powerpoint presentation lcd for alzheimers disease ... prognosis for nursing home residents with ......

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MNHPC 28th Annual Conference | April 8-10, 2018 www.mnhpcconference.org

The Implications of Inadequate Interdisciplinary Team

Documentation & Strategies that Reduce Risk.

Terrence Maag MD & Beth Werner MS, RN CHPCA

HealthPartners Hospice & Palliative Care


• List current pitfalls in discipline wide documentation practices today that do not support Medicare eligibility of the hospice patient

• Demonstrate effective strategies that improve discipline specific documentation and decrease risk

Objectives


The hospice must designate an interdisciplinary group or groups composed if individuals who work together to meet the physical, medical, psychosocial, emotional and spiritual needs of the hospice patients and families.

418.56 Standard: Approach to Service Delivery

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Must include doctor of medicine or osteopathy employed or contracted, Registered Nurse, social worker, counselors (spiritual, dietary and bereavement) who are employed by the hospice

– Registered Nurse member of the IDG provides coordination of care

– Services may include hospice aide, integrated therapies- massage, music as well as volunteers, PT, OT, ST and others

Makeup of the IDG


• Assess the patient/family needs

• Prepare written Plan of Care (must be full participation of the IDG members as well consultation with the attending physician)

• Provide services and care according to the plan

• Supervise the care (face to face, telephonic, evaluations, discussions and general oversight as well as direct observation)

• Document the journey

Functions of the IDG


Documentation as evidence that:

• the hospice has a standardized approach to the delivery of end of life care.

• the patient is terminal.

Functions of the IDG: Documentation

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Medical Director Documentation- Certification Note

• The patient is an 87 year old female admitted to Hospice on 7/24/24/15 with a terminal diagnosis of Alzheimer’s Disease and contributing conditions vascular dementia, HTN, CAD and seizure disorder. She resides in a memory care unit.

• Clinical Findings: Current weight is 115 lb, which has decreased from previous weight of 126 lb. Palliative Performance Scale is 30%, FAST scale is 7D. Patient has had a recent falls that resulted in hip fracture in May 2015. Mortality risk index score is 12 which predicts a 70 percent chance of dying within 6 months.

• The patient is struggling with the symptoms of dementia including weight loss, risk for aspiration, sleeping more, restlessness, paranoia, poor appetite, unable to take po meds consistently. She is now a mechanical lift for transfers; nectar thick liquids and pureed food to minimize aspiration. She has been bed bound for last couple of days, incontinent of bowel and bladder and requires total care.

• Based on these indices of decline and a desire to focus on comfort, I certify that the patient meets criteria for hospice with a prognosis of < 6 months if the illness runs its usual course. I confirm that I personally composed the narrative based on my review of the medical record.

• MD Signature

Case Review: Alzheimers Disease


Medical Director Documentation

• Medical Directors and/or hospice physicians as members of the interdisciplinary team provide input to the other disciplines on various aspects of the medical care. – e.g. nurse admission note

• Medical Directors and/or hospice physicians also receive input from the other disciplines on various aspects of the medical care. – Now is your time!


Based on the Medical Director documentation, was our patient terminal?


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Medical Director Documentation- Certification Note

• The patient is an 87 year old female admitted to Hospice on 7/24/24/15 with a terminal diagnosis of Alzheimer’s Disease and contributing conditions vascular dementia, HTN, CAD and seizure disorder. She resides in a memory care unit.

• Clinical Findings: Current weight is 115 lb, which has decreased from previous weight of 126 lb. Palliative Performance Scale is 30%, FAST scale is 7D. Patient has had a recent falls that resulted in hip fracture in May 2015. Mortality risk index score is 12 which predicts a 70 percent chance of dying within 6 months.

• The patient is struggling with the symptoms of dementia including weight loss, risk for aspiration, sleeping more, restlessness, paranoia, poor appetite, unable to take po meds consistently. She is now a mechanical lift for transfers; nectar thick liquids and pureed food to minimize aspiration. She has been bed bound for last couple of days, incontinent of bowel and bladder and requires total care.

• Based on these indices of decline and a desire to focus on comfort, I certify that the patient meets criteria for hospice with a prognosis of < 6 months if the illness runs its usual course. I confirm that I personally composed the narrative based on my review of the medical record.

