats, which are opportunities for certificates to come together and connect on topics that are important to them and topics that are necessary for them to effectively do their work as a hospice physician. So we hope to see many of you at those events. More information on the dates of those, the official dates, the final dates of those will be available as we head into 2022. So we'll be sure to share those with all of our certificates at that time. And finally, just wanted to share with you that there's an upcoming event put on by our partner Weatherby Services called the Hospice Physician Documentation Clinics, which are taking place on January 14th, 21st, and 28th, it's a three-part series. And we're pleased to share that Weatherby is offering all current HMDCs a 10% discount on participating in those events. And so wanted to let you know that you can go to hmdcb.org slash events and to learn more. And also you can email Gina Parisi at gparisi at hmdcb.org to get the discount code for those events. If you're interested in participating, we'll also be sending an email to the certificates to let everyone know that those will be coming and to provide the information on the discount code. So wanted you to be aware of that. A little perk of being HMDCB certified is this discount. Just a quick reminder that as we go out, go on through the remainder of the webinar to be sure to keep yourself on mute and provide all questions in the chat. And with that said, I'm going to turn it over to today's presenters, Ron Krosno, Bethany Snyder, and Ed Martin. Ron, take it away. Thank you so much. I appreciate that. And season's greetings, everybody. Appreciate the opportunity to talk. We're going to talk a little bit about telehealth today and best practices for hospice. Next slide. There we go. I don't have any real, any pertinent disclosures in the chat. So I'm going to turn it over to Ron Krosno, Bethany Snyder, and Ed Martin. Ron, take it away. Thank you so much. I appreciate that. And season's greetings, everybody. Appreciate the opportunity to talk. We're going to talk a little bit about telehealth today and best practices for hospice. Next slide. There we go. I don't have any real, any pertinent disclosures in this information is subject to change. It changes pretty frequently these days. Next slide. Hospice medical director. Oh, I'm trying to get something. Just a reminder to everybody, you may want to mute. Thank you. So today we're, my section, we're going to talk about how telemedicine and telehealth have kind of been utilized in hospice. When I gave this talk previously, the talk this was based on, there were a lot of regulatory changes. It was very new to folks. And we've changed it a little bit because I think most of us have had some experience with it now. And so we're going to talk a little bit about best practices. Next slide. So before the pandemic started, there was a kind of this slow, almost glacial acceptance of telehealth. There were a lot of regulations, the regulations regarding where you could do it from, where the patient needed to be when you did it, that all kind of got waived during these public health emergency waivers that came about with COVID-19. And at least one source that I ran across, and I think everybody agrees with it, that more has happened in the last year regarding telehealth than has happened in the previous 20 years. As we start, hopefully, to enter the post-pandemic period, we're hopeful that some of the legislative actions that are necessary to keep some of these changes in place will happen. But if they don't, many of these waivered provisions snap back to the way they were before. And so we've got a lot of restrictions potentially returning. CMS has actually been a little reluctant to come on board saying that they want these changes to be permanent, in part because they've said it's going to increase their costs. They have concerns that telehealth makes it easier to see folks, we'll have more visits, and will result in more billing. Now, in the hospice world, that's not necessarily the case. So we're going to start off talking a little bit about general telehealth, general telehealth with the next slide, and then we'll move more specifically to hospice. There is an annual, if you didn't know it, there's an annual telehealth summit done every year nationally. The one this year, there was a nice presenter talking about information at his university-based medical system and presented some unpublished data from them from March to May of 2020. In March of 2020, they were averaging for the preceding year about 300 telehealth encounters a month. And in April, by May, it had gone up to 3,000 a day, quite a big increase, and I think most people have experienced something like that as well. They utilized their medical students who kind of went into lockdown as being the educators for a lot of patients and families and got people up to speed regarding how to use telehealth. And then they surveyed about 4,000 of their patients and got a 40% response rate, and it pretty uniformly showed that patients are on board with telehealth too. They're accepting of it. One thing they didn't ask but other studies have shown since then is, given a preference, they would probably rather do in-person, about 60-40 in-person to telehealth, but most people are very satisfied with telehealth. Next slide. The same report from the same group surveyed their own faculty physicians, about 140 of them. They got almost an 80% response rate, and there, again, pretty overwhelming favorability towards using telehealth. The lowest was that 73% reported it met patient needs, and most of the concerns of those 27% that didn't say yes were concerned because of physical exam issues. You just can't do a physical exam very well on telehealth. There was a strong preference amongst those physicians, though, to use it for follow-up rather than for initial visits. They felt it was much better used for follow-up visits. Next slide. So, what are some of the types of visits that are good and not so good for this? Again, follow-up for chronic conditions, if you have diagnostic testing that you're going to get results about or counseling in regard to what to do with those and what somebody's therapeutic options are, those seem to be pretty amenable to telehealth discussions. There's also dermatologic kinds of issues actually do pretty well with telehealth. Most people have pretty good cameras these days, and it's surprising to some of the derm people, but it actually worked very well. On the flip side of that, not so good for certain types of visits. If you needed a procedure, obviously that didn't work very well, and if your visit is really dependent on an exam, for example, if somebody had abdominal pain or eye issues, ophthalmologists don't like this very much, neither do gynecologists or at least