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The vast majority of hospice services are delivered in patient’s homes or other places of residence like nursing homes.  This makes the traditional model of hospice care vulnerable in this coronavirus pandemic, especially in the era of social distancing and limited personal protective equipment (PPE). So how are hospice’s responding to the COVID-19 pandemic?

On this weeks podcast, we talk to two leaders of two large hospice agencies, Drs. Kai Romero and Todd Cote, to get their views on this question. Kai is the Chief Medical Office of Hospice by the Bay in California. Todd is the Chief Medical Officer at Bluegrass Care Navigators in Kentucky.

It’s inspiring to hear how these hospices and others are stepping up
to the challenge of caring for both COVID positive and non-COVID
positive patients during this time.  Among subjects we talk about include:

  • The variability how this pandemic is affecting hospices in how they are responding to COVID (even if they take COVID positive patients)
  • Supply limitations (PPE, medications, etc)
  • The role of telemedicine in hospice visits and the challenges with trying to do some hospice visits virtually
  • How COVID influences prognostic eligibility to hospice
  • Special issues in vulnerable populations like homeless and rural populations
  • The surv

Here are some other important links we talk about in this podcast that can also be found on our new COVID page:

by: Eric Widera (@ewidera)

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, this is like number seven, I think of our COVID podcast.

Alex: I’ve lost count.

Eric: And we focused a lot on hospitals and nursing homes we’ve done. Haven’t yet talked about the impact on hospice, but we have some special guests with us today.

Alex: We do. We are delighted to be joined by Todd Cote, who is chief medical officer for Bluegrass Care Navigators, which covers two thirds of Kentucky. Welcome to the GeriPal podcast, Todd.

Todd: Thank you. Always great to be here.

Alex: And we welcome back to the GeriPal podcast, Kai Romero, who is chief medical officer of Hospice by the Bay, as in San Francisco Bay. Welcome back to the GeriPal podcast, Kai.

Kai: It’s great to be back.

Eric: So, before we start off every podcast, we ask for a song request. Do any of you have a song request for Alex?

Todd: Yes. Thank you, Eric. I do. I’d like to request Waves by a young Australian singer, songwriter, named, Dean Lewis.

Alex: And could you say a little bit about why you chose this song, Todd?

Todd: That’s a great question. I think it’s about four years old. It probably put Dean Lewis on the map at least in Australia and European countries, a little bit here in the US. So it’s been on my playlist for a couple of years. To me it’s very reminiscent song. I think more about, innocence lost. I’m getting older, so I just kind of a sense of mood passing time. But more recently in the last two to three weeks, as you will see through the lyrics, it’s kind of talked to me directly about the swelling storm that’s amongst us even in my professional life. So it’s kind of changed my mood toward that.

Alex: All right, well here goes. (singing).

Todd: That was great. Thank you.

Kai: Sounds great.

Eric: I can always tell Alex likes the song because he does the intro nice and long.

Alex: That is just such a beautiful song. I love the way it goes from a drone to a heavy build up. Thank you for sharing that with us.

Todd: Thank you Alex.

Eric: So I’m going to open it up. Maybe I’ll start with Todd. How is this pandemic affecting hospice? Maybe let’s start off on a bigger kind of national level. What have you been hearing? And then we can kind of drill down to how it’s affecting both of you.

Todd: Thank you. Again, I think because although we’re a small service line, when you compare it to the greater health care system in the United States, we do have a lot of networking. So we’ve been able to hear a lot and share our experiences. So a lot of that’s going on and I hope it is in other areas of healthcare. But overall it’s interesting. The impact has been quite variable and diverse for hospices.

Todd: I think maybe an important point to make, right off the bat is most hospice or I should say the average hospice in the United States as many of us know, is about 100 patients a day, give or take that number. So in context, that’s basically a fairly small organization. So the impact of crisis management, the impact of actually the realities of your own health care workers in a smaller organization being effected, even exposure, that sort of thing can greatly impact your ability to care for end of life care patients.

Todd: So there’s a lot of fear, anxiety, nervousness, particularly overall. Many hospices, like our own have noticed actually more referrals. Many hospices in smaller communities, rural America have kind of realized a much decreased referrals and their patient basis is crumbling down into half in just a few weeks of typical patients they care for.

Eric: Why do you think that is? Why are people seeing less referrals right now?

