This document is designed to serve as a reference tool for new Hospice staff and will contain the most recent forms and tools.

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Marjorie Lucas
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1 Patient-Focused IDG Meeting Process 1 This job aid summarizes the Hospice IDG meeting process and describes the key roles and steps in the process. The document serves as a reference for all Hospice staff. Included in the documents are references that define the regulatory requirements for IDG, roles and responsibilities for all IDG members as well as forms to be used. This document is designed to serve as a reference tool for new Hospice staff and will contain the most recent forms and tools. Key Points: The purpose of the IDG is to review all deaths, new admissions, recertfications and all current patients to ensure that the most comprehensive patient centered plan of care is developed, documented and agreed upon by all IDG members. All members of the IDG are expected to come to the meeting prepared and in so doing the documentation will always reflect the current status of the patient, interventions in place, an evaluation of the effectiveness of the interventions and continued eligibility for the Hospice Benefit. The patient and family goals serve as the cornerstone of the plan of care. Document Review: The attachments follow: IDG Regional Training IDG Process IDG Meeting Process Diagram IDG Agenda Kindred At Home, 2015 Patient-Focused IDG Meeting Process

2 Patient-Focused IDG Meeting Process

3 IDG Team Meeting Kindred s Mission To help patients remain at home and in their own communities, surrounded by friends and family, while receiving the highest-quality, most compassionate homebased care possible. The IDG team meeting is an essential component of what we do for the patient & family. It requires thinking through the anticipated questions that others may have, while also having your own questions cued up. All care should be aimed at achieving our Mission Statement

4 What is an IDG The interdisciplinary group (IDG) is the team responsible for the holistic care of the hospice beneficiary. It is the team which is responsible for the development and review of the beneficiary s plan of care (POC).

5 IDG Requirements Interdisciplinary Group: Works together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement Required Members are: Hospice physician Registered Nurse Social Worker Pastoral or other counselor

6 Hospice Medical Director Hospice physicians have the ultimate responsibility for, and medical judgment regarding, the clinical eligibility of all patient s on service The Hospice physician determines diagnosis related & non-relatedness for patients Certification is based solely on the physician(s) determination of a prognosis of six months or less if the disease continues along its normal course

7 IDG Requirements 5 Standards Approach to service delivery POC Content of the POC Review of the POC Coordination of Services

8 418.56(c): Content of the Plan of Care Must include all services necessary for the palliation and management of the terminal illness and management of the terminal illness and related conditions, including the following: Interventions to manage pain and symptoms Scope and frequency of services necessary to meet the specific patient and family needs Measureable outcomes anticipated from implementing and coordinating the POC Drugs and treatment necessary to meet the patient s needs Medical supplies and appliances The IDG s documentation of the patient/representative's level of understanding, involvement, and agreement with the POC

9 415.56(d): Review of the Plan of Care The IDG (in collaboration with the patient s attending physician, if any) must review, revise, and document the individualized POC as frequently as the patient s condition requires, but no less frequently than every 15 calendar days. A revised POC must include information from the patient s updated comprehensive assessment and must note the patient s progress toward outcomes and goals specified in the POC

10 IDG Meeting: Foundation for Care In Hospice, the IDG is the basis for decisions involving patient s care and services It is about the patient and family Provides an opportunity to anticipate possible crisis in the disease progression for active care planning and improved outcomes Allows time to assess eligibility of patients and their appropriate level of care

11 How to Convene an Effective IDG Meeting Adhering to the developed process and company standards will ensure successful care planning and delivery of excellent care. Assure the inclusion of each discipline in the discussion of patient. Keep team focused on the true work of problem solving and care planning. Drive the team to focus on objective measures and comparative documentation in order to support ongoing eligibility. Evaluate impact of interventions as they relate to patient outcomes, eligibility, co-morbidities and decline.

12 Kindred at Home Interdisciplinary Group Meeting Process EXPECTATIONS: All Kindred IDG members are required to follow these guidelines. Critical to the success of the IDG is preparation prior to the IDG meeting. The patient s Plan of Care is an active document that is updated by each team member at ever visit or encounter, and those updates communicated to all other members of the IDG. The IDG meeting should focus on three main areas 1) Review of updated assessment findings, 2) On-going patient/family needs, and 3) All updates to the Plan of Care. The team should actively anticipate and plan needed care and interventions versus merely reporting care and interventions already provided. Clinicians should review: Results from all patient/family assessments The anticipated outcome The interventions for the next visit(s) Anticipated visit frequency of each team member The changes to the Plan of Care/Medications based on IDG input (the scribe should capture changes) ROLES & RESPONSIBILITIES: Role Designee Resources/Needed Equipment Facilitator MCP or designee IDG Agenda/Signature Sheet/Reports/IDG Binder Reports as location deems useful Kindred Eligibility Toolbox as a reference Scribe/Timekeeper MCP or designee Completed Signature Sheet and Agenda. These documents need to be able to be retrieved for external review as necessary. Laptop and access to EMR. Projector Coordinator Local office designee Required projector and access to Kindred Care Link AGENDA CATEGORIES Required Categories: 1 Deaths (Discuss Bereavement needs) 2 Admissions 3 Recertification s 04/20/2016 IDG Process Page 1