• MD Signature



NGS LCD for Alzheimers Disease

• Patients with Dementia should have:

– Stage seven or beyond according to the FAST Scale

– Unable to ambulate without assistance

– Unable to dress without assistance

– Unable to bathe without assistance

– Urinary and fecal incontinence, intermittent or constant

– No consistently meaningful verbal communication: stereotypical phrases only or ability to speak is limited to 6 or fewer words


NGS LCD for Alzheimers Disease

• Patients with Dementia should have had ONE in the last 12 months: – Aspiration pneumonia

– Pyelonephritis

– Septicemia

– Decubitus ulcers, multiple, stage 3-4

– Fever, recurrent after antibiotics

– Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous 6 months or albumin <2.5g/dl

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Problems with the guidelines for Dementia

• Medicare guidelines were not valid predictors of survival in hospice patients with dementia: – Schonwetter RS, Han B, Small BJ, Martin B, Tope K, Haley WE. Predictors of six-

month survival among patients with dementia: an evaluation of hospice Medicare guidelines. Am J Hosp Palliat Care 2003; 20:105–113.

• The decline in these patients is not linear.

• Different dementias behave differently (e.g. mixed pictures)

• The list of complications in the past 12 months only covers some of what can happen to dementia patients...


A Better predictor than the Medicare guidelines for Alzheimer’s Dementia

• Mitchell Mortality Risk Index – Mitchell SJ, Kiely DK, Hamel MB, Park PS, Morris JN, Fries BE. Estimating

prognosis for nursing home residents with advanced dementia. JAMA 2004; 291:2734–2740.


• In August of 2014, she was hospitalized for pneumonia and never returned to her baseline. The patient was hospitalized again in October 2014 for altered mental status. Moreover, in 2015 she suffered a hip fracture for which she underwent repair. Pneumonia and hip fracture individually portend a high risk for death over the following year. Having had both of these complications, this patient is at even higher risk of recurrence and of dying related to pneumonia and/or hip fracture.

Medical Director Documentation- History to Include!

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Prognosticating Kaplan, V, etal. Arch Intern Med. 2003;163:317-323


• In this case the patient lost almost 9% of body weight in the previous 6 months. Call that out?

• Was there a change in condition that led to the referral?

• POLST- antibiotics?

• Comfort focused measures: coronary artery disease meds were stopped.

Medical Director Documentation- Other documentation


• The patient is 87 year old admitted to hospice on 7/24/15 with a terminal diagnosis of Alzheimers and contributing conditions of vascular dementia, CAD, seizure disorder and femur fracture. Theresa has had 2 falls this last benefit period and has required med adjustments for sleep. She required total care for ADLS and is non-ambulatory. Her FAST is 7D and stable PPS of 30%. Weight is stable.

• Based upon these indices of decline and a focus on comfort, I certify

that this patient meets hospice eligibility criteria for a life-limiting illness with a prognosis of 6 months or less if the illness runs its usual course. I confirm that I personally composed this narrative based on my review of the medical record.

Medical Director Documentation- Recertification Note

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• Does she still qualify for hospice?

• What was good about the note?

• What could be improved?

Medical Director Documentation- to Include!


• Terminal Prognosis: A two edged sword – 1. We have to cover expenses for all of the contributing

conditions.

– 2. Helps to justify a patient qualifying for hospice.

• Especially for those patients not meeting the Local Coverage Determinants for one disease.

• This patient had coronary artery disease and had stopped medical management.

• Also history of hip fracture and falling out of bed this period.



Medical Director Documentation- Avoiding Pitfalls

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Medical Director Documentation- Let the horses out of the Stable!


• Call out that the patient originally qualified for the Medicare hospice benefit, may not be as rapidly declining, and yet still has a reasonable expectation of continued decline for a life expectancy of less than 6 months based on clinical judgment.



• Nurses should provide physical aspects of care, medical/clinical assessments and findings that support evidence of decline

– Obtain anthropomorphic measurements such as, mid-arm circumference or abdominal girth, BMI on admission, in addition to weighing the patient. (Weigh and conduct anthropomorphic measurements no less than once per month.)

– Visual presentation of the patient and changes over time

– Pain and other distressing symptoms

– PPS and FAST, mortality index used when possible

Nursing Documentation

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• Clinical Findings: Current weight is 115 lb, which has decreased from previous weight of 126 lb. Height is 60.5”. Arm circumference is 9”. Palliative Performance Scale is 30%, FAST scale is 7D. BMI is 22.1. Patient has had a recent falls that resulted in hip fracture in May 2015. Mortality risk index score is 12 which predicts a 70 percent chance of dying within 6 months.

• The patient’s past medical history includes seizure disorder after a closed head injury in 2011. She had been living with her daughters until later fall of 2014. In August 2014, she was hospitalized for pneumonia and at the time, was noted to have significant cognitive difficulties. While in the TCU she improved some but never returned to baseline. She was also hospitalized in Oct 2014 with altered mental status and yet again in early 2015 when she was admitted to St. Joseph’s Hospital for neurologic, metabolic, infectious and psychiatric evaluations which unfortunately did not identify a reversible cause. In May 2015, due to her need for more care, she moved to an AL memory care unit. In May, shortly after moving to the AL, she fell and sustained an acute right intertrochanteric hip fracture.