gynecology patients. Not so cool doing those kinds of exams. Also, and this is a little more like what we would experience perhaps for highly nuanced care for multiple complex, very difficult, complicated patients, doesn't work as well. Patients generally do prefer in-persons, as I mentioned, and if the patient says they want an in-person exam, it's not going to work as well for a telehealth exam. Next slide. There's some regs out there that have come about in the hospice world as we switched to more hospice thing, and this was dependent on that public health emergency waiver, and this actually was a regulatory change made to the conditions of participation. Then in effect, this is a quote from it, but in effect it says, hospices can provide telecommunication services if it's feasible and appropriate to do so, as long as we ensure that Medicare patients can continue to receive those services that are reasonable and necessary for the palliation and management of their terminal illness and related conditions, the kind of usual language we see in that. One caveat is that the technology, if you're using this, you need to document in the plan of care that it is being used and why you're using it, and the why is pretty simply just public health emergency due to pandemic. Most of us are aware too that some of the HIPAA enforcements that have gone into telehealth kind of visits in the past have been, enforcement anyway, has been relatively suspended during this public health emergency, but we're still expected to protect health information and keep it secure, and whatever platform we use during the PHE, the public health emergency still needs to be a secure platform with no public-facing components, so don't do your visits on TikTok or Facebook, FaceTime, or something that's public-facing. Next slide. So the two main categories that hospice uses this in is for our meetings and for our visits with patients, and primarily the meetings I think most people are familiar with are the meetings of the team, the IDG meetings, and actually the regs never really require that these be done in person in the first place. It is recommended that you document when you're doing it. You still, because of the regs do require it, you need the core disciplines all present and able to sign the plan of care in real time. That's the physician, our social worker, and a counselor, usually the chaplain, and you can also do other meeting visits this way as well, such as a co-op meeting or the like, but most of what we're talking about I think most people are interested in are telehealth visits, and we were given considerably greater flexibility during this public health emergency to do this. We do need to document that we are using it in the note when we use it and why, and we also need some sort of documentation of that the patient consented to use it. Next slide. The notes need to contain enough information to show that there was meaningful encounter. You do have to use real-time two-way interactive communication, and in most instances, and I'll talk about the exception shortly, it can be audio, video, or audio only, that is by telephone, for things like comprehensive visits, for routine visits by any of the core team members, for a supervisory visit by the RN with the hospice aide, and for physician encounters as long as it's not the face-to-face. Now the exception I mentioned is that face-to-face, the regulatory face-to-face by regulation has to be audio, video, can't be telephone only. It can be done by the hospice nurse, practitioner, or the hospice physician, and this actually required a legislative change that happened early during the pandemic, retroactive back to the start of the public health emergency. But everything on this screen right now, unless something happens, and hopefully it will in the near future, but unless something happens, these all snap back and kind of go away for the authorization to do any of this. Next slide. Once the public health emergency ends. I mentioned I'm doing a little bit different here. Some best practices during virtual visits, because I think most of us have had some experience with this now, but maybe it's time to figure out how to do things a little bit better. You need to identify the patient, make sure that the patient knows what's happening, knows what's going on. We've all had those experiences, I think, if we've done telehealth, where the patient just couldn't really do telehealth, you need to identify who's going to be with the patient, if our staff needs to be there and the like, have things scripted out, have things scheduled properly, educate patients about how to use things, have a callback number in case the connection is lost. And then, it's not on the slide, but if you can see me, you'll notice I don't have the blurring on that so many of us use during meetings. That's potentially confusing to some patients. They're wondering what you're hiding behind you, and so it's recommended that you look professional, you be professional during the call that you use, not that blur feature, explain to them where you are and how things are working. Next slide. That first minute that you're on with the patient, you need to make sure that you set a very professional and competent tone. If you're not dressed the way you would normally see them, if you see them in person, you need to explain why you're in scrubs or whatever. You need to be warm, participatory, and respectful during the talk and during the presentation. You do want to get that informed consent and talk about what we're going to do if you lose the connection. Next slide. It's best to kind of set up the experience, explain to folks that other people can't see us, it's just you and me and whoever was on the screen. You can ask for patients to help during certain parts of things that they might show you a body part or something like that for exam. You can do a little bit of an exam by just watching body language and their physical appearance, and make sure that you ask them to repeat anything that you couldn't understand and make sure they know they can ask you to repeat things if they don't understand it. Next slide. And then there's kind of other, another best practice is to have a closing checklist. Summarize what you talked about when you get to the end, reinforce and explain again anything that you need to do that they need to do, actions that need to be taken, review any questions and answers, make sure that they're answered fully regarding what happened during the course of the visit. Provide guidance on what you want to watch, what you want them to watch for, how the rest of the team is going to follow up on what you've talked about during this visit, and then offer some instructions regarding how to contact us back again or how to reach out to the team if that's not clear to them. Next slide. In