Part I: The prognostication conundrum
There has certainly been a good bit of negative press about hospice in the media in the recent past. Adding insult to injury, in early November the story broke about a hospice medical director in Pennsylvania who was convicted for “falsely certifying that patients were appropriate for hospice care.”[i] Yes, there are bad apples in the bunch. However, the vast majority of hospice medical directors are committed, passionate physicians who take their role and responsibilities very seriously.
The focal role of determining clinical eligibility for the Medicare hospice benefit is not an easy one. Day by day, the hospice medical director has to navigate the complex world of prognostication, especially for the frail elderly with organ system failure. The 2014 NHPCO Facts and Figures: Hospice Care in America showed an upward swing in the top three non-cancer principal diagnoses -- dementia, heart disease and lung disease and an increase in the average length of service.[ii]
Prognosis is both an art and a science. Physicians tend to overestimate the probability of survival.[iii] Prognostication has not been a priority area for research nor has it been adequately addressed in medical education and training. The existing tools are limited in their predictive accuracy. Every hospice physician has experienced difficulties in assessing “gray” patients. These are the ones who, at admission, do not have a principal diagnosis or terminal story that leaps out from the record, although for many of these patients, the physician is able to answer “no” to the “would you be surprised if your patient dies within the next six months” question. These are the patients who, while further along the continuum, are not evidencing clear-cut or rapid decline. Some of these patients experience the “hospice cure” as a result of the great care provided by the hospice team.
- Are these patients truly terminally ill?
- Is a period of seeming stabilization sustainable?
- Should these patients be evaluated for discharge due to extended prognosis?
These are the patients over whom there may be team disagreement, discouragement and even disillusionment – the “tough” patients. Added pressures of heightened external scrutiny and the internal pressures of census growth further compound the uneasiness.
Within this very prognostication conundrum lies the opportunity for the unique strengths of hospice to shine. The interdisciplinary group (IDG) is at the core of hospice and adds immeasurable value in the delivery of end-of-life care. The IDG addresses patient and family-specific goals through an individualized plan of care. It seeks to palliate “total pain” -- whether expressed through physical, psychosocial, spiritual, or financial symptoms. The diversity and expertise of the group facilitates individual and collective storytelling at its best. It is a dynamic system based on diversity, trust, conversation, collaboration, interdependence, and integration.
Although the hospice physician bears the singular responsibility for the determination of clinical eligibility, certification and narrative composition, these are the final outcomes of a process dependent on other members of the IDG and admission team. To be able to paint the picture, the physician must build on the information shared by the team, both in the IDG meetings and through the medical record. Seen through the eyes of the different disciplines, the full story of the terminal illness can unfold.
Both the internal and external environments in which hospice exists are becoming increasingly more complex. The quality and reliability of documentation in the clinical record has a big part to play in ensuring payment for services rendered. The physician narrative, as part of the certification process, has a key role in this. “Not hospice appropriate” was the top denial reason code for Palmetto GBA in July- September of this year. “Physician narrative statement not present or valid” was ranked third.[iv]
Patients who fall into the gray category will continue to be referred. For those who are determined to be terminally ill, there is no greater gift than hospice. These patients are challenging the system to evolve in response to the increasing burden of chronic illness and the difficult and unclear transition to end of life. They are depending on hospice for ongoing growth and transformation to ensure that they not only receive excellent palliation to relieve their total pain, but that the care provided can be justified through documentation that supports clinical eligibility.
- What does it look like when the IDG is functioning at its best?
- What is it that energizes, motivates, inspires, and gives life to the team?
- What has worked well in the past during team discussions of complex patients?
Questions like these arise from the assumption that the development of a system will be shaped by where it chooses to place its focus and the kinds of questions it asks itself. They are not lofty or wishful thoughts, but part of a paradigm for change that seeks to uncover the “best of what is,” tapping into the creative energy of the positive to drive innovation that is inspired, hopeful and energized. There is appreciation and encouragement for what emerges when the focus is on strengths, rather than problems. This process is called “Appreciative Inquiry” (A.I.) and at its core is the “Four-D cycle” of Discover, Dream, Design, and Destiny. [v]
Stay tuned for insights into how the A.I. process can inform our certification process!
Posted by: Suzanne Karefa-Johnson, MD, Senior Physician Consultant, Weatherbee Resources, Inc.
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[iii] Christakis et al. Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study. BMJ 2000: 320: 467 - 473