Rehab and Death in Skilled Nursing Facilities: Sarguni Singh, Christian Furman, and Lynn Flint

Eric 00:00

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:03

This is Alex Smith.

Eric 00:04

And Alex, who do we have with us today?

Alex 00:06

Today, we’re delighted to welcome back Sarguni Singh, who’s a hospitalist researcher at the University of Colorado. And you can listen to her on our prior podcast on palliative care and rehab. I last saw Sarguni and Banff. I think we were painting together in painting class.

Sarguni 00:24

We were. Yeah.

Alex 00:25

That’s how palliative care researchers roll. Sagruni, welcome back to GeriPal.

Sarguni 00:29

Thanks for having me.

Alex 00:31

And we’re delighted to welcome Christian Furman, who’s a geriatrician and palliative care doc at the University of Louisville Christian. Welcome to GeriPal.

Christian 00:40

Yes, thank you so much.

Alex 00:42

And we’re delighted to welcome back Lynn Flint, who’s been on many times as a guest. As a host. As a guest host. She is a palliative care doc and directs UCSF’s GeriPal Fellowship. Lynn, welcome back to GeriPal.

Lynn 00:55

Thanks for having me.

Eric 00:56

So we’re going to be talking about rehab and death. This is kind of a playoff. A past podcast we did on rehab to death, talking about skilled nursing facilities, hospices and hospitals. These transitions all between the two, the incentives that may misalign with people’s goals. But before we do that, I think we have a song request. Lynn, do you have a song request?

Lynn 01:22

I have a favorite singer.

Eric 01:24

Who could that be? Lynn is a Swiftie.

Lynn 01:29

I’m a Swiftie. Nothing from the new album was appropriate for today. [laughter]

Eric 01:33

Is that because you don’t like the new album?

Lynn 01:36

We will do some supplementary materials about that. However, I like a very direct metaphor for the GeriPal podcast. So I thought we could do out of the woods because I think it’s a good metaphor for when you go from the hospital to the sniff. It’s like, okay, are we out of the woods here? And it’s never totally clear. And that’s, you know, Taylor’s not talking about the hospital. She’s talking about a relationship. But close enough.

Alex 02:09

All right. Great choice. I had a lot of fun with this. For the prerecorded version, you’ll hear I went a little crazy.

Lynn 02:17

Great.

Alex 02:18

This is a lot of fun. So here’s. Here’s the live version for YouTube.

Alex 02:34

(singing)

Lynn 03:42

Awesome.

Sarguni 03:43

That was so good.

Lynn 03:44

What an interpretation.

Alex 03:47

Well, I saw there was a version of Taylor Swift doing it live on solo piano at the Grammy Museum. She was incredible. I mean, she is an incredible artist. Hit every note perfectly, didn’t make a single mistake in the piano. It was an amazing performance, very emotional. And she tells a little story about it, too. Check it out.

Eric 04:09

We’ll put a link. Well, this podcast is not going to be talking about Taylor Swift.

Lynn 04:13

I’m keeping my mouth shut.

Alex 04:15

Yeah.

Eric 04:16

Despite Lynn’s. So we’re going to be talking about rehab and death. But before we do that, Lynn, you wrote a paper, New England Journal. Jama. New England Journal, one of those two on rehab to death. We’ve had you on a podcast, too. We’ll have a link to that on our show. Notes. But can you just briefly describe what is rehab to death? Would you be willing to do that?

Lynn 04:42

Absolutely. Alex and I worked on that paper together. It came from when I worked in a short stay SNF as a palliative care doctor, didn’t know much about nursing homes. And I saw all around me people with palliative care needs coming out of the hospital really sick, thinking they were out of the woods, going to get better, and realizing they maybe weren’t going to get better, maybe having something happen that put them back in the hospital.

And I then came to be an inpatient palliative care consult attending. And I saw those people on the other end coming back. And so I got really interested in that cycle and what are the policy drivers and clinical drivers that lead to that happening. And so that’s what that original paper was about.

Eric 05:31

I mean, it feels like we see this cycle a lot. People being discharged to rehab, they come back to the hospital. This happens multiple times. Is this common Christian of Sarguni?

Christian 05:43

Yes. I mean, I used to see this a lot at the VA when I would discharge patients to the nursing home. With hospice, you know, actually at this time, it was. We knew they were dying and they still came back, you know, because of the payment systems and the way our system works, that when they get to the nursing home, they say, okay, you want to die at the nursing home?

The Medicare Hospice benefit, you have to pay for room and board, or you can stay here free and use your skilled Medicare benefit. And of course, people choose free and then they don’t get hospice, and then they get worse because they’re dying and they get sent back to the hospital. And it’s this vicious, vicious cycle. And so trying to break that cycle is the purpose of all this.

Sarguni 06:21

Yeah, yeah, it feels very common. I primarily work on our inpatient oncology service as a hospitalist and also our ACE service. So taking care of generally older adults with multiple chronic conditions and cancer. And some of the studies that we looked at using like SEER Medicare, you know, estimates around 20% of patients use the SNF benefit with readmission rates in the high 20%, 30%.