summary, I think telehealth is here to stay. It's going to take some legislative things to make that happen, at least in the hospice world as well as to some effect in the general medical world as well. Stay tuned to hear more about those real changes as these happen. And those don't necessarily happen just at the federal level but also may involve your state level also. Two major areas that hospice uses telehealth are meetings and patient visits. Make sure that you make preparation for your visits with patients by telehealth ahead of time, and recommend following those best practices and tips during these actual visits. Next slide shows some resources and references, and I think that turns us over for me to hand it off to our next speaker, Ed Martin. Thank you. Ed, I think you're on mute. Thanks. I'm gonna talk about the notice of election addendum. And I think, you know, we thought we would be inundated with doing these. Unfortunately, that hasn't come to pass, but I think sometimes when you're doing something less frequently, it becomes more of a challenge. And then what goes before that is relatedness, determining what's related. And that's really the key to completing the notice of election. Next slide. So I think that, you know, we play a critical role in developing the notice of election, because really we're at the, you know, the key person in determining what's related. Next slide. So, you know, one of the big changes years ago was when we migrated from a terminal diagnosis to really the terminal prognosis. I mean, years ago, you know, we would, you know, come up with one diagnosis, COPD, for example, and then be responsible for everything related to COPD, all the inhalers. And if they also had congestive heart failure, then that was often considered unrelated to their terminal diagnosis. But several years ago, Medicare made it clear that they consider us responsible for virtually all the care, and particularly anything that's contributing to that patient's terminal prognosis. So next slide. And again, this was, they pointed back to 1983 that hospitals are required to provide virtually all the care that is needed by terminally ill patients. I was practicing in 1983, and I can say virtually almost nothing that I prescribe nowadays was there in 1983. So things have certainly changed. Next slide. So it makes it clear we're now responsible for the terminal diagnosis, which we always have been. Diagnoses and conditions related to that diagnosis, and then particularly other diagnoses that contribute to the six-month prognosis. And so this really expanded, I think, what we're expected to cover as we now, when we have a patient on hospice. I think one area that I think can get you into trouble is your narrative. I think, you know, for years when we've started narratives, that we often saw the kitchen sink narrative, a long list of every diagnosis the patient ever had, you know, tinea pedis, everything got thrown in there. And, but the thing is, if you're basically putting that in the narrative to make the case that the patient has a six-month prognosis, you basically have said that that's related to their terminal prognosis. So I would just be cautious about, you know, anything, any diagnosis you put in to support the six-month prognosis. I think you're probably gonna be on the hook for covering those things. Next slide. So the way this came to the surface for CMS is what they call leakage. That CMS, Medicare, was paying for services and medications that they thought should have been paid for by hospice. And you see the, in 2012, this came to their attention, $33 billion paid for analgesics, anti-medics, anxiolytics, and laxatives by Medicare D. So they're wondering, why isn't hospice paying for this? And then of course, when patients are, on Part D, patients are paying for co-pays. Again, in 2013, for hospice patients, $439 billion was paid, and then a significant amount was being paid for by patients. So this really was what brought it to their concern and the concern that perhaps many hospices were not paying for medications that they should be paying for. Next slide. But it isn't just medications, of course. Just one thing to mention related in this is hospitalization. And again, I think, years ago, this was somewhat simpler. So if a patient, if we had a patient on for COPD and they went to the hospital and then ED found that they had an MI, they often were kept on hospice saying, well, this is not their COPD that they're being hospitalized for. And so they may have been in the CCU for a few days and then in the hospital for several days and then finally going home and staying on hospice the whole time for this unrelated condition, and then you leave the hospital. Now, I think it's hard to come up with a hospitalization that's so minor. I mean, it's hard to get into the hospital these days, as you know. And so the idea that the condition is so minor, I mean, if you can think of maybe if somebody was hospitalized for some kind of ophthalmologic intervention, but it's hard to come up with a reason that somebody would be hospitalized and not have it being related to their terminal prognosis. So I think that has certainly changed in the past few years. Next slide. So what do we cover? You know, the big four that were right in the regs, analgesics, anti-nauseants, laxatives, anti-anxiety drugs are expected to be covered by all patients so that's sort of the start. But I think it's important to remember these are not the only meds covered by hospice. And sometimes I think that was confused early on that we were responsible for those four and the rest we didn't have to. And again, as we mentioned, it's not just the medications, but it's labs, diagnostic studies, hospitalizations, pretty much any of these services that are gonna be related to their terminal prognosis. And really, and it's up to us, and it's our job to document why some medications and treatments are not related and covered by hospice. And so I know what some of us have done as a best practice is we even either as an addendum to the narrative or as a Medicare part D note, put in in detail what diagnosis we thought were not related and then the medications and services related to those unrelated diagnoses that hospice will not be covering and we'll pass those through the Medicare. Next slide. So this was the addendum that came out, patient notification of hospice, non-covered items, services and drugs. So next slide. So this basically goes through the purpose of the addendum. And it's basically, we're gonna notify our patients and families in writing the situations that are unrelated to the terminal illness related conditions and not covered. And it explains that we have to provide it within five days. If day one, they asked for it and within three days out of subsequent, if they asked for it any subsequently. So