Hospice Care

Issues of Concern

The Medicare Hospice Benefit

Medicare was designed to provide comprehensive medical care for older Americans. Among its sections, Medicare Part A covers hospice services almost entirely, with all services provided at no cost to the beneficiary, as long as they are related to the terminal condition and have been approved by the hospice for payment. Given that this is a carve-out benefit, patients enrolled in hospice waive their traditional Medicare Parts A and D and elect the Medicare hospice benefit for care related to their terminal illness, including prescription medications. Historically, the Medicare hospice benefits only applied to medications related to the terminal diagnosis; for example, a hospice patient with congestive heart failure as their terminal diagnosis, but with coexistent diabetes mellitus and hypertension, would remain covered by traditional Medicare Parts A and D for the latter 2 comorbidities. Since 2015, under new guidance from Medicare, the hospice benefit now centers around a terminal prognosis rather than a diagnosis, given that prognosis is often worse in the setting of multiple comorbidities. For example, patients on hospice benefit from congestive heart failure who also suffer from chronic stage 4 kidney disease have a worse prognosis than patients with congestive heart failure but preserved kidney function. 

Hospice Benefit Periods

All hospice services are rendered during benefit periods. Hospice care begins with 2, 90-day periods, followed by an unlimited number of 60-day periods. At the end of each benefit period and before the next one begins, the hospice team reevaluates the patient and recertifies that the patient has a terminal illness and that the prognosis is less than 6 months. Each 60-day benefit period also requires a face-to-face visit with a hospice physician or nurse practitioner, who must promptly provide clinical information to the certifying hospice physician. At any time during this process, a patient can change their mind about continuing hospice care.

Patients also may be discharged from hospice care for specific reasons, such as if they no longer have an expected prognosis of 6 months or if the patient moves away from the hospice’s service area. Patients are also free to re-enroll in the hospice benefit and must be recertified to remain eligible for hospice services. Whether patients revoke the hospice benefit or are discharged, traditional Medicare coverage becomes immediately available. Since its inception, the Medicare hospice benefit has been a per-diem capitated payment arrangement: hospices are paid a fixed dollar amount per day of patient care, based on the level of care. The reimbursement rates are fixed annually and vary by geographic location.

Hospice Levels of Care

Four levels of care exist under the Medicare hospice benefit—2 levels of care in the home and 2 inpatient levels. Medicare reimburses differently, with higher or more intensive levels of care receiving higher reimbursement.

Routine Home Care

This level of care is administered in the patient’s place of residence, which could be a private home, a personal care home, a nursing facility, or a prison. In most states, the benefit does not cover the cost of a patient’s room and board in a nursing home. For a hospice program to obtain Medicare certification, it must have 80% of its patients in their own homes. 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. Physical assessment involves reviewing the patient’s symptoms, the need for adjustment of medications, level of dependence, and psychological and spiritual distress. Environmental assessments focus on patient safety (eg, gait and balance, loose carpets, or inadequate lighting) as well as adaptations needed to accommodate the patient’s changing condition, such as having a hospital bed available for a patient who has become bedbound. Family assessment is crucial to detect caregiver burden and needs for additional support. When hospice care is rendered in the patient’s home, a family member serves as the primary caregiver and, when appropriate, helps make decisions for the terminally ill individual. Hospice staff, usually nurses, are on-call 24 hours a day, 7 days a week.

Continuous Home Care

This level of hospice care, which is more intense than routine home care, is given during brief periods of crisis management of acute symptoms with the intention of maintaining the patient in their home setting. To justify continuous home care, the patient requires direct skilled care for 8 hours per day, at least 50% of which must be delivered by the nurse. An example of skilled care would be intractable pain management with frequent assessment and administration of intravenous medications. A nursing home cannot provide this level of care.

General Inpatient Care 

Provision of this level of care is outside of the patient’s usual home environment, in a Medicare-approved facility such as a free-standing inpatient hospice facility, a contracted nursing home, or hospital. This setting does not include custodial or residential. Indications that might determine a need for general inpatient care include managing uncontrolled pain, delirium, or other symptoms, especially ones that fall outside the purview of home care. As with continuous home care, a skilled need is necessary for general inpatient care. Though general inpatient care does not have a specified limit, patients are assessed daily by the hospice team regarding the necessity and eligibility of continuing that level of care. The expectation is that the patient be stabilized and returned to their previous level of care/residence, if possible.

