Relatedness *, Terminal Prognosis and Multiple Diagnoses

Transcription

1 Relatedness *, Terminal Prognosis and Multiple Diagnoses *Is Relatedness a word? John C. Tangeman MD FACP The Center for Hospice and Palliative Care Buffalo, New York

2 The Good ol Days Single Hospice Diagnosis Loose med coverage Symptom management meds Inexpensive chemo Limited inhalers Medical Directors signature was proof of eligibility

3 Non-Hospice Medicare Spending A.K.A Leakage For beneficiaries after hospice election Parts A & B: $694.1 million Part D: $347.1 million TOTAL: $1.2 Billion dollars Average total per beneficiary: $7.65 per patient care day in non-hospice costs Highest states: $12.10 to $13.74 per patient care day Source: FY2016 Hospice Wage Index proposed rule, April 30, 2015, NHPCO Webinar

4 No more Frailty

5 You Can t Die of Old Age Anymore Source:NHPCO Compliance Guide 8/2015

6 2015 Pepper

7 Single Hospice Diagnosis Source: 2015 Pepper

8 Federal Register CMS 1629-F The December 16, 1983 Hospice final rule (48 FR 56008) requires hospices to cover care for interventions to manage pain and symptoms. Additionally, the hospice Conditions of Participation (CoPs) at (c) require that the hospice must provide all reasonable and necessary services for the palliation and management of the terminal illness, related conditions and interventions to manage pain and symptoms.

9 FY 2016 Hospice Payment Rate Update CMS-1629-F However, as articulated in section II of this rule, since the implementation of the Medicare hospice benefit in 1983, we have stated that it is our general view that hospices are required to provide virtually all the care that is needed by terminally ill individuals and we would expect to see little being provided outside of the benefit.

10 CMS-1629-F It is our general view that hospices are required to provide virtually all the care that is needed by terminally ill patients. Therefore, unless there is clear evidence that a condition is unrelated to the terminal prognosis; all conditions are considered to be related to the terminal prognosis. It is also the responsibility of the hospice physician to document why a patient's medical needs will be unrelated to the terminal prognosis.

11 Terminal Prognosis Stepwise approach Diagnosis list Stable or unstable Associated medications or therapies Pick the worst first If we took away diagnosis x, would the terminal prognosis be any different?

12 ICD-10 Plenty of choices! V97.33XD Sucked into a jet engine, subsequent visit Z63.1 Problems in Relationships with In-Laws W56.22 Struck by Orca R46.1 Bizarre Personal Appearance V91.07 Burn due to Water Skis on Fire

13 Six Degrees of Separation

14 Relatedness and Unrelatedness Diagnosis or Symptom? Depression, anxiety etc. are both Separate Symptoms? CHF and COPD Dyspnea Fibromyalgia vs metastatic disease How far back to you go? ESRD Diabetes HTN If you took away the diagnosis, would anything be different? Is the diagnosis well controlled?

15 Our approach Single Medical Director Attempts to be evidence based All admissions are reviewed in real time Diagnosis list, related and unrelated Medication list, related and unrelated Formulary Most inhalers non-formulary Ongoing education for admission RN s Clinical Pharmacist review, places note in EMR De-Prescribing

16 What s the diagnosis? PMD says they ve got the dwindles Former Failure to thrive Hospice MD can use their judgement to make a diagnosis Dementia = Alzheimer s Dwindles = Protein Calorie Malnutrition, Sarcopenia Unresponsive = Catastrophic CNS event?

17 Formulary Pain, bowel, delirium, anxiety and depression meds covered COPD Inspiratory pull likely inadequate for most inhalers > non-formulary Oral steroid, Douneb, morphine concentrate Surprising acceptance PBM Clinical Pharmacist De-Prescribing Statins, dementia meds, Rilutek, Megace Daily med costs dropped from $ /day to $7-8.00/day

18 Pause for some Positive News 2016 District court ruling in Alabama DOJ put forth a False Claims Act case against AseraCare, a national hospice company 200 million judgement based on 123 charts Lacked clinical information to support terminal prognosis Judge ruled that differing medical opinions among experts does not prove falsity

19 Prognostication

20 Estimating and Communicating About Prognosis: Predicted vs Observed Survival in 468 Terminal Hospice Patients 63% overestimated 17% underestimated (BMJ 2000;32: )

21 LCD s Created years ago (1990 s) Guide to be used with clinical judgement Never validated Ineffective at predicting prognosis

22 National Hospice and Palliative Care Organization Guidelines for admission to hospice (<6 month prognosis) General Guidelines Must meet the following: Life limiting condition Documentation of progression of disease by any: physician, lab tests, multiple ER visits, multiple inpatient hospitalizations, home health care assessment if patient homebound? AND/OR Recent decline of functional status Karnofsky Performance Scale 50% (Requires considerable assistance and frequent medical care, disabled, unable to care for self) AND/OR Dependence in 3 of 6 Activities of Daily Living (bathing, dressing, feeding, transfers, continence of urine or stool, ambulation to bathroom) AND/OR Recent impaired nutritional status (unintentional weight loss of over 10% over the past six months, or albumin < 2.5gm/dl)

23 Medicare Learning Network CMS Loves Numbers 11/27/16 SE Patient-specific clinical findings and other documentation supporting a life expectancy of 6 months or less Guidance: The certification should give specific clinical findings, for example, signs, symptoms, laboratory testing, weights, anthropomorphic measurements, oral intake.

