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HOSPICE ALLIANCE WORKSHOP: Hospice Compliance
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P R E S E N T E D B Y :
K AT I E W E H R I , C H P C
H E A LT H C A R E P R OV I D E R S O LU T I O N S , I N C .
T A R G E T E D P R O B E A N D E D U C AT E . C O M
I N F O @H E A LT H C A R E P R OV I D E R S O LU T I O N S . C O M
Session 1: Hospice Regulatory and Policy Update
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Payment Rates and Aggregate Cap
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FY2018 Hospice Payment Update PROPOSED
Code/Description FY2018 Rate Proposed FY2019 Rate
651/Routine Home Care days 1 - 60 $ 192.78 $196.25
651/Routine Home Care days 61+ $ 151.41 $154.21
Rates NOT adjusted for wage index, sequester or failure to meet HQRP requirements
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FY2018 Hospice Payment Update PROPOSED
Code/Description FY2018 Rate Proposed FY2019 Rate
652 -- Continuous Home Care (hourly rate
for SIA)
$976.42 ($40.68/hour) $998.77 ($41.62/hr.)
655 -- Inpatient Respite $172.78 $176.01
656 -- General Inpatient Care $743.55 $758.07
Rates are not adjusted for wage index, sequester or failure to meet HQRP requirements
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Hospice Cost Report Data Analysis
Median Cost Rate
Routine Home Care $125 $161.89
Continuous Home Care
(hourly)
$51 $39.37
Inpatient Respite $343 $167.45
General Inpatient Care $879 $720.11
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Total Cost Per Day by Level of Care FY2016
Hospice Cost Report Data AnalysisIs your agency correctly completing the hospice cost report?
“Level 1” edits◦ 66% of hospice cost reports would have been rejected
◦ “evident that hospices may not be providing thorough and representative cost data currently”
◦ “…substantial variation in the reported cost per day…”
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Aggregate Cap
FY2018 cap amount: $ 28,404.99
FY2019 proposed cap amount: $ 29,205.44
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Aggregate Cap Accounting Year Transition Time Frames
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Streamlined Patient-by-patient (Proportional)
Patients Payments Patients Payments
2016 9/28/15-9/27/16 11/1/15-10/31/16 11/1/15-10/31/16 11/1/15-10/31/16
2017 9/28/16-9/30/17 11/1/16-9/30/17 11/1/16-9/30/17 11/1/16-9/30/17
2018 10/1/17-9/30/18 10/1/17-9/30/18 10/1/17-9/30/18 10/1/17-9/30/18
Payment RatesSequester
MACRA
CMS analysis of “new” cost report data◦ Rebasing
◦ Recalibrating
MedPAC◦ Recommendations of no increase
◦ Site of service
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Electronic Processing NOE
CR10064 – Accepting Hospice Notices of Election via Electronic Data Interchange
Effective: January 1, 2017
Voluntary
Guidance for vendors to create interface
Overall intent: beneficiary status information to CWF faster
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Electronic Processing NOE
Updates to Medicare Claims Processing Manual, Chapter 11
Reasons for exceptions to the 5-day NOE submission
Other sections added/updated◦ NOTR
◦ Change of provider/transfer
◦ Change of ownership
Corrections to admission date◦ Occurrence code 56
◦ Condition code D0
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Hospice and Managed Care
2014 MedPAC recommendation – bring hospice under MA bundle of services
Currently sets with Senate Finance Committee – Chronic Care Work Group
Same benefit bundle as FFS
Potential impact◦ Insufficient payment
◦ Selective contracting (no consumer choice)
◦ Copays for patients
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Payment - Other Providers
Bipartisan Budget Act of 2018
Hospital transfer policy for early discharge to hospice care
Effective: October 1, 2018
Definition of “early”
Hospice now more closely aligned with post-acute providers
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Trends in Hospice Utilization
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CMS Monitoring - Data
Length of stay
Live discharges
Skilled visits in last days of life
Non-hospice spending
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Hospice Utilization
$17.5 billion Medicare spending on hospice care
Expected to grow 8 percent annually
Central Budget Office (CBO)◦ all Medicare spending expected to grow 7% annually through 2028
◦ 5% due to cost
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FY2002 FY2007 FY2013 FY2015 FY2017
Lung CA Debility Debility Alzheimer’s Alzheimer’s
CHF Lung CA CHF CHF COPD
Debility CHF Lung CA Lung CA Heart Failure – unspec.