But I sometimes think about the surprise question, you know, would you be surprised if someone passes away within a timeframe? And sometimes I, you know, my Cosmos colleagues and I are like, nobody would be surprised if this patient came back from the snf, given how sick they are when we’re sending them there. So I feel like it’s quite common.

Eric 07:03

And then just for my own clarification, when we say snf, are we talking about nursing home? What are we talking about when we say snf? Those skilled nursing facilities.

Christian 07:14

So the nursing home is just two sections to. One is the skilled part and one is a long term part. You know, people can just live at the nursing home, but the snf, this skilled nursing facility, is really, it’s a benefit. This is a policy issue. It’s what Medicare pays for. And Medicare pays for this skilled nursing benefit where you have to be skilled and they pay for a hundred days or until you meet your maximum rehab potential. So sometimes that’s only like a week or two.

They pay and they pay 100% at the beginning, but they only pay 100% for 21 days. And to be skilled, usually people think of skilled as physical therapy, occupational therapy, speech therapy. But what we figured out in writing this paper and talking to our colleagues that have done it other places you can skill people for end of life care. I mean, end of life care is complicated. Nursing care is skilled nursing care. So you can skill people for feeding tubes or IV antibiotics or IV fluids, but you can also skill them for end of life care. And that’s what we’re talking about is like, hey, there’s a way to do this. And, and you can still use your snf, the skill Medicare benefit and, and, and die in patients.

Sarguni 08:21

Yeah, essentially it’s a bridge. It’s a short term bridge to have people go back into the community, whether they were living at home or in an assisted living facility for people who need continued care, whether it’s rehabilitation care, nursing care for a period of time. And so that’s the intent when we send them out of the hospital, is that you’ll be there for a short while and then hopefully get back to your usual routine at home.

Eric 08:43

Yeah. And a skilled nursing facility, they, they do skilled nursing care. So people with skilled needs, they also do long term care and then they also do hospice care.

Lynn 08:54

Well, there’s the SNF part, which is the, which is the Medicare unit, which is like what we call rehab when we send people out of the hospital. Then there’s the nursing home part where people might live for long term care. They’re paying for that out of pocket or maybe Medicaid, for example. And hospice can come in, an outside agency can come in and help support those patients while they’re living in the nursing home. But traditionally, hospice does not concurrently care for people who are in the SNF part in the rehab, short stay part of the nursing home.

Eric 09:33

And why not?

Lynn 09:34

People are pretty afraid of double dipping.

Christian 09:36

That’s the crux of this home.

Eric 09:38

What is the issue there?

Christian 09:39

That’s the crux of it.

Eric 09:40

What’s the crux, Christian?

Christian 09:42

The Medicare hospice benefit does not include room and board at the nursing home. So patients have to choose, you know, Medicare pays for rehab and Medicare pays for hospice. They don’t pay for both at the same time. And so the poor patients are having to choose, you know, and the families are having to choose when they get to the nursing home, pay us.

And what happens is, since the Medicare hospice benefit does not include room and board, the families when they get there, if, you know, I ordered hospice, they were supposed to go to the nursing home with hospice, die at the nursing home, and then they show up back in the emergency room short of breath and they die in the emergency room. And it’s because they never got hospice. And they didn’t get hospice because the nursing home says, pay us a hundred dollars a day, a thousand, however much it is, for room and board, or you can stay here free and use your skilled Medicare benefit.

Eric 10:23

Yeah, so I can.

Christian 10:24

And so we figured out the workaround and.

Eric 10:26

Yeah, well, before we get to the workaround. So I’m just gonna make sure that I get this straight. So Medicare will pay for skilled nursing facility for things like rehab, skilled needs fully for 20 days, 21 and longer. There’s going to be a co pay up to 100 days. But they won’t pay for concurrent hospice care during that time and hospice is not a skilled need, so it’s. They can’t do that. And Medicare does not pay for long term care.

They will pay for hospice. So you have to figure out how you’re going to pay for that long term care here, Lynn. Medicaid, if you have Medicaid eligible. Um, so if you don’t make a lot of money, don’t have a lot of assets, you can get Medicaid, they’ll pay for long term care, and then you can get concurrent hospice care while they’re getting room and board through Medicaid. Yeah, but from a skilled nursing facility perspective.

So now we’re talking about a different point of view. The incentive, it feels like from their perspective is they don’t like those Medicaid or long term care rates which are significantly lower probably around here. $300 a day versus like $600 a day for skilled nursing facility, rehab or other skilled needs. Is that right?

Sarguni 11:44

That’s correct, yeah.

Christian 11:46

So then that’s a mess.

Eric 11:47

So there is an incentive. Well, let me get this. So what’s the incentive of the hospital?

Sarguni 11:53

The incentive to the hospital is to decrease the length of stay for a patient. So to send patients to the SNF as soon as they’re ready to go.

Eric 12:01

All right, so just get them to rehab. It’s the quickest thing. What the incentive for the skilled nursing facility is.

Sarguni 12:07

What is to Medicare? Yeah, have the patient on the Medicare benefit for as long as possible from a financial standpoint.

Eric 12:16

And that’s that skilled nursing rehab. Benefit where 20 days is fully covered. More than that, there’s a co pay up until 100 days.