24 Clinical Symptoms and Survival National Hospice Study Data 5 symptoms predicted decline/death Anorexia Weight Loss Xerostomia Dysphagia Dyspnea Reuben DB, Mor V, Hiris J. Arch Int Med 1988;148:

25 Clinical Symptoms and Survival KPS 50 + No symptoms: Median survival = 6 months KPS symptoms: Median survival= 2 months KPS No symptoms: Median survival= 8 weeks KPS symptoms: Median survival= 2 weeks Reuben DB, Mor V, Hiris J. Arch Int Med 1988;148:

26 Cancer

27 Reviewed 383 articles Fairly consistent picture of terminal disease Decreasing performance status Advanced age Weight loss Metastatic disease Thromboembolism Lab abnormalities

28 Organ Failure

29 74 studies reviewed Poor performance status Malnutrition Multiple co-morbidities Organ dysfunction Hospitalization(s) for decompensation Amer. Jour. Med.(2012) 135:512

30 CHF Hospitalization for NYHA III or IV with 3 or more: 70+ EF < 20 Fourth admit or re-admit in 2 months BNP>950 Co-morbidities Low BP, Creatinine >2 (aka cardiorenal), Sodium <135

31 COPD Hospitalization for exacerbation, hypoxic and/or hypercarbic with 3 or more: 70+ RV failure/overload (edema) aka cor pulmonale Readmit in 2 months Mechanical vent KPS < 60 Weight loss, BMI <18

32 Frailty, Dementia, Dwindles

33 Frailty 75 + Albumin < 3.5 Dependent 2 or more ADL Hospital or SNF admission CHF Renal failure Delirium in hospital Post hospital decline

34 Dementia Dependent in all ADL with one or more BMI < 18.5 Skin breakdown At least one co-morbid condition Male, 90+ History of aspiration pneumonia Feeding tube Where s the FAST?

35 FAST limitations Not all patients progress through the stages as outlined Tested in a small population of hospice patients (n=47) Luchins et.al. J.Am.Ger.Soc Median survival 4 months (7c) 38% lived longer than 6 months (7c) Those not yet at 7c, all lived > 6 months FAST appears to be more sensitive than specific predicting who will NOT die in 6 months

36 Palliative Performance Scale Dementia 466 hospice patients followed 6 months PPS more predictive than FAST in nursing home residents PPS 30% (bedbound, total care, drowsy or confused) 80% 6 month mortality Harrold et.al. J.Palliat.Med. 8:503-9

37 CASCADE Study Choices, Attitudes and Strategies for Care of Advanced Dementia at End of Life NEJM 361: 1529 (2009) 323 SNF residents with advanced dementia followed for 18 months 86% eating problems (39% 6 month mortality) 41% pneumonia (47% 6 month mortality) 52% febrile episode (45% 6 month mortality)

38 Care Limits Matter Important bullet in the RN and MD narrative Dementia, Frailty, FTT always COPD, CHF sometimes Admission RN discusses goals, MOLST Care limits include DNR, do not return to hospital, no artificial nutrition, withhold antibiotics for life threatening infection Boost, protein shots etc. artificial

39 Infections 50% of dementia patients have pneumonia in last 2 weeks of life 6 month mortality (all cause) after pneumonia is 50% CASCADE study Pneumonia treated with antibiotics lived 273 days longer with increasing discomfort scores

40 Admission Process RN reviews medical, does evaluation, reviews medications Calls Medical Director Hospice appropriate? Related/unrelated diagnoses Medication list Related, unrelated Medically Necessary?

41 Medications Medication list given to patient and family with initial coverage decisions Related, Necessary, Hospice pay Unrelated, Necessary, Insurer pay Related, Not Necessary or Formulary, Patient pay Marinol, Megace, Advair, Spirva, Aricept, LOVENOX De-Prescribe where possible Statins, Aricept, Namenda, Supplements Clinical Pharmacist backup

42 Documentation RN admission paragraph Records reviewed, summarized, first two lines are for CMS Meds marked covered/not covered Clinical pharmacist reviews and documents Will use remaining drug then fill from formulary Inhalers > Douneb and steroid, Lovenox > Xarelto

43

44 Cases

45 97 year old man

46 Diagnosis? Cerebrovascular disease CAD BPH Dysphagia History of Falling

47 Medications Straightforward, chronic meds discontinued Morphine, Haldol, Ativan

48 CTI Narrative Patient passed 6 days later

49 92 year old man

50 Diagnosis Alzheimers Disease CHF Related Atrial Fibrillation Related Type II Diabetes Unrelated

51 Medications Haldol Covered Eliquis Covered Douneb Covered Metoprolol Lasix Covered Covered Humulin-N Not Covered

52 CTI

53 86 year old woman

54 Diagnoses Alzheimer s Related Sarcopenia Related Protein Calorie Malnutrition Related A Fib Unrelated

55 Medications Memantine Discontinue, restart with behaviors Remeron Covered Diltiazem Not Covered Digoxin Discontinue, not covered Eliquis Not covered

56 Clinical Pharmacist

57 CTI Narrative

58 64 year old man

59 Diagnoses COPD Anxiety Depression Abnormal CXR BPH

60 Medications Alprazolam Mitirzipine Morphine Tamzulosin Not covered

61 Medications Brovana Non-formulary, not covered, d/c Spiriva Non-formulary, not covered, d/c Pulmacort Non-formulary, not covered, d/c Douneb via nebulizer Covered Decadron Covered, was on prednisone

62 Clinical Pharmacist

63 CTI Narrative

64 Summary Points Terminal Prognosis, not Diagnosis Hospice Medical Director can formulate a diagnosis Develop a formulary and stick to it! Try not to play the six degrees of separation game De-prescribe where possible Document decisions, use numbers Use multiple diagnoses for frailty, FTT, debility