CSAC Excess Insurance AuthorityAnnual Medical Malpractice Programs

Training

Wednesday, April 23, 20089:00 a.m. - 4:30 p.m.

Sacramento, CA

WelcomeMichael Fleming, ARM, Chief Executive

Officer, CSAC Excess Insurance Authority

“housekeeping”HandoutsCEU’s & Sign-in SheetsTravel reimbursement formsElectronic evaluation formQuestionsBreaks, lunchBathrooms, public telephonesCell phone reminder

AgendaLegal and Risk Management UpdateTort Reform: MICRA UpdateFalls, Wandering, Elopements and AMAMedication ErrorsCorrectional Care - Pre-Booking Medical CostsCombining Mental Health and Substance AbuseHIPAA Update/Confidentiality ConcernsAdvance Directives for HealthcareHospice Care

Resourceswww.csac-eia.org

California State Association of Counties Excess Insurance Authority - check out Resources (Best Practices Library) and Services (Loss Prevention)

www.rmscotati.com Risk Management Services - use “links” button

www.leginfo.ca.gov California statutes - “x” one Code at a time, then

“search” for table of contents

www.calregs.comCalifornia Code of Regulations (CCR) - helpful

to know which Title and Section number

www.cdcr.ca.govCalifornia Department of Corrections and

Rehabilitation - click on “Corrections Standards Authority” and then, (on left side) click on “Regulations” then find Adult and Juvenile Health Regulations and Guidelines

www4.law.cornell.educlick on Federal Constitution, US Code (laws), or

CFR (Code of Federal Regulations)

www.coce.samhsa.govU.S. Department of Health and Human Services,

Substance Abuse and Mental Health Services Administration (click on “COCE” - SAMHSA’s co-Occurring Center for Excellence)

www.youthlaw.orgNational Center for Youth Law

www.calhealth.orgCalifornia Hospital Association (click on

“publications” and then “forms and posters”)

www.californiahia.orgCalifornia Health Information Association (click

on “publications”)

www.lac.orgLegal Action Center, click on “publications” to

get to Confidentiality and Communication (2006 edition), A Guide to the Federal Drug and Alcohol Confidentiality Law and HIPAA

Linda Garrett, JDRisk Management Services

9:05 a.m. - 10:00 a.m.

Update: Laws, Regs, Risk Management Issues

Records retention

Confidentiality

HIV Consent

Mental Health

Errors/Hospital Acquired Conditions

Records Retention: Proposed new legislation

SB 1415 - An action to add

H&S Code 123106a) 10 years minimum records retentionb) at time record is created, patient may elect

to have record archived longer than 10 yearsc) no fewer than 60 days before records are

destroyed healthcare provider must notify the patient and ask if they’d like them archived!

Records Retention - Old Law - New Solution

Clinic records should be maintained, at a minimum, for 7 years past the last date patient is seen, or in the case of minors, until 1 year past the age of majority, whichever is longer

1/1/07 - Business and Professions Code 2919 Psychologists’ records for minors must be retained until minor turns 25 years of age! Most providers keep until year that client would turn 26

Most counties now keep all minor records that include mental health services according to this rule so that they don’t have to search each record for notes that might have been written by a psychologist

Speaking of records…Be careful who you contract with to destroy

the records, and who you contract with to transcribe records - beware the overseas subcontractor!

Make sure you have a Business Associate Agreement and “hold harmless” language in the contract and that company has adequate insurance coverage and you have proof of insurance (certificate)

Confidentiality/Privilege

Domestic Violence Victim-Counselor Privilege

SB 407 clarifies and strengthens the definitions of domestic violence victim-counselor privilege and extends it to communications to “domestic violence counselors” not previously included in the definitions (amends Evidence Code sections 1037.1, 1037.2, 1037.4 and 1037.5; also Penal Code 679.05)

Sharing medical info about “300” or “600” kids (dependents or wards):

AB 1687 amends Civil Code 56.10 by adding 56.103 to permit disclosures of information about children and youth that is protected under CC 56.10 to a county social worker, probation officer or other person legally authorized to have custody or care of a minor for the purpose of coordinating health care services and medical tx provided to the minor.

LPS Act (county mental health) info NOT covered by

this new law : (

HIV disclosuresWritten authorization normally needed to disclose

HIV test results and related info

Exceptions to this rule include:To the patient or patient representative (e.g.,

conservator)To the health care provider (ok to include in chart)To an agent or employee of the provider who

provides direct patient care and tx

Exceptions (continued):

To a provider under the Uniform Anatomical Gift ActPursuant to an organ donationAnonymously to a “designated officer” under the

Ryan White Act when there has been a possible first responder exposure

After an occupational exposure, following strict guidelines

Under certain Penal Code sections w/court order or search warrant

HIV Consent to TestingLaw now says a physician treating a patient

must obtain INFORMED (rather than using the word WRITTEN) consent

Everyone else (other than alternative/anonymous site, blood bank or plasma center) must get written consent

Old solution: the best way for a physician to demonstrate and prove informed consent, is to get it in writing!

Mental Health5150 Update

SB 916 allows non-designated hospitals to detain individuals who are danger to self, others or gravely disabled, up to 24 hours while they look for a 72 hour involuntary bed to transfer the patient to.

Note: this is not a “hold” -- it is merely protection from litigation for false imprisonment if an individual is prevented from leaving for up to 24 hours while a transfer is arranged - the hospital can choose to let the person leave sooner if the condition is “stabilized”

Health and Safety Code 1799.1111799.111. (a) A licensed general acute care hospital,

… that is not a county-designated facility pursuant to Section 5150 of the Welfare and Institutions Code, a licensed acute psychiatric hospital, … that is not a county-designated facility pursuant to Section 5150 of the Welfare and Institutions Code, licensed professional staff of those hospitals, or any physician and surgeon, providing emergency medical services in any department of those hospitals to a person at the hospital…

…shall not be civilly or criminally liable for detaining a person who is subject to detention pursuant to Section 5150 of the Welfare and Institutions Code, if all of the following conditions exist during the detention:

(1) The person cannot be safely released from the hospital because, in the opinion of the treating physician and surgeon, or a clinical psychologist with the medical staff privileges, clinical privileges, or professional responsibilities provided in Section 1316.5, the person, as a result of a mental disorder, presents a danger to himself or herself, or others, or is gravely disabled. For purposes of this paragraph, "gravely disabled" means an inability to provide for his or her basic personal needs for food, clothing, or shelter.

