Although most patients in hospice are discharged due to death, live discharges do occur and are reviewed for each survey. The reasons for live discharge can include extended prognosis, leaving the service area, revocation, transfer to another hospice and discharge for cause.

Medicare details the expectations for live discharges in the State Operations Manual Chapter 2 – The Certification Process and the Medicare Benefit Policy Manual Chapter 9 – Coverage of Hospice Services Under Hospital Insurance.

Discharge for Extended Prognosis

Hospice organizations must have a discharge planning process that considers the prospect that a patient’s condition might change, eliminating the patient’s eligibility to be certified as terminally ill. The discharge planning process must include planning for any necessary education or counseling before the patient is discharged.

Medicare does not expect that a discharge for extended prognosis would be a sudden occurrence that would not allow for discharge planning. The expectation is that when the interdisciplinary group identifies a patient who is no longer able to be certified as terminally ill, then planning should begin. Discharge planning should be a process and should begin before the date of discharge

In some cases, the hospice must provide Advance Beneficiary Notification (ABN) or a Notice of Medicare Non-Coverage (NOMNC) to patients who are being discharged.

Discharge for Leaving the Service Area

The definition of the service area for a hospice includes not only the geographic area where the hospice is licensed to provide services, but also when the hospice is unable to access the patient to provide hospice services. This is commonly seen when a hospice patient is receiving treatment for a condition unrelated to the terminal illness or related conditions in a facility with which the hospice does not have a contract. However, Medicare expects that in that situation, instead of an automatic discharge, the hospice should consider the amount of time the patient is in that facility and how the treatment impacts their plan of care before discharging the patient.

When a patient is on vacation, hospices can choose to have the care contracted to another hospice in the service area during that time without discharging the patient.

Revocation of Hospice

Revocation of the hospice benefit must be a patient’s or legal representative’s choice without a request or pressure from the hospice organization to revoke the hospice benefit. Hospices should be clear during the signing of the election statement to educate the patient and legal representative that hospice entails certain limitations in the way care will be provided. This includes restrictions on obtaining care outside the care arranged for or provided by the hospice, and the patient’s liability for care received without the hospice’s involvement.

Discharge for Cause

Medicare is very clear that discharge for cause should be rare and attempts to resolve the situation prior to discharge should be well documented.

To discharge a patient for cause, the patient’s (or other people in the patient’s home) behavior must be disruptive, abusive or uncooperative to the extent that delivery of care to the patient or the hospice’s ability to operate effectively and safely is seriously impaired.

The hospice must do the following before it seeks to discharge a patient for cause:

• Advise the patient that a discharge for cause is being considered;
• Make a serious effort to resolve the problems presented by the patient’s (or other persons in the patient’s home) behavior or situation;
• Ensure that the patient’s proposed discharge is not due to the patient’s use of necessary hospice services; and
• Document in the clinical record the problems and efforts made to resolve the problems.

Thorough discharge planning and care coordination between the hospice and receiving providers are vital to withstanding the regulatory scrutiny for live discharges. Axxess Hospice, our enterprise hospice software, has a detailed live discharge plan of care and discharge documents to ensure your organization easily withstands any review.