Dr. Timothy Dauwalder - California Hospice and Palliative Care

Dr. Timothy Dauwalder
Executive Medical Director
VNA and Hospice Care of Southern California
Palliative Care Consultant
HMD Purpose?

Referrals

IPA/ACO/Hospitalist

…PCP
IDG
Old
rationale:
Sign
and dash
Referral source without leadership or
understanding of team
IDG

Accurate rationale:

Team member

Signature means understanding care plan

Professional prognostic opinion

Medical oversight of non-hospice and hospice plan of care including medication

Education

Policy expertise

Resource for team
Who should be your HMD?

???
Qualifications of HMD

Hospice and Palliative Care Board Certified ?

HMD Certification ?

…..
HMD required to know policy…

CTI

Medical director vs. attending
Policy continued

FTF

LCD’s/Coding
Policy continued

Technical denials

MediCal HMO contract (passive enrollment)

MediCare part D
IDT (IDG): Defines HMD

Team
Survey of Hospice Staff
Important qualities in an HMD?
Results of all disciplines except administration and
marketing
Note: Results are prioritized differently for each
discipline
Responses in relative order of frequency
1. Accessible to staff
2. Availability and orders in timely manner (answers phone)
3. Respect nurses’ knowledge
4. Approachable to all disciplines
5. Actively listens to staffs and families
6. Bedside manner, kindness, empathy, compassion, humor
More personality traits than ….
Continued:
7. Comfortable in sharing concerns
8. Diverse and extensive palliative care experience
9. Good understanding of multiple coexisting complex diseases
10. Confident in prescribing hospice meds
11. Efficient with supportive paperwork for social work
Continued:
12. Able to explain medical knowledge in understandable manner
13. Pay attention in IDG
14. “Talk to not at”
15. Address Medicare regulations and discuss with IDG
16. Frequently acknowledges a job well done
17. Concern for staff safety in field
Marketing Response

Near identical to previous with exception of the following
1. Eager to educate
 2. Actively engaged by promoting hospice in community
 3. Name recognition connected to hospice agency
 4. Peer to peer education with other physicians

Administrative Response to Questionnaire

Know LCD guidelines

Know regulations:
 F2F
 Certification periods


Narrative
MD visit note: new regulations, what is related/unrelated to hospice
Continued Admin Response

Medication management, cost-containment

IDG:
 Team goals for future
 Ensuring nurse documentation matches MD

Review medication in IDG
HDM Community Education

From the single conversation to the Meeting Hall….
What is POLST?
Physician
Orders for
Life
Sustaining
Treatment
POLST Success
Comfort Measures Only
11,836
Full Treatment
1,153
Hospital Death 6.4%
Hospital Death 44.2%
Out Hospital Death
55.8%

58,000 deaths reviewed, 31% had POLST in Oregon Registry

Patient treatment choices honored, including avoiding dying in hospital
Limited Interventions
4,787
Oregon Study: Location of Death and POLST Orders
Hospital Death 22.4%
Out Hospital Death
77.6%
Fromme EK, JAGS 2014
Out Hospital Death
93.6%
POLST vs.
Advance Healthcare Directive
POLST

For seriously ill/frail,
at any age
 Physician orders for
medical treatment
AHCD

For anyone 18 and
older
 General instructions
for treatment
 Appoints
decisionmaker
California POLST Project
Translating an individual’s wishes for care during serious or chronic illness
into medical orders that honor those preferences for medical treatment.
POLST
Conversation
A rich conversation with
each individual patient
Community Collaboration
Consistent Form
Integrating POLST into the
community standard of care
Standardized form recognized
across care settings
Comprehensive Education
To promote excellent conversational
skills with patients and families
HMD- Patients and Psychosis
Breath of education requirement of the HMD
Rate of elderly patients with psychotic
symptoms
25
The elderly currently account for about 12% of the US population, but
that figure is expected to rise to 20% by the year 2030.[3]
http://www.medscape.com/viewarticle/564899_2
Jessica Broadway, Jacobo Mintzer
DisclosuresCurr Opin Psychiatry. 2007;20(6):551558.
26
Prevalence of Psychosis in Elderly Persons

Community: 0.2% to 4.7%;
In NYC study (Cohen et al, 2004): 3% psychosis (7% Blacks vs 2%
Whites), but if include paranoid ideation: 14 % of sample.

