March Hospice Fundamentals All Rights Reserved 1. What We ll Cover

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1 The Clinicians Connection to Documentation: Using the PPS, FAST, BMI, MAC and NYHA What We ll Cover Common scaling and measurement tools Importance of tools in supporting eligibility Effective use Common challenges Subscriber Webinar Assessment Tools Tools provide a data point or points that, used in context with the whole person, help to make a determination of eligibility. It is important to assess the data points over time. The purpose of an assessment scale is reduce subjectivity and increasing objectivity Importance of Tools Communicates patient symptoms and functional status Supports effective care planning Determine if care plan is effective Revise care plan to meet current needs Anticipate future needs Foundational to eligibility determination All Rights Reserved 1

2 Data Points Data points are just that, points of data The more the accuracy and consistency of data points, the clearer the picture of the patient Put them together to paint your patient s picture Medicare Coverage Requirements Medicare wants to know what they are paying for They review hospice records and decide whether to pay or not (or take money back) Report card A get paid in full C partial payment F free care provided It s the evidence Top Denial Reasons Palmetto GBA CGS NGS Not Hospice Appropriate Six month terminal prognosis not supported According to Medicare hospice requirements, the information provided does not support a terminal prognosis of six months or less It all means the same thing: the documentation does not tell the reviewer the story of why the patient has a prognosis of 6 months or less Common Problems 1. Using wrong tool(s) for patient or diagnosis or not using it at all 2. Inconsistencies among clinicians Scoring Usage some do, some don t Documentation placement (especially with EMRs) 3. Clicking templates without actual data 4. Not identifying scores that don t make sense or are in conflict with others 5. Scoring without reference to context 6. No baseline measurements All Rights Reserved 2

3 Assessment Tools - Today s Focus Functional performance measurement tools Palliative Performance Scale (PPS) Functional Assessment Staging (FAST) (measures both cognition and function) New York Heart Association Classification (NYHA) Nutritional status measurement tools Weight scales Body Mass Index (BMI) Mid Arm Circumference (MAC) Effective Use of Tools Requires Decision Making 1. Determination of which tools will be used (for which patients and when) 2. Defining how tool data will be incorporated into documentation system so it goes in the same place in the same way for trending and retrieval 3. How tool data will connect to care planning and delivery of care 4. On going education needs 5. Monitoring and auditing plans The PPS & FAST Using Functional Measurement Tools Excellent tools for monitoring, quantifying and documenting the functional performance and decline in hospice patients Documents a dementia patient s current cognitive abilities How they manifest in the patient s functional abilities Predict and document disease progression All Rights Reserved 3

4 Probability of Death within Six Months PPS >60 Cancer 98.3% 95.5% 92.8% 89.1% Cardiovascular disease 89.8% 74.2% 65.3% 51.8% Dementia 73.6% 54.9% 51.4% 36.6% Pulmonary disease 92.4% 79.9% 71.6% 63.8% Stroke 67.4% 48.4% 39.4% 32.6% Harris, et al Can Hospices Predict which Patients Will Die within Six Months? Journal of Palliative Medicine; Vol 17, Number 8, 2014 Palliative Performance Scale (PPS) Designed to measure functional performance and progressive decline in palliative care patients Ambulation Activity Evidence of disease Self care Intake Level of consciousness Designed to measure what a person is capable of doing, not what they choose to do Palliative Performance Scale % Ability to Activity and Evidence of Disease Self-Care Intake Level of Ambulate Conscious. 100 Normal activity, no evidence of disease Normal 90 Normal activity, some evidence of disease Normal 80 Normal activity with effort, Normal or some evidence of disease 70 Reduced Unable to do normal work, Normal or some evidence of disease 60 Reduced Unable to do hobby or housework, Occasional assist necessary Normal or or confusion Evidence of significant disease 50 Mainly sit/lie Unable to do any work, extensive disease Considerable assistance Normal or or confusion required 40 Mainly in bed Unable to do any work, extensive disease Mainly assistance Normal or, drowsy, or confusion 30 Totally bed Unable to do any work, extensive disease Total care Normal or, drowsy, or bound confusion 20 Totally bed Unable to do any work, extensive disease Total care Minimal sips, drowsy, or bound confusion 10 Totally bed Unable to do any work, extensive disease Total care Mouth care only Drowsy or coma bound FAST (Functional Assessment Staging) 16 item scale designed to parallel the progressive activity limitations associated with Alzheimer s Disease A 7 step staging system, to determine hospice eligibility which identifies progressive steps and sub steps of functional decline Designed for Alzheimer s Disease Little information on other dementias Problems of non ordinate patients Stage 7 identifies the threshold of activity limitation that would support a six month prognosis To qualify under Alzheimer's Disease the patient should have a FAST of 7 along with secondary conditions 0 Death Copyright 2001 Victoria Hospice Society 15 All Rights Reserved 4

