The HPM Practitioner

Business/Practice News and Views for Physicians in
Hospice and Palliative Medicine
Issue No. 9                                                                                                           June 2011
Greetings!

 

Doctors find their way into the field of hospice and palliative medicine (HPM) in different ways. Some just seem to know that this is the work they want to do; others encounter it in the course of other medical pursuits and gradually discover a congenial career path. In the two features presented in this issue of HPM Practitioner, we have one physician, Dr. David Wensel, whose personal experiences with terminally ill family members led him to become a hospice patient care volunteer even before he applied to medical school. For the other, Dr. Glenn Panzer, establishing a family medicine practice naturally drew him into the long-term care arena, where his participation in the American Medical Directors Association introduced him to the role of hospice in long-term care.
 
Both doctors do HPM full-time, although in different settings and with different mixes of clinical, administrative and regulatory responsibilities. Both believe they are in the right place at the right time, doing the right work to achieve professional satisfaction with their jobs.

 

Tim Cousounis
In This Issue
HPM Practitioner Profile - Dr. Glenn Panzer
WilliamsonDr. Glenn Panzer: Enhancing Care of Quality Agency Wide
Interview with HPM Physician
Glenn Panzer, MD,   
by Larry Beresford

Dr. Pranzer
Dr. Glenn Panzer, currently the full-time chief medical officer for Elizabeth Hospice in Escondido, Calif., had a busy practice in family medicine back in Northeastern Pennsylvania for more than 20 years, much of that time in solo practice. He started seeing patients in the nursing home as a natural extension of his practice, which eventually led to responsibilities as a long-term care medical director. He learned geriatrics on the job, and eventually was grandfathered into board certification in that specialty. He also became active in the American Medical Directors Association (AMDA) and its state and local chapters, becoming a certified medical director of LTC facilities.

 

Through AMDA's educational offerings, he learned more about hospice care, eventually becoming board-certified in HPM. "I have learned to love hospice care," he says. "It's a great field to help people get the best quality of life, and to treat their pain and suffering." Although he didn't approach the field with the missionary zeal----borne of personal experience----that others in the field sometimes report, he has come to appreciate HPM both as good medicine and as a legitimate career path for physicians.

 

Dr. Panzer moved with his wife to San Diego in 2003, in part because of the weather, and he joined Elizabeth Hospice as a part-time clinical team physician the following year. His administrative responsibilities for the hospice gradually grew into the position of medical director and then, in May 2010, to his current, full-time salaried position. That required him to mostly leave direct patient care behind. For an agency with a census of 400 hospice patients, he now oversees two full-time regional medical directors, eight per-diem physicians and three nurse practitioners. For 70 percent of its admissions, Elizabeth Hospice's physicians become the patients' attendings.

 

"My role evolved over time, with less and less clinical involvement, to the point where it wasn't too hard to let go of that," he reports. "Basically, it goes back to the concept I learned as a medical director in long-term care. When you see patients as a physician, you are helping one patient at a time. But as a medical director, you're working with a team to help enhance quality of care for all of the patients in a facility or under a service. And I'm good at that."

 

Dr. Panzer serves on the hospice's leadership team, helps to develop policies, procedures and standards, chairs its pharmacy management committee and provides clinical training for staff. "I've also been meeting with our marketing people, and I sometimes go out to physicians' offices with them. I work with the director of clinical operations to make sure that everything runs smoothly in the clinical realm." Increasingly, that responsibility includes a focus on regulatory requirements such as the physician's narrative statement affirming the patient's terminal illness and, starting this year, physician face-to-face encounters with patients before their third hospice benefit period starts.

 

He estimates that his full-time position at Elizabeth amounts to 40 to 45 hours per week, on top of which he is part-time medical director of Villa Pomerado, a long-term and post-acute facility on the campus of Pomerado Hospital, where he sees patients about 15 hours a week. At one point he was contracted to do both jobs at 30 hours a week, but both grew into full-time expectations. It became too much, so he cut back on the long-term care work. He also chairs a hospital palliative care committee for Palomar Pomerado Health System, as well as the hospital's ethics committee, both more or less as volunteer positions on top of his two other jobs.

