HPS ALLIANCE MEMBERS ONLY HOSPICE WEBINAR SERIES

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Doreen Lewis
5 years ago
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1 HPS ALLIANCE MEMBERS ONLY HOSPICE WEBINAR SERIES PRESENTER(S): LESLIE HEAGY, RN, COS-C & MELINDA A. GABOURY, COS-C Documenting to support the Hospice Terminal Prognosis February 15, 2019 DOCUMENTING TO SUPPORT THE TERMINAL PROGNOSIS Today will be taking a deeper dive in documentation supporting hospice eligibility for a six month or less prognosis We will discuss the financial impact for hospice agencies that fall short of painting the picture of the patient s terminal condition Learn how to build the foundation for eligibility starting with the admission assessment and beyond to help clinicians document the terminal condition every visit. ADR (Additional Medical Documentation Request) TPE (Targeted Probe and Educate) OIG (Office of Inspector General) SMRC (Supplemental Medical Review Contractor) 1

2 FINANCIAL IMPACT The amount of time spent your clinicians spending on documenting Consequences of Documentation not supporting Hospice Eligibility Directly Impacts Reimbursement What if there was a process or better yet a question that was answered at every hospice admission that would begin the foundation of the care plan that sets the agency up for success in documenting eligibility every time? ADMISSION ASSESSMENT (INITIAL HOSPICE ASSESSMENT) The RN completes an initial assessment within 48 hours from the patient s election date Identifies the patient/family s immediate needs Determines the patient s baseline status Begins the Problem List to be addressed in the plan of care Assessment supports hospice eligibility 2

3 ADMISSION ASSESSMENT The RN is the first contact with the patient/family and completes the initial assessment. These findings are then communicates to the Hospice team. ADMISSION ASSESSMENT (INITIAL HOSPICE ASSESSMENT) The RN completes an initial assessment within 48 hours from the patient s date of hospice election Completed in the location where hospice services are going to be provided Identifies the patient/family s immediate needs Determines the patient s baseline status Begins the Problem List to be addressed in the POC (Plan of Care) Completion of the initial assessment lays the foundation for hospice eligibility Assessment Findings are communicated with the IDG(Hospice Interdisciplinary Team) including the attending physician (if any) 3

4 COMPREHENSIVE ASSESSMENT (TIMEFRAME FOR COMPLETION) The hospice interdisciplinary group, in consultation with the individual's attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care in accordance with CONTENT OF THE COMPREHENSIVE ASSESSMENT (1) The nature and condition causing admission (including the presence or lack of objective data and subjective complaints). (2) Complications and risk factors that affect care planning. (3) Functional status, including the patient's ability to understand and participate in his or her own care. (4) Imminence of death. (5) Severity of symptoms. (6) Drug profile. (7) Bereavement (risk assessment findings must be incorporated in the POC) (8) The need for referrals and further evaluation by appropriate health professionals. 4

5 COMPREHENSIVE ASSESSMENT The comprehensive assessment must include data elements that allow for measurable outcomes. The hospice must measure and document data in the same way for all patients. The comprehensive assessment must include all aspects of care related to hospice and the palliation of symptoms. Updated at least every 15 days. BUILDING THE FOUNDATION OF AN EFFECTIVE PLAN OF CARE Initial Assessment Visit Completed by RN within 48 hours of the hospice date of election in location where hospice services are being delivered. Identifies the patient/family s immediate physical, psychosocial, emotional and spiritual needs. Determines the patient s baseline status and begins the list of problems to be addressed. Comprehensive Assessment Completed by the IDG and attending physician (if any). The nature and condition causing admission (including the presence or lack of objective data and subjective complaints). Complications and risk factors that affect care planning. Functional status, including the patient's ability to understand and participate in his or her own care. 5

