NHPCO CTC 2012 Terri Maxwell PhD, APRN VP, Strategic Initiatives Weatherbee Resources, Inc. Hospice Education Network, I

1. Disease-Specific Hospice Eligibility and Recertification Assessment and Documentation NHPCO CTC 2012Terri Maxwell PhD, APRNVP, Strategic InitiativesWeatherbee Resources, Inc.Hospice Education Network, Inc.

2. DISCLOSURE Presenter discloses no financial relationships with a commercial entity producing healthcare-related products and/or services. This presentation is for educational and informational purposes only. It is not intended to provide legal, technical or other professional services or advice. 

3. OBJECTIVES At the end of this session, participants will be able to: Identify and utilize the correct LCD, based on the patient’s terminal diagnosis Describe clinical documentation criteria that supports disease-specific clinical eligibility Name the clinical data points necessary to substantiate hospice eligibility for dementia, debility, and cardiopulmonary conditions. Identify “secondary” and” comorbid” conditions associated with common disease states

4. ELIGIBILITY Medicare hospice coverage depends upon a physician’s certification of a life expectancy of 6 months or less if the terminal illness runs its normal course

5. ELIGIBILITY, CONT’D The physician’s clinical judgment must be supported by “clinical information and other documentation” that provide a basis for a life expectancy of six months or less Medical necessity must be evaluated and clearly and objectively documented in the clinical record

6. ELIGIBILITY, CONT’D Recognizing that determination of life expectancy during the course of a terminal illness is difficult, CMS established LCD guidelines (“medical criteria”) for determining prognosis for cancer and non-cancer diagnoses LCD= “Local Coverage Determination”

7. ELIGIBILITY, CONT’D LCD guidelines Created to assist in determining eligibility based upon disease severity and burden of illness. Allows for decline of the beneficiary’s condition be to a factor in determining prognosis. Many do not reflect current research or medical information on prognosis.

9. ELIGIBILITY, CONT’D Hospice coverage for patients not meeting LCD guidelines may be denied Some patients may not meet the criteria, yet are deemed “hospice appropriate” because of co-morbidities or rapid decline Coverage for these patients may be approved on an individual basis

10. LCD PART I: Decline in clinical status guidelines: Appropriate for all diagnoses Clinical status: weight loss, infections, ↓ albumen or cholesterol, dysphagia Symptoms: dyspnea, cough, poorly controlled nausea, diarrhea, increasing pain Signs: ↓BP, ascites, edema, pleural effusion, weakness, Change in LOC

11. PART I, CONT’D Laboratory: ↑pCO2, ↓pO2, ↓O2 sat, etc. KPS or PPS < 70% ↑ ER or physician visits, ↑ hospitalizations FAST score 7A or > ↑ dependence for ADLs Stage III-IV pressure ulcers

12. PART II Non-disease specific baseline guidelines – both A and B should be met Physiologic impairment of functional status as demonstrated by: Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) < 70% (HIV Disease, Stroke and Coma establish a lower qualifying KPS or PPS). Dependence on assistance for 2 or more activities of daily living (ADLs)

13. PART II, CONT’D NOTE: The baseline guidelines (Part II) do not independently qualify a patient for hospice coverage.

14. COMORBIDITIES Although not the primary hospice diagnosis, the presence of diseases such as the following, the severity of which is likely to contribute to a life expectancy of six months or less, should be considered in determining hospice eligibility:

15. PART II/IIICOMORBIDITIES COPD CHF Ischemic Heart Disease DM Neurologic (CVA. ALS, MS, Parkinson’s) Renal Liver Cancer AIDS Dementia

16. PART III: NGS, CGS, NHIC DISEASE-SPECIFIC GUIDELINES Cancer ALS Alzheimer’s and related disorders Heart disease* Pulmonary disease* HIV Liver disease Renal disease Stroke or Coma

17. Palmetto DISEASE-SPECIFIC GUIDELINES Cancer ALS Alzheimer’s Dementia Cardiopulmonary HIV Liver disease Renal care Neurological Conditions

18. DOCUMENTATION All certification (admission) and recertification documentation must contain enough information to support the patient’s terminal status upon review (by an outside party such NGS, CGS, Palmetto). All clinical indicators of decline that form the basis for certifying / recertifying the patient should be documented.

19. DOCUMENTATION, CONT’D Recertification for hospice care requires the same clinical standards be met as for initial certification. Documentation should “paint a picture” of why / how the patient is appropriate for hospice as well as the level of care being provided. Documentation should include observations and measurable data, not merely conclusions.