Alex 12:26

Is that right?

Lynn 12:27

Have them on the SNF benefit for as long as possible and then not be on anything other than the SNF benefit. Get them out of as sure as possible, Right? Yeah.

Eric 12:38

How about from a patient family perspective? What’s the incentive there?

Christian 12:43

They just want their family member in a good comfortable place and die comfortably and not be all these, these transitions of care they do not want or.

Lynn 12:51

I would even also say they’re getting out of the hospital fast, they’re not walking well anymore. Yeah. The doctor told me I’m going to go to rehab and get stronger.

Eric 13:01

Yeah. So their goals may be I want to get stronger, I want to get better, I want to get all the care you got.

Sarguni 13:07

Yeah, yeah. And I think a SNF stay also can relieve caregiver burden significantly. You know, just even a week or two weeks can be so meaningful for family members who are struggling to care for the patient at home. So it can feel like a reprieve as well.

Lynn 13:24

Yeah.

Alex 13:24

Oh, go ahead, Christian.

Christian 13:26

I think they just want honesty too, you know, if they’re not going to get better and they are actually dying, I think they would like somebody to tell them that. Go ahead, Alex. What are you going to.

Alex 13:34

Yeah, that’s what I was going to say. And that if you, if the hospital clinicians were honest with the patients about their chances of recovery, they might be make different choices. On the other hand, like for a lot of them, it’s not all the way, one way or the other. Like you’re going to go to rehab to get stronger, as if you’re absolutely going to get stronger is the interpretation the patient and family take away or you’re not going to get stronger in rehab.

We don’t know that too. There are some patients who surprise us, right. Who we think, oh boy, I think they’re dying. I’m worried about sending them to rehab, but boy, they really want to give it a shot. And maybe, you know, there is a world in which maybe that happens. And I hope that does happen. Right. Like we hope that they’re able to achieve that goal.

Sarguni 14:19

And yeah, there’s so much hope. Yeah, there’s so much hope in this transition. I don’t mean to interject, but I, you know, because I, I talk to patients in the hospital all the time and I try to do what you, what you said, Alex, is, is lay out what it looks like, the concerns I have, what the data shows, and still, you know, you then hear stories about times when people were told they wouldn’t survive this hospital stay or this chemo wouldn’t work.

And then they, they just want to try and that’s really important to them. And so it’s tricky. And then you add on the fact that if they don’t choose the SNF benefit and they want to need to stay in a nursing home, they have to pay room and board for them. It’s kind of a no brainer. One, this is the path they want to go down and then it saves them money. So we definitely need to improve our counseling for when patients go to snf. But I think there’s just a lot of hope and people oftentimes want to see what their bodies can do.

And the other thing I will say is there’s a lot of limitations in the Medicare hospice benefit that people just are not willing to accept, like not being able to See their cancer doctors or not being able to get a blood transfusion or come back to the hospital if they get sicker. And so these things compound into kind of the expectations patients have when they go to the SNF from the hospital setting.

Christian 15:33

And I think the other thing they want is honesty about just the whole. And education about the whole process is. I had a neighbor, this is my neighbor, a friend of mine. And she really wanted her mom. Her mom would have died to go to the nursing home and die at the nursing home with hospice. The nursing home never offered her hospice. She was willing to pay room and board, but, you know, no. So that happened so much.

Eric 15:53

And that’s because the nursing home will make more money if they admit her under skilled.

Christian 16:00

Yes. And they did not want. They didn’t even offer hospice. And so hospice really, it depends on the nursing home. Because I think you said, you know, there’s different sections of the nursing home. One is the hospice part. Some nursing homes do not know how to do hospice. And this poor neighbor friend of mine’s mom did not have good end of life care because she was not in a facility that could really provide good palliative care. But hospice could have, if they would have consulted hospice. So she was very, very mad about.

Eric 16:25

Yeah, we’re seeing that a lot more. Where nursing homes will not take people under hospice. Where nursing homes will say, oh, we, we do our own comfort care here, which is really just skilled nursing with not really doing rehab, but billing for. For that level of care where they’re not providing an interprofessional expert team who can manage people at the end of life, that hospice care. I’m hearing from hospices too, like they’re seeing this happen more and more where the goals are very much aligned with hospice, but hospice can’t go into that nursing home.

Sarguni 17:04

I think the new payment model might be influencing that to a degree. Where nursing home SNFs in particular aren’t incentivized by the number of rehab hours they deliver anymore. Instead, it’s based on patient complexity and comorbidity. So they can get reimbursement for taking care of a really sick person under the SNF Medicare benefit. And they don’t have to provide rehab to the same. And by rehab, I mean physical therapy, occupational therapy, or speech therapy to the same degree that they had to before this payment model switched.

Eric 17:34

This payment model is the patient driven payment model. Pdpm?

Lynn 17:40

Yep.

Eric 17:40

Pdpm?

Sarguni 17:41

Yeah.

Christian 17:42

Age driven payment model.

Eric 17:44

Yeah.