it's a fairly short turnaround. Next slide. And then you see, we have a list of diagnoses related to terminal illness and related conditions. And so this is where we put all of the illnesses that we're being, or we're covering and feel are related to their prognosis. So that might be their congestive heart failure, their COPD, their cancer, whatever illness we feel is related. And then the diagnosis unrelated and I think it always gets thrown out as hypothyroidism, glaucoma, things that we don't think contribute to that patient's terminal prognosis. And so this would be listed in this section. Next slide. And so then the non-covered items, services and drugs determined by hospice should be unrelated to your illness and related conditions. So it might be laboratory work for their thyroid illness. It might be the medications for their thyroid, for their glaucoma. And so that would be what would be documented in this section. Now, as you notice, there's not a big space for reason for not coverage. Next slide. And then this is basically the notification for the signatures where the beneficiary signs. And it does say that it's acknowledgement of receipt. It does not constitute your agreement with the hospice's determinations and then the signature of the representative. And I think normally this is gonna be the nurse who's bringing this out to the house or to the nursing home, sitting down with the patient or family and going through it. So they would be the ones typically who would be signing this. Although it would again be based on our input into what diagnoses are related, what services are related. Next slide. I think one thing that's missing from the addendum is probably what would be most important to the patient family. Because I think the fact that it's not gonna be covered by hospice, but would be covered by their Medicare Part D. There may be a co-pay, but that's not gonna have the same impact as when we say that actually something is not gonna be covered because we feel it's not medically necessary or we have an alternative. And this year on a call with NHPCO and CMS and the intermediaries suggested that perhaps you might wanna consider adding to the addendum the items that we felt were related, but were no longer gonna be covered. And they did not agree with that. And so it stands as is. And so the mechanism we have to address that is through the advanced beneficiary notice. So that when we provide them with the information that we're not gonna be covering, we feel this is advanced dementia and that Aricept would have no benefit. Or that yes, Lubinox is something they've been taking, but we feel we have an alternative to that in an oral anticoagulant. And so, but that was at this point, the mechanism we have to address that. And they did make the point, if a patient dies or evokes or is discharged before the five-day or three-day deadline, the hospice is not out of compliance if the addendum is not delivered. And then one of these quirky things in the rule, if the addendum is requested the day after admission, it is still expected to be provided in three days. And so that's one of the quirky things we live with on this. But as I said, I think initially there was concern that we would be inundated with these kinds of requests. I know in our program, I think we found these to be extremely unusual and not very common that patients and families are looking for this documentation. So I think then it's always a stretch because if your team hasn't done one in a few months, then I think those are things that are always more of a challenge to get it out and put it together. But I think on all of our patients, we need to be documenting relatedness. And so all of this information should be readily available in our record, as well as documenting if we're not covering something, even though it's related and why we think it's not medically necessary or we have an alternative. Next slide. So I'm gonna hand off now to Bethany to talk about GIP, general inpatient care. Thanks, Ed. It's great to be with you all today. So on the next slide, I will just reinforce that I have no disclosures. And as has been said before, things change. And as they change, we will update them in the appropriate avenues. So on the next slide, my hope is that over the next few minutes, we'll just talk a little bit more about general inpatient care as a level of care and ways that you as the hospice medical director can ensure your organization is compliant, but also providing high quality. So on the next slide, I think what's most important is we start with the patient, because I know we're all here to make sure that the patient has access to high quality hospice care and the best experience. And so let's level set around GIP. So this patient is a 67 year old. She's got metastatic cancer with lung mets. She's been in hospice for a few weeks. You've been titrating her pain medications. And then as what often happens with many of our patients that need GIP, there's kind of this acute event. So she starts having nausea, vomiting, can't take the medications, and has been without those pain meds that were moderately controlling her pain for 36 hours. I think we can all agree that this lady would be eligible for a general inpatient level of care. So on the next slide, just to refresh, GIP is one of the four levels of care that we're all required to provide. Now we can get at providing it in different ways, but we must be able to deliver general inpatient care to a patient that qualifies. It can be provided in a Medicare certified hospital, a skilled nursing facility, or of course in your own hospice's inpatient unit. And what's most important about GIP is it's used for intractable symptoms, such as pain or other symptoms that cannot be managed at a lower level of care. I think what is forgotten sometimes is the language in the regulation is very specific that this should be a short-term intervention. So the intention is, and has always been for a short-term stay. What I think is curious, right, is though over even my decade in this practice, it feels like those rules and those definitions of short-term stay are changed. So it's important to be on top of that. So on the next slide, GIP eligibility, it's what we all remember and what we know. It's really for things that at the home level of care, you're no longer able to control and to manage. That can be pain. It can be intractable, nausea and vomiting. Wound care. So I think this is one not to lose sight of. There are, and I'm sure many of you have experienced, very complex wounds that need some skilled around-the-clock intervention to figure out what that plan of care is at a lower level of care. And that qualifies for a short-term GIP stay. Of course, respiratory distress, agitation, delirium and other uncontrolled symptoms. What's critically important is to