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The State of Hospice in the State of Oregon 2010 in Review and 2011 Challenges 2010 Annual Membership Meeting January 28

The State of Hospice in the State of Oregon 2010 in Review and 2011 Challenges 2010 Annual Membership Meeting January 28, 2011 Deborah Whiting Jaques CEO. The State of Hospice in the State of Oregon 2010 in Review and 2011 Challenges. Oregon Hospice Association’s Programs

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The State of Hospice in the State of Oregon 2010 in Review and 2011 Challenges 2010 Annual Membership Meeting January 28

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  1. The State of Hospice in the State of Oregon2010 in Review and 2011 Challenges2010 Annual Membership MeetingJanuary 28, 2011Deborah Whiting JaquesCEO

  2. The State of Hospice in the State of Oregon2010 in Review and 2011 Challenges • Oregon Hospice Association’s Programs • Hospice in Oregon – Profiles of Care • Data from Oregon and the nation • Hospice Licensure • Oregon Drug Takeback • POLST Registry • Health Care Reform – Hospice impacts • CMS Update • Hospice Care in Nursing Homes • Q&A

  3. OHA ProgramsHelp for Hospices The best way to ensure Oregonians have access to quality end-of-life care is to help the hospices who provide direct care. Accreditation & Hospice Consult Services Denis Carnaby and Linda Downey, RN, MSHA • Hospice consultation services Hospice-specific comprehensive program advice and solution development • Accreditation/licensure surveys Collaborative reviews to fulfill licensure requirements and identify program strengths and areas for improvement OHA is authorized as an accrediting body by Oregon Department of Human Services

  4. OHA ProgramsHelp for Hospices (continued) Member support services Help for real problems in real time -Telephone/email problem-solving -List Serves -Hospice Providers’ Council • Regulatory -Represent Oregon’s hospices on the NHPCO Regulatory Committee -Face-to-face encounter -Pediatric Concurrent Care -Health Care Licensure and Certification -Department of Medical Assistance Program (DMAP – Oregon Medicaid) • Legislative Hospice Licensure • Health Policy Drug Take Back POLST Concurrent Care Demonstration Projects

  5. OHA ProgramsResource Development - Meg McCauley Fund development to increase services for Oregon’s terminally ill and to support OHA programs. • 30th Anniversary Benefit Luncheon (April) • Memorial Day Campaign (May) • Portland Marathon (October) • Dynasty Dinner (October) • Light Up a Life (December) • Grants/Bequests (Year round)

  6. OHA ProgramsMe, Too - Meg McCauley Through a partnership with Legacy and Providence, ensure Oregon’s grieving children have a place to heal. • Professionally staffed 8 week grief counseling for children and families provided at no cost. • Revised program brochures and materials • Three sessions • Providence Child Center • Portland First Church of the Nazarene • Helped 21 families in 2010

  7. OHA ProgramsProfessional Education Be a premier source of staff and professional education for hospice and palliative care organizations serving Oregonians. Event Evaluations • Annual Meeting (January) 96% Excellent or Very Good • Physician Billing Seminar (June) 100% Excellent or Very Good • Professional Practices Exchange 100% Excellent or Very Good (October)

  8. Hospice Registry 2011Profiles in Care • Hospices licensed in Oregon 52 • End of Life Care – Correctional Institutions 4 Eastern Oregon Correctional Institution (Pendleton) Oregon State Penitentiary (Salem) Two Rivers Correctional Institution (Umatilla) Coffee Creek Correctional Facility (Wilsonville)

  9. Hospice in Oregon and in the Nation 2011 Oregon Hospice Association Report2009 Medicare Data1/19/11

  10. 2009 Hospice Utilization(Medicare Hospice Deaths / Total Medicare Deaths)

  11. 2009 Demographics & Hospice Utilization

  12. Oregon County-Level Hospice UtilizationAll 36 CountiesHospice Utilization= Medicare Hospice Deaths / Medicare Total Deaths

  13. 2009 Total Days of Hospice CareNational= 76,724,901 Days

  14. 2009 Median Days / Patient of Hospice Care

  15. 2009 Total Medicare Hospice PaymentsNational= $12,064,905,206

  16. 2009 Medicare Hospice Percent Cancer Diagnosis National= 32% Cancer; OR= 32% (#29)

