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Hospice – Eligibility (Reading & Sharing)

Hospice is an all-encompassing service available for patients with a prognosis under 6 months. Under the Medicare hospice benefit, patients eligible for hospice are greater than 65 years or receiving Medicare disability payments. At the start of care, two physicians must sign a statement certifying that the patient’s life expectancy is six months or less based on their best estimate of the patient’s medical prognosis. While hospice benefit was originally designed for Medicare recipients, most insurance providers cover hospice care for patients not eligible for Medicare. But hospice eligibility depends on more than only a physician determining a prognosis of six months or less until death.

In order to be eligible for hospice services, the patient must be determined to have at least one hospice-appropriate diagnosis, for example, a diagnosis of metastatic colon cancer. The careful and thorough documentation of hospice-appropriate diagnoses is also vital to obtain approval for hospice services. When describing hospice appropriate diagnoses in Centers for Medicare & Medicaid Services (CMS) paperwork, it is important to designate primary versus secondary neoplasms as appropriate to avoid delay in acceptance. Documentation should aim to be complete, clear, and factual regarding the patient’s circumstances and the impact their diagnoses have on their prognosis. Hospice appropriate diagnoses involve conditions that will lead to the patient’s death, as well as impact the patient’s ability for activities of daily living and requirement of symptom management. whether or not diagnoses impact the ability of patients to achieve life-long goals does not directly impact hospice service eligibility.

Hospice is a medical service based on a holistic approach to providing quality end-of-life care to patients with a prognosis less than six months in duration. Patients may continue to seek out palliative therapies while receiving hospice care, such as palliative radiation therapy or debulking procedures, but must not seek out interventions aimed at curing their primary diagnoses such as curative chemotherapy or immunotherapy. Thus, in order to be eligible for hospice services, the adult patients must be willing to forego the pursuit of further curative treatments, but may still get interventions that improve quality of life

Hospice is required to accept all patients who agree with the hospice philosophy regardless of their preferences for resuscitation. Yes. Hospice care does not require patients to accept their terminal prognosis or to have a do not resuscitate (DNR) order. Hospice works with each patient and family member to provide support and education to help them come to terms with approaching death.

The hospice interdisciplinary team (IDT) comprises skilled professionals including at its core: nurse, physician, social work, and chaplain. Hospice works with each patient and family member to provide support and education to help them come to terms with approaching death. During home visits, the hospice team makes physical and environmental assessments and assesses the patient’s and family’s needs for additional services and assistance. Hospice staff, most often nurses, are on-call 24 hours a day, seven days a week. They attend to calls from patients and families. However, hospice does not provide a 24-hour caregiver to patients. If families need caregivers for the patient, they usually hire them privately at their own expense. The hospice team can provide the resources and help that a family needs to take care of a terminal patient at home. Therefore, it is unwise to send the patient home without making arrangements first.

So, does everyone with a serious illness qualify for hospice services? No. Not everyone qualifies for hospice care. Most hospice follow the requirements from Medicare and Medicaid to deliver high-quality, safe, and timely care. Hospice programs that are Medicare certified must follow three requirements to be admitted for hospice care:

  1. The patient’s physician must affirm that this is a terminal illness
  2. That the prognosis for the patient is six months or less if the disease runs its usual course
  3. The patient or their power of attorney for health care understands that hospice is not providing curative therapies

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