ED Hospice ProcessVanderbilt University Medical Center

Presentation 2/7/2020

Hospice inthe ED in quick & simple terms

Problem Statement

These are the Final Wishes of Patient and/or Family

Admit to Hospice

Signed EHB & Move to Correct Status Upon Transition

Comply with Center for Medicare and Medicaid Services

Ensures Provider is Routed to right EHR and Route Charges to Revenue Cycle for Reimbursement

Hospice in the ED

Patient Admitted Into The ED

• Emergency Patient

• H&P

• Patient does not have recovery options

• Starting with Medical Futility

• Determination that Patient has < 48 hours to live

• Decision for possible need of Hospice

Patient Choice Provision• ED Physician

• Meets with Patient’s Family• Calls and Discusses by Phone

• Patient/ Family Choice: Alive Hospice or Caris Hospice

• CM or SW sends a referral through AIDEN or Hard Fax

• Call made to Liaison with chosen Hospice

• Alive: 615-250-1348/ F 615-963-4807

• Caris: 615-776-1445 (after hours: 1-800-Hospice) /F 866-694-7878

Hospice Liaison Arrives• Liaison Reviews Case and Meets with Patient’s

Family (2 hour Limit to be there)

• Patient’s Family signs the Election Hospice Benefit (EHB) to permit CMS billing

• Fax EHB to Registration/ Admitting for Discharge/ Readmit, followed by a call to ensure receipt

• Scattered Bed: Has to be actively dying and unable to transfer due to instability

• Patient GIP– transferred to Swing Hospice Bed at Alive (has to be actively in a crisis)

• LTC facility – understand hat Medicare does not pay for this, it is a patient/family paid for service for Hospice without support in the home

• Home with Hospice set-up with 2- Ride (has expectation < 6 months)

Example of Hospice Care Order

• Patient Name: Sammie Smith• MRN: 00123567• Date: 2/20/2020

Hospice Certification

• Admit to hospice. Life expectancy is six months or less if the illness runs its usual course.

• Terminal Diagnosis: Severe Hemorrhagic Stroke

• Ordering Provider: Attending MD /Your name and credentials

Smart Phrase in EPIC: .orderforhospice

Scattered Bed (Hospice)

1. CM, SW calls Hospice Liaison (Caris or Alive)2. Sends electronic copy of referral to Hospice3. Collects data for Liaison

a. Current meds, set of vital signs, height and weight, ICU attending name and number (SW, bedside Nurse may need to talk to Liaison with your help)

b. Post form if needed (MEDEX– Bedside RN may need to help)4. Ensures the signing of the EHB with liaison and patient/family. Makes a copy of

EHB and gives it to the ICU team.5. ICU Handover: Gather ICU provider, Bedside RN, and CSL for a timeout at the

bedside

GIP Hospice

• Highest level of hospice care• Crisis Symptom(s)

• Uncontrolled pain, status epilepticus, uncontrolled dyspnea, frequent tracheal suctioning, intractable nausea and vomiting, management of NG tube for gastric decompression

• Inpatient setting (attempts to manage symptoms if routine level of care is not effective)

• Titration of medications• Medications that cannot be provided at home Fentanyl, Versed, IV push

medications• Care by the comprehensive hospice team, primarily MD, NP, and RN• Intended to be temporary until crisis is resolved

Home Hospice Services

• Treatments are directly related to the terminal diagnosis and symptoms• DME: oxygen, hospital bed, overbed table, bedside commode, shower chair,

lift, wheelchair, walker• Supplies: wound care, incontinence care, gloves, chux, mouth swabs• Medications• Respite Care: up to five days in a 90-day benefit period in a LTC facility or

residential hospice facility• Advance to LTC or GIP appropriately

Its all in the Details

• Is Patient Discharged from ED?• Is Patient Readmitted to Hospice? • Is there a Scattered Bed Flag for

Hospice? What ICU has a Scattered Bed for Admission?

• Should Patient admit in Observation Status? Can patient transfer to Palliative Care Unit?

• Should Patient be Transferred to a GIP facility? Appropriate staff and Equipment? Transportation?

DETAILS NEEDED ICU Transfer

• Can Chart be started for Hospice from the Beginning?

• ICU Primary Care Team to Cover Orders and Initiate Care?

• Alive or Caris will help guide orders needed by ICU Team.

• Exclude from O/E Mortality Calculations & Identify Billing Workflow?