20. DOCUMENTATION, CONT’D Patients with…long term survival in hospice, or apparent stability, can still be eligible for hospice benefits. If this is the case, sufficient justification for a less than 6-month prognosis should appear in the record. Inconsistent documentation should be specifically addressed and explained, including findings suggestive of a > 6-month prognosis.

21. CASE EXAMPLE Mrs. Turner is an 88 yr. old with a diagnosis of dementia. She weighs 92 lbs., eats little and is totally dependent in all ADLs. She’s not speaking and is sleeping a lot. She was hospitalized two weeks ago for a UTI. Is she hospice appropriate?

22. Terminal vs. Custodial Conditions A 265 lb man who is losing weight does not equate with terminal frailty, even if he is disabled. Gradual worsening of cognition or ADL status or periodic behavioral issues in patients with dementia- in the absence of choking/aspiration, Stage III/IV pressure ulcers, etc. Refer to specific requirements in the LCD guidelines to help guide prognostication.

23. Terminal vs. Custodial “Is this patient receiving terminal or custodial care?” If your documentation doesn’t reflect a 6 month or less prognosis (usually evidenced by clinical decline) you are at risk for payment denial. Don’t wait until the recertification date to discharge an ineligible patient.

24. Distinguishing Chronically from Terminally Ill “There was no indication in the submitted documentation that beneficiary’s life expectancy was 6 months or less. There was no documentation of co morbidities that would have contributed to a short life expectancy. The documentation shows that the patient required full time custodial care, but not the services of Hospice”. Comments extracted from a de-identified ZPIC finding

25. DOCUMENTATION, CONT’D There are patients for whom a particular LCD guideline does not match; and/or An LCD may be inadequate to predict the terminal prognosis of an individual patient who meets the guideline at the SOC and continues to do so over a prolonged period (> than 6 months).  In such cases, it is important to use Part I: Decline in clinical status guidelines to document all factors that support the terminal prognosis.

26. DOCUMENTING ELIGIBILITY FOR DEBILITY General Decline: Patients demonstrating significant functional and nutritional decline that cannot be attributed to a primary clinical condition. (ICD9 is Adult Failure to Thrive) General Decline: Use Part 1 Guidelines General decline patients should have low levels of function (KPS/PPS 40-50%) Decline in a specific condition (ex. Alzheimer’s) which doesn’t meet that condition’s eligibility criteria should not be admitted as “general decline”.

27. DOCUMENTING ELIGIBILITY FOR DEBILITY: Recommendation If there are multiple major medical problems present, choose one of them as a primary diagnosis. Use the remaining co-morbids to support a poor prognosis Document clinical decline as supporting data This may be preferable to having a lot of patients on under “general debility”.

28. BEGINNING THE ASSESSMENT: HOSPICE REFERRAL What prompted your call today? Identify the precipitating event resulting in hospice referral now How has the patient changed over the past 12 months? Establish baseline and illness trajectory (type and momentum)

29. ANSWER THE QUESTION: WHY HOSPICE? WHY NOW? What triggered the referral? Change in condition? Hospitalization? New or worsening symptoms? New or worsening co-morbidity? Need for additional care? Change in cg status or setting of care?

30. ENVIRONMENT OF CARE Environmental issues that facilitate or impede care Caregiver availability Caregiver ability Adaptive equipment Financial issues High/low intensity of available healthcare providers

31. BURDEN OF ILLNESS AND “NORMAL COURSE OF ILLNESS” Burden of illness and factors that influence the “normal course” of illness Inter-related secondary and comorbid conditions Advanced age Degree of frailty Environment of care Access to other healthcare providers

32. CLINICAL ELIGIBILITY The clinical presentation for determining terminal status should include the following: Impairment in the structure and function of body systems Decline in activity and functional status Secondary conditions Comorbid conditions

33. SECONDARY CONDITIONS Conditions that are directly related to and occur as a result of the primary condition

34. SECONDARY CONDITIONS Examples of conditions that are directly related to the terminal illness: Dysphagia is a secondary condition of dementia Dyspnea is a secondary condition of CHF Examples of a conditions that manifest as a result of the terminal condition: Decubitus ulcer is a secondary condition of coma Pneumonia is a secondary condition of ALS

35. COMORBID CONDITIONS Diseases or conditions that are distinct from the primary diagnosis, but may contribute to the patient’s life expectancy. The terminal diagnosis of Alzheimer’s Disease with comorbidities of Rheumatoid Arthritis and Diabetes The terminal diagnosis of CHF withcomorbid COPD The terminal diagnosis of FTT with comorbid renal insufficiency When supporting prognosis: It isn’t the number of co-morbid conditions but the severity that counts.