Todd: Well, it’s interesting. I think there’s this preparedness of… it’s a very good question, Eric. A lot of us have talked about it. When there’s a snow storm and or winter comes, there’s less referrals. Why is that? Because the death rates don’t necessarily change. So I do think there’s impact, just a societal impact of what’s been going on in just a very rapid period of time. Hospitals are clearing out in preparation.

Todd: Again, and the focus of hospice is really trying to, again maintain high quality of end of life care while maintaining safety of their own employees. And a growing dilemma is caring for patients, which is the majority of hospice patients in the United States that don’t have COVID positive, but also trying to be available and assist hospitals, nursing homes and others caring for COVID positive patients.

Eric: Are you saying also that people don’t want more people coming into their houses? I mean, part of the role of the hospice is to get that interprofessional team into people’s houses.

Todd: Right. All kinds of stories in our own experience. The same pain you will have the family members that are more nervous and fearful of care. So they ask for more care. And then you have similar families really being very fearful and anxious and actually refusing for any team members in the hospice team to come in. You have nursing homes that refuse hospice teams all the way to nursing homes that are begging for more care, particularly nursing, CNA care and that sort of thing.

Kai: I also found that, we had a lot less confusion once we made our policy really clear to patients, which is kind of based on department of public health and CDC guidelines. We know that limiting face to face contact has to be a priority for your safety, for our safety. Here are all the things that we are doing to try and continue to provide you high quality care with those limitations in mind.

Kai: That actually I think helped us to some degree limit some of that confusion on the patient’s part. Because I agree that the anxiety goes in two directions. And one of those directions is in both our CFEs and patients demanding nursing visits for, something like an abrasion, saying, “You need to have a nurse out here to evaluate this.” And on the other end saying, not even a nurse can come in and do a visit when there’s some real urgent need.

Alex: What things are you doing to minimize contact that doesn’t need to be face and face and those things that actually do?

Kai: I mean, that’s really a telemedicine heavy framework. We have been trying at our organization to get people to use telemedicine for years and all of a sudden people are actually doing so. I think what’s challenging in a hospice population is that you have elders, and you have people who really aren’t tech savvy, who really may not feel up to kind of even the small amount of legwork that you have to do, to do a video visit.

Kai: So I suspect that more hospices are relying on phone visits than like large healthcare institutions, for example. But we are now including in our admissions packet instructions for how to download Zoom. We’re distributing iPads, or we’d be gone distributing iPads to nursing facilities where we have multiple patients so that we have kind of a way of getting in there with Zoom. So I think people are kind of trying to figure out, it’s a funny problem.

Kai: We had a problem getting our own staff who are kind of relatively younger, relatively more tech savvy to start using Zoom and now we’re expecting hospice patients to be able to do it. And it’s a big ask. So I think we’re still figuring out how to do that.

Alex: And Todd, what are you doing on your end?

Todd: It’s interesting…and Kai mentioned the CDC. Thank goodness for the CDC and their outsource information because, from day one here in Kentucky, our first case was March 6th. We’ve had a brilliant governor response early that has really flattened the curve. And I say that up front because it’s given us some time. We don’t have a surge yet. We are caring for COVID positive patients, but we’ve just had this time now.

Todd: Time is what? Three or four weeks. But what we’ve been able to accomplish through really following CDC guidelines and structuring our own leadership to that point, being as transparent as we can to our employees particularly. And then again, caring for the patients. But it’s interesting and CDC gives some input into how to start it all up kind of thing. And what was interesting to me as a leader in our company is, the supply inventory was talked about a lot right up front for a healthcare organization.

Todd: And of course we hear about PPE and mask and gowns and gloves and all these problems throughout the country. But, four weeks ago, once, just a simple thing we did was really through leadership, top down, we actually inventoried our supply including N95 mass. And now we’re spread out through the state of Kentucky in seven to eight different geographic areas. And so we actually pulled it in central.

Todd: But having the supply chain is so critical to even what we’re talking about as far as [inaudible 00:12:28] for visits. So as another example, we have very minimal small N95s, and interestingly, we have many more of our clinicians that fit tested with the small. So our concern right now is small N95s. And I’ll say that nationally if anyone has any, please. But that’s just kind of tells you that it’s… and one of my frustrations in leadership is I’m always been ready for a challenge, particularly in innovation, doing things differently.

