101 kiedrowski hospice essentials #7 mjhs sept14 slide

Hospice Essentials Brian J. Kiedrowski, M.D.,C.M.D Chief Medical Officer Miami Jewish Health Systems

Objectives • Describe the Medicare Hospice Benefit (MHB) • Knowledge of eligibility process for MHB • Define the 4 levels of care for hospice patients • Understand the Funding mechanism for the Medicare Hospice Benefit • Understand Physician reimbursement for hospice care • Appreciated the origins and early days of hospice

Background and Early Days • Considered the model for quality compassionate care for people facing a life-limiting illness – Provides expert medical care

– Pain management – Emotional and spiritual support – Tailored to the patient’s needs and wishes. (family too)

• Hospice focuses on caring, not curing – Varied settings

• In 1905: Irish Sisters of Charity founded St. Joseph’s Hospice in the East End of London.

Dame Cicely Saunders

• Nurse

• Social worker • Physician

Modern Hospice Movement • Modern hospice movement began with the work of Dr. Cicely Saunders.

• Credited with developing the art and science of modern hospice care • Established physician training programs to improve competence • Formulated the basic principles of hospice care – Vigilant attention to details of patient care – Careful research to support claims about an intervention’s effectiveness • Pioneered the use of oral opioids to control pain • Developed the concept of total pain

• 1967: opened world-renowned St. Christopher’s Hospice in South London – “medical model” while still recognizing the emotional, spiritual, and social aspects of care.

• St. Christopher's Hospice

Development of Hospices in the United States • 1969: Dr. Elizabeth Kubler-Ross, MD – Interviewing terminal ill patients about their reactions to dying – Published On Death and Dying – Five common stages or reactions to dying: • Denial, anger, bargaining, depression, acceptance

First US Hospice program: Connecticut Hospice: 1974 • Spearheaded by Florence Wald, RN – Former dean of Yale University’s School of Nursing – Model on St. Christopher’s.

• Consulting with Dr. Saunders to ensure that the principles of care were consistent

• Both of these programs were established in inpatient settings.

Florence Wald • Nurse • "Mother of the American Hospice Movement"

• Dean of the Yale School of Nursing

Evolution of US Hospices • Development of a model that emphasized care in the patient’s home • 1983: Medicare coverage for hospice began • Now available through almost all US insurance plans.

Fact and Figures • 2010: almost 42% of all US deaths~1.58 million involved with Hospice Care.

• 41.1% provided in private residences • 18% in nursing homes • 7.3% in ALF’s • 21.9% in inpatient hospices • 11.4% in acute care hospitals • 54% of hospice patients being 75 years or older

Organizational Models of Hospice Care in the United States • 2010: over 5,000 hospice organizations in the United States.

• 58% for-profit, 36% not-for-profit, 6% gov’t • Several Models – Free-standing programs (58%) – Affiliated with hosp/health sys. (21.3%) – Home health agencies (19.2) – Nursing home base (1.4%)

Census Size • Less that 25 : 28.9% • 26-100: 40.1% • >100: 31%

Medicare Hospice Benefit • Medicare Hospice Benefit (MHB) pays for 80% of all Hospice Care in the United States.

• Established 1983 • Pays for medical, nursing, counseling, and bereavement services • Original goal to support families caring for a dying relative at home – Can also be provided in a nursing home or acute care hospital

Eligibility: Medicare Hospice Benefit •

Patients must be entitled to Medicare Part A – –

•

They sign off Part A and sign on (elect) the MHB. This process is reversible – patients can and do elect Medicare Part A.

Patients must be certified by the Hospice Medical Director and primary physician to have a life expectancy of <6 months –

•

“If the patient’s disease runs its natural course...”

Patients can continue to be eligible if they live beyond 6 months as long as the physicians believe death is likely within 6months –

“Snap shot” at 6 months

Benefit Periods • Initial 90 days • Recertification 90 days • Then unlimited 60-day periods • Reason why some patients are on the program more than a year.

• Hospice physician with team input makes decision

Covered Services •

Case oversight by physician Hospice Medical Director

•

Nursing care: symptom assessment, skilled services/treatments and case management – Nursing visits routinely; 24-hour/7-day per week emergency contact is also provided.