(2) The hospital staff, treating physician and surgeon, or appropriate licensed mental health professional, have made, and documented, repeated unsuccessful efforts to find appropriate mental health treatment for the person.

(3) The person is not detained beyond 24 hours.

(4) There is probable cause for the detention.

5) If the person is detained beyond eight hours, but less than 24 hours, all of the following additional conditions shall be met:

(A) A transfer for appropriate mental health treatment for the person has been delayed because of the need for continuous and ongoing care, observation, or treatment that the hospital is providing.

(B) In the opinion of the treating physician and surgeon, or a clinical psychologist with the medical staff privileges or professional responsibilities provided for in Section 1316.5, the person, as a result of a mental disorder, is still a danger to himself or herself, or others, or is gravely disabled, as defined in paragraph (1) of subdivision (a).

Subsection (d) specifically states that the time detained, up to 24 hours, shall be credited against the subsequent 5150 (72 hr) hold

SB 1606 - Yee (Laura’s Law)An act to amend Laura’s Law to make

implementation easier (as originally proposed)

Introduced February 22, 2008; read first time on February 25, drastically amended April 3, heard on April 15, re-referred to committee on April 16, next hearing set for Monday, April 28.

Tarasoff Warnings

Psychotherapist has a duty to warn when client communicates (even through a family member) a serious threat of harm against a reasonably identifiable victim or victims

Civil Code 43.92 - no liability against psychotherapist if he/she makes reasonable efforts to communicate the threat to the victim or victims and to a law enforcement agency

W&I Code 5328 Exceptions to Confidentiality:

r) When the patient, in the opinion of his or her psychotherapist, presents a serious danger of violence to a reasonably foreseeable victim or victims, then any of the information or records specified in this section may be released to that person or persons and to law enforcement agencies as the psychotherapist determines is needed for the protection of that person or persons. For purposes of this subdivision, "psychotherapist" means anyone so defined within Section 1010 of the Evidence Code.

But, W&I Code 5328 only applies to records

“…created in the course of providing services under Division 4 (commencing with Section 4000),

Division 4.1 (commencing with Section 4400), Division 4.5 (commencing with Section 4500), Division 5 (commencing with Section 5000), Division 6 (commencing with Section 6000), or Division 7 (commencing with Section 7100), to either voluntary or involuntary recipients of services …. “

So, what about private pay, private practice therapists?

AB 1178 clarifies that private pay, private practice, psychotherapists who are covered by Civil Code 56.10 (and do not fall under the LPS Act confidentiality protections) may do Tarasoff warnings and that this would be an exception to their confidentiality rules, too!

Civil Code 56.10 - Confidentiality of Medical Information Act or CoMIA

56.10. (a) No provider of health care, health care service plan, or contractor shall disclose medical information regarding a patient of the provider of health care or an enrollee or subscriber of a health care service plan without first obtaining an authorization, except as provided in subdivision (b) or (c).

New subsection:(c)(19) The information may be disclosed, consistent

with applicable law and standards of ethical conduct, by a psychotherapist, as defined in Section 1010 of the Evidence Code, if the psychotherapist, in good faith, believes the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a reasonably foreseeable victim or victims, and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Old law:

Civil Code 56.10 (b)…disclosures shall be made…(9) When otherwise specifically required by law.

Adverse Event Reporting1998 IOM report

Leapfrog Group - 28 “never events”

July 1, 2007 - reporting of specific adverse events must be reported by hospitals to their local California Department of Health Services Licensing and Certification Office

Deficit Reduction Act

Preventable Errors/HAC’sAs of October 1, 2008 CMS will no longer pay

for certain “preventable errors” and “Hospital Acquired Conditions”

Many other health insurance companies are following that lead (the Blues, CIGNA, etc.) and sending letters to hospital administrators “asking” them not to bill them, or their members, for certain adverse events

February 2008 - the AHA sent a letter to its hospital members asking them to voluntarily adopt a no-charge policy for serious adverse events (“never events”)

Crucial that medical staff charts POA (“present on admission”)

HAC’s include:Object left in during surgeryAir embolismBlood incompatibilityCatheter-associated urinary tract infectionPressure ulcers (bed sores)Vascular-catheter-associated infectionSurgical site infection (specifically mediastinitis

after coronary artery bypass grafting surgery - CABG)

Hospital-acquired injury due to external causes such as falls crushing injury, burns , etc.

Joint Commission publicationCultural Sensitivity: A Pocket Guide for

Health Care Professionals

www. jcrinc.com

> Publications: >> search “Cultural Sensitivity”

($35 for 5 booklets)

Questions?

Anthony D. Lauria, Esq.

Lauria Tokunaga Gates & Linn, LLP

10:00 a.m. - 10:30 a.m.

historyTHE CRISIS

In the early 1970s, a medical malpractice insurance crisis gripped California. Liability premiums soared more than 300 percent because of more frequent and severe liability claims and larger malpractice jury awards. Many physicians — particularly in high-risk specialties such as obstetrics and neurosurgery — were forced to close their doors, either unable to get insurance or unable to afford inflated rates. Denied access to affordable care, California patients suffered. In 1975, Governor Jerry Brown called a special session of the California Legislature to solve the "malpractice crisis."

Pre-MICRA ProblemsCalifornia in the early 70’s saw a dramatic

increase in number and size of malpractice lawsuits

As a result malpractice insurance companies had huge underwriting losses, and raised their premiums anywhere between 300% and 500%; other insurance companies just left the state

One survey showed that more than half of the doctors planned to reduce or entirely stop providing services to California residents

MICRA protects patients' access to:  Acupuncturists Chiropractors Clinical laboratory technicians Dentists Dietitians Hearing aid dispensers Hygienists Licensed Midwives Marriage and Family Therapists Nurse Anesthetists Nurse Practitioners Nurses Occupational Therapists Opticians

Optometrists Perfusionists Pharmacists Physical Therapists Physician Assistants Physicians Psychiatrists Psychologists Research Psychoanalysts Social Workers Speech-Language Pathologists

and Audiologists

Telephone Medical Advice Services

Veterinarians

Provisions of MICRA1. Limits on Non-Economic Damages

Non-economic damages in a claim against a health care provider for medical negligence are limited to $250,000. Economic damages, such as lost earnings, medical care, and rehabilitation costs, are not limited by statute. California Civil Code Section 3333.2.

2. Evidence of Collateral Source Payments A defendant in a medical liability action may introduce evidence of collateral source payments (such as from personal health insurance) as they relate to damages sought by the claimant. If a defendant introduces such evidence, the claimant may also introduce evidence of the cost of the premiums for such personal insurance. Civil Code Section 3333.1.

