What Physicians & Hospitalist Groups Need to Know
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- As a physician, I am trained to provide curative treatment. Does hospice require physicians, patients and families to “give up”?
- Why should I refer my patients to hospice?
- Disease progression and prognostication are at times difficult to determine. What if my patient with a non-oncological diagnosis outlives his 6-month prognosis while on hospice care? Would he then have to forego hospice services? What are his options?
- Will my patient lose their insurance coverage if they choose hospice services?
- So what does my patient give up in order to receive hospice services?
- A colleague just referred one of his patients to hospice and is serving as the attending physician. What are the advantages of serving as a hospice attending physician? I am considering it.
- If I continue to see my patient can I bill for it?
- Can my patient continue their medications?
- Who will prescribe the patient's medications?
- Would the nurse call if there were a change in the patient’s status and ask for direction?
- Will I be responsible if I refer and my patient is not hospice appropriate?
- Can my patient change their mind if they wish to go to the hospital or receive aggressive treatment?
- Will the quality of care and goals of treatment for my patient remain the same once they are on hospice?
- If I remain as attending physician, how will the hospice team physician assist me?
- Am I informed when the patient dies?
- What physical symptoms can help determine when the time may be right for hospice?
- How do I refer a patient to VITAS?
For Physicians and Hospitalist Groups
As a physician, I am trained to provide curative treatment. Does hospice require physicians, patients and families to “give up”?
No. When patients are no longer responding to curative treatment, hospice provides a way for people to live in comfort, peace and dignity without curative care. Hospice improves quality of life by ensuring the patient is aggressively treated for symptoms such as pain, surrounded by family or loved ones and in the comfort of a place they choose, typically at home.
When you refer a patient to hospice, you, as a physician, know that you have done everything your patient has asked to offer a cure and extend their life. While hospice care means stopping curative efforts, it doesn’t mean giving up on your patient or hastening (or delaying) death in any way. On the contrary, hospice care improves the quality of patients’ lives as they near the end of life and such an approach has demonstrated to help patients to live longer.
Why should I refer my patients to hospice?
At some point in any serious illness, the treatment and its side effects become less efficacious/more debilitating than the disease. This is the time to focus on the patient and their quality of life—the time for hospice. Given the time—months or weeks, rather than days or hours—hospice can improve the quality of life and help the patient and family focus on the things they find most important, such as quality of time together, freedom from discomfort and the environment they choose.
Disease progression and prognostication are at times difficult to determine. What if my patient with a non-cancer diagnosis outlives his 6-month prognosis while on hospice care? Would he then have to forego hospice services? What are his options?
Hospice patients receive an initial certification upon admission from a hospice physician and, usually, the referring physician. The first two benefit periods last 90 days a piece. The hospice physician certifies the patient after each of these periods for continued appropriateness for service. Then, starting with the third benefit period, the patient is recertified every 60 days until they die or leave hospice. Neither a hospice-appropriate patient nor his physician is penalized for experiencing a longer prognosis than expected.
If a patient's health improves, they may no longer need hospice. Patients have the right to revoke the election of hospice care at any time via a signed statement. if a patient stops hospice care, they will revert to the type of Medicare coverage they had before they chose a hospice provider, like Original Medicare, a Medicare Advantage Plan (like an HMO or PPO) or another type of Medicare health plan. It is important to determine if there is a waiting period to resume prior coverage (for example, the beginning of the month). If a patient is hospice eligible, they can return to hospice care at any time.
Will my patient lose their insurance coverage if they choose hospice services?
No. When a patient selects hospice, the terminal disease(s) is identified and it becomes the focus of hospice therapy. Insurance that covers hospice services, including Medicare, also continues to cover any illness or accident unrelated to the terminal illness, as usual. Hospice is reimbursed only for services related to the terminal diagnosis.
What does my patient give up in order to receive hospice services?