COPD COPD COPD COPD Senile Deg. of Brain
Alzheimer’s AFTT Alzheimer’s Senile Deg. of
Brain
Malignant Neoplasm Of Unsp
Part Of Unsp Bronchus Or
Lung
CVA/Stroke Alzheimer’s AFTT Parkinson’s Parkinson’s
Prostate CA Senile Dementia
(uncomp.)
Senile Dementia
(uncomp.)
Heart Disease ALZ – late onset
AFTT CVA/Stroke Heart Disease CVA/Stroke Atherosclerotic heart disease
native coronary w/o angina
pectoris
Breast CA (unspec.) Heart Disease CVA/Stroke Cerebral
Atherosclerosis
COPD – acute exacerbation
Senile Dementia
(uncomp.)
Prostate CA Dementia in Other Diseases
w/o Behaviors
Breast CA Cerebral atherosclerosis
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Length of StayFY2015 FY2016 FY2017
Average Length of Stay 78.1 79.2 79.7 days
Average Lifetime Length
of Stay
96.1 96.2 96.2 days
Average Lifetime Length
of Stay (RHC at
admission)
114.02 113.5 days
ALOS Cancer (RHC) 63.7 days 63 days
ALOS
Chronic/Progressive
Neuro Disease (RHC)
165.3 days 177 days
Median Length of Stay Not Available 18 18 days
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Live DischargesOverall decreasing trend of 23.7% between FY2007 and FY2017
Approximately seventeen percent of all discharges were live discharges◦ revocations 44%
◦ discharges due to no longer terminally ill 45%
◦ transfers 11%
Median percentage of live discharges 17.3%◦ Range 6.9% to 47.6%
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Skilled Visits in Last Days of LifeMonitoring especially since implementation of payment reforms and changes to the HQRP
Concern: lack of increase in visits
Hours of care in final days of life stable at 1.6 hours/day
Incremental improvement in FY2017 compared to FY2016◦ 42% of patients did not receive RN or MSW visit during last seven days
◦ 20% of patients did not receive RN or MSW visits on last day of life
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Non- hospice SpendingMedicare non-hospice payments under Parts A, B and D during hospice election
Analysis suggests unbundling of items and services that perhaps could have been provided and covered under the Medicare hospice benefit
Decreases have occurred each year since reporting began◦ Overall decrease of 23% from FY2011 to FY2017
◦ Will continue to monitor
◦ Increase in Part D spending
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Non-hospice Spending – Part DPA process has reduced payments in the four targeted categories
Analgesics Anti-nauseants
Anti-anxiety Laxatives
BUT INCREASE in Part D spending on maintenance drugs◦ Medications for heart disease, high blood pressure, asthma, diabetes
◦ Beta blockers, calcium channel blockers, corticosteroids and insulin
Are you properly assessing “relatedness”?
