Hospice Care Referral Guides

Understanding Hospice Eligibility and Referrals

Hospice care is a vital service for those facing terminal illnesses, providing comfort and support in a patient's final months. Yet, understanding how to navigate the eligibility and referral process can be daunting for healthcare professionals, patients, and families alike. This guide aims to demystify hospice referral procedures, clarify eligibility criteria, and elucidate the roles medical professionals play in this critical transition. Through informed decisions, patients can benefit from quality end-of-life care, supported by Medicare and Medicaid services.

Hospice Care Eligibility Criteria Explained

What are the eligibility criteria for hospice care?

To qualify for hospice care, a patient must have a terminal illness characterized by a prognosis of six months or less to live, certified by a physician. Importantly, the patient must choose to stop curative treatments and focus on palliative care instead. Here are some specific criteria depending on the diagnosis:

• Cancer: Patients must demonstrate clinical findings of malignancy, usually with a Palliative Performance Scale (PPS) score below 70% and must refuse life-prolonging therapy.
• Dementia/Alzheimer's Disease: Eligibility is determined when patients reach Stage 7C or beyond on the Functional Assessment Staging Test (FAST) and show significant functional decline.
• Heart Disease: Those suffering from severe symptoms such as NYHA Class IV heart failure qualify for hospice care.
• Chronic Renal Failure: Patients must not seek dialysis and should meet specific laboratory criteria, including a certain creatinine level.
• Pulmonary Disease: Eligibility includes individuals displaying symptoms like disabling dyspnea at rest.

Conditions affecting eligibility

Beyond the primary diagnosis, other factors play a crucial role in deciding a patient's appropriateness for hospice services. Common indicators include:

• Frequent hospitalizations or exacerbations of disease.
• Significant declines in daily functioning, often measured with performance scales.
• Recurrent infections which may signal an overall deterioration in health.
• Comorbidities that contribute to worsening health conditions.

Functional decline and performance scales

Assessment of functional decline often involves the Palliative Performance Scale (PPS).

PPS Score	Functional Level	Implications
70%	Full Ambulation, Normal Activities	May not yet qualify for hospice; monitor closely
50%-60%	Limited Self-Care, Requires Assistance	Suggests eligibility; requires detailed evaluation
<50%	Total Care Required, Bedbound	Strong indicator for hospice; urgent referral advised

Understanding these guidelines ensures timely access to hospice care, ultimately enhancing the quality of life for those facing terminal illnesses.

Typical Illnesses and Non-Qualifying Conditions for Hospice

What types of illnesses typically qualify for hospice care?

Hospice care is designed for patients with serious, life-limiting illnesses and a prognosis of six months or less. Those eligible often choose to discontinue curative treatments, focusing instead on comfort and quality of life. Common conditions that typically qualify include:

• Advanced Heart Diseases: Including congestive heart failure and severe symptoms from heart disease.
• Various Types of Cancer: All stages but particularly those with metastatic disease or no longer receiving curative treatment.
• Chronic Obstructive Pulmonary Disease (COPD): Especially with significant respiratory decline.
• End-stage Renal Disease: Patients requiring extensive support and management of symptoms.
• Liver Disease: Including advanced cirrhosis or liver failure.
• Neurological Disorders: Such as Alzheimer’s, Parkinson’s, and multiple sclerosis.

Evaluating hospice eligibility requires assessing both the patient's specific illness and functional decline. Starting hospice care early can greatly enhance life quality for patients and provide valuable support for families.

What diagnoses do not qualify as a primary reason for hospice?

Certain diagnoses are not appropriate for hospice care as primary reasons. These include:

• Nonspecific Symptom Codes: Such as debility (ICD-10 code R53.81) and adult failure to thrive (ICD-10 code R62.7), which do not reflect terminal conditions.
• Specific Dementia Codes: Codes like F02.80 and F02.81 are not suitable as principal diagnoses, as they generally represent manifestations of other underlying disorders.

Hospice providers should select accurate principal codes to avoid recoding issues and ensure compliance with coding guidelines. Effective October 1, 2014, any claims with invalid principal diagnoses face returns for resubmission, underlining the importance of precise documentation.

The Referral Process for Hospice Care

Steps in the referral process

The process for referring a patient to hospice care begins with healthcare professionals assessing the patient's condition against specific eligibility criteria. This includes having a terminal illness with a life expectancy of six months or less. Once a referral is initiated, several steps follow:

1. Initial Assessment: The patient's medical history is reviewed to confirm eligibility.
2. Documentation Review: Critical medical documentation is gathered to justify the hospice referral.
3. Verification of Coverage: Insurance information is checked to ensure the patient has access to hospice benefits.
4. Patient and Family Discussion: Key conversations about goals of care and hospice philosophy occur.

