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So what exactly does a hospice medical director do?  Why do some choose to become hospice physicians?  What additional training is needed, if any, beyond Hospice and Palliative Medicine fellowship and boards?  Who should take the new Hospice Medical Director Certification Board Examination? A recent study in JAGS found high rates of hospice disenrollment (“live discharge”) for people with dementia – is that a good thing or a bad thing? Hmmm…

We address these and other questions in this week’s podcast with Tommie Farrell, hospice physician in West Texas and Chair of the Hospice Medical Director Certification Board, and Kai Romero, Chief Medical Officer for Hospice By the Bay (that’s San Francisco Bay).

And I get a re-do attempt at REM’s “Everybody Hurts!” Apologies for the first attempt!


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

Alex: This is Alex Smith.

Eric: Alex, we are going to be talking about Hospice Medical directors today. What the heck are they, who they are. And we actually have some with us. I see some there. They’re in my Zoom window.

Alex: So we have Kai Romero who’s returning to this podcast. She’s been on this podcast multiple times. She’s chief medical officer of Hospice by the Bay and attending physician in the emergency department at Kaiser San Francisco. Welcome back to the GeriPal podcast, Kai.

Kai: Thank you so much for having me.

Alex: And we have Tommie Farrell who is family medicine trained, and is in West Texas in Abilene, Texas, where he practices hospice and palliative medicine. He’s also the chair for the Hospice Medical Director Certification Board. Welcome to the GeriPal Podcast, Tommie.

Tommie: Thank you. Glad to be here.

Eric: So I’m really excited. I never did a palliative care fellowship, actually, we were on an inpatient hospice unit here, but I’ve never been working as part of a home hospice agency so I don’t really understand what a hospice medical director does. So I’m really excited about this podcast. But before we start, who has the song request for Alex?

Kai: Me.

Eric: Kai, What do you have for Alex?

Kai: I would like to hear Everybody Hurts by REM.

Alex: And why this song?

Kai: I think this song really speaks to one of the core Hospice values, which is that we’re kind of trying to dismantle some of the medicalized hierarchical structure with which physicians and patients kind of operate in and recognize that we are kind of humans in bodies, all of us, and that all of us are suffering and trying to help one another. And I think it really, it gets to that that recognition that we are not that different from our patients. And in fact, we will one day be in their shoes.

Alex: Mm-hmm (affirmative). Yeah, it is. Wow. Well said. It’s like the quintessential sort of hospice and palliative medicine sort of song isn’t it?

Kai: Yeah.

Alex: So we did this one before in 2017, but I wanted to do over because I’m hoping to do better than last time. So we’ll see what happens folks.

Alex: (singing)

Kai: That was beautiful.

Tommie: You almost sounded like Michael Stipe there.

Eric: All right, subject at hand. Hospice medical directors. I’m going to start off with Tommie since Kai has been on our podcast like what…13 times? How’d you become a hospice medical director, Tommie? What pulled you towards that field?

Tommie: I feel like there’s a series of events that kind of drew me in, which is a lot of people’s stories that they kind of fell into it for lots of different reasons. But I started, I was a family doctor that thought I should go see my patients in their homes if they were, for different reasons, if they were dying, if they just had a baby, they just had surgery. So I had a day set up twice a month where I’d go check on patients in their homes as a family doctor starting off. And the hospices noticed that I was doing that. And so they started asking me if I would do more visits for home and then I learned just what a great need there really was in that area. So I was teaching at Texas Tech University Health Science Center in Lubbock at the time and so I kind of transitioned myself to becoming the, making visits every day to patients on hospice in their homes. So that’s the short story of it, but it just kept growing and growing on me and the need grew on me. And I just found quite a love of getting to be able to see people in their homes where, and when they needed it the most was the biggest appeal for me.

Eric: Yeah. How about your Kai?

Kai: Yeah, I think frankly some of the same things that you’re describing Tommie, I think family medicine doctors and emergency medicine doctors kind of are two apples that fall from the same tree. And I think there’s a kind of common pathway in my mind that leads to hospice in the sense that your… What was intriguing to me was the notion of dealing with emergencies at home with no resources and with limited medications. That kind of appealed to the part of me that is still appealed to by emergency medicine. And I also think the freedom to make kind of unusual or innovative symptom management choices without having to kind of double check and enroll someone in an IRB. I mean, basically what you need is buy in from the patient and the agreement that you don’t want to go to the hospital and you have this whole world open to you about what could be done.

