Most patients enter hospice when a physician refers them for end-of-life care, often after they have been hospitalized or spent time in a nursing care facility. Alternatively, patients or their loved ones may “self-refer” by contacting a hospice provider directly to discuss the patient’s medical status and care needs.
In either case, any hospice provider that participates in Medicare must follow federal regulations, which outline basic eligibility requirements for patients. These include:
- A general decline in clinical status.
- A probable lifespan of six months or less if the disease progresses as expected.
- Disease-specific requirements that must be evaluated and confirmed.
The hospice team meets with the prospective patient to assess their condition and determine whether they are eligible for hospice care.
Eligibility assessment
Depending on the patient’s symptoms, the eligibility assessment may happen very quickly or take place over several days.
The hospice team visits and assesses the patient wherever they are — in a private home, a nursing home, an assisted living center, or a dementia care facility. If the patient is hospitalized, the team meets with the patient and family to assess what their needs will be once the patient is discharged.
During the assessment visit, the hospice team conducts a comprehensive evaluation that includes:
- A review of pertinent medical records, if available.
- A complete physical examination of the patient.
- A psychosocial, emotional, and spiritual needs assessment of both the patient and their caregivers.
Patients who meet eligibility requirements can begin to receive services. For patients at home, hospice care may start immediately.
For hospitalized patients, hospice coverage begins once they are discharged. The hospice team works with the family to ensure that necessary supplies and equipment are delivered to the patient’s home (or care facility, if that is where the patient lives) before they leave the hospital.
Baseline documents
The hospice team carefully documents their visit and the eligibility assessment. If the patient is deemed ineligible for admission, or if the patient/family decides against hospice care, these records provide a baseline to help define future eligibility.
For example, this documentation can be valuable if, at a later date, the patient’s condition declines or the patient/family decides they do wish to begin hospice care.
Should conditions change
Hospice care is provided in what is known as “benefit periods.” They consist of two 90-day periods (the initial six months after admission), followed by an unlimited number of 60-day periods in which benefits may continue so long as re-assessment evaluations confirm that the patient is still eligible for hospice care.
Extensions: Although medical eligibility generally relies on the physician’s opinion that the patient’s life expectancy is six months or less, neither the patient nor the physician is penalized if the patient lives longer. The patient can be re-certified for as long as they continue to be medically eligible. Ongoing eligibility is determined by a “recertification evaluation” completed by a member of the hospice’s medical/nursing staff at the patient’s home.
Discharge: If a patient’s condition stabilizes or improves enough that they no longer meet medical eligibility requirements, the patient is discharged from the hospice program. When this happens, their Medicare benefits revert to the coverage they had before entering hospice.
Revocation: If a patient chooses to seek a cure, perhaps by entering a clinical study for a new medication or procedure, they must withdraw from (“revoke”) hospice care.
Patients who are discharged or choose to revoke hospice care are eligible to re-enroll at any time so long as they meet the medical eligibility criteria when they re-apply.
