Newsletter I N T H I S I S S U E. Facilitating Difficult. Conversations about Discontinuing Medications or Interventions.

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1 V O L U M E 1 0. I S S U E NEWS THAT MATTERS TO HOSPICE Facilitating Difficult Conversations about Discontinuing Medications or Interventions Kyna Setsor Collier, RN, BSN, CHPN, Clinical Nurse Educator, HospiScript Services I don t have time to deal with that. The patient will stop taking the medicine when she can t swallow or she ll just decide she doesn t want to take it anymore. I m not sure he s really taking all that anyway. As a hospice clinician, whether you are a medical director, admission nurse, case manager, or social worker; and, whether you work full-time, part-time, or contingent; your day is too busy for non-essential activities. Patients and families trust, sometimes even demand, that you will provide relief of their physical pain and that you recognize their emotional and spiritual suffering. You partner with your hospice interdisciplinary teammates to address those issues. Not only do patients and families expect it, you expect it of yourself; it s why you do this work. Knowing that you cannot change the ultimate outcome, but that you can impact the journey and relieve suffering, is what brings you fulfillment. So why would you want to talk to patients and families about discontinuing medications? How does that contribute to quality of life? Where is the fulfillment in that? The patient will stop taking those non-essential medications eventually on his own anyway, won t he? At end of life, the patient reprioritizes many things, either intentionally or unintentionally: what to eat, what to drink, how much time to spend out of bed, who to spend time with, what conversations to have, and what medications to take or not take. The family and caregivers also must help make some of those decisions. For example, an on-call nurse was sent to the home of patient experiencing a pain crisis one evening. Upon asking the daughter when her mother had last received her pain medication, she learned the patient was having increasing difficulty swallowing. Figure 1: The BUILD Model Component Method Goal H O S P I S C R I P T N E W S L E T T E R V O L U M E 1 0. I S S U E The daughter had not been able to get her mother to swallow the MSContin that morning, because they were both too exhausted after working so hard to get her to take her multivitamin. The daughter had prioritized the multivitamin over the pain medication. Patients and health care professionals often prioritize medications differently. Patients may prioritize medicines according to out-of-pocket costs, side effects, what family or friends have told them about efficacy, or even what they have read on the Internet. At some point, the patients were probably taught about the importance of the medicine at a point in their life when the benefit outweighed the risk. Talking with patients and families about discontinuing medications that are no longer essential to symptom or disease management can help reset those priorities. Discontinuing medications can add to patients quality of life by simplifying their medication regimen, minimizing side effects such as nausea or sedation, and decreasing patient expenses. Perhaps most importantly, the process helps patients and families choose the medications that will provide them the most relief from distressing symptoms. The following two cases illustrate use of the BUILD model to help facilitate discussions about discontinuing medications or interventions. BUILD stands for Building, Understanding, Informing, Listening, and Developing (see figure 1). 1 Continued on page 2 Building Build a foundation of trust and respect. Affirm the patient and caregiver; listen more than you talk; validate their efforts. Understanding Understand what the patient knows Facilitate the patient and caregiver drawing their about the topic. own conclusions about the topic. Informing Inform the patient of evidence-based Provide information in a neutral manner; bridge medical information. terminology and reasoning to the patient level. Listening Listen to the patient s goals and expectations. Learn what is important to the patient and relate that to goals of care. Developing Develop a plan of care in collaboration with Empower the patient and caregiver to take part in the the patient, family, and interdisciplinary team. collaboration and to realize their choices and decisions matter. EMPOWERING HOSPICE CARE THROUGH INNOVATION TM Newsletter I N T H I S I S S U E Bridget McCrate Protus, PharmD, CGP, MLIS, Director of Drug