Kai: I’ll give one brief example of this, I had a patient the other night who I got a call because he had a seizure disorder. He was diabetic and he was imminent. And he had a low blood sugar. And the question was well, we can’t get 15 grams of carbohydrate in him because he can’t swallow anymore. And I thought that is like the perfect hospice problem. He may start seizing if he becomes more hypoglycemic, because he’s prone to seizures and people who are hypoglycemic can seize anyway, and we can’t get enough glucose in him because he’s dying. So what do you do next? Anyway, what we ended up doing was just giving him additional doses of his Ativan and just saying, we’re going to raise the seizure threshold that way. But I think that’s like to me really what pulled me into hospice work, was the recognition that you kind of… This wasn’t me having a larger conversation with five colleagues, this was me waking up blurry eyed at one in the morning and having to like figure out a plan.

Eric: Thinking outside the box.

Kai: Yeah.

Eric: And it’s not something you can quickly look on UpToDate. How to manage seizures in hospice. Hypoglycemic patient who is not eating, UpToDate answer.

Kai: Right. Exactly.

Alex: That sounds like a board’s question.

Kai: I know. I know. Except there’d have to be something about like a metabolic pathway or something.

Eric: Well maybe we can just start off then. What is a hospice medical director? Because in my head, I have two very different views. I have the view that you’re telling me, you’re answering these questions, you’re… Tommie’s going to people’s homes and you’re integrally involved in the care of these patients. And then there’s this other opposing view that I see out there. I actually did a PubMed search. 10 articles came up on hospice medical directors. Not a lot of research aside from stuff like from Debbie Oliver. But there’s this other view of you have these part-time physicians, maybe their primary care docs who do a little bit of hospice medical director. They get no orientation, they have no palliative care experience training. And they come in and they sign some forms and they leave.

Tommie: Which is kind of how I started. I didn’t have, when the hospices came to me, they were coming to me and saying, “Hey, we need someone that will do this because no one else will.” Or could at the time. And I had no training. I was actually nervous about that so I went to a doctor I really respect, Cynthia jumper, who’s I think still chair of internal medicine at Texas Tech and I called her because she had done hospice before and I, “Hey, I’m a new doctor.” She was one of my attendings when I was a resident there in training. And I said, “I’ve only been out for three years and they’re asking me to be a medical director. I don’t know enough.” And she said something important to me at the time. She said, “Well, you’re right you don’t know enough.” So truthful answer. But she said, “Your heart’s in the right place.” And she says, “If you will go about it that way, the nurses will help teach you the rest.”

Tommie: And I think early on in the hospice medical director genre, that was not too uncommon that the doctor’s doing it were just learning from the nurses. And as I got more and more training and got involved with HPM and got certified in hospice and palliative medicine without a fellowship availability, I was learning as I went along, but I did start learning that there was things I needed now to go back and teach the nurses that were kind of some of the traditions of treatment that we could do even better at. That’s kind of the whole field of HPM, right? Is that we’ve had this growing body of evidence that’s been great to have as we go along. And then we get the generation of doctors who are fellowship trained, which has just really enhanced the whole field by having-

Alex: Can you give an example of something that hospice and palliative medicine research has contributed that you went back and taught the nurses?

Tommie: Sure. I’ll tell you one is, I think early on I didn’t recognize how often, because nurses are so compassionate towards making sure people are comfortable, that I was getting descriptions of pain that were actually neurotoxicity of the opioid. And now I could go back to nurses and say, “Hey, when you say this patient doesn’t look comfortable, that’s fine. What are you seeing?” And they describe the classic of neural toxicity, that twitching appearance and the hypersensitivity. And I’m like, “Oh, I think we’re actually giving them too much opioids. So let’s shift gears and treat this different.” And now I get to take that back. That’s one example.

Kai: I will say that it’s interesting the, I think for people who are palliative care trained, there’s this sense that like you should be able to kind of show up and do hospice work. But I think most people who’ve done a palliative care fellowship, similar to the fact that there’s such a range of where hospice providers are coming from. And I think Tommie will agree when I say that there are lots of hospice providers that continue to kind of come in without a ton of experience before they do their first hospice job. But I think many people have done a fellowship and what it means for you to have done a hospice component to your fellowship very… It actually doesn’t vary that widely. I think a lot of it is not as robust as people would like, right? They come in and they’re like I guess I know how to do hospice work, but depending on where they were, depending on, and certainly in COVID it adds in a whole additional layer.