5 Keys to Scoring The scoring must be done sequentially: Its not the lowest score for which the patient qualifies, it s the lowest uninterrupted score Unable to ambulate without assistance This means personal assistance, someone holding them up so they can walk It is not: walker, cane, standby assist Verbal communication Ability to speak limited to approximately a half a dozen intelligible different words or fewer, in the course of an average day or in the course of an intensive interview Deficits are a result of the dementing process Walking limitation can not be from osteoarthritis or other non related disease processes Case Study Patient with Alzheimer's living in a SNF Unable to ambulate safely without assistance, but tries and falls frequently Cannot hold his balance on the edge of the bed No longer smiles. Frequently tells staff things like don t touch that, leave me alone, this isn t my house, I want ice cream Is incontinent of bowel and bladder Needs assistance to dress, bathe and toilet What s the FAST? New York Heart Association Functional Classification NYHA Classification NYHA Functional Classification Provides a simple way of classifying the extent of heart failure Places patients in 1 of 4 categories based on How much they are limited during physical activity Limitations / symptoms are in regards to normal breathing Varying degrees in shortness of breath and / or angina pain 2017 All Rights Reserved R&C Healthcare Solutions All Rights Reserved 5

6 End Stage Heart Disease- Prognostication NYHA 1 Year Mortality Class I 5-10% II-III 10-15% IV 30-40% Fast Facts and Concepts #143 Gary M Reisfield, MD & George R Wilson, MD New York Heart Association Functional Classification Class I Class II Mild No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath) or angina Mild Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea or angina Moderate Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or Class III dyspnea, or angina Severe Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency or the angina Class IV syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown & Co; 1994: Mr. Smith 78 year old admitted with ASHD. Depressed and anxious because of disease. Wife states his function has declined lately. His medical records show he has CHF, COPD, HTN, anemia, and a history of TIA s. Echocardiogram of 4 months ago notes an EF of 25%. His hemoglobin is 10.3 Mr. Smith denies any real complaints. States I don t have the same energy as I used to, probably should quit smoking. He does admit to having some chest pain with exertion. His wife states he gets short of breath just walking around the house but not at rest. He has oxygen but doesn t like to use it. He is much less active compared to a three months ago when he was fully ambulatory with only occasional dyspnea and chest pain. Mr. Smith s Assessment Medications include Lisinopril, Nitroglycerin prn, Lasix 40 mg. daily, Albuterol prn, Atrovent and aspirin. Assessment shows that he gets around the house some, but spends a lot of time sitting in a chair. He needs assistance bathing, but otherwise can do his own ADLs. However, states he is very fatigued afterwards. His appetite is fair and has lost 10 lbs. (6% of his body weight) in the past 3 months. He states he is too tired to eat and nothing tastes good. His wife is worried because he doesn t eat and use to be a big eater. He has 2 3+ edema to his lower extremities. Lungs sounds have coarse rales with expiratory wheezes. O2 sat on RA is 88%. What is his NYHA Classification? All Rights Reserved 6