Todd: But, this has been a completely, fairly uncomfortable challenge in the sense of, I’m worrying more about small N95 mask than anything else. Another thing we did initially was, screening. How do we screen our ourselves every day? And then how do we screen patients and families through exposure? And that’s been really critically important. Testing. I’ll just say the word, it’s still a problem in our area at least and probably nationally.

Todd: And that leads them to, what Kai is talking about getting to the telehealth, telemedicine, telecare is our word for it, which means audio and video. And we’ve kind of been each week, changing and again, being transparent with good communication to our employees, particularly our frontline clinicians on, how many visits to make, how you can visit. Of course nationally we’ve been very active in, waiving some of the stringent criteria for visits, of course, and then now tele-health that we can do. They’ve also waived some of the stringent timeliness of reporting issues for hospice. So we’re indebted to that. But that took about three weeks to get going.

Kai: I will say,Todd, that regarding the CMS regulation changes, that’s actually been interesting this morning. One of the new regulation changes that came out were that they’ve kind of sequentially been saying, okay, initially they allowed for physicians to build for telemedicine. Then they allowed for our face to face visits, which are a Medicare requirement to be done via telemedicine.

Kai: Today they said, initial nursing assessments, meaning the admissions [inaudible 00:14:57] telemedicine. And so, when we were talking about that this morning, I thought to myself like, this field, this is great. We love the fact that this is true and we can now kind of remove another group of people who was actually being very exposed from the field. And if I lived in New York, I would be furious about the timing of this, that I had been living through a pandemic.

Kai: And it took CMS until today to waive this requirement, feels really late for places that are already having their surges. And so I think we have tried as much as we can to kind of align our visits really only to what CMS continued to require, because at the back of your mind is always, if we are no longer able to build for the patients we have on service, we’re spending, hundreds of thousands of dollars trying to acquire PPE, trying to kind of shore up our safety for our clinicians. We actually can’t remain afloat if we’re not able to bill Medicare for our visits. And CMS has acted, I think it’s fair to say faster than they ever have in the whole history. And I could imagine feeling very frustrated about that timeline.

Eric: Both of you care for unique populations. Kai, a large homeless population in San Francisco. When I think about homeless in San Francisco and hospice, Hospice by the Bay has really done amazing things at that population. And Todd, I imagine you have a larger rural population. Do you want to each speak about that? I’m going to turn to Kai first. How have you been dealing with the homeless population in hospice right now?

Kai: So I think, one of the things that is always a challenge when we’re managing our unhoused folks is, figuring out how to reliably and safely, get people, access to their medications, many of which are controlled, and make sure that there is kind of enough of a support system for people when they are kind of truly entering the terminal phases of their disease. It is as hard now as it’s always been.

Kai: You can imagine if someone is kind of resistant to remaining in one spot period, it’s hard to organize their hospice care. And so we continue to end up having to kind of wait later in a person’s disease process to enroll them in hospice or, facilitate placement in a facility to make that happen. That last piece is a little bit harder. Here in the city of San Francisco, there’s been a lot of efforts to actually begin putting people into housing, putting people into hotels.

Kai: Initially there was a push to shelters and then a relatively quick recognition that having COVID in a shelter is not a perfect choice. So I think actually as they move people into hotels and people have individual rooms, that’s actually going to make our job much easier. We admit people all the time who are either in one of those single residence occupancy hotels or SROs or who even who live in a car or [inaudible 00:17:58] as long as there’s like one place we can go to, to find them that is relatively protected. So that continues to be true. And I actually think the work of the city of San Francisco actually, may help us serve those patients earlier than we have in the past.

Eric: And Todd, what about you from a rural perspective?

Todd: Eric, thank you. And I will just comment on the homeless population because, I’m delighted you mentioned that and Kai is doing great work. I think it’s important for hospice to think of how else can they help communities. And not to plug our good work, but I’m really proud of our nurse transitional care program, which is a nurse coach post-discharge hospital program that we’ve had for several years.

Todd: But we were asked by the city and the University of Kentucky to help with PUI patients that were homeless and didn’t have a place to go after the emergency rooms. So we actually have a hotel program. So we had to fit test our nurse and CNA and they actually visit the patients that are assigned a room at this particular hotel in our area. So that’s worked out really well. It’s just a little thing to do.

Todd: But I just wanted to point that out that hospices can do a lot of other things, particularly if they have, you don’t have to furlough everybody. There’s other duties that people can do. But the rural population, we’re in a very interesting area and I mentioned kind of seven to eight sites, all the way from Appalachian Mountain area, Southeastern Kentucky, through central Kentucky and then up into Northern Kentucky area.

Todd: All have a kind of city or townships or metro areas, but they’re essentially rural. We fortunately just had a pulse on that because of our hospice services. We’re well connected with the hospital systems and the home care agencies and such, and we’ve been connected for many years. So we kind of took the lead and how we can address it. We have centralized our leadership, as I mentioned kind of earlier, how we handled the CDC approach and even our supply inventory.

Todd: There was interesting in over the last few weeks, the anxiety in Southeastern Kentucky because they hadn’t had a case yet for a week or two, whereas everything was kind of unfortunately spreading in central Kentucky and certainly in Northern Kentucky, which is right bordering Cincinnati area in Ohio. So, we were dealing with different anxieties, different fears. But we again, continued to standardize our approaches.

Todd: And again, each week has shown a different set of what we want to require or to keep our employees safe. Everyone’s wearing mask now, that sort of thing. Two weeks ago we weren’t doing that. Now we’re switching into telehealth and of course, telehealth, we’ve dabbled with it in the mountain areas of Appalachia. So this is, as Kai says, within a week, everyone’s kind of boosting up and we’re starting to do that, which I think is going to be very helpful. We had a pretty successful chaplain, hospice chaplain telehealth program in the past, and it kind of fizzled out just because of bandwidth and all kinds of things I didn’t understand. So we’ve had some experience, which is really going to be helpful.

Eric: I’d imagine though that the ability to do video conferencing in rural areas is challenging.

Todd: It is for various reasons. It usually, I mentioned just, having wifi available, that sort of thing. We still have areas where cell phone reception is difficult. And so nurses are finding themselves at the pay phone that still exists and that sort of thing. And I suspect that in other rural areas of the United States there’s similar kinds of issues. But we’re going to hope for the best and then do the best. But again, I’m always impressed with particularly in Appalachian Mountain that’s always struggled with floods and all the ravages of the world. They really do really good work and they really take care of their people well. So that’s great.

Kai: I definitely, just to piggyback off something you said Todd, kind of the anxiety before people really know what they’re dealing with. I think obviously not a challenge that for our colleagues that are in areas that are completely overrun. But I’ve definitely found that, for me, I’m still a practicing ER doctor. I have been surprised by how much calmer I’ve been in the ER, than I am day to day trying to figure out this challenge for our clinicians and actually our clinicians to have noted that they have felt calmer when they were actually in a COVID positive patient room wearing full PPE than they were sitting around thinking about what it was going to be like.

Kai: And so, that’s been, part of our task is kind of managing that fear and worry and trying to meet it as much as we can emotionally. And then also with all of the adjuncts of, encouraging telemedicine, reducing visits, giving as much PPE out as we can, for every encounter, not just COVID positive encounters. But recognizing that a huge piece of this is kind of the internal messaging to one another about being held and being safe. And that has been, a moving target. But I think, I’ve been surprised at how much I’ve learned about how important that is kind of keep that flow of information going to patients and staff, to make sure that they feel like something is really happening.

Alex: I wonder if you could each say something about like, what your census is and how much of your census is COVID positive, and then maybe we can segue from there into what it’s like to care for COVID positive patients on hospice. What sort of symptoms, what is their trajectory? Are these patients who are dying of COVID or are they dying of something else and then that happen to be COVID positive? Maybe Kai, we’ll start with you.

Kai: So our census is 528 patients on hospice as of today. We have only one known COVID positive patient. But as you guys know, not necessarily easy to get most patients with symptoms tested for a variety of reasons, not least of which is that it doesn’t really change their management fundamentally. We do test our own patients for COVID, but pretty much only if they’re in a facility or if they’re in an area where it’s going to impact people around them. Otherwise they remain people under investigation and we just give guidance to caregivers. So we have another kind of, probably, I don’t want to misstate it, but I think about a half dozen people that are under investigation right now. And we’re beginning to get more COVID positive referrals, starting this week.

Alex: And Todd?

Todd: Yes. So we have a about 1,050 patients, a little over 1,000 patients. We’ve cared for, if I recall five COVID positive patients. We currently have I think three on service right now. Two are in nursing homes and one is at home. And like Kai’s experience, we have several, I hate the term PUI, but we have several patients that are PUI right now.

Alex: PUI, it sounds like a criminal investigations.