Information, HospiScript Services Facilitating Difficult 1 Conversations about Discontinuing Medications or Interventions On a Lighter Note What s the Impact of Unused Medications in Hospice Care? IN THE SPOTLIGHT HospiceScript Pharmcists ASHP Awards On-Site Accreditation of HospiScript s PGY2 Program Lunch & Learn Teleconferences Register Online! HospiScript Regional Conference May 1 th & 2 nd Register Today! Wound Care at End of Life: A Guide for Hospice Professionals Ask HospiScript Sharing information and updates about the HospiScript program The HospiScript Newsletter is a quarterly publication for the clients of HospiScript Services. Articles for publication consideration may be submitted to the attention of the Managing Editor, Kim Konczal (kkonczal@hospiscript.com). The clinical information contained in this newsletter is not medical advice. Health care providers should exercise independent clinical judgment. Some information cites the use of a product in a manner or for an indication other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

2 Continued from page 1 Patient 1: Amyotrophic Lateral Sclerosis (ALS) AJ is a 68 year old male with ALS, diagnosed about 4 years ago. He also has a history of depression. He lives with his wife who is his primary caregiver. He has been bedbound now for several months due to weakness and fatigue from ALS. The hospice admission nurse assessed his palliative performance status last week at 30% (bedbound, total care for all activities of daily living (ADL), reduced food intake, alert). He is experiencing increased dyspnea, increased secretions, and difficulty swallowing leading to anxiety and insomnia. He has neuropathic pain in his lower extremities that is controlled with gabapentin (Neurontin ). A comfort care kit was ordered on admission to hospice. He is reluctant to use the morphine or the lorazepam for dyspnea, stating he s fearful they will sedate him and he will then choke on his secretions. AJ says he is ready to die but is fearful of not being able to breathe. AJ and his wife are hopeful that he will die peacefully at home. AJ has been taking riluzole (Rilutek ) 50mg PO q12h for about 2 years. His speech is slurred and difficult to understand, but he is able to ask his wife to suction him every 1-2 hours while awake during the day, and every 2-3 hours during the night. She is exhausted. AJ had a 20 day supply of riluzole remaining when he was admitted to hospice. The admission team discussed the use of riluzole with AJ and his wife. AJ agreed he would finish his supply, but he was struggling with whether or not he wanted to discontinue taking riluzole. During the initial hospice interdisciplinary team (IDT) meeting and comprehensive medication review, the hospice IDT determined that riluzole was highly unlikely to provide any benefit for AJ and could potentially be contributing to adverse effects. They recommended to AJ s nurse-case manager that riluzole be discontinued. The nurse-case manager contacted AJ s neurologist who confirmed the decision of the hospice IDT. AJ has no known drug allergies and his current medication list includes: Medication Riluzole (Rilutek ) 50mg tablet Gabapentin (Neurontin ) 300mg tablet Citalopram (Celexa ) 20mg tablet Scopolamine (Transderm Scōp ) 1.5mg Morphine oral concentrate (20mg/mL) Lorazepam (Ativan ) 0.5mg tablet Senna+docusate (Senna S) 8.6mg-50mg tablet Bisacodyl 10mg tablet Orders 1 tab PO q12 hours 1 tab PO q8 hours 1 tab PO every morning 1 patch placed behind ear every 72 hours 5mg SL/PO every 4 hours as needed for pain or dyspnea ½ tab SL/PO every 6 hours as needed for anxiety or dyspnea 2 tabs PO BID 1-2 tabs PO daily as needed for constipation Using the BUILD model to frame a discussion with AJ and his wife: Build a foundation of trust and respect. Clinician: I admire the way the two of you work together to fight this disease. I m sure it hasn t been an easy road. Understand what the patient knows about the medication. Clinician: What is your understanding about the benefit of riluzole? How long do you expect to see a benefit from taking it? AJ: I know they don t recommend taking it longer than a year. But I m afraid if I stop taking it my breathing and secretions will get even worse. I don t want to suffocate. Can t we increase the dose? Inform the patient of evidence-based information about riluzole. Clinician: That must be very scary to think about stopping a medicine that you feel is helping you breathe. What we know is that increasing the dose only increases the risk of side effects, including decreasing your lung function. We also know that there is been no benefit to