remember that GIP is not indicated for caregiver breakdown in the absence of that higher level of care need for symptoms as above. The other thing we also have to remember is that GIP is not indicated for a dying patient who's comfortable and that can be managed with oral or liquid medications. So on the next slide, I think one of the pitfalls of organizations is around consistent documentation. And so the OIG reported that over 30% of GIP stays lacked accurate documentation around technical pieces. So not even your GIP documentation. It was an incorrect notice of election or the CTI wasn't dated correctly or wasn't signed by your hospice physician. So don't miss out on those critical regulatory requirements that could impact your GIP stay. The other thing that I think is really helpful for organizations is to think about why does my patient qualify today? So general inpatient qualifications matter every day and each discipline needs to be documenting in their scope around those ongoing needs. So I think an opportunity that organizations have is to make sure that you're looking at documentation across your team members. And so we actually had this experience a few years ago. We were looking at a couple of disciplines documentation and it looked great. You could see that picture being painted of general inpatient criteria and why that patient was appropriate. Then we looked at another discipline and it wasn't consistent. It was using those words you don't wanna see, patient is stable. Okay, well, why are they stable? It's the four parenteral medications that they're getting on a routine basis that we can't transition to oral equivalent. And so I think that's one of those low hanging fruits for most organizations. It can really make a big difference as we're standing up to these audits that continue to come fast and furious. The other thing that doesn't always feel good, but I think is really important and it speaks to that short-term stay is discharge planning. It needs to start at the time of admission. I would actually argue it needs to start in your home if the patient's coming from the home to the general inpatient level of care so that families have an understanding of the intention around GIP and it makes that transition easier should they stabilize and convert to a regimen that allows for transitioning to a lower level of care. So on the next slide, if you think about, well, how can you do this as a hospice medical director? I think the first thing is invest in discipline specific education. And so what they need to consider is everyday matters, what's happened before and didn't work needs to be reflected in the documentation, both at the home setting, both at what's been required in your inpatient setting. Additionally, as I spoke to you before, the patient's symptoms may be managed, but what are we doing to actually manage them and ensure that the language that they're using is really painting that picture. You've also got to train your disciplines on discharge planning and tips for that conversation. I've had so many conversations with our staff about, oh, well, I'm uncomfortable. I don't know how to start that conversation. Give them phrases to help them show compassion and care for that patient and family, but to start that discussion of, well, what is most important to you should these symptoms become managed and we can transition them back home? Where would you like them to be? How can we help prepare you for that? Because we've all seen those patients that hit your inpatient unit and you suspect that they're gonna continue to decline rapidly with escalating symptom needs and then they plateau and they need a different disposition. So just having those conversations with care and concern and showing compassion for those families. So on the next slide, one thing that I think can be really helpful is having an audit program. Now, I recognize we all are in hospices of very different sizes. And so larger hospices can have departments that are focused on this, whereas smaller hospices may not have those resources, but this can be very simple. So whether it's you as a hospice physician or another nurse leader in your organization can just create this program where you're randomly auditing GIP documentation and comparing the different disciplines to ensure consistency. I would also recommend you consider a process looking at long lengths of stay. So we have within our audit program, once a patient reaches so many days of GIP, there's more scrutiny around that documentation and our audit team is really looking to make sure, okay, are we really showing that they're still appropriate outside this five days of the GIP level of care? And if not, what do we need to do differently? Or have they already started that disposition planning to really stay focused in on those long lengths of stay patients? And this I think will help every organization be prepared when those audits show up because it's not an if, it's a when. And you want to make sure that you've got the processes in your organization to prepare you for that. So on the next slide, I want us to talk about a different patient that shows up to your unit. So we've all experienced the patient I spoke about earlier where they come in, they've got symptom needs, they absolutely require parenteral medicine, skilled adjustments, and then thankfully their symptoms are managed. You rotate them to oral medications and it's time for them to go home. And then their family says, we're not going home because we love it here and you're caring for us and we don't want to leave the inpatient unit. You have to have a plan for this and Medicare tells us we have to have a plan. So on the next slide, I just want to remind everyone that some of our obligation is to make sure that we have a way to address these families with compassion. And so at this point, the hospice would be talking to those family members and providing an ABN that states the GIP level of care ends on this day and that the family becomes responsible financially for that difference between the routine home care rate and the GIP level of care. In my humble opinion, this is why the language that your team is using at home and the language of the team in the inpatient setting is so important and they need to have alignment. We hear this all the time. I was just talking to my CEO this week about a case where we had gotten feedback from a family and what they had heard in the home setting was not consistent with what they heard in the inpatient setting in this community. And that just causes you to hurt yourself. And so I would say invest in time and energy and effort to get the same language across your organization. We're all on the same team. We wanna make sure we have access to GIP for the right patients at the right time. And we need to do the things to communicate with