•

Social work: counseling and planning (living will, DPOA)

•

Counseling services including chaplaincy

•

All medications and supplies related to the terminal illness. The hospice may charge a $5 co-pay per medication. (most choose not to charge this).

Medication for conditions not related to the terminal condition are not covered.

•

Durable medical equipment: hospital bed, commode, wheelchair, etc

•

Home health aid and homemaker services (light cooking, cleaning, shopping)

•

Speech, nutrition, physical, and occupational therapy services as determined by the plan of care (see below)

•

Bereavement support to the family after the death of the patient.

•

Not Covered: custodial care or nursing home room and board charges

Physician Role • At the time of enrollment the patient indicates the primary physician who will direct care – Patient may select primary doctor

– May select a hospice physician • The primary physician is responsible for working with the hospice team to determine appropriate care

Plan of Care (POC) • Home team and the patient’s physician work together to maximize quality of life by jointly developing the Plan of Care.

• Based on patient’s diagnosis, symptoms, and other needs.

• Hospice program and the patient’s physician must approve any proposed tests, treatments, and services.

• Only those treatments that are necessary for palliative and/or management of the terminal illness will be approved.

Places of Care • Home – Majority (95%) of hospice care takes place at home.

Medicare rules do not require a primary caregiver in the home, but as death nears, it becomes increasingly difficult to provide care

• Long-term care facility: – 25% of patients in the US die in Nursing Homes.

Medicare recognizes that this can be the resident’s “home”. Individual hospice programs must establish a contract with the facility

• Hospice inpatient unit

• Hospital

Levels of Hospice Care: Four different levels of hospice services

1. Routine Home Care – The most common type of hospice services (85%)

– Hospice interdisciplinary team provides core services in the patient’s home – The patient’s home may be a private home, an assisted living facility, long-term care facility – wherever the patient lives.

Levels of Hospice Care: Four different levels of hospice services

2. Respite Care – Respite care is short-term inpatient care to relieve the family/primary caregiver – Caregivers often schedule respite in order to travel or tend to their own healthcare needs.

– Limited to 5 consecutive days

– Hospice agency may provide respite in a variety of contracted settings (inpatient facility, local nursing home, etc.)

Levels of Hospice Care: Four different levels of hospice services 3. General Inpatient Hospice Care (GIHC)

– MHB provides for care to be provided in: • an acute care hospital – Dedicated inpatient unit – Contract beds » Facilities staff provides routine care, with supplemental services provided by hospice personnel.

• A nursing home with proper staffing.

– Criteria for this level of care includes: • Uncontrolled distressing physical symptoms – Uncontrolled pain, intractable nausea, respiratory distress, severe wounds, etc.

– Psychosocial problems (e.g. unsafe home environment, imminent death where family can no longer cope at home)

Levels of Hospice Care: Four different levels of hospice services

4. Continuous Home Care – For hospice patients who qualify for General Inpatient, but desire to remain in their home.

– Continuous care intends to support the patient and their caregiver through brief periods of crisis.

• CC provides care for up to 24 hours a day. Can be nonconsecutive hours.

• Care must be primarily provided (more than 50%) by a LPN or RN.

Case #2 • Mrs. G is a 53 y.o. w female with 4 year history of breast Cancer. Now with bone metastasis and pain at 8/10. Pt with increasing nausea and vomiting.

• Medication: – MS ER 60mg po BID – MS IR 15mg po q 4 hours prn

– Compazine 10mg po q 4 prn.

What would you do?

Case #2 continued • • • •

• • •

You try to add Motrin 400mg po TID as adjuvant agent and increase long acting Morphine.

Pt starts to have increased N/V. Order Continuous Care.

– Change in Level of Care.

HHA shift 8am to7pm. LPN shift 7pm to 8am.

– LPN uses “emergency kit” in home with Compazine 25mg suppository. May also use Lorazepam from e-kit.

Makes sure long acting morphine increased to 90mg “twice daily”.

Educate family to stay ahead of the pain.

Staff during the day helps with caregiver burnout.

•

Patient improves: return to Routine Home Care – Sometimes difficult since the family is now accustomed to around the clock care.

•

What if develops delirium?

•

***** MHB patients may be admitted into a hospice program at any level of care

Funding/Payment • The rates of reimbursement are fixed for each category of care on a annual basis.

– Vary by geographical location and county.