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Session 2: Hospice Quality Reporting Program
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HQRP UpdateNo new measures
Proposed changes to public reporting◦ Removal of routine reporting of 7 HIS measures
◦ Adding public use file (PUF) data to Hospice Compare
Data review and correction timeframes for HIS data
Extension of CAHPS Hospice Survey requirements
Procedures:◦ Announce QM ready for public reporting
◦ Public reporting timelines
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Meaningful MeasuresImproving Patient Outcomes and Reducing Burden Through
Meaningful Measures
CMS initiative: Patients Over Paperwork
Aimed at identifying the highest priority areas for quality measurement and quality improvement in order to assess the core quality of care issues that are most vital to advancing our work to improve patient outcomes
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Meaningful MeasuresAddress high-impact measure areas that safeguard public health
Patient -centered and meaningful to patients
Outcome-based where possible;
Fulfill each program’s statutory requirements
Minimize the level of burden for health care providers
Significant opportunity for improvement
Address measure needs for population based payment through alternative payment models; and
Align across programs and/or with other payers
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Social Risk FactorsCMS asked for input for hospice last year – specific to CAHPS
Comments from FY2019 Hospice Proposed Rule◦ Stratified reporting
◦ Considering options to increase transparency of disparities
Dual eligibility most powerful predictor of poor health outcomes
NQF has extended the SES – Socio Economic Status trial
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HQRP - MeasuresTwo new measures added FY2017◦ Hospice Visits When Death is Imminent (paired measure)
◦ Hospice and Palliative Care Composite Process Measure
National Quality Forum (NQF) status◦ Composite Process Measure approved
◦ CMS will submit the Paired Measure after data analyses
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HQRP – Composite Process Measure
Hospice and Palliative Care Composite Process Measure
Data on seven care processes will be captured
Calculates the percentage of patients who received all care processes at
admission
Individual components assessed separately for each patient and
aggregated into one score for each hospice
Serves to ensure all hospice patients receive a comprehensive assessment
for both physical and psychosocial needs at admission
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HQRP MeasuresProposed:
Add Composite Process Measure to Hospice Compare
Eliminate routine reporting of 7 HIS measures from Hospice Compare◦ NQF #1641 – Treatment Preferences ◦ Modified NQF #1647 – Beliefs/Values Addressed ◦ NQF #1634 & NQF #1637 – Pain Screening and Pain Assessment ◦ NQF #1639 & NQF #1638 – Dyspnea Screening and Dyspnea Treatment◦ NQF #1617 – Patients Treated with an Opioid who are Given a Bowel
Regimen
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HQRP - MeasuresPrevious CMS Comments: Measure concepts under consideration
Access to levels of hospice care
Potentially Avoidable Hospice Care TransitionsLive discharges
- Shortly followed by death or acute stay
- Comparison of performance to peers
- Would be risk adjusted
Claims-based measures
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HQRP – MeasuresTransitions From Hospice Care, Followed by Death or Acute Care
Live Discharges followed by:
- Death within 30 days
- Acute care within 7 days
-hospitalization/ER visit/observation
CMS requested feedback recently
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Hospice CompareProposed:
Add Composite Process Measure to Hospice Compare Fall 2019
Add Hospice Utilization and Payment Public Use File (PUF) data
Anticipate:
Adding Hospice Visits When Death is Imminent measure later in FY2019
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Hospice ComparePUF Data
User-friendly format
Section separate from the HIS and CAHPS Hospice Survey results
Align with other providers
Examples of PUF data• Percent of days a hospice provided routine home care (RHC) to patients, averaged over
multiple years
• Percent of days a hospice provided routine home care (RHC) to patients, averaged over multiple years
• Site of service (long term care or non-skilled nursing facility, skilled nursing facility, inpatient hospital) with a notation of yes, based on whether the hospice serves patients in that facility type
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Hospice CompareProposed:
Eliminate routine reporting of 7 HIS measures from Hospice Compare- NQF #1641 – Treatment Preferences
- Modified NQF #1647 – Beliefs/Values Addressed
- NQF #1634 & NQF #1637 – Pain Screening and Pain Assessment
- NQF #1639 & NQF #1638 – Dyspnea Screening and Dyspnea Treatment
- NQF #1617 – Patients Treated with an Opioid who are Given a Bowel Regimen
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APU – Current Measures
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Hospice Compare
Proposed:
Timeframe to review and correct data to be publicly reported HIS data
Align with PAC
Approximately 4.5 months after the end of each CY quarter
- 15th of the month - 11:59:59 PST
- January 1, 2019
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Hospice Compare
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Hospice Compare
Proposed:
Announce future intent to report a quality measure on Hospice Compare through sub-regulatory means
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Measure Removal Factors7 finalized FY2018 Final Rule
Proposed for FY2019:
The costs associated with a measure outweighs the benefit of its continued use in the program
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Measure Removal FactorsMeasure performance among hospices was so high and unvarying that meaningful distinction in improvements in performance could no longer be made.