taking it longer than year, which is why it s recommended to discontinue it after a year. The medication has provided all the benefit it can provide. But the good news is that there are other medications that can relieve your shortness of breath and help with anxiety. Listen to the patient s goals and expectations. AJ: I just don t want to die gasping for air or drowning in my own secretions. Clinician: I can certainly understand that. We don t want that for you either. AJ: What if I want to continue taking it until I die? Clinician: You do have choices, but there are also some limitations. After our discussion last week, the hospice team collaborated with your neurologist and determined that riluzole is no longer beneficial for you. If you choose to continue taking it, you will need to pay for riluzole yourself. It cannot be covered by your hospice benefit or by Medicare Part D. As you may be aware, riluzole is expensive. The bigger issue however, is that it s not preventing or controlling your shortness of breath or secretions. We do have other medicines that can control those symptoms. Develop a plan of care in collaboration with the patient. Clinician: The morphine and lorazepam that are in the comfort care kit are very effective for shortness of breath and anxiety. I heard you say that you are concerned about being too sedated. Would you consider taking a low dose of the morphine while I am here so I can monitor your breathing? AJ: Do you really think it will help? And it won t make me stop breathing? Clinician: I have seen it work many, many times. And at the very low dose that we use, it will not cause you to stop breathing. I am going to stay right here with you. We want you to be peaceful. Patient 2: Cardiac Disease LM is a 65 year old male with end stage heart disease. He is being admitted to hospice today. LM is bedbound, experiencing dyspnea and angina with turning and repositioning. He uses continuous oxygen therapy at 4 L per nasal cannula. His wife is having difficulty administering all his medications due to his decreased responsiveness. His PPS is assessed at 20% (bedbound, total care all ADLs, minimal intake, drowsy). His past medical history includes coronary artery disease (CAD), hypertension, myocardial infarction (MI), depression, and gastroesophageal reflux (GERD). LM s wife reports he has increasing dyspnea, angina with minimal exertion, decreased appetite, decreased responsiveness, and difficulty taking his medications. LM has an automatic implantable cardioverterdefibrillator (AICD) and a pacemaker. LM signed a DNR-CC order during his last hospitalization. His medication profile notes an allergy to sulfa causing rash, and includes the following medications: Medication Furosemide (Lasix ) 20mg Lisinopril 10mg Metoprolol tartrate (Lopressor ) 50mg Digoxin 0.125mg Potassium (K-Dur ) 10mEq Atorvastatin (Lipitor ) 20mg Fluoxetine (Prozac ) 20mg Esomeprazole (Nexium ) 20mg Trazodone 50mg Aspirin 81mg Nitroglycerin (NitroQuick ) 0.4mg Morphine oral concentrate (20mg/mL) Lorazepam (Ativan ) 0.5mg tablet Centrum Silver multivitamin Bisacodyl 10mg tablet Senna+docusate (Peri-Colace ) 50mg-8.6mg Orders 2 tabs PO every morning 1 tab PO BID 1 tab at bedtime 1 tab daily 1 tab SL Q5 mins as needed for chest pain 5mg SL/PO every 4 hours as needed for pain or dyspnea ½ tab SL/PO every TID and PRN for anxiety or dyspnea 1 tab PO every morning 1-2 tabs daily as needed for constipation 2 tabs BID H O S P I S C R I P T N E W S L E T T E R V O L U M E 1 0. I S S U E EMPOWERING HOSPICE CARE THROUGH INNOVATION TM P A G E 2

3 Continued from page 2 When a patient is admitted to hospice, part of the admission team s role is to prioritize care interventions during the admission visit. Sometimes conversations about discontinuing medications and de-activating an AICD can wait and sometimes they can t. When the disease is quickly progressing and death is approaching, every hospice clinician assumes the responsibility of preparing the patient and family for what may happen. Understanding the disease process, anticipating what may occur in the final days and hours, and collaborating with the patient and family to meet their quality of life goals are what make hospice care unique. First impressions are lasting ones. The admission visit and end-of-life discussions establish the foundation of trust. These conversations are not one-time occurrences. Patients and families are often physically and emotionally overwhelmed and therefore able to take in only limited amounts of information. Important topics may need to be revisited several times. Discussions regarding interventions that