– Payment is made from Medicare to the hospice agency, which then pays the hospital or nursing home, depending on the specifics of the contractual arrangement.

• • • •

Routine Home Care: ~$154/day Inpatient Respite Care: ~$163/day General Inpatient Care: ~$794/day Continuous Home Care: ~$38/hour

Physician Services â&#x20AC;˘ Direct Patient Care services by physicians related to the terminal care are reimbursed

by Medicare, and are not included in the per diem. â&#x20AC;˘ Example 1: You are attending physician (not associated with hospice): physician bills Medicare Part B in the usual fashion

Physician Billing Flow Chart

Medicare Hospice Benefit Special Interventions • • • • •

Parenteral Fluids Enteral feedings Total Parenteral Nutrition Radiation Therapy Transfusions – inpatient

• Chemotherapy • Antibiotics • Laboratory/Diagnostic Services

Special Interventions • Since there is no Medicare regulation that specifies what treatments are deemed “palliative”, it is up to the individual hospice agency • Financially vs. philosophically • Hospices with a large number of enrolled patients have a greater financial resources and thus better able to provide high-cost treatments.

• Concept of “open-access”

Case #3 • Your long time pt Mr. R. is 85 y.o. white Latin male with metastatic prostate cancer to the bone. Pain level 5/10. PPS 50- 60. You certified a 6 month prognosis and he has been on hospice for 1 month.S/p orchiectomy, radiation seed implantation. PMx: early to moderate dementia, CAD

• Medication: Donepezil, Amlodipine, Motrin, Prednisone, Morphine ER, Morphine IR • Pt comes to your office.

Case # 3 continued • You are the primary physician you can bill your normal route (Medicare Part B) with a modifier GV if you are attending to Prostate Cancer issues.

• What if patient wants to see his oncologist?

His urologist?

– These are consultants…need contract…and will bill hospice…

Case #3 continued â&#x20AC;˘ What if patient develops chest pain and goes to the ER? Hospice related? Who pays the hospital? â&#x20AC;˘ What if he went to the ER with a pain crisis? Who pays the ER? Other options?

Health Care Continuum â&#x20AC;˘ The Medicare Hospice Benefit provides excellent options for our patients. We as good physicians need to be well versed in helping our fellow physician and patients maneuver in are rapidly progressing health care system.

So you are asked to be a Hospice Medical Director……

The Medical Director “Old School” • Show up……

• Shut up………

• Sign stuff…….

The Ideal Medical Director

….The “Ideal” Medical Director • That punctual, sensitive he or she that arouses, motives and educates the participants of IDG. Choreographs an effective/efficient IDG in a timely manner while actually reviewing the Plan of Care. Appropriately addresses pain and symptoms while expertly managing medication.

Is proactive in attending to the potential needs of the patient and their family. The super-being, that when necessary, communicates with the attending physician, and mentors in the magic of end of life care. Yet, is fiscally aware and sure footed with regard to eligibility and recertification.

Tasks • Be On Time!!

• Schedule II narcotic prescriptions • Sign medical records in “rolling bins” – DNR’s, orders

• • • • •

Itineraries !

Sign web bases transcription notes Narrative certification (Suncoast available)_ Sign all death certificates “Natural Progression of the Patient’s Disease” – “Teachable Moments”

• Pharmacy Interaction – Review Medication • Now is the time to call attending physician or the other team Doctors.

Balance • Nothing can make or break your day or team faster…

• Can’t live with them…Can’t live without them…(no IDG without a doctor) • Just like any relationship…”it’s a living organism”…

• Days…they will drive you nuts…Days..they will save the day..

• They work for us……but….they may be our customers too…….however Patients and Families always come first.

Medicare Payment Advisory Commission (MedPAC) â&#x20AC;˘ In October of 2008, MedPAC convened an expert panel of hospice providers and determined that some hospices were enrolling and recertifying patients who were not eligible. â&#x20AC;&#x201C; Required that the hospice medical director and/or AMD compose a brief narrative statement attesting to eligibility at certification and recertification.

