Dr. Ed Martin began working in hospice in 1987 after hearing families talk about their experiences with those services.

Today, he is chief medical officer of Rhode Island-based HopeHealth. The more than 50-year-old nonprofit organization also serves parts of Massachusetts.

Martin recently spoke about the complicated issue of care that is deemed “unrelated” to a patient’s terminal diagnosis at the National Hospice and Palliative Care Organization’s Annual Leadership Conference in Denver.

Hospice News sat down with Martin at the conference to discuss how he and his organization are addressing the matter of unrelated care, as well as the efficacy of requirements for an addendum to the election statement.

What are some of HopeHealth’s biggest priorities right now?

A big priority has been to provide care upstream and to try and make sure that patients add access services and attention sooner in this trajectory. So we have a large palliative care program.

We supply palliative care clinicians to a number of the hospitals, the teaching hospitals in Providence and some hospitals in Massachusetts. Then we have a home program where we have an advanced illness program where our nurse practitioners go to the home of patients with advanced illness to assist them in symptom management and often assist them in changing their focus of care from back and forth to the hospital, to focus on being at home and even accessing hospice services.

You’ve spoken on the complex issue of unrelated care. What would you say are some of the biggest hurdles that hospices face when it comes to that process?

The standards have changed over the past few years, and have become much stricter. And with that understanding, it’s unfortunate there are patients that don’t get hospice services because of their diagnosis. Because even if they’re dying, if they need dialysis for their kidney failure, for example, they really can’t come on to hospice, because it’s hard to say that’s totally unrelated.

So as a result, patients with kidney disease are most likely to die in the hospital and have the shortest length of stay in hospice.

Just making sure that your hospice is financially solvent is important. We want to have money for our chaplains program and our bereavement services, and you could easily spend all of the money that we get from Medicare on pharmacy. So we try to be judicious about that.

We have a pharmacy benefits manager to make sure that we’re being using as cost effective an approach as possible. But with an effective approach to controlling symptoms, it’s pretty unusual that a patient would go into the hospital nowadays and not be sick enough that it impacts their prognosis.

So that often requires a discussion: Is the care really going to focus on palliation and comfort, in which case they might even come over to our inpatient unit, or have they decided to put hospice aside and go to the ICU for more aggressive treatment, in which case they have the opportunity of revoking their benefit? But it’s a complex web of regulations that requires understanding.

How are you navigating these issues at HopeHealth?

We pay a lot of attention, and we’re always reviewing our processes. There are certain areas that Medicare is focused on right now. One is general inpatient stays, and the other is long length of stay. So for a general inpatient stay, they will look at our patients who came on to the general Inpatient level and died a little too slowly. They often still had very complex care. They often came from the hospital or sometimes from home with uncontrolled nausea, vomiting, severe pain, severe agitation, and they’re now on a number of injectable medications.

If they’re able to take it by mouth, we switch the medicines to oral and get them out to a nursing home or to a home. If they’re not able to swallow, that’s often not an option. And oftentimes, near the end of life, patients may have respiratory secretions that are coming out of their mouth, so you can’t put medicine under their tongue.

There is no nursing home in our state, and I’m not sure in the country that will come in and give a patient 24 injectable medications. A nurse in a nursing home who’s got 30 patients, how soon are they going to come back and check on that patient?

So our setting, we often very strongly believe that it’s the most appropriate setting for the patient at that point, but we understand that our Medicare reviewers may disagree with that. So we may have to appeal, and ultimately, even go before an administrative law judge to get that care approved.

In terms of long length of stay, if all of your patients die within six months, you’ve probably been too strict in terms of who you’ve let on. When we admit a patient, we expect that some patients will die within 10 days. We expect some patients are going to die a little more slowly.

I think President Carter has sort of brought this to the country’s attention, because I think he’s over a year and a half out now in hospice, with advanced cancer.

There clearly are some agencies that are out there admitting patients without providing care, or they just discharging everybody at six months so they don’t have any regulatory issues and hope they stay off the radar. So my complaint has been that the regulatory agencies are out giving parking tickets while the banks are being robbed. And I think it’s just so frustrating for those of us in hospice.

In that vein of unrelated care, are people asking for the addendum to the election statement? Is that making any difference?

People don’t ask for it because, basically, most of the medicines are related. So it’s not really a useful document. Sometimes there might be a handful of medications, but they understand that’s not related. They still go to the pharmacy and get them. It’s extraordinarily unusual in our program that somebody requests one of those forms.