Kai: But I think the recognition that even for people who’ve done the fellowship, there is a subset of how you do hospice medicine that’s very hard to kind of farm out in the same, not farm out, I guess to incorporate learners into in the same way as there is in hospital structure. In the hospital structure, they’re there, there’s a space for them. It’s carved out by Medicare and you plop them in, it works great. In hospice medicine where it is so much more relationship based, so much more nursing based, oftentimes figuring out exactly how to fit learners into that dynamic can be more challenging. So we actually find that even though at our hospice organization, we have a lot of fellowship trained physicians, they don’t always come in. I mean, to my mind, it’s not always easy to just plot. Certainly they have a shorter runway to learning than someone with no background, but you don’t get the whole picture necessarily before you start, even if your fellowship trained.

Eric: Do you think that’s why there’s less… One of the issues in hospice palliative medicine is a lot of the fellowship trainees go into palliative care and not hospice. And do you think that it has to do with their experiences in hospice during fellowship?

Kai: I think it’s very possible because I am the, I’m writing, preparing myself to hear all of this feedback about our fellowships since I am the director for the hospice portion of the UCF fellowship. But I do think that there’s been, when I was trying to figure out when I first took over in this role, how do we make this a more robust component of the fellowship, I talked to a bunch of palliative care doctors who were board certified and said, “What was your hospice experience like?” And it was not, some people were like it was great because it was laid back, but there wasn’t a ton of… and I learned all of these things that made me feel like I really know how to do this work well. So I definitely think that there is room, especially as the field of palliative medicine grows, especially as there are more people that are kind of interested in education going into the hospice space.

Kai: I remember early when I started someone talking about going to HPM and you could tell right away who the academic palliative care doctors were because they were wearing suits. And then there was like the hospice doctors with like a bongo and I’m always bringing up bongos on this podcast, I don’t know why. It’s you, Alex [crosstalk 00:14:08]. But showing up in their tie dye and they were, it was just a very, very different vibe. And I think as there are more and more, we’re affiliated with UCF so naturally the way that we approach hospice medicine is going to A, involve the type of complexity that UCF patients bring to the table which, having had many, many sub-specialty clinicians involved, having many really, really talented symptom management doctors involved, it shapes the way that we approach hospice medicine for sure. And it shapes the way that we teach it also to the fellows I think for the better. Although please interview the fellows afterwards and ask them if that’s true.

Tommie: Yeah. I was going to say, I agree with Kai. I’ve been a fellowship director and you’re more comfortable with palliative medicine in the hospital because that’s where you get to spend most of your time. And you just think about even the model of care. Hospital is a model that all doctors can wrap their brain around and clinic is a model that all doctors can wrap the brain around and now it’s like, now you’re going to do something different. And it’s some home-based and it’s a lot nursing home based where we have great stories of times I’ve been to patient’s homes, but the bulk of my care in a given day, I can go see three to four to five patients depending on my driving radius and being in West Texas where we’ve got several counties. But since the COVID has come up, I’ve been mainly in the hospital and I’ve been doing all my hospice care with the nurses that are going to see these patients. And there, there can be a dozen patients or more I’m taking care of daily through the nurse interactions. So you’d build a lot of trust with these nurses and you learn how to manage, co-manage with nurses.

Eric: So what does a hospice medical director actually do? The feedback that I used to hear is that there was a lot of paperwork involved and a lot of not seeing patients. But in your eyes, what’s the role of a hospice medical director?

Kai: Yeah. It’s mostly stamping things. I’m glad you brought that up. So I do think that what’s interesting to me, I think the spin that I’ve come to understand about the administrative portion of hospice medical director work is that it is unlike every other physicians administrative work, as you all have it, right? Everyone’s writing notes, everyone’s doing some baseline amount of administrative work. You are compensated for your administrative work as a hospice physician. And that to me is actually the distinction. It’s not that there’s that much more of it. You are paid for the time you spend doing it. And I think that’s where, I mean, in my mind, when I talk to primary care doctors in general, part of their frustration is around how much time they spend on EMR, how much time they spend on all these things other than kind of direct patient care.

