Admission without evaluation

Who is doing the explanation of benefit? Who is getting the consents signed? There is your problem.

If you are doing this ( obtaining consents ) and are also doing the admission the issue lies within the referral source. Dr's are clueless often with hospice guidelines and often will sign a cert to just get grandma out of the monthly office visit as a routine. Or to offer home draws on labs so grandpa doesn't have to get his monthly PT INR...

Look at those two sources...

In our state (not sure if this applies nationally), a physician now needs to perform a face to face assessment with the pt for certification. I don't know what your hospice criteria is, but if a physician refers a pt that the physician deems "likely to die within 6 months if the disease process progresses normally," then we admit. The RNs do an assessment for "appropriateness for hospice," but usually that involves a discussion with the physican, or otherwise finding signs of decline physically, or in lab results, etc.

If a pt has a terminal dx of Alzheimer's, it's extremely difficult to find hardcore signs of decline. Painting of picture of declining ability to perform ADLs, appetite, weight loss are sometimes all you have to support appropriateness. I have needed to visit pts with a referral dx of Debility Unspecified. In other words, it's not always possible to assess for appropriateness on the first visit.

So, If the doc feels the pt's will likely die in terms of months, rather than years, I believe it's better to start hospice, provide education and support to the pt/family/caregivers, and then if the pt remains stable, discussions about taking a pt off the benefit will be a lot easier to have with the family and pt. Predicting how long a person will live is not our job...but it is the role of hospice to initiate end of life care if death is LIKELY to occur within the time frame the doctor suggests.

I agree with the point that the problem lies with referral sources and/or person obtaining the consents. Medicare has tightened up the criteria for hospice eligibility, e.g. End-Stage Cardiac must present with NYHA Class 4 and/or ejection fraction

We will not admit even with a referral if pt does not meet CAHABA guidelines. This is a Medicare requirement and the hospice's responsibility to verify. Also the new Medicare guidelines (for Sterling) require MD face to face for 3rd benefit period and all benefit periods after.