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Hospice is a concept of care delivered by an interdisciplinary team that focuses on providing best supportive care to terminally ill patients and their families with the goal of maintaining the patient’s comfort and quality of life. Hospitalists, caring for patients with chronic, progressive illness, many of whom are nearing the end of life, are uniquely positioned to improve the quality of care that these vulnerable patients receive and to more closely align their care with patient preferences. Hospitalization represents an opportunity to reassess patients’ prognoses, their understanding of their illnesses and how available treatment options align with their care preferences. Hospice offers high-value end-of-life care and minimizes unwanted interventions and care transitions.

In the United States, “hospice” is an insurance benefit as well as a concept of care. More than 85% of patients enrolled in hospice in 2014 were covered under Medicare Hospice Benefit (MHB). Most commercial insurers, state Medicaid programs and other government insurance programs have eligibility requirements similar to those for Medicare. This chapter will review the hospice benefit and strategies to overcome common barriers to the timely transition of appropriate patients to hospice care.


Out of 2.6 million total deaths annually in the United States, one in five occurs in the hospital setting. Many of those patients who died had multiple advanced chronic illnesses, suffered from progressive frailty and had a series of hospitalizations prior to their deaths. Many had a likely prognosis of less than 6 months during at least one of the hospitalizations preceding the terminal hospitalization. As payment reform shifts from an episodic, fee-for-service model to a longitudinal, shared risk model, an acute care hospitalization is no longer viewed as an isolated event along the patient’s trajectory of illness. Hospitalists play an increasingly important role in this longitudinal model of care as each hospitalization represents an opportunity to reassess a patient’s prognosis, his or her understanding of their illness and how goals of care may have changed in the face of disease progression. Hospitalists should consider referral for palliative care for those patients who require assistance with complex symptom management and advance care planning (Figure 74-1). For those patients without complex symptom management or advance care planning needs and who have a likely prognosis of less than 6 months and comfort as the primary goal, the hospitalist can manage the transition to best supportive care with hospice. The transition to hospice care may, at times, present a unique set of challenges from provider, patient and hospice standpoint.

Figure 74-1

Access to palliative care and hospice along the trajectory of disease.


While the number of patients served by hospice has steadily risen over the years and the percent of patients ...

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