Kai: And I actually don’t think our hospice doctors complain about it as much because they’re actually being compensated for that time appropriately. Anyway, so certainly at the very most basic certifying that someone is terminally ill, filling out the appropriate documentation to certify that initially, and then repeatedly over time, collecting the appropriate data to make those determinations on the cadence that Medicare dictates. That’s a significant proportion of time. The remainder of the time is symptom management and that symptom management can be done in person via a visit themselves, remotely by managing with telemedicine or also fielding calls from the nurses who are doing even more visits than the physicians are in order to facilitate that care. And I think the last piece of it is actually for us, that is a differential burden depending on what environment you’re in, is coordinating safe transfers out of the hospital and into hospice care.

Kai: So we actually find that our clinicians based out of San Francisco do a whole lot more of that work than our clinicians based out of rural Napa County. Because frankly the patients coming out of hospitals in San Francisco may come out with a Pleurx, with a biliary stent and a midline, and we’re navigating all of those things and coordinating all of those things in a way that we’re not when someone is coming from a County clinic in Napa. Does that cover it Tommie? Or is there something I’m forgetting?

Tommie: You said it great. And Medicare requires that the hospice director is on top of all the medical aspects of the patient’s care and the medicines of their care, even if they’re not the attending. So a patient gets to pick who their attending is. That’s an important part of Medicare’s benefit. So I can say I want my family doctor of X number of years, or my cancer doctor who has been taking care of me very intently for the past year, I want them to stay attending and we do make sure that person stays in the attending role of the one that the nurses call and check by all the needs for. But then you still need to have someone that’s watching all that care to make sure, even though they have a primary doctor, we got to make sure that the diabetes medicines are approved and such.

Tommie: So we’re still coordinating the plans of care with the attendings out there. If they have one, many patients come without an attending, many of the doctors are shy and have taken on that role themselves. And they say we’d prefer that you turn it over to the medical director. So the bulk of the patients where we become the attending, but whether we’re the attending or not, we’re in charge of making sure that care is being overseen and managed regardless. And then there’s the after hour calls because not everybody’s attending can be available after hours. So that by the most part goes to one of the hospice doctors in the evenings.

Kai: I always say that we’re the world’s most compassionate and accessible insurance coverage, right? So we are paying for DME, we are paying for medicines. And the reality is we’re hospice doctors so you don’t, contrary to popular belief, don’t go into it for the glory, you don’t go into it for the fame or the pay, but you when people come to you and say, “I really need this medicine.” And you say, “Well, I don’t really think you need that medicine anymore.” And they start crying and say they need the medicine, do you know what they do? You give them the medicine because you’re a hospice doctor, I’m not like United health. I’m not going to tell you you can’t have something. And so I think really what it comes down to is trying to kind of make the case for what the appropriate care is and then very quickly retreating from that stance when it seems like that’s causing suffering. That’s my assessment at least.

Eric: And do hospice medical directors, it seems like there’s a lot of variety out there. Do most of them go see patients? Do most of them just have the nurses see patients and they review the care plan? Do you just not know?

Tommie: There’s no Medicare requirement that you have to go see patients, except for one thing we’ll talk about briefly. But mainly for the patient care you’re right, a medical director could sit in an office and do everything from there. Now the people that get attracted to it often liked to make visits. But again, you have a wide variety. You might be at a smaller town hospice might be tapping internal medicine doctors on the shoulder saying, “Hey, we really need someone to cover our hospice needs. And we realized that you have a busy clinic, so you can’t go without, so we’ll bring everything to you.” So it might be out of necessity that a given city has to use use that model of just going. But then you have the doctors, obviously like Kai is and myself that really love going to see the patient. So that’s where we’d like the focus to be, but it’s not a requirement. There is a requirement that to re-certify for hospice at certain periods, you do have to have a face-to-face visit from a clinician. And that can be the medical or hospice doctor, the medical director, or it can be a nurse practitioner that the hospice is hired. But that’s the only required visit.

Kai: I do think that we, and I imagine this is true of many hospices who have kind of gone through waves of how we’ve thought about visits, a lot of it’s dependent on our census. When our census is super high and everyone has a ton of work that they’re supposed to accomplish during the day, the number of visits per clinician goes down. That said, when I think about kind of what fills their cup and makes them excited about the work, it really is the direct patient care. Direct patient care during COVID involves a lot more telemedicine than in-person visits as compared to how it was before. But I do think that’s what kind of makes people want to go to work.

Alex: I wanted to ask, is it fun? What attracts you to this role of being the hospice medical director? Who is it suited to?

Eric: Yeah. We’ve got fellows who listen. Tell them why they should think about hospice as a career.

