Hospice Providers and Patient’s Primary Physicians

Study Finds that Dying Patients and Families Suffer from Lack of Continuity of Physician Care: NHPCO Stresses the Importance of Continued Involvement between Hospice Providers and Patient’s Primary Physicians

( Alexandria , Va ) – In study published in March 9 issue of Archives of Internal Medicine, researchers found that patients and families can suffer from feelings of abandonment when a physician who had been actively involved in care is no longer involved. Additionally, when there was no continuity between care providers, a lack of closure following the patient’s death was found among families as well as the referring physicians and their staff.

National Hospice and Palliative Care Organization wants to emphasize the importance of the primary physician’s ongoing involvement with a patient and family once a person has been referred and made the transition to hospice care.
“There are certainly challenges in maintaining ongoing communication between referring physicians and hospice providers, but this study demonstrates that there is a need,” said J. Donald Schumacher, NHPCO president/CEO NHPCO. “Having a process in place that enables all parties to stay connected and informed is critically important in keeping the patient at the heart of care. In fact, regulations require it.”

In the Centers for Medicare and Medicaid Services conditions of participation (CoPs) for Medicare certified hospice providers, involvement of the primary physician is indicated. Current CoPs require that the hospice interdisciplinary group complete the patient’s initial comprehensive assessment in consultation with the individual’s attending physician (if any) within five days of the election of hospice. And the care plan developed by the hospice team must be done in consultation with the patient’s attending physician.

As healthcare providers continue to work on creating a more seamless continuum of care from diagnosis through hospice, the need for patients and families to feel supported is critically important. “All physicians who have cared for a person during a life-limiting illness should continue to be a part of the patient’s journey at the end of life. While the primary physician’s role will change, his or her involvement should not stop when hospice starts,” Schumacher noted. Recognizing the importance of supporting families, hospices offer bereavement services to family members for a year after the death of their loved one.

For more information about hospice, palliative care and advance care planning, please visit NHPCO’s Caring Connections Web site or call the HelpLine at 800/658-8898.

Contact:
Jon Radulovic
NHPCO, Vice President of Communications
Ph: 703-837-3139

ASK THE DOCTOR - Pneumonia Vaccine

My doctor told me that I should get a pneumonia shot, what is that and is it the same as the flu shot?

Viral pneumonia is a serious complication of Influenza (the flu). Taking the flu shot each season will help protect you from the most common flu strains for that year.

The adult pneumonia shot, Pneumovax, is different from the flu shot. It protects against 23 strains of pneumococcal bacteria. These bacteria commonly cause pneumonia, which can be life threatening in older adults. The bacteria can also cause serious infections in the blood, spinal cord and brain which life are threatening as well.
The vaccine does not prevent every type of pneumonia, but it's very effective at protecting people from these more dangerous pneumococcal diseases. The pneumococcal vaccine has been shown to be safe and effective at preventing illness for up to 10 years. Side effects include pain or redness at the injection site, fever and muscle aches. A booster is recommended after 10 years.
The shot is covered by Medicare and recommended for all patients over 65. The vaccine protects against 88 percent of the pneumococcal bacteria that cause pneumonia. No shot can protect you against all types of pneumonias but pneumococcal pneumonias are the leading cause of vaccine preventable deaths in the US. Just think - here is a great New Year’s resolution that Uncle Sam will even pick up the tab for.

If you would like to submit a question please contact Jennifer Trebler at jtrebler@ramonavna.org.

ELDER ABUSE - Constructive Fraud

George F. Dickerman, Attorney

In elder financial abuse cases, it is often difficult to prove that the defendant intended to commit a fraud against an elder. Many times, the elder is incapacitated and unable to give meaningful testimony at trial and the only eyewitness that can testify is the defendant.

Constructive fraud can then play an important role in proving the case of financial abuse. The defendant's actual fraudulent intent is not required. Instead, the law looks to other factors to show that a fraudulent occurrence took place. These other factors include the existence of a confidential or fiduciary relationship where the defendant had the opportunity to take advantage of, or exercise undue influence over, the elder.

For example, a paid caregiver who spends a substantial amount of time with an elder will have developed such a special confidential relationship. When this occurs, the caregiver owes a moral, social and domestic duty not to take advantage of the elder's weaker state of mind. But how can a fraud be committed when the defendant did not have an actual intent to commit fraud?