Provisions of MICRA3. Limits on Attorney Contingency Fees

In an action against a health care provider for professional negligence, an attorney’s contingency fee is limited to 40% of the first $50,000 recovered; 33% and 1/3 of the next $50,000; 25% of the next $500,000, and 15% of any amount exceeding $600,000. California Business and Professions Code Section 6146.

4. Advance Notice of a ClaimTo further the public policy of resolving meritorious claims outside of the court system, MICRA requires a claimant to give a 90-day notice of an intention to bring a suit for alleged professional negligence. If the notice is given within 90 days of the expiration of the statute of limitations, the statute is extended 90 days from the date of the notice. California Code of Civil Procedure Sections 364 and 365

Provisions of MICRA5. Statute of Limitations

 In California, a claim for alleged medical negligence must be brought within one year from the discovery of an injury and its negligent cause, or within three years from injury. Code of Civil Procedure Section 340.5.

6. Periodic Payments of Future DamagesA health care professional may elect to pay a claimant’s future economic damages, if over $50,000, in periodic amounts. This avoids a claimant’s wasting of an award prior to actual need. Code of Civil Procedure Section 667.7.

Provisions of MICRA

7. Binding Arbitration of DisputesPatients and their health care providers may agree that any future dispute may be resolved through binding arbitration. California statute requires specific language for such contracts and also provides that all such contracts be revocable within 30 days. Code of Civil Procedure Section 1295.

Impact of MICRA

Insurance Information Institute2003

Impact of MICRA

Lower Median Awards

Effects of MICRAInsurance Information Institute003

A General Accounting Office report on medical malpractice published in December 1986 singled out the reforms enacted in California as among the most effective in moderating increases in the cost of insurance and the size of awards. According to Jury Verdict Research data, the median jury award in medical malpractice litigation in California in the period 1997 to 2002 is $402,500, significantly lower than other states with no reforms. It compares with an award median for the period 1996 to 2001 of $1 million in New York, $806,750 in Florida and $840,000 in Pennsylvania, for example (Exhibit 12).

Effects of MICRA -continuedInsurance Information Institute003

In addition, the frequency of million dollar plus medical malpractice awards in California is considerably lower than in other states (Exhibit 13). California’s doctors also pay significantly less for their liability insurance than their colleagues in other states. The AMA reports that since 1976, medical liability premiums across the US have increased three times faster than in California. It puts the savings to Californians at more than $1 billion a year. According to the HHS, states with limits of $250,000 or $350,000 on noneconomic damages experienced an average premium increase of just 12 percent to 15 percent in 2001, compared with a 44 percent increase for states with no caps on noneconomic damages.

How successful has MICRA been?At the height of California’s medical liability crisis,

insurance premiums for anesthesiologists reached $22,702 per year. Current rates are $10,337 per year – 50% below the rates charged in 1975.

(Norcal Mutual Insurance Company, January 31, 2003)

Since MICRA was enacted 27 years ago, medical liability premiums in CA have risen just 167% compared to 505% for the rest of the nation.

(Physician Insurers Association of America)

Where we are going?In 1998 there was a huge effort to “reform” MICRA

(especially the “cap” on pain and suffering) --

A study by LECB, Inc. concluded that there were as many claims in 1998 as before enactment of MICRA and that adjusted for inflation, the medically injured received higher compensation after MICRA than before

There has been talk of other attempts to change MICRA -- especially CAP on damages and attorneys fees-- Currently, no pending or threatened legislation

Questions?

BREAK

Linda J. Garrett, JDRisk Management Services

10:45 a.m. - 11:30 a.m.

Quick reviewConsentInformed ConsentCapacityThe Right to Refuse CareRestraints

Patient rightsPeople have the right of self-determination over

their bodies and property.

People have a right to consent to medical care and to refuse care.

Individuals who are unable to exercise this right, have the right to be represented by another person who will speak on their behalf.

RestraintsPatients have right to be free from

restraints

Restraints for medical purposes

Restraints for behavioral purposes

Medical consentShould be informed

Should be understood (language and level of communication)

Should be voluntary

Chart capacity if it is “lacking”What is the nature of the Lack of Capacity?

(unconscious? psychotic? drunk? minor?)

Who will be the surrogate decision maker who will act on behalf of the patient?

FallsJoint Commission: National Patient Safety Goals

> 2006 goal: reducing harm due to patient falls

> Implement a falls reduction program and

conduct ongoing assessment of the efficacy

of the program.

CMS requires facilities to provide care within a safe

setting

> after October 2008, no reimbursement for 8 hospital acquired “preventable” conditions which include falls

Fall facts (ECRI Institute)1.6 million falls reported each year10% in acute setting (30% of those

result in serious injury)Most common injury is hip fracture (24%

die within 1 year, 50% never return to normal level of functioning); after hip fx, risk of falling again increases

Falls cost acute care facilities over $1 billion in 2002 (to treat the 30% of serious injuries)

Insurance claims average $70K

2002 Alabama verdict - $7 M

What are the risks for our patients/residents?

Intrinsic (patient specific) risk factors (physical, mental, cognitive)

Age greater than 65 History of fallsIncontinence, urinary frequency or urgencyLower-extremity weaknessGait and balance deficitsMedications (esp. sedatives, antihypertensive,

tranquillizers, etc, or more than 4 prescription drugs at a time)

Postural or orthostatic hypertensionReduced visual acuity/slowing darkness

adaptation/ depth perception/contrast sensitivityLoss of hearingNeuropathyProprioceptive dysfunctionCervical degenerative disordersFunctional impairmentChanges to mental status (depression, dementia)

Foot disordersPoor impulse controlBelief that asking for help is

inappropriateOther things too!

Extrinsic (environmental) risk factorsDangerous bathrooms (e.g., no rails near toilet)Furniture on wheels or furniture with sharp edgesFlooring that is slippery or covered with loose

rugsIll-fitting shoes, or shoes with soles that stickPoorly maintained equipmentPoor instruction on use of assistive devicesTime of day (shift change, less staff at night)Bed too high; toilet too low

Use of restraints; full length bed railsColors that are monochromatic or that

agitateDistracting noisesPoor communicationPoor staff trainingAttachment to equipment such as monitorsCall button too far; side table too cluttered

Strategies to reduce fallsPolicies and procedures

include definition of “fall” and “near miss”Patient assessment at time of admission and

periodically throughout stayEnvironmental assessmentFrequent toileting (recent study shows 50%

of falls related to toileting needs)Reduce use of restraints, bed rail hazards

Adequate staffing is crucial and staff must communicate risk of falls with patient, family and each other

Identify at-risk patients at admission and during stay; medication review

Train everyone! (patients, family, staff, students, volunteers)

Wandering and Elopements

Wandering off the unit or out of a facility is the 4th most common adverse event in Long Term Care (Gurwitz, JH, et al, J of American Geriatric Society 42(1):33-8)

Potential for significant harm

e.g., 1/5/08 48 year old patient found dead on Detroit street, frozen, dressed only in a hospital gown, t-shirt and boxer shorts

2005 case settled for $750,000 involving 83 y/o woman who suffered fatal head injuries in fall she sustained while wandering away from PA nursing home

Policies, procedures, drills and training are essential

Identify who is at risk (what are the intrinsic and extrinsic factors?)