Age 85+ (without dementia): 7.1% to 13.7%. May be prodromal for
dementia

Age 95+(without dementia): 7.4%

Nursing Homes: 10% to 62%

Geriatric Psychiatry In-Patient Units: 10% late onset psychosis--¾ are
women, 40% due to AD or VaD
27
Etiologies of Psychoses in Older Adults (order
of frequency)
1.
Alzheimer’s disease and other dementias (40%)
2.
Depressive disorder (33%)
3.
Medical/toxic causes including substances (11%)
4.
Delirium (7%)
5.
Bipolar Affective Disorder (5%)
6.
Delusional disorder (2%)
7.
Schizophrenia spectrum disorders (1%)
Manepalli et al, 2007 and Webster et al, 1998
28
Problems with prescribed meds
http://www.npr.org/player/v2/mediaPlayer.html?action=1&t=1&islist=false&id
=5033873&m=5033874
Two Preliminary Points
In older adults, for all conditions:
think “Comorbidity”
Any new psychiatric conditions or change in
symptoms:
Must assume physical cause until proven
otherwise
30
Lifetime Risk
(1 in 4 lifetime risk)
Up to 23% of the older adult population will
experience psychotic symptoms at some time,
with dementia being the main contributing
cause (Khouzam & Emes, 2007).
31
Delirium
1.
Perceptual disturbances are common; however, hallucinations also are
frequent:


Hallucinations: 40% to 67%
Delusions: 25% to 50%
2.
Psychotic symptoms are more commonly seen with hyperactive rather than
hypoactive delirium
3.
Visual > > auditory> other hallucinations
4.
Paranoid delusions are the most common delusions
5.
Clinical evaluation should help identify; dementia and delirium are often
related
32
Alzheimer’s Disease
1.
Prevalence of psychotic symptoms: 16% to 70%; Median: 37% for delusions; 4% to 76% (Median
23%) for hallucinations
2.
Rates of psychoses: about 20% in early stages to 50% by third or fourth years of illness (Overall:
30% to 50%).
3.
Most common in middle stages.
4.
Hallucinations: visual> auditory> other
5.
Hallucinations most commonly people from past, e.g., deceased relatives, intruders, animals,
objects.
6.
Delusions: most common are false beliefs of theft, infidelity of one’s spouse, abandonment,
house not one’s home, and persecution. Decreases in later stages.
33
Vascular Dementia
Cache County study found prevalence
of hallucinations similar between AD
and VaD, but delusions were higher in
AD (23% vs 8%).
HDM
 Impetrative
to understand complexity of
disease relevant to demographic:
Disproportionate risk?
 HMD
to be study savvy
Example: CATIE study
(Clinical Antipsychotic Trials of Intervention Effectiveness)
35
Alzheimer’s Disease
CATIE study, in which time to discontinuation did not
differentiate antipsychotic medications from placebo, and
black box warnings regarding higher mortality rates,
suggests that medications must be used judiciously. In
CATIE study, the median time to the discontinuation of
treatment due to a lack of efficacy favored olanzapine and
risperidone, but the time to the discontinuation of treatment
due to adverse events or intolerability favored placebo.
Mean doses used in CATIE trial: risperidone(1mg),
olanzepine (5.5mg) , and quetiapine (56.5mg).
Recommended doses:
Risperidone:0.75mg to 1.5mg
Olanzepine: 2.5mg to 7.5mg
Quetiapine : 25mg to 200mg
Psychosocial modalities:
Sensory enhancement, structured activities,
social contact, behavior therapy.
The Older Adult Brain
As people age, they usually
experience slower information
processing and mild memory
impairment.
Older brains frequently decrease in
volume and some nerve cells, or
neurons, are lost as aging occurs.
What is Normal Or To Be Expected?