Tommie: Kai is thinking, do you want me to go while you’re thinking?

Eric: Yeah, go ahead Tommie.

Tommie: I like the fact that, especially the home visit part, I mean, there’s the regulation part, yes, and that has its own aspects to it. But going back to that home visit part, if I, especially here in West Texas, if I don’t drive down to Winters, Texas to go see a person, they’re not going to see a doctor. The patients in the hospital, if I can’t make it to see them, someone’s going to see them. You can’t spit without hitting a doctor in the hospital, right? But going out to the patient’s home when they need it, where they need it. And especially for these families, I get to go in these homes and these families are they’re scared, they’re uncertain.

Tommie: They know if they can do take care of them right. And just the reassurance that I can bring to them and say, “You’re doing okay, you’re taking care of your mom correctly. You’re taking care of your sister right. And we’re going to do this to make sure you’re okay. And please call us when you need us.” That aspect is just so rewarding for me. That’s really the part that I like the most, is that that reward of really taking care of a person who really needs it. And in fact, we all want to make a difference as a doctor, and we all do. All the fields make a difference, but this is just a very obvious way to be making a difference in the life of these patients and their families.

Kai: I think that’s really right. And I would say it’s this combination of kind of what Tom is talking about, the one-on-one personal touch with patients where you can really see that impact. But I actually find that also some of our physicians really love knowing that you’re kind of operating at scale more than you can sometimes as a physician. So we have 600 patients almost on service at Hospice by the Bay. And when I’m on call overnight, I can make decisions to impact really sometimes too many of them in a given night. And when we want to make changes to how patient care happens, part of this is being in like a medium-size organization rather than a huge academic institution, right?

Kai: You can just decide that the care would be better if you did X based on the information that you have and do it and there’s something deeply satisfying about just being able to do the right thing because it’s the right thing, instead of having to go through layer after layer of kind of bureaucracy and regulation. It is a very regulated industry but I’m thinking specifically about symptom management. So I think it’s the awareness that you know people’s lives intimately. One of my favorite memories was going into a patient’s home, she was in her mid nineties and finding her sitting on a couch between her two sisters. She was 97 and her younger sister was 95 and her older sister was 99. And they were all sitting on this velvet couch together, waiting for me to get there.

Kai: And they all had wigs on. And I was like these are just three sisters dressed up to see this doctor. This would have existed if I were never here, but I got to see this. I got to be here to kind of experience this thing that was going on in the world. There’s this way in which you get into people’s homes and into people’s lives in this incredibly intimate way. And it’s true for everyone doing home visits, I think, but especially for people at the end of life, there’s an intimacy about that. And then as I said, just being able to do really good medicine and not having to fight the fights that it feels like many other physicians have to fight around whether insurance will cover it, whether… You can just make the case for doing the right thing at the right time and it’ll happen. And that is just deeply satisfying.

Tommie: Kai tell me if this is true for you too, I think you might be hinting at it. This might be a funny reveal, but when you talk about not having fight, I also don’t have to fight other doctors. Whereas when I’m doing my palliative care hat, sometimes part of what I’m trying to do right by the patient is also fighting through a few other teams. And on hospice it’s just me and the nurse oftentimes, that’s the only person I have to convince that we’re doing the right thing. It’s the patient, the family and the nurse. And we’re usually on board a lot easier to say yes, let’s do this because it’s going to help this person the most. And I don’t have to talk any other doctors into it.

Eric: Thinking about fighting other doctors, are there… So you get a lot of referrals potentially from other doctors, from the hospitals. Do you have some pet peeves? Things that we do, including inpatient palliative care docs or outpatient palliative care, geriatricians, things that they do that just like [inaudible 00:27:31] please stop. In probably more vulgar terms.

Kai: The most challenging thing for me is when there’s been an expectation set by them around what we will or will not provide.

Eric: Sure, they’ll do 24 hour care. Seven days a week. You need all that health care.

Kai: That. And then I would say also around medications, when people kind of insist that a patient should keep taking a Statin when they’re in the last six months of their life. Stuff like that can be frustrating. The other challenge that we come across is when, and this is usually not palliative care doctors, when people get really frustrated around why we’re not providing certain types of aggressive life-prolonging care. So this comes up with platelets, this comes up with TPN, this comes up with lots of different things. And I think that can be frustrating. I would say honestly my only pet peeve, this is like the only thing that I would actually really, really, really bothers me is when people are dismissive or disrespectful when they make recommendations, because they think you must not understand the like incredible brilliance that they’re bringing to the table from their specialty knowledge.

