Do the Right Thing – And Document It
By Bob Miller, EVP of Operations and Compliance Officer, and Karen Peterson, SVP and Chief Nursing Officer
It seems like every day we are hearing more in the news about audits, edits, lawsuits and allegations of fraud and abuse in hospice. You might be tempted to ask yourselves why this is the case, especially since the people drawn to work in a hospice environment – you, and your colleagues – are people motivated by the kind of principles that are reflected in our VITAS values. Our first value “Patients and Families Come First” is one that resonates with virtually every hospice professional. At VITAS, these principles are not just nice words on a page that no one ever reads. They are being lived out today in challenging patient situations as you and your colleagues seek to do the right thing for patients and families. We hope the excellent care you and your colleagues provide to people during more than four million visits per year makes you as proud as it makes us.
One reason we are seeing more scrutiny of hospice is that end of life care is maturing as a sector within healthcare and Medicare. Hospice is a relative newcomer on the healthcare scene, having only been established in the late 1970s. As VITAS and other premier hospice providers champion access to the best end-of-life care medical science and caring clinicians can offer, utilization of hospice and associated expenditures for hospice have increased. So it stands to reason that, like more established sectors of medicine, we will continue to see a spotlight shined on every aspect of the care we provide and which is reimbursed by a Medicare budget challenged to become more efficient and effective.
At VITAS, we welcome this scrutiny. Honest providers, providers who encourage staff members to do the right thing, providers who carefully follow the rules and guidelines established by Medicare; in short, providers like VITAS, applaud this development. It means we have the opportunity to shine as we do the right things and make a difficult or unbearable situation like the loss of a loved one just a little bit better, a little bit easier. More than four million times a year.
If the kind of care you and your colleagues provide every day is to continue as hospice and the Medicare rules evolve, the responsibility is on each of us – every day – to think critically, offer alternatives, document thoroughly, and assure that patients and families get the appropriate care that addresses their needs (and document it). In short, each of us needs to do the right thing. This is one aspect we don’t often think about with respect to VITAS’ second value. “We take care of each other” means that each of us – every day – upholds our responsibility to provide the best possible care for our patients and families (and document it) so that patients and families get what they need and no one else has to do our work for us.
Taking care of each other includes helping each other to do the right thing. Know our scope of practice, know compliance issues, speak up when someone may be contemplating taking a short cut, bring your co worker back to ‘doing the right thing’ every day with every patient in every situation…don’t look the other way. Teach, remind, seek guidance, review new policies and new standards, ask questions, keep each other compliant knowing that VITAS standards and protocols are in place to help us meet rules and requirements while ultimately putting patients and families first, and in the end delivering care of the highest quality.
Doing Our Best Today
We realize this is nothing new to those of you who have worked at VITAS for any time. We have always been focused on these important matters. It is also true that doing the right thing (and documenting it) is our single best defense against audits, edits, lawsuits, and allegations of fraud and abuse. So while our attention in this document is going to turn toward VITAS’ quality and compliance program, remember that this “code of conduct” is really just our attempt to put into clear and direct step-by-step guidelines what it means to do the right thing.
A robust compliance program like the one at VITAS has several key components. These include:
- Training – like what we provide every employee upon orientation and with our Annual Update in April
- Enforcement of compliance guidelines through coaching and accountability
- Creating a culture of compliance and encouraging employees to raise concerns
Some of the main areas of concern from a compliance standpoint are listed below.
Eligibility includes the checks and balances we provide as part of the admission, discharge, and revocation processes. We are consistently refining our admission processes to assure that we provide access to VITAS’ unique way of caring only to hospice appropriate patients. The same applies to discharges and revocations – we want to be sure to explore every appropriate option to continue providing care to meet the needs of appropriate patients. Below we will focus on eligibility for higher levels of care. Eligibility is one of the top target areas for compliance reviewers.
Billing Practices: VITAS invests in comprehensive compliance oversight including a subject matter expert on billing documentation at each of our programs. Of course, our compliance program is more expansive than just accurate consents, certifications, and recertifications, though. It also refers to documentation you as a clinician might complete and your responsibility to assure that your documentation reflects the patient’s condition and how well each of their symptoms is being managed by the interventions we are providing. It means you are attentive to and document things your expertise leads you to notice. Things like looser fitting rings or dentures that evidence the patient’s decline in condition. Things like what the disease means to the family and how our interventions are helping relieve suffering and provide hope. Things like dreams and wishes that we might yet be able to help them fulfill.
Hospice Services in Nursing Facilities are a special area of interest as some have the perception that nursing homes should be providing everything the patient and family need, including end of life care. Only you and your teammates can document the unique care you provide to help make the patient more comfortable in their last days, the way you can help them take pride in their appearance despite the ravages of their disease process, the dignity you support by managing their care in ways even the most well intentioned nursing home staff cannot because they do not have your expertise. In addition to this, relationships with nursing homes come under scrutiny because of the potential for kickbacks and other inappropriate behavior relating to referrals. VITAS does not tolerate these sorts of behaviors, and neither should you.