7 What is his PPS? PPS = 50% % Ability to Ambulate Activity and Evidence of Disease Self-Care Intake Level of Conscious. 100 Normal activity, no evidence of disease Normal 90 Normal activity, some evidence of disease Normal 80 Normal activity with effort, Normal or some evidence of disease 70 Reduced Unable to do normal work, Normal or some evidence of disease 60 Reduced Unable to do hobby or housework, Occasional assist Normal or or Evidence of significant disease necessary confusion 50 Mainly Unable to do any work, extensive disease Considerable Normal or or sit/lie assistance required confusion 40 Mainly in Unable to do any work, extensive disease Mainly assistance Normal or, drowsy, bed or confusion 30 Totally bed Unable to do any work, extensive disease Total care Normal or, drowsy, bound or confusion 20 Totally bed Unable to do any work, extensive disease Total care Minimal sips, drowsy, bound or confusion 10 Totally bed Unable to do any work, extensive disease Total care Mouth care only Drowsy or bound coma Functional Performance: Connection to Care Planning Examples Fall precautions Oxygen safety Skin breakdown Incontinence Assistive devices DME and respiratory equipment Assistance with ADLs Hospice Aides Family education Caregiver fatigue 0 Death Nutritional Measurement Nutritional Measurement Extremes of nutritional status are associated with increased mortality >10% weight loss in elderly, over 6 months associated with high mortality BMI < 22 kg/m 2 in the elderly associated with increased mortality 2017 All Rights Reserved R&C Healthcare Solutions All Rights Reserved 7

8 Weights Admission Accurate actual weight (not reported) For NF patients, if weights fluctuate find out why and then get an accurate admission weight Obtain weight from 6 months ago (if available) Obtain MAC for baseline future need Ongoing Accurate actual weight (not reported) For NF patients, don t accept wide discrepancies Take into account impact of fluid retention BMI Measure of body fat based on height and weight that applies to adult men and women Underweight BMI is less than 18.5 Accurate actual weight (not what is reported) Maximum adult height (reported) Half arm span Multiply the half arm span measurement by 2 Nutritional Assessment-MAC Provides an indication of skeletal muscle mass, bone and subcutaneous fat Used for patients who cannot be weighed Key point is consistency in measurement Standard method Centimeters Obtain a MAC on every patient at admission Nutrition: Connection to Care Planning Examples Weight loss Nutritional assessments Calorie consumption Diet Family and caregiver education food intake and end of life Weight gain Fluid retention: heart failure, chronic lung disease, kidney disease, liver disease, cancer, medications Physical assessment All Rights Reserved 8

9 Where Are the Opportunities for Improvement? Could This Be Improved? Mid Upper Arm Circumference (MAC) Date cms 2/15/ /1/ /23/ /16/ /11/ Frequency of measurements Which arm Consistency Date Weight MAC O2 sats FAST 9/9/ cm LA 98% 7c 10/7/ cm LA 94% Ra 7b 11/15/ cm LA 97% 7b 12/15/ cm LA 96% Ra 7c 1/24/ cm LA 92% 7c 2/21/ cm LA 92% 7c Audit Tool Example All Rights Reserved 9

10 Actions of The Prudent Hospice Determine which tools will be used (and for which type of patients and when) Define how tool data will be incorporated into documentation system so it goes in the same place in the same way for trending and retrieval Understand how the trending ability of your EMR Use the power of your documentation system Teach staff how tools connect to care and care planning Educate and then educate some more Implement effective auditing and use the results to develop and implement improvement activities References BMI App IPhone: app.shtml Droid: calculator Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown & Co; 1994: The Criteria Committee of the New York. Reisberg, B. Functional Assessment Staging (FAST). Psychopharmacology Bulletin, 1988; 24: To Contact Us Susan Balfour Roseanne Berry Charlene Ross The information enclosed was current at the time it was presented. This presentation is intended to serve as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. All Rights Reserved 10

11 Audit Tool Example Consistent Use of Tools Eligibility Score Admission/Recertification (circle one) Comments Weights (MACS if can t weigh) are documented Yes No n/a MAC documented at admission regardless if can be weighed Yes No n/a Weights are consistent without wild fluctuations Yes No n/a Assistance with ADLs is descriptive Yes No n/a Documentation supports the ADL scoring Yes No n/a PPS is documented Yes No n/a Documentation supports the PPS score Yes No n/a FAST is documented (for patients with dx or comorbidity of dementia) Yes No n/a Documentation supports the FAST score Yes No n/a NHYA Class is documented for patients with dx or co-morbidity of heart disease Yes No n/a Documentation supports the NHYA Class score Yes No n/a Hospice Fundamentals September 2017 Subscriber Webinar Handout