Diagnoses such as dementia, Alzheimer’s, psychiatric illnesses

Prior historyStated desire to leaveHigher risk when first admitted, at shift change,

during storm or inclement weather

Factors, continued:

Boredom

Personal problems - depression, agitation

strategiesCamouflage enclosures (hide doors so they don’t

look like doors)Enhance signage and clues for finding way back to

roomEnclose outdoor spacesAssign rooms away from high traffic or noiseCreate wandering “path” or space

“Elvis has left the building” codes

Clothing - ask family to bring only one color of clothing (e.g. blue) for resident so staff are “alerted” when person in blue is near a door

Reassessment when there is a “just in time” intervention

Resident-worn transmitters/door alarms (help identify those who are potential exit-seekers)

Window restrictors as allowed by fire code

Video surveillanceSecurity guards

Finding lost patientsRemember, patients with dementia

don’t ask for helpdon’t respond to shouts, don’t travel far,leave few physical clues, lack the ability to turn around.

Canadian study: Searchers should be as quiet as possible so they don’t scare person

Person may hide in a closet

Things that help searchersPersonal items for scent - every six months

change items in zip lock bags (use gloves) with resident’s name so search and rescue animals can have fresh scent

Physical description on all residents (pre-typed) and recent photo

Copy of residents’ shoe treads

GPS devices in clothing Alzheimer's’ “Safe Return” Program - ID

bracelet with toll-free numberAdequate supply of flashlights for night

searchIf you can’t find in 15 minutes, call police!

Leaving the Hospital Against Medical Advice or “AMA”

Patients have the right to…..

Leave the hospital even against the advice of physicians.

Recommended procedureNotify physician immediately

Try to delay patient until he/she can speak with physician

If patient leaves before MD has an opportunity to discuss situation:

attempt to get patient to sign AMA form (see handout)

when appropriate, notify Administration, Risk Manager and/or other staff physician

Physician should discuss the request with the patient either by phone or in person, if possible, and try to dissuade patient from leaving

Information provided should include potential consequences of leaving, benefits of staying, and alternatives

If appropriate (and with authorization to share protected health information from patient) consider involving family, clergy or friends

Consider “capacity” issue

Get help from ethics committee if appropriate (e.g., when leaving means withdrawing life-sustaining treatment)

If leaving will have serious consequences to patient always notify administration and risk management

Carefully chart “informed refusal” (“patient warned of consequences of leaving hospital in unstable condition; patient advised to call physician immediately if …. and to return to nearest hospital ED if ….”)

Make a copy of discharge instructions

Take steps to ensure that the patient leaves in a safe manner, e.g., escort to the exit in a wheel chair, make arrangements so patient doesn’t drive and endanger third parties (e.g., call a taxi or family member)

EMTALA Patienthave patient sign:

EMTALA “Patient Request for Transfer or Discharge” form, and/or

“Patient Refusal of Transfer” form (See handouts)

If patient refuses to sign form, fill out form and note on form that patient has been warned of consequences but refuses to sign form; have witness sign form

If patient has left without telling nurse, chart last time seen, and circumstances; notify physician immediately

Other issues that you may have to consider

Call APS for help in getting conservator appointed if appropriate

If patient is a child, you may have to call CPS for intervention (medical neglect)

Homeless patients require extra care

Questions

A medication error is any preventable event may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health care professional, patient or consumer.

Medication errors are one of the leading causes of injury to hospital patients.

Over half of all hospital medication errors occur at the interfaces of care.

Poor communication of medical information at transition points is responsible for as many as 50 percent of all medication errors and 20 percent of adverse events.

Medication history, in most cases, has no clear standardized process.

Obtain a detailed description of the medication from the patient or family member: strength, size, shape, color, markings.

Talk to any family members present. Contact someone who could possibly bring in the medication or read it over the phone.

Try calling the patient’s pharmacy to obtain a list of medication(s) the patient has been currently prescribed.

Contact the patient’s physician(s) and try and get an accurate listing of current medications.

Medication Reconciliation I Defined as a formal process of obtaining a

complete and accurate list of each patient’s current home medication including name, dosage, frequency and route.

Compare to the physician’s admission, transfer, and/or discharge orders. If there are any discrepancies, bring them to the attention of the prescriber.

Medication Reconciliation IIThere are three steps to this process:

Verification – collect the medical history

Clarification – make sure the medication and dosages are correct

Reconciliation – document any changes in the order

For example, do not accept:

“Continue previous medications”

“Resume preoperative medications”

“Continue orders from med/surg unit”

“Discharge on current medications”

Any order previously written, should

be re-written in its entirety

Order forms and prescriptions should have margin lines to indicate where writing is not permissible.

Avoid fax orders if possible – electronic transfer is preferred where available.

Print all orders for improved legibility.

Never cross out or overwrite a mistake! The order must be rewritten

High alert medications increase the risk significantly for a bad patient outcome, including death.

Examples: • Chemo agents • IV Heparin

• IV and SQ Insulin • TPN etc • IV Thrombolytics • IV Potassium Chloride

Reduce the Risk of High Alert Medications

Each Hospital should have a standardized list of “High Alert” medications.

Each Hospital must have a written policy regarding the administration of these medications.

Reduce the risk by limiting access to these medications.

Use auxiliary labels

Standardize the orderingHave the pharmacist, when possible, be

responsible for the mixing of these medications.

Employ double checks.

Never trail a zero after a decimal point

(1.0 mg may be mistaken for 10 mg if the decimal point is not seen.)

Make sure there is adequate space between the drug name and the dosage

This is especially important in medications ending in the letter “l” where the letter may be mistaken for the number one.

For Example: Inderal40 mgvs.

Inderal 40 mg

Make sure there are properly placed commas

For Example:100000 may be mistaken for 10,000.

Best Practice: Always use a comma orwrite out thousand, or 10 thousand, or 100thousand.

Best Practice for Look Alike or Sound Alike Medications:Determine the purpose of the medication before

dispensing or administering medications. Most, not all, look alike or sound alike drugs are for a different purpose, for example Clonidine verse Klonopin.

Develop a policy for look and sound alike medications.

Review with medical staff annually to raise awareness.

Do not keep these “Alike” medications in the same proximity

Navane or Norvasc

Coumadin or Avandia

Best Practice for Look Alike or Sound Alike Medications

Accept verbal or telephone orders only when necessary.

Always read back the orders, spell the name of the medication and state its intended use.

Use preprinted orders when appropriate to minimize the chance of error.

Try to avoid verbal ordersDo not accept verbal orders for chemo

medications.Have the lab work done before physician

rounds to avoid over the phone dosage changes.

The order should make sense, if it doesn’t, then it probably isn’t right

Record the order directly onto the order sheet to eliminate another chance for error.

Receiver should sign, date, and time the orderThe prescriber must verify, sign, date the order

within a predetermined time frame based on the facilities Policy and Procedure.

Allow no verbal orders when the physician is present.

Limit verbal orders to formulary drugsSpell back the drug name and repeat all orders

back to the prescriber.

Create a list of confusing abbreviations that staff should NOT use due to potential for error and misinterpretation.

Create a list of approved abbreviations:general, laboratory, obstetrics, physical therapysurgical.

“º”

Intended Meaning: Hour(s), i.e. “q1º”

Misinterpretation: Mistaken for a zero when handwritten. i.e. every “10”

Correction: “Hr”

“MgSo4” Intended Meaning: Magnesium Sulfate

Misinterpretation: Mistaken for Morphine Sulfate (MSO4)

Correction: Write out “magnesium”

“MSO4”

Intended Meaning: Morphine Sulfate

Misinterpretation: Mistaken for Magnesium Sulfate

(MgSO4)

Correction: Write out “morphine”

“ug” or “μg”

Intended Meaning: Micrograms

Misinterpretation: Mistaken for “mg” when handwritten because “u” looks like “m”

Correction: “mcg”

“sq”

Intended Meaning: Subcutaneous

Misinterpretation: The “q” has been mistaken for “every”

Correction: “SQ”

”Intended Meaning: Inch

Misinterpretation: Mistaken for “11”

Correction: Write out “inch”

1. Right Patient2. Right Medication3. Right Dose4. Right Route5. Right Frequency6. Right Documentation

Best Practice:Always take the MAR (Medication

Administration Record) or chart with you to the patient’s bedside or into treatment room

Compare medication to the MAR or chart at the bedside or chairside.

SummaryMedication safety practices are everyone’s

responsibilityInvolve the medical staff at their meetingsHave staff approve policies to gain their

buy inBring administration to the table on safety

and quality issues to raise awareness and send the message of its importance.

Questions?

Lunch(back at 1:00 p.m.)

Linda Garrett, JDRisk Management Services

1:00 p.m. - 1:30 p.m.

Jail healthcare responsibility

Title 15 Regulations and Guidelines are clear that the facility administrator (sheriff) is responsible for housing inmates and that part of this responsibility includes providing for necessary medical, dental and mental health care while the person is in the jail (15 CCR , section 1200)

There is considerable leeway in how those services will be provided

Where can services be provided?Outside facilities (all services)

Only first aid at jail; everything else goes out

Only emergencies go out (911); all other services

at jail

All services are provided at jail

Who can provide jail healthcare services?

Employed health care providers who work as employees of the sheriff’s department or corrections

Contracted local hospital, private doctor, psychiatrist, medical group, correctional healthcare company (e.g., CFMG, PHS), medical center

County health department and/or mental health department

Regional agreement among counties to have “roving doctors” and support personnel

Pre-booking medical carePrior to going to the jail, law enforcement will take

individual to hospital for obvious medical needs and/or DUI testing

Sometimes person will ask to go to hospital for non-obvious medical needs

Sometimes jail medical personnel will refuse the individual and ask law enforcement to get the person “medically cleared” at a local hospital

Who pays for pre-booking care?

If the person is seen at the hospital ED prior to being booked into the jail, the individual is responsible for his/her medical costs (private pay or insurance, including MediCal/Medicare) NOT the sheriff!

Penal Code 4015(a) (the board of supervisors shall provide

the sheriff with necessary food, clothing, and bedding, for prisoners which meets minimum standards and requirements prescribed by Board of Corrections for feeding, clothing, and the care of prisoners…)

(b) Nothing in this section shall be construed in a manner that would require the sheriff to receive a person who is in need of immediate medical care until the person has been transported to a hospital or medical facility so that his or her medical needs can be addressed prior to booking into county jail.

(c) Nothing in this section shall be construed or interpreted in a manner that would impose upon a city or its law enforcement agency any obligation to pay the cost of medical services rendered to any individual in need of immediate medical care who has been arrested by city law enforcement personnel and transported to a hospital or medical facility prior to being delivered to and received at the county jail or other detention facility for booking.

(d) It is the intent of the Legislature in enacting the act adding this subdivision to ensure that the costs associated with providing medical care to an arrested person are borne by the arrested person’s private medical insurance or any other source of medical cost coverage for which the arrested person is eligible.

(This section of the Penal Code was amended to read this way by a bill sponsored by the state Sheriff’s Association after an AG opinion -- 90-911 filed on January 31, 1991 -- concluded the sheriff was responsible)

DHS Letter 93-42July 7, 1993

Person is ineligible for Medi-Cal from the time that the person actually becomes an inmate until he is released, paroled, or on probation

But, any other time he is eligible!