Kai: And it’s one of those things where it’s like, yes, I get it, you know everything there is to know about cancer of the left ear canal. I am not going to argue that with you, but I know about people dying. And that really is my specialty and my expertise. So how about you don’t flex on the left ear canal, I won’t flex on the death stuff, we can just meet in the middle. But I think that’s the only thing that really gets my [inaudible 00:29:21]. Otherwise I mean, you can explain and have conversations and really do just fine as long as people are approaching it with a little bit of humility around what it looks like for someone at the very end of life and aware that perhaps a hospice physician has something to bring to the table in that discussion.

Eric: How about you Tommie?

Tommie: Mine is the same. It is for the families. If you look at the family satisfaction surveys for hospice, there’s a number one complaint on every hospice’s survey, and that is we didn’t know about hospice soon enough. And this is better when we get handoffs from palliative care teams, you kind of see the timing for the transition, but usually when I’m getting a referral from a physician and they’re actually taking the time to call me directly, which I always love, they’re saying, “I don’t know if it’s time for hospice yet. This patient is…” and they start filling in the blanks and I’m like, “Yes, this patient was ready to months ago. We’re very happy that they’re here now.” And I don’t say that to them. I say, no, no, they’re very ready. They’re eligible for hospice and we’re very glad to take care of them now.

Eric: And sometimes when I have questions I just, I call up my local friendly hospice medical directors. Is that something that you think why are they calling? Or do you guys actually like that when you get-

Eric: Is this person hospice eligible?

Tommie: Yeah, we love it. The sidebar consults is super because that shows a doctor cares and we care. And that’s the doctor that we say we hope you stay attending so we can keep coordinating care together. Because you know the patient and as Kai pointed out, we know the medicine aspect and the nuances of the regulations that we can work through. And you know the patient, that’s the ideal thing is when the attending does stay involved, if they can, so we can work together with them. And I’ve developed that relationship, especially with our oncologists here where I’ve gotten more of the oncologists to stay comfortable staying the attending so we can work together. Because those patients and families would like that. They would like to know that the doctor that knows him is still involved with their care. And if I can promise them I’ll do the paperwork part and they keep taking the calls from the nurses, that’s an ideal relationship.

Eric: Yeah. So what are the requirements to be a hospice medical director? First you got to be a physician, right?

Tommie: That’s right. They have to be a doctor. And that’s why the hospice, of course, I got a vested interest as the board president for the Hospice Medical Director Certification, but there’s two things we’re hoping there and one of them Kai’s brought up, which is kind of the respect of the field that we know palliative care in general, now you don’t have any palliative care doctors that don’t have some type of training and certification, and it’s nice to be able to show hey, I, I am an expert in this field. And the second part is kind of raising that universal bar that even if you’re a physician that has been the very busy internal medicine doctor that’s been recruited to do this, we’d like that doctor who he or she could be in their fifties or sixties and not interested in going back to a fellowship, but sure we’d like to be able to say hey, no, I have studied up. I do know these regulations, I do know the management issues and how do I show that I really do belong as a medical director instead of just being told, or just being type casted as being a doctor who doesn’t really know what I’m doing and is just tapped on the shoulder and stamps things.

Kai: And I actually did a fellowship, got certified in palliative care and then was working as a hospice physician for a few years. And then this role became available as the chief medical officer and then one of the prerequisites was that I complete my Hospice Medical Director Board certification. And so I got to kind of see the process of what it means to kind of come to the table with this palliative care background and really having even worked in this space. And the real difference for me was I had always understood, I had a vague sense of the Medicare guidelines and regulation, but you didn’t have to know them intensely even as a hospice physician, right? To be a medical director though, now all of a sudden you’re pulled into every conversation, every ADR, every potential Medicare issue in so much more robust way that I was so glad to have had really just the high level overview of studying for the medical director board certification to have a reference point for a lot of this stuff, which I did two and a half years of hospice work and knew a little bit about them, but just really didn’t have to know in a kind of in-depth manner because I frankly wasn’t holding the bag at the end of the day. Once I was, I was really glad to have that information in my back pocket.

