To recertify or not recertify

To recertify or not recertify? That is often the painful question hospice interdisciplinary teams (IDTs) must answer. For me, it is important for those outside of the industry to understand the challenge of the recertification discussion and the diligence and care with which the Weinstein Hospice IDT takes to answer the question.

To be clear, when a patient is admitted to hospice, the referring physician signs an order stating that if the patient’s illness takes its usual course, the patient is likely to “expire” in six months or less. This verbiage comes directly from the language in the legislation that made hospice part of the Medicare benefit. I spend a good part of everyday explaining to patients and families that the six month “term” is just a guideline and not a hard and fast rule. It is a guideline.

More specifically, and what many people don’t understand is that within the first six months and beyond, hospices are required to demonstrate the need for recertifying the patient at set intervals: the first 90 days after admission, the second 90 days, and then every 60 days thereafter.

To recertify a hospice patient, the hospice IDT must be able to answer the following three questions with concrete evidence: does the patient still have the terminal diagnosis under which he or she was admitted? Is the patient seeking any curative or aggressive treatment for said illness? AND, has the patient demonstrated any form of decline since the last certification period? It’s in that last question that a committed IDT like Weinstein’s needs to roll up its collective sleeves and dig for information.

First and foremost, Weinstein Hospice will neither accept nor recertify patients who do not meet the eligibility requirements as we understand them. There has been serious abuse of the hospice benefit around the country in taking or keeping patients who do not meet Medicare criteria. Abuse leads to tighter regulations and less access to the hospice benefit which is a true shame.

The challenge is the “right answer” is not always clear. First of all, illness does not always follow a “usual course” so how do we justify patients who outlive their prognosis? Second, studies upon studies demonstrate the bountiful benefit of hospice care. Patients and families receiving the benefit sometimes stabilize – or even improve – simply because the care is there. In the absence of the hospice care, visits, medicine, supplies, they would certainly decline. However, recertification forces us to demonstrate decline.

You might ask, what exactly is decline? It can be any number of things: weight loss, loss of ability to perform activities of daily living, increased need for pain and symptom management, occurrence of sentinel events like falls or infections.

But if the patient has been getting great care OR his or her illness is not following the “usual” course, what’s a hospice to do?

Recently, though not uniquely, the Weinstein IDT was tasked with trying to recertify a patient with a stage IV cancer who has been on service for almost two years. MD Anderson sent this patient away stating there were no treatment options available. She has been receiving regular visits from each discipline in the IDT and likely as a result, she hasn’t declined. Pulling out, however, seems inconceivable, given her admitting diagnosis.

This patient’s case is one of many our team debates and probes for more information and works tirelessly to make a case to do the right thing. Like so many things in hospice, the answers to certain questions are not always clear, but the commitment to find them remains steadfast.

Jenny Buckley, RN, BSN, CHPN
Community Outreach Coordinator for Weinstein Hospice

“My primary job in hospice is to evaluate patients referred to us, as well as provide information about hospice to them and their families. Mostly, I love my job. I love being the first, intentionally positive, face that scared and sick people see after the word hospice has been uttered. I know it is likely the worst day of their lives and yet I have the sacred opportunity to deliver them some hope.

For more than 10 years I have continued to hold the belief that while hospice can’t change the outcome of your or loved ones illness, it can certainly change the experience of it. HOWEVER, I’ll admit that I’ve done this long enough to identify some of the “belly groan” interactions. If you are a hospice professional reading this, I hope you can identify. If you are an individual whose loved one may need hospice in the near or distant future, I hope you remember these things.”

Take time to visit Jenny’s own blog, http://www.jenny-buckley.com/hospice-blog/