Hospice Referral Requirements: Everything You Should Know

Appropriately identifying hospice-eligible patients is imperative to ensure that patients and their families receive compassionate end-of-life care. The law dictates that a healthcare professional must certify that a patient meets the requirements for hospice care to be eligible for a referral to a hospice provider. 

Eligibility for Hospice Care

To establish eligibility for hospice care, a medical professional must certify that a patient is terminally ill, with a life expectancy of six months or less. The staff of the hospice provider, particularly the medical director, must agree with the doctor’s diagnosis. The following circumstances are often present when a doctor recommends hospice care: 

  • Lack of progress: A patient may be referred to hospice care if their situation is not improving after significant medical intervention. All treatment options are usually exhausted before a hospice care admission. 
  • Goals of care have changed: Many patients choose to remain at home instead of going to the hospital after several unsuccessful treatment attempts. In these cases, hospice care is often recommended. Anxiety about death may also require hospice care. 
  • Significant health events: If a patient suffers an acute medical event such as a stroke or heart attack, end-of-life care may be necessary. 

Overview of the Hospice Referral Process

Each referral goes through a round of reviews and must meet several hospice referral requirements before services can begin. The process often starts with data entry. 

Some hospice providers immediately enter the medical documentation into the EMR, which speeds up the intake process. However, other providers choose to wait before entering information into an EMR. 

Either way, each case must be reviewed and approved before care can begin. The first step is to check insurance coverage, verify hospice benefits, and confirm eligibility. The agency will consider active coverage and whether the hospice patient needs to pay out of pocket. 

Next, the agency will examine the medical history, and confirm the patient has a hospice eligibility certification. The hospice team then meets with the patient to confirm and collect additional information and discuss the hospice process. Once the initial assessment is complete, the provider reviews the referral with the hospice medical director and considers staffing requirements and availability.

After approval, the intake team transfers the referral to patient status, and the physician establishes a plan of care and writes orders to proceed. The patient signs consent to have hospice care instead of curative treatment, and care begins. 

Referral Criteria and Documentation

Palliative providers consider several criteria for hospice admission before accepting a patient referral. A key factor is agency bandwidth, and some agencies may decline or refuse a referral if there isn’t enough staff to process referrals or initiate care. 

Documentation is another critical factor. Without the correct signed orders, certifications, and patient information, hospice agencies can’t proceed. Referral management software allows agencies to track referrals and monitor documents from a central dashboard. The result is an easier document collection workflow and faster referral processing. 

The Role of Medical Professionals in the Referral Process

Hospice referral processing requires a team of medical professionals, each with a role in a larger system. Communication between teams is essential for efficient referral review and approval. 

The Role of Medical Directors

The medical director oversees the agency and ensures the agency has enough staff to serve and care for patients. The medical director also works closely with hospice physicians to review patient history and referrals and certify eligibility. The medical director offers professional insight and helps make the final decision. 

The Role of Palliative Care Providers

Palliative care providers, specifically hospice physicians, review the referral and patient history after a nurse or nursing aide completes the initial assessment. A physician may also do a comprehensive health exam to determine overall presentation and symptoms and the patient's needs. 

Physicians review the medical history, prognosis, and additional information from the nursing aides with the medical director. Together, they decide whether the agency has the resources to handle the referral and build a plan of care for the patient. 

The Role of Nursing Aides

The nurse or nursing aide performs the initial health exam, providing additional information needed for referral processing to the agency. During this exam, the aide collects and verifies demographics and other information, including:

  • Medicare or Medicaid coverage
  • Insurance coverage
  • Medical directives, such as Do Not Resuscitate or Health Care Proxy
  • Medications

How WorldView Can Assist Your Hospice Team Care for Patients

WorldView simplifies the referral process with automated document management tools. Our hospice software helps agencies seamlessly process records, track orders, and monitor and maintain documentation. Our fully integrated mobile application can help streamline hospice referrals so you can focus on providing care. 

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