The Referral Process and The Hospice Benefit under Medicare Guidelines

The Referral Process and The Hospice Benefit under Medicare Guidelines

1. Physician, or other health care provider, has conversation with the patient and their family about end of life when curative options are no longer feasible. Requires a physician to deem the patient could have six months or less of life expectancy if the disease process takes its normal course. Upon completion of this conversation, the health care provider refers the patient to a hospice provider. The patient and family should have input into the hospice provider of choice, should they have a particular one in mind. Payor sources for hospice – Medicare, Medicaid, Private Insurance
2. The hospice provider receives the referral with history and physical, face sheet, diagnosis, and latest medical records. The order usually will state, “Please evaluate and admit to hospice if appropriate”.
3. Hospice contacts the patient and family to schedule a visit to evaluate, or in some instances, the patient and family request an information/educational visit prior to the evaluation process. Medicare Guidelines determine appropriateness.
4. Hospice providers must adhere to strict Medicare guidelines in qualifying patients for hospice. There are many diagnosis’s for admittance – senile degeneration of the brain, drastic weight loss (protein malnutrition), terminal cancers, renal/liver/heart failure, advanced Dementia’s (Alzheimer’s, Lewy Body, Vascular), COPD, Advanced Parkinson’s, ALS, severe stroke (CVA).
5. The ‘Admission’ process includes signing election to hospice (Medicare Hospice Benefit, Consent to Hospice paperwork). These forms basically state that the patient won’t, or can’t, seek any aggressive treatments. Some aggressive treatments as outlined by Medicare include: Chemotherapy, Radiation, and Dialysis. The patient always has the option to revoke hospice and return to aggressive treatments if available and deemed curative in nature. Some patients also cease to decline while under hospice care, they must be discharged under Medicare Guidelines. These two examples occur with about 20% of hospice patients.
6. Hospice is for comfort and care and the elimination of symptoms such as pain, nausea, anxiety, and sleeplessness. No curative measures. Although infections like UTI’s and URI’s are generally treated with antibiotics.
7. Hospice services include wound care, weekly RN visits, meds associated with the admission diagnosis, DME, and 24/7 on-call availability. Elective services are CNA’s, Social Work, Chaplaincy, Volunteers, and Bereavement
8. Hospice remains with the patient until the end of life, and supports the family with selected services like Social Work, CNA’s, Chaplain, and Bereavement. Hospice is approved for up to six months. Should the patient still be alive, then the patient must be re-evaluated every 60 days. Recertification is required after six months to remain on hospice (must have declines to recertify). Recertification are most often performed by Nurse Practitioners in face to face encounters.

Written and Submitted by:

Richard McCuen

Lutheran Hospice of The Low Country

Community Outreach Director

1885 Rifle Range Rd. Suite 46

Mt Pleasant, S.C. 29464

843-856-4735 – Office

843-856-4737 - Fax

843-609-7147 - Cell