The Medicare Hospice Benefit is an option for any Medicare beneficiary to receive hospice care, but it’s not a requirement. Revoking the benefit is the right of the patient, however, it generally does not result in improved outcomes.
To prevent hospice revocation, ensure during the admission process that patients who are at high risk for revocation are identified and a proactive plan is in place to provide the additional support that patients and families need, helping them avoid more costly, less beneficial care options.
Why Do Patients Revoke Hospice Care?
A study on reasons for hospice revocations that result in hospital admissions identified eight primary causes for revocation:
- Patient does not fully understand hospice care
- A lack of clarity about disease prognosis
- A desire to continue receiving care from nonhospice physicians and hospital
- Caregiver burden
- Distressing or difficult-to-manage signs and symptoms
- Caregivers’ reluctance to administer morphine
- A faster response time with emergency services compared to hospice
- Families’ difficulty accepting the patient’s mortality
Other studies have revealed that patients who are non-white are at higher risk for revocation, with the odds for a Black patient revoking for aggressive treatment being 70% higher than white patients. Studies identified additional risk factors, including younger age, full code status, male gender, home setting of care and cancer as the terminal diagnosis.
Have a Plan for High Risk for Revocation Patients
Increase visits from the social worker and chaplain during the first weeks of hospice care to provide emotional and spiritual support while adjusting to the change in focus of care from disease modification to palliative.
Hospice physician or nurse practitioner visits can also assist with the transition away from frequent visits with a practitioner that the patient and family may be used to when in active disease-modifying treatment. This can also assist with the patient’s and family’s understanding of the patient’s disease process and terminal status.
Education on proactive symptom management is essential for symptom management crises. Ensuring that patients and their caregivers know what to expect and how to manage the symptoms can reduce the chance of calling emergency services when these symptoms arise. In addition, increased use of continuous home care, inpatient respite care and general inpatient care when patient or caregiver crises occur can provide the security a patient and their family needs during times of distress.
While hospices regularly admit patients with full code status and work with the patient and legal representative on coming to terms with the futility of CPR in frail and terminally ill patients, having this conversation early when dealing with patients at high risk for revocation is essential. Hospices can consider the use of treatments, such as transfusions, intravenous therapies and other more aggressive measures with hospice patients who are at high risk of revocation when there is an expressed desire to explore these options.
Thorough education on response times for on-call and regular staff is also essential. When a patient is in crisis, stay in contact with them and monitor the patient’s status until a staff member can arrive and assist. When patients are identified as having symptoms and treatments are being adjusted, regular phone contact during the day, evenings and weekends can assist with reducing revocation for aggressive treatment.
Reducing revocation risk is a team effort. Physicians, social workers, chaplains, nurses and on-call staff working together will help ensure that the patient receives the care they need in the location they desire.
Axxess Hospice is an enterprise hospice software with HIPAA-compliant documentation and robust IDG features for easier team collaboration.