Physician Narrative • Brief narrative explanation of the clinical findings that support a life expectancy of six months or less • Composed by the physician • Reflect the patient’s individual clinical circumstances • No check boxes or standard language • Signed/dated narrative attestation

Hospice Face-to-Face Encounters for Recertification â&#x20AC;˘ 2011

Highlights of the Face to Face (FTF) Rule Affordable Care Act 1814(a)(7) • Physician visits (face-to-face encounters) must be made for patients entering their 3rd and subsequent benefit periods • Can occur up to 30 days before the recertification • The physician making the visit must attest in writing that the FTF was done.

• Initial certifications and re-certifications may be prepared no more than 15 days before

Steps to Compliance 1. Identify patients who are entering their 3rd benefit period and beyond 2. Schedule the visits 3. Admission nurses and CMs inform patients and families of the FTF requirement.

4. Equip the physicians: Notes, Billing Forms, FTF/CTI Form 5. Physicians do the visits and submit the notes, FTF attestation and CTI 6. Enter the information in the EMR 7. Save the forms in MNP 8. Monitor and Audit

Patient/Family Refuses Visit â&#x20AC;˘ If a patient or family member refuses to allow the hospice physician or NP to make the required visit, a hospice could consider discharge for cause, as the refusal would impede the hospiceâ&#x20AC;&#x2122;s ability to provide care to the patient. The hospice would need to follow the procedures for discharge for cause, which are given in §418.26.

What You Need to Know about Eligibility & Election • How to assess for and document eligibility of patients with noncancer diagnoses (LCD, PROG’s, 12 points to determine eligibility, Protocol ) – – – – –

Local Coverage Determination - Protocol 2003 12 point Cards Medical Director Approval - Protocol 2020 Eligibility Checks Protocol 2094 Eligibility Approval for AFTT, Debility and Dementia - Protocol 2079

• That the patient’s attending physician and the hospice Medical Director must certify that the patient is terminally ill • How to explain the Medicare Hospice Benefit to patients and caregivers

Levels of Care

• • • •

ROUTINE HOME CARE GENERAL INPATIENT CARE RESPITE INPATIENT CARE CONTINUOUS CARE

What the Per Diem Rate Covers • • • • • • •

RN visits Social Worker visits Spiritual Care Home Health Aide Music Therapy visits Volunteers PT, OT, Speech, Dietician

• All medications related to the primary diagnosis • DME • Medical and Personal Care supplies • 24 hour on-call services • Bereavement Care

Medicare Hospice will not pay for: • Treatment intended to cure the terminal illness • Care from any provider that was not set up by the elected hospice • Care from another provider that is the same care that the individual must receive from his/her hospice • Services that are not reasonable and necessary

418.56(a) Approach to Service Delivery • The hospice must designate an IDG – Who work together to meet patient needs – And supervise care and services • • • • •

Physical Medical Psychosocial Emotional Spiritual

of hospice patients and families – Supervision must occur by all members of the IDG whether or not they are seeing patients.

§418.54 Initial and Comprehensive Assessment • The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional and spiritual care.

Focus of the Comprehensive Assessment (CA) â&#x20AC;˘ This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions.

Initial assessment • The initial assessment guides decisions about who comprehensively assesses the patient.

– The initial contact does not constitute an initial assessment – Medicare requires the initial assessment to be completed with 48 hours of admission but Seasons Hospice’s policy requires it to be completed on the day of admission.

The Plan of Care is created after the nurse completes the initial assessment.

The Comprehensive Assessment â&#x20AC;˘ The IDG in consultation with the AMD (if any), must complete the CA within 5 days of the EOB. â&#x20AC;˘ SH requires all patients to have an assessment by the Social Worker.

The Registered Nurse’s Role • Provide coordination of care • Ensure continuous assessment of patient and family needs • Ensure implementation of the interdisciplinary plan of care

418.56(b) Plan of Care • Must be individualized • In collaboration with the AMD, the patient or representative and caregiver • In accordance with the patient and family’s needs • The patient and caregiver must receive education and training regarding their responsibilities.

418.56(c) Content of the Plan of Care Must reflect patient and family goals and interventions identified in the initial, comprehensive and updated assessments and must include the following: â&#x20AC;˘ Interventions to manage pain and symptoms. â&#x20AC;˘ A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.

â&#x20AC;˘ Measurable outcomes anticipated from implementing and coordinating the plan of care.

418.56(c) Content of the Plan of Care (continued)

• Drugs and treatment necessary to meet the needs of the patient.

