The hospice evaluation is the formal process used to determine if a patient meets the medical and administrative criteria for admission. This assessment is the necessary first step to access hospice care, which focuses on comfort and quality of life rather than curative treatment. The evaluation ensures the patient’s condition aligns with standards set by the Centers for Medicare & Medicaid Services (CMS) and other payers. It begins the collaborative effort to establish a plan of care tailored to the patient’s specific needs and goals.
Medical Criteria for Hospice Eligibility
Access to the hospice benefit, particularly under Medicare, is governed by clinical rules centered on prognosis. The primary requirement is certification that the patient has a terminal illness, defined as a life expectancy of six months or less. This prognosis must be supported by a combination of declining health indicators.
This certification must be provided by two physicians for the initial election: the patient’s Attending Physician and the Hospice Medical Director. The Attending Physician is the doctor chosen by the patient who manages their medical care. The Hospice Medical Director reviews the patient’s clinical information, including diagnoses, symptoms, and treatment orders, to confirm the prognosis.
The determination relies on clinical judgment supported by objective medical evidence. Physicians use disease-specific criteria and functional status indicators, such as significant weight loss, frequent hospitalizations, and declining physical or cognitive abilities, to support the six-month prognosis. When a patient meets these clinical rules, they must also choose to accept palliative care for their terminal illness instead of treatment aimed at a cure. This election is a formal administrative step that unlocks the full hospice benefit.
Steps in the Initial Hospice Assessment
The process begins with a referral, which can be made by a physician, a social worker, or the patient or family contacting a hospice provider directly. Following the referral, the hospice schedules an in-person assessment, often within 24 to 48 hours, conducted wherever the patient is located. This visit is typically performed by a Registered Nurse and may include a Social Worker, representing the core of the interdisciplinary team.
During the visit, the nurse performs a comprehensive clinical assessment, including a physical examination and a review of the patient’s medical history and current medications. The team gathers details about the patient’s symptoms, pain levels, and how the illness impacts daily activities. This step confirms the medical criteria established by the physicians and identifies the patient’s immediate needs.
A key part of the assessment involves a detailed discussion with the patient and family to understand their personal goals and preferences for care. The team assesses the psychosocial, emotional, and spiritual needs of both the patient and their caregivers. This information is used to establish a preliminary plan of care, which outlines the specific services, medical equipment, and supplies the hospice will provide. The assessment is a holistic review designed to ensure the hospice can meet the patient’s needs before formal admission.
Understanding Hospice Benefit Periods
Once the evaluation confirms eligibility, the patient is admitted to the hospice benefit, which is structured into specific time frames. The Medicare hospice benefit begins with two initial 90-day periods, followed by an unlimited number of subsequent 60-day periods. The benefit period starts on the day the patient elects hospice care.
At the end of each benefit period, eligibility must be re-evaluated to confirm the terminal illness is still present. This process is called recertification, which maintains coverage under the hospice benefit. For recertifications after the second 90-day period, a hospice physician or nurse practitioner must conduct a face-to-face encounter to document clinical findings that support the prognosis of six months or less.
Recertification ensures that the hospice benefit remains an ongoing process. As long as the Hospice Medical Director or a hospice physician recertifies that the patient remains terminally ill, the benefit continues. If a patient’s condition stabilizes or improves beyond the eligibility criteria, they may be discharged from hospice, though they can re-enroll later if their condition declines again.