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Hospice & Long Term Care –
A Medical Director in the Middle
Jerry Bruggeman, MD, MBA, CMD
JeffCo – Missouri
Who are these patients? NH numbers
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In the United States,
– About 1.8 million Americans
– Live in ~17,000 NHs
– In 2010, 1:8 people 85+ years old resided
in LTCFs
– Life expectancy is increasing
– SNF/NF patients seem to be “sicker”
– Medicaid pays for about 40% of NHs
– Patient resources and control are
dwindling during this time
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– Hospice: for… “serious illness”… “no
longer responsive to cure-oriented
treatment”…
– Is this… unusual… in NHs??
– If these patients were… triangles, they’d
be congruent!
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1/18
SNF/NF  Hospice?
Medicine’s most natural, yet taboo,
Segue?
The average stay for elderly patients
who die in NH is almost two years
Only 20-25% of people who die in the
US utilize hospice
Barriers… (TNTC)?+
Hospice is not easy
• No one talks about death
• Regulatory compliance
• Billing is a bird’s nest
• Pharmacy needs are unique
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Orders, equipment
Whose responsibility is it?
Paperwork
Admission to either NH or hospice –
often during time of crisis
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2/18
And everyone lives in fear… narcotics, diversion,
“did I give the terminal dose?”, state surveyors,
family, etc.
People are terrible crisis decision makers
NH care is not easy
• Also a regulatory quagmire
• No one understands anyone else’s billing
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Pharmacy
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Med A, Medicaid, Med B
SNF, therapy, physicians, etc.
Contracts, E-kits, after hours?
Staffing: turnover, it’s not glamorous work
Documentation burden is huge
NH admission often occurs at same time as
hospice
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Can confuse patients and loved ones
Why must hospice get involved?
• About 20% of NH residents die each year
– In NHs or shortly after transfer to acute care
• Data suggest that end-of-life care in NHs is not stellar
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Poor pain/symptom mgt
$ disincentives
“Passing lane” default: feeding tubes, etc.
Despite great intentions, NHs are just not equipped
• Hospice, not NH, have dedicated end-of-life resources
• Enter: Jerry’s “Momma Rule!”
– Who is going to advocate?
3/18
Simple causes for complex problems?
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4/18
Care in NHs  based on restorative/rehabilitative model
– What to do when this is not feasible?
• How often is this feasible?
– Where do people die?
• For every 100 residents in NH in a given year:
– 35 will die…
– 37 will be admitted to hospital… They will either die or recover/return to NH
Hospice has a different set of goals and desired outcomes
– Barriers to new paradigm – multiple
– Myths, education gap, etc.
PCP offices are ill-equipped to handle NH care… AND hospice care
– Deluge of information – fax, phone, email, text, etc.
– Older, sicker patients
– …more of ‘em
– Regulatory nightmare
A Hospice Walk: An encounter with hospice
Jerry’s (partially plagiarized) steps of hospice admission:
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Pre-Admission – Making hospice an option
Referral & Admission – Black Box No More!
Ongoing needs – IDT, on-call, etc.
Recertification process
Death/Discharge
Post Hospice Care – Consider this a cycle
This is a wash/rinse/repeat and reproducible cycle,
but each step is fraught with traps.
5/18
1) Pre-Admission
• Put hospice on the menu!
• Stigma busters?
• Achieve buy-in from:
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Patients & loved ones
Community
NHs (and hospitals, ALFs, etc.)
Home health, pharmacies, etc.
and… (drumroll please)… physicians
• Marketing & PR marathon
6/18
Problems at the pre-admission stage
Resistance
Problems
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Med A vs. hospice
– Healthcare is adversarial
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Follow the $
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Cultural differences
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Local medical practices vary
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Tail tries to wag the dog
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Resistance/agenda from unexpected sources
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US Healthcare is stuck in the fast lane
7/18
Potential Solutions
How can a medical director make a dent?
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Foster relationships
– Hospitals, provider groups, HH
– Let them know we are HELPFUL
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Demonstrate value
– Quality, cost, outcomes
– Relieve pain (not just the patient)
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Can we EDUCATE the greater community?
– Med A is temporary
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“Hallmark movie”?
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Physicians need to OWN the issue
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Screening tools, red flags
2) Referral & Admission
• What counts as a referral?
– No clear single pathway to admission
– This allows “non-champions” to have influence
• Whose job is it to refer?
– SW, patient/family, admin, DON, PCP, pizza guy?
• You only die once (if you’re lucky), but…
– You can have multiple events, crises, declines, symptom
complexes, etc.
• MANY stages in this step, and it is often painful
8/18
The Hospice Admission 101
What are the “essential elements”?
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Need referral name and actionable item, such as a phone number
CTI… x2 “<= 6 months of life expectancy if normal course”
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Deploy your troops:
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9/18
Who does it?
Call patient or decision maker – elect hospice or not?
Obtain records and prepare to “make your case” to CMS/payer
Obtain an order to “admit”
Signatures; “legals” – probably the rate-limiting step
Admission staff (nurse?) visits
Equipment, medications, etc.