Common age-related cognitive decline is often slower information processing and
mild memory loss.

Mild cognitive impairment. Some people develop cognitive and memory problems
that are not severe enough to be diagnosed as dementia but are more pronounced
than the cognitive changes associated with normal aging. Many patients with this
condition later develop dementia, some do not.

Depression. People with depression are frequently passive or unresponsive, and
they may appear slow, confused, or forgetful.

Delirium is confusion and rapidly altering mental states and sometimes disoriented,
drowsy, or incoherent. Delirium is usually caused by a treatable physical or
psychiatric illness, such as poisoning or infections. Patients with delirium often make
a full recovery after treated.
Reasons for Memory Loss
 Normal
 Brain
Aging Process
Damage
 Trauma
 Medications
 Drugs
Abuse
 Alcohol
Abuse
•
•
•
•
•
•
Small Strokes
Depression
Toxic Chemicals
Too Much Thyroid
Infections
Disease
Normal Aging Process
As we age, our brains frequently decrease in volume and some nerve cells, or
neurons are lost.
Medications
Medication can also affect memory.
Alcohol and Drug Abuse
Alcohol and drugs impairs memory and can result in acute and/or chronic
cognitive deficits.
Small Strokes
During a stroke, blockage of blood to the brain can occur. Lack of blood flow in the
brain can result in memory loss.
Depression
Depression is a condition marked by memory loss. The signs and symptoms can be
similar to dementia. Depression is more common in older people who have
dementia, especially Alzheimer’s.
Disease
Symptoms that include decreased intellectual functioning that interferes with normal
life is dementia.
Types of Dementia

Alzheimer's Disease

Vascular Dementia

Lewy Body Dementia

Frontotemporal Dementia

HIV-associated Dementia

Huntington's Disease

Dementia Pugilistica

Corticobasal Degeneration

Creutzfeldt-Jakob Disease
The Caregiver’s Role

Help maximize the patient’s independence

Assists with the tasks the patient can no longer do

Set up activities, such as leaving notes around the home as reminders,
to aid memory retention

Educate self on the disease process and side effects the patient may
experience

A caregiver must be patient with a loved one experiencing memory loss
and accept help from others