have worked in the past but may no longer work are essential. Place emphasis on hospice s dedication to quality of life and comfort rather than curative care. Initiating a discussion with LM s wife about discontinuing nonessential medications, such as atorvastatin and multivitamins should be framed in a manner that is patient- and family-centered: Everything we do is focused on providing comfort to LM. Some of these medications were very helpful to him when he was more alert, eating, drinking, and able to participate in activities, but now they are not helpful to him. Some may actually be causing side effects. Let s look at how we can simplify things for both of you and ultimately improve his comfort. Just as the BUILD model can be used to discuss medication appropriateness, it can also be used to as a guide for other difficult conversations such as de-activating LM s AICD. Using the BUILD model to facilitate a discussion with LM s wife about the AICD: Build a foundation of trust and respect: Clinician: You do a great job caring for LM. Your love for him is obvious. Wife: Yes, we ve been married 41 years. This is the hardest work I ve ever done. Understand what the patient or family knows about the treatment(s): Clinician: LM s heart is getting weaker. He s getting short of breath and having chest pain with less exertion. Has LM s AICD ever fired? Wife: Once, about 3 months ago. It was very painful for him. Clinician: What s your understanding about what may happen with his AICD and pacemaker as his heart weakens? Wife: Well, I suppose his defibrillator will fire. What should we do? I can t just let him have a heart attack. If we turn off his pacemaker he ll die so we can t do that, can we? Develop a collaborative plan of care with the caregiver: Wife: Yes, I d like to know what his cardiologist thinks we should do. Clinician: I can go ahead and give Dr. C. a call now and give him an update. We ll see what his recommendation is. Using the BUILD model to facilitate a discussion with LM s wife about the discontinuing medications: Build a foundation of trust and respect: Clinician: You do a great job caring for LM. Your love for him is obvious. Wife: Yes, but I don t feel like I m doing a very good job. I can t even get him to take all his medicines. I know how important it is that he takes them all, every day. Understand what the caregiver knows about the medication: Clinician: He takes a lot of medicine, and I know it s hard for him to swallow now. How do you decide which medicines to give first, which ones are most important, and which ones can wait? Wife: I start with the biggest pills first, like the potassium, when he s most awake and has the most energy. Sometimes, like this morning, by the time I get to the real tiny ones, like his digoxin, he just doesn t have the energy left to swallow and he starts choking. So, he didn t take it today. Inform the caregiver of evidence based information: Clinician: He s going to continue to have difficulty swallowing all these medications as he declines. When we look at him right now, we see he s short of breath and anxious. The medicines that relieve those symptoms, the morphine and lorazepam, can be given under the tongue. Many of his other medications, such as the Lipitor and Centrum, aren t relieving a symptom. They aren t making him feel better. We can stop struggling to get him to swallow those and help you prioritize the rest. Listen to the caregiver s goals and expectations: Clinician: What is your biggest concern about LM s comfort today? Wife: It scares me when he gets short of breath and has chest pain. Develop a collaborative plan of care with the caregiver: Clinician: Let s focus on the medications that are going to relieve his symptoms and provide him comfort. We will discuss LM in hospice team meeting tomorrow. I ll call his cardiologist to update him. I ll see what his recommendations are for discontinuing some of the medications. Does that sound agreeable? Wife: Yes, if Dr. C. thinks it s ok to stop some of these medications then it s ok with me. REFERENCES: Inform the caregiver of evidence-based information: Clinician: His defibrillator will only fire if he has a ventricular arrhythmia, but there s no way to know for sure if that will happen or not, it s always a possibility. If it does fire, it will be very painful for him. Remember the AICD will not be shocking a healthy heart, so it s not likely that it will return his heart into a normal rhythm. The AICD may shock him several times. We would talk to his cardiologist first and then his AICD could be de-activated here at home. His pacemaker does not need to be turned off. He can and will die a peaceful death even with his pacemaker active. The pacemaker will not keep him alive nor cause him any discomfort. 