Who Qualifies for Hospice Care

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Last Updated on September 6, 2021 by Frank Davis

Hospice care has a vital role to play at the late stage of a patient’s life who is suffering from a terminal illness. The patient and their family will get to benefit from the services and support hospice care provides. By identifying when a patient is eligible for hospice early on, there is a higher likelihood that the patient and their families will avoid from getting hospice care too late and benefit from what this end-of-life care has to offer.

In order to abide by the law, a healthcare professional has to confirm that a patient meets the guidelines for receiving hospice care by getting a referral to one of the many hospice providers. Once confirmed, a patient becomes able to receive 24/7 comfort care and support. Hospice care also assists families in resolving practical challenges that inevitably come up during the end of someone’s life.

How to Qualify for Hospice Care

To qualify for hospice care, a doctor will have to determine the eligibility of a patient for the program. By doing so, the patient and their family can receive peace of mind. When it comes to hospice care, it is always ideal to receive the full amount of care possible.

There are a number of common hospice diseases and illnesses. These include:

• Cancer
• Dementia
• Respiratory illnesses
• Heart disease
• ALS
• COPD
• HIV
• AIDS
• Liver disease
• Renal disease
• Sepsis and concomitant end-stage disease

A doctor will certify that a patient has a terminal illness. Additionally, they will confirm that the prognosis for the life expectancy is six months or less. The prognosis is based on how long it generally takes for a particular terminal illness to develop until the death of the patient. Once a doctor makes the certification, a hospice medical director will need to confirm that the assessment is accurate.

Besides this being the main criteria for deciding who qualifies for hospice care, there are also three situations that a doctor will usually identify before recommending a patient to enter hospice care. These are:

Patient’s Condition Is Not Improving

If a patient is receiving treatment for an illness, yet their condition is not improving, then the patient is likely entering the end-stage of the disease. The more the disease progresses, the more likely it is that the disease will become terminal.

Goals of Care Need to Change

If a patient who is suffering from a disease is not getting better, yet they do not want to be in and out of hospitals anymore, the goals of care will immediately change. Additionally, if a patient is becoming increasingly anxious due to facing the fact that they are dying, a referral to receive hospice care may become the next step.

Acute Health Events Occur

When a patient experiences an acute health event, such as a heart attack or stroke, end-of-life care may be necessary.

After a doctor has referred a patient to receive hospice care, a specially-trained hospice nurse will visit the patient and perform a health assessment. As part of the assessment, a number of telling signs that they may need hospice are looked for. These include:

• Significant weight loss (10%) in the past 3-6 months
• Inadequate intake of food and water
• Difficulty swallowing
• Increased bouts of shortness of breath
• Daily tasks, errands, and activities are unable to be performed independently
• Majority of time is spent either sitting or lying in a bed
• Elevated levels of fatigue
• Increased daytime sleeping
• Numerous infections or ones that repeatedly return
• Higher levels of cognitive impairment and confusion
• Speech becomes increasingly unintelligible
• More frequent visits to hospitals or emergency rooms, with barely any noticeable improvement
• Accelerated disease progression regardless of treatment method
• Intense pain or emotional suffering

Once the assessment is conducted by the hospice nurse, a decision is made, usually by the hospice medical director regarding the eligibility for entering into hospice care. If a patient is eligible, they must agree to receive it and forgo any curative treatments.

There are 1.55 million Medicare beneficiaries in the United States who are receiving hospice care currently. These patients are helped by 4,300 hospice care agencies, spread out across the country. Each patient first has to go through the process listed above in order to receive hospice care.

Living Beyond Six Months While in Hospice Care

As mentioned earlier, a doctor needs to certify that a patient has six months or less left to live to enter hospice care. What happens if someone lives beyond the six months they were given?

If the patient is a Medicare beneficiary, they are entitled to receive as many 60-day benefit periods after the initial six months are up as they need. The key to continuing receiving hospice care is if they are recertified as being terminally ill patients, with six months or less left to live. The entire process described earlier will have to be repeated to continue receiving hospice care.

The Medical Rights Center recommends that the assessment process should be taking place prior to the end of the current period of hospice care. However, it shouldn’t be done any sooner than 30 days before the next period. For patients who are receiving hospice care from private insurance providers, reviewing the insurance policy will be necessary to find out what it takes to continue receiving coverage.

Conclusion

When a patient is suffering from a disease that is terminal, having six months or less left to live, he or she is eligible to receive hospice care. After a careful assessment conducted by both a doctor and a hospice care provider, a decision is made to determine who qualifies for hospice care. Now that you have this information, you can make a decision as to whether you or a loved one should start the process of entering hospice care.