Person is eligible for Medi-Cal:

1. After arrest but before booking if escorted by police to a hospital for medical treatment and held under guard

2. Person who transfers from jail temporarily to a halfway house or residential treatment

facility prior to a formal probation release order

3. Released from jail on probation, parole, or release order with a condition of home arrest, work release, community service, outpatient treatment or inpatient treatment

4. Released under a court probation order due to a medical emergency

5. a minor in a juvenile detention center prior to

disposition due to care, protection or in the best

interest of the child if there is a specific plan for

that person that makes stay at the detention

center temporary (could include juveniles

awaiting placement but still physically present in

the Hall)

6. a minor placed on probation by a juvenile court on juvenile intensive probation with home arrest restrictions

7. a minor placed on probation by a juvenile court on juvenile intensive probation to a secure treatment facility contracted with the juvenile detention center if the secure

treatment facility is not part of the criminal justice system

8. A minor placed on probation by a juvenile court on juvenile intensive probation with treatment as a condition of probation in a psychiatric hospital, resident treatment

center, or as an outpatient

DHS Letter 94-02 January 5, 1994

Stated 1 year retroactive period for eligibility stated in clarifying guidelines on Medi-Cal eligibility of “inmates of a public institution” in letter 93-42

EMTALA duties of HospitalsWhen a person (including an arrested person)

comes to any hospital seeking medical care, the hospital must provide:1) a medical screening examination to …2) rule out any emergency medical condition, 3) stabilize that condition if found, or 4) transfer the patient to a hospital that can

stabilize it if the first hospital can’t

Sharp Healthcare v. County of San Diego (new case law)

California Appellate Court held that counties are not responsible for the medical expenses of arrestees before they are booked

January 2008 - California Supreme Court denies petition for review of that case.

The future….

Sen. George Runner (R-Antelope Valley) is carrying state legislation related to this issue (CHA is advocating for “fair payment for hospitals” and wants sheriff to pay!)

See SB 1169 introduced February 7, 2008

Questions?

Linda Garrett, JDRisk Management Services

1:30 p.m. - 2:30 p.m.

Substance abuse and mental health services integration

/http://www.coce.samhsa.gov

Link to COCE Resources

Why are we interested in “integration” of MH and SA?

1. It’s better for the client

2. It’s better for the provider (us)

Better for the client:One stop shopping

Smooth coordination of care; fewer interfaces

Collaboration amongst caregivers increased when they are on the same case managed treatment team - more continuity of care and less confusion

Benefits for client - continuedImproved client outcomes

Improved adherence to treatment plans where both interventions are supported (it’s easier to be compliant)

Better for the providerUse less resources - people and money

If you don’t treat the “whole” problem you have a lot of people you are trying to treat who aren’t getting much better

High community rates of COD: California DMH study concluded that 50% of all Mental Health clients have Substance Abuse issues, and 50% of all Substance Abuse Clients have Mental Health Issues

Given high number of clients with COD seeking both services, makes sense to address COD in an integrated program since that is what the majority of your clients need

Benefits for the provider - continued

Improved adherence to treatment plans

+ Improved client outcomes

= Less frustration for staff and

Increased job satisfaction

Benefits for provider -continuedReduce need to shuffle between providers

+ Reduce need to make outside referrals

= less likelihood of conflicting advice from several sources

= better integration of information provided to client

Dual dx or COD programs - more reasons they work betterStudies show that there is a negative impact of one

untreated disorder on recovery from the other

Studies also show that effective responses to persons who need treatment for either mental health or substance abuse disorder are compatible

Successful when dealing with severe disorders as well as less severe disorders

Single Agency ApproachMore efficient (reduces staff and saves money)

You only need:One HR departmentOne billing officeOne admissions officeOne healthcare risk manager

Agency approach - continuedOne compliance officeOne HIPAA Privacy OfficialOne records departmentOne IT departmentOne financial officeSame maintenance and housekeepingEtc., etc., etc.

So, what’s the problem?

If it is good for the clients and good for the County why are we even discussing this?

Why not just go ahead and combine the various medical and mental health and substance abuse services in one big program and leave it at that?

The problem is this -- treating COD at the same time is a rather new concept -- only in the last 10-15 years has this approach become an accepted way to approach COD and all of the laws, particularly the confidentiality laws, were written with the old model in mind.

There is a “wall” between the disciplines that makes disclosures between providers impossible unless certain steps are taken -- the wall is known as 42 CFR Part 2

An illustration of the problemLet’s look at an example from somewhere else

in the County:

Why not put all of the attorneys that are on the County’s payroll into one Agency and call it the “Legal Agency” and have them share support staff, records rooms, IT, computers, reception, HR, etc.?

Confidentiality (and conflict) is why!

Medical confidentiality laws put similar barriers between the various disciplines -- even though they are all healthcare providers, that doesn’t necessarily mean they can all sit down and talk to each other about their patients and clients

Review of confidentiality laws

Civil Code 56.10W&I Code 532842 CFR Part 2HIPAA (45 CFR Part 160, 164)

Sharing with other providers:General health info may be shared with other healthcare professionals for purposes of treatment, diagnosis or referral

Civil Code 56.10(c) (1)

Mental health info may be shared in communications between qualified professional persons in the provision of services or appropriate referrals, or in the course of conservatorship proceedings, including providers outside your program if they have “medical or psychological” responsibility for the client

W&I Code 5328(a)

Substance abuse treatment program information can only be shared with members of the team within the program (not OUTSIDE the program – see next slide for definition of “program”) EVEN though the program is within the same agency!

There is an exception for a medical emergency (e.g., overdose, or suicide attempt)

42 CFR section 2.11 - DefinitionsProgram means:

(a) an individual or entity (other than a general medical care facility) who holds itself out as providing, and provides, alcohol or drug abuse diagnosis, treatment, or referral for treatment; or

(b) an identified unit within a general medical facility which holds itself out as providing, and provides, alcohol or drug abuse, dx, tx, or referral for tx; or

(c) medical personnel or other staff in a general medical care facility whose primary function is the provision of alcohol or drug abuse dx, tx, or referral for tx and who are identified as such providers.

42 CFR section 2.12(e)Explanation of applicability. These

regulations cover any information (including information on referral and intake) about alcohol and drug abuse patients obtained by a program ...However, these regulations would not apply, for example, to emergency room personnel who refer a patient to the ICU for an apparent overdose…

Simply stated, a “drug and alcohol treatment program” is any defined program that receives state or federal funds to conduct drug and alcohol treatment

For example, the 8th floor of an acute care hospital where drug and alcohol treatment is provided

One alternative?Some argue that they will subject the entire

agency to the stricter rules, but because you will then be extremely limited in uses and disclosures that you have come to rely on in the Mental Health side (e.g., checking with the pharmacy, Tarasoff warnings, reporting elder abuse) it is really not the optimal way to approach this

Better alternativeGet permission (authorization) permitting

members of the different clinical disciplines to work together within the County Agency

Note: if you have a Human Services Agency that includes Social Services, Probation, etc. they would NOT be part of the authorization - separate authorizations would be needed for these types of disclosures

2 approachesEvery client who walks through the door

receives the same NPP and signs an authorization before ANY services are provided

Only clients who are identified during initial assessment, or later by one discipline or the other, are asked to sign an authorization before a referral to COD is made

Additional challenges for the CountyIdentify and respond to gaps in workforce

competencies, certifications and licensureAddress staff concerns related to changes in

roles and responsibilitiesInstitute modifications in record keeping to

include COD considerationsModify facilities to meet additional needs (group

or individual counseling)

Revise staffing patterns and work schedules

Reconcile differences in confidentiality regulations, policies, and practicesMake sure all staff are trained in all

confidentiality laws & differences in lawsVery important that records room staff

understands the differences

Revise policies, practices and requirements regarding dispensing and managing medications

Utilize new reimbursement sources and procedures

Train financial staff on billing issues

Multi-disciplinary and multi-agency teams

Get authorization first, especially if community based organizations participate

Ok to include social services, probation, law enforcement with proper authorization

Questions?