36. HOSPICE PATIENTS – DISEASE TRAJECTORIES RAPID DECLINE Cancer SAW-TOOTHED DECLINE Organ system failures (COPD, Heart Failure, etc.) SLOW INSIDIOUS DECLINE Neurodegenerative disorders Dementia Debility Decline HealthStatus Death Time Resource: Field MJ, Cassel CK (eds), Institute of Medicine. Approaching Death: Improving Care at the End-of-life. Washington, DC: National Academy Press. 1997

37. Decline: Short period of evident decline TRAJECTORIES OF ILLNESS TO DEATH: Predictable Terminal Phase • Health Status Illnesses such as cancer have a progression that ends in a steady inexorable decline in function until death • Death • Time • Resource: Field MJ, Cassel CK (eds), Institute of Medicine. Approaching Death: Improving Care at the End-of-life. Washington, DC: National Academy Press. 1997

38. CANCER DIAGNOSESEligibility Criteria Documentation must demonstrate that the patient meets Part II Non-disease specific baseline guidelines AND Cancer guidelines in Part III/appendix PLUS Comorbid conditions in Part II/III, if applicable

39. CANCER Eligibility Criteria, CONT’D KPS or PPS < 70% Dependent in 2/6 ADLs Metastases at presentation OR Progression from an earlier stage of disease to metastatic disease with either A continued decline in spite of therapy; or Patient declines further directed therapy. Note: Certain cancers with poor prognoses (e.g., small cell lung, brain and pancreatic cancer) may be hospice eligible without fulfilling the other criteria.

40. REFERRAL # 1 Mr. Jones: DX: Glioblastoma Age: 46 Residence: Home PCG: Wife (3 children, all under 7 yrs old) PTA: On the job injury; PMH is unremarkable; 6’3”; 235 #; BMI = 29% (overweight) Secondary Conditions: Headache, dizziness, nausea. Co-Morbid Conditions- None

41. ADMISSION NOTE S – Pt reports, “I can’t believe this is happening. I get hit in the head and find out that I have a tumor. My doctor says the chemo and radiation treatments are no longer working. How is my wife going to cope with three kids by herself? My head’s throbbing, I can’t focus my eyes, and I want to throw up all the time. What am I going to do?” O – Pt in darkened room, holding head in both hands and grimacing at slightest noise

42. ADMISSION NOTE, CONT’D Admitted 4/18/12 w/ Glioblastoma. Fully and completely meets Medicare eligibility: Terminal diagnosis Life expectancy of six months or less if the disease runs its normal course (as certified by the pt’s attending and hospice physician) Opting for a palliative rather than curative approach to end-of-life care (per hospice election and advance directives)

43. MEASURABLE DATA POINTS Pt: Mr. Jones DX: Glioblastoma SOC: 4/18/12

44. TRAJECTORY OF ILLNESS:Prolonged Insidious Progression Decline: prolonged dwindling Health Status Typical course of debility, Alzheimer’s and related disorders, Stroke & Coma, etc. Steady progressive disability leading to death Death Time Resource: Field MJ, Cassel CK (eds), Institute of Medicine. Approaching Death: Improving Care at the End-of-life. Washington, DC: National Academy Press. 1997

45. DEMENTIA Irreversible, progressive brain disease that slowly destroys memory, thinking, and motor skills. Caused by various diseases and conditions

46. DEMENTIA SUBTYPES Alzheimer's- Most common type 60-80% of cases Results from deposits of protein plaques and tangles in the brain Vascular dementia (multi-infarct dementia) 15-30% cases

47. RISK FACTORS FOR VASCULAR DEMENTIA Hypertension Peripheral arterial disease Diabetes mellitus NOTE: When a patient is admitted to hospice with vascular dementia, the conditions above are generally considered “related” and their associated therapies should be covered by hospice

48. DEMENTIA SUBTYPES CONT’D Lewy Body dementia 10-15% cases Frontotemporal dementia <1% cases Parkinson’s Disease w/ dementia Occurs in 20-40% of patients with PD Risk rises in patients with PD for > 8 yrs

49. Natural History of AD Progression Olson, 2003

50. ALZHEIMER’S & RELATED DISORDERS GUIDELINES Patient’s with Alzheimer’s Disease should have: KPS or PPS < 70% Minimally dependent in 2/6 ADLs FAST score of 7 or beyond and one of the following w/in past 12 months: