Hospice Care

Hospice is a type of care provided to people who have a terminal condition; it provides supportive medical care designed to make a patient more comfortable at the end of his life.  In order to qualify for hospice, the patient’s doctor as well as the hospice medical director must agree that the patient will probably die within six months if the disease runs its normal, natural course.  It’s important to understand that hospice is not a place; it’s a type of comfort care – or palliative care – the patient receives to manage the pain and symptoms for his terminal condition. 

In addition to the doctors certifying that a patient qualifies for hospice, the patient must agree to stop all aggressive treatment related to his terminal condition.  For example, a diabetic patient with terminal cancer is still able to take insulin, but he agrees not to seek chemotherapy or radiation for the cancer.  The hospice will oversee all of the care related to his cancer and do its best to ensure that the patient is as comfortable as possible.   

Patients are often hesitant to sign onto hospice because they think that they’ll only require help the last week or so of their lives – but nothing could be further from the truth.  The sooner a person signs onto service, the greater the opportunity for them to have their pain & other symptoms managed.  They’ll be more comfortable and have the opportunity to benefit from all of the services the hospice has to offer, including emotional support. 

Most hospice patients are able to continue seeing their primary doctor, with the hospice medical director available as a backup.  Before signing onto a hospice program, it’s best to speak with your doctor to ensure you’ll be able to continue seeing him if you wish.   However, if you visit the emergency room or seek additional treatment for the terminal condition without approval from the hospice program, you may have to pay for it out-of-pocket. 

The Medicare program and most insurance companies pay hospices a daily rate of about $140.00 for every day the patient is signed onto their program.  Although the amount seems high ($4,200 per month), hospice is much less expensive than the multiple hospitalizations, home healthcare, ambulance transportation, and other costs associated with aggressively treating a terminal condition. 

The Medicare hospice benefit provides for light homemaking, personal care, nursing, social services, spiritual care and delivery of medications to the patient’s home.  It also provides medical equipment and supplies such as gloves, wipes, and incontinence briefs.   Unlike home health care services, hospice patients don’t have to be homebound to receive hospice care; in fact, patients are encouraged to get out as much as possible if they can.

Even though hospice doesn’t provide 24-hour care in the home, the agency can send in workers more frequently for a very short period of time in order to manage a patient’s symptoms under the continuous care benefit.  The hospice can also move a patient to a skilled nursing facility or hospice inpatient unit for a few days if the patient requires nursing to manage symptoms under the inpatient benefit.  Another benefit available to hospice patients is respite, where the patient is placed in a facility for five or so days to give the caregiver a break.  All of these services are provided at no cost to the patient.

Hospice care supplements the care in the home, but it doesn’t replace the primary caregiver.  If a patient requires more care than the family can provide, there are options available such as in-home care, group homes, assisted living facilities, or nursing home placement.  A hospice social worker can help with referrals for caregiving – but the hospice itself doesn’t pay for this service.   The Medicare benefit pays for the hospice care – but not the room & board in any of these facilities.  The hospice patient will either have to pay privately for his room & board or apply for Medicaid, if he’s eligible.  

Hospices provide care in a nursing home in the same manner that they provide care if the patient lived in a private home.  The goal is for the hospice to direct the patient’s care, and to send in staff to supplement the care that the patient receives in the facility.  If a hospice patient’s room and board is paid by Medicaid, the Medicaid program reduces its payment to the nursing home by 5%.  Most hospice programs are willing to pay the difference to the nursing home, which is perfectly legal – but it’s not legal for a nursing home to charge a patient or his family that 5% difference.  

Nursing home patients who choose hospice are limited to those hospice agencies that contract with that specific nursing home.  If a patient prefers a different hospice, they will either have to move to a different nursing home or ask the nursing home to sign a one-time contract with that hospice. 

Hospice can be beneficial to nursing home patients and families in the following manner:

• If the patient is paying privately, he’ll save hundreds of dollars in out-of-pocket costs for supplies and equipment by signing the patient onto a hospice program.
• Hospices specialize in pain management, whereas many nursing homes aren’t able to adequately manage pain and symptoms without the hospice oversight.
• Hospices provide additional spiritual and social work support.

Hospice is big business, with new programs springing up all over the country.  The competition between hospices and home healthcare providers is fierce, with many home health agencies adding hospice programs in order to retain their patients until they die.  Every hospice provides the exact same service, even though each one claims to be the best. 

Most hospices employ commission-based marketers who aren’t required to have any professional licensure at all (meaning that they’re not required to follow a code of ethics); their job is to get as many referrals as possible and to get the patient to sign on the dotted line.  They will use whatever high pressure sales tactic they can in order to make their commission, and then you’ll never see them again.     

You have the right to ask friends and family for the names of programs that they’ve used – and to use any program that you’d like.  You have the right to cancel hospice or to change hospice programs if you don’t like the first one you use – even if the hospice attempts to intimidate you into staying with their program by telling you you’ll lose benefits if you change to a different program.  Many hospice programs will insist you meet with a supervisor or their medical director before you make any decision, but you have the right to change or stop without pressure. 

The paperwork that they give to you when you sign on is required to tell you how to transfer to a different program and provides the number of the program that provides oversight for Medicare.  You can always call that agency for advice if you feel like the program that is serving you won’t allow you the right to choose a different hospice program. 

Hospice medical directors often refer patients from their private practice, even though this is a violation of a set of laws called the Stark Laws that address sweetheart deals such as this.  It’s illegal to refer patients to agencies in which they have a financial interest – but unfortunately, violations are rarely reported and/or prosecuted. 

Hospice care can be beneficial to patients and their families if and when they’re ready to accept the patient’s prognosis and allow him to die naturally.  For additional information regarding hospice programs, Refer to http://www.medicare.gov/publications/pubs/pdf/02154.pdf