Christian 17:44

And that payment model says they don’t have to make Progress. Right. They don’t have to improve. They just used to be they had to improve. If they didn’t improve, then rehab was over, but now they can just be. So, you know, you understand a little bit better. But they didn’t have to be maintained.

Sarguni 17:56

Right.

Christian 17:57

I think is.

Sarguni 17:57

Yeah.

Lynn 17:58

And, and they have to be complex. They have to be complex. A lot of the nursing homes have like people whose job it is to make sure we’re eking out all the complexity.

Eric 18:09

Yeah. So if you had a choice between a oral opioid or an IV opioid, you can maybe increase complexity. Even though you can swallow things by thinking about IVs instead. Or you know, talk about, you know, that, that skilled wound care for somebody maybe just doesn’t have a lot of.

Lynn 18:31

Yeah. Or you change the doses regularly, that kind of thing.

Eric 18:35

So you all, you wrote a great article in jags, Rehab and death Improving End of Life Care for Medicare Skilled Nursing Facility beneficiaries. I wonder if you can like put this in context. Cause you did a good kind of summary of. About a patient. I think it was a hypothetical patient.

Lynn 18:50

Yes.

Eric 18:50

Mr. Z, could you just kind of give us a brief overview of who was this Mr. Z? Because I think this puts it all into context.

Lynn 18:57

Sure. And I think like a few different, several different clinical scenarios came up and there’s a lot of different ways that the incentives push things maybe in the wrong direction in a lot of different clinical scenarios. So this is just one example. A per 80 something year old person who’s got multiple medical problems, predominantly congestive heart failure, gets hospitalized for heart failure, is there at the hospital for a week or so, and during that time gets treated for heart failure, but also is kind of in bed for the entire week, can’t really walk well at the end of the week and so gets discharged to SNF, ends up being at the SNF for rehab.

Because of course this person came from home, wants to get stronger, then gets sick again, gets another heart failure exacerbation, goes back to the hospital, comes back to snf because now he sort of belongs to the SNF. Happens a couple times. And then, you know, the last time this person lands back at the hospital, he says, you know, I don’t really, it’s not in me anymore. I don’t really want to do rehab anymore. And the question is, well, okay, what is the, what do we do? How do we line up all of this person’s benefits and services to help support him now? Yeah.

Eric 20:16

And what I’m hearing Sargini, is this right? So now we’re in this tough bind where there’s not a payer source for long term care for him unless he’s Medicaid. Hospital still wants to get him out quickly. You know, you’re thinking about home, but if home isn’t an option, where do we go from here? Am I hearing that correct?

Sarguni 20:38

Yeah, definitely. I think, I think during those repeated transitions, I imagine a hospitalist trying to approach Mr. Z to be like, this is your second readmission. And Mr. Z kind of declining hospice for the reasons we mentioned it might not be aligned with his goals. There’s limitations in the benefit.

Eric 20:55

May want to come back to the hospital, may still want, you know, these interventions.

Lynn 21:01

Yeah.

Sarguni 21:01

And a lot of people I, I hear are like, want to come back if it’s like a quick fish, you know, if it’s like a UTI, some antibiotics that turns around in 48 hours, which is, you know, I understand, but sometimes we can’t, we can’t really predict what’s a quick fix, what versus what’s not. But then at the end here, you know, his values and goals finally align with hospice. And we would essentially say we have to either see if we could safely send you home with enough social caregiving support if you have that.

And if not, then you would need to go to a nursing home and pay for room and board out of pocket. And whether that is spending down his savings and then filling out a long term Medicaid application. Rarely people have long term care insurance. So that might kick in. But that’s kind of what we would be talking about from the hospital standpoint at that juncture at the end.

Eric 21:51

And that nursing home may not want them because they’ll get paid at a significantly less rate than they would if that bed was occupied by somebody with getting skilled needs. Is that right, Christian?

Christian 22:01

Yeah. And the thing is that like we came up with a solution, you know, and I think that’s what this paper was just really. And really there’s the workaround. Like we have a workaround now that what we’re doing now is like. But you have to really understand the system to make it work. And we, this paper was a way to just to tell everybody our workaround and also to make it.

Eric 22:22

Okay, let’s talk about, let’s talk about the solutions because the first one is actually not a workaround. It felt more like we want some more data. And you mentioned something called the Government Accountability Office. Is that still there? Well, let’s not get into that. Gao, what was the very first recommendation. Why is it gao, Government Accountability Office.

Sarguni 22:45

The GAO is essentially a nonpartisan governmental entity that provides reports to members of Congress. And we want more information about the use of the Medicare SNF benefit in the last hundred days of life for Medicare beneficiaries. We just don’t have up to date data on who is using the benefit, what are their characteristics? And that’s very important information for us to know as we counsel patients in the hospital. And then there’s all these new hospital at home models and SNF at home models. And so that information, we think, is vital to better understand who is currently using the benefit in 2025 and what are their outcomes.

Lynn 23:26

And there hasn’t been a report like this in many years.

Sarguni 23:29

Yeah, yeah, yeah.

Christian 23:30

And the whole point of the SNF benefit is really rehab, physical therapy, occupational therapy, speech therapy. But what we think is happening is they’re all dying. And that’s not the purpose of the benefit. It’s for rehab. Really. It was really meant to be rehab, but we’re trying to make it do other things. So let’s just be honest about it, you know, instead of just trying to do this workaround. So that’s what I think the data would help.

