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The VITAS Physician and Nurse: Partners in Compliance

By Karen Peterson, Chief Nursing Officer

The Medicare Hospice Benefit as defined by Congress in the 1980s is unique in that it emphasizes the role of the entire team in establishing the plan of care for a terminally ill patient. Those of us who work in hospice care recognize that this was a wise decision. It means that each member of the hospice care team brings his or her own unique set of skills and expertise to the bedsides of the vulnerable population we serve. Doctors, nurses, chaplains, social workers and hospice aides each do what they can while in a patient’s home. Our shared goal is to strike the right “balance” of compassion and skill.

Many of our peers are in awe of hospice clinicians—they admire our skill and compassion in working with patients and families facing terminal illness because they prefer to focus on rehabilitation and recovery. We hone our clinical skills, tools we have learned in our professional education, along with more subtle interventions we have picked up from mentors over the years. In all of this, we strive to palliate distressing symptoms of illness with that special VITAS touch that helps patients and families make the most of the time remaining with their loved ones.

We are a team, and our care is the better for it. However, this paper is intended to focus attention on the “medical” component of that team, and in particular, how the nurse and physician work together to assure compliance with hospice rules and regulations. At VITAS, this partnership is one of mutual respect and dedication to offering the best that medicine can bring to alleviate suffering. It is just one more way that we at VITAS put patients and families first.

Certification in Hospice and Palliative Medicine / Certification in Hospice and Palliative Nursing

“I am proud to make a difference” is VITAS’ fourth value, and it’s one that I believe resonates for hospice workers everywhere. VITAS professionals are proud to be part of a team that delivers quality end-of-life care, which almost all of our patients say they would recommend to their friends and families. We also know that the type of medicine that we provide at the bedside is a very different kind of medicine from the kind our peers practice and provide. While most physicians and nurses prefer to work in an environment in which the interventions they prescribe lead to rehabilitation and recovery, VITAS clinicians focus on the alleviation of suffering. And this is, in fact, “healing” in the best and broadest sense of the word.

As a nurse, I can tell you it takes a special kind of doctor to work in hospice. The idea of working on a team— being one component of a team as opposed to being “in charge” of a team”—would not be satisfying to many physicians. This makes our doctors unique. It also makes them the absolute best at what they do. I have heard more than one of our physicians say that they have learned as much by working alongside hospice aides, chaplains, social workers and nurses as they did in medical school working alongside other physicians. I believe it is this mutual respect among members of the VITAS team that results in the kind of care about which families express the satisfaction rating mentioned above.

Our physicians and nurses have also been recognized as having these unique skills by respected organizations outside of VITAS. In 2006, 10 of the certifying boards of the American Board of Certifying Specialties recognized Hospice and Palliative medicine as a sub-specialty and created new rules around obtaining this certification. VITAS is a strong proponent of the Hospice and Palliative certification.

A parallel certification for hospice nurses (and hospice aides) has been created by the Hospice and Palliative Nurses Association. VITAS strongly supports this certification for these disciplines as well as a way to assure the highest quality care for patients and families.

Certification of Terminal Illness

And now we move on to a different kind of certification—the certification that a physician makes when a patient comes onto hospice. The collaboration between VITAS physicians and nurses who are in compliance starts, quite literally, at the moment care starts. The Medicare Conditions of Participation (CoPs) require the hospice provider to obtain written certification of terminal illness as care begins. Anyone involved in the admissions process will tell you this does not just mean that the doctor signs a certification.

The “certification will be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness.”[Medicare Conditions of Participation 418.22(b)] This means that the doctor will interact with the admissions team and the VITAS nurse to obtain enough information to determine the patient’s prognosis. The physician also oversees the establishment of the initial plan of care, collaborating with the hospice nurse to address the patient’s symptoms. In some cases, the certifying physician will need to make a house call to visit the patient, or call the patient’s referring physician, or review medical records in an effort to confirm eligibility or to best understand the patient’s symptoms that need to be addressed.

At any moment—24 hours a day, seven days a week—there is a designated VITAS physician who the admissions team can contact—and must contact—to provide this support as a part of the admissions process. It is only at the conclusion of this process that the doctor can compose the ‘physician narrative’ that technically meets the regulation referenced above. This process is a true case of form following function. Certainly the form (the physician narrative) needs to be completed, but the form is completed at the conclusion of the process that involves a great deal of collaboration as medical and nursing professionals assess the needs of the patient and family.

Reaching out to the Attending or Referring Physician

The initial certification process is only one of the times that the VITAS physician and nurse might need to reach out to the attending or referring physician. This communication may need to be facilitated at any point during the course of a patient’s care. The team will reach out to the referring physician to complete the initial certification process, as the referring physician also needs to indicate in writing that the patient’s prognosis meets the patient’s eligibility for hospice care, that in the physician’s judgment the patient’s prognosis more likely than not will result in death in six months or less if the illness runs its normal course. Sometimes it is the team physician and the attending physician putting their heads together that results in this conclusion or in changes to the plan of care that will make the patient’s last days and weeks more comfortable.