1) Collier KS, Protus BM, Kimbrel JM. Medication appropriateness at end of life: a new tool for balancing medicine and communications for optimal outcomes, the BUILD model. Home Healthcare Nurse 2013;31(9): ) Miller RG, Mitchell JD, Moore DH. Riluzole for amyotrophic lateral sclerosis (ALS)/motor neuron disease (MND). Cochrane Database Syst Rev;2012 March 14;3:CD ) National Hospice & Palliative Care Organization (NHPCO). Position statement on the care of hospice patients with automatic implantable cardioverter-defibrillators. Alexandria, VA: NHPCO, May Available at Listen to the caregiver s goals and expectations: Clinician: We ve talked about a lot of things today: resuscitation status, medications that could be discontinued, de-activating LM s AICD. What do you have the most concern about? Wife: I really need to make a decision about his AICD. I want to do what s right for him. I know he s going to die and I want to make sure he s comfortable. HOSPISCRIPT NEWSLETTER VOLUME 10. ISSUE E M P O W E R I N G H O S P I C E C A R E T H R O U G H I N N O VAT I O N T M PAGE 3

4 What s the Impact of Unused Medications in Hospice Care? Sean Marks, MD, Medical College of Wisconsin With reports of pharmaceuticals being found in ground-water, lakes, and drinking water, there is increasing anxiety regarding the potential public health risks of pharmaceutical waste. These anxieties are especially relevant in home hospice care considering the types of medications utilized and the challenges in accurately determining the amount of medication any particular patient may need. Sean Marks, MD Prognostic uncertainty is one of those challenges. If a prescriber wished to minimize the amount of unused medication by prescribing a small amount of medication, the patient s comfort could be jeopardized. For patients with expected longer lengths of stay, the need for frequent small quantity refills can be inconvenient and time-consuming for the patient s family. Conversely, in order to maximize convenience for a patient, providers may prescribe for an extended period of time even when a hospice patient may be imminently dying. Beyond the prognostication concerns, patients at the end of life often have not just one, but multiple distressing symptoms (pain, nausea, fatigue, constipation, etc.). Thus, trials of many different medications may be required. Home hospice providers often strive to make these empiric therapies readily available in a time of symptom crisis by providing prepackaged emergency kits of commonly needed therapies. Because there are federal and state regulations that prohibit the return and reuse of medications, these medications often end up discarded. The task of discarding unused medications for deceased hospice patients is most often done by the home hospice nurse. It should come as no surprise then that this task can take an emotional toll on home hospice nurses. In fact, research suggests hospice nurses have significant concern for the legal and environmental impact of the drug disposal that they engage in. 1 Unfortunately, there has not yet been extensive research characterizing the unused medications from a hospice patient s death. How much medication is discarded? Which medications are most frequently left unused? What s the estimated cost attributed to these discarded medications to the home hospice agency? Speer et al performed a retrospective study of 296 consecutive patients who died while receiving care from a nonprofit home hospice organization in El Paso, Texas over a three year period to investigate these questions. The research team reviewed written recordings by the hospice nurses utilizing a standardized death form to estimate the amount of each particular medication in milligrams that had not been used by the patient at the time of death. They then utilized an online cost calculator HealthTrans.com to estimate the cost. The patient population was unique and may not be easily generalizable to the US hospice population. The median length of stay in hospice was only 16 days; 62% of the patients were Hispanic; and the mean number of medications prescribed by the hospice was relatively low only three. Still, it was apparent that analgesics and anti-anxiety medications made up a sizeable majority of the unused medications. In particular, liquid morphine was discarded in 218 decedent cases and lorazepam was discarded in 166 decedent cases. The estimated cost for all the discarded medications during the study period was $14,980, with morphine accounting for over $6,000 of that cost. These results suggest that a sizeable number of medications must be discarded at the time of death for hospice patients. In addition to the significant cost of these unused medications, often the unused medications are controlled substances such as opioids and benzodiazepines. Future research and quality improvement projects should better delineate which care factors in the home hospice care system most greatly contribute to unused medications, particularly the role of emergency kits. Hopefully creative methods could be then designed to reduce the amount of unused medications without sacrificing the care and convenience for patients and families. REFERENCES: 1) McCullagh MC, Schim S, Ortner P. Drug disposal among hospice home care nurses: a pilot study of current practice and attitudes. J of Pain and Sympt Manag 2012; 43(2): ) Speer ND, Dioso J, Casner PR. Costs and implications of discarded medications in hospice. J of Pall Med 2013; 16(8): ASHP Awards On-Site Accreditation of HospiScript s PGY2 Program HospiScript, in partnership with The Ohio State University College of Pharmacy and The OSU Center for Palliative Care, recently received on-site accreditation of their PGY2 Pain and Palliative Care Residency Program during the February ASHP surveyor visit. The PGY2 is a second-year postgraduate training program for pharmacists who wish to become experts in pain management, palliative care and hospice clinical practice. During the PGY2 residency year, the resident gains patient care training at the HospiScript Clinical Office in Dublin, OH. HospiScript clients in the central Ohio area that provide patient care learning experiences include OhioHealth Hospice, Zusman Hospice, and Nationwide Children s Hospital. On-site accreditation from the American Society of Health-System Pharmacists (ASHP) is rare and reserved for programs that demonstrate strong precepting, excellent patient care, and full compliance with ASHP s standards. Congratulations to the HospiScript pharmacists involved in the PGY2 residency: residency program director, Jason Kimbrel, PharmD, BCPS, preceptors, Bridget McCrate Protus, PharmD, CGP, MLIS, Maureen Jones, PharmD, CGP, Marliese Gibson, PharmD, and current resident, Lacey Shumate, PharmD, BCPS. IN THE SPOTLIGHT HospiScript Pharmacists Congratulations to the HospiScript pharmacists who have joined the elite group of HospiScript clinicians with specialized certifications. Jason Cleland, PharmD, CGP; Maureen Jones, PharmD, CGP and Nimita Varga, PharmD, MBA, CGP have successfully passed the Certification in Geriatric Pharmacotherapy (CGP) examination. In addition, Lacey Shumate, PharmD, BCPS has successfully passed the Board Certified Pharmacotherapy Specialist (BCPS) Examination. The Commission for Certification in Geriatric Pharmacy (CCGP) established the CGP credential to identify and recognize those pharmacists who have expertise and knowledge of drug therapy principles for older adults. The BCPS examination is obtainable through the Board of Pharmaceutical Specialties (BSP) and is a voluntary process confirming a pharmacist s education, experience, knowledge and skills in a particular practice area are well beyond what is required for licensure. Lacey Shumate, PharmD, BCPS Nimita Varga, PharmD, MBA, CGP Maureen Jones, PharmD, CGP Jason Cleland, PharmD, CGP H O S P I S C R I P T N E W S L E T T E R V O L U M E 1 0. I S S U E EMPOWERING HOSPICE CARE THROUGH INNOVATION TM P A G E 4

5 Teleconference Programs Schedule Register Online Today! HospiScript strives to meet your educational needs. Every month, HospiScript hosts teleconferences on topics of special interest to hospice staff. All HospiScript clients are encouraged to participate free of charge. Continuing Education Credits are also available for a nominal processing fee. To register, please visit and click on the Educate, Event Registration link. APRIL 2014 MAY 2014 JUNE 2014 Medical Management of End Stage Neuromuscular Diseases (ACS) Patient Centered Wound Care at End of Life To Heal or Not to Heal? Part 1 (ACS) Essential Medications for End of Life Symptom Management (ACS) Allison Webb, PharmD, CGP, HospiScript Services Kyna Collier, RN, BSN, CHPN, HospiScript Services Jason Cleland, PharmD, RPh, CGP, HospiScript Services Monday 04/07/14 9:00 AM ET Monday 05/05/14 9:00 AM ET Monday 06/02/14 9:00 AM ET 04/09/14 3:00 PM ET 05/07/14 3:00 PM ET 06/04/14 3:00 PM ET 04/10/14 05/08/14 06/05/14 Did You Hear What I Didn t Say? Chuck Behrens, M.Div., Hospice of Western Reserve Tuesday 04/22/14 11:00 AM ET Patient Centered Wound Care at End