Caregivers must take time for themselves for physical exercise and
relaxation each day
HDM responsibility: to share resources
to both clinical staff, patients, and
families
Online Apps and Game Resources
1. Lumosity: Online and mobile app game center
2. Merriam-Webster Encyclopedia Website:
3. AARP
http://www.aarp.org/health/brain-health/brain_games.html
4. Games for t he Brain
http://www.gamesforthebrain.com/
Delivering bad news
HMD should be an expert in the nuance of delivering bad news,
including teaching future doctors the same skill
HDM- Local Medical Education
To deliver bad news, complex understanding of disease trajectory is a must…
You have to know how you got there…
Setting a template for understanding
disease trajectories‘
Curative
Restorative
Palliative
Bereavement
EMPATHY
…. IS THE HIGHWAY TO FACILITATE HEALING..
…cure sometimes
relieve often
comfort always.
HDM-Policy Details
An attempt to control the chaos
HMD At Work
Know the Rules
And what they morph into
CMS FY 2014 Rule
•
•
Reinforced that all providers should code and report the
principal diagnosis as well as all coexisting and additional
diagnoses related to the terminal condition or related
conditions.
Clarified the use of nonspecific, symptom diagnosesRef: FY 2014
Hospice Wage Index and Payment Rate
Update; Hospice Quality Reporting Requirements;
and Updates on Payment Reform [CMS-1449-P]
CMS Changes
Related to Coding
•
Codes under the classification, “Symptoms, Signs, and Illdefined Conditions” (ICD-9 780-799) are not to be used as a
principal diagnosis; however, they may be used as other,
additional, or coexisting in the additional diagnoses lines on
the claims form.
o
•
Includes “Debility unspecified” (ICD-9 799.3) &
“Adult Failure to Thrive” (ICD-9 783.4)
Effective date: October 2014
Changing Regulatory Climate
Why did this CMS take this action
•
In FY 2012, both “debility” and “adult failure to thrive” were in the top
five hospice diagnoses reported on claims
o
•
•
first and third most common hospice diagnoses, respectively.
Trending upward over the past decade
“Vascular Dementia”
“Traps Encoding”
A new go to ICD may be as inaccurate
as the old even though allows for
billing revenue
IE
CHF
The Changing Regulatory
Climate Cont’d
What industry experts are saying:
•
•
•
CMS equates debility with hospices enrolling chronically ill patients
requiring custodial care who are not terminally ill
Debility patients typically have longer LOS
CMS trying to reign in hospice expenditures...
Additional Clarifications: Diagnosis Reporting on
Hospice Claims
•
“All of a patient’s coexisting or additional
diagnoses” related to the terminal illness or
related conditions should be reported on the
hospice claims
Federal Register/ Vol. 77, No. 145/ Friday July 27, 2012
Diagnosis Reporting:
CMS’ Position...
•
•
•
•
Hospice patients at the end-of-life are elderly and likely have
multiple co-morbidities.
Claims that report only one diagnosis are “not providing an
accurate description of the patients’ conditions.”
After doing a comprehensive assessment “providers should
code and report coexisting or additional diagnoses to more
fully describe the Medicare patients they are treating.”
Will provide data needed for hospice payment reform.
ICD-9-CM Guidelines for
Coding and Reporting
•
•
•
Requires reporting of all
additional or co-existing
diagnoses.
Adherence to these guidelines when
assigning ICD-9-CM diagnosis and
procedure codes is required under
HIPAA
Imperative that hospice providers
follow ICD-9 coding guidelines and
sequencing rules for all diagnoses.
Implications for Coverage
Are hospice agencies responsible for all of the care,
medications, and equipment for all of the diagnoses
listed on the claim form?
YES
Implications for Coverage
cont’d
CMS reiterated what was stated in the original Conditions of Participation (1983):
...“hospices are required to provide virtually all of the care that is needed by terminally
ill patients”. (48 FR 56010-56011).
CMS states “Therefore, unless there is clear evidence that a condition is unrelated to
the terminal prognosis, all services would be considered related. It is also the
responsibility of the hospice physician to document why a patient's medical need(s)
would be unrelated to the to the terminal prognosis. ...determination of what is
related versus unrelated to the terminal prognosis remains within the clinical
expertise and judgement of the hospice medical director in collaboration with the
IDG.”
HDM is responsible for directly stating unrelated diagnosis and treatment
Diagnosis Reporting
Requirements On Claim Form
•
•
•
List the primary hospice diagnosis
List all related “other” diagnoses
Do not list unrelated co-morbidities
o But be sure to list them in the clinical record
•
The hospice claim includes a field for the patient’s principal
hospice diagnosis, and allows for up to 17 additional
diagnoses on the paper UB-04 claim, and up to 24 additional
diagnoses on the 837I 5010 electronic claim
Individual Primary Dementia Codes
Individual Primary Dementia Codes contd.
ICD-9 Dementia Fact Sheet
How to recognize a manifestation code when you
see one….

Does the condition have an underlying etiology?

Dose the Note in the ICD-9 book state “code
first”?

Is “in disease classified elsewhere” in the code
title?

If the answer to any of these is “yes”, the condition/code is probably a
manifestation code.

“In diseases classified elsewhere” codes are never permitted to be used as
first listed or principal diagnosis codes. They must be used in conjunction
with an underlying condition code and they must be listed following
underlying condition

In these cases, code the etiology (the cause) first, followed by the
manifestation.