patients and families effectively about what that is and what that means. So on the next slide, just why does this matter? Why are we talking about GIP when the regulations have been consistent? Well, it's because there's a lot of attention around this level of care and inappropriate use of this level of care. So you all have probably heard about the OIG study completed a couple of years ago. It stated there was $250 million in GIP care that was billed inappropriately. One really important detail that they mentioned in that study was what they saw as many times the hospice physician was not involved in the care or the level of care decisions. I would really encourage you within your organizations to make sure you all as hospice medical directors, or if you have a team of physicians, to have involvement in that level of care. This is really our acute inpatient level of care. And so I always think, you know, if you're in a hospital at acute care, you're gonna have providers involved in overseeing your care. We need to have that same level of involvement in the hospice side of the business with the GIP level of care. And as I'm sure many of you like us are experiencing now, GIP audits feel like they're coming every day. And so they have a lot of attention on them. They're going to continue. And what we're seeing just preliminarily is those initial denial rates, maybe 70 to 80% for some organizations across the country. And they're kind of expecting 30 to 50% of GIP days were inappropriately billed. So the best thing that you can do to get your organization ready for this is to have some of those tools in place that we've talked about. So in summary, on the next slide, few things I would recommend you just look into if you haven't already is get into the documentation, get into those weeds, give your staff tip sheets on what is appropriate language to use, what really paints that picture of documentation. I would encourage you to create an audit program if you don't have one already to really stay ahead of the curve around the GIP requirements and make GIP education a routine part of your training curriculum for the organization. So for us, it's an annual requirement, whether it's a live in-person or virtual session, or it's one of those refreshers that we do on our LMS system but it's always something we want to be top of mind for our staff, particularly in this world of staffing shortages. I'm sure you're experiencing turnover. You have all these new staff coming into your organization. Make sure GIP is top of mind for all of your staff and that will help you build a successful program but to ensure that the level of care is being used appropriately but also patients have access to it. And lastly, ensure you as the physician are involved in the care and services of these patients. You have tremendous value and knowledge that others in the organization don't have and we have a responsibility to help ensure that the organization is healthy and compliant with the regulations. And so with that, I will turn it back to Bruce. All right, thank you very much, Dr. Snyder and thanks to our other speakers as well. We had some good questions come in during the session that I will get to in just a moment but if you have any questions on the slide here are the contact information for our speakers. So please feel free to reach out to them specifically if you have a specific question to their topic or their area but also feel free to put them in the chat here and we'll get them to answer them for the next 15 minutes or so before we close up. So the first questions I'm gonna came in during your discussion, Dr. Krosno. So I'm gonna ask you to, if you're okay going first here the first question came in that mentions is there a separate rule regarding face-to-face for readmissions that requires in-person visits? Is that out there? There's not a separate rule. The public health emergency applies to any face-to-face can be done with real-time audio video that includes for somebody that's being readmitted into hospice into the third or later benefit period that requires a face-to-face. I say that and then I always hesitate a little bit because sometimes there are state specific rules. Some states have different rules but at the federal level, to my knowledge there's no specific difference between readmissions regarding face-to-face and other face-to-faces. Great, thank you. And Dr. Wilms asked while you were speaking what technology or platforms are recommended for both face-to-face and other visits. Also, is there going to be a lead time for when regulations snap back to pre-pandemic? Are we aware of that? The second part is easier to answer and that is we're not clear. All the public health emergencies or declarations are typically made for 90 days. Some of them have been a little longer than that. And unfortunately, we kind of get the word out that something is going to be renewed but usually you don't know for sure until they renew it usually within a day or two of its expiration. And so it may happen suddenly. There's not any mechanism to give us any specific lead time. Regarding specific TACR platforms, you're a little more wide open now because of the PHE, the public health emergency. You are limited by HIPAA concerns. I would strongly urge anybody who's planning to continue to do this that they want something that's HIPAA secure, HIPAA compliant, and to proceed with that going forward. Standard Apple FaceTime or Google Hangouts or things like that have been used currently but they don't meet the standard HIPAA compliance requirements. You want to be looking into that. I can't give you a specific recommendation but that goes beyond the scope of what we can talk about today. Thanks very much, Dr. Cross. No, appreciate it. So Dr. Martin, we had a question come in during your presentation that actually had an answer provided in the chat but I'll ask you to see if you've got a thought on this as well. Dr. Joseph asked a common reason for acute hospitalization is a fall with injury. For example, a hip fracture. Is this related to the terminal condition? Any thoughts there that you could share? I think that's the question we used to ask exactly. Is the patient with Parkinson's and their gait is, you know, the reason we brought them on the hospice is they've had multiple falls and now they've fallen and broken their hip. Probably related, but I think in addition now where we have the responsibility does this impact their terminal prognosis? And it's hard to imagine a hip fracture not impacting this prognosis of a seriously ill patient. And so I think that's where we're stuck with that. I say years ago, we'd say, oh, well, they were pushed. So it's not related to their terminal diagnosis. But now I think that we have this situation where yes, the falls could be related to their terminal condition