There are cases in which a patient does not have an attending physician of record. It might be a hospitalist or even an emergency room physician who made the referral to hospice, or the patient might not have established an ongoing relationship with a specific physician. Nonetheless, it is important that we establish who the patient prefers to have as his or her attending/following physician at the time of admission. This tells us who the patient wants us to get orders from on an ongoing basis. Whenever possible, we support this preference.

The physician the patient chooses to be his or her attending physician might not agree to follow the patient while the patient is receiving hospice care. Although the absence of an attending physician is not ideal, when this happens, the CoPs provide for the hospice physician meeting the medical needs of the patient. Sometimes this includes even the initial certification when various efforts to obtain the referring physician’s signature on the certification statement fail. In these instances, the hospice physician functions as both the hospice and the attending doctor, as set forth in the CoPs.

Determining the Terminal Diagnosis

For most patients referred to VITAS, the primary terminal diagnosis as well as any other conditions affecting the patient will be completely clear from the initiation of the referral. For other patients who are referred to VITAS, the primary terminal diagnosis is unclear at the time of referral. While these patients have a prognosis of six months or less to the best of the physician’s ability to judge, the underlying disease state that is most likely to contribute to their death is unclear.

These patients are correctly referred to hospice and appropriately admitted because they are declining and have a terminal prognosis. The actual cause of their decline may be unclear beyond the fact that they are dying. It might take a few days after the admission to allow for additional evaluation and medical-record review and even physician-to-physician conversation with the referring doctor before the hospice physician can determine the most appropriate primary terminal diagnosis. The clinical experience, judgment and teamwork of the hospice physician and nurse in this process are critical, and the physician’s role in establishing the primary diagnosis is an important step in supporting the development of the comprehensive plan of care. This process is an ongoing one throughout the patient’s length of stay on our service where the comprehensive diagnoses (primary, secondary, co-morbids) are constantly being reviewed, evaluated and documented accordingly.

Establishing the Comprehensive Plan of Care

The cooperation of the VITAS team physician and nurse is especially critical when the initial and comprehensive plans of care are established. As the hospice team gets to know the patient, ongoing feedback and IDG review provides additional information the team nurse needs to know in order to fulfill his or her responsibility under the CoPs to coordinate the various interventions that are needed to manage the patient’s symptoms. That first team meeting during which the patient is discussed is a key point at which the whole team is able to see the “big picture” as they review and discuss the comprehensive plan of care that has been in the process of being developed over the first days of care.

One of the most critical parts of this review–and this is one of those places where responsibility rests solely on the team physician–is the review of the patient’s medication profile. As we know, many patients come to us without their attending physician having had a serious conversation with their patient about what their disease really means in practical terms. So, for example, a patient might continue to take cholesterol-lowering medications, despite the fact that these drugs are of little or no benefit when dealing with a terminal illness. Do we continue providing medications such as Aricept where the primary purpose is to delay the progression of Alzheimer’s disease? These medications often have side effects and invite complications from which the patient should be spared. When faced with such circumstances, the hospice physician might consider discontinuing these medications so that challenging symptoms can be better controlled without the interference of ineffective medications. Sometimes this aspect of managing the comprehensive plan of care requires reaching out to the attending physician to discuss an appropriate strategy towards discontinuation. And it certainly involves a thoughtful, knowledgeable and skilled conversation with the patient and family.

The issue of medication efficacy continues to receive a lot of attention. Hospices have historically made a determination about whether or not each individual medication is related to the terminal diagnosis. The Centers for Medication/Medicaid Services (CMS) recently stated that it expects hospices to do more to address medication efficacy, the potential for medication interactions and reviewing the patient’s medications whether related to the terminal diagnosis or not. CMS expects the team to encourage the elimination of medications that are no longer effective in the treatment of the patient. In fact, CMS expects that most patients will not continue to receive medications that are unrelated to the terminal diagnosis. This makes the review of the medication profile upon admission and at regular intervals throughout the patient’s time on VITAS that much more critical.

At VITAS, the comprehensive plan of care is reviewed at team meeting, generally every two weeks. The VITAS team physician and nurse are key participants in this review and help the team assure that the plan of care continues to meet the needs of the patient and family in light of the trajectory of the patient’s illness.

Recertification

At regular intervals, the hospice physician, with support from the nurse and other members of the team, must again certify that the patient remains eligible and appropriate to receive hospice services and dictates a physician narrative to that effect. This means the physician again certifies that, to the best of his or her medical opinion, the patient will not live longer than six months if the illness runs its normal course.