Performance or improvement on a measure did not result in better patient outcomes.
A measure did not align with current clinical guidelines or practice.
A more broadly applicable measure (across settings, populations, or conditions) for the particular topic was unavailable.
A measure that was more proximal in time to desired patient outcomes for the particular topic was not available.
A measure that was more strongly associated with desired patient outcomes for the particular topic was not available.
Collection or public reporting of a measure led to negative unintended consequences
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CAHPS Hospice SurveyProposed:
Extend participation requirements to all future years
Extend public reporting policies to future years
Continue policy for volume based exemption to future years
Continue policy for newness exemption to future years
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Social Risk Factors
CMS asked for input for hospice last year – specific to CAHPS
Comments from FY2019 Hospice Proposed Rule
• Stratified reporting
• Considering options to increase transparency of disparities
• Dual eligibility most powerful predictor of poor health outcomes
• NQF has extended the SES – Socio Economic Status trial
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Social Risk Factors
Previous CMS Comments:
Some concerns over selective admissions
Future rulemaking
CMS considering publishing adjusted data and confidentially providing hospices with unadjusted data
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Comprehensive Patient Assessment Instrument
HEART – Hospice Evaluation & Assessment Reporting Tool
CMS currently in early stages of development of comprehensive patient assessment instrument tool
Tool would serve two primary objectives
• provide the quality data necessary for HQRP requirements and the current function of the HIS; and
• provide additional clinical data that could inform future payment refinements
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HEARTAllows more detailed clinical information collection
- Symptom burden
- Functional status
- Patient, family, and caregiver preferences
Information for use in development of future quality measures
Data used for both quality and payment purposes
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HEART
• Would replace HIS
• Would NOT replace current assessment requirements
• Would be completed at
◦ Admission
◦ Discharge
◦ Intervals in between, possibly
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HQRP & Payment
HEART ◦Value based purchasing
◦Case-mix based payment system
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HQRP – Public ReportingFive Star Rating
Will be part of the HQRP
Historically implemented approximately one year after Compare site
Hospice may take longer
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Requests for Information, Physician Assistants as Attending Physicians
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Request for InformationFY2018 Proposed Rule: National conversation on improvements that
reduce unnecessary burdens
lower costs
improve quality
One particular suggestion warrants revision to current policy – removal of detailed drug data on hospice claims effective October 1, 2018
option to report detailed information or aggregate data
option to report detailed DME information or aggregate data
Change Request (CR) 10573 released April 27, 2018
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Request for InformationInteroperability
◦ Possible Establishment of CMS Patient Health and Safety Requirements for Hospitals and Other Medicare-Participating Providers and Suppliers for Electronic Transfer of Health Information
◦ Conditions of participation/Conditions for coverage
◦ Patient and provider access
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Physician Assistants Recognized as Attending PhysiciansPAs recognized as attending physicians
January 1, 2019
PAs Cannot:◦ Certify or recertify a hospice patient
◦ Conduct F2F encounters
◦ Fulfill the physician role on the Interdisciplinary Group (IDG)
PA services reasonable and necessary for beneficiaries who elect the PA as their attending will be paid by Medicare at 85% of the physician fee schedule
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Oversight
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OIGDuplicate Drug Claims for Hospice Beneficiaries
Medicare Payments for Unallowable Overlapping Hospice Claims and Part B Claims
Trends in Hospice Deficiencies and Complaints
Hospice Home Care — Frequency of Nurse On-Site Visits to Assess Quality of Care and Services
Review of Hospices’ Compliance with Medicare Requirements
Medicare Payments for Chronic Care Management
Medicare Hospice Benefit Vulnerabilities and Recommendations for Improvement: A Portfolio
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MedPACNo payment update◦ Projected 2018 aggregate Medicare hospice margin is 8.7%
◦ Adequate access to capital – number of hospices increasing
Greater program integrity focus:◦ Hospices over the aggregate cap◦ Long stays and high live-discharge rates
◦ Medical review focused on hospices that have many long stay patients◦ All sites, and
◦ Assisted Living Facilities (ALF)
◦ Possible: providers that receive a high share of their payments for hospice patients before the last year of life
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Regulation/Policy
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Medicare Part D PrescribersRequires active and valid physician or eligible practitioner NPI on the claim
All prescribers must be enrolled in PECOS/have valid opt out by January 1, 2019◦ Tiered implementation
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Prescriber-Enrollment-Information.html
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Inpatient Units – Life Safety CodeS&C 17-38 LSC
Effective: January 1, 2018
Annual inspection and testing in accordance with the 2010 NFPA 80 is required for all fire door assemblies
Non-rated doors, including corridor doors to patient care rooms and smoke barrier doors, are not subject to the annual inspection and testing requirements of either NFPA 80 or NFPA 105.
