Hospice Medical Directors' Resources
Care Delivery: The Compassus Way
Care Delivery the Compassus Way is based on the foundational understanding that all patients with serious illness and at the end of life have universal needs. These needs are Comfort, Safety and Autonomy, and Quality of Life
- Establish goals of care to determine Patient/Family Greatest Concern
- Develop team-based plan of care SBAR Model & Symptom Management
- Medication reconciliation Guide to Medications
- Monitor disease progression and address pain control Total Pain Management
- Reassess goals of care at each IDT focused on Quality of Life
Workplace Essentials and Tools
- Lead Interdisciplinary team (IDT) (Bimonthly meeting to develop patient and family centered plan of care)
- Hospice eligibility
- Document clinical disease progression to initiate, maintain, or recommend to discontinue hospice services
- Prognostication and scoring tools
- Participate in QAPI (Quality assessment Performance improvement)
- American Academy of Hospice and Palliative Medicine
- National Hospice & Palliative Care Organization
Understand the organization
Hospice Admission & Certification Pearls
Referral > Prognosis > Eligibility > Admission >Certification
- Initial Certification: 15 days prior to 2 days after election of hospice services
- Recertification: 15 days prior to 2 days after new benefit period
- Conduct face-to-face visit: within 30 days prior to new certification period (Only required prior to 3rd benefit period and any subsequent benefit periods).
- Notice of Termination: within 5 days after patient is discharged from hospice
- Certification of Terminal Illness
Homecare Homebase (HCHB)
- Hospice Electronic Medical Record (EMR)
- Patient documentation for all specialties
- Review and create narratives
- Order signature & medication reconciliation
- Documentation of face-to-face visits
HCHB F2F Guide (PDF, 180 KB)
MEDICAL DIRECTOR RESPONSIBILITIES
- Timely documentation (IDT notes, F2F, CTI, order signatures & timesheets)
- Activate & utilize Compassus email, promptly respond to messages and calls
- Timely face-to-face completion
- Participate in quarterly medical director meeting
- Notify DCS when taking time off and coordinate coverage
- Death certificate completion
- Establish and maintain accreditation Hospice Medical Director Certification
- Medical Directors Roles and Responsibilities
General Inpatient Care (GIP)
- Short-term hospice care for symptom control not achieved in outpatient setting (intractable pain, terminal agitation, IV drip)
- Daily documentation supporting need for inpatient care
- Develop disposition plan in advance of symptom control
- GIP is not substitute or bridge to nursing home placement
- GIP Toolkit (PDF, 4.1 MB)
- GIP Presentation
Interdisciplinary Team Meeting (IDT)
- Review patient clinicals prior to IDT to discuss patient care plan and complete CTIs
- IDT Agenda and Sign-in
- CTI Physician Tip Sheet
- CTI Examples (PDF, 65 KB)
- De-prescribing Recommendations
- Optum formulary
- Enclara formulary
- Document subjective & objective data to demonstrate progression of illness
- Recommend discontinuation of hospice services if ineligible with transition to palliative care
- Cloning notes is strictly prohibited
- Avoid use of signs or symptoms as hospice diagnosis (FTT or debility)
Pain assessment & opioid stewardship
- Pain is complex and multifactorial
- Identify pain threshold and goals
- Utilize PQRSTE (Palliating/provoking factors, Quality, Radiation, Severity, Time, Effect)
- Utilize PAINAD scale (PDF, 60 KB) for patients unable to self- report
- Therapy should focus on medication and non-drug treatment
- Total Pain Management Tool
- Guide to Opioid Stewardship
- CDC Opioid Conversion Calculator
CME, Meetings & Resources
Our Care Delivery Mobile App @
The Care Delivery web app presents the methodology, reference, tools, and resources to ensure patients receive care and training to be successful in the home.