Eric 23:53

So number one is data. Number two is this. What’s the workaround?

Christian 24:00

Well, the workaround that we’re doing now is we’re skilling people for end of life care. And we did talk to CMS and got official approval. And a lot of nursing homes are doing this. Is you, you know, you are. It’s complicated nursing care, and we are skilling people for complicated nursing care. So they’re at the nursing home using their skilled Medicare benefit. But for end of life care, you’re not torturing these people, making them walk up and down the hall and do rehab and physical therapy when they’re dying.

Alex 24:28

Go ahead. No, yeah, yeah, keep going.

Eric 24:30

Well, is it complicated end of life care? Because as I heard from you, these end of, like nursing homes have a hundred percent turnover rate in their nursing staff. Their training and skill set in end of life care is not hospice. I actually asked Carl Steinberg, an expert around nursing home care. He’s part of Cal TCM here in California and nationally involved kind of how he thinks about this.

And I think his biggest concern is like, even when we think about like this PDPM kind of workaround, is that these individuals, these nursing homes, they get paid for skilled neet. Right? Like, they would certainly take this as a way to get $600 versus $300 a day and provide the exact same care as they would have at $300 a day. Cause they don’t have the training or skills like hospice does. And the interprofessional team, they’re just billing more for less. Thoughts on that?

Christian 25:35

So part of. Yeah, part of what our model was is that you’d have to have these quality measures in place. You’d have to show that you can have 24 hour access to IV, you know, opioids. You to have a chaplain, a social worker, interdisciplinary team, or else you cannot get this benefit. But I thought that’s how we started.

Eric 25:52

Wait, wait, that’s the third one, Right, that. The second one is the workaround under pdpm, which does not require any of that.

Sarguni 26:01

Right, that.

Christian 26:02

Well, and the second one is a hybrid of having palliative care and, and skilled care at the same time. Yeah, I mean, there’s, you know, maybe sargina. You can kind of show there’s like three different pathways that we, you know, kind of put out there as a model.

Alex 26:16

Yeah, yeah, it was a great figure.

Christian 26:18

Yeah.

Alex 26:19

Check out the figure in jags.

Eric 26:20

We’ll have a link on our show notes.

Sarguni 26:22

That was Lynn’s creativity and artwork and making it happen.

Christian 26:26

Yeah.

Sarguni 26:26

I think our second recommendation was to figure out ways within the existing payment model to encourage nursing homes to bill for palliative care principles that they are delivering. And so that was kind of the main. A recommendation for the second aim.

Eric 26:42

Do you think they can deliver that?

Alex 26:44

Yeah, this is the TLDR version of what Eric said earlier is, well, okay, the nursing home can bill for this skilled palliative care need, but are they delivering skilled palliative care?

Lynn 26:59

Good question.

Eric 27:00

I’ll be honest. In my, my, my recent experience with it, having had a nursing home that refused to take somebody under hospice care, but said, oh, we can do palliative care, he will be under comfort care, which is not a thing. It’s skilled. And it was terrible. It was the. And the hospice that this person could have been in was amazing. And it was a absolute failure system. And it was just about a money grab because they would make double the amount.

Christian 27:34

And so, you know, there’s definitely the state, there’s reviewers that review these nursing homes for their, you know, to make sure they’re up to snuff for their guidelines. So my sense is that if we’re saying, okay, you’re gonna, we’re gonna provide this, that yes, you can use this skilled Medicare benefit for end of life care, then the surveyors have to know These are their criteria for end of life care. You have to have a doctor, nurse, chaplain, social worker. You have to have an emergency kit that has morphine in it.

You know, you have to have the conversations and all the details. And really the same holding the same standards that hospice is held to. Right. That you have to have these to be able to have Medicare pay for hospice, you have to meet these criteria for Medicare to pay for the skilled rehab. You have to meet this criteria for end of life care. So, yeah, but right now it’s nothing. And so I think if we actually are being honest about it and like, okay, this is. We’re letting this happen, then these are the criteria that you have to meet. And maybe if you can’t do it, then you have to let hospice in and let them do it.

And like in Louisville, we have certain nursing homes that we know do a good job and certain ones don’t for end of life care. And we make sure they go to.

Sarguni 28:35

Those certain nursing homes.

Christian 28:37

And those nursing homes have palliative care doctors that come and hospice doctors.

Eric 28:40

It’s interesting. What we’re seeing is people want them on comfort care, which is skilled care for 20 days. Why 20 days? Why 20 days?

Lynn 28:49

Can I just also point out, I think another piece of this is that policy change is hard. You know, certain things have to be. You have to have a policy window to make a major CMS policy change. I’m not going to comment on whether we’re in that window or not at this minute in time. And we were talking about this as a way of how do we use the current existing policy to improve what we think is already happening. And so I think that was a big part of our initial discussion here, was like, okay, well, we have now a way to build on complexity for snf. What are the things we need to add in there to. To make it so that decent end of life care can be given under that?

Eric 29:37

What do you think the things to add into there is?

Christian 29:40

Well, all the things, criteria, criteria. Like you have to have. So it’s like access to opioids in house, not that the pharmacy’s, you know, half an hour away. So you have to have an emergency kit that has like the comfort pack that has all the end of life meds on hand. Um, and then you have to have a doctor, nurse, chaplain, social worker that’s trained in palliative care. And that’s the big things. Maybe there’s. I can’t, you know, I don’t know.

Eric 30:05

Yeah. Is there anything else that you’d add to that that you’d want to see.

Sarguni 30:10

Well, I guess a little bit of a tangent, but I think that patients need to be better prepared in the hospital, that this is the kind of care that they can receive in the nursing home. As Christian is saying, because there’s such stigma. Like, you come from the hospital, you’re monitored, you have a nursing alarm, everyone’s there, you get a lot of attention. Then you go to this nursing home setting where there’s less monitoring, there’s less people. And so then if you start receiving, you know, end of life care in the nursing home, patients can be like, well, they didn’t talk about this with me in the hospital. Like, you’re just giving up on me. And they never did this in the. We never had these conversations at the hospital.

So I think it’s super important to, like, start this conversation in the hospital setting and to set expectations so that when patients do go to the SNF and maybe don’t improve the way that they want to, if the care is transitioned in that setting, it’s not necessarily something that’s brand new to them.

Eric 31:01

And can I ask that the third big recommendation was a demonstration project.

Alex 31:06

Yeah. And this is the pie in the sky. Blue sky, best possible option. Well, in defense of the second option, I like it as a workaround within the existing system because what we have is very broken. The second option, I’m not.

Eric 31:20

I’m not. I’m not with Alex.

Lynn 31:21

That’s not on board.

Eric 31:23

I’m seeing it go awry. I don’t like it.

Lynn 31:25

You’re a sinner.

Alex 31:26

I think we disagree about that. I think that. I think that this is an attempt and maybe it’s possible. One can hope that once you create the billing structure, then nurse SNFs will feel incentivized to provide a robust palliative care service that they can bill for. So once you create that payment mechanism, then it might be possible. But we should talk about the third, which is the blue sky best possible option.

Lynn 31:52

Yes. Shall I talk about it?

Eric 31:54

Yeah. What is it?

Sarguni 31:55

You started off, I’ll start it off.

Lynn 31:57

And my colleagues can jump in. So I’m looking at my own diagram. Our suggestion is if you have somebody leaving the hospital, you hope that some rehab’s gonna help them, but you’re pretty worried that surprise question is you’re pretty worried things might not go well for them. They’re in a similar mindset after good conversations of, I want to give it a shot at rehab. And I also see if things don’t go well with rehab, I don’t think I want to get caught in the vortex. I want to shift my care more towards comfort care. What we’re suggesting is during that first 20 day period, people have a trial of quote unquote rehab or SNF and hospice.

You can’t. Not just one or the other, you get to actually have both. And then that’s the part where you’re like still in the woods. Get my reference. You can’t tell. You know, it’s sort of allowing the person’s trajectory, giving the person’s trajectory a little bit more time to declare itself. Those 20 days, we went around a lot on how many days should that be? And we decided it should really fit within the existing policy.

Eric 33:07

And the nursing home is getting paid at that higher building rate.

Lynn 33:11

That’s right.

Eric 33:12

Discharge them because nursing home will accept him.

Lynn 33:15

That’s right.

Eric 33:15

And if there is a place for them to go. Because Medicare is paying for both hospice and the skilled nursing.

Lynn 33:20

Exactly.

Christian 33:21

And we’re honest and we’re honest about what’s happening.

Lynn 33:23

And having hospice involved allows that extra layer of support to actually allow for those ongoing conversations to happen as we see how the person is doing.

Eric 33:34

And from a financial perspective from Medicare, is, is the hope that despite now having to pay for both skilled nursing and, and hospice, so now they’re also paying what, 150, $170 a day for hospice care. Again, a little bit more complicated, a little bit more upfront in the end, like, what’s the incentive for Medicare?

Christian 33:53

But they’ll save money because the patients aren’t going back to the hospital. Those transitions of care is where all the expenses and they end up in the ICU sometimes, you know, on the ventilator. And that’s where there’s a lot of expense. So the ER visits and the, and the pain and suffering of the family and the patient and dying in emergency room. So there’s some existential suffering, but there’s some cost that’s not always just financial costs.

Sarguni 34:16

Right.

Christian 34:16

There’s cost to people’s wellbeing, but the financial incentive is the decreased cost from the ER visits and the unnecessary hospital stays. And it’s a demonstration project, so it’d be through like the center for Medicare and Medicaid Innovation, which is now the CMS Innovation Center. So that way they’d study this. Right. Just like the hospice was a demonstration project, the Guide Dementia Project. A demonstration project. You have to try it, see what happens, study it, have the data and then implement it for Everybody, every Medicare beneficiary, if it works. Because there’s always unintended consequences that we can’t predict. All the unintended consequences.

Eric 34:54

Yeah, because there are some. Like, what would be the incentive then for the nursing home to ever take patients not on this pathway?

