A hospice referral is a formal request for comfort-focused, palliative care services for an individual with a life-limiting illness. This process allows patients to transition from aggressive, curative treatments to a care model centered on pain management and quality of life. This guide provides a clear roadmap for obtaining a referral and beginning the hospice care process.
Medical Criteria for Hospice Eligibility
Accessing hospice care depends on meeting specific medical requirements that confirm the progression of a terminal illness. The primary criterion is a prognosis of six months or less, assuming the disease runs its expected course without aggressive medical intervention. Patients may continue to receive care beyond this period if they continue to meet the eligibility standards.
The terminal prognosis must be certified by two physicians: the patient’s attending physician and the medical director of the selected hospice organization. This dual certification process provides a necessary clinical check before care can begin.
To elect hospice care, a patient must make an informed decision to shift their goal away from curative treatments. The focus changes entirely to comfort care, or palliative care, which manages symptoms and supports the patient’s emotional, spiritual, and physical well-being. This choice is formalized by signing a statement electing the hospice benefit.
Clinical indicators support the prognosis, such as a decline in functional status measured by tools like the Palliative Performance Scale (PPS) score of 50% or less. Other signs include significant, unintentional weight loss, frequent hospitalizations within the last six months, and increasing dependence on others for daily activities. These physical markers help physicians confirm the terminal decline.
Initiating the Referral Process
The hospice referral process can be started by any concerned party, including the patient, a family member, a friend, or any healthcare professional. This ensures multiple avenues for access to care.
If the patient or family decides to pursue hospice, the first step is communicating this need to the primary care physician or specialist. This conversation requests that the physician submit a formal order for a hospice evaluation based on the patient’s declining condition and change in care goals.
If the physician agrees that hospice is appropriate, they typically contact a local hospice provider to make the referral and share the necessary medical records. Alternatively, a patient or family can directly contact a hospice organization, which coordinates with the patient’s physician to confirm eligibility. Many hospice organizations offer a no-cost consultation to discuss the process.
The physician’s role is to document the medical basis for the referral and confirm the terminal prognosis. If the patient lacks an attending physician or the physician is unwilling to make the referral, the hospice medical director can assume the role of the attending physician to facilitate admission. The referral can be submitted through a form, an electronic system, or a direct phone call to the hospice agency.
Steps in the Hospice Admission Process
Once a referral is made, the hospice organization begins a sequential intake process to ensure a smooth transition to care. The first step involves an initial phone call from the hospice team to the patient or family to gather basic information and schedule an in-person meeting. This call helps the hospice staff determine preliminary eligibility and address immediate questions about the process.
Following the initial contact, a registered nurse or social worker from the hospice agency conducts an in-person assessment, often at the patient’s current location, such as their home or a hospital room. During this visit, the nurse performs a clinical assessment, reviews current medications, and gathers comprehensive medical history to confirm that the patient meets the clinical criteria for admission.
If the patient is found eligible, the team presents the required admission paperwork, including consent forms and the election statement for the hospice benefit. The patient or a legally authorized representative must sign these documents, confirming that the care is palliative rather than curative. This is also the time to select a specific hospice provider, as the Medicare benefit requires choosing one agency for terminal illness-related services.
A core component of the admission process is the development of an individualized Plan of Care (POC). The interdisciplinary hospice team, which includes nurses, social workers, and the medical director, collaborates with the patient and family to create this plan. The POC outlines specific services, such as frequency of visits, pain management strategies, and necessary medical equipment, all tailored to the patient’s goals and needs.
Admission to hospice care is typically rapid, often occurring within 24 to 48 hours of the initial referral call. The goal is to begin providing support services quickly, including arranging for necessary medical equipment and supplies to be delivered to the patient’s residence. Once the consent forms are signed and the POC is established, hospice care officially commences.
Financial Coverage for Hospice Care
Hospice care is primarily funded through the Medicare Hospice Benefit, which covers nearly all costs related to the terminal illness for eligible individuals. The benefit structure includes two initial 90-day periods, followed by an unlimited number of 60-day benefit periods, provided the patient is continually recertified as terminally ill. This coverage includes physician and nursing services, medications for symptom control, medical equipment, and support services.
For individuals who do not qualify for Medicare, coverage is often available through state Medicaid programs, which offer a similar hospice benefit in most states. Medicaid’s coverage and eligibility requirements are needs-based and can vary by state, but the benefit generally mirrors Medicare’s in scope, sometimes even covering room and board costs in a facility setting.
Private insurance plans, including employer-based and marketplace plans, frequently include a hospice benefit, although the extent of coverage can differ. It is important to contact the insurance provider directly to understand any potential co-payments, deductibles, or limitations on services. Most hospice organizations have financial staff who can verify coverage and explain the specifics of the patient’s plan.
For those who are uninsured or underinsured, many hospice providers operate as non-profit organizations and offer care at a reduced rate or no cost, relying on grants and charitable donations. No one is turned away from hospice care solely due to an inability to pay. Financial assistance programs ensure that all patients who meet the clinical criteria can access the necessary end-of-life support.