But, non-rated doors should be routinely inspected as part of the facility maintenance program as all required life safety features and systems must be maintained in proper working order
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Medicare Beneficiary Identifier
In lieu of social security number/identifier
No later than April 1, 2019
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Bipartisan Budget Act of 2018Physician Assistants allowed as attending physicians for hospice patients
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Opioids/Medications
DEA Disposal Act ◦ Effective October 9, 2014
◦Many states responding with state-specific legislation
Nursing home requirements – F757 Unnecessary Medications◦ PRN Anti-psychotics
◦ PRN Psychotropics
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IMPACT ActThe Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 ◦ Requires home health agencies and other health care providers to report
standardized patient assessment data in an effort to provide better and more affordable care
◦ Reporting of standardized patient assessment data with regard to quality measures, resource use, and other measures◦ Data elements are standardized and interoperable
◦ Cross-setting quality comparisons
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Session 3: Live Discharges, Long/Short Lengths of Stay
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Live DischargesOverall decreasing trend of 23.7% between FY2007 and FY2017
Approximately seventeen percent of all discharges were live discharges◦ revocations 44%
◦ discharges due to no longer terminally ill 45%
◦ transfers 11%
Median percentage of live discharges 17.3%◦ Range 6.9% to 47.6%
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Live DischargesOverall decreasing trend of 22.8% between FY2007 and FY2016
Timing
◦ 26% within 30 days of start of hospice care
◦ 13% between 31-60 days
◦ 14% between 61-90
◦ 19% between 91-180
◦ 28% after 180 days
Seventeen percent of all discharges were live discharges
◦ revocations 38%
◦ discharges due to no longer terminally ill 51%
◦ transfers 11%
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Types of Live Discharges◦Transfer (NOT a discharge)
◦Revocation
◦No longer terminally ill
◦Move out of service
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Live Discharge DifferencesWHO initiates the discharge◦ Patient can revoke at any time for any reason
◦ Hospices can only discharge a patient for certain reasons◦ Moves out of service area
◦ No longer terminally ill
◦ Discharge for cause
Revocations must be in writing
Revocations can not be backdated
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Length of StayLong length of stay: 180, 240, 365, 730 days
Continuing concerns
Targeted probe and educate
Short length of stay: 2, 7 days
10th and 25th percentile respectively
Unique challenges with expenses and quality of care
“high” and “low” routine home care rate has helped
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MonitoringKnow which diagnoses are prone to longer lengths of stay
Know YOUR diagnoses
Know YOUR LOS – median, average, CURRENT patients
Know YOUR live discharge rate
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Hospice – When?
Prognosis of 6 months or less if the illness follows its normal course
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Eligibility - Common Problems
Terminal condition not supported◦ Lack of consistent, objective data
◦ Lack of comparison
◦ Karnofsky/PPS not supported by other documentation
◦ Incorrect use of scales/screening tools◦ FAST
◦ PPS, etc.