 

"I'm facilitating the development of the palliative care service at the hospital, but having other physicians do the actual clinical work, because I can't do everything," he explains. He helped the health system obtain a grant from the Archstone Foundation to demonstrate the benefits of spiritual care on palliative care teams, which supported additional staffing for the interdisciplinary team.

 

Describing a typical day, he says, "This morning, I went to a meeting of a consortium of agencies trying to improve dementia care for North San Diego County. Then I went down to Villa Pomerado to review short-term patients' charts, and then out on the floor to see an hour's worth of patients," he says. After that, he attended the hospital's ethics committee meeting, which lasted two hours. "Last night I spent an hour on the computer after work catching up on hospice paperwork."

 

Quality Standards and Processes

 

According to the Medicare conditions of participation, hospices are supposed to have a quality framework, which starts at the level of the board of governance. "I'm in charge of medical services here, but each department has its own clinical quality team, and we all set goals we try to reach." Dr. Panzer also monitors physician billing as a quality mandate, looking at codes, dates, places of visit and the like to make sure the coding was done correctly. "My basic responsibility is overall oversight of quality," he explains.

 

"We have policies and procedures defining our standard on face-to-face visits, which need to happen within 15 days. We set up a process so that we can comply with that standard. Our customer service center set up a process for determining whether new patients needed a face-to-face visit (because of previous hospice enrollments), and I double-check through a back-end review system. I get reports so I know if the face-to-face visits haven't been made."

 

Several years ago Elizabeth Hospice was under post-payment medical review by its fiscal intermediary, with a particular target of dementia patients, for which the hospice had developed specialized programming. "Part of my job was to review each case going before the Administrative Law Judge (ALJ). I was able to formulate spread sheets on each appealed claim, and present those to the judge," along with copies of the claims denials. "The judge sat down with us and said: 'Do you agree with their reasons----or not?' We were able to get 90 percent of our appealed claims overturned."

 

Through this experience, Dr. Panzer learned what ALJs look for, and how to help the agency improve its overall documentation. "When we were under medical review, staff sometimes became reluctant to admit patients with dementia. But we realized we were doing everything right----we just needed to document it better." Another thing he found was that the claims reviewers didn't always distinguish between Alzheimer's dementia and stroke dementia. "I realized that we had to categorize these cases better in our documentation," and look more carefully at the debility and decline guidelines. The hospice has now been off medical review for 1-1/2 years.

 

How does he feel about the current level of regulatory scrutiny focused on hospice care and hospice claims? "It's a lot of extra paperwork," especially with the new requirements for narrative statements and face-to-face visits, he says. "I was able to hire an extra part-time nurse practitioner, and so with our staff, we've been able to cover it," with the regional medical directors making some evening and weekend visits and the nurse practitioners stretching to cover weekends. "But I could imagine that hospices without a full-time medical director are struggling to cover the face-to-face visits, or set up a system that works." Hospices are responsible to do these things, but without increased compensation. "The regulations are increasing our workload at a time when Medicare is looking to decrease our compensation," he observes.

 

"Here, we look closely at the regulations to figure out how to comply with them. We have a very good CEO, Laura Miller, who encourages the leadership team to be visionary about what's coming down the pike. She encouraged me to delegate the recertification responsibilities to my regional medical directors, and to get them more involved in that. She also sent me to the NHPCO Management and Leadership Conference the past three years."

 

Dr. Panzer is part of a family of physicians, including his father, a dermatologist, and four siblings who are physicians. He has three grown sons; two have business degrees and work in San Francisco, and one is a physician practicing in Chicago. In San Diego, he takes advantage of the agreeable climate, enjoys the outdoors, goes on hikes, climbs and bike rides and walks the dog. Contact Dr. Panzer at

glenn.panzer@ehospice.org.

PracticeOpportunityFeatured Practice Opportunity

 

Community Palliative Care Officer

 

As hospices transform themselves into community-based palliative care enterprises, new practice opportunities are emerging for Hospice and Palliative Medicine (HPM) physicians.  While incorporating some traditional aspects of the hospice medical director, these positions are distinguished by a focus on caring for persons with advanced or complex illnesses in late-life (in contrast to end-of-life) in a multitude of settings throughout the community. 

 

One such opportunity is currently available in a waterfront city on the East Coast. This full-time position will work closely with a recently appointed chief medical officer to carry out (clinically and administratively) a highly ambitious plan to reposition the hospice as the community's leading network of palliative services to the chronically and seriously ill.

