Transcript Medical Confidentiality: Risk Management Concerns for

CSAC Excess Insurance Authority
Annual Medical Malpractice Programs
Training
Wednesday, April 23, 2008
9:00 a.m. - 4:30 p.m.
Sacramento, CA
Welcome
 Michael Fleming, ARM, Chief Executive
Officer, CSAC Excess Insurance Authority
“housekeeping”
 Handouts
 CEU’s & Sign-in Sheets
 Travel reimbursement forms
 Electronic evaluation form
 Questions
 Breaks, lunch
 Bathrooms, public telephones
 Cell phone reminder
Agenda
 Legal and Risk Management Update
 Tort Reform: MICRA Update
 Falls, Wandering, Elopements and AMA
 Medication Errors
 Correctional Care - Pre-Booking Medical Costs
 Combining Mental Health and Substance Abuse
 HIPAA Update/Confidentiality Concerns
 Advance Directives for Healthcare
 Hospice Care
Resources
 www.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.com
 California Code of Regulations (CCR) - helpful
to know which Title and Section number
 www.cdcr.ca.gov
 California 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.edu
 click on Federal Constitution, US Code (laws), or
CFR (Code of Federal Regulations)
 www.coce.samhsa.gov
 U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services
Administration (click on “COCE” - SAMHSA’s coOccurring Center for Excellence)
 www.youthlaw.org
 National Center for Youth Law
 www.calhealth.org
 California Hospital Association (click on
“publications” and then “forms and posters”)
 www.californiahia.org
 California Health Information Association (click
on “publications”)
 www.lac.org
 Legal 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, JD
Risk 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 123106
 a) 10 years minimum records retention
 b) at time record is created, patient may elect to
have record archived longer than 10 years
 c) 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 disclosures
 Written 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 Act
 Pursuant to an organ donation
 Anonymously 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 Testing
 Law 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 Health
 5150 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 1799.111
 1799.111. (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 Reporting
 1998 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’s
 As 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 surgery
 Air embolism
 Blood incompatibility
 Catheter-associated urinary tract infection
 Pressure ulcers (bed sores)
 Vascular-catheter-associated infection
 Surgical 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 publication
 Cultural 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.
history
 THE 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 Problems
 California 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 MICRA
 1. 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 MICRA
 3. 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 Claim
To 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 MICRA
 5. 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 Damages
A 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 Disputes
Patients 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 Institute
2003
Impact of MICRA
Lower Median Awards
Effects of MICRA
Insurance Information Institute
003
 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 -continued
Insurance Information Institute
003
 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, JD
Risk Management Services
10:45 a.m. - 11:30 a.m.
Quick review