• Family are struggling with the patient’s decline. She requires significant assistance with all ADLs and is essentially total care. The last two days the patient has been bedbound.

Case Review: Nursing Admission Summary


Case Review Admission Assessment 7/24/15

• Non responsive, bedbound x 2 days

• Weight 115# down from 126# one month ago, BMI 22.1

• Scheduled tylenol and ibuprofen, morphine ordered but not used

• Some bruising, no open areas

• FAST 7C (total dependence with ADLs)

• Palliative Performance Scale 30%

• No dyspnea

• Difficulty swallowing (diet is pureed with nectar thick liquids)/pt. fed



Nursing documentation during the review period

• Speech nonsensical • No pain • Difficulty swallowing • Total dependence with ADLs • 25-50% of meals • Weight remained 112-115# • PPS 30% • Skin intact


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Document/describe the level of which the patient is able to participate in the bath each visit

– i.e. patient is not able to hold wash cloth, patient does not know what to do with wash cloth when placed in her/his hand, patient became extremely tired with cares today, slumped in chair more today with the bath, patient required more frequent positioning to sit up in chair

Document what you see

– New open area observed during bath, contact care team RN and reported to facility nurse

– Less verbal today during bath, sat quiet and is usually very talkative

– Patient no longer able to assist with removing her clothing for bath

Hospice Aide Documentation


Case Review Hospice Aide documentation through the review period

– Patient tolerated full whirlpool bath

– Indicated was having pain

– Sitting comfortable in activity

– Slept through cares

– Fed lunch by staff, ate 75%

– Patient awake and talkative during cares

Hospice Aide Documentation


• Visual presentation of the patient (what has changed from visit to visit? Is the patient unable to make eye contact now? Is the patient unable to engage in conversation?

• Family systems and coping (ability to care for patient as patients condition changes, disorder in family systems)

• Ask more complex open ended questions that may elicit a nonsensical response.

• Emphasize the need for additional services and the impact of the change in condition requiring more care.

Medical Social Work Documentation

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Case Review Admission Psychosocial Assessment

– Patient not able to participate in assessment

– Strong catholic faith

– Daughter visits facility often

– No discussion regarding daughters acceptance of patient decline and prognosis

Medical Social Worker Documentation


Medical Social Worker Documentation during the review period

– Comfortable and in good spirits

– Patient requested to take a walk

– No concerns

– Patient appears to be doing fairly well despite disease process

– Daughter visiting often

Medical Social Worker Documentation


• Visual presentation of the patient: – Patient slumped in w/c leaning to left side, chin down, drooling, no

expression on face, does not raise her head or move at all in the chair when I call out her name.

• How has the patient/family decline affected the patient spirituality? – The dementia patient may be able to recite the Lords prayer. Avoid

documentation supporting long term memory. Conduct your narrative based on the present.

• Patient cannot follow along with reading of scripture

• Patient does not recognize me from my last visit or from visit to visit

• Patient no longer able to or interested in attending facility church services

Spiritual Counseling Documentation

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Case Review Spiritual Counseling Initial Assessment

– Spoke with daughter, no new concerns

– Patient lived with daughter for 2+ years prior to facility

– Patient more stable than last week

– Faith very important, patient taught children to believe in miracles



Spiritual Counseling documentation during the review period

– No changes or concerns

– No signs of discomfort

– Patient stated, “Too many people speaking”

– Pocketed food and then spit it out (daughter emotional about her mother not wanting to eat)

– Daughter visits often



Based on the Interdisciplinary Group documentation, was our patient terminal?

Case Review: IDG Documentation

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Documentation and Risk

• This patient was found by NGS to not meet eligibility criteria for hospice in a 2017 CMS probe.

• Explanation in the denial letter from NGS:

“there was no acute respiratory problem, uncontrolled discomfort, acute systemic infection or evidence of a sustained clinical decline to support a terminal prognosis of six months or less according to the Medicare guidelines.”


Additional Development Request (ADR) is a request for information from a Medicare contracted agency. Contractors have broad ability to perform pre-payment and post-payment medical reviews of hospice claims.

• MAC (Medicare Administrative Contractor) National Government Services (NGS) for this region

• QIC (Quality Independent Contractor) Maximus for this region • CERT (Comprehensive Error Rate Testing) Calculates

inappropriate payment rates. • ZPIC (Zone Program Integrity Contractor) Identifies suspected

cases of fraud.