6 BUILDING THE FOUNDATION OF AN EFFECTIVE PLAN OF CARE Initial Assessment Visit Communicates the assessment findings to the hospice IDG and attending physician (if any) Lays the foundation of hospice eligibility and developing the hospice comprehensive plan of care. Comprehensive Assessment Imminence of death. Severity of symptoms. Drug profile. Bereavement (risk assessment findings must be incorporated in the POC) The need for referrals and further evaluation by appropriate health professionals. Include measureable outcomes and updated at least every 15 days. BUILDING THE FOUNDATION OF AN EFFECTIVE PLAN OF CARE Things to consider when developing the hospice plan of care: What is important to the patient/family now? Does the problem list include what needs to be documented against every visit? How many and what kind of problems should you anticipate? What are the anticipated needs as the disease progresses? Are the care plans individualized to meet the patient/family s specific needs? Did you include the bereavement risk assessment in the plan of care? Are all the initial assessments completed and discipline specific care plans incorporated in the plan of care? Are all visit frequencies present? 6

7 DEVELOPING THE HOSPICE PLAN OF CARE First: Identifying Problems: Initial Assessment and Comprehensive Assessment Second: Setting Goals: What are the patient/family centered goals at the time of hospice admission? Third: Interventions Fourth: Evaluation DEVELOPING THE HOSPICE PLAN OF CARE First: Identifying Problems Initial Assessment-immediate needs Comprehensive assessment completed by the IDG, in consultation with the attending physician (if any) 7

8 DEVELOPING THE HOSPICE PLAN OF CARE Second: Set Goals What are the patient/family centered goals? What does the patient/family want? - Adequate pain/symptom control - Avoid inappropriate prolongation of dying - Achieve sense of control - Relieving burden - Strengthening relationships with loved ones Goals should be measurable and meaningful Goals should be attainable and realistic DEVELOPING THE HOSPICE PLAN OF CARE Third: Interventions Steps towards achieving goals What interventions are necessary? Who will perform the interventions? How often? Monitoring IS okay Remember interventions will change as the patient/family situation changes to meet the overall goals. 8

9 DEVELOPING THE HOSPICE PLAN OF CARE Fourth: Evaluate Outcomes What is the patient s progress towards goals? Are the interventions effective? Any new problems? Any needed changes to the plan of care? HOSPICE PLAN OF CARE The plan of care should be fluid meaning that is changes as the patient/family conditions change. The plan of care should flow from patient assessments. The plan of care is updated at least every 15 days. The plan of care includes interventions that are documented against at each visit. 9

10 HOSPICE PLAN OF CARE Common Problems seen with the hospice plan of care Missing interventions/goals for all disciplines providing care Missing visit frequencies Bereavement Risk Scores Misuse/overdependence on the EMR software - canned documentation/not individualized - Check boxes too many or not enough choices - Multiple interventions - Copy and Paste HOSPICE PLAN OF CARE What Should Be Documented EVERY visit? Assessment Results Patient s response to treatment Effectiveness of interventions Patient s progress towards goals Your work on behalf of the patient-communication with other team members or others outside of the organization 10

11 Every Visit Every Time Supports Hospice Eligibility Defines the terminal condition Contains objective measurable findings Supports disease specific LCD Visit note narratives include assessment findings to support the terminal condition Shows the affects of endstage disease on patient IDG meeting notes Updates the hospice plan of care Documents changes since the last IDG meeting Includes input from the entire IDG including the attending physician (if any) Supports ongoing hospice eligibility Recertification Review baseline data collected on admission Review chronological IDG documentation Review both persistent and new symptoms supporting the terminal condition Compare baseline data with current data when supporting the ongoing eligibility Explain any symptom improvements LOCAL COVERAGE DETERMINATION (LCD) Created in 1996 as a Guide to be used in conjunction with clinical judgement and was never intended to be used as public policy, it was never validated and often ineffective at prognosis prediction. LCD does NOT = Prognosis therefore, recommend using the disease specific LCDs only as a guide with patient specific findings when determining prognosis. 11