Eric: And who do you think should take that Hospice Medical Director Board? I guess the question is what is the Hospice Medical Director Board? Is it a test or is it something more than that? And the second thing is who should take it? Is it all hospice medical directors? Is it if you’ve done hospice bowel medicine as a specialty and you’re certified, you have to, or should you do the Hospice Medical Director Boards?

Tommie: HPM originally created the launch pad for HMDCB at first for those mid-career physicians because there’s a lot of mid-career physicians that weren’t going to go back. What’s been interesting is seeing it evolve to have value for the fellowship train. So I’m actually a hospice physician and not the medical director. And the medical director was someone I trained as a fellow and she does this fantastic job. And she wasn’t our target audience, but Kai mentioned, she saw the value in what she was doing and saying, I am doing this and I not only want to show that I can do it. She wanted to, yeah. So it’s not only that she was already learning it, but she wanted to show. So instead of just being able to say, “I’m an HPM certified hospice medical director,” now she can say, “I’m an HPM certified and a hospice medical director certified physician in this role.” But it would be for any physician involved with hospice who we would like to offer it to. But its original target was for those mid-career physicians. And it’s evolved from that because of value that I think the physician seeing it themselves.

Kai: And I’ll say that at my organization, historically anyone who has board certification in palliative care, we don’t require it. We recommend it, but we don’t require it. And for people who are coming in really with no hospice or palliative background, we require it.

Alex: And what is it? Is it a test? Is it more than a test?

Tommie: The initial certification is the test, is an exam. Now that you have to have enough experience in hospice to take the exam. There are some, if you go to the location, it talks about how many hours you need to have had and the experience time. And then there’s a recertification process and that’s actually in evolution like most recertification processes are because we’d like to, we’re considering can we move this away from being an exam because everyone’s already taken the exam and shown that they have that minimum competency. And what are they activities that show that you still qualify to be that competent. The exams are just about being minimal competence. We hope doctors are even better than the exam because the exam just gets us on a minimal competence for the knowledge that you need to be a medical director. And we’d like to think that those who have the passion to do that, go on and become excellent hospice medical directors. And we just want to keep measuring that. So we’re evolving what we’re going to do with the recertification process, but right now that’s also an exam.

Eric: And if our listeners want to learn more about the Hospice Medical Director Certification Boards where do they go to again?

Tommie: So the initials are for that hospice medical director certification. So

Alex: Shall we do a lightning round? 2016 hospice payment reform, hospice payment change so that hospices receive more money around the time of hospice enrollment and more money around the time the patients died and less money in between. Thoughts on that, reflections on that, lightning round so snappy answers. And we’ll go through a bunch of questions.

Kai: It’s an effort to try and make sure that people understand, patients are understand and kind of oriented to the hospice philosophy and that there’s enough intensity in terms of visits at the end of life so that they’re adequately being symptom managed so that caregivers are receiving enough emotional, spiritual support from all the people on the team. It’s around incentivizing the kind of acute phases of being on hospice, which are when you arrive and you’re dealing with all the intensity lot and obviously at the end of life.

Alex: Yeah. Tommie, anything you’d add?

Tommie: Kai’s a pro, she’s got it.

Eric: All right. I have somebody without a primary terminal illness. They’re old, they’ve got tons of comorbidities, they are failing to thrive, whatever that means. But they’re just not doing well. They’re losing weight, they’re frail, very, very frail. I think they still have six months to live because of everything that’s going on in trajectory. Do they qualify for hospice or do they need like a primary diagnosis?

Tommie: You said the key thing there. If you think they have less than six months, if you think they have more than that’s not necessarily the benefit that’s meant for. But if you’re sitting there saying, I can tell that this patient’s declining, I just don’t have the right term to put down for it, then that’s where we are in our keep as hospice medical directors. And that’s where I do, I get extra records. And I usually what I ended up finding there is something. I’ve never sat there and said, “Yep, yep. It looks like this person’s about to go and I don’t have any reason to bring them on.” We dig and we look and I find out this person has major coronary artery disease that they’re no longer even going to see the doctor for and this is probably the primary driver of their weakness. And there’s a lot of other things that I find as I go along. That’s just one example.

Kai: Usually what we aim for is a chronic disease that they already had in there, was diagnosed many years ago that could be explaining their decline. Often it ends up having to do with the status of their vessels, whether it’s in their brain, in their heart or in their periphery or some other kind of global process neurologically. Obviously it’s super simple when it comes to things like cancer, but most elders have some kind of chronic illness that you can point to as a primary driver of their decline and then what we just say is everything else that’s ever happened to them in their whole life is related to their hospice diagnosis so we will pay for any medications or anything else that are related. The key piece is just recognizing that a thing that is likely to be the driver.