Over the years, CMS has assured hospice and attending physicians that they understand that this medical opinion is not an exact science. This is not negated by the current focus on longer stay patients. While CMS is increasing its focus on the physician documentation supporting certification of patients who remain on hospice longer than 180 days (six months), the statute and the regulations remain clear that it is the clinical judgment of the team physician that must determine whether a patient is appropriate for admission to hospice, and whether or not the patient continues to meet the criteria to warrant remaining on service.

Our physicians not only provide outstanding care, but they are keenly aware of these rules governing the Medicare Hospice Benefit. They honor the six-month guideline and do so even when it is most difficult, such as with non-cancer diagnoses. In this area, like other areas of hospice care, VITAS physicians are industry leaders. It should be noted here that VITAS’ experience determining any given patient’s prognosis is remarkable. Nearly 90 percent of patients admitted to our care are with us for six months or less. In fact, about half of all patients admitted die within two weeks of admission. Even for patients on hospice for only a short period, the documentation of their status at admission is critical.

VITAS doctors are highly skilled at determining a patient’s prognosis upon admission and at the time of recertification. And, in instances when we are reviewed by CMS’s Medicare Administrative Contractor (MAC) regarding a patient’s eligibility, our physicians’ decisions to admit patients as appropriately eligible are almost always upheld. As part of such regulatory reviews, our team physicians and medical directors periodically testify before Administrative Law Judges in these cases to explain why, from the physician’s perspective, certification or recertification was appropriate.

A regulation put into effect in 2011 is intended to ensure patients receiving hospice services continue to be eligible for hospice even if they have been on service for more than six months. Every patient who remains on service longer than 180 days must have a visit, or “face-to-face encounter,” with a hospice physician, and again at each subsequent 60-day recertification period. In other words, for these “outlier” patients who defy prediction and happen to live longer than 180 days, a VITAS physician (or nurse practitioner) makes a house call every 60 days. During that “encounter,” the physician/nurse practitioner does a physical assessment, determines ongoing eligibility and makes any changes to the patient’s medical orders that are necessary as a result of this visit. While the face-to-face requirement is costly to hospices, we joined our trade organization, the National Hospice and Palliative Care Organization, in supporting this directive, which has promoted public trust in our services.

Changes in Level of Care

One last place where the team physician and nurse play a key role in compliance is related to changes in level of care. A change in level of care is very similar to other physician orders discussed earlier. One of the functions of the team, in addition to medication management, treatments, the provision of supplies, home medical equipment, etc., is the placement of the patient on the correct level of hospice care.

Higher levels of care reflect the intense needs of the patient and the ability of the family to manage those intense needs. When the nurse identifies that the patient’s symptoms cannot be well-managed by the family in the home setting, the nurse can consult the physician to report what he or she is seeing. Using the nurse as his or her eyes and ears, the physician might assess that either Continuous Home Care (CHC) or General Inpatient Care (GIP) are appropriate to order. Either of these higher levels of care provides the patient and family with more intensive services to meet the more challenging needs of the patient.

VITAS education materials summarize the different levels of care, and in a previous article published on the VITAS compliance website called Continuous Care at VITAS, we provided a greater explanation of continuous care and inpatient care. Although the eligibility requirements for each of the higher levels of care are virtually the same, it is critical to take the patient and family’s preferences for the setting of this higher level of care into account. The interdisciplinary team, which includes the patient and family, drives the choice as to whether to receive CHC or GIP.

Historically, these patients have a short length of stay on the higher level of care. The very short length of stay for patients receiving these higher levels of care is the result of the expertise of VITAS clinicians at controlling symptoms. VITAS clinicians are often able to manage symptoms quickly and return patients to a “routine” level of care; however, sometimes the symptoms that made the patient appropriate for GIP or CHC are also signs of impending death. In either case, when appropriate, these higher levels of care ease the “crisis” of unwieldy symptoms and allow patients and families to spend more quality time at one of life’s most important moments. As you can tell, the partnership between the physician and the nurse in these situations is critical.

Back to Where We Started

Ultimately, at VITAS, it is the partnership between nurses and physicians, developed over years of training and honed as members of the interdisciplinary team, that enables the outstanding medical aspects of the care that VITAS clinicians deliver to 15,500-plus patients on any given day. It is part science and part art that make such an effective combination. It is also part skill and part compassion.

As a nurse at VITAS, I have “grown up” appreciating this partnership. In this article I have elevated the importance of this partnership in delivering care to our patients and families. VITAS physicians and nurses provide the highest-quality hospice and palliative care and remain advocates for our patients while, at the same time, assuring compliance with all government rules.

As Chief Nursing Officer, I especially want to acknowledge what each and every nurse/physician team brings to the medical aspects of the care we deliver. Our nurses and doctors really do make a difference. I am proud of these physicians and nurses and of all of the dedicated team members and office/support personnel who interact with our patients and families every day.