Todd: It does, and you know what PPE sounds, it’s just, we just throw these around but it is easier to say…and what does investigation mean? Because we have many people that we think may have COVID, but we can’t get them tested.

Alex: Right. We can’t do the investigation. We’d like to investigate if we were able to investigate.

Kai: People who will remain suspicious [laughter].

Alex: Right.

Todd: We have other services, palliative service lines and stuff that we have in the hospital setting and in the nursing home. And we’ve been involved with consultation of those patients.

Alex: And Kai, what’s it like to care for people who are under investigation or people were dying of COVID?

Kai: I mean, I think overwhelmingly our referrals actually have not been primarily for COVID. They’ve been someone who would, which is to me raises an interesting question about how this will impact hospice over time. But they’ve been people who would have been referred to hospice probably a few months from now, because they were end stage Alzheimer’s beginning to lose weight, beginning to kind of have the things that would allow them to meet the hospice criteria.

Kai: But this was kind of the thing that pushed their providers, for a variety of reasons. Sometimes I think because their providers were aware that they were no longer going to be able to make visits, sometimes because the nursing homes want to limit the number of people coming into their facilities. So they’re like, “Well, hospice income and just that hospice and send one nurse to see everybody.”

Kai: And so, overall they’ve actually been relatively mild. The known COVID positive patient we have now has been relative amount. We did have a patient on service who died of COVID, a few weeks ago. And that really looked like respiratory distress, aspiration. It kind of looked a way that our patients look when they have a pneumonia, they have a end stage COPD. Not thankfully kind of all within our wheelhouse of how we manage these patients at home heavy on opioid / ativan.

Kai: We haven’t found, I mean, I think the two management things that have come to mind recently are, I’m thinking through the use of nebulizers anywhere. Right now our policy, obviously no one who’s known COVID positive or a person under investigation, but the thing that came to light yesterday was should anyone in any nursing facility be using a nebulizer? We know we have asymptomatic COVID positive patients. Is that just asking for aerosolization of that?

Kai: And then as a piggyback to that, should any person period be using nebulizers right now? Nebs in a young healthy asthmatic, easily, you can trade it out for five pumps of an inhaler with a spacer. That’s not true for our end stage COPD patients. And so it’s a really serious consideration. Do we balance the symptom management that benefit that people will get from routine neb use with the potential public health, the risk behind it? And we haven’t kind of fully arrived at a conclusion about that, but I think we’re leaning towards trying to reduce that neb use even in people with no concerning symptoms of COVID out of a worry that we could be kind of sparking a flame into a brush.

Alex: And I also heard that for inhalers that, it started with like toilet paper where it’s getting harder to find those inhalers.

Kai: I feel like you bring anything up and all of a sudden people are like, you know what I need, I need all the Tylenol in the world now. So I think we’re trying to figure out creative ways to address that. I think our standard approach, at least in our hospice was, if you come in on, Advair and Spiriva, we’re going to schedule you two four-hour nebs and let me tell you about why that’s better than your Advair and Spiriva because you actually can’t take a deep enough breath to get that into your alveoli anyway. The neb will do that for you. Now we’re having to kind of rethink that.

Alex: And what are you doing to help protect the caregivers?

Kai: Great question. So I suspect that no healthcare organization has enough PPE to give out, a huge amount. What we are doing in our program is we have a ton of volunteers who are no longer doing in person visits, who are making masks, who are making things like that. And so we’re helping to provide those to facilities and to patient families. That’s kind of been the main thing that we can do for people. But obviously that’s not ideal. We wish that we had enough of a supply that we could give people what they really needed. But at a minim we’re giving people masks and gloves.

Alex: Todd, how about you?

Todd: I’ll add to Kai’s comment and I’m listening to her and we’re experiencing the exact same issues with our COVID positive patients. More of our focus has been awaiting the surge in this kind of onslaught, which again, all the modeling as we’re all kind of probably looking at different models is every day it seems to be better. I mean, that’s something to pray about I guess. But we’re hoping that we won’t have this onslaught.

Todd: So our preparation has been everything from pharmacies. As Kai already mentioned, we own our own pharmacies. So we regularly met as a task force with our pharmacy to manage our availability of drugs, particularly opioids and benzodiazepines. If, again, if we need to handle this sort of surge. We are dialoguing better with our hospitals, what kinds of help they need if there is this crisis that we’ve seen in other places in our country, we hope not of course, but there is, how can our hospice be of help, particularly for hospital to home transitions, for COVID positive patients. So we’ve been prepping for that. So we’ve done, probably much more preparedness, which of course is a good thing. Then we have had to do direct care to COVID positive patients so far.

