Hospice care became a recognized benefit under Medicare in 1983, and approximately 90% of all hospice programs are Medicare certified. As 28% of all Medicare costs go to persons in their last year of life, and 50% of such costs are expended during the last 2 months of life, hospice can indeed be viewed as an alternative to more expensive and lengthy hospitalizations. While there is an upper limit to what Medicare will reimburse, patients cannot legally be discharged from services if their Medicare ceiling has been reached. Typically, assuming this ceiling is not reached; 6 months’ worth of care is covered, unless the dying person’s prognosis is re-certified by the hospice medical director. For low-income persons, hospice services are also qualified under Medicaid in most states.
Studies have shown that while dying persons represented only a small percentage (1%) of all Medicare beneficiaries at any given time, such persons were consuming a disproportionate share of all Medicare expenditures. Thus, 3 years after hospice care was made reimbursable under Medicare, legislation was passed permitting state Medicaid programs the option of covering hospice. The hospice benefit under Medicare requires that core professional services – physician, nursing, hospice grief counseling, and medical social work services – be directly provided by the hospice. However, it does not re-quire that hospices directly operate home care or in-patient care facilities. Rather, Medicare simply requires that the hospice staff maintain responsibility for all services regardless of their location and that they guarantee access to such services on a 24- hour basis. Hospices receive a specified amount for each day that regular home care is provided to a patient, and all funds paid to the hospice indeed go directly to the hospice program. The same concerns regarding the costs of acute care for dying persons North America. Changes in attitudes toward death and dying, legal decisions and legislation affirming the right of the individual to refuse life-sustaining treatment, and the development of the Medicare Hospice Benefit have also encouraged the expansion of hospice in the United States. Other events important to the hat convinced Congress to establish a Medicare benefit has prompted private health insurance companies to move toward hospice coverage. Even when covered by Medicare, hospice costs are sometimes unnecessarily paid by patients and families because questions about private health insurance coverage were not asked.
Case management ensures that quality care is available to, and continuous for, each patient and family. This is especially important because patients and families often know little about caregivers and caregiving and may have difficulty in dealing with other agencies. The coordination of care within the interdisciplinary team as well as with other professionals outside of hospice is an essential component of the case management mold in hospice. Case management matches each unique patient-family unit with whatever services they may need, as well as monitoring changes in their needs for such services. Case management also helps patients and families arrange for insurance coverage, plan for emergencies, and if necessary, arrange for services from other agencies. In hospice, case management is often carried out by the primary caregivers nurse or by the social worker.
The care plan for the patient and family is implemented with the patient’s and family’s needs in mind. It is a process that the dying patient and family actively participate in. Information about the patient’s needs is often gathered via interactions with patient and family. This information is utilized by the interdisciplinary team in formulating a care plan. The team also arranges to coordinate and deliver hospice services, monitors the effectiveness of these services, and if necessary, reevaluates the care plan if the patient’s physical or emotional status changes. Numerous decisions regarding everyday changes in the dying person’s energy level, emotional state, functional (decision-making, self-care) skills, and needs for pain medication must be made by the team, yet must be balanced against the quality of the dying person’s life as well as against the demands on the family of work, school, raising children, house-cleaning, cooking, and bill paying. Additionally, changes in the family’s needs for support and information are likely. For example, the patient and family may initially ask about life insurance coverage, the nature of the illness, its progression and treatment, or what the family can do to help care for a dying loved one. They may also want to know about the side effects of pain-relieving medications. As the patient’s condition worsens, needs for reassurance and support may surface, and concerns about planning a funeral, writing a will, or living without a loved one may be shared. When their loved one is near death, the family may be less verbal about their needs, and emotional support from a staff member or volunteer may be all that they require. Rather than ‘doing something,’ hospice personnel may meet this need by simply ‘being there.’ Indeed, perhaps the greatest lesson that hospice teaches us is that person can grow spiritually and emotionally by being with a loved one at a very sad and emotionally difficult time of life.