13 Kindred at Home Interdisciplinary Group Meeting Process 4 Live Discharges, Revocations & Transfers 5 All other active patients (Can be pulled by Case Manager) 6 Level of Care Changes (can also be covered during active patient see above) * See actual Agenda template for additional detail IDG PREPARATION Responsible Party Detail 1 Hospice Admission Admitting RN Upon admission, planning and preparation begins for the IDG s establishment, reviews and updates to the Pt s POC 1. 2 RN completes Comprehensive Assessment and initiates the ID POC Admitting RN At the visit to complete the Comprehensive Assessment, in the electronic medical record (EMR) the admitting clinician opens the Interdisciplinary Plan of Care (ID POC) which is Form HOS4407; the clinician will document pertinent assessment findings and 3 Additional Disciplines complete their comprehensive assessments and document in the ID POC or ID POC Review Update 4 MCP or Designee reviews Admission Packet and ensures ID POC is open and information added. SW SCC MCP/Designee frequencies in the ID POC and will establish the POC with the IDG. Additional disciplines (e.g., social work and spiritual care) will complete their respective comprehensive assessments and document in the ID POC. If the first IDG Meeting occurs prior to the completion of a discipline s comprehensive assessment, the documentation will occur in the ID POC Review Update which is Form HOS4068 The MCP/Designee completes a quality review of the documents in the Admission Packet and, as a part of this process, the MCP/Designee ensures that the ID POC is open and all appropriate information has been added. A comparison is made between the Initial Assessment to the Plan of Care to make sure that each current or potential problem is addressed appropriately in the Plan of Care. If this has not occurred, the MCP/Designee will return the document to the admitting clinician for corrections/completion. 5 Existing Hospice Patient IDG Team For existing Hospice patients, reviewing and updating the POC is an ongoing process performed at routine intervals. The patient s POC will remain current as each member of the IDG Team will update the ID POC Review Update form with all new or amended information at each patient visit or phone call. 6 At every patient visit/encounter, team members update the ID POC Review Update. IDG Team Prior to each IDG meeting, all updates are added to the IDG POC or ID POC Review Update. At the end of every visit each IDG member will update the POC with the interventions provided during the visit and note the response to the intervention, to include the current date. 7 Prior to the IDG meeting, all updates are MCP/Designee The MCP/Designee will complete the IDG Meeting agenda prior to the IDG Meeting. 1 For additional information about the admission process and the associated forms, please refer to the following Hospice Job Aids: Hospice Admission Process and Admission Process Checklist. 04/20/2016 IDG Process Page 2

14 added to the IDG POC or ID POC Review Update. 8 Patient names added to IDG Agenda, which is updated throughout the week, and then forwarded to IDG members1 week and again 1 day prior to the meeting. 9 IDG Meeting is facilitated by the MCP and a Scribe is used Kindred at Home Interdisciplinary Group Meeting Process MCP Scribe The final agenda will continue to be developed throughout the week (e.g., with patients who are admitted, discharged, or had level of care changes) and the tentative agenda will be provided to IDG Team members hours prior to the meeting. The final agenda will be provided to the team 1 day prior to the meeting The IDG Meeting is facilitated by the MCP. Prior to convening the meeting, the MCP will identify a staff member to serve as a Scribe. Upon calling the meeting to order, the MCP will ensure that all participants sign the Sign In Sheet for the meeting and that these, along with the agendas, are centrally stored and accessible for review as needed or upon the request of an auditor/surveyor. (This can be in a binder, administrative folder or in a shared drive.) 10 During IDG Meeting, Scribe adds frequencies for next 2 weeks, final updates and IDG members present at the meeting. 11 In the EMR, HMD signs the IDG POC or ID POC Review Update Scribe HMD Prior to convening the IDG Meeting, all members of the team will ensure that the patient s POC is up-to-date and contains all necessary information. The Scribe will capture any and all changes during the meeting. Each patient is discussed as follows: The ID POC is displayed on the wall for all members to review. As each problem is opened each discipline will provide a brief update to the IDG members regarding the patient s current condition as well as a brief summary of the interventions provided, and the effectiveness of each one. The plan for the next 2 week period will then be discussed. The focus is on planning rather than on reporting. As each patient is discussed, the Scribe will make updates in the patient s POC as appropriate based on the IDG s discussion; Enter IDG determined visit frequencies for all disciplines for the upcoming two week period; and List the names of the patient s ID Team members present at the meeting. The Scribe s screen will be projected throughout the meeting so that team members can view changes to the POC as they are being made. The Scribe will close the ID POC or ID POC Review Update Form in the EMR. After the patient has been discussed and the Scribe has finished entering required information into the patient s POC, the HMD, as the designated member of the IDG, will sign the ID POC or ID POC Review Update and close the form (only if no new DX 04/20/2016 IDG Process Page 3