Kai: And it’s been interesting, at least for me, every other disaster that we’ve had kind of most recently the fires up in Napa and Sonoma, you don’t get a warning, you don’t get a heads up. And so it’s this very strange space to be in where with each passing week when there isn’t this tsunami, you actually have the time. And then there’s also this huge, at least for me, and I think for a lot of people kind of sense of survivor’s guilt.

Kai: You’re looking at what’s happening in other areas and thinking, they didn’t have the luxury. If we’d had our surgery patients, a month ago, we would have had nowhere near the PPE that we needed. We would have had nowhere near the preparation. And so, I definitely feel like kind of constantly at the back of my mind is so much sadness and empathy for our colleagues. And then when you read some of their first person accounts, they’re still feeling survivor’s guilt.

Kai: Like the most recent article I read was from an ICU doctor in a Brooklyn hospital who’s like, “It’s not as bad as it would be for that guy.” And you’re like, “God, how does every physician in the world feel guilty and strange and sad and weird even when they are literally at the very front of this?” But that’s been definitely a big part of my kind of internal dialogue in all of this. It’s like this feels like a huge luxury right now to have the time.

Todd: And to add to the emotion, it’s fascinating to me, and I’ve talked to many hospice colleagues across the country, and it’s a very interesting time even for everybody, but particularly hospices because, our philosophy and our focus is obviously caring for people at the end of their life, for comfort and alleviating suffering and all those things you always hear and hopefully we always do.

Todd: Whereas the conversation in healthcare is, completely about saving the most lives. I mean, we’re in this pandemic. Just look at pandemic science that I’ve learned a lot about. You look at pandemic ethics that I’ve learned a lot about. And it’s not a dualistic approach that we’re caring for the dying and they’re trying to save everybody. We save people in different ways I hope, metaphorically.

Todd: So it really is prudent for hospices to try to figure out how we fit into this. And I think we fit in very well would be my answer. And I think hospitals need us and all those hot zones need the hospice service, for various things. I’ve already given some examples. But certainly, it is a little bit of a struggle for hospices to kind of be challenged with our philosophical approach when everyone else is trying to save as many lives. Thank goodness. Save as many lives as they can.

Eric: The utilitarian argument of save most lives is really utilitarian argument for hospice of comfort for the most.

Todd: I agree. Exactly.

Kai: Well, that said, I also feel like there have been moments when I’ve heard the national discussion around like, we’re really going to have to take into consideration, will a person benefit? Will they, kind of get back to what they’re hoping for in terms of, the way that they see their lives? We have to consider all of those things before we intubate someone. And there’s a part of me that feels like, well, of course. Of course you should consider all of those things every time you intubate a person.

Kai: And it feels like you wouldn’t, I know that the decisions that are being made are much more severe than that. There’s kind of absolute resource allocation decisions that are being made under tremendous duress and trauma. And at the same time, what this has brought to light, I think is a slightly more rational approach to offering aggressive life-prolonging measures to people who may not get what they’re hoping from them. And if that became a more robust part of the national conversation, that wouldn’t be a bad thing.

Alex: Well, talking about ethics. Did either of your organizations struggle with the question of whether or not to accept COVID positive patients since some hospices are not accepting them?

Kai: So I’ll tell you that at our organization it was never really a question of if, but a question of when. Because when we didn’t have enough face shields to safely allow our nurses out in the field, when we didn’t have any type of protocol for how to admit hospice patients, when we didn’t have, we now have a COVID task force of nurses who have volunteered to kind of do these initial visits, who are experts in donning and doffing a 17 and 21 step process.

Kai: When we didn’t have those things, it felt a little bit reckless to say, sure, let’s just do this. And so we took a little bit of time, and in order to have those things in place. And I think that for me was always kind of at the back of my mind was, this is what we do. Fear, uncertainty, grief, vulnerability. This is where we are supposed to be for our communities, for our patients. That was never in question. The question for me along the way has been, do we have the kind of operational pieces ironed out to make sure that our staff who are fundamental and essential to our ability to do this feels safe and supported enough to be able to do their work well?

Alex: Todd, how about you?