Here's an example: A caregiver wants to receive a cash gift from the elder and convinces her that it would be wonderful if she would sign several checks to the elder's children, and then also drops a hint that the caregiver would also appreciate such a gift. The elder agrees, signs all of the checks, and the caregiver agrees to deliver them to the children. However, the caregiver then decides that she wants all of the money, and forges the signatures of the elder's children and endorses each of their checks to the caregiver. Under this scenario, the fraudulent intent was not present until after all of the checks were signed by the elder. However, the totality of the circumstances, including the caregiver's initial desire to receive her own gift, clearly show that the caregiver's actions were fraudulent and that she breached her duty in order to gain an advantage over the elder.

In California, the fiduciary relationship has been extended to every possible case in which a fiduciary relation exists as a fact. Such relation need not be legal; it may be moral, domestic or merely personal (Foster v. Keating (1953) 120 CA2d 435).

When such a special relationship can be shown, the law then imposes a presumption that the elder was subjected to undue influence. This acts to shift the burden to the defendant to prove that fraud did not occur.
This presumption is implemented to further the public policy of securing an elder's property and money when they have been entrusted to others.

Constructive fraud is another theory to prove that elder financial abuse occurred when the evidence is limited because of the elder's incapacity. The theory should be utilized by attorneys as one of numerous other causes of action to be included in a lawsuit for financial abuse.

Law Office of George F. Dickerman
3879 Brockton Avenue, Riverside, California 92501
(951) 788-2156
www.Elder-Law-Advocate.com
george@Elder-Law-Advocate.com

If you would like to submit a question please contact Jennifer Trebler at jtrebler@ramonavna.org.

ASK THE DOCTOR - Silent Heart Attacks

Question: I recently heard about someone who had a “silent heart attack”. What is a “silent heart attack” and how can you tell if you have had one?

Answer: A heart attack, also known as a myocardial infarction, is a condition caused by a blockage in one or more of the blood vessels that supply the heart with oxygen. Blockage of these blood vessels deprives the heart muscle of oxygen and results in permanent damage to the heart and possible death. Common symptoms of a heart attack include chest pain that may radiate into the shoulders, arms or jaw; shortness of breath, sweating, dizziness and nausea. Less common symptoms include abdominal pain, severe fatigue, or an impending feeling of doom. Anyone having these symptoms should seek emergency medical attention; unless that feeling of impending doom occurred while doing your taxes – I consider that quite normal.

Many people assume that everyone having a heart attack will have chest pain when in fact only about 50% of people having a heart attack will experience typical chest pain. Patients older than 65 as well as those with diabetes are less likely to have typical chest pain at the time of a heart attack and are more likely to report vague symptoms such as fatigue or indigestion like symptoms. Some patients have heart attacks without any symptoms, when this occurs it is referred to as a “silent heart attack”.

An electrocardiogram (EKG) is a test that can determine if a patient has had a heart attack in the past. In one study done on elderly patients, 21-68 % of patients with EKG evidence of a prior heart attack had no known prior symptoms. Many people mistakenly think of heart disease as being more common in men than women. According to the CDC; heart disease is the leading cause of death in both men and women accounting for a nearly identical 27% of all deaths in both men and women.

Patients with risk factors for heart disease such as smoking, hypertension, diabetes, elevated cholesterol, obesity or a family history of heart disease should discuss their condition with their physician to determine if they should undergo evaluation for silent heart disease. All patients should seek emergency attention whenever they experience chest pain or any of the other warning symptoms of a heart attack.

If you would like to submit a question please contact Jennifer Trebler at jtrebler@ramonavna.org.

Encouraging Quality & Discouraging Abuse

Visiting Nurse Associations of America (VNAA) the official national association for Visiting Nurse Agencies (VNAs) and nonprofit, community-based home healthcare agencies (HHAs) has released a white paper on Medicare fraud and abuse titled “Medicare Home Health: Encouraging Quality and Discouraging Abuse” during the week of March 2.
In early 2008 I was invited to participate with the VNAA in preparing this important document, the purpose of which is to raise awareness among the general public and policymakers of the sources of fraud and abuse in the home healthcare field and to contribute useful suggestions for reform of the Medicare home health benefit. Recommendations for reform include changes in payment policy, Medicare Conditions of Participation (CoP), Medicare home health enrollment procedures, medical review and anti-kick back rules.