Do NOT use the manifestation code as the principal diagnosis.
Case Study
Initial certification narrative:
84yr old F w mild COPD, mild dementia. On recent CXR, she was found to
have an enlarging lung mass for which w/u was declined. She has had
increased weakness, decreased appetite with weight loss in 3 months from
130 to 125 lbs, and 1 episode of hemoptysis, all attributed to presumptive
lung CA. Patient recently seen by primary care MD who noted weight loss,
risk for sudden decline, and her belief that more likely than not that
patient will have terminal event in the next 6 months…
(narrative continued on next slide).
Case Study cont’d
Initial certification narrative cont’d:
Pt is DNR/DNH/CMO, clear in her wish for no interventions to prolong
her life. Given this patient’s clinical decline, likely lung cancer,
weight loss, episodes of hemoptysis, and wish for DNR/CMO, pt is a
high risk for massive hemoptysis, respiratory failure, rapid decline. It
is my professional judgement that prognosis is less than 6 months.
•
What is the current nature of her decline?
o
•
No further hemoptysis, has lost 4 lbs, and has had very slightly increased
weakness. No new symptoms have arisen.
Do you believe it is more likely than not that she will have a
terminal event in the next 6 months?
o
Nothing to suggest a terminal decline...
Case Study cont’d
•
•
•
Can use “at high risk of life-threatening hemoptysis and
respiratory failure” when enrolling this patient, but if these
do not occur, cannot keep using them for recertification.
Clinical record needs to demonstrate downward trajectory.
If none exists, patient is no longer eligible for the hospice
benefit.
Coding “Suspected Cancer”
•
•
•
799.3 Unspecified debility (use this 2nd)
784.2 Swelling, mass, or lump in chest (use this 1st)
793 Nonspecific abnormal findings on radiological and other exam of body
structure.
Instructional notes: “...(780-799)~this section includes symptoms, signs, abnormal results of laboratory or
other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere
is recorded.~ The conditions and signs or symptoms included in categories 780-796 consist of : (a) cases for
which no more specific diagnosis can be made even after all facts bearing on the case have been investigated;
(b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes
could not be determined; (c) provisional diagnoses in a patient who failed to return for further investigation
or care; (d) cases referred elsewhere for investigation or treatment before the diagnosis was made; (e) cases
in which a more precise diagnosis was not available for any other reason;...”
Certification of Terminal Illness (CTI)
when the Diagnosis Changes
•
•
A new CTI is not required because the principal diagnosis
changes, nor do benefit periods or election status change
Physician documentation (including IDG documentation)
should include:
o
New terminal diagnosis and why it changed
o
Why it is causing a 6 month or less prognosis
o
Evidence of prognostic indicators
o
Reference to outcomes of symptom assessment scales as applicable
What if you can’t determine a
single hospice diagnosis?
CMS…
•
•
•
States that they expect hospice providers will not discharge
beneficiaries who meet eligibility requirements, even if they can’t
determine a single principal diagnosis.
Recommends listing all related diagnoses, picking the predominant
one as the terminal dx
If the patient meets the eligibility requirements, they will have
access to hospice services under the Medicare Hospice Benefit.
Summary
•
•
•
•
•
As of October 1, 2014, failure to thrive or debility can no longer be used as a
primary diagnosis.
Select a diagnosis from the patient’s list of comorbid conditions and document
the effects of other significant co-morbids to support eligibility.
Discharge patient if they no longer meet eligibility requirements and monitor
disease trajectories.
Ensure that your HMD documents why a condition is not related.
Ensure that your hospice has ICD-9/ICD-10 coding expertise
Biomarkers used to
support Prognostication
In addition to Prognostic indicators
LCDs (Local Coverage Determinations) and other tools
General
used to support frailty, debility (ill defined diagnosis)
•
•
•
•
•
•
•
BMI < 21
5% wt loss < 6 months
Albumin < 3.5 mg/dl
Anemia
High CRP
Cholesterol < 150 mg/dl
Low Lymphocytes
References
Zakai, Neil MD, et al, A Prospective Study of Anemia States, Hemogloblin Concentration, and Mortality in an Elderly
Cohort, 2005, Arch Int Med, pp 2214-19