Eligibility - Common ProblemsLCD not supported
Chronic v. terminal condition
Assessment is not thorough/not thoroughly documented
Not utilizing IDG documentation
Not referencing the plan of care
Eligibility
Must a patient decline in order to remain eligible?
Does decline equal eligibility?
Compare patient over time
Eligibility
Ongoing Eligibility
◦ every update to the comp assessment
◦ IDG summaries
◦Visit Notes
ToolsLCDs◦ Guidelines
◦ Validated?
Non-LCD Tools◦ H&P
◦ Patient examination – comprehensive assessment
◦ ADLs, BMI, Weight, MAC, etc.
◦ Diagnosis and expected disease progression
◦ Physician judgement
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Tools
Non-LCD◦PPS/KPS, FAST, NYHA Class, Wong-Baker, etc.
◦PaP – Palliative Prognostic Score
◦ADEPT
◦MELD
◦Others….
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Starts At AdmissionBaseline
◦ Upon which all further comparisons are made
Why hospice now?
Physician synthesizes information/data available
Still needs a comparison over time
Why is the patient not considered chronic/custodial care
All comorbidities
OBJECTIVE MEASURES
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RecertificationYes, address LCDs, but…
Is it the patient or is it the documentation
Comparison◦ Baseline
◦ Start of benefit period
◦ Last update to the comprehensive assessment
Answer◦ Why is the patient not chronic/custodial care
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RecertificationLooking for significant changes◦ Charts/graphs helpful
ADLs◦ Time to complete
◦ Severity of dependence
Responsiveness
Strength
Sleeping
Lucidity
I/O
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Discharge?Is it the patient or is it the documentation
The patient is eligible TODAY
Do not wait until end of benefit period!
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Session 4: The IDG Meeting & Hot Topics in Hospice
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The IDG Meeting
624 HOURS
$30,000
IDGComposed of individuals who work together to assess and meet the physical, medical, psychosocial, emotional and spiritual needs of hospice patients and families facing terminal illness and bereavement.
The individuals must include◦ Physician
◦ RN
◦ Social Worker
◦ Pastoral or other counselor
IDG ResponsibilitiesTimely completion of the comprehensive assessment, in consultation with the patient’s attending physician (if any)
Update of the comprehensive assessment, in consultation with the patient’s attending physician (if any), as frequently as the patient’s condition requires but no less than every 15 days
Prepare, in consultation with the patient’s attending physician (if any), a written plan of care (must also include the patient/representative, and primary caregiver, in accordance with the patient’s needs, if any of them so desire)
Must provide the care and services offered by the hospice AND,
The group, in its entirety, must supervise the care and services
IDG Responsibilities, contd.Review, revise, and document the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days.
Document patient’s/representative’s level of understanding, involvement and agreement with the plan of care
Must maintain responsibility for directing, coordinating, and supervising the care and services provided.
Order HHA services and prepare instructions for homemaker services
Person coordinating homemaker services must be a member of the IDG
Confers with an individual with education and training in drug management as defined in hospice policies and procedures and State law, who is an employee of or under contract with the hospice to ensure that drugs and biologicals meet each patient’s needs
Must determine the ability of the patient and/or family to safely self-administer drugs or biologicalsto the patient in his or her home.
IDG Responsibilities, Contd.
Coordination of services◦Develop and maintain a system of communication and
integration…to ensure◦ The IDG maintains responsibility for directing, coordinating, and supervising the care and
services provided
◦ Ongoing sharing of information between all disciplines providing care and services in all settings (directly or under arrangement)
◦ Ongoing sharing of information with non-hospice providers furnishing unrelated care
◦ That care and services provided are in accordance with the plan of care
◦ That care provided is based on all assessments of patient and family needs
What Can Be Accomplished During The IDG Meeting?Update of the comprehensive assessment
Review/revision of the plan of care
Directing, coordinating, and supervising care and services provided
Coordinating services (system of communication and integration)
Update of the Comprehensive AssessmentALL components of the comprehensive assessment must be addressed
Severity of symptoms and progress toward desired outcomes
Clearly identified
Do this as often as the patient’s condition requires but at least every 15 days
REMINDER: Must be done by the IDG in consultation with the patient’s attending physician (if any)
Review/Revision to the Plan of CareDirect link between needs identified in the comprehensive assessment and the plan of care
Problem, intervention, goal
Measurable outcomes◦ Note patient’s progress toward goal
◦ Are the interventions effective?
