Who is the Doctor? Meds Covered?

[RNGreen]

Hi all,

I have been reading this thread for sometime, and now I am a ft hospice nurse (case manager). I was per diem for several months very part time and on call, then they offered me the ft position, and here I am. It is sooo different, before I was only filling in and triaging. Now I am responsible for the Case. Meds being correct, paperwork correct and filled out, pprs faxed as needed, charts correctly filed, and that is just the paperwork. It is more work than I thought and more questions now than before. My main question of this week, which I cannot seem to get a straight forward answer to, is who is the main doctor, the attending??

I know we have a medical director and sometimes he is the Attending physician, that is easy and great.

Next there is an Attending and he knows the patient is on hospice and may have even ordered it and agrees to be the attending. Good.

Next there is the (for example) cardiologist who referred the patient to hospice, and is written down as the attending, so when called for new meds, he does not want to be called, only for cardiac issues. (Not so good.) So I call the patient's primary physician, and he is upset his patient is on hospice because he was not informed and this is an ethical issue....etc, etc. So in the mean time I asked the medical director to be her Attending until the issue with the other docs can be worked out. Pt alert and oriented, no pain meds.

Another case: A new patient, and they are on about 20 meds(no pain meds). They have a renal doc, and a primary, and a pulmonologist, who discharged the patient from the hospital and the patient goes home on tons of meds. I faxed all the meds to her Attending md (her pcp), and he d/c'd only 2. The patient is alert and oriented. The family asks, who do we call her renal doctor, to change or d/c renal meds? Her primary diagnosis is severe aortic stenosis, then chf, I believe (chart in car).

Which leads me to another question: Meds are only covered that have to do with the Hospice Dx, OK, so who decides this, me? I was told I decide what meds are needed for her hospice dx. I really quite frankly don't know. Should I call the pharmacist, her pcp? I know what meds are covered also depends upon the cost. I know most meds are covered for pain. But why is a patient on so many meds while on hospice, she is still walking (with walker) and alert and oriented. Are these meds to control her symptoms, can't they be cut down? What meds are r/t Severe Aortic Stenosis? I know what meds are covered for chf: lasix... I feel these two patients are more for skilled, and they both have Severe aortic stenosis as Hospice Dx.

I hope I didn't confuse anyone too bad. Any words of wisdom are greatly appreciated!

[tewdles, RN]

Hi all,

I have been reading this thread for sometime, and now I am a ft hospice nurse (case manager). I was per diem for several months very part time and on call, then they offered me the ft position, and here I am. It is sooo different, before I was only filling in and triaging. Now I am responsible for the Case. Meds being correct, paperwork correct and filled out, pprs faxed as needed, charts correctly filed, and that is just the paperwork. It is more work than I thought and more questions now than before. My main question of this week, which I cannot seem to get a straight forward answer to, is who is the main doctor, the attending??

I know we have a medical director and sometimes he is the Attending physician, that is easy and great.

Next there is an Attending and he knows the patient is on hospice and may have even ordered it and agrees to be the attending. Good.

Next there is the (for example) cardiologist who referred the patient to hospice, and is written down as the attending, so when called for new meds, he does not want to be called, only for cardiac issues. (Not so good.) So I call the patient's primary physician, and he is upset his patient is on hospice because he was not informed and this is an ethical issue....etc, etc. So in the mean time I asked the medical director to be her Attending until the issue with the other docs can be worked out. Pt alert and oriented, no pain meds.

Another case: A new patient, and they are on about 20 meds(no pain meds). They have a renal doc, and a primary, and a pulmonologist, who discharged the patient from the hospital and the patient goes home on tons of meds. I faxed all the meds to her Attending md (her pcp), and he d/c'd only 2. The patient is alert and oriented. The family asks, who do we call her renal doctor, to change or d/c renal meds? Her primary diagnosis is severe aortic stenosis, then chf, I believe (chart in car).

Which leads me to another question: Meds are only covered that have to do with the Hospice Dx, OK, so who decides this, me? I was told I decide what meds are needed for her hospice dx. I really quite frankly don't know. Should I call the pharmacist, her pcp? I know what meds are covered also depends upon the cost. I know most meds are covered for pain. But why is a patient on so many meds while on hospice, she is still walking (with walker) and alert and oriented. Are these meds to control her symptoms, can't they be cut down? What meds are r/t Severe Aortic Stenosis? I know what meds are covered for chf: lasix... I feel these two patients are more for skilled, and they both have Severe aortic stenosis as Hospice Dx.

I hope I didn't confuse anyone too bad. Any words of wisdom are greatly appreciated!

Wow...

The referring physician generally decides if he/she is going to manage the hospice care...often, because this is a hospitalist or specialist, they defer to the medical director. It should be rare for the PCP to be completely uninformed about the hospice referral or admission. This is REALLY a failure in communication between that patient's physicians.

