The Referral Process

Hospice Local Coverage Determinations

LCDs provide guidance in determining medical necessity of services. Cahaba has developed a hospice LCD, Determining Terminal Status, using the National Hospice and Palliative Care Organizations (NHPCO) guidelines. The LCD allows for the decline of a beneficiary to be a factor in determining prognosis. The LCD consists of three parts, and disease specific appendices: Part I is related to the decline in a beneficiary predictive of a six month prognosis. Part II is related to the functional limitations of a beneficiary, and is used in conjunction with the disease specific appendices. Part II does not stand alone in prediction of a limited prognosis. Part III are co-morbidities that may be helpful in predicting and documenting a six-month prognosis. Medical review uses the hospice LCD as a guideline to aide in consistency of review.

What Makes a Patient Eligible for Services?

ES Terminal Illness in which a life expectancy of 6 months or less is expected if the disease runs its usual course Refusal of Curative or Life Sustaining Treatment (Chemotherapy, radiation, dialysis, feeding tubes, ventilator support etc) Patient is not utilizing the Medicare Part A benefit for skilled time.

Step by Step Guide to Completing a Referral

Its as Easy as 1-2-34

Step 1
Introduce yourself to staff; let them know you are there to evaluate Mr./Mrs. Whomever, for hospice care. Ask who the nurse is and ask that nurse what he/she has been seeing lately i.e. What decline has this patient has been having? What brings them to hospice?

Step 2
Review chart, physician orders (be sure order is there for hospice eval.), review meds, co-morbids, nurses notes (may be computerized and need to ask for them), pt weight history (also may be computerized), pt usual meal consumption, look for labs, hospitalizations. Any information that will support hospice care. Check for PT, OT, SLP orders- (patient cannot be admitted to hospice while on skilled time)

Step 3
Utilize the Quick reference guide booklet for hospice diagnosis. There are also worksheets that provide more detailed information for each diagnosis, should the pt be questionable. Make sure youve spoken to staff and called the primary physician if further information is needed to support bringing onto hospice. If pt still seems questionable ~ call the LCH office and speak with your PCM to determine if pt is appropriate. (review all information with them, co-morbids, recent decline, wt. loss, labs and what physician said.)

Step 4
Complete the necessary documentation and notify both the facility staff and LCH Intake of the outcome of the evaluation.

LCH Connections
If eligible: Copy pts chart information and leave in back in a plastic folder or clipped together for whomever does the admission. (face sheet, POA, living will, meds, labs, important hospital information, dietary information, facility POC. If pt is not eligible; inform staff and let them know why and that we will continue to monitor for appropriateness. We will put them on our Connections program.

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