Admission: Another “transition of care”
Like asking our patients to cross the interstate blindfolded
• Chaos theory comes to hospice:
– “… the flutter of a butterfly’s wings…”
– “… can derail a hospice admission halfway around the world”
- J. Bruggeman
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More hospice metaphysics:
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Problems inherent to NH care (TNTC)
And problems inherent to hospice care (TNTC)
And unforeseen problems that arise when they converge!
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Who’s job is it to ___?
Who’s paying for ___?
Who do I call for ___?
Take home point:
– ALL transitions of care are potential problems
10/18
Admission problems occur at each step
Problems:
Actions:
• No one willing to broach subject
• Preach & proselytize
• Or willing to give CTI (crickets)
• Medical directors are often asked to ____
• Finding a decision maker willing to “make • Work on scripting and discussion strategies
the call”
– With ALL staff (RNCM, admission, on• Records: Needle in a haystack
call, etc.)
• A willing/reachable physician
• Plan ahead: know pharmacies, DME
suppliers, SNF quirks, etc.
• Antiquated requirements – everyone is busy
• Staff, supplies, meds are difficult to obtain at • Other steps in the “hospice walk” affect this
one
odd hours/times.
– Know what our HCCs are promising,
etc.
11/18
3) Meeting ongoing needs… daily grind
The Facts:
• Hospice happens
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Admissions, recertification
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12/18
Narratives, documentation, F2Fs
Deaths and discharges
Everyone else?
Teaching?
If a FACT gets up to use the john…
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24/7
Assume: no weekends, holidays, breaks, after-hours
Problems don’t wait for IDT
IDT is jam-packed with:
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Dirty Little Secrets:
• The status quo is king
A MYTH takes its seat!
$2,309 saved
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It makes money
It’s comfortable
Unbelievable inertia
Default setting = aggressive care
We need to sell ourselves
Healthcare is business
We are bad at prognosis
… and bad at goal setting
Every treadmill is set on 10 and an incline
Decrease re-hospitalizations, in-hospital
deaths, hospital days & ICU days
“Routine” stumbling blocks?
Obstacles:
Defenses:
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Orders are needed (for EVERYTHING)
Rx’s… NOBODY has a phone, script pad, pen or
fax
Our RN becomes a courier
On-call carousel
IDT can be like unruly hair
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13/18
Anticipate problems
– Count controlled meds; Check MAR!
Find a source of patience
Prepare your own office staff/infrastructure
Be involved in staff orientation?
Know who’s “on”:
– Nursing, admin, pharmacy
Anything can be accomplished with:
– Smart phones/tablet, PDF editor,
electronic fax & email
4) Recertification – the knuckleball
Problems:
Suggestions:
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These narratives are often difficult
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Multiple observers, yet nobody is
documenting?
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14/18
Multiple reasons
2-3 shifts per day/7 days per week
SNF staff, hospice staff
Agendas
Family, friends, etc.
F2F visits – who’s tracking them?
Data often conflicting or absent
Use a trajectory sheet
Insist on data:
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Try to make F2Fs useful – not just a formality
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PPS, FAST, VS, weights, arm circ.
Dates/frequency of events, falls, etc.
Provider should know if this is a “difficult recert.”
Assume the NH chart is incomplete
It’s OK to be the “bad cop”
5) Death & Discharge
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Often preceded by escalation of symptoms/crescendo of “chaos”
This is ironic in the NH (b/c of 24 hour staff), but it’s ubiquitous
– Code status & advance directives
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This is not the time for ambiguity
– Defibrillators, etc.
– Last minute family requests… hospital, IVF, TFs
– Death certificate shuffle
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Get info BEFORE the trail goes cold
Medical director often completes these – and has never met the patient
– We are:
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15/18
Final common pathway
Safety net
This is the part the family and NH staff will remember  We need to knock it outta the
park
6) Post-Hospice Matters…They Matter!
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PLEASE don’t rush in to get the equipment…
– Whether it’s a death or a discharge
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This is a TRANSITION OF CARE…
– Lacks tact… boorish
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Bereavement services
– Hospice is the ONLY way loved ones (and NH staff) get this
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Memorial services
Sympathy cards/calls
Feedback is difficult to obtain
– Surveys
– “Secret shop”?
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16/18
I plant “confederates” and nose around
Discussion?
17/18
References
• http://www.annalsoflongtermcare.com/article/4783
• Hirschman, et al. Hospice in Long-Term Care, Annals of Long-Term Care,
Vol 13 – Issue 10, Oct. 2005.
• https://www.caregiver.org/selected-long-term-care-statistics
• https://www.longtermcarelink.net/eldercare/nursing_home.htm
• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2682390/
• Finestone, et al. Death and dying in the US: the barriers to the benefits of
palliative and hospice care, Clin Interv Aging, Sep; 3(3) 595-599.
• https://www.washingtonpost.com/national/health-science/us-lifeexpectancy-continues-to-climb/2014/12/05/9edb2ffe-4fc2-11e4-8c24487e92bc997b_story.html
• Conversations with multiple (past and present) all-star members of JeffCo.
18/18