Harris, Tamara, B, MD, MS et al, Association of Interleukin6 and C-Reactive Protein Levels with Mortality in the
Elderly, 1999, Am J Med, vol. 106, pp 506-12
Herman MD, MPH, Francois, et al,Serum Albumin Levels on Admission as a Predictor of Death, Length of Stay, and
Readmission, 1992, Jan, Arch Intern Med, Vol 152, 125-130
Rudman, Daniel, MD, et al, Relationship of Serum Albumin Concentration to Death Rate in Nursing Home Men,
1987 Journal of enteral and Parenteral Nutrition, vol 11, pp 360-63
Verdery, Rob B, et al, “Hypocholesterolemia as a Predictor of Death; A Prospective Study of 224 Nursing Home
Residents,” 1991, Journal of Gerontology, Vol 46,(3), pp M84-M90
Noel, Margaret A MD, et al, “Characteristics and Outcomes of Hospitalized Older Patients Who Develop
Hypocholesterolemia,” JAGS, VOL 39, pp455-61
Cardiac Disease
•
Hyponatremia
•
Cr (> 2) - some studies >1.4
•
BNP > 480 pg/dl ( 42% 6 mo mortality)
•
Troponin
•
BUN > 30
•
CRP
•
Seattle Heart Model
•
EFFECT Model
References
Palliation in heart failure, Davis, AJHPM 2005: 22, 211
Fast Fact Concept #143
NEJM - 5/2008 Zetheilius
Biomarkers in Heart Failure, NEJM, Vol 358; 2148-2159
Bonnie et al., Circ. Heart Fail. 2012; 5: 183-190
JAMA 2OO3: 290(19): 2581-2587
Am J Cardiol 2006; 98:1076-1093
Maisel, B-Type Natriuretic Peptide Levels: Diagnostic and Prognostic in Congestive Heart Failure , Circulation,
2002, 105;2328-2331
Pulmonary Disease
•
BODE
•
CRP
•
Fibrinogen
•
High WBC count
References
Respiratory Care January 2004, 48 (1) 90-98
Am J Respir Crit Care Med. 2012 May 15;185(10):1065-72. dol:
10.1164/rccm.201110-1792OC. Epub 2012 Mar 15. Inflammatory biomarkers improve clinical
prediction of mortality in chronic obstructive pulmonary disease. Thorax 2008;63;665-666
community acquired pneumonia
CHEST 2010; 138(3):559-567 ARDS
Crit C Med. 2008;36(7):2061-2069 ICU ventilation
N Engl J Med 2010;363:266-74. Pulm embolism
Am J Respir Crit Care Med Vol 182. pp 1178-1183, 2010 Pulm embolism
Dementia
Mortality Risk Index
•
•
MRI - Mitchell, JAMA 2004: 291:2734-2740
Coexisting Fracture or Pneumonia - Morrison RS JAMA 2000;
264:47-52
Liver Disease
•
•
MELD score - INR, Bilirubin, CR
Sodium - (hepatocellular carcinoma-use MELD- Na score)
References
Kamath, Hepatology 2001 Feb 33; A464-70 A model to predict
survival in patients with end-stage liver disease
Renal Disease
•
Albumin < 3.5
•
BNP, NT - Pro BNP, Troponin, CRP
References
Friedman, JACN JASN February 1, 2010 vol. 21 2 223-230
Reassessment of Albumin as a Nutritional Marker in Kidney Disease
Fast Fact #191
Chaykovska L, Clin. Lab. 2011;57:455-467 Biomarkers for the prediction of mortality and morbidity in patients with renal
replacement therapy.
Cohen, J Palliat Med. 2006;996):977-992. Predicting Six-Month Mortality for Patients Who Are on Maintenance Hemodialysis
Stroke
•
BNP, CRP
References
LaBorde Expert Rev Proteomics. 2012;9(4):437-449. Potential
Blood Biomarkers for Stroke
JAMA 2007’297 Mitka Hemorrhagic stoke guidelines issued
Stroke 2008;39:2304-2309
Sacco et al, Stroke 2009;40:394
HIV and HAART
References
http://www.art-cohort-collaboration.org
Other Resources
Pallipedia.org
http://www.eprognosis.org
http://www.victoriahospice.org/health-professionals/clinicaltools#
Sobering Data
•
•
•
•
Malignant Hypercalcemia
8 weeks
Malignant Pericardial Effusion
8 to 12 weeks
Carcinomatous Meningitis
8 to 12 weeks
Multiple Brain Mets
o
Without XRT
4 to 8 weeks
o
With XRT
12 to 24 weeks
“Predication is very difficult, especially if it is about the future”
Niels Bohr
CHF - Prognostic Variables
•
NYHA Functional Classification
o
-Class I - 5% to 10% mortality per year
o
-Class IV - 40% to 50% mortality per year
•
Recent cardiac hospitalization
•
Elevated BUN
•
Systolic BP < 100 under/or pulse > 100
•
Decreased LVEF
CHF - Prognostic Variables
•
Ventricular Dysrhythmias
•
Anemia
•
Hyponatremia
•
Cachexia
•
Reduced functional capacity
•
Co-morbidities (DM, COPD, CVA etc.)
Frailty as an
Accumulation of Deficits
•
•
•
•
•
The Frailty Index
Number of Deficits divided by the number of deficits considered
Numerical value between 0 and 1
Strongly correlated with the risk of death
If > 0.5 - close to 100% mortality at 6 months
Rockwood K, Miniski A Mech Aging Dev 2006;127; 494-496
Rockwood K et al, J Am Geriatr Soc 2010; 58:316-323
Clinical Frailty Index
1. Very Fit
2. Well
3. Well with treated comorbid disease
4. Apparently vulnerable - “Slowed Up”
5. Mildly frail - Limited dependence
6. Moderately Frail - Help with all ADL’s
7. Severely Frail - Completely dependent upon others
GeriPal - www.eprognosis.org