• Medical supplies and appliances necessary to meet the needs of the patient.

• The IDG’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC.

418.56(d) Review of the Plan of Care • The plan of care is reviewed and updated no less frequently than every 15 calendar days.

• In MD: General In-patient care requires review and update of care plan every 7 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.

418.56(e) Coordination of Services The hospice must develop and maintain a system of communication and integrationâ&#x20AC;Śto ensure that care and services are provided as needed and in accordance with the patientâ&#x20AC;&#x2122;s and familyâ&#x20AC;&#x2122;s needs.

What You Need to Know • The patient's needs must be identified, communicated and addressed.

• That the POC must be INDIVIDUALIZED with each patient/family’s problems, the planned interventions and goals • That the POC must reflect interdisciplinary input • That it must be updated and signed every 15 days • That the clinical record must indicate that the POC is being followed in terms of scope and frequency of services

And Even More You Need to Know!

• The POC is based on interdisciplinary thinking and planning:  What are the problems?  What are we, as a team, going to do about them?  How are we going to do what we need to do?  Making sure everyone writes about what they do  Making sure everyone is on the same page all the time

Documentation Must Reflect • • • • •

Interdisciplinary input and review The patient’s progress towards goals Response to care Expected outcomes Medication review and reconciliation

INTERDISCIPLINARY TEAM • Must include MD, RN, SW and pastoral or other counselor (state regs may require additional members) • Establishes and updates plan of care • RN coordinates the plan of care

Volunteers • Must document recruiting, retention, orientation and training of volunteers • Must document cost savings • Use of volunteers must at a minimum equal 5% of total patient care hours of all paid hospice staff and contracted employees

Core Services • • • •

Physician services Nursing services Medical social services Counseling services (bereavement, spiritual, dietary)

Other Services • Physical, speech and occupational therapies • Home health aide services – Home health aides must be trained acc. to federal guidelines (42CFR484) • Medical supplies, drugs, biologicals and DME • Short term inpatient care (incl. respite)

Communication • Is critical to the function of the Interdisciplinary Team • Is documented every 15 days at the Interdisciplinary Team meeting • You must remember to communicate information to people who will be following you • Remember to develop a communication plan of care with the primary caregiver which includes name, contact # and contact time.

Central Clinical Records • One for each patient • Entries for ALL services provided • Our policy requires documentation to be completed on the day services are provided • Initial and subsequent assessments • Plan of Care • Identification data • Consents, election forms • Medical history

Remember…

IF IT ISN’T DOCUMENTED, IT ISN’T DONE

Hospice Knowledge

Letâ&#x20AC;&#x2122;s begin with a baseline quiz

Hospice Quiz - Question 1 â&#x20AC;˘ Any patient who has a Medicare card with a Valid Medicare Number can receive hospice services if they meet the requirements for hospice services? â&#x20AC;&#x201C; True or False

Answer • FALSE • 2.1.1 Entitlement • To qualify for the Hospice Medicare Benefit (HMB) a beneficiary must be entitled to Medicare Part A. • A beneficiary who is only entitled to Medicare Part B does not qualify for the HMB.

Question 2 • A Medicare HMO enrollee may elect the hospice benefit?

– True or False

Answer • TRUE – A patient who is enrolled in a Medicare HMO may elect the HMB if the HMO does not have a hospice program.

Question 3 â&#x20AC;˘ The election statement for HMB is designed and printed by each hospice? â&#x20AC;&#x201C; True or False

Answer • True – There is no standard required CMS form. The election statement should include, at a minimum, the following information: – 1. Identification of the hospice – 2. The effective date of the HMB election – 3. A general overview of the HMB which gives the beneficiary a full understanding of hospice care

Question 4 • The Hospice Medicare Benefit is divided into the following periods – 90 days – 90 days – 60 days – Unlimited number of 30 day periods – True or False?

Answer • False – · 90 Days – · 90 Days – · Unlimited number of subsequent 60-day periods

Question 5 â&#x20AC;˘ For hospice services to be considered for coverage, a certification of the terminal illness, an election statement, and a plan of care must be established before services are provided â&#x20AC;˘ True or False

Answer • True

Question 6 â&#x20AC;˘ Medical appliances and supplies including drugs and biologicals are not covered under hospice benefit â&#x20AC;&#x201C; True or False

Answer â&#x20AC;˘ False â&#x20AC;&#x201C; All related supplies, equipment, and medications to the terminal illness are covered under the HMB

Question 7 â&#x20AC;˘ Physical therapy, occupational therapy, and speech therapy should not be provided for a hospice patient â&#x20AC;&#x201C; True or False?