 

Expectations of this position are high, of course, yet will be compensated accordingly.

 

This role provides an exceptional opportunity for a HPM physician to showcase one's clinical skills and knowledge of HPM best practices, as well as developing strategies to build sustaining relationships with community organizations to establish palliative care as a recognized and sought after service within the community.

 

If you're considering advancement along your career path and would like to learn more about emerging HPM physician practice opportunities, contact Tim Cousounis at tcousounis@digital-action.com or (610) 733-7201. 

 

For more opportunities, click here.

Contact Us

Tim Cousounis
Managing Director,
DAI Palliative Care Group
Phone: (610) 941-9419

tcousounis@digital-action.com


Larry Beresford
Editor
Phone: (510) 536-3048
larryberesford@hotmail.com
www.larryberesford.com
Larry's Blog

The DAI Palliative Care Group is a national consultancy partnering with hospices and palliative care practices to build their medical staffs. Recruiting, medical staff development planning, physician performance management and opportunity assessments for palliative medicine practices are our competencies. We invite a discussion of how a partnership would benefit you.

StratonDr. David Wensel: It's not about the Regulations
Interview with HPM Physician
David Daniel Wensel, DO

by Larry Beresford

Dr.Wensel

Topeka, a city of 122,000 in Eastern Kansas, is home to one of the country's most innovative and diversified non-profit hospice programs. Midland Care Connection's menu of services includes hospice care with three home-based teams serving 14 counties, a freestanding hospice inpatient facility, a certified home health agency, a certified residential care center, a hospital palliative care consultation service, home and community-based palliative care, an outpatient clinic, two adult day care centers, grief, loss and respite services, and one of the first PACE (Program of All-Inclusive Care for the Elderly) sites in the Midwest.

Since August 2010, David Wensel, DO, has been co-medical director (with Dr. Greg Nelson) for Midland Care, responsible for the medical components of those diverse service lines. "We believe that diversification will be very helpful given the current financial pressures on hospices," Dr. Wensel says. "For non-profit hospices that only rely on the Medicare hospice benefit to pay their bills, it will always be a struggle."

Key to the diversification strategy, he adds, has been the strategic vision of CEO Karren Weichert. "She's been here since the beginning, and has developed so many productive relationships, both locally and nationally. I feel very fortunate to be part of this organization."

 

Midland's current priorities include growing the palliative care program and the hospice caseload as well as the continued expansion of PACE, which is a model of capitated, coordinated, all-inclusive care for elders with long-term care needs, originally modeled after On Lok in San Francisco. "PACE is just good palliative care in a primary care setting----for patients who mostly have a limited life expectancy measured in years," Dr. Wensel says. Midland has a census of 126 hospice patients, 104 PACE enrollees and about 30 patients receiving outpatient palliative care, either in the clinic or in their homes, with a full-time nurse case manager coordinating the palliative care program. "Dr. Nelson and I also drive out of town quite a ways for home visits."

 

Midland started as a non-profit hospice in 1978 and grew from there. "Its approach has been to identify unmet needs in the community and then look for service lines that could meet those needs," he explains. "Right now we're looking at a transitional program for patients with dementia, which is a huge need in our community. We're also talking about housing for Alzheimer's patients."

 

Recognizing that caring for Alzheimer's patients at whatever stage of illness is not like caring for a normal, healthy adult, it is essential to tailor supportive services to the needs of the individual patient. "It takes the right kind of person, the right team of people, with a sense of purpose and the expertise to provide that care," he says. And these issues will only increase in importance since dementia is expected to become the number one diagnosis under Medicare in the not-too-distant future.

 

Never a Second Choice

 

Dr. Wensel's interest in hospice and palliative medicine traces back to his experiences as a young man watching two grandparents receive hospice care at the end of their lives. Based on what he saw, he wanted to become a hospice patient care volunteer and so he called up a hospice in Des Moines, Iowa.