Consent
Informed Consent
Capacity
The Right to Refuse Care
Restraints
Patient rights
 People 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.
Restraints
 Patients have right to be free from
restraints
 Restraints for medical purposes
 Restraints for behavioral purposes
Medical consent
 Should 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?
Falls
Joint 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 year
 10% 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 falls
 Incontinence, urinary frequency or urgency
 Lower-extremity weakness
 Gait and balance deficits
 Medications (esp. sedatives, antihypertensive,
tranquillizers, etc, or more than 4 prescription drugs
at a time)
 Postural or orthostatic hypertension
 Reduced visual acuity/slowing darkness
adaptation/ depth perception/contrast sensitivity
 Loss of hearing
 Neuropathy
 Proprioceptive dysfunction
 Cervical degenerative disorders
 Functional impairment
 Changes to mental status (depression, dementia)
 Foot disorders
 Poor impulse control
 Belief that asking for help is inappropriate
 Other things too!
Extrinsic (environmental) risk factors
 Dangerous bathrooms (e.g., no rails near toilet)
 Furniture on wheels or furniture with sharp edges
 Flooring that is slippery or covered with loose
rugs
 Ill-fitting shoes, or shoes with soles that stick
 Poorly maintained equipment
 Poor instruction on use of assistive devices
 Time of day (shift change, less staff at night)
 Bed too high; toilet too low
 Use of restraints; full length bed rails
 Colors that are monochromatic or that
agitate
 Distracting noises
 Poor communication
 Poor staff training
 Attachment to equipment such as monitors
 Call button too far; side table too cluttered
Strategies to reduce falls
 Policies and procedures
 include definition of “fall” and “near miss”
 Patient assessment at time of admission and
periodically throughout stay
 Environmental assessment
 Frequent 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 history
Stated desire to leave
Higher risk when first admitted, at shift change,
during storm or inclement weather
 Factors, continued:
 Boredom
 Personal problems - depression,
agitation
strategies
 Camouflage enclosures (hide doors so they don’t
look like doors)
 Enhance signage and clues for finding way back to
room
 Enclose outdoor spaces
 Assign rooms away from high traffic or noise
 Create 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 exitseekers)
 Window restrictors as allowed by fire code
 Video surveillance
 Security guards
Finding lost patients
 Remember, patients with dementia
 don’t ask for help
 don’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 searchers
 Personal 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 (pretyped) and recent photo
 Copy of residents’ shoe treads
 GPS devices in clothing
 Alzheimer's’ “Safe Return” Program - ID
bracelet with toll-free number
 Adequate supply of flashlights for night
search
 If 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 procedure
 Notify 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 Patient
 have 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.
Remember to ask about any over the
counter medications, herbal medications, or
medications that may have been purchased
outside the country.
Medication Reconciliation II
There 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 ordering
Have 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 mg
vs.
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 or
write out thousand, or 10 thousand, or 100
thousand.
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 orders
Do 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 order
The 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 drugs
Spell 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 therapy
surgical.
“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 Patient
2. Right Medication
3. Right Dose
4. Right Route
5. Right Frequency
6. 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.
Summary
Medication safety practices are everyone’s
responsibility
Involve the medical staff at their meetings
Have staff approve policies to gain their
buy in
Bring 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, JD
Risk 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 care
 Prior 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 93-42
 July 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 Hospitals
 When 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, JD
Risk 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 - continued
 Improved client outcomes
 Improved adherence to treatment
plans where both interventions are
supported (it’s easier to be compliant)
Better for the provider
 Use 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 -continued
Reduce 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 better
 Studies 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 Approach
 More efficient (reduces staff and saves money)
 You only need:
 One HR department
 One billing office
 One admissions office
 One healthcare risk manager
Agency approach - continued
 One compliance office
 One HIPAA Privacy Official
 One records department
 One IT department
 One financial office
 Same maintenance and housekeeping
 Etc., 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 problem
 Let’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 56.10
W&I Code 5328
42 CFR Part 2
HIPAA (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 - Definitions
Program 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 alternative
 Get 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 approaches
 Every 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 County
 Identify and respond to gaps in workforce
competencies, certifications and licensure
 Address staff concerns related to changes in
roles and responsibilities
 Institute modifications in record keeping to
include COD considerations
 Modify facilities to meet additional needs (group
or individual counseling)
 Revise staffing patterns and work
schedules
 Reconcile differences in confidentiality
regulations, policies, and practices
 Make sure all staff are trained in all
confidentiality laws & differences in laws
 Very 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, JD
Risk Management Services
2:45 p.m. - 3:15 p.m.
Basic Review of HIPAA
 HIPAA - 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 disclosures
 Mandatory - 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
Complaints
 5,397 cases investigated and resolved that
required changes in privacy practices and
other corrective actions
 2,633 cases - no violation found
 17,219 complaints - not an eligible case for
enforcement of the privacy rule
Most frequent compliance
issues (DHHS)
 1. Impermissible uses and disclosures of PHI
 2. Lack of safeguards of PHI
 3. Lack of patient access to their own PHI
 4. Uses or disclosures that exceed Minimum
Necessary
 5. Lack of or invalid authorizations for uses and
disclosures
Penalties for violating HIPAA
 HIPAA 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 examples
 Stolen identity of Washington patient
 Offer 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 problems
 Stolen 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 concern
 March 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 Checklist
 Unofficial 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. Garrett
Risk Management Services
3:15 p.m. - 3:30 p.m.
Background
 Patient 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
agent
 usually 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 be
 the supervising healthcare provider
 An employee of the health care institution
where the patient is receiving care
 An 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 revocation
 AD 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)
 Date
 Either or both:
 Name of agent (and back up agents if
desired)
 Individual instructions
continued
 Signature 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
Capacity
Primary 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 Care
 Care 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
Many types of hospices
 Small v. Large
 Community based
 Hospital based
 Nonprofit v. for profit
7/18/2015
259
Hospice Eligibility
 Prognosis
 <6 months to live
 Physician signed CTI