BREAK

Linda Garrett, JDRisk Management Services

2:45 p.m. - 3:15 p.m.

Basic Review of HIPAAHIPAA - Health Insurance Portability

and Accountability Act of 1996

Privacy Rule - April 14, 2003

Security Rule - April 20, 2005

HIPAA Terms “PHI”

“Covered entity”

“Business Associate”

“pre-emption analysis”

“minimum necessary”

“uses and disclosures”

“authorization”

“patient representative”

New interpretation from OCR re: subpoenas

Old rule (from OCR in direction to its surveyors) - Covered entity that received subpoena seeking medical records had to obtain documentation (“satisfactory assurances”) showing the patient had filed no objections to the subpoena, or that any objections raised by the patient had been resolved

holding the records the requisite time period for the patient to make a motion to quash or modify the subpoena was not enough

Old rule - continued

“the passage of a deadline is not considered sufficient ‘satisfactory assurances’”

New Rule - March 7, 2008 - effective immediately, complying with California law is enough -- if you wait the required length of time, and hear nothing to the contrary, you may release the records

3 kinds of disclosuresMandatory - where you must disclose…

Permissive - where you may disclose…

After opportunity for the individual to agree or object - where patient is told that UNLESS they object, a disclosure may be made (e.g., hospital directory)

Most common “permissive” disclosure?

With patient authorization!

Most common privacy complaints?Disclosures to family members

Disclosures to employers

Disclosures to law enforcement

Most common actual privacy breaches?Curious staff “peeking” at records (and leaked to

the tabloids?) - e.g., UCLA woes re: Brittany Spear’s and Farrah Fawcett’s medical files

Gossip with peers within the facility

Work gossip with friends and family

Privacy Rule Violations listed by US Dept. of Health and Human Services (as of 11/30/07)

Since April 2003, over 31,956 Privacy Complaints5,397 cases investigated and resolved that

required changes in privacy practices and other corrective actions

2,633 cases - no violation found17,219 complaints - not an eligible case for

enforcement of the privacy rule

Most frequent compliance issues (DHHS)1. Impermissible uses and disclosures of PHI2. Lack of safeguards of PHI3. Lack of patient access to their own PHI4. Uses or disclosures that exceed Minimum

Necessary5. Lack of or invalid authorizations for uses and

disclosures

Penalties for violating HIPAAHIPAA violation can result in $100 fine for each

violation up to $25,000 in a single year for violation of any one standard, and criminal penalties of up to $250,000 and ten years in prison

Office of Civil Rights refers to Department of Justice appropriate cases for criminal investigation involving knowing disclosure or violation of the Privacy Rule

Since April 2003, there have been 418 referrals to DOJ

A couple of examplesStolen identity of Washington patientOffer to sell names of patients to undercover

cop

Also, two other “penalties”:Malpractice lawsuit alleging breach of

privacy

Damage to facility’s reputation

Security Rule requires that we:

1) ensure the confidentiality, integrity and

availability of electronic PHI;

2) protect against any reasonably anticipated

threats or hazards to the security or integrity of

electronic PHI, and

3) protect from any uses or disclosures not permitted under the Privacy Rule.

For example:Most counties recognize that electronic PHI sent

over the internet could be “intercepted” or “hacked” into or might be insecure in some other way, so email with PHI is not permitted, or discouraged, unless encrypted.

Most counties also forbid text messaging, etc. for the same reason

But, don’t forget 45 CFR 164.522(b)HIPAA gives patients many rights, including the

“right” to request communications of PHI from the provider by alternative means or alternative locations.

The provider must accommodate reasonable requests, and cannot require an explanation from the individual as to why he/she is requesting an alternative means or location of communication.

If a client requests TTY, Relay Phone Services, email instant messaging, text messaging, etc., you may ask that they put the request in writing (AND YOU SHOULD WARN THEM OF ANY RISK YOU BELIEVE THEY MAY BE EXPOSING THEMSELVES TO), but you should accommodate the request unless it is totally unreasonable.

Most common security problemsStolen laptops

Lost CDs or memory sticks

Mis-directed mail or faxes - e.g., the record shipped from a Central Florida Regional Hospital for a Medicare Audit that ended up being sold to a Salt Lake City teacher at a surplus store for about $20 (she was using them as scrap paper for her 4th grade class)

Other common violations in Counties

PHI left at workstations or on computer screens

Sharing of passwords

Waste basket next to copy machine

DHHS: referrals to CMS of Security Rule violations

Since April 2005, there have been 212 referrals

New concernMarch 2007 - Instead of waiting for complaint,

HHS has launched an enforcement website, and delegated subpoena authority to OCR and through Office of Inspector General (OIG) announced the first audit on March 5, 2007 at Piedmont Hospital in Atlanta for compliance with the security regulations

April 16, 2007 - HHS also delegated authority to OCR to issue subpoenas etc.

HIPAA Audit ChecklistUnofficial list of 42 items that Piedmont

Hospital was presented with and told to provide information within 10 days

Will they ask you the same questions?

See Audit Checklist in Handouts

Questions?

Linda J. GarrettRisk Management Services

3:15 p.m. - 3:30 p.m.