…. Good resource…
Final considerations...
•
Prognostication is a critical skill for physicians
•
Our ability to prognosticate accurately is limited, especially with organ
system failure and frailty

AAHPM

Reference too box website

Table of contents

Link
Face to Face
On July 16, 2010, CMS posted a proposed rule for Section 3132
of the new health care reform law, the Affordable Care
Act (ACA), which requires a hospice physician or nurse
practitioner to have a face-to-face encounter with each hospice
patient before their 180-day recertification and for each 60-day
recertification period after that date. This new statutory
requirement will better enable hospices to comply with hospice
eligibility criteria, and to identify and discharge patients who do
not meet those criteria.
Face to Face Encounter Update: CMS has issued CR7337 to
include exceptional circumstances for the face to face encounter
requirement for new hospice admissions in the third or later
benefit period. In cases where a hospice newly admits a patient
who is in the third or later benefit period, exceptional
circumstances may prevent a face-to-face encounter from being
conducted prior to the start of the benefit period.
Requirements:
New hospice admission
Third or later benefit period
Exceptional circumstance
Timing:
ONLY if the above requirements are met and documented:
Face to face encounter which occurs within 2 days after
admission will be considered timely.
If the patient dies within 2 days of admission without a face
to face encounter, the encounter will be deemed complete.


Examples (as provided by CMS):

The patient is an emergency weekend admission and it may be impossible for
a hospice physician or NP to see the patient until the following Monday, or

CMS data systems are unavailable and the hospice may be unaware that the
patient is in the third benefit period, or

Other exceptional circumstances as documented by the hospice.
Documentation requirements:

Documentation will be required for the exceptional circumstance that
prevented the face to face encounter from being conducted in a timely way.