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13 Eligibility Reference Tools PPS Level Ambulation Activity & Evidence of Disease Palliative Performance Scale (PPSv2) version 2 Self-Care Intake Conscious Level 100% Normal activity & work Normal No evidence of disease 90% Normal activity & work Normal Some evidence of disease 80% Normal activity with Effort Normal or Some evidence of disease 70% Reduced Unable Normal Job/Work Normal or Significant disease 60% Reduced Unable hobby/house work Significant disease Occasional assistance necessary Normal or or Confusion 50% Mainly Sit/Lie Unable to do any work Extensive disease Considerable assistance required Normal or or Confusion 40% Mainly in Bed Unable to do most activity Extensive disease Mainly assistance Normal or or Drowsy +/- Confusion 30% Totally Bed Bound Unable to do any activity Extensive disease Total Care Normal or or Drowsy +/- Confusion 20% Totally Bed Bound Unable to do any activity Extensive disease Total Care Minimal to sips or Drowsy +/- Confusion 10% Totally Bed Bound Unable to do any activity Extensive disease Total Care Mouth care only Drowsy or Coma +/- Confusion 0% Death Instructions for Use of PPS 1. PPS scores are determined by reading horizontally at each level to find a best fit for the patient which is then assigned as the PPS% score. 2. Begin at the left column and read downwards until the appropriate ambulation level is reached, then read across to the next column and downwards again until the activity/evidence of disease is located. These steps are repeated until all five columns are covered before assigning the actual PPS for that patient. In this way, leftward columns (columns to the left of any specific column) are stronger determinants and generally take precedence over others. Example 1: A patient who spends the majority of the day sitting or lying down due to fatigue from advanced disease and requires considerable assistance to walk even for short distances but who is otherwise fully conscious level with good intake would be scored at PPS 50%. Example 2: A patient who has become paralyzed and quadriplegic requiring total care would be PPS 30%. Although this patient may be placed in a wheelchair (and perhaps seem initially to be at 50%), the score is 30% because he or she would be otherwise totally bed bound due to the disease or complication if it were not for caregivers providing total care including lift/transfer. The patient may have normal intake and full conscious level. Example 3: However, if the patient in example 2 was paraplegic and bed bound but still able to do some self-care such as feed themselves, then the PPS would be higher at 40 or 50% since he or she is not total care. 3. PPS scores are in 10% increments only. Sometimes, there are several columns easily placed at one level but one or two which seem better at a higher or lower level. One then needs to make a best fit decision. Choosing a half-fit value of PPS 45%, for example, is not correct. The combination of clinical judgment and leftward precedence is used to determine whether 40% or 50% is the more accurate score for that patient. 4. PPS may be used for several purposes. First, it is an excellent communication tool for quickly describing a patient s current functional level. Second, it may have value in criteria for workload assessment or other measurements and comparisons. Finally, it appears to have prognostic value. Copyright 2001 Victoria Hospice Society BMI Formula (or go to My BMI Calculator on your smart phone to download app): Weight (lb) / [height (in)] 2 x 703 Calculate BMI by dividing weight in pounds (lbs by height in inches (in) squared and multiplying by a conversion factor of /22/2012

