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The Hospice Admission Decision: Who’s on First?


When it comes to hospice care, “making it easy” for patients and families requires vigilant attention to an admission process that is facing both internal and industry pressure to “get it right” the first time. Julia Maroney, RN, and Ruth KV Recchia, RN, work with hospice teams across the nation to help them understand the current environment of scrutiny, and to implement best practices for the admission process with 3 goals in mind:  improving decisions regarding eligibility, reducing organizational risk, and enhancing communication for better patient care. 

The two Senior Managers at Simione Healthcare Consultants say that regulatory requirements and audits have raised the bar for performance while many other changes in process, information technology, and staffing needs are also taking place.  “Hospice leaders have legitimate concerns for their organizations’ ongoing viability.  We focus on helping them verify eligibility, improve documentation to meet regulatory requirements, and enhance the flow of the admission process,” says Maroney. 

“The fear factor with mounting regulations is very real,” Recchia explains, “yet, we need to remember that regulations by design provide a specific structure to follow when developing processes. While regulations may be excessive, they can help hospices refine roles in the admission process and support the industry by reducing fraud, which hurts everyone.

“In many cases, hospice organizations have been remiss in educating staff about regulations and Medicare criteria, or have neglected to correct forms, documentation practices, and policies to reflect changes that they fully know about and understand.  If found during an audit, these missteps and omissions can constitute fraud in the same way that intentional admissions of poorly eligible patients and kickbacks to referral partners have been flagged.  Fraud is fraud, even when a hospice did not intend to mislead Medicare regarding patient data,” Recchia adds.

Intentional fraud – in the form of inappropriate admissions, kickbacks to referral partners and improper patient recertification – has precipitated government review of an increasing number of hospice organizations, especially those with long lengths of stay that are coupled with patients in care facilities, with non-cancer diagnoses, and/or classified within high-paying levels of care.

According to Recchia and Maroney, keys to implementing best practice in the hospice admission process include:

  • Practical application – easily implemented and replicated
  • Least steps – fewer opportunity for errors
  • Use of technology
  • Clearly assigned roles with staff awareness of others’ roles and responsibilities
  • Evaluation and monitoring of every step and procedure in the process

Maroney acknowledges that the processes for admission are unique to each hospice.  “Patient admission is market-specific, and when a hospice considers a patient ‘admitted’ is determined by each organization,” she explains.  Along with adoption of the National Hospice and Palliative Care Organization’s Hospice Admission Care Map, she suggests that the following questions be asked and considered in developing best-practice hospice admissions:

  • Who meets with the patient and family after referral?
  • Who is reviewing the clinical information to ensure eligibility?
  • When does the patient/representative sign the election statement?
  • When do the initial and comprehensive assessments take place?
  • What is the role of the hospice medical director?

“A process map needs to include the accountable person or role at every step – from hospice benefit election to certification of terminal illness, assessment, and developing the individualized plan of care,” Maroney says.

Recchia adds to this by emphasizing the need for accountability across the entire hospice team.  “We don’t want hospice professionals to say that they had a ‘sinking feeling’ after an IDG meeting or a chart audit because critical information was not shared or documented to support optimal patient care and appropriate reimbursement,” she adds.  “We can no longer approach patient admission by assuming someone else is ‘taking care of that detail’.  We have to hardwire every step.  It sounds elementary, but asking ‘who is doing what, and when’ is essential for providing exceptional hospice care that will earn both high marks from the community and appropriate payment for services provided.”