Answer • False – 3.2.2.1 Physical Therapy, Occupational Therapy, and Speech-Language Pathology – Reference: CMS Manual System, Pub 100-2, Medicare Benefit Policy, Chapter 9, – Section 40.1.8 – Therapies may be made available for purposes of symptom control or to enable the individual to maintain activities of daily living and basic functional skills

Question 8 â&#x20AC;˘ An individual may designate an effective date for the hospice to start that is prior to the date the election (consents) is made â&#x20AC;&#x201C; True or False?

Answer • False – 2.5.1 Election Statement – The Medicare beneficiary must complete an election statement before the HMB period can begin.

Question 9 â&#x20AC;˘ A hospice agency (Seasons) may discharge the patient when the patient enters a hospital without hospice approval â&#x20AC;&#x201C; True or False

Answer • False – 3.7.2 Non-Compliance – When a patient is non-compliant, the hospice may counsel the beneficiary on his/her option to revoke and any advantages or disadvantages of the decision that he/she makes.

– A patient would be non-compliant if: – He/She seeks aggressive treatment for the terminal illness; – He/She seeks treatment in a facility that does not have a contract with the hospice; or – He/She seeks treatments that are not in the hospice plan of care or are pre-approved by the hospice.

Question 10 • All of the following are covered services under the HMB – Physicians’ services – Medical social work – Nursing care – Sitter services – Inpatient level of care

Answer â&#x20AC;˘ False â&#x20AC;&#x201C; It does not include sitter services

Question 11 â&#x20AC;˘ If a patient is in a hospital for a non-related condition, you should bill for the routine level of care â&#x20AC;&#x201C; True or False?

Answer • True

Part D

Essence of change…

• Part D providers will no longer assume cost of meds that are reasonably asserted to be related not only to a hospice beneficiaries’ primary hospice diagnosis, but also to include comorbid conditions that are contributory to the terminal status.

• CMS believes it will be extremely rare for meds to be “completely unrelated”

Medications â&#x20AC;&#x201C; Who Pays?

Related

Not Medically Necessary

Medically Necessary

Not Related

I. R-MN Hospice Haldol

III. R-NMN Patient Aricept

II. NR-MN Part D Trusopt eye drops IV. NR-NMN Patient Lipitor

84 year old patient with Alzheimers, hypercholesterolemia, and glaucoma

Another way to look at itâ&#x20AC;Ś PERSON / Big 6

Symptoms

Pain

Pain â&#x20AC;&#x201C; Physical, spiritual, emotional

Environment

Depression

Respiratory/CV

Dyspnea, edema, oral secretions

Skin

Wounds / pressure ulcers

Output/Input

Nausea/vomiting, Constipation / diarrhea

Neuro

Delirium, agitation, insomnia, anxiety

Med Review Prep pt/family Determination of med status Documentation

Appropriate at end of life?

Having the conversation re possible changes /Physician consult Physician consult: Covered / Not Covered Med List: Liability for Non-Covered Meds form

Critical Connections..

Primary/Co-morbids & Part D… Definitions/Litmus tests on admission • Primary Diagnosis = primary condition causing patient demise (terminal illness) • Secondary Diagnoses (comorbids) which we will cover: a) One which would independently carry a prognosis of less than a year OR b) One which is leading to symptoms which need to be palliated (Big Six/PERSON) OR c) One for which a lack of treatment would clearly worsen symptoms associated with the primary diagnosis

Diagnosis Definitions Example Pt has had CVA, and also has DM, hypertension, hyperlipidemia, and moderate-severe DJD of the knee • Primary = CVA • Co-morbid = DJD Hypertension may be comorbid if believe that would worsen CVA symptoms (Fosinopril) DM may be comorbid if believe would worsen CVA symptoms (Insulin) Hyperlipidemia – not comorbid as lack of treatment will likely not worsen CVA symptoms given pt life expectancy (Lipitor = non-formulary)

Thank you.

Questions?