• Read your denial letter closely. Is the explanation in line with the patient’s clinical picture?

• MD documentation: either show how patient’s disease course is in line with the guidelines OR why clinical judgment shows that the patient is eligible.

• Documentation from IDG members must support clear evidence of decline during the review period.

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• Each discipline must: – review the patient’s primary terminal diagnosis and

contributing conditions prior to each visit and conduct your assessment and documentation focused on these conditions.

– review previous visit notes conducted by other team members (avoid inconsistencies from one discipline to the next.)

– clearly describe patient decline from visit to visit.

• Each note must: – Standalone, not look like previous notes. Do not copy and

paste or repeat information with the same text from one visit note to the next.

– No check boxes without a narrative statement with an explanation

All Disciplines: Avoiding Pitfalls in IDG Documentation


We tend to want to focus documentation on the good work we’ve done!

• Phrases to avoid: – No new concerns – Had a good day today – Tolerated cares well – Enjoyed visit – Symptoms managed (without qualifying statements) – No changes since last visit – Planning on visiting next week (noted in an IDG meeting) – Comfortable

Discipline Documentation: Avoiding Pitfalls



• The reviewing agencies may or may not look outside of the ADR review period so each telephone call, IDG meeting note, visit etc. counts. (It may not matter that the patient died the following month.)

• Our patient died 4 months after the review period.

– Are the guidelines better at predicting death than real life???

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Know Your Target Audience

• The nurse reviewers knowledge base may vary.

– CAD (coronary artery disease)

– ADL (activities of daily living)

• The medical directors may not have a hospice/pall care/home care or geriatrics background.

– Provide even more detail about how clinical judgment is being formed- don’t assume a fundamental knowledge.


• In August of 2014, she was hospitalized for pneumonia and never returned to her baseline. The patient was hospitalized again in October 2014 for altered mental status. Moreover, in 2015 she suffered a hip fracture for which she underwent repair. Pneumonia and hip fracture individually portend a high risk for death over the following year. Having had both of these complications, this patient is at even higher risk of recurrence and of dying related to pneumonia and/or hip fracture.

Medical Director Documentation- Spell it out!


Medical Director Documentation- interpretation of the FAST Scale

• FAST Scale:

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• The impact of poor documentation may result in:

– Patients who should receive hospice will not (medical directors less likely to certify those terminally ill)

– Hospice providers sustaining significant financial repercussions

– Medicare member’s families receive a denial letter stating their loved one was not eligible for hospice services



Mitchell, S., Advanced Dementia. NEJM 372;26 June 25, 2015.

Sachs, G.A., Shega, J. W., Cox-Hayley, D., Barriers to Excellent End of Life Care for Patients with Dementia. J GEN INTERN MED 2004;19:1057–1063. Giulio, P.D., Toscani, F., Villanni, D. et.al. Dying with Advanced Dementia in Long Term Care Geriatric Institutions: A Retrospective Study. JAMA vol. 11, no. 7, 2008. DOI:10.1089/jpm.2008.0020. Schonwetter RS, Han B, Small BJ, Martin B, Tope K, Haley WE. Predictors of six-month survival among patients with dementia: an evaluation of hospice Medicare guidelines. Am J Hosp Palliative Care 2003; 20:105–113. Mitchell SJ, Kiely DK, Hamel MB, Park PS, Morris JN, Fries BE. Estimating prognosis for nursing home residents with advanced dementia. JAMA 2004; 291:2734–2740.

References: Journal Articles


Local Coverage Determinations (LCDs) for Hospice-Determining Terminal Status (L33393) www.ngsmedicare.com/ The Medicare Conditions of Participation for Hospice Care 42, CFR418, https://www.ecfr.gov/cgi-bin/text-idx?SID=1e60a115cd2f086b2c32af0cce72353d&mc=true&node=pt42.3.418&rgn=div5

……or……. https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/Hospice.html

References: Web Based

http://www.ngsmedicare.com/

https://www.ecfr.gov/cgi-bin/text-idx?SID=1e60a115cd2f086b2c32af0cce72353d&mc=true&node=pt42.3.418&rgn=div5






https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/Hospice.html






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CMS Targeted Probe and Educate Flow Chart https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/TPE-Pilot-Flow-chart06-20-17v9-final.pdf

CMS website: Targeted Probe and Educate (TPE) https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html

References: Web Based

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/TPE-Pilot-Flow-chart06-20-17v9-final.pdf































https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html

























powerpoint presentation lcd for alzheimers disease ... prognosis for nursing home residents with ......

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