Hospice Eligibility Checklist For Emergency Department Staff

By Joelle Y. Jean, FNP

Due to its busy nature, providers in the Emergency Room (ER) may not immediately identify patients for hospice care. Approaching patients or family members about hospice can also be challenging-especially if they have specific questions. This hospice checklist can help guide providers on when they should consider a patient for hospice.

What is hospice?

Hospice is for patients who are at the end of life. Patients can have a terminal illness or declining health from a chronic illness. The hospice team can coordinate care with health care providers to manage and treat patients.

Benefits of hospice

Initiating hospice early in the disease process has many benefits for the patient and family members. Hospice is there to improve the quality of life and provide comfort for patients during their end of life. Benefits of hospice include:

  • Improved physical and psychological symptoms
  • Caregiver relief
  • Reduced hospitalizations
  • Lowered hospitalization costs
  • Reduced hospital deaths

Barriers to initiating hospice

Studies have shown that providers initiate hospice too late- patients die within weeks of entering hospice. There are barriers that cause ER providers to wait or not consider hospice. Some barriers include:

  • Not having the right resources
  • Breakdowns in patient-clinician communication
  • Failing to identify terminal stage of life
  • Geographical and socioeconomic barriers

Head-to-toe hospice checklist

Alzheimer’s disease and dementia

Patients in the late stages of Alzheimer’s disease or dementia are candidates for hospice. At this stage, they start to lose activities of daily living (ADLs) and cannot complete basic functions on their own. These functions include:

  • Bathing
  • Dressing
  • Eating
  • Swallowing

Other signs providers should consider patients with Alzheimer’s disease or dementia for hospice are:

Heart disease

Patients in their late stages of heart failure (HF) are candidates for hospice. Providers should consider hospice if the patient has:

  • Visited the ER two or more times in the past six months
  • A decline in ADLs
  • Severe HF symptoms such as dyspnea, angina, fatigue
  • Not responded to pharmacological and non-pharmacological interventions
  • Ineligible for surgery
  • Weight and muscle loss
  • NYHA class three/four heart failure

Lung disease and lung cancer

Patients with end-stage lung disease and lung cancer are hospice candidates. Providers should consider hospice if the patient:

  • Has frequent ER visits
  • Increased weight loss
  • Increased dyspnea at rest even with oxygen
  • Stage four non-small lung cancer

Liver disease

Patients with end-stage liver disease are candidates for hospice. Liver disease is the 12th leading cause of death in the United States. Patients with liver disease are often overlooked for hospice care. Providers should consider hospice for patients with end-stage liver disease if they are:

  • Ineligible for a liver transplant
  • Increased pain
  • Increased pruritus
  • Increased nausea
  • Depression and anxiety
  • A decline in cognition and weight

Cancers

ER providers can opt for hospice for patients with cancer if treatment is no longer working or there are no other treatment plans. Patients also at the end stage of their cancer can benefit from entering hospice early. Other signs a patient is ready for hospice are if the patient:

  • Has increased weakness
  • Significant weight loss
  • Pain control
  • In bed for most of the day

Sepsis

It’s not always easy to identify patients with sepsis who qualify for hospice. However, some patients meet the criteria. Providers should consider patients with sepsis for hospice if the patient:

  • Has impaired kidney failure
  • Not responding to pharmacological treatment
  • Require mechanical ventilation
  • Injury to the liver
  • Hyperlactemia

Hospice is available to patients who are at the end of their life. They can entire at any stage in their disease process. Initiating hospice early benefits the patient. Studies have shown that hospice improves mood, decreases medical interventions, and enhances the patient’s overall quality of life.

COPD Patients: Doctors Call For Earlier Hospice Referrals

By: Wilma Peterson, RN

According to the American Lung Association, Chronic Obstructive Pulmonary Disease (COPD) is the third leading cause of death in the United States. Due to the distress and panic caused by difficulty in breathing, living with COPD can be stressful for both the patient and the family. Doctors are beginning to call for earlier hospice referrals for these patients. If accessed at the right time, hospice care can better manage symptoms, prevent unnecessary hospitalizations, and better quality of life.

Patients with advanced COPD are eligible for hospice care, which is fully covered by Medicare, some private insurances, as well as assistance from Veterans Affairs. Hospice patients have access to the appropriate care and medications, allowing for more restful periods and easier breathing. Identifying these factors early can relieve symptoms such as anxiety, panic, labored breathing, and intractable coughing that are uncontrolled with regular medications and traditional therapies.

Factors to consider when deciding whether a COPD patient is appropriate for a hospice referral include:

  1. The patient has a projected life expectancy of 6 months or less
  2. All therapies, including medications and rehabilitation, have been exhausted
  3. The patient has frequent emergency room visits and hospitalizations due to exacerbation of COPD

At this point, the patient is considered to be in the advanced stages of COPD, and the discussion for hospice and end-of-life care should begin.

Eight benefits of early hospice referral for those with COPD

Receiving hospice care early allows for the expertise of a focused team of professionals:

  • Physician
  • Nurses
  • Social worker
  • Chaplain
  • Ancillary services

Hospice services are available 24/7. The team will provide medical, emotional, psychological, and spiritual support to the patient and family. Here are eight benefits of early hospice referral:

  1. Early intervention. The earlier the referral is made, the more it allows the patient and the family to choose the right hospice company and be a part of the care plan.
  2. Managed care. A physician leads the hospice care team. The physician can order the appropriate medications and therapies and cater to a plan to meet the patient’s specific needs.
  3. Skilled Nurses. A registered nurse will meet with the patient and family and can admit the same day. The nurse will also reconcile all medications, put together a plan that focuses on managing symptoms, and provide relief of pain and respiratory distress.
  4. Hospice Aides. Health aides assist with normal daily activities:
  • Washing
  • Grooming
  • Dressing
  • Ambulating safely
  • Other household chores
  1. Medical Social Worker. A social worker will assist with accessing support in the community, such as respite care and other services. The end-stage of COPD causes a severe reduction in personal and social quality of life with increased stress levels for all involved.
  2. Chaplain. Clergy to meet the patient and their family’s psychological and spiritual needs, assisting them through the grieving process.
  3. Ancillary services. Other ancillary services like physical therapy and occupational therapy, strengthen muscles to assist with safety and allow for a sense of independence.
  4. Respite Care. Allows time for self-care and rest, which can help with a change in attitude and mindset in caring for your loved one.

Living easier with hospice care

Early hospice referrals allow for the early management of symptoms by:

  • Having the appropriate therapy and staff when needed
  • Avoiding the stress of emergency exacerbations and hospital visits
  • Providing a more focused approach to the patient and caregiver
  • Alleviating stress and encouraging future planning like spending quality time and making plans

Early referral can provide more support for both the caregiver and the patient as they go through the grieving process.

Hospice: Keeping Loved Ones Home for the Holidays

The holidays can be a challenging and bittersweet time for those with a seriously-ill loved one. Electing the hospice benefit may seem like one more item on your to do list, but hospice can ease the burdens of facing a life-limiting illness. If a loved one has unmanageable symptoms, they could end up spending their holiday in the hospital, away from family and friends.

AT Home Care Hospice helps families manage their loved one’s pain and symptoms so they can spend the holidays in the comfort of home–whether that means in their own home, in a loved one’s home, or in a skilled nursing facility or assisted living facility that they’ve made their home.

Hospice Care in the Comfort of Your Home

Whether your loved one is being cared for at home or in a facility, the additional layer of support that hospice can provide can make all the difference. Hospice care can help manage complex symptoms of pulmonary disease, cancer, dementia, Parkinson’s, heart disease, stroke, liver or kidney disease.

Our interdisciplinary approach, which includes care from a nurse, aide, social worker, chaplain, medical director, and the patient’s primary care physician, is designed to support patients and their families physically, psychologically, and spiritually. With the assistance of this personalized care team and the guidance of the patient’s primary physician, your family can have the support necessary to keep your loved one comfortable and supported without unnecessary hospital visits or doctor appointments.

AT Home Care Hospice’s team is local and available 24 hours a day, 7 days a week, 365 days a year to provide care for our patients and for admissions.

Hospice can also provide necessary durable medical equipment, such as a hospital bed; medications related to the patient’s primary hospice diagnosis; and incontinence products and nutritional supplements. By utilizing hospice services, families have more time to enjoy the most meaningful moments of the holidays — time spent together with family.

Family & Caregiver Support this Holiday Season

With holidays comes stress, as time runs out to shop, run end-of-year errands, and attend special events. Combine that with caring for a seriously-ill loved one during these unprecedented times, and life can become overwhelming quickly.

Our hospice care extends beyond the patient. AT Home Care Hospice works closely with family members to assure they have the tools necessary to cope with stress or caregiver burnout surrounding what may be the final holiday with someone they love. In addition to scheduled visits, patients and their families will have access to a dedicated hospice nurse by phone who is available to answer your questions and dispatch a nurse to your home as needed.

Our team of chaplains and social workers collaborate to address patient and family members’ emotional, psychological and spiritual needs. They make certain our patients’ families have a plan for the holidays, so they can make the most of the holidays without piling up additional stress.

Caring for a loved one facing a terminal illness can be demanding, but it can also be incredibly fulfilling. AT Home Care Hospice can partner with you or your loved one’s facility to ensure everyone – patient and family alike – is supported and cared for this holiday season.

If you have a loved one with a life limiting illness, please contact us to learn more about how AT Home Care Hospice can help your family this holiday season, because home should be more than a holiday wish!

The Hospice Benefit for Veterans

Care at no cost to Veterans and their families.

AT Home Care Hospice collaborates with local VA agencies and programs to raise awareness about the benefit of hospice services for Veterans. As a Veteran, expenses for hospice-related services or enrolled veterans are covered in full.

We Honor Veterans Program

AT Home Care Hospice partners with the We Honor Veterans program to give veterans the best care possible. This program provides resources and training to meet the needs of our veteran patients and their families through respectful inquiry, compassionate listening, and grateful acknowledgement so that veterans can have a peaceful end-of-life experience.

VA Hospice Program Benefits

Hospice is a benefit that the VA offers to qualified Veterans who are in the final phase of their lives. This multi-disciplinary team approach helps Veterans live fully until they die. The VA also works very closely with community and home hospice agencies to provide care in the home. The VA hospice benefit includes:

  • Care available wherever you call home
  • No co-pay for hospice care
  • Medical equipment, medication and personal care supplies
  • Personalized pain and symptom management
  • Care coordinated with your doctors
  • Physical, occupational and other therapy services
  • Spiritual care and support
  • Volunteers with military experience (when available)
  • Ongoing grief counseling for patients and family

Veteran-To-Veteran Volunteer Program

AT Home Care Hospice’s Veteran-to-Veteran volunteer program pairs Veteran volunteers with hospice patients who are Veterans as well. Veteran volunteers have the ability to develop a unique connection with patients and their families through their common experiences and stories, establishing a strong relational bond.

How can Veteran Volunteers Help?

  • Reminisce or tell life stories
  • Educate and answer questions regarding Veteran benefits
  • Assist in pinning ceremonies, distribute certificates and help with other recognition events
  • Assist in replacing lost medals

Common Hospice Qualifiers

For many people, the decision to receive hospice care is made following the diagnosis of a life-limiting illness. Even so, some families still question this decision. Here are some common Hospice qualifiers to help determine when it might be time to elect the hospice benefit. 

  • Falls
  • Frequent physician, ET and/or Hospital visits
  • Weight loss and or BMI < 22
  • Decline aggressive therapy or is not a candidate
  • Wounds
  • EF < 20%
  • NYHA Class IV symptoms at rest
  • Little or no response to Bronchodilators
  • Serum < 2.5
  • Dysphagia and/or aspiration pneumonia
  • Shortness of breath and/or o2 sat of 88% or less
  • Frequent injections
  • Edema
  • UTIs
  • Upper respiratory infections, bronchitis or pneumonia

If you or a loved one are experiencing any of these symptoms and have questions about our services at AT Home Care Hospice, please contact one of our office locations near you to speak with a staff member about these Hospice qualifiers.

Common Hospice Diagnoses

AT Home Care Hospice is here for you – 24/7/365.

Choosing Hospice is often a difficult decision. We help lead this conversation and can ease the anxiety of the transition from cure to comfort for patients who are appropriate for hospice care. If two or more of these potential indicators are present, hospice should be considered.

Common Hospice Diagnoses

End Stages of: Cancer, Heart Disease/CHF, Pulmonary Disease/COPD, Dementia/Alzheimer’s Disease, Neurological Disease/CVA, Renal Disease & Liver Disease.

If your loved one is requiring increased assistance with Activities of Daily Living (ADLs) such as bathing, dressing, grooming, oral care, toileting, transferring to their bed/chair, walking, eating, etc.; this may be an indicator that hospice should be considered.

Additional indicators include:

  • Muscle Loss/Weakening or Weakness
  • Multiple Falls
  • Multiple ER Visits/Hospitalizations
  • Recurrent/Multiple Infections
  • Altered Mental Status
  • Unintentional Mental Status
  • Unintentional Weight Loss
  • Difficulty at Mealtime
  • Increasing Shortness of Breath
  • Multiple Medication/Frequent Medication Changes
  • Sleeping Longer/Napping More
  • Skin Breakdown/Wounds
  • Other Diagnoses that Contribute to Decline

If you have questions about the hospice benefit or when to elect your benefit, please contact AT Home Care Hospice at 804-359-3400.

One Word: Hospice

One word… One word that’s the most solidifying word you will ever hear. A word that can often be misinterpreted.

One word… Hospice.

This means you are dying. Maybe not dying today, tomorrow or the next day – but it is a word not many want to hear. As a hospice liaison, helping people understand to not be afraid is part of what makes my job so rewarding. Watching potential patients and their family member begin to ease as I explain the role of hospice is an incredible feeling.

As a hospice liaison, I help ease all your previous notions about what we do and assure you that we are here to help.

Hospice doesn’t mean you will die tomorrow. It does not mean you will be taken off all your medications or stay home while waiting for the end. What it does mean is that you have a terminal illness and instead of continuing to seek aggressive treatment, it is better for you to be comfortable and have a quality of life with loved ones, however that may be defined by you.

It is shown that a hospice patient lives more comfortably when: a nurse visits to manage pain and symptoms, a home health aide provides personal care, a social worker assists with community resources and counseling, a chaplain offers spiritual support, volunteers play cards with and a physician oversees it all to ensure you are as comfortable as possible for however long that may be.

That one word… Hospice. Let’s look at it in a more positive way, focusing on the benefits we can offer a patient and their family.

So, I ask both professionals and patients – Why would you not want to live more comfortably with support from hospice?

-Tracy Wagoner, Hospice Liaison

COVID-19 & Hospice

Pandemic Relief via legislation, CMS waivers, and enforcement discretion

  • Telehealth
  • Waived requirement to use volunteers
  • Waive non-core services (physical, occupational, and speech pathology) *hospice only
  • Waive on-site visits for hospice aide supervision

Telehealth and Telephonic Visits

  • CMS permits hospices to provide telehealth to a Medicare patient receiving routine home care during the emergency period, if it is feasible and appropriate to do so.
  • Face-to-face encounters for purposed of patient recertification for the Medicare hospice benefit can now be conducted via telehealth (must be 2-way audio-visual)
  • Must be physician-ordered and on the plan of care

In an effort to protect patients, some SNF, LTC, hospice, and other facilities are limiting the number of visits that Abode Healthcare staff may make to patients in their care. Some patients are even requesting fewer in-person visits to reduce their exposure to the outside world.

Abode Healthcare understands and joins in these protection measures by offering telehealth visits. In some cases where access has been limited or is desired, Abode staff are utilizing telehealth on a weekly or bi-weekly basis in order to maintain contact with high-risk patients.