BackgroundPatient Self-Determination Act (1992) -

required hospitals participating in Medicare or Medicaid (Medi-Cal) to provide patients with information about their right under state law to state their wishes re: health care decisions, ahead of time

Info needs to be given on or before every admission; chart must state if person has an AD

California Health Care Decisions Law (2001)

Advance directive can name an “agent” and/or

Advance directive can specific individual instructions

Purpose of law is to ascertain patient’s wishes

Health care provider should chart oral designation of surrogate decision maker so later it is clear

Normally AD doesn’t take effect until patient loses capacity (must have capacity at time it is written), but patient can ask that another person make decisions even though patient still has capacity

agentusually a family member or trusted friend

should be someone 18 or older

agent must make decisions according to patient’s stated wishes or known wishes

Cannot bethe supervising healthcare providerAn employee of the health care institution

where the patient is receiving careAn operator of employee of a community care

facility or residential care facility Prohibition above does not apply if the agent is

related by marriage or blood or registered domestic partner; or co-worker of patient who also works there

LPS Conservator cannot be designated as the agent unless the conservatee was represented by an attorney

Agent cannot make decisions that patient objects to

Agent cannot consent to placement in a mental health treatment facility, convulsive treatment, psychosurgery, sterilization, and abortion

Individual directives

Traditionally focused on end of life care

Useful in helping agent know what you would want under different circumstances

Duration and revocationAD lasts indefinitely unless revoked

May revoke all or part (except part naming agent) at any time and in any manner that communicates an intent to revoke (e.g., by tearing it up, writing something new, verbally stating new wishes, refusing meds)

This is why in California Psychiatric Advance Directives (PAD’s) are not as “useful” as some imagine

If you want to change your agent, be sure to orally inform your healthcare provider, or put it in writing!

Written AD must include:Signature of patient (can be done at

direction of patient if patient can’t write)DateEither or both:

Name of agent (and back up agents if desired)

Individual instructions

continuedSignature of notary or at least two witnesses

Witnesses have to see the patient sign it or state that the signature is his

Neither witness may be the patient’s health care provider, an operator or employee of a community care facility, or residential care facility for the elderly or the agent

At least one witness must be a person who is not related by blood or married, or entitled to part of the person’s estate under a will

If patient is in a skilled nursing facility, the patient advocate or ombudsman must either be one of the two witnesses or sign in addition to the notary

CapacityPrimary physician is responsible for determining

capacity

Capacity means the person’s ability to understand the nature and consequences of a decision and to make and communicate a decision, and in the case of proposed health care, the ability to understand its significant risks, benefits and alternatives

Person is presumed to have capacity; primary physician decides when that is no longer true

Questions?

Don Lewis, LCSW

UC Davis Medical Center

Hospice Program

Sacramento Hospice Consortium

3:30 p.m. - 4:00 p.m.

Hospice CareCare for people in a terminal phase of any

illness or disease process

Hospice is a philosophy of health care focusing on the needs of the patient and care givers

Success is determined by redefining goals of care that support the patient’s quality of life

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Many types of hospices

Small v. LargeCommunity basedHospital basedNonprofit v. for profit

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Hospice EligibilityPrognosis

<6 months to livePhysician signed CTI

Certificate of terminal illnessMoving window

No Curative Measures DesiredMedically exhausted all possibilitiesChoosing not to pursue further treatment

Can change mind later

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Hospice flexibilityPatient can revoke (choose to go off

hospice)Patient may be “decertified”

MD sees change in status and believes patient has improved and will live longer than first believed

Patient may be dischargedHospice unable to locate patient; patient

leaves hospice coverage area, etc.

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Hospice flexibilityMedicare v. Medi-Cal

Patient has a “lifetime benefit” for hospice if covered by Medicare

Medi-Cal has a cap of 13 months, divided into finite benefit periods90/90/60 60 etc

Patient can revoke, be discharged, or decertified, and return later for continued hospice care

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Hospice ServicesHospice Team Visits

Nurse, physician, social worker, home health aide, therapies (ST, OT, PT), dietitian, chaplain, grief counselor, volunteer

DME & Medical suppliesThose related to terminal diagnosis*

Respite CareMedications

Those related to terminal diagnosis*Authorized hospitalizations24 hour on-call RN for triage & visits

*Items unrelated to diagnosis may still be paid for by existing coverage, or purchased privately

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Myths about HospiceYou must have a caregiver –FALSE

Must be willing to work with hospice team to devise a plan for providing care

You must have a DNR – FALSEMost do, but not required!

Hospice is a place you go –FALSEHospice is a team approach to end-of-life care

Provided wherever a patient lives—home, SNF, hospital, assisted living, board & care, SRO, homeless

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Myths about HospiceHospice is “giving up” –FALSE

Hospice is a team approach to provide care to the patient and support to the home care giving team—family, caregivers, friends—with a strong focus on aggressive pain and symptom control

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Myths about HospicePatients can’t use duragesic patches and be on

hospice—FALSEPatients can’t have IV’s, feeding tubes, etc. --

FALSE Patients must be home bound – FALSEPatients cannot see their own doctors –FALSEPatients must give up all treatment –FALSE

Hospice aggressively treats symptoms and manages pain

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More MythsHospice services end at 6 months—

FALSEOnce you enroll, you can’t change your

mind –FALSEHospice only sees adult patients –

FALSE(determined by each program)

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Still More Myths…Hospice treats only cancer patients –FALSE

Hospice is care for anyone in the terminal phase of any chronic illness.

Typical hospice diagnoses—Cancer, cardiac disease, end stage kidney, liver,

lung disease, AIDSCOPD & CHF

Chronic Obstructive Pulmonary DiseaseCongestive Heart Failure

ALS and other neuromuscular diseasesDementia, Alzheimer’sDebility & Decline

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Admission CriteriaFinancial eligibility

Medicare, Medi-Cal, private insurancePrivate pay Memorial/donated funds cover cost of

care for the uninsured who are also unable to pay privately

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Referring a PatientPhysician order for hospiceReferral can originate from patient, family,

legal representative of patient, friends of family, any health care provider, nurses, social workers, etc.

Ultimately, patient or representative sign paper to admit patient

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Considerations with Skilled Nursing Facilities & RCFE’s

Medicare patient with qualifying hospital stay transferred to SNF may receive up to 90 days of coverage (dependant upon need)Qualifying stay -- more than 3 days in hospital within

last 30 daysMedicare will not cover SNF and Hospice

simultaneouslyOften patient waits for end of Medicare SNF coverage to

opt for hospice care

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Skilled Facilities (cont’d)Hospice coverage in SNF does not cover

room and board. Medicare patient becomes “private pay” for room and board

Medi-Cal will cover room and board and hospice care

RCFE Must have hospice waiver to provide care

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How to find hospiceContact your local hospitalNHPCO website (National Hospice and Palliative Care

Organization)www.nhpco.org

“find a provider”Search by locationEnter city and state

CHAPCA website (California Hospice and Palliative Care Association)www.calhospice.org

“find a hospice”411

Questions and

Discussion

AdjournDon’t forget to pick up your CEU Certificate

Please take the time to fill out the evaluation form

For Travel Expenses Reimbursement, be sure to pick up Travel Forms

See you next year! (April 29, 2009)