Todd: Just to add to the ethics, this concept of as health care workers and providers, is it our duty and responsibility to care for the sick? My answer is yes, but, your organization and in this case, our hospice, needs to balance that duty and responsibility with providing, safety to the clinician, providing safety to the clinicians family, accommodation, which is all this what we’ve been talking about, decreasing in person visits and accommodating other things, incentivizing with pay and that sort of thing.

Todd: So, we never questioned taking care of COVID. It was the exact same answer Kai gave, which is, how are we going do it and when are we going to do it? And so everything’s been in preparation for that. I mean, it’s been quite an exercise. Fascinating exercise. I’ve learned so much and hopefully contributed, but little things like do we need in our inpatient units to convert rooms to negative air pressure rooms.

Todd: And actually it’s not a really complicated thing to do. I never knew that until now to be challenged with that. But all those kinds of little technical things all the way to, again, how are we going to keep our workforce safe, has been really important to us.

Eric: I have one last technical question. How do you think about, since hospice is also about prognostic eligibility, how does COVID fit into that, given that we’re still trying to figure out like what does the prognosis look like? So if somebody has COVID, multiple problems, and maybe certain have some, like when would you consider somebody hospice eligible?

Kai: So as I said, kind of a lot of our patients have actually been hospice eligible and then and are now COVID positive. So that’s one bucket. I think the separate group is, when I think about COVID being the hospice admitting diagnosis, I think of it the same way I think about pneumonia. Not every pneumonia is going to be appropriate for hospice admission. But most clinicians can tell you if they think that this pneumonia might be this person’s terminal event.

Kai: And so we use those same guidelines that if someone is showing signs of kind of rapid decline, worse day over day, the same types of things that we would expect to see in a pneumonia, that’s when we would admit them to hospice for COVID. But the mortality, kind of unclear. If the person was already hospice eligible beforehand will COVID potentially their terminal event? Sure. But for people who are otherwise would not be considered for hospice, I really think of it as like a proof of clinical decline.

Todd: I agree with that.

Eric: Any other lessons learned either from your organization or just being on these national calls that you’d like to share?

Kai: I mean, I think the thing that Rose really brought home to me was to recognize that when, the importance of maintaining your staff’s sense of their own safety, their ability to do the work well, and that if you have people that are extremely resistant, angry, skeptical, the approach needs to be to spend more time with them. I think it’s very tempting to be like, this person doesn’t understand it or be dismissive and like that person needs one on one conversations with their manager. That’s what they actually need. And that’s been a remarkably effective strategy for kind of managing some of the fear and anxiety.

Todd: And I’ll just say, negatively, it’s fascinating how all truism is challenged by resource allocation in real life. We’ve always talked hypothetically about that. But on a positive note, what I continue to hear is how much we’re learning from this. We all hope there’s less deaths in all that. Even hospice is definitely hope that. But the telemedicine technology boost the ability for us to come together, almost in military format quickly to accomplish good things, I think is something we all are going to value deeply in the future reminiscing back on this time.

Eric: Just thinking back to the days that we didn’t use telemedicine, which was like a month ago. It’s just-

Alex: Right.

Kai: True.

Eric: It’s so long ago.

Alex: The silver lining maybe there’ll be. There’ll be some rapid changes, some rapid changes are taking place, have taken place that will endure after this epidemic ends, when it ends, not if, when it ends.

Kai: This is something that I’ve said several times, is that we’re really creating the groundwork for what will happen when all of this is over. That it may feel painful and terrible and onerous right now, but we’re actually creating a structure for a new way of doing this work that will continue to benefit us when this is all over. But it is really hard to have perspective when you’re right in the middle of it.

Todd: Yes.

Eric: Well, I want to thank both of you for joining us today. I think what we’re trying to do here with our podcast is give people’s perspectives. And I appreciated both of your perspectives. But before we leave, Alex, do you want to give us some more of that song?

Alex: Okay, a little more. (singing).

Kai: That was great, Alex.

Todd: That’s beautiful.

Eric: It is kind of hard not to cry when you listen to the lyrics of that song.

Kai: I know.

Alex: Thanks again, Todd for suggesting. Todd, thank you so much for joining us.

Todd: Pleasure. Pleasure.

Alex: Really appreciate it. Kai, great to have you back on. Good to see you.

Eric: I want to thank everybody for joining us today. And thank you Archstone Foundation for your support. We will continue with these COVID podcasts. If you have any other suggestions for them, please tweet either me or Alex or email us. Thank you very much. Goodbye everybody.

Alex: Thanks everybody. Bye.

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