What makes a patient eligible for hospice?
Is it meeting the LCD, is it 418.20 and 418.22, or is it something else entirely? Does the patient have to decline? What do we do if we’re just not sure?
If you have ever had to admit a patient, answer an additional development request (ADR) or help your team navigate patient eligibility questions you have probably asked yourself many of these questions. Of all the things we learn in hospice, the “art” of eligibility it one of the most complicated and anxiety provoking topics for most nurses, physicians and other clinicians. At Hospice Support Specialists, we often work with shell-shocked clients who become so fearful of certifying terminal illness that they pass on admitting eligible patients or they discharge patients because they haven’t had “enough decline” despite the fact that they meet hospice criteria. ADR PTSD is real to anyone who has ever survived one of these claim reviews.
How do we answer these complicated questions? The answer is not in any black and white checklist or fact sheet. The fact I that no two patients are alike. One patient may check all the boxes and seem to not be eligible, and another might meet none of the LCD Guidelines and die within days. The answer to these questions lies not in a single response but in the process that your organization uses to validate terminal illness and ongoing eligibility.
Organizations that implement a strong, interdisciplinary approach that eliminates the “single point of failure” processes are more likely to make good decisions about eligibility. These organizations admit all eligible referrals while passing on those that are not yet hospice ready, they recertify with confidence and discharge as soon as a patient is identified as having a disease that is no longer progressing along the anticipated trajectory. Managing hospice eligibility requires a implementation of processes such as an eligibility team, targeted patient reviews by an interdisciplinary group of subject matter experts, IDG process that drives ongoing conversation and clinical education that enhances skill and documentation.
How do you know if you need help with this process? There are some telltale signs that your eligibility process needs work, most are found in your data. Start evaluating your process by looking at referral to admission conversion rates, look at your LOS – is it long or short? Are you admitting too soon or too late? Look at your live discharge for extended prognosis rates – every hospice should have some of these, if you have none, you are missing something…somewhere. Who is making the decisions about admission and re-certification? Is it one person or is it collaborative? One of the biggest red flags that we hear often is that hospices are passing on referrals that are then being admitted by a competitor or that are dying before they are deemed “eligible”.
Hospice Support Specialists can help you assess your opportunities and risks, and help you implement best eligibility practices. We work with ADR/TPE response and have the resources you need to take on hospice eligibility with a new confidence.