of Life: Is that Any Way to Treat a Wound? Part 2 Kyna Collier, RN, BSN, CHPN, HospiScript Services 04/23/14 Tuesday 04/24/14 2:00 PM ET 05/20/14 11:00 AM ET 05/21/14 05/22/14 2:00 PM ET Learning About Ourselves from the People Who Drive Us Crazy: A Self-Centered Approach to Conflict Resolution Elizabeth Young, D.Min., Vitas Innovative Hospice Tuesday 06/17/14 11:00 AM ET 06/18/14 06/19/14 2:00 PM ET Make plans to join your fellow hospice professionals in this legendary Lowcountry. The educational lineup will focus on management of pediatric hospice and palliative care patients. So, whether you have a current pediatrics program in place, are interested in establishing one, or have only the occasional pediatric patient, this conference is for you. Space is limited so be sure to sign up early. HOSPISCRIPT NEWSLETTER VOLUME 10. ISSUE E M P O W E R I N G H O S P I C E C A R E T H R O U G H I N N O VAT I O N T M PAGE 5

6 Empowering Hospice Care through Innovation TM 4525 Executive Park Drive, Suite 100 Montgomery, Alabama (800) Ask HospiScript The Ask HospiScript column shares information and updates about the HospiScript program for our clients. Please forward your comments or questions to Our hospice agency has many questions related to the recent CMS information regarding hospice care. Can HospiScript provide any guidance? Yes. The HospiScript Team communicates daily with key stake holders such as CMS, NHPCO and National Medicare Part D providers to continue to advocate for hospice care and provide clear guidance on the regulations. There have been significant changes in the way the Medicare hospice benefit is to be managed, including the way certain diagnoses are utilized and reported. There are also new requirements surrounding medication coverage and Medicare Part D. We know this information is important to you and have recorded presentations and written materials including answers to frequently asked questions available to our partners via the client exclusive section of We make frequent updates as new information is received so be sure to visit frequently. In addition, our clinical team is working on a CMS Part D toolkit in conjunction with NHPCO which will be available soon. To access this information, please login to the client section and select the CMS Updates link under the Hospi-U Resource Center. After reviewing this information and listening to the webinars, please submit any additional questions you may have via to CMSUpdates@hospiscript.com. We want each of our hospice partners to know that HospiScript is committed and will continue to do everything we can to support you and your mission. Please feel free to contact your Account Manager directly for more information or if you have any concerns regarding how these changes will impact your hospice. Will HospiScript provide reporting that meets the CMS requirement around CR8358? Yes. Described in further detail in the video presentations which can be found in the Hospi-U Resource Center under the CMS Updates link. HospiScript is actively engaged with EMR s (a list can be viewed in Hospi-U ) and we will provide a standard file layout that will either be made available to each of our hospice partners or to their electronic medical record (EMR) vendor. HospiScript will ensure that each of our hospice partners at a minimum have access to all the needed data prior to the required start date. Please contact your Account Manager for more information or assistance. Wound Care at End of Life: A Guide for Hospice Professionals - GET YOUR COPY TODAY! As a leader in hospice pharmacy benefits management, HospiScript recognizes the critical relationship between wound care and pain and symptom management. Therefore, the clinicians at HospiScript have developed the publication, Wound Care at End of Life A Guide for Hospice Professionals. This quick reference guide for palliative management of wounds in hospice care is a valuable resource with a collection of guidelines to help provide a consistent and reliable reference that focuses on clinical best practices. It can support all levels of hospice practitioners; serving as a learning guide, reference or training tool. An electronic version of this publication is available free of charge for our partners via the Hospi-U Resource Center. In addition, a print version can be purchased at The list price is $24.99, but as an added benefit for our partners, a discount of $10.00 is available if the discount code (see Hospi-U ) is entered when the order is placed. H O S P I S C R I P T N E W S L E T T E R V O L U M E 1 0. I S S U E EMPOWERING HOSPICE CARE THROUGH INNOVATION TM P A G E 6