12 LOCAL COVERAGE DETERMINATION (LCD) Non-Disease Specific Decline in Clinical Status LCD Progressive exhaustion caused by lack of nourishment as documented by: Weight loss not due to reversible causes such as depression or use of diuretics Decreasing serum albumen or cholesterol Inadequate oral intake documented by decreasing food portion consumption Patient Weight loss (10% of body weight over last year), BMI of 18.6, all despite 1:1 feeding assistance. Malnutrition (Albumin of 2.5) Decreased oral intake (10% of meals) LOCAL COVERAGE DETERMINATION (LCD) Non-Disease Specific Decline in Clinical Status LCD Worsening Signs Weakness Decline in Palliative Performance Score (PPS) from <70% due to Progression of Disease Progression to Dependence on Assistance for Two or More Activities of Daily Living (ADLs): Feeding, Ambulation, Continence,Transfer, Bathing, Dressing Progressive Stage 3 4 Pressure Ulcers in Spite of Optimal Care Unable to feed self Patient The patient also has decreasing functional status (PPS was 60% six months ago currently 30%) Progressed from using a walker to chair/bedbound status in less than six months, requires a 1 person transfer. Stage III pressure ulcer despite optimal wound prevention and treatment. 12

13 SUGGESTIONS FOR DOCUMENTATION Documentation to support hospice eligibility Change in weight (loss, gain due to fluid retention, albumin < 2.5mg/L) Change in anthropomorphic measurements (Mid-arm circumference(mac), abdominal girth) or loose fitting clothes Worsening diagnostic lab results Change in pain Change in responsiveness Change in skin (turgor, fragile, excoriation, skin tears, wounds, edema) Worsening functional status, Dependence in ADLs Change in vital signs (RR, O2 saturation, BP, pulse) SUGGESTIONS FOR DOCUMENTATION Examples of strong documentation supporting eligibility The patient continues to take oxycodone 10 mg every 6 hours for pain with current regimen effective. The patient s has shown a decrease in anxiety with respiratory symptoms managed and increased visits from the priest and social worker. The patient s respiratory symptoms are currently managed current medication regimen and effectively using positioning techniques instructed by the nurse. The patient now requires a walker for ambulation due to leg weakness and reports she is upset because she cannot sit up long enough to attend worship service. Provided the patient briefs for incontinence as the patient is no longer able to make it to the bathroom. Daughter states: My dad is gasping for breath even when he is just sitting and talking and he did not do that last week (Dyspnea at rest) 13

14 SUGGESTIONS FOR DOCUMENTATION Examples of strong documentation supporting eligibility The patient s clothes are hanging off him with recent weight loss, the facility has requested the family to purchase new clothes. The patient has difficulty feeding self as most of the food is dried on his face and shirt, now requiring assistance from the facility staff for meals. The patient requires cueing from the facility staff to eat and is having difficulty staying awake during meals according to the facility staff. The patient has contractures in the BUE and the BLE with hands curled in to fist and feet turned inward and down. The patient has progressed to a 7D requiring pillows to prop him up when in the wheelchair to keep from leaning/falling over. The patient has progressed to a 7F on the FAST scale no longer able to hold head up COMMON PROBLEMS WITH DOCUMENTATION Lack of consistent, objective date Lack of comparison over time Prognostic tools used (Karnofsky, PPS, FAST score) not supported by other documentation Documentation supports a chronic condition vs a terminal condition Documentation does not consistently show persistent and new symptoms of disease progression to support ongoing eligibility criteria. LCD guidelines not supported 14

15 COMMON PROBLEMS WITH DOCUMENTATION DON T document the below phrases without elaborating in the documentation a detailed description: Stable Slow progressive decline Appears to be losing weight Eating well Deteriorating PROGNOSTIC TOOLS FOR ELIGIBLITY PPS Karnofsky FAST score ECOG performance scale NYHA class, PaP(Palliative Prognostic score) ADEPT MELD 15

16 THANK YOU FOR PARTICIPATING & BEING AN HPS ALLIANCE MEMBER! 16

Hospice Documentation Strategies

HOSPICE DOCUMENTATION REQUIREMENTS: Hospice Documentation Strategies The hospice clinical record must support the plan of care and frequencies of visits along with the findings of the comprehensive assessment