Directing, Coordinating, and Supervising CareEnsure care provided is based on all assessments (don’t forget bereavement)
Ongoing sharing of information ◦ Between all disciplines
◦ All settings
IDG MeetingsIDG responsibilities - summary◦ Comprehensive assessment and plan of care development
◦ Update to the comprehensive assessment
◦ Review (and revision) of the plan of care
◦ Directing, coordinating and supervising care and services provided
◦ Ongoing sharing of information between all disciplines providing care and services in all settings
IDG MeetingsWhat can be accomplished?
Update of the comprehensive assessment
Review/revision of the plan of care
Directing, coordinating, and supervising care and services provided
Coordinating services (system of communication and integration)
What Spectators See
Unprepared participants/The RN case manager who can’t give a report
because she didn’t make the last visit
Absent participants and no coverage
No mention of plan of care, interventions, goals!!!!!!
A report of the nurses’ last visit
No reference to the LCDs during recertification decisions
Tangents, tangents, tangents!!!
Culture of the IDG◦An interdisciplinary culture must be a culture by design – the IDG
must be designed – it does not happen naturally
◦ It requires commitment from team members – they must be prepared
How to fix it??Develop an agenda for the meeting
Assign individuals to the following roles:◦ Facilitator
◦ Timekeeper
◦ Recorder
◦ Come prepared to the meeting
◦ Make sure each staff person has a DNR
DO NOT RAMBLE!!!!
IDG AgendaDeaths
Admissions
Recerts
Review of existing patients
Presentation of…deathsPatient’s name, place and date of death
BRIEF description (peacefully at home, family present, daughter made it in time to say good-bye, etc.)
Any bereavement risks
Assign someone to bereavement
Bereavement plan of care
Presentation of…admissionsCall facility
Patient’s name, age, sex, diagnosis, location, attending physician
BRIEF history of terminal illness and comorbidities
Review of patient’s eligibility – using LCD guidelines
Review of the comprehensive assessment and plan of care that was developed on admission
◦ Problems (are there too many?)
◦ Goals (palliative care outcomes)
◦ Interventions
◦ Scope and frequency
◦ Any necessary revisions?
◦ If revisions, the recorder needs to give a summary of the revisions before moving on to the next person
Presentation of…recertificationsCall facility
Patient’s name, age, sex, diagnosis, location and attending physician
LCD guidelines and how patient meets them (e.g. “Patient continues to be eligible as evidenced by…” or “no longer eligible as evidenced by…”)
Any updates to the comprehensive assessment
Review of the plan of care
Presentation of…existing patientsCall facility
Patient’s name, age, sex, diagnosis, location and attending physician
Review of the update to the comprehensive assessment and the plan of care
◦ State the problem on the plan of care (or any new problems that need to be added)
◦ Was the problem resolved? If so, REMOVE it
◦ If symptoms/issues being controlled currently and nothing further is needed, then state just that –NOTHING ELSE
◦ Were there any changes to the interventions (or any new interventions that need to be added)
◦ Be sure to include spiritual and social work in this process
◦ Continued eligibility
◦ Summary if any changes needed
IDT “Do’s” and “Don’ts”DO have access to the Plan of Care and updates to the comprehensive assessment
DO come prepared (know the problems, goals, and interventions for each of your patients)
DO hold each other accountable to staying on script
DO provide food
IDT “Do’s” and “Don’ts”DON’T come to IDG unprepared
DON’T miss IDG without preparing someone to cover for you
DON’T save all of your communication for the IDG meeting
DON’T share the story of your last visit
DON’T hesitate to hold others accountable
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Top Ten Hospice Deficiencies 2017ALL
1. Plan of Care – L543
2. Timeframe for completion of assessment – L523
3. Content of the comprehensive assessment – L530
4. Supervision of Hospice Aides – L629
5. Content of plan of care – L545
AO ONLY
1. Coordination of Care – L555
2. Plan of Care – L543
3. Rights of the Patient – L512
4. IDG, Care Planning, Coordination of Services – L536
5. Clinical Record – L671
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L-tags
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https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf
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All services provided must follow an:
Individualized
Written, plan of care, that is
Established by the Hospice IDG in consultation with
o the attending physician (if any)
o Patient or representative
o And primary caregiver
In accordance with the patient’s needs if any of them so desire
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Plan of Care – L543
Plan of Care – L543Survey finding examples:
Not delivering care according to the plan of care
Not having orders for items on the plan of care
Not including the required individuals
Not incorporating updated comprehensive assessment information into the plan of care/not individualizing this information
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Plan of Care – L543Interdisciplinary group
◦ Physician
◦ RN
◦ Social worker
◦ Chaplain, or other counselor
In consultation with attending physician, if any
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QUALIFIED AIDE
CNA
Competency program
Training and competency program
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Every Patient, Every ClaimCertification of terminal illness (CTI)
Valid election statement
Notice of election – timely submission and acceptance
Plan of care
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Certification of Terminal Illness (CTI)Purpose is for physician(s) to certify/recertify that a patient is terminally ill
Eligibility component
Technical component
◦ Timing
◦ Form components
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CTI – ConcernsOIG – “Hospices Should Improve Their Election Statements and Certifications of Terminal Illness”
Current requirement is that medical director must consider at least
the following
◦ Diagnosis of the terminal condition
◦ Other health conditions, related or unrelated
◦ Current clinically relevant information supporting all diagnoses
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Certification of Terminal Illness (CTI)Purpose is for physician(s) to certify/recertify that a patient is terminally ill
Eligibility component
Technical component
◦ Timing
◦ Form components
121
CTI – ConcernsOIG – “Hospices Should Improve Their Election Statements and Certifications of Terminal Illness”
Current requirement is that medical director must consider at least
the following
◦ Diagnosis of the terminal condition
◦ Other health conditions, related or unrelated
◦ Current clinically relevant information supporting all diagnoses
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CTI – F2F EncounterSome Common Problems
• Illegible signatures/dates
• Unsigned/undated documents
• Initial certifications aren’t obtained from both attending physician (if one) and hospice physician
• Recertification not obtained from hospice physician
• Required components not placed in proper location/not titled properly
123
CTI – F2F EncounterSome Common Problems
• Not utilizing the proper professional (e.g. NP is not employed, etc.)
• CTI completed prior to the 15 days before the start of the benefit period OR more than two days after the start of the benefit period
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Election StatementPurpose is for the patient to make the election of hospice care and to understand this election
◦ Waiver of traditional Medicare benefits
◦ Choice of attending physician
◦ Effective date
Technical components
125
Election Statement – ConcernsOIG – “Hospices Should Improve Their Election Statements and Certifications of Terminal Illness”
◦ Complete and accurate information
Missing required information
126
Election Statement – Common ProblemsDoes not contain:
◦ Name of the hospice
◦ Waiver
◦ Attending physician
◦ Acknowledgement of palliative nature of hospice care
◦ Signature of patient or legal representative
127
Election Statement – Common ProblemsDoes not contain:
◦ Name of the hospice
◦ Waiver
◦ Attending physician
◦ Acknowledgement of palliative nature of hospice care
◦ Signature of patient or legal representative
128
Resourceswww.ngsmedicare.com
www.cgsmedicare.com
www.palmettogba.com
Technical requirements of the CTI/F2F and Election
◦ Medicare Benefit Policy Manual, Chapter 9, Section 20
◦ http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c09.pdf
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Healthcare Provider Solutions, Inc.
810 Royal Parkway, Suite 200
Nashville, TN 37214
615.399.7499 - 615.399.7790
www.healthcareprovidersolutions.com