Who can initiate hospice referrals

Anyone can initiate a hospice referral, including family members, friends, healthcare providers, and even the patients themselves. However, a physician’s order is required to receive services. This openness allows for timely discussions, which can significantly enhance the patient's experience regarding end-of-life care.

Documentation and evaluation

Accurate documentation is crucial for the referral and admission process. It ensures the hospice team can assess eligibility thoroughly. After the initial referral, a Patient Access Specialist or nurse contacts the referrer to further evaluate the patient’s situation, confirming that hospice services align with the patient’s needs and preferences. Over 70% of families rate hospice care as "excellent," underscoring the importance of effective referrals and comprehensive evaluations in achieving high-quality end-of-life care.

Understanding Medicare Guidelines and Benefits for Hospice

What are the Medicare guidelines for hospice referrals?

To qualify for Medicare hospice benefits, patients must be terminally ill with a prognosis of six months or less. This certification is provided by both the patient’s attending physician and the hospice medical director. The hospice benefit typically consists of two initial 90-day periods, followed by an unlimited number of 60-day periods, during which ongoing recertification is required every 60 days.

Benefit periods and recertification

Upon acceptance, an individualized Plan of Care (POC) is developed by a multidisciplinary hospice team to address the patient’s specific needs. It is important for patients to waive curative treatment and accept hospice care to be eligible for these benefits. Documentation confirming terminal illness, as well as continuous assessment of the care provided, are critical components of the hospice referral process. This approach ensures that patients receive appropriate and timely support during their final stages of life.

Patient and service requirements

All hospice services must be delivered by a Medicare-certified hospice agency. Patients and families are encouraged to discuss these options early, enabling them to maximize the benefits of hospice care, enhance quality of life, and ensure that care is centered around their goals and preferences.

Resources and Tools for Efficient Hospice Referrals

VITAS Mobile App

The VITAS mobile app serves as a vital resource for healthcare professionals involved in hospice referrals. It provides users with disease-specific guidelines and tools that support goals-of-care conversations with patients. This accessibility allows for timely discussions regarding end-of-life options and eligibility requirements, streamlining the referral process effectively.

Communication with Patients and Families

Communication plays a key role in facilitating hospice referrals. Both healthcare providers and families are encouraged to engage in open discussions about care preferences and end-of-life wishes. These conversations, ideally initiated during regular office visits, help clarify the patient's condition and readiness for hospice services, ensuring everyone is aligned on the care goals moving forward.

Facilitating End-of-Life Discussions

End-of-life discussions should not be delayed. Utilizing resources like the VITAS app can guide conversations and assist in assessing eligibility based on specific clinical criteria. Timely referrals to hospice care can significantly enhance patients' quality of life, providing crucial emotional and physical support during their final days.

Additional Resource

To find a CMS-approved list of hospice diagnoses, you can refer to the Local Coverage Determination (LCD) documents provided by Medicare. These documents outline the guidelines and specific clinical variables that indicate a life expectancy of six months or less for hospice eligibility. Conditions such as cancer, ALS, dementia, and heart disease have particular criteria that are detailed in these guidelines. It is important to note that while specific diagnoses are outlined, individual patient circumstances and additional clinical factors must be documented properly to support hospice certification. For further information, you can visit the Medicare website or contact the hospice provider directly for guidance on eligible diagnoses.

Optimizing Hospice Care Referrals

Hospice care provides essential support and comfort to those with terminal diagnoses, emphasizing dignity and quality of life over extended treatments. By understanding the eligibility criteria, effective referral processes, and leveraging tools like the VITAS mobile app, healthcare providers can aid patients and families through this sensitive transition with grace and information. With compassionate communication and timely referrals, hospice care can be a source of relief and support during life's final chapter. It is imperative for healthcare professionals to embrace these guidelines and embrace the opportunity to honor patient preferences in end-of-life care.

References

• How to Refer a Patient to Hospice - VITAS Healthcare
• Hospice Referral Requirements: Everything You Should Know
• Your Step by Step Guide to Making a Hospice Referral
• Hospice Eligibility Guidelines for HCPs - VITAS Healthcare
• Physician's Guide to Hospice Referrals - We Care For People
• Guideline For Hospice Referrals
• Navigating the Hospice Referral Process: A Step-by-Step Guide for ...
• Anyone Can Refer Someone to Hospice - Lower Cape Fear LifeCare
• Hospice - CMS
• The Complete Guide to Understanding Hospice Care - Amedisys