but also unlikely to not be related to their terminal prognosis. I think NGS, which is the MAC for our area, one of the examples they gave on one of their frequently asked questions of a hospitalization that potentially was not related to a terminal prognosis was a patient who had an ankle fracture, twisted their ankle and got that repaired. And they put that out as something that perhaps was not related to their terminal prognosis or terminal diagnosis. But I think hip fractures, most fractures that are gonna land someone in the hospital, it'd be hard to say it's not related to their prognosis. Great, thank you, Dr. Martin, appreciate that. That was the one question that came in during your part. So we'll let you off the hook here for a second and go to Dr. Snyder. If there was several questions that came in during your part here, so we'll ask you those kind of in as best order as I could grab them from the chat here. So there is one here that says a hypothetical question, could GIP be used for a suicidal patient who has the intent slash plan and cannot be safe at home? And then in parentheses, it says in a state without physician assisted death. Is that something that you can share or answer? Yeah, so the first thing I'll say, Bruce, is we have two other experts on this panel with me that can also contribute to the GIP questions, but because I see they've come in fast and furious. So what I will say is if it meets that expectation that it's a short term, requires a higher level of care, skilled intervention, 24 seven nursing, that would meet criteria. My challenge would be, is I'm not sure that's our level of expertise. And so in our organization, as an example, we would leverage our psychiatric colleagues. And if we truly feel that that patient is suicidal and could harm themselves, we work with them to make a transfer to those locations where they have the experts there to provide the mental health care that they need. So that would kind of be my bias, but if it meets those level of care requirements, and I think obviously you could make that argument. Yeah, and if I might jump in, I would just add that when you make that transfer to the psychiatric facility, most times that's outside of where we can continue to supervise the plan of care. So they're not gonna continue on our service. Totally agree. Okay, thank you for that. The next one that came in, I think in the order is, if the only way that a hospice can provide GIP level of care is by transferring to a different hospice, does this meet the regulatory requirement? So hospices need to have a contract with a qualifying location. So while we don't have to do this, my understanding, and I see Ron, who's gonna have something to say, which I appreciate, is you would contract with that hospice for their facility. So if they have a qualifying facility, your organization would have a contract with them to provide GIP level of care, just like you would with a hospital or with a SNHU. Yeah, exactly right. A great question. What needs to be clear though, is you can't just tell a surveyor coming in saying, well, we always transfer them over and then we'll show us the contract and you don't have a contract. You'd have to have a contract in place with that other hospice to do that every time he comes out. Yeah, I will say in our area, I think there are some small hospices that do transfer them. I think we found in the past that trying to have two hospice teams managing the patient in our inpatient facility often was confusing for the patient and the family, but there's a contract that clearly lays that out. Great, thank you very much. Very insightful answers there, thank you. The next question is, is there any requirement that a patient on GIP be seen by a physician? And a follow-up question, what is the requirement on GIP for a patient to be seen by a medical provider? So technically the regs do not spell this out. However, my argument would be, if you're in an acute inpatient level of care, how could you not have the physician or provider involved in that level of care? And so our practice is, yes, that they're seen daily. I know some others kind of do hybrid schedules, but unless I'm wrong, Ron and Ed, the regs don't spell that out, but I think you have to live by the argument of, well, if they really are needing this higher level of care that cannot be managed at a routine home care level, how could you not have some involvement by your provider? Whatever that looks like. Yeah, I completely agree. The one thing that does come up sometimes if you're using a contracted bed is that facility may have its internal policies that have specific requirements, but the best practice is every day, like you just said, I agree. Great, thank you. One of the things that came in here was going back to the stats, I think that you had shared, Bethany, related to the GIP days that weren't considered appropriate days. And this person says, I wonder with regards to the GIP days that were not considered appropriate days, what percentage were hospital to hospice generated? I don't know that that's a question you can answer, but just something that was shared in the chat that I thought was interesting. Yeah, and this is something that I should have emphasized during the talk too. I would actually pay more attention to your patients that are sitting in hospital beds that aren't in your inpatient unit, as an example, where your staff are going in to provide GIP level of care, but to what Ron had mentioned before, that the hospitals might be seeing those patients or other specialists might be seeing those patients. In our experience, that's where your documentation can get you in trouble if they don't really understand the GIP level of care. So while I don't remember it being articulated, kind of the difference in those statistics, I can tell you from experience, when you have contracted out GIP versus like, what we do in our own inpatient unit, the documentation there is just as important. And so your organization is going to have to do more work to make sure that you're still able to show appropriateness for a general inpatient level of care. And kind of going down that space, I'm sure y'all are all living this too. Hospitals have other incentives than we do, right? They have other things that motivate them. And so we have a lot of hospitals now that just want all their hospice patients off of their mortality index based on the one that they use. And so they've just want everybody on GIP. That doesn't meet the criteria. And so I would just caution you when you're talking to your hospital partners, because you're going to need them, right? They're communities where that's going to be your way to provide GIP, but you just got to make sure that everybody's on the same page about what GIP actually means. Great, thank you for that. Just a couple of more