Lynn 35:02

Like.

Alex 35:03

Yeah, because they could get both SNF and the hospital.

Eric 35:06

Yeah. Like nobody would. If I was a nursing home, you know, administrator, I would. Everybody would go through this pathway coming.

Alex 35:13

From the hospital, comes in on hospice.

Lynn 35:15

And well, you’re still, I mean, and this was pointed out to us. I think you are still left with the question, if the person goes on to hospice, you’re then go. The nursing home is then going to get that lower reimbursement rate if they keep the person in the nursing home.

Eric 35:33

And you’d still need a figure.

Sarguni 35:34

They would have to pay room and board.

Lynn 35:36

Yeah. Still a discharge, but it’s not, it’s, it’s not a perfect solution.

Alex 35:41

It’s still 20 days. Yeah. Sarguni, do you want to say more about what happens after this 20 day period?

Sarguni 35:49

Yeah. So I think, you know, we talked a lot about this with Joe and Tina, who was also a co author on our paper. And you know, this idea that, you know, it’s so hard to prognosticate, as you mentioned earlier, Alex, like when we’re discharging someone and so then they get information that the SNF stay is valuable, information that if they don’t improve, that in itself is information. So at day 20, then technically patients and families would decide, you know, do I want to go on just exclusively this hospice route?

If so, then do I need to be in a facility or can I go home if I need to be in a facility? You pay for room and board just like everyone else. If you go home, then you get the Medicare hospice benefit at home. And then if you continue to say, I want to go down this rehab path, I’ve improved to the degree that I thought I would, then they continue on with the Medicare SNF benefit, incurring a copay on starting on day 21.

Eric 36:41

So it’s really interesting because there are healthcare systems, the va that will pay for the room and board in a nursing facility, they will pay for hospice concurrently with that nursing home stay and they’ll also pay for concurrent care. So if they want to continue their, let’s say, immunotherapy, they’ll pay for that. And I don’t know, is there any data that actually saves money? Because kind of feels like it does. Like Those people actually utilize less in the long run. But should that be what the system.

Christian 37:18

Looks like you can get, you know, all of the above. Right. And they’re doing that with pediatrics.

Sarguni 37:23

Right.

Christian 37:23

Where you know, it’s, it’s a lot more flexible. But I don’t, I don’t have the data for that for adults.

Sarguni 37:29

I always struggle with this comparison with the VA and like our multi payer system, it’s like there’s such great learnings at the va, but we don’t have a single payer system. We have Medicare Advantage and Medicare and long term care insurance. And so I just, I was.

Eric 37:43

That’s the real blue sky.

Lynn 37:45

Yeah.

Christian 37:46

Yeah.

Alex 37:48

I think we talked with Vince Moore about this on our podcast that was a while back now about this idea of concurrent care.

Eric 37:55

Yeah, we’ve definitely had a podcast on concurrent care and that actually does save money. The question about if you pay for like in this pathway, this pathway of decide I’m going to go hospice route after the 20 days, it’d be interesting to know, like maybe that’s another demonstration project.

Christian 38:14

It needs to have data. And I’ll tell you what was nice about our model is that we don’t have to like get a bill passed in Congress or do anything. You know, it’s the existing Medicare model already and just use the current model and just tweak it so it seems more doable now.

Sarguni 38:29

And I think that’s super important to emphasize is like, you know, you can create the policy change to whatever degree you want. And so if you have a more narrow, kind of concise policy, policy build or idea that you’re floating, it’s much easier, I think, to get initially passed and get momentum for it than to do a wide sweeping change. And then from that you can continue to develop other policy ideas. But it’s really just getting your foot in the door and getting one change and then doing other things after that. I think that’s something that I really learned over the last few years.

Lynn 39:00

Well, I was going to say that’s what I learned from. As a clinician who looks at everything that’s wrong with the world, I’m somebody who wants, I have a lot of ideas about fixing things. What I really learned from this work, from working with three policy experts on this is the first thing when you see a problem is like, let’s look at what’s existing already in the policy and how can we work with that?

How can we work inside that framework, however weird, messed up, intricate, dysfunctional that framework is. And maybe this is why we’re in this really complex dysfunctional thing. Cause we keep layering things on top. But the truth of the matter, what I learned is like, let’s look there first and see if there’s ways we can do tweaks to what exists. Because it’s so hard to push through a sweeping change.

Sarguni 39:51

Yes.

Christian 39:52

And because it’s already exists. Because I was really trying to get the Medicare hospice benefit to change to include room and board in the nursing home. And they’re like, we already have a benefit in the nursing home that pays for room board. It’s a skilled benefit. Just use that benefit. I was like, okay, well, let’s just advertise it. I really appreciate this opportunity to educate people. It does exist now. Just use what’s there now.

Eric 40:13

Yeah.

Christian 40:13

And then make sure.

Lynn 40:15

These were from your con. These are from your conversations with people in cms. Yeah.

Sarguni 40:22

So, yeah.

Christian 40:23

Because they’re like, no, we’re not going to change the whole benefit. Thank you very much. But we will let you use the.

Sarguni 40:27

Existing benefit and, and, and just use.