Eric: Jag’s article just came out today or yesterday, I forget which day, but survival and hospice patients with dementia, the effect of home hospice and nursing visits. That nearly 40% of patients with dementia in their study had either a live discharge or a long length of stay, which was greater than 180 days. And the conclusion was man, we need to fix this problem. Is that a problem we need to fix?

Tommie: No, they had a problem that we fixed the patient. The patient wasn’t getting enough close care and then we show up and we actually pay attention. We get rid of the over medications, the polypharmacy, we give them the social support they need, we get them the nutritional support they need. Because despite the myth that hospice is about just trying to see how quickly we can get them to die, it’s about giving them quality care. And when that happens, people live longer. So yes, just like palliative medicine is going to keep increasing people’s lifespan, even though we don’t try to, which providing good medicine leads to longer life. And so-

Kai: And these are the hardest discharges for sure. Because patients and caregivers know how much worse it is without hospice care. I will say that recently we’ve been trying to figure out how to admit patients onto hospice with COVID. And so what we did early on was just look through the data and try and extrapolate which high risk conditions would predispose you to severe COVID and then look, try and hit the like 50% mark for deaths after six months. And we at Hospice by the Bay, we came down to an age cutoff, chronic condition cutoff. If you lived in a nursing home, blah, blah, blah, we would admit asymptomatic COVID patients that filled those criteria and then did a retrospective look back to see where we actually right. And we were right about at 50% actually, which was surprising. And then I was like, we should look back on everything, on things that there are Medicare criteria for. Because I’m pretty sure they would not hit the 50% mark, especially if you looked at things like dementia and Alzheimer’s. I feel confident that we’d have, and that’s fully following Medicare criteria, I just feel like we haven’t been collecting this type of data on is this accurate really.

Eric: Yeah. And I don’t want to get a bad email from Holly Ferguson who wrote the study in the JAGS article. She didn’t say that it needs to be fixed actually. She said that hospice guidelines need to change to permit longer stays. So I was thinking well…

Tommie: But the thing is they’ll keep changing guidelines and we’ll keep fixing the problems that they keep throwing at us. And I don’t mean that disrespectfully to them, but it a bit depends on what you’re looking at this as. Are you looking at this as a management need or a medical need. And the two can’t be separated and that’s why good medicine and good management go hand in hand. As long as we have good programs, we’re going to keep finding more and more reasons to say well maybe we need to cut back on this program so they don’t get too much business in a sense. We don’t want too much money going into this one program, but when you have a quality program, you can keep throwing us as much. One goes back to that face to face that they first set up.

Tommie: It was first set up to make sure that we discharge more patients because we want the doctors to see the patients correctly, which comes down to, you had to believe one of two things. Either that the nurses were lying or the nurses were not competent to assess that patient’s lifespan. In the end we found out the nurses were very good at telling that these patients don’t need to be on hospice and actually though we found more patients to keep on hospice when the doctors started to go see them because we were finding different comorbidities that needed to be addressed. And so every time Medicare throws us a regulation to try to potentially limit the number of patients we take care of, we’re going to find more reasons to take care of them because we’re good clinicians. That’s the pride of the hospice medical director showing up right there. We’re good clinicians.

Eric: That’s awesome. I love it. Sometimes everything is wrong. Now it’s time for a sing along Alex.

Alex: Good segue.

Eric: Good segue. Got to throw some lyrics in there. Didn’t really fit the conversation but what the heck (laughter). Tommie, Kai, thanks for joining us. But before we end, let’s do a little bit more because the day is long and the night is yours alone.

Alex: (singing)

Eric: That was like the HPM sing along that we had last week. Tommie, Kai, big thank you for joining us on this podcast. Also, is now the time to sign up for the boards?

Tommie: Yes. You can to right now and sign up if you want to take the initial exam. We welcome you.

Eric: Do you know when the registration closes?

Tommie: We still have several weeks. We still have several weeks to go. And then the exam happens in the late May to early June period.

Eric: Wonderful. Big thank you guys again for joining us. To all of our listeners if you do do hospice work, please sign up for the boards and a big thank you to Archstone foundation for your continued support.

Alex: Thanks everybody.

Kai: Thank you.

Eric: Goodbye, everybody.

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