In all cases, telehealth visits are meant to be supplementary to in-person patient visits. Telehealth visits should not replace in-person visits altogether.

Telehealth Tools

Our commitment, as always, is to serve our patients as best we can. Our clinical team has been trained in effective ways to utilize telehealth systems to streamline patient care through our own remote access system using the following tools:

  • Phone: Abode Healthcare staff may conduct remote visits with patients through phone calls.
  • Video: Abode Healthcare staff may conduct remote visits with patients through Doxy.me. (All F2F between NPs or MDs, DOs must be done through a 2-way type of technology. This is for both HH and Hospice)
  • me can be utilized via tablets or phone and has been selected by Abode due to the ease of use for both the clinician and the patient/family/caregiver as well as its ability to capture/validate that the tele visit occurred, and its security features.

Though telehealth is never our first choice, it is the right choice during this time. Abode Healthcare continues to partner with providers to preserve the health and wellbeing of all of our patients.

Making the Hospice Decision

Before a baby is born, planning around the baby’s life begins. The parents prepare for the baby by creating a registry. Friends plan and host a baby shower. Family helps decorate the nursery. As the baby grows, the parents teach the baby, now a child, how to read. They prepare the child for kindergarten, then elementary school, then middle school, and then high school. The child, now a young adult, decides on a trade school versus entering the work force directly after high school versus college, and if college is selected, the young adults selects a major, and prepares to earn a degree. Then the young adult applies for and accepts a job, decides to get married, and chooses when to start a family. He or she then decides how many children to have and how to raise those children.

We spend so much of our life preparing and planning—so why should it be any different when making a hospice decision? Ideally, from the start of a diagnosis of a life-limiting illness, people should begin planning their goals and priorities with their physician. By having these conversations early, the person with a life-limiting illness can be fully involved in planning and making decisions regarding their wishes before the stress of a medical crisis.

Hospice is a continuation of care that shifts the goals of the patient from curative to comfort. When you or a loved one has a life-limiting illness and medical treatment is no longer effective, the doctor may refer you to hospice care. It should not be seen as a last resort but rather as an opportunity to focus on managing pain and other symptoms to find relief. This approach lets you dedicate your attention to what truly matters: living the rest of your life to the fullest.

A study by the National Palliative Care Organization found that patients who spent their final days on hospice reported having a better life experience than those who spent the end of their lives in intensive care. The researchers found that the patient’s choices often influenced the end-of-life care they got, which is why it is so important for people to plan for hospice, long before the need arises.

So, when should you make the hospice decision? Talk to your physician about signs and symptoms to consider prior to electing hospice care. Frequent hospitalizations, frequent infections, a decline in functional status, and an increase in uncontrollable symptoms or pain can all be indicators. Decide what you wish to do when treatment is no longer effective. Consider the benefits of managing symptoms from home rather than frequent visits to the physician or hospital. Consider the benefit of having a team of specialists available to you in your home—from a registered nurse to an aide, your doctor, a medical director, a social worker, and a chaplain. Consider access to your hospice team by phone 24 hours a day, 7 days a week, 365 days a year, where you could call your team if you had a question or a medical need. Consider the benefits of having medications related to your diagnosis and medical equipment made available to you in your home. These are all resources included in the Medicare hospice benefit, at no cost to the patient or their family.

If you have questions about the hospice benefit or when to elect your benefit, please call us at 1 (804) 612-3737.

Hospice Care That Focuses On Quality of Life

The hospice benefit is a multi-disciplinary approach to end of life care. When hospice patients are able to utilize the benefit, in its full capacity, self-fulfillment needs, psychological needs, and basic needs are met. At AT Home Care & Hospice, we seek to meet all levels of needs for each hospice patient in order to maximize their end of life journey and hospice benefit utilization. 180 days on hospice not only allows for better end of life transitions for patients, but allows family members to be family members and our team to become caregivers. Thank you for allowing us to be a part of your journey.