Common Misperceptions About Hospice
1) Hospice is a place.
Hospice is a philosophy, an interdisciplinary approach to end of life care, and a program of services available to the patient and his/her loved ones wherever the patient may be.
2) Hospice requires the patient to forego a continuing relationship with his/her primary care physician; it also requires the primary care physician to forego his/her relationship with the patient.
Hospice programs encourage an ongoing relationship between the primary care physician and the patient. In this case, the primary care physician becomes part of the team and contributes to the hospice plan of care.
3) The patient must have a primary caregiver to be eligible for hospice.
In the past, some hospices required a primary caregiver. This is not now the case for hospice programs in New York State.
Unfortunately, many physicians and other potential referral sources believe a primary care giver is a prerequisite and fail to make referrals for patients without such an individual present.
4) The patient must have a DNR (Do Not Resuscitate order) to elect the hospice benefit.
In the past, many hospices required a hospice patient to have a signed DNR to enroll in hospice care. This requirement has been discontinued.
5) Only cancer patients are appropriate for hospice.
In the past, most patients who enrolled in hospice were cancer patients. Currently, there are physicians who believe only cancer, particularly solid tumor cancer, lends itself to the prognostic timeframe outlined in the Medicare hospice benefit.
Despite this history and perception, recent statistics demonstrate an increasing number of patients with diagnoses other than cancer are choosing hospice. The National Hospice and Palliative Care Organization has issued standards to help in defining hospice-appropriate prognostic indicators for non-cancer patients.
6) Hospice provides good psycho-social supports but because the benefit is limited to the terminally ill, clinicians are not skilled health care practitioners.
Hospice clinicians demonstrate expert pain management, symptom control, and supportive care. Clinicians are experienced with these interventions; in addition, they are also uniquely well-qualified to address end-of-life issues with patients and their loved ones and to work as members of an interdisciplinary team.
Improved coordination of pain management with the use of anti-depressant medications is an important current and future focus.
7) Only older people (Medicare-eligibles) enroll in hospice.
In the early days, hospice cared primarily for older patients. As hospice utilization has grown, more patients of all ages are electing the benefit. We are seeing an increasing number of families of terminally ill children choosing hospice for them.
8) Hospice patients in nursing homes are ineligible for hospice.
This was once true. However, both Federal and New York State governments now provide for nursing home patients to receive hospice care.
9) As two different providers with shared patients, Nursing Homes and Hospice find it impossible to collaborate effectively.
Collaboration has sometimes been difficult; however, there are many instances in New York State where nursing homes have created a positive synergy on behalf of the patients each serves.
10) Hospice means hopeless.
Under current definitions, hospice-appropriate patients must have a specified and limited life-expectancy. However, the hospice philosophy emphasizes the creative and positive outcomes to be realized by defining and achieving personal goals and by living life as fully as possible.
It is not uncommon for patients entering hospice to experience an improved sense of well-being and comfort. This sometimes happens because pain management and symptom control issues are openly discussed and effectively resolved. Sometimes, this sense of well-being is a reflection of the patient's sense of control gained from defining his/her goals and from active participation in developing the plan of care.
11) A prospective hospice patient must have a home to be eligible.
Because hospice is a philosophy of care and not a place, it can be provided wherever the patient lives: at home, in a nursing home, or in any accommodation or shelter.
New York State has provision for hospice residence(s). However, there is not at this time provision for federal and/or state Medicaid funding for room and board support in a hospice residence setting. This issue will need to be resolved if the hospice residence is to be a meaningful alternative for our citizens.
12) Once a patient revokes the hospice benefit, he/she cannot receive hospice care again.
If a patient wants to return to hospice care, Medicare, Medicaid, and most private insurance companies will allow readmission.
13) When patients revoke or are discharged from hospice, they are on their own to "begin again" identifying alternate health care providers.
Regardless of the reason for revocation or discharge, the Medicare Conditions of Participation require hospice to facilitate the transition from hospice to another care provider.
14) Managed Care companies don't pay for hospice.
In actuality, each managed care company makes a decision about the services covered by its basic and supplemental premiums. There is substantial variation in the services covered and the length of time a patient is eligible to receive hospice care.
In New York State, HMOs are required to offer but not required to provide hospice coverage. This means that individuals may be required to pay an additional charge for hospice eligibility. Many insureds do not understand the difference between "must provide" and "must offer."
15) Self-insured companies don't pay for hospice.
Each self-insured company makes its own decisions about what specific health care its insurance coverage will include. We do not at this time have comprehensive information about how many self-insured companies include hospice or how each of them defines hospice care.
Because New York State defines a hospice as an Article 40 entity and requires each Article 40 to obtain and maintain Medicare certification, the definition of hospice should be consistent.
16) Physicians determine which of their patients should receive hospice care and make the necessary referral.
Hospice does require physician certification of the appropriateness of the patient for hospice care. However, hospice is always an elected benefit; the patient determines whether or not this approach to care is consistent with his/her needs and expectations.
There are physicians who choose not to refer to hospice. Patients of these physicians are not precluded from receiving hospice care and may self-refer. Another physician and/or the hospice medical director will then determine whether the patient meets eligibility requirements and, if so, will certify the patient to receive hospice services.
17) After 6 months on the hospice benefit, the patient is no longer eligible for hospice care.
In reality, a patient is eligible for hospice as long as he/she has a life-limiting illness with a prognosis of 6 months or less to live if the disease process proceeds on its expected course. There is no absolute time limit.
An unfortunate recent trend is very late referrals to hospice. As a result, the median length of stay for some patients is too short to allow them and their loved ones to gain the full benefits of hospice care.
18) Hospice patients are denied treatment(s) because they are terminally ill.
If the purpose of any treatment is to manage pain and/or control symptoms and is consistent with the patient's wishes, it may be included in the plan of care.
19) Once a patient has elected the hospice benefit, she/he may no longer access other health insurance.
Each insurer has rules defining eligibility for covered services.
When a Medicare-eligible patient elects hospice, all care related to the terminal illness is automatically covered under Medicare Part A.. Medical problems unrelated to the terminal illness are covered under Medicare Part B.
When a Medicare hospice patient revokes the benefit or is discharged, he/she is again immediately eligible for regular Medicare coverage.
20) When a patient is admitted to an acute care hospital, hospice services cease.
When a hospital admission is part of the hospice plan of care, the hospice continues to care for the hospitalized patient and to provide case management services including coordination of care and discharge planning.
21) Hospice ends when the patient dies.
All hospice programs must provide bereavement services for loved ones for up to one year following the death of the patient. In some cases, bereavement support continues beyond that timeframe.
Most hospice programs also offer bereavement support to those in need even if their loss is unrelated to a patient who received hospice care.
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