As the U.S. Centers for Medicare and Medicaid Services (CMS) pays closer attention to increasing rates of live discharges, hospice organizations are seeking ways to balance their mission to provide patient-centered care with their obligation to meet regulatory requirements.

In 2015, U.S. hospice providers discharged 160,000 individuals before end-of-life, representing 16.7 percent of all hospice discharges that year, according to the National Hospice and Palliative Care Organization.

“There is going to be some regulatory scrutiny for long stays that use up the patient’s hospice benefit, as will indications of large numbers of patients dying in the hospital because they used their lifetime benefit,” Susan Enguidanos, Ph.D., associate professor of Gerontology at the University of Southern California, told Hospice News.

According to Medicare requirements, patients are eligible for the hospice benefit if they have been diagnosed with a terminal condition, and death is expected with in six months. High rates of lengths of stay in exceeding six months have attracted regulatory attention in recent years.

Improper billing for patients is a leading cause of CMS audits as well as allegations of fraud. Several high profile cases have led to multi-million dollar settlements. However, a live discharge isn’t necessarily a sign of malfeasance, nor does it necessarily mean that the patient has recovered.

A patient may choose to leave the hospice, either to resume more aggressive treatment, or because the patient moved outside the provider’s service area. Some are discharged for-cause, due to a safety risk in the home environment that poses a risk to the patient or staff.

A patient may become afraid or acquire a condition unrelated to their terminal diagnosis and call an ambulance. When they arrive the patient must revoke their hospice benefit in order to receive hospital care.

“Many of these patients still die within 6 months; so they meet the prognosis but not the regulatory requirements,” said Stephanie Wladkowski, Ph.D., assistant professor at Eastern Michigan University. “In other instances, the patient may stabilize, but not improve. They reach a plateau in the progression of their illness that extends beyond the six month requirement.”

These structures have financial implications for hospice organization and have a detrimental effect on patients and caregivers. Revocations of the hospice benefit when a patient returns to a hospital disrupts the hospice provider’s revenue stream. If a family appeals the revocation, the hospice undergoes a labor-intensive process involving substantial paper work.

Burdensome transitions in which a patient moves repeatedly between settings, such as from hospice to a hospital and then back to hospice, represent 8 to 10 percent of live discharges, according to Enguidanos. These transitions are costly to both the patient and the hospice and seriously disrupt the continuity of care.

An additional consideration is that hospice provides services that other health care settings do not, including advanced durable medical equipment, grief counseling for family and caregivers, and interventions to address the patient’s psychosocial needs. The hospice benefit often will cover equipment that is not covered in other settings, such as pressure control air mattresses to prevent skin breakdown or geri chairs to promote mobility.

“Hospice service cannot be replicated. It is the only philosophy of care that provides 24/7 support in the home to patients and their families,” Wladkowski said. “Maintaining continuity in the care plan in another setting is a challenge, as is trying to minimize the gap between what the hospice provides and what everybody else provides.”

While some live discharges are unavoidable, hospices can take action to reduce their incidence and their impact, as well as to provide support to patients and caregivers through the discharge process. For example, reviewing processes for patient and family education to ensure they understand what it means to be in hospice, as well as the support and services that are available to them.

“They need to know the hospice is available 24/7. They need to know how and when to contact the hospice when they have questions or need additional services,“ Enguidanos said.

Wladkowski is working with hospice social workers to develop a protocol for discharge planning. The goal is to address the logistical aspects while also helping the patient and family line up other resources they will need after leaving hospice. The protocol would also address a follow-up process to maintain the connection with the patient and family in case they need to resume services.

Beyond implementing improvement strategies at individual hospices, some say a larger discussion including health care providers, payers, and regulators is necessary.

“The greatest struggle is inconsistency between regulators, payers, and clinicians.” Ihrig said. “As we see 10,000 new patients entering hospice care every day, this vulnerability needs a solution.”