While receiving hospice care, patients cannot seek traditional curative care although the hospice continues to provide aggressive treatments that preserve patient comfort such as management of disease exacerbations, antibiotics, or wound care. If they present to the ED or call 911 in what feels like an emergency, a hospital admission could indicate a desire for non-hospice care for the identified terminal illness. If this is the case, the patient would sign a revocation form and their hospice care would be terminated. However, a patient selecting to remain on hospice may, under certain conditions, be admitted to the hospital under continuing hospice care. Or they might return home to home-based hospice care and forgo hospital care. Hospice patients and their interdisciplinary teams are prepared to handle emergencies without involving the hospital. As long as patients and families understand that hospice care is palliative, not curative, and is intended to maintain comfort and dignity and improve quality of life, there is no downside to being a hospice patient.
A colleague just referred one of his patients to hospice and is serving as the attending physician. What are the advantages of serving as a hospice attending physician? I am considering it.
The patient’s PCP can be the following physician, writing orders, conferring with the hospice team nurse, giving direction. The hospice team physician would be available for consults. Or the patient’s PCP can choose to be the attending, being informed by the hospice team and contributing to the dialogue, but leaving the duties of the following physician to the hospice physician.
If I continue to see my patient can I bill for it?
Yes. If the patient designates you the attending physician of record, you would bill Medicare directly for the all patient care provided by you, including the terminal diagnosis. The PCP can also turn the patient over to the hospice team and not be involved at all. Note: Any physician treating the patient for the terminal diagnosis who is not the attending physician must contract for their services through the hospice in order to be paid.
Can my patient continue their medications?
It depends on the situation. The hospice team reviews all medications in light of the palliative hospice plan of care. Some may be discontinued or dosages changed as the patient’s condition changes. New ones may be introduced. As the patient’s PCP, you can be part of the decision-making process.
Who will prescribe the patient's medications?
The following doctor usually prescribes, but consulting physicians may be hired by the hospice if the need for specialized care is determined. Those doctors may also prescribe under the review of the following physician.
Would the nurse call if there were a change in the patient’s status and ask for direction?
Yes, the hospice nurse informs both the following and the attending physician of changes and asks for direction. As noted earlier, the attending physician may choose to allow the hospice physicians to follow the patient and not be called upon for care management.
Will I be responsible if I refer and my patient is not hospice appropriate?
No. The initial hospice certification by a referring physician is only a statement of opinion. There is no responsibility for the course of illness after that point. Every patient is evaluated before admission and continually while they are on hospice. If at any time the patient does not meet hospice eligibility guidelines, hospice is discontinued. Patients can come off hospice care and, if appropriate, resume hospice care multiple times with no penalty to them or their PCP.
Can my patient change their mind if they wish to go to the hospital or receive aggressive treatment?
Yes. Additionally, please understand that hospice is aggressive treatment of pain and other symptoms of the terminal illness. Hospice patients always have the right to revoke their hospice benefit for any reason. If they change their minds, they can begin hospice again, as long as they are evaluated and meet eligibility requirements.
Will the quality of care and goals of treatment for my patient remain the same once they are on hospice?
Hospice goals are different from curative goals, but a care plan is written and the hospice team meets weekly to assess the patient’s status and revise the care plan accordingly. Information considered in that weekly assessment may come from the hospice aide, the family, the physician, the social worker, even the patient. Determining the goals of treatment for a patient is a collaborative process driven by the patient-family with guidance and support of the hospice team.
If I remain as attending physician, how will the hospice team physician assist me?
The hospice physician is trained in hospice and palliative medicine and an expert in reducing pain and other EOL symptoms.
Am I informed when the patient dies?
Yes, the PCP is informed when a referred patient dies.
What physical symptoms can help determine when the time may be right for hospice?
VITAS has an app for your smartphone: download it at VITASapp.com. The same information is available in a small spiral-bound notebook, the Hospice Eligibility Reference Guide. There is an app for the Apple Watch as well. Talk to a VITAS representative for other pieces, from brochures to badge cards, which arm professionals with hospice referral information.
How do I refer a patient to VITAS?
The VITAS app for smart phones and the Apple Watch are perhaps the easiest ways to refer a patient. But our admissions staff is available 24/7/365 to take a referral, visit a patient/family or discuss a case with you.
Refer your patient to VITAS: Online | Mobile App | 800.873.5198