Respite Care

This level is designed to provide relief to caregivers; it is allowable for no more than 5 consecutive days per occurrence and is provided in a Medicare-approved facility, such as an inpatient hospice facility or a nursing home. These patients don’t require skilled care.

Clinical Significance

Benefits of Hospice Care

Hospice care offers numerous benefits, including greater patient and family control over medical care, familiar surroundings for patients, reduced isolation, and better access to loved ones. Hospice care does not require patients to accept their terminal prognosis or have a do-not-resuscitate (DNR) order. Instead, hospice works with each patient and family member to provide support and education to help them come to terms with approaching death. At the crux of hospice care is the interprofessional hospice team. 

Hospice Interprofessional Team

The core hospice team comprises the hospice nurse, social worker, and chaplain. Medicare requires the core team members to be employed by the hospice agency. The core hospice team provides all levels of hospice care, with the nurse at the forefront of coordinating the patient's care. The hospice medical director is also required to be a part of the interprofessional team (IDT). Together, these comprise a hospice IDT, which develops an individualized plan of care for each patient-family unit. The plan of care is designed to meet the patient’s physical needs as well as the patient's and family's psychological, social, and even spiritual needs.

The interprofessional hospice team serves numerous roles. It manages the patient’s pain and other symptoms, assists the patient and family members with the psychosocial, emotional, and spiritual aspects of dying; it provides medications and medical equipment, instructs the family on how to care for the patient, and provides grief support and counseling both to the patient, surviving family, and friends after the patient’s death. Additionally, it provides short-term inpatient care when pain or symptoms become unmanageable at home or when the caregiver needs respite. When available, an IDT can provide specialized services like speech and physical therapy.

Role of the Clinician

A clinician can serve in 1 of 3 roles in hospice care: the Hospice Medical Director (HMD), the attending clinician, or the consultant clinician. As the HMD, the clinician assumes overall responsibility for the medical component of the care plans for all hospice patients, certifies and re-certifies a patient’s terminal illness, reviews and updates a patient’s plan of care, participates in hospice’s quality improvement initiatives, and educates members of the IDT on evidence-based symptom management and communication techniques. 

The HMD also collaborates closely with the patient’s attending clinician, or the clinician with the most significant role in determining and delivering the patient’s medical care. In most cases, the patient’s usual attending clinician is a primary care clinician, but can also be a subspecialist. The intent is for the attending clinician to be the clinician who knows the patient best, likely from a previous clinician-patient relationship. The patient/family must choose the hospice attending if they can identify one. The attending clinician can then continue to serve in a similar collaborative capacity when the patient is admitted for hospice care.

The hospice must contract with a consultant clinician, typically a subspecialist, who provides a specific service related to a hospice patient’s terminal condition (eg, a single fraction of palliative radiation treatment for a painful metastatic lesion, administered by a consulting radiation oncologist). The hospice can bill Medicare Part A for these services and any medically indicated services provided by the HMD. These clinician charges are reimbursed in addition to the per diem hospice rates paid by Medicare. The hospice per diem rate includes all of the administrative responsibilities of the Hospice Medical Director. The hospice attending clinician typically bills Medicare directly for their services under Part B, using a hospice modifier to indicate whether the service was related or unrelated to the terminal hospice diagnosis. 

Nursing, Allied Health, and Interprofessional Team Interventions

Hospice end-of-life care requires an interprofessional team that includes clinicians (eg, family clinician, specialists as outlined above), specialty-trained nursing staff, home and inpatient health aides, psychological and mental health professionals, pharmacists, and, if necessary, clergy. All these specialties and disciplines must coordinate their activities, communicate openly, work with the patient's family and friends, and exercise the utmost compassion during this sensitive time. While no actions can change the outcome, an interprofessional team can make the experience much less traumatic and more comfortable for patients and their families.