Hospice Resources for Medical Directors

Care Delivery: The Compassus Way

Care Delivery the Compassus Way is based on the foundational understanding that all patients with serious illnesses and at the end of life have universal needs. These needs are comfort, safety and autonomy, and quality of life.

Establish goals of care to determine Patient/Family Greatest Concern
Develop a team-based plan of care SBAR Model & Symptom Management
Medication reconciliation Guide to Medications
Monitor disease progression and address pain control Total Pain Management
Reassess goals of care at each IDT focused on Quality of Life

Onboarding Checklist

Annual Training Checklist

Workplace Essentials & Tools

Hospice Admission & Certification Pearls

Hospice eligibility
Prognostication and scoring tools
PointCare: Physician’s or NP’s Guide to Face-to-Face Encounters
DrFirst Login Details & User Manual
American Academy of Hospice and Palliative Medicine
National Hospice & Palliative Care Organization
Face-to-Face Recertification Encounter Timesheet
MD Time Sheets
Bring your own device – request form

Understand the organization

Know your hospice team

Referral > Prognosis > Eligibility > Admission >Certification

Initial Certification: 15 days prior to 2 days after election of hospice services
Recertification: 15 days prior to 2 days after new benefit period
Conduct face-to-face visit: within 30 days prior to new certification period (Only required prior to 3rd benefit period and any subsequent benefit periods).
Notice of Termination: within 5 days after a patient is discharged from hospice
Certification of Terminal Illness

Homecare Homebase (HCHB)

Hospice Electronic Medical Record (EMR)
Patient documentation for all specialties
Review and create narratives
Order signature & medication reconciliation
Documentation of face-to-face visits
Utilization of nVoq HIPPA compliant speech recognition (see video here)

HCHB IDT Console

Medical Director Responsibilities

Timely documentation (IDT notes, F2F, CTI, order signatures & timesheets)
- F2F Point Care Training Video
- Face-to-Face Recertification Encounter Timesheet
- MD Timesheet
- IDT Time Template
- Elements (Discussion 5-6 min. for new admit, 2-3 min for recerts and recurring)
Activate & utilize Compassus email/Microsoft Teams
- Promptly respond to messages and calls (urgent requests within the hour)
Timely face-to-face completion
Participate in quarterly medical director meeting
Notify DCS when taking time off and coordinate coverage
Death certificate completion
Establish and maintain accreditation Hospice Medical Director Certification
- Face-to-Face Recertification Encounter Timesheet
Medical Directors Roles and Responsibilities
Participate in QAPI (Quality assessment Performance Improvement)
Lead Interdisciplinary team (IDT) (Bimonthly meeting to develop a patient and family-centered plan of care)
Document clinical disease progression to initiate, maintain, or recommend discontinuing hospice services

General Inpatient Care (GIP)

Short-term hospice care for symptom control not achieved in an outpatient setting (intractable pain, terminal agitation, IV drip)
Daily documentation supporting the need for inpatient care
Develop a disposition plan in advance of symptom control
GIP is not a substitute or bridge to nursing home placement
GIP Toolkit(PDF, 4.1 MB)
GIP Care for the Hospice Patient

Interdisciplinary Team Meeting (IDT)

Review patient clinicals prior to IDT to discuss patient care plan and complete CTIs
IDT Agenda and Sign-in
CTI Physician Tip Sheet
CTI Examples(PDF, 65 KB)
De-prescribing Recommendations
Optum formulary
Enclara formulary
Document subjective & objective data to demonstrate the progression of illness
Recommend discontinuation of hospice services if ineligible with the transition to palliative care
Cloning notes is strictly prohibited
Avoid the use of signs or symptoms as hospice diagnosis (FTT or debility

Pain Assessment & Opioid Stewardship

Pain is complex and multifactorial
Identify pain threshold and goals
Utilize PQRSTE (Palliating/provoking factors, Quality, Radiation, Severity, Time, Effect)
Utilize the PAINAD scale(PDF, 60 KB) for patients unable to self-report
Therapy should focus on medication and non-drug treatment
Total Pain Management Tool
Guide to Opioid Stewardship
CDC Opioid Conversion Calculator
Opioid Stewardship: Self-guided clinical compliance video training
Download the Guide to Opioid Stewardship