 

"I showed up for the first day of volunteer training and I was the only male there and virtually the only person under 65," he recalls. "But I was hooked from the beginning." Along with graduating with a certificate in theology from Creighton University, he also volunteered as a rural fireman, which led to training as an EMT and paramedic, and eventually application to medical school. "It was during medical school that I started getting rumblings about hospice as a viable career choice. As soon as I heard that, I connected with the American Academy of Hospice and Palliative Medicine (AAHPM)." He regularly attends academy meetings and has served on a number of committees, including chairing its Communities Committee.

 

Hospice was never a second choice for Dr. Wensel as he worked through medical school and a family practice residency. While still a resident, he and a couple of colleagues designed an HPM fellowship program at Mercy Medical Center North Iowa, a community hospital in Mason City, with assistance from Dr. Martha Twaddle of the Midwest Palliative and HospiceCare Center in Glenview, Ill. The fellowship was rolled out in conjunction with launching a hospital-based palliative care consultation service at Mercy North, which provided a practice setting.

 

Dr. Wensel then was the first fellow of the program he helped to establish, during academic year 2005-2006. "I'm not sure you could do that today, but all the pieces just fell into place." After the fellowship, he continued to do hospice and palliative care in Mason City until an opportunity came up to participate in diversified program development in Topeka.

 

As currently structured, the two medical directors' roles at Midland cover either the inpatient hospice unit and palliative care service or the PACE program, day care and clinic. The doctors trade off these roles alternate weeks. Each also sits on a hospice home care team, with on-call responsibilities two nights a week and one weekend a month. "Plus the two of us are running around trying to complete all of the hospice face-to-face encounters required by Medicare," he says. Two per-diem physicians help fill in the gaps, including weekend call.

 

"I really enjoy the variety of settings and intensities, and it helps to keep us fresh," he says, adding that clinic-based work is a nice balance for hospice care and utilizes his family practice training. "My first love is hospice and palliative care, but I really enjoy the opportunity to do primary care." The growing demands of government regulations and scrutiny for hospice providers can be a headache, he acknowledges. "It drives us nuts sometimes. But this work is not about that. It's about patients and families and addressing symptoms and suffering."

 

Emotional Stress and Self-Care

           

Dr. Wensel normally works from about 7 am to 5:30 or 6 pm, with Thursday afternoons off. He describes his job as 90 percent clinical, with the rest of his time spent on administrative duties such as staff meetings, administrative leadership, quality programs and marketing----although when it comes to the hospice weekly team meeting, the distinction between administrative and clinical isn't always clear. "Nobody here tells me what to do. I do what needs to be done. I stay very busy, but I can spend as much time with the patient who's in front of me right now as I need to. It's all up to me and my current patient volume."

 

Although there are a lot of hats to wear and a lot of clinical needs to fill, Dr. Wensel doesn't consider the work stressful. "It is emotional work, and the intensity of emotion working with dying patients and families can be difficult," he says. "I've had physician friends who would get into this work but found that they couldn't keep it up because it's so challenging emotionally. It will add up on anybody----although I work hard to take care of myself, not just physical exercise but my own emotional and spiritual well-being. I'm responsible for caring for myself," he says. "I also have three young kids, who keep me active. I'm an avid reader, and I pay attention to what's going on in the world," Dr. Wensel says.

 

"For me, it's everything I really wanted to do since I started medical school. This work allows you to really get to know patients and families at a very vulnerable time in their lives----and at a much deeper level. The closest comparison I can make in medicine is caring for women during pregnancy through delivery.... For people who read this interview, HPM is the hardest type of medical practice but at the same time the most rewarding in terms of the experiences you have with patients and families. I could not imagine doing any other kind of medical practice." Contact Dr. Wensel at: dwensel@midlandcc.org.

CareerAdvancementToolCareer Advancement Tools

 

Emerging Leaders Program - a program offering insights into securing and then succeeding in the right HPM leadership position.  Contact Tim Cousounis at tcousounis@digital-action.com to learn more.

 

Palliative Care Network - a membership group on LinkedIn providing a forum for timely exchange of issues influencing HPM practices. Join LinkedIn if you're not a member, and then search under Groups for Palliative Care Network.

 

Palliative Care Success - a subscriber blog posting commentaries on trends shaping the future of HPM practices www.palliativemedicine.blogspot.com

 

CV Writing Service - a professional consultation to make your credentials shine.  Send an email to Tim Cousounis at tcousounis@digital-action.com to arrange for a consultation with a Physician CV Specialist.

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