Christian 40:30

The existing benefit and just skill people for end of.

Sarguni 40:33

And.

Christian 40:33

But you have to have the quality there. You have to have that quality. You have to have somebody there at the nursing home making sure that palliative care is, is really happening.

Eric 40:40

Yeah. That’s my biggest concern right now. Like, if we used current state, it’s just, I feel, I don’t know, I would love all of your, like, do we have enough mechanisms in place to ensure that there’s quality? Because let’s face it, money in medicine matters.

And if you are a skilled nursing facility and you have to decide, you know, I don’t have that, but I can use this workaround to get $600 a day instead of $300 a day. Let’s do that. Even though, like, we can’t provide that hospice care. But if we get the experts in the hospice care experts, we’re gonna make a lot less money.

Alex 41:18

You mean because you have to pay these, the chaplain, the social worker?

Eric 41:22

Well, I don’t even have that, But I’m gonna get paid less per day if they’re not under skilled nurses.

Lynn 41:28

Right, right.

Eric 41:29

And to get that hospice care, the only way to get the expert hospice team is actually under the Medicare hospice benefit, which you can’t have at the same time.

Sarguni 41:38

Yeah.

Christian 41:38

So what we’ve done is we’ve, you know, a lot of our palliative care team members work in the nursing home. And that’s kind of what you were doing, Lynn. Right. You were so you know, so consulting palliative care doctors are nurse practitioners to come to the nursing home. That’s not the whole team, but it gives you more than some that they have now.

Alex 41:55

Yeah, I think there are models. And I remember when I was in palliative care fellowship, there was a model in Boston that provided terrific palliative care within the snf. And I don’t know how they charged it back then, but somehow they had a palliative care unit. Maybe it was under a bridge benefit, I’m not sure, but.

And I feel like there are potentially models in San Francisco that I’ve heard of where palliative care has a, has a major presence. So I’m hopeful there may be exemplars. And I agree with you, Eric. I worry about the many underfunded SNFs who might bill for this skilled palliative care, but not deliver skilled palliative care.

Sarguni 42:33

Yeah, I mean, I think ultimately the nursing homes are going to behave in the way that they’re incentivized by payment models. So advocating for a payment model in which you’re delivering, you know, high quality palliative care, adding ways to assess and survey nursing homes to make sure they’re doing it, you know, ethically and that patients aren’t being forced into hospice against their will is really important.

But I think the nursing homes are reactive. Like they’re, they’re behaving in a way that will get them the most money. And if we change it so that they can get money for delivering palliative care, then there’s. I’m not sure why we wouldn’t think that they wouldn’t follow suit with that.

Eric 43:08

Okay, let me. I know we’re coming close. Can I ask all of you kind of if you had a magic wand, you could fix kind of one thing or make one change to the current system, what would you use that magic wand on? Sarguni, I’m going to start off with you.

Sarguni 43:24

Oh, gosh. I would like to have Medicare pay for some long term services and supports and start providing coverage for that in some form.

Eric 43:34

Wonderful. What would that look like? One thing. What would that look like? What kind of long term?

Sarguni 43:38

Yeah, I think it would be more like caregiving at home, like nursing aid support at home, which I think would institutionalize less people. It would look like room and board coverage for older adults who need to be in an institution. It would, you know, potentially bankrupt the Medicare trust fund. But that’s why it’s my wand solution. And I think we have to figure out how to pay for that. But I do think that’s an important next step as we think about how to evolve the Medicare benefit.

Eric 44:03

Christian, what would you use that magic wand on?

Christian 44:07

I love our third option, the concurrent, you know, where you can get rehab and hospice at the same time, because that’s.

Sarguni 44:12

You just don’t know.

Christian 44:12

And that way you get both.

Eric 44:14

Get that demonstration project.

Lynn 44:15

Rol Poland Lynn, I think very specifically, I would really like for Medicare to pay for room and board in a nursing home for when people are on hospice.

Eric 44:27

I thought you were going to say, I’d like to hear another Taylor Swift song.

Sarguni 44:29

Yeah, that’s what I. I would like.

Lynn 44:31

Taylor Swift to do a tour on the new album.

Eric 44:37

But he didn’t like the new album. Well.

Eric 44:43

Alex, I’m gonna use my magic wand on some Taylor Swift.

Alex 44:48

All right. That was a great discussion. I’ll shake it off. I don’t know if the four of you are ever getting back together again.

Lynn 44:55

Oh, my gosh, this is amazing.

Alex 44:56

Again, if you do. All right, here’s a little bit.

Alex 45:20

(singing)

Eric 45:43

Lynn, Are we out of the woods yet? With hospice and skilled nursing facilities? We’re not in the clear. We’re still in the woods.

Christian 45:48

We’re in the pit.

Sarguni 45:49

We’re in the thick of it.

Eric 45:51

Not in the woods. In the woods. Lynn, Christian, Sarguni, thank you for joining us on the GeriPal Podcast.

Lynn 45:58

Thanks for having us.

Sarguni 45:59

Thank you so much. It’s always such a pleasure.

Eric 46:02

And thank you to all of our listeners for your continued support.

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Disclosures:
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