Clinical Risks: These include assuring that our care and services meet standards of practice – again, doing the right thing (and documenting it). Coordination of services falls in this area, and our responsibility to manage the whole patient and family situation. Part of this is knowing and following the Medicare Conditions of Participation and state licensure laws, the rules that govern the care we provide.
Lastly, assuring that our Marketing Practices are appropriate and reflect best practices. Like these other areas of compliance, this means more than simply behaving ethically with respect to referral sources. It also reflects the great care VITAS takes to publish marketing and educational materials that describe the services we offer in language that the referral source AND the patient and family can understand. After all, we have a unique obligation to help patients and families understand the full range of care and services VITAS, and all hospices, must provide.
Focus: Higher Levels of Care
Part of providing the full range of care and services is making sure that patients have access to the right intensity of services at the right time. There are four levels of hospice care and it is our job to make sure the appropriate level of care is provided when it is needed. Since higher levels of care are reimbursed at a higher rate, these are under particular scrutiny by surveyors and reviewers.
VITAS has always been – and always will be – committed to assuring that both higher levels of care, general inpatient care and continuous home care, are available when needed. Both of these are challenging services to provide. Did you know that there are many hospice providers out there that don’t provide either of these higher levels of care in any consistent way? In fact, a study recently released by the OIG found that 27% of Medicare hospices (953 hospices) did not provide any general inpatient care during 2011 and that most of these hospices also did not provide continuous home care. The OIG rightly pointed out that “Like [general inpatient care], continuous care and inpatient respite care are covered by Medicare and must be provided if needed.”
Your experience tells you what a relief it is for the patient and family to have access to inpatient or continuous care when it’s needed and appropriate under the regulations. Imagine working for a provider unwilling to invest in these required levels of care. Imagine what a negative impact that would have on your work, and more importantly on the lives of patients and families.
What’s your responsibility when a higher level of care is called for? Nothing less than what we have been reviewing throughout this article. Doing the right thing. Documenting the reasons. It’s really as simple – and as complex – as that. Acute medical symptoms may appear differently depending on the particular patient. Some will present with intractable symptoms like nausea or vomiting, pain, bleeding, or respiratory distress – things too obvious to ignore. Some will be less obvious, but will be a clue that something is happening with these patients that needs to be attended to and may result in the need for a higher level of care, based on a physician’s order.
Always reach out to the physician and share what you are seeing. If the physician feels that a higher level of care is warranted, talk to the patient and family about their preferences. For some, staying at home surrounded by the people, pets and things they love will lead to the conclusion that continuous care is the best avenue. For others, the thought of having someone in their home up to 24 hours a day will seem too intrusive so that general inpatient care will seem more attractive. Some symptoms are better managed in an inpatient setting, so the physician may recommend a setting for the higher level of care according to the symptom being managed.
Importantly, the documentation at these higher levels of care needs to detail the reasons that the higher level of care is appropriate. It needs more depth, more description, more of all those aspects we described above. Write your notes in the same way you would want someone to document the care of someone you love. Let anyone who reads them afterwards know how excellent your care was.
Isn’t it Both Quality and Compliance?
Although we have been focusing on compliance, we have also been talking about quality all along. It’s impossible to separate the two. As you know, VITAS has invested a great deal of time and energy to give clinicians and clinical managers the best tools to help manage patient’s symptoms. VITAS has pioneered the use of data since the early 1990s when we developed the VITAS Exchange. We’ve used patient’s pain scores through reports available in the system to help us evaluate and improve our care since these early beginnings. At a time when many hospices were scheduling initial admission visits days after the date of a referral, we were measuring our response to referrals in hours.
So being focused on access, quality and compliance is nothing new to our clinicians and managers. Our latest effort in this area is the Quality Assessment and Performance Improvement Dashboard. The dashboard contains 62 measures, many of them aggregated from things you document routinely during care. The dashboard is set up in such a way so that trends can be seen and performance improvement plans initiated in the program when needed. The dashboard is much more elaborate than our early reports, but it really just demonstrates our level of commitment to quality coupled with the kind of data that is now available to help us take that commitment to the next level.
I Am Proud to Make a Difference
At the beginning we said we hope you are proud of what you do every day. Hopefully, reading this article has helped you see other ways in which you should be proud of what you do and of doing it with VITAS. You and your colleagues are making a difference, when it matters most to our patients and their families. At VITAS, following the rules, doing the right thing, and documenting it, is its own reward. And most importantly, is the right thing to do for our patients.