It sounds like there is some communication problem in your agency. The majority of these physician questions should be answered during the referral process...and not left for the case manager to sort out. In the case with the annoyed PCP, ok, that is understandable and he had a tantrum...next ask him if he wants to manage the hospice care, then just move on. Clearly it is much easier for us when the med directors are managing the care...we have a really good idea what to expect and do not need to spend valuable time educating physicians and their staff about palliative pathways for care.

Remember that when you have a patient with say, CHF, they may continue all care and visits related to other medical diagnosis when on hospice without payment problems. They may visit their pulmonologist or neurologist, etc and treat those specific diseases seperately from the hospice care. Having said that, it makes good sense to be actively counseling patients and families who are pursuing aggressive medical care for one diagnosis when another diagnosis is terminal and will cause their death within 6 months. Still, I have patients who are on hospice for one thing and continue dialysis or some other routine treatment until they are just too ill to continue, they are never emotionally able to decide to give it up.

Yes, you do have to develop a good sense of what meds will be covered by your hospice for different diagnosis'. Mostly because you need to communicate it to the patient and family, so they know what to expect in terms of bills, etc. Personally, I never fax the admitting med list to the doc, I speak with them on the phone so that I can ask directly about any meds which I, as the hospice professional, question in terms of relevance to the hospice goals of care expressed by the family. So, I ask the patient and family if they prefer to continue each of the meds in turn...and then I communicate patient wishes and hospice philosophy to that managing doc. I often get what I want, but not always...sigh, just like my life in general...

Clearly some medication questions are more straightforward that others...remember that you are not an island and that you have an office support team which can help you with some of these questions. So, on the more convoluted cases, like the aortic stenosis patients you mentioned, bend the ear of your team leader/supervisor...compare the meds to the your pharmacy list...speak with the hospice pharmacist or a medical director. Do not be afraid to take their time to answer these questions...everybody is busy, even you, and you MUST have answers to these questions in order to provide good hospice care.

I find it helpful to remind myself that a patient has a great deal of say in what their hospice experience looks like. So I have patients who come to hospice and are eager to DC all of their meds...I have to encourage them to continue some to prevent complications or symptoms...and there are others who want ALL of their meds, even those big honking vitamin and mineral tablets that are doing nothing for them. So, for me, it starts first with what the patient wants and then what the physician wants/changes. Of course, as the case nurse, I speak regularly with my patients about their POC including their med profile, pretty much every visit.

Case management is a very different groove than what you were doing. It is important to be as efficient at the visit as you can, and to keep a notebook for yourself. I try to take care of all calls, orders, refills, MD questions, etc. at the patient home with patient or family present for 2 reasons...first, they know it got done and won't call 20 times wondering...and second, it removes the possibility that I will get busy and not get it done that day...saving myself from as much "roll-over" of tasks from day to day is a priority for me.

I love case managing and I hope you are successful in this transition. Good luck and let us know how you are doing!

[AtlantaRN, RN]

usually the agency is in such a hurry to get a patient on service, that it is left to the case manager to contact admitting physician to see indeed if he is going to continue to be the attending. Some physicians will write an order, medical director to be attending...........those are rare instances. On our admission paperwork, it asks if admission nurse has contacted admitting physician, and if they are going to maintain attending status........if it is rolled over to the medical director (in a perfect world, this is what I prefer, because I don't have to wait weeks for a signed order for a CII medication), then I have to get an order from the medical director that he will accept patient.

In a perfect world, this has been written as an order during the pre admission process--but this is not a perfect world and it usually falls to me.

As to the medications----anything that is considered a primary medication for the patients admitting diagnosis is covered...................i LOVED hospice pharmacias' program, you would enter in the patients diagnosis, and enter their medications and the program would TELL YOU what was covered under their MUG (medication usage guide).....it was great because you could print it out and take to your follow up visit with the patient and family and the nurse wasn't the "bad guy" not wanting to pay for their medications.........what my company uses is EHO, which is essentially a billing system, and it does not have the ability to tell you what med is covered........

Essentially what I do, is profile meds in eho system, and hit the "info" button which tells me what meds are for.....if it's a chf patient, we will cover meds like lasix for edema, and the resulting potassium supplement because lasix is potassium wasting; also pain medications and sleep meds that are formulary (we pay for restoril, but not ambien and lunesta, etc). pretty much its like sitting down with a drug book and looking up the meds and I will profile as such.....lasix 20mg by mouth daily for edema...that way when i print out the mar for the chart, nurse and family, it lists exactly what that medication is for and if it is covered or not.

linda

[tewdles, RN]

I agree, Linda, that HP's MUGs are very helpful...

In my previous hospice job we didn't use HP but we had a pharmD who reviewed all the profiles at time of admission...that was a huge bonus and I learned a great deal from her.

[RNGreen]

Thank you both for your help and input. We soon will be on Cerna and Hospice Pharmacia, so I look forward to the changes. Right now we are all paper. There are still many things to understand for me, so I will be back. I did speak to my supervisor and she is going to be going over more info with me on a weekly basis now, so I will have a chance to ask questions and get answers. Of course I still ask my coworkers and they are helpful too. It is a work in progress (me and my job

Thanks again!!