questions came in. So we'll try to get through them here in the next couple of minutes. One is, our IPU often has GIP patients who we achieve symptom management on scheduled parenteral medicines while the patient is actively dying. Do others routinely challenge some sublingual meds at that point to see if the parenteral meds could be changed over to sublingual? So this is forever the question. And I would say, I think it depends patient to patient. So there will definitely be examples, right? Where you can do a rotation to see if they can tolerate your parenteral medications in a sublingual version. But then I will argue that there are patients that that's not appropriate. And so I think there's a lot that's going to play into that. That's your organization, your mission, your tolerance, various things, your ability to serve them in a different way, like that routine home care level, or if you have access to residential locations where you can still provide, perhaps those medications, but not at a GIP level too. So I think that's complicated. And I think that's forever the discussion we always have in our organization. And so I will see what Ed and Ron have to say about that as well. Because at the end of the day, right, you're going to do what's best for the patient, but that can look very different in all circumstances. I think when, if we feel a patient really is, we're looking at hours to days, it just seems to try and adjust their regimen in a way to switch them. When you know that may well, oftentimes the reason they're in the unit first time, because the drizzling under the tongue was not effective. So I think we would just ride it out at that point with parenteral medications. Unless we really thought the patient had some time and would benefit from getting to, particularly if they might benefit from getting, family really wants to take them home, then, oh, we will do whatever we can to get them on a regimen we think the family can manage at home. Yeah, I a hundred percent agree. I don't have anything extra to add. Dr. Snyder, there was a question that just came in that I think goes back to your point that you just were talking about, about the hospital's interest in flipping to GIP. Can you discuss that a little bit more? Sure. So I'm not the expert in this, but you all have probably seen and heard. There are a couple of different ways that hospitals and health systems are evaluated. And some of that can be around the mortality data, depending on which organizations they use and report through. So I'd say a couple of things. One, some of them see a huge benefit in their metrics as getting hospice involved and getting those patients off of that list, as we would see. The other thing I have to remind everyone, right, is when you admit to hospice, you'll have a contractual relationship that will have financial payment, but then you're paying to that hospital. So if you think about the business of medicine, but then also some of these metrics that they're graded against, they have different incentives that are motivating them to consider, is it important or valuable to get hospice involved? And so I just, what I would challenge you, and I didn't know this until I got into hospice too, is like, learn what motivates your health system leaders and then help educate them on how you can or cannot be a solution. Because I think some of where hospices can get in trouble is trying to be everything to everyone all the time, and we just can't do that. And so, we have regulations that govern us as well. And so I think it's important for us to know kind of what they're looking at and what motivates them, but then also to be able to educate them on what is the hospice benefit, how was it designed and the intention behind those regulations, and then help foster that relationship of using it at the right time for the right patient. Great, thank you. We have two questions and we have three minutes left. So I'm gonna try to throw them out there real quick and hopefully we can get a quick answer on them. What about a patient on for cancer and goes to the hospital for CHF exacerbation? It seems that if CHF is bad enough to require hospitalization, that it impacts prognosis and requires hospice to cover. What are your thoughts on that? Yeah, I mean, yeah, again, I guess the question then is, is it gonna be a GIP admission? Is that hospital you have a contract with and how are you gonna manage that? Or is this something you could have managed in your inpatient unit? So I think that would be a conversation with the physician, the hospice medical director, the patient, the family to try and sort that out. But I don't think most hospitals are not gonna want a patient in their CCU on the GIP rate and maybe heading to the cath lab. So I think it just has to be a clear idea of what the goals of that admission are. Great, thank you. And then the last question might go back to something that was talked about earlier. It says, if a patient is admitted for a hip fracture, then can they be discharged and bill surgery through Medicare? Or are you saying that the hospice must pay for the surgery? I think this was back to the fall, the question earlier about the falling down. Quickly, our nurse is often in the emergency room making a type of conversation with the patient. Would they like us to focus on comfort, manage their pain at that point? And it's often a start of GIP care because oftentimes I think a hip fracture can be difficult to manage at home, at least in the first few days. But if they should know, we're gonna go for surgery and then we're gonna go for rehab. There may be some hospices that are taking that on, but typically if that's the case, they wanna pursue repair and rehab, we'd say that would be sort of beyond what we would cover under the benefit. I don't know of others, if Bethany or Ron have a different approach to that. It's very individualized and sometimes it's an issue of whether it's really within our palliative plan of care for that particular patient. It's really something beyond that. That's a justification to counsel them regarding how if they stay on hospice and it's not something hospice is gonna cover, the patient becomes responsible for the bill, at which time they may wanna revote hospice benefit. Well, as we close, I just wanted to take one quick moment to say thank you once again to Drs. Martin, Snyder and Krosno for your great presentation today. Thank you all for attending. We really appreciate it. We will be sending a recording of the session to you soon. And again, please feel free to reach out, connect with us, engage with us in 2022 as we launch our next webinar series. Then we look forward to seeing you all. Happy holidays to everyone and we'll see you soon. Have a great day. Thank you, it was great. Thanks.

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