15 Kindred at Home Interdisciplinary Group Meeting Process codes are needed). If new codes are required the form is sent to coding and remains open. If this is an initial IDG meeting for a patient (ID POC form used) or ID POC Review Update contains new diagnoses, prior to signing the form the HMD will also review diagnoses and indicate their relatedness. 12 Is there a new or changed diagnosis? If Yes: Go to Step 13 in this process. If No: Go to Step 14 in this process. 13 Follow the Centralized Coding Process MCP/Designee Please refer to the Hospice GL Central Coding Process. Upon completion of coding, go to Step 14 of this process. 14 MCP completes IDG POC or ID POC Review Update and opens ID POC Review Update for next 2 weeks 15 Updated POC sent to Attending Physician MCP MCP/Designee After the HMD signs the ID POC or ID POC Review Update, the MCP will complete the form in the EMR. The MCP will open a new ID POC Review Update that will be used for POC documentation until the next IDG meeting. The updated and completed POC will be sent to the patient s Attending Physician for information and care coordination purposes. Ensure all new diagnosis categories are sent out for coding. ACRONYMS AND ABBREVIATIONS: EMR: Electronic Medical Record HOS: Hospice ID: Interdisciplinary SW: Social Work HMD: Hospice Medical Director MCP: Manager of Clinical Practice Pt: Patient IDG: Interdisciplinary Group POC: Plan of Care SCC: Spiritual Care Coordinator ATTACHMENTS: A. IDG Process Diagram B. Sample Agenda C. Sign In Sheet 04/20/2016 IDG Process Page 4

IDG MEETING PROCESS DIAGRAM 1. Pt admitted to Hospice 5. Existing Hospice Pt 15. Updated POC sent to Attending Physician 2. RN completes Comprehensive Assessment and initiates the ID POC 6.

Additional Disciplines complete assessments and document in the ID POC or ID POC Review Update 7. Prior to IDG meeting, all updates are added to the IDG POC or ID POC Review Update 9.

16 IDG MEETING PROCESS DIAGRAM 1. Pt admitted to Hospice 5. Existing Hospice Pt 15. Updated POC sent to Attending Physician 2. RN completes Comprehensive Assessment and initiates the ID POC 6. At every Pt visit/ encounter, ID Team members update the ID POC Review Update 14. MCP completes IDG POC or ID POC Review Update and opens ID POC Review Update for next 2 weeks NO 3. Additional Disciplines complete assessments and document in the ID POC or ID POC Review Update 7. Prior to IDG meeting, all updates are added to the IDG POC or ID POC Review Update 9. IDG Meeting is facilitated by the MCP and a Scribe is used 12. Is there a new or changed diagnosis? YES 4. MCP or Designee reviews Admission Packet and ensures ID POC open and information added 8. Pt names added to IDG Agenda, which is updated throughout the week, and then forwarded to IDG members 1 week and again 1 day prior to meeting. 10. During IDG Meeting, Scribe adds updated frequencies for next 2 weeks, final updates and IDG members at meeting. 13. Follow the Centralized Coding Process Acronyms and Abbreviations EMR: Electronic Medical Record IDG: Interdisciplinary Group HMD: Hospice Medical Director MCP: Manager of Clinical Practice ID: Interdisciplinary Pt: Patient ID POC: Form HOS4407 POC: Plan of Care ID POC Review Update: Form HOS4068 RN: Registered Nurse 11. In the EMR, HMD signs the IDG POC or ID POC Review Update 04/21/2016

17 IDG Agenda IDG Meeting Date: Team for Review: DEATHS/BEREAVEMENT (Since last IDG) Patient Name Date of Death RN Case Manager Clinician Attending Death LIVE DISCHARGES, REVOCATIONS, & TRANSFERS OUT Patient Name Date RN Case Manager Disposition ADMISSIONS & TRANSFERS IN Patient Name Primary DX BP # Admitting Clinician RN Case Manager LEVEL OF CARE CHANGES Patient Name Date of LOC Change New LOC Change RN Case Manager RECERTIFICATIONS Recertification: Current (For Signature Today) Patient Name New Cert Dates New BP Face-to-Face Date for Recert BP 3 RN Case Manager

18 IDG Agenda Recertification: Upcoming (2-4 Weeks) Patient Name New Cert Dates New BP Face-to-Face Date for Recert BP 3 RN Case Manager SIGNIFICANT CHANGE IN CONDITION/PSI SCORE Patient Name Current Cert Dates Current BP RN Case Manager ROUTINE REVIEW Patient Name Current Cert Dates Current BP RN Case Manager

19 IDG Meeting Signature Page IDG Meeting Date: Team for Review: Printed Name Title/Discipline Signature

Hospice Clinical Record Review

Hospice Clinical Record Review Purpose: Surveyors may use this worksheet when conducting clinical record reviews during a hospice survey. Directions: Fill in appropriate data. Table 1. Patient Information Patient Information Residence