  17. 2009 Top 6 ICD-9 Diagnostic Categories (out of 19)

  18. 2009 Patients by Level of Care (days)

  19. 2009 Location of Care (new in 2007)

  20. 2009 Visits by Discipline (new in 2008)

  21. Hospice Licensure • Statute effective July 2009 (http://pub.das.state.or.us/LEG_BILLS/PDFs_2001/SB161.pdf) • Implemented January 2011 • DHS now licenses hospices • $750/year license fee (set in statute cannot be changed without legislation) • The standards for licensure in Oregon are the same as the Medicare Conditions of Participation • Criminal Background Check 3 year re-dos to be required in 2012. (http://www.oregon.gov/DHS/ph/hclc/index.shtml)

  22. Hospice Licensure-continued Statute requires that hospices have a CMS survey no less frequently than every three years. • DHS may conduct on-site investigation whenever deemed necessary • Certification survey (a surprise) • Done by DHS (who is the contractor for CMS), or • Done by JCAHO, CHAPS, DME or others who have deemedstatus authority • Accreditation • Oregon Hospice Association (scheduled by the hospice) • JCAHO, CHAPS, DME or others who provide accreditation

  23. Hospice Licensure-continued • Licensure Survey – May be done by: • DHS (as part of license fee), or • OHA DHS Website FAQs: The Division will also accept surveys from approved accreditation organizations to satisfy the requirements for state licensure. Hospices may choose to have the initial licensure or re-licensure survey performed by entities approved by the Division. Currently, the Oregon Hospice Association is the only approved entity. Approval of additional accreditation organizations is pending and will be posted in the FAQs.

  24. Oregon Drug Takeback • Hospice & Palliative Care Drug Mail Back Trial • Mail back program (including opioids) • Clatsop and Columbia Counties • Partnership with • Oregon Association for Clean Water • Lower Columbia River Estuary • Astoria Police Department • Grant funding acquired • Awaiting final approvals from USPS to implement. • Community Take-Back Days all over the state

  25. POLST Registry State-wide implementation in December 2009. • Over 40,000 POLSTs in Registry • Not registry ready (NRR) reasons: • No signature (50%) • Must be signed by NP, PA, MD, DO • No date (66%) • Can not determine what the patient’s most recent wishes are. • OHA received Hospice Award for leadership and “outstanding contribution to the greater respect for patient wishes” • Revised POLST Form in 2011

  26. Ho Health Care Reform – Hospice Impacts • Rate cuts • Face to face encounter • Concurrent care demonstration projects • Pediatric curative and palliative care • Medical review for hospices with high % of long stays • Cost report • Quality reporting

  27. Health Care Reform: Rate Cuts • Productivity Adjustment Reduction Cuts • FY2013 through FY2019 • 1.3% reduction in hospital market basket • 0.3% reduction additional for hospice • Net market basket increase = 0.8%  • BNAF • Began in FY2010 • 4.2% adjustment in wage index over 7 years

  28. Health Care Reform: Face to Face Encounter • Effective January 1, 2011 • Enforcement waived until March 31, 2011 • Every patient within 30 days prior to the beginning of the 3rd recertification period and each subsequent recertification • Encounter by: • Hospice physician or • Nurse practitioner •  No tele-health provision • Administrative visits are not billable.

  29. Heal H Health Care Reform - Concurrent Care Demonstration • 3 year demonstration project • Patients receive hospice care and also receive all other Medicare covered services • Up to 15 sites • Urban and rural areas • Independent evaluation of its impact on: • Patient care • Quality of life • Medicare spending

  30. Health Care Reform - Concurrent Care DemonstrationTimeline • 2010: CMS will develop an application process • Expected Spring 2011: RFP published for provider application • 3 year demonstration from 2012-2015

  31. Health Care Reform: Pediatric Palliative Care • For children insured in Medicaid and CHIP • Effective immediately upon passage – March 23, 2010 • Requires hospice eligibility (6 mo or less prognosis) • Requires election of hospice to receive palliative care • The Oregon Department of Human Services Division of Medical Assistance Program (DMAP) made changes to Hospice Services Rulebook effective January 1, 2011 • http://www.dhs.state.or.us/policy/healthplan/guides/hospice/142%20RB%20170%200111.pdf