Certificate of terminal illness
Moving window
 No Curative Measures Desired
 Medically exhausted all possibilities
 Choosing not to pursue further treatment

7/18/2015
Can change mind later
260
Hospice flexibility
 Patient 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 discharged
 Hospice unable to locate patient; patient
leaves hospice coverage area, etc.
7/18/2015
261
Hospice flexibility
Medicare 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 periods
 90/90/60 60 etc
 Patient can revoke, be discharged, or
decertified, and return later for continued
hospice care
7/18/2015
262
Hospice Services
 Hospice Team Visits
 Nurse, physician, social worker, home health aide,
therapies (ST, OT, PT), dietitian, chaplain, grief
counselor, volunteer
 DME & Medical supplies
 Those related to terminal diagnosis*
 Respite Care
 Medications
 Those related to terminal diagnosis*
 Authorized hospitalizations
 24 hour on-call RN for triage & visits
*Items unrelated to diagnosis may still be paid for by
7/18/2015
existing coverage, or purchased privately
263
Myths about Hospice
 You 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 – FALSE
 Most do, but not required!
 Hospice is a place you go –FALSE
 Hospice is a team approach to end-of-life care
 Provided wherever a patient lives—home, SNF, hospital,
assisted living, board & care, SRO, homeless
7/18/2015
264
Myths about Hospice
 Hospice 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
7/18/2015
265
Myths about Hospice
 Patients can’t use duragesic patches and be on
hospice—FALSE
 Patients can’t have IV’s, feeding tubes, etc. -FALSE
 Patients must be home bound – FALSE
 Patients cannot see their own doctors –FALSE
 Patients must give up all treatment –FALSE
 Hospice aggressively treats symptoms and
manages pain
7/18/2015
266
More Myths
 Hospice services end at 6 months—FALSE
 Once you enroll, you can’t change your
mind –FALSE
 Hospice only sees adult patients –
FALSE
 (determined by each program)
7/18/2015
267
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, AIDS
 COPD & CHF





Chronic Obstructive Pulmonary Disease
Congestive Heart Failure
ALS and other neuromuscular diseases
Dementia, Alzheimer’s
Debility & Decline
7/18/2015
268
Admission Criteria
 Financial eligibility
 Medicare, Medi-Cal, private insurance
 Private pay
 Memorial/donated funds cover cost of
care for the uninsured who are also
unable to pay privately
7/18/2015
269
Referring a Patient
 Physician order for hospice
 Referral 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
7/18/2015
270
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 days
 Medicare will not cover SNF and Hospice
simultaneously
 Often patient waits for end of Medicare SNF coverage to
opt for hospice care
7/18/2015
271
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
7/18/2015
272
How to find hospice
 Contact your local hospital
 NHPCO website (National Hospice and Palliative Care
Organization)
 www.nhpco.org
 “find a provider”
 Search by location
 Enter city and state
 CHAPCA website (California Hospice and Palliative Care
Association)
 www.calhospice.org

“find a hospice”
 411
7/18/2015
273
Questions
and
Discussion
Adjourn
 Don’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)