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Medical Policy

Policy Num:       09.001.002
Policy Name:     Hospice Services at Home
Policy ID:          [09.001.002][Ac L M+ P+][0.00.00]

Last Review:       November 11, 2020
Next Review:      Archived
Issue:                   November, 2020

Archived

Related Policies: None

Hospice Services at Home

Summary

Hospice care is the kind of care and philosophy that focuses on the palliation of pain, anxiety, suffering and other symptoms of chronic and terminal illness to meet all the emotional and spiritual needs and those of their families.

The hospice concept was born in the Middle Ages when these places were for pilgrims and other travelers to rest and feed. In the 19th century hospices were places designated to care for the dying. In 1967 in Ireland and then England under the direction of Dr. Cicle Saunders, doctor, nurses and social workers developed in these sites with a commitment focused on patient care, pain management, research and education.

In the United States it began as a voluntary movement to meet the needs of the dying providing direct care and thus avoiding unnecessary medical care. In the last two decades there has been an increase in programs or hospice. In 2009, 40% of Medicare patients who died used hospice services at some point. In 2010, 42% of deaths were under hospice care. In 2012 there were 5,560 hospices in the United.

In the last two decades there has been an increase in hospice programs. In 2009, 40% of Medicare patients who died used hospice services at some point. In 2010, 42% of the deaths were under hospice care. In 2012 there were 5,560 hospices in the United States.

Hospice programs are currently located in all 50 states, as well as the District of Columbia, Puerto Rico, Guam, and the US Virgin Islands, further illustrating the growth of hospice care nationwide.

Hospice care provides medical care and support to terminally ill patients and their families focusing on quality of life rather than its prolongation or cure. Its philosophy is targeted in the principle of a dignified and peaceful death. The hospice concept identifies Hospice with the suffering of the terminally ill and is derived from a combination of symptoms and impairments that destroys their physical, psychological, spiritual and social balance.

Hospice interdisciplinary team

This team consists of specialized clinical staff that supports and ensures that the patient and their families receive adequate care at this difficult time. It consists of:

·         Registered nurse. Is the case manager and responsible for specialized care and main coordinator of the interdisciplinary team.

•   Hospice physician. Has a medical and administrative role. Visits the patient and provides primary care if there is no physician in charge.
•   Patient’s physician. This professional works with the registered nurse and in    collaboration with the hospice doctor.
• Social worker.   Provides psychological support to patients and their families
• Chaplain. Is in charge of the spiritual needs of patients and their families
• Housekeeper. Assists the patient in personal care. Prepares and serves food, shops.
• Community volunteers. Visit and entertain the patient, reads, perform errands

Medical guidelines to determine the appropriateness of the referral to a Hospice

If a patient is considered to have a life expectancy of 6 months or less if it meets the criteria in its clinical status and his/her condition is not considered reversible:

1. Progress of the disease documented by deterioration in their clinical condition

a. Clinical status           

1)Recurrent or intractable infections like pneumonia, sepsis or upper urinary tract infection
2) Starvation - Progressive documented starvation due to weight loss but not due to reversible causes.   

b. Symptoms

1). Dyspnea with tachypnea
2). Intractable cough
3). Nausea /vomiting unresponsive to treatment
4). Diarrhea, untreatable
5). Pain that requires analgesia

            c. Findings       

1) Decrease in blood pressure <90 or progressive postural hypotension
2). Ascites
3). Venous or arterial lymphatic obstruction or progressive metastatic disease
4). Edema
5). Pleural effusion
6). Weakness
7). Changes in the level of awareness or knowledge

d. Laboratories

1). Increase in PCO₂ or decrease in PO₂ or decrease in O₂ Sat

2). Increased calcium, creatinine, liver function

3). Elevation in tumor markers (CAE, PSA)

4). Progressive increase or decrease in sodium or increase in potassium

2. Decrease in personal function measures

    3. Increase in emergency room visits

   4. Progress in dependence on assistance for activities of daily living (2 or more)

a.     Feeding

b.     Ambulation

c.     Progressive incontinence, both fecal and urinary

d.     Transferences, from bed to chair, to standing

e.     Grooming

f.      Dressing

g.     Stasis ulcers

  5. Progress in ulcer stage (3 to 4) regardless of optimum care

Comorbidities- even though its presence is not an indication, a comorbidity contributes to hospice eligibility:

1)    Chronic obstructive pulmonary disease

2)    Heart failure

3)    Ischemic cardiomyopathy

4)    Diabetes mellitus

5)    Neurologic conditions (CVA, ALS, MS, Parkinson’s disease)

6)    Renal failure

7)    Neoplasia

8)    Acquired immunodeficiency

9)    Hepatic disease

10)   Dementia

These care services to patients are offered by agencies or organizations committed to: provide chronic pain relief, management of symptoms and offer support services to patients with terminal illness.

Terminal illness is defined as a stage of disease in which the patient fails to respond to accepted treatments, does not recover or eventually leads to death in a period of 6 months or less. 

Objective

Text

Policy Statements

Hospice services are considered for payment if they meet the following criteria:

1.     Physician certifies in writing that the patient is terminally ill and with a life expectancy of   6 months or less.

2.     Patient receives hospice care at home.

3.     Hospice care program offered by a   Triple-S provider

4.     Services included in the perdiem are the following:

a.     House keeper

b.     Health assistant

c.     Grief assistance

d.     Spiritual counseling

e.     Nursing

f.      Dietitian and nutrition counseling

g.     Durable medical equipment

h.     Acute Pain medicine (not maintenance)

i.      Medical supplies

j.      Social worker

 This service does not limit insured’s free choice for hospital coverage as long as there is a medical necessity and admission criterion.

Policy Guidelines

N/A

Benefit Application

BlueCard/National Account Issues

N/A

Background

N/A

Regulatory Status

N/A

Rationale

Population Reference No. 1 Policy Statement

For individuals who are terminally ill and with a life expectancy of   6 months or less. Interventions of interest are hospice services at home.          Comparators of interest are non-palliative care.   Outcomes of interest are improvement of quality of life and to avoid unnecessary medical care.  The evidence is sufficient to determine the the medical necessity of this services.

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1. Saunders C. Introduction: history and challenge. In: The management of terminal malignant disease, Saunders C, Sykes N. (Eds), Hodder and Stoughton, London 1993. p.1.

 2. National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. National Quality Forum; New York, NY 2004

3.Salpeter SR, Luo EJ, Malter DS, Stuart B. Systematic review of noncancer presentations with a median survival of 6 months or less. Am J Med 2012; 125:512.e1.

4.A National Framework and Preferred Practices for Palliative and Hospice Care Quality. National Quality Forum; Washington, DC 2006

5.Morrison RS, Meier DE. Clinical practice. Palliative care. N Engl J Med 2004; 350:2582.

6.Kissane DW. The relief of existential suffering. Arch Intern Med 2012; 172:1501

7. hhtp://www.cms.gov/Medicare/Eligibility-and-Enrollment/OrigMedicarePartABEligEnrol/index.html (last acceded 10 Aug 2015)

8. Hospice: Phylosophy of care and appropriate utilization in the United States; Meier. Diane,MD ;McCormic, Elizabeth,MD ;Lagman, Ruth,MD ;Arnold, Robert,MD Up To Date Feb 2016

9. Medicare Benefit Policy Manual, Chapter 9-Coverage of Hospice Services Under Hospital Insurance (Rev.209,05-08-15)

10. Stabenau HF, Morrison LJ, Gahbauer EA, et al. Functional trajectories in the year before hospice. Ann Fam Med 2015; 13:33

Codes

Appplicable Modifiers

Some modifiers

Policy History