  32. Health Care Reform: Medical Review for high % of Long Stays • Secretary will medically review certain patients in hospices with high percentages of long-stay patients • 100% FI/MAC medical review for patients over 180 days • Expectation: If the hospice has 40% or more of patients with long lengths of stay

  33. Health Care Reform - Cost Report • Date: 2011 • Expect some clarifications • May see number of visits for • Chaplains and spiritual counselors • Volunteers • NHPCO submitted comments and in dialogue with CMS

  34. Health Care Reform: Hospice Quality Reporting • Requires hospice report on quality measures determined by the Secretary or face a 2 percent reduction in their market basket update • Measures published in 2012 • Reporting to begin in 2014

  35. Quality: Performance Measures Being Tested Structure and process • M1: % of patients admitted to hospice who had a screening for symptoms during the admission visit  • M2: % of patients who had a comprehensive assessment completed within five days of admission  Care for physical symptoms • M3: For patients who screened positive for pain, % whose pain was at a comfortable level within two days of screening  • M4: For patients who screened positive for dyspnea, % who improved within one day of screening

  36. Quality:Performance Measures Being Tested Care for physical symptoms • M5: For patients who screened positive for nausea, % of patients who received treatment within one day of screening • M6: % of patients on opioids who have a bowel regimen initiated within one day of Opioid initiation

  37. Quality: Performance Measures Being Tested Care for psychosocial symptoms • M7: For patients who screened positive for anxiety, % who received treatment within two weeks of diagnosis  Social aspects of care • M8: % of families reporting the hospice attended to family needs for information about medication, treatment and symptoms Cultural aspects of care • M9: Provision of interpreter or translator for non-English-speaking or deaf patients

  38. Quality:Performance Measures Being Tested Care of the imminently dying • M10: % of patients who had moderate to severe pain on a standard rating scale at any time in the last week of life Ethical and legal aspects of care • M11: % of patients with chart documentation of an advance directive or discussion that there is no advance directive

  39. Quality: Performance Measures Being Tested Adverse events • M12: Selected number of occurrences per 100 patient days • falls • medication errors • DME issues (complaint, malfunction or error), • patient/family complaints

  40. H H Health Care Reform - Hospice Payment Reform • No earlier than October 1, 2013 for FY2014 • Revise methodology for routine home care • Not required to change other payment structures for other levels of care • Likely to be some version of U-shaped curve

  41. Health Care Reform - Hospice Payment Reform – Moran Project • NHPCO work with Moran to collect hospice data. • Providers: 665 provider numbers • Vendors: 10 software companies • States represented: 45 • Focused on hospices with vendors because of data availability in a format that could be aggregated.

  42. Health Care Reform - Hospice Payment Reform – Moran Project • First analysis: representation of field • Geography • Size of provider • Second analysis: modeling of different payment models • Ongoing meetings with Data Advisory Council • Initial meeting with MedPAC and CMS held in late 2010 • Both very impressed and want more!

  43. CMS: What to expect • New CMS administrator – Don Berwick • New health care reform law • Expect lots of change with regulations issued • Need more patient level data • Payment reform • Cost report changes • Pressure on hospice growth and spending • Focus on recoupment of Medicare dollars • Fraud, abuse, inaccurate claims

  44. CMS: What to expectData DataData • Tying costs to patients • DME and drugs by patient • Costs based on diagnosis • Costs based on length of stay • How do we measure care management? • Visits in facilities • Sorting out the costs in hospice facilities

  45. Hospice Care in Nursing Homes • State surveyors required to look at a hospice patient’s chart when surveying the nursing home. • Nursing facility deficiencies could include hospice: • F-309 “Failure to coordinate care and services” • Draft SNF Conditions of Participation released for comment • Companion to our 418.112

  46. Hospice Care in Nursing Homes What do we know? • Visits are not diminished • Different mix of disciplines and services • Diagnoses different from home care • Home Cancer COPD CHF • SNF Dementia Disability Alzheimers • Length of stay not different

  47. Questions and Discussion Thank you! Deborah Whiting Jaques jaques@oregonhospice.org t: 503.228.2104 c: 541.490.9073

  48. Resources • OHSU Center for Ethics • CMS • Oregon Department of Human Services • NHPCO • OHA

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