14 New York Heart Association Classification Class I Class II Class III Class IV (Mild) No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath). (Mild) Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea. (Moderate) Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea. (Severe) Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased. Mid Arm Circumference (MAC) 1. Ask the pt to bend their non-dominant arm at the elbow at a right angle with the palm up. 2. Measure the distance between the acromial surface of the scapula (bony protrusion surface of upper shoulder) and the olecranon process of the elbow (bony point of the elbow) on the back of the arm. 3. Mark the mid-point between the two with the pen. 4. Ask the pt to let the arm hang loosely by his/her side. 5. Position the tape at the mid-point on the upper arm and tighten snugly. Pull the tape just snugly enough around the arm to ensure contact with the medial side of the arm and elsewhere. Make sure that the tape is not too tight that it causes dimpling or pinching of the skin. Keep the tape perpendicular to the shaft of the upper arm. 6. Measure again. Check to see if the 2 measurements are within 0.4 cm of each other. If they are not, take two more measurements and record the mean of all four 7. Record measurement to nearest millimeter and document which arm. Functional Assessment Staging (FAST) Check highest consecutive level of disability: 1. No difficulty either subjectively or objectively. 2. Complains of forgetting location of objects. Subjective work difficulties. 3. Decreased job functioning evident to co-workers. Difficulty in traveling to new locations. Decreased organizational capacity.* 4. Decreased ability to perform complex tasks, e.g., planning dinner for guests, handling personal finances (such as forgetting to pay bills), difficulty marketing, etc. 5. Requires assistance in choosing proper clothing to wear for the day, season, or occasion, e.g., patient may wear the same clothing repeatedly unless supervised.* 6. A) Improperly putting on clothes without assistance or cueing (e.g., may put street clothes on over night clothes, or put shoes on wrong feet, or have difficulty buttoning clothing) occasionally or more frequently over the past weeks.* B) Unable to bathe properly (e.g., difficulty adjusting the bath-water temperature) occasionally or more frequently or the past weeks.* C) Inability to handle mechanics of toileting (e.g., forgets to flush the toilet, does not wipe properly or properly dispose of toilet tissue) occasionally or more frequently over the past weeks.* D) Urinary incontinence (occasionally or more frequently over the past weeks).* E) Fecal incontinence (occasionally or more frequently over the past weeks).* 7. A) Ability to speak limited to approximately a half a dozen intelligible different words or fewer, in the course of an average day or in the course of an intensive interview. B) Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview (the person may repeat the word over and over). C) Ambulatory ability is lost (cannot walk without personal assistance). D) Cannot sit up without assistance (e.g., the individual will fall over if there are not lateral rests [arms] on the chair). E) Loss of ability to smile. F) Loss of ability to hold head up independently. * Scored primarily on the basis of information obtained from acknowledgeable informant and/or category. Reisberg, B. Functional assessment staging (FAST). Psychopharmacology Bulletin, 1988; 24: /22/2012

15 Test/ Assessment Pulse Ox Patient types Cardiac, pulmonary, dementia/ stroke, or anyone using oxygen Weights All No Guidelines for Eligibility Assessments Supporting Information* Order No (unless required by state or accreditation body) ACHC does require order. Who obtains Nurses Nurses, hospice aides Frequency Admission and monthly Admission and monthly. More frequently for symptom management such as fluid retention Comments Activity (ambulatory feet if able to tolerate) without oxygen and time takes to recover. If unable to tolerate removal of oxygen, document such. Standing scales as possible. Bed scales or WC scales for NF patients only if unable to use standing scale. If using NF weights look for wild swings and if necessary re-weigh or always have the Hospice Aide weigh the patient. BMI All No Nurses Admission and monthly Only if able to have an accurate weight Admission and then monthly Follow written guidelines for consistent measurements. Mid Arm All No Nurses when patient can no longer be (Consider a calf or thigh circumference for those who have Circumference weighed minimal body fat or muscle) Prealbumin Dementia/stroke or patients with comorbidity of AFTT or debility Yes RN Admission (if available) and recertification BNP level Cardiac Yes RN Admission (if available) and recertification Creatinine Renal disease or Admission (if available) and Yes RN cardiac disease recertification PT/INR Liver Yes RN Admission (if available) and recertification FAST Alzheimer s (primary or co-morbid) No Nurse Admission and monthly PPS All No RN / LPN Admission and monthly Dependence in ADL All No RN / LPN Admission and monthly Only if eligibility in question Only if eligibility in question Only if eligibility in question Only if eligibility in question Document number of ADLs patient needs assistance and the amount of assistance required for each *These are guidelines to help in decision-making. They are only some of the data points utilized in helping support eligibility and in some cases for care planning. If a patient is clearly eligible based on other parameters, such as entering the terminal phase, it would not be necessary to complete these. Always consider the patient response to any of these in making a determination to proceed. Always treat the patient s troublesome symptoms regardless of the test results. R&C Healthcare Solutions August 2016