Andy Carter, President and CEO of VNAA, wrote, “While most home health agencies (HHAs) provide high-quality home healthcare and comply with Medicare policy, abusive and even fraudulent conduct by a minority of Medicare certified HHAs threatens the quality of patient care, drives up Medicare costs and undermines the perceived value of home healthcare. This comprehensive document was developed with input from specific VNAA membership committees and was vetted on a broader scale through a membership wide survey conducted in October, 2008. Since then, it was presented to the Centers for Medicare and Medicaid Services’ (CMS) staff in a December, 2008, meeting and shared with the Medicare Payment Advisory Commission (MedPAC) in January, 2009.”

“It’s particularly important to raise these issues to ensure patients are able to get and receive high-quality care. Across the board payment reductions to the Medicare Home Health Program could result in limiting patient access to good clinical care,” stated Bob Wardwell, VNAA’s Vice President of Regulatory and Public Affairs.

I invite and encourage you to read this important document, and to support the efforts of the not-for-profit agencies whose efforts in the provision of ethical, high quality care, must continue. With the new Administration’s proposed changes to the federal budget, it is critical that our legislators understand the potential negative impact to the provision of home health and hospice services, which will result if there are further cuts to the Medicare and Medicaid programs for home health and hospice care. “We believe the timing for releasing these recommendations is right. With so many proposals addressing changes and cuts to the Medicare system we wanted to highlight the importance of staying focused on quality of care in the home healthcare system,” added Carter.

Read this important White Paper by CLICKING HERE

NHPCO Statement on MedPAC Recommendations to Congress

(Alexandria, VA) – Today, the National Hospice and Palliative Care Organization released the following statement upon the release of the Medicare Payment Advisory Commission’s (MedPAC) March report to Congress. The report includes recommendations to revise the Medicare hospice benefit.

Each year, more than 1.4 million patients and family caregivers seek hospice care. The Medicare hospice benefit is responsible for millions of people living as fully as possible until the end of life. The hospice community is dedicated to not only preserving the benefit, but enhancing it so that hospice is able to continue to appropriately serve the unique and changing needs of dying Americans. Hospice and palliative care providers, through the support that comes from Medicare, are recognized as the leading providers of the interdisciplinary, holistic care considered to be the “gold standard” of end-of-life care.

Hospice care is also cost-effective. As was reported in a 2007 Duke University study, hospice reduced Medicare costs by an average of $2,300 per patient, amounting to a $2 billion savings in a single year.

Statement on MedPAC’s Recommendations for Hospice Reform:

Over the past several years, MedPAC has undertaken a review of the Medicare hospice benefit. While specific reforms and enhanced accountability measures are laudable and should be encouraged, those changes should be framed in the context of a comprehensive review of the various and complex components of end-of-life care, and how the continuum of care can be expanded to increase access for patients and families. Included in this comprehensive review of hospice should be payment methodologies, fiscal constraints review, alternative eligibility criteria, testing of new models of care, as well as any number of other issues. The hospice community is committed to work toward these goals.

Guiding this review ought to be several clear principles. Among them are:

>Advancing hospice and palliative care programs as the recognized providers of end-of-life care;
>Preserving and enhancing the Medicare hospice benefit;
>Recognizing “high quality” as the standard to which all providers must subscribe;
>Ensuring accountability through transparency and fair regulatory scrutiny; and
>Promoting increased access through expansion and collaboration.

Payment policy is one of the areas of the Medicare hospice benefit that needs to stay current, so that payment appropriately recognizes changes on patient demographics and treatment protocols. Updates should be carefully considered and evidence-based to ensure that behavioral consequences are understood prior to implementation. The present payment methodology has served the hospice community and the public well since its inception, virtually without change. Analysis of both current and historical patient level data is necessary to fully understand and predict future behavior and needs, and make changes that continue to provide benefits to patients and to the Medicare system.

As with any payment system, dramatic changes to the hospice benefit from established patterns of reimbursement are sure to produce displacements and unintended negative consequences. Given the nature of hospice referrals and the unique characteristics of the end-of-life patient demographics, unintended consequences of such changes are inherently difficult to predict. Any number of issues might warrant attention, but effectively quantifying such items in terms of behavior changes of patients and providers would be difficult. Payment reforms should be incremental, based on adequate data analysis, and need to be undertaken carefully, with effects on the patient and family in mind.

The hospice community applauds the open and informed process that MedPAC undertook to produce the recommendations, and looks forward to working with the Commission, appropriate oversight agencies, and Congress to ensure that the Medicare hospice benefit continues to serve patients at the end of life in the compassionate and high-quality manner that they deserve and expect.”

Contact:
Sara Perkins
Manager, Public Policy Communications
Ph: 703-837-3135
sperkins@nhpco.org

used with permission from NHPCO