Hospice eligibility and hospice recertification

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As an experienced hospice nurse, I understand how overwhelming and emotional it can be for terminally ill patients and their loved ones to navigate the hospice process. Hospice care is a compassionate and comprehensive approach to end-of-life care designed to provide comfort, pain management, and emotional support to patients and their families. However, many people have questions about hospice eligibility and hospice recertification. In this article, I will provide a generalized guide to help you understand these important aspects of hospice care.

Hospice Eligibility — what families need to know

Hospice care is available to individuals who have been diagnosed with a terminal illness with a prognosis of six months or less to live. A physician can make this diagnosis, and the patient must agree to forgo curative treatment to receive hospice care.

In addition to meeting the medical eligibility criteria, hospice patients must also desire comfort care and symptom management. Hospice care focuses on enhancing the quality of life for patients and their families rather than curing the illness. Patients who meet the eligibility criteria can receive hospice care in various settings, including their homes, nursing homes, or assisted living facilities.

Hospice Recertification — and how families and caregivers can help

Hospice recertification is a process that takes place once every benefit period for hospice patients. Ensuring that the patient meets the eligibility criteria for hospice care is necessary. During recertification, the hospice team will evaluate the patient’s condition and determine if they are still eligible for hospice care.

For families that feel the hospice benefits and services are truly helping their loved one have a good quality of life for whatever life remains, you can help the hospice team with the recertification process by keeping a journal of the PRN (as needed) medications given and if they helped or didn’t help the situation at hand along with the various declines you’ve noticed as you notice them.

The hospice team will review the patient’s medical records and consult with the physician to determine whether the patient’s condition has improved, stabilized, or declined. If the patient’s condition has improved or stabilized, they may no longer meet the hospice eligibility criteria and may be discharged from hospice care. However, if the patient’s condition has declined or remained the same, they will continue to receive hospice care.

It is important to note that hospice recertification does not mean the patient’s prognosis has changed. Instead, it is a routine process to ensure that the patient meets the eligibility criteria for hospice care.

Final Thoughts — for families

Navigating the hospice process can be difficult, but it is essential to understand the eligibility criteria and recertification process to ensure that you or your loved one receives the best possible care. Hospice care can provide comfort, pain management, and emotional support during a challenging time, and it is crucial to take advantage of these services if you or your loved one meets the eligibility criteria.

Remember, hospice care is not giving up; it is choosing to focus on quality of life rather than quantity. If you or your loved one have questions about hospice care, contact a hospice provider to learn more. You are not alone; resources are available to help you through this tough time.

Nurses

Nothing is worse for the patient and family than to admit a patient under a non-qualifying diagnosis or just because management told you to admit the patient. I know I’m writing to the choir about the disservice you are doing to yourself and the family because somewhere along the line, the patient will be discharged for failure to decline the admitting terminal diagnosis.

For every admission, you should be reviewing two things: 1) is the patient eligible under the primary terminal diagnosis listed, and 2) If not, then is the patient eligible under another diagnosis for whose case you are comfortable proving eligibility with the understanding there are circumstances you can prove your case under the umbrella admission argument that if the prognosis takes its normal course there is a greater than fifty percent chance the patient will die in six months or less. Know your LCD’s and qualifying criteria and do your best to admit.

For example, I had a case where I was told to admit a patient, and the intake department told me the admitting diagnosis was Alzheimer’s disease. The onsite evaluation involved asking the family and the patient various questions to see where the patient was on the FAST scale. The patient turned out to be at FAST 6C which means the admission would not pass Medicare guidelines; and more importantly for the family if admitted under the Alzheimer’s diagnosis would mean a quick discharge once the IDG team and medical director knew the facts or if the patient’s chart was audited by any accrediting agency. However, while the patient did not have a qualifying situation under the dementia umbrella, the patient did have sufficient sudden weight loss to be admitted under protein-calorie malnutrition (PCM).

May I recommend you always treat an admission as an evaluation, looking for all the reasons to admit and being willing to call management on issues that raise red flags? In my experience, if you are willing to be a patient advocate trying to find the right diagnoses for whose case you can prove, you will win from two angles. The families will be happy, and upper management will be happy.

Then, once admitted, from every visit (best case) to at least before each IDG, you should catalog the declines the family and caregivers are reporting as well as what you are seeing.

Just as I recommend families keep a journal of the PRN medications they give and their effectiveness and declines, I recommend my fellow hospice nurses keep a recertification journal to help them continue to provide the absolute best service to their patients by keeping eligible patients on service.

Conclusion

Understanding hospice eligibility and recertification is vital for families and new hospice nurses. Navigating the hospice process can be daunting, but being well-informed about these aspects ensures that terminally ill patients receive the best possible care during their end-of-life journey. The hospice eligibility criteria are fundamental, focusing on a prognosis of six months or less to live and the patient’s agreement to forgo curative treatment. Emphasizing comfort care and symptom management, hospice extends its services across various settings, including homes, nursing homes, and assisted living facilities.

The recertification process, occurring once every benefit period, ensures ongoing eligibility for hospice care. Families play a crucial role by aiding the hospice team with detailed records, such as a journal of PRN medications and observations of the patient’s condition. The evaluation during recertification considers the patient’s medical records and physician consultation to determine if there have been improvements, stabilization, or declines. Significantly, recertification doesn’t alter the patient’s prognosis but reaffirms their eligibility for hospice care.

Hospice care provides comfort, pain management, and emotional support for families in challenging times. It is a choice to focus on quality of life rather than quantity, which should be well-informed and understood by families. Navigating this process might be challenging, but reaching out to hospice providers for guidance and support can make a significant difference. Remember, you are not alone; resources are available to help you through this journey.

For hospice nurses, ensuring accurate admissions is paramount. Admitting patients under qualifying diagnoses and diligently advocating for patients’ needs contribute to successful outcomes. Familiarity with Local Coverage Determinations (LCDs) and qualifying criteria is crucial. The recommendation to treat each admission as an evaluation, seeking the right diagnoses, benefits both families and management. Keeping a recertification journal further aids in providing optimal service, allowing nurses to catalog declines and observations and ensuring eligible patients receive the care they need.