Stanford Med · Unit 5B Medicine·Day shift·Mon · 9:42 AM

Patient workflow

Eleanor Park · End-stage Alzheimer's dementia; failure to thrive (G30.9 + R62.7) · assigned pathway with step status

Active pathway · HOSPICE_HOMEhigh riskmatch 70%

Hospice · home

Medicare Hospice Benefit at home — two MD certifications, election form, interdisciplinary hospice team, comfort-focused care for prognosis ≤6 months.

Matched on: disposition=HOSPICE_HOME · services=HOSPICE_OVERLAY+HOME_DME

LACE+ 11 (HIGH) + HOSPITAL 2 (LOW) → HIGH. · bumped by: Barthel 15 < 50; HRRP-tracked condition

← Back to library

4 / 15 steps

4 done5 in progress6 blocked0 pending

Service stack

· Hospice · all settings
· Home DME
· Outpatient pharmacy

Evidence basis

· 42 CFR §418 (Medicare Hospice Benefit)
· NHPCO Standards of Practice
· POLST / MOLST framework
· Serious Illness Conversation Guide (Ariadne Labs)

Outcome metrics

· Hospice length of stay (target: ≥7d for benefit + ≤6mo prognosis)
· Death in preferred location (home vs. acute)
· Caregiver bereavement survey
· Symptom control composite (pain, dyspnea, anxiety)

Disposition reference

· UB-04 50 · Hospice · home

Pre-discharge

2 of 10 done

#1T-3d·Hospitalistpatient agreementBlocked
Use Serious Illness Conversation Guide to confirm goals-of-care shift to comfort; document the conversation, who was present, what was said.
Without an explicit goals-of-care conversation, families later report 'we never agreed to hospice.' The conversation is the keystone of the transition.
Ariadne Labs Serious Illness Conversation Guide + ACP guidelines·Evidence: Goals-of-care conversation note with participants documented
#2T-3d·HospitalistmedicalDone
First MD certification — referring hospitalist certifies prognosis ≤6 months if disease runs its expected course.
Medicare requires TWO certifications (referring + hospice medical director). Missing the first cert delays hospice election.
42 CFR §418.22 (certification of terminal illness)·Evidence: Hospitalist hospice certification signed in EHR
#3T-3d·Social WorkerresourcesHITLIn progress
Identify hospice agency — payer-network match, geographic catchment, family preference, CMS Hospice Compare star rating. Confirm capacity for same-day or next-day intake.
Hospice agency choice shapes the entire experience. Network mismatch = self-pay; capacity gap = death-in-acute risk.
CMS Hospice Compare + NHPCO Family Choice Guide·Evidence: Hospice agency confirmed + intake slot
#4T-2d·Social WorkermedicalDone
Hospice agency assigns medical director who provides the second certification — usually within 24h of referral.
Two-cert requirement under Medicare. Hospice cannot bill until both are in place.
42 CFR §418.22(a)(1)(ii)·Evidence: Hospice medical director certification in chart
#5T-2d·Patient / Caregivercost coverageHITLIn progress
Patient (or surrogate) signs the Medicare Hospice Election Form (Form CMS-1450 attachment) — formally elects the hospice benefit and waives curative coverage for the terminal illness.
Election form is the legal trigger of the hospice benefit. Without it, Medicare won't pay and patient retains curative coverage.
42 CFR §418.24 (election of hospice care)·Evidence: Signed Medicare Hospice Election Form in chart
#6T-2d·Hospitalistpatient agreementBlocked
Complete POLST / MOLST form with patient or surrogate — code status, scope of treatment, artificial nutrition, antibiotics.
POLST is a portable medical order. Without it, EMS will resuscitate even at home.
National POLST Paradigm + state-specific POLST/MOLST statutes·Evidence: Signed POLST/MOLST form provided to family + on chart
#7T-2d·PharmacymedicationHITLBlocked
Comfort kit prescriptions — morphine concentrate, lorazepam, haloperidol, hyoscyamine, acetaminophen — delivered to home before patient arrives.
Comfort kit at home from minute one is the difference between symptom control and ED return. Hospice benefit covers all comfort meds.
NHPCO Comfort Kit Standards + 42 CFR §418.202 (drugs)·Evidence: Comfort kit delivery confirmation
#8T-2d·Case ManagerresourcesIn progress
Order hospice DME — hospital bed, bedside commode, wheelchair, oxygen if needed. Hospice benefit covers all DME related to terminal illness.
Hospital bed at home arriving 3 days late = family struggling to transfer the patient. Order ≥48h ahead.
42 CFR §418.202(c) (DME under hospice benefit)·Evidence: DME delivery confirmation pre-discharge
#9T-1d·RNpatient agreementBlocked
Family caregiver teach-back — comfort kit dosing, when to call hospice (NOT 911), expected dying process, what to do at moment of death.
Untrained family = call to 911 = paramedics attempt resuscitation against POLST. Caregiver education is the difference between a peaceful death and a traumatic one.
NHPCO Caregiver Education Toolkit + AHRQ Caring at Home·Evidence: Caregiver teach-back note + 24/7 hospice phone number provided
#14T-1d·Social Workerpatient agreementBlocked
Caregiver burden screen — Zarit Burden Interview short form. If burden HIGH, pre-emptively arrange respite admission rights (hospice respite benefit covers 5 days/episode in a contracted SNF/IPU).
High-burden caregivers revoke hospice or end up in the ED with their loved one. Respite access prevents the cascade.
42 CFR §418.108 (respite care) + Zarit Burden Interview·Evidence: Zarit score + respite plan if HIGH

Day of discharge

0 of 2 done

#10Day of DC·Case ManagerresourcesHITLIn progress
Transport via NEMT or BLS — confirm hospice intake RN will be present at home within 4h of arrival.
First-day RN visit is the keystone of the transition. Patient should not arrive home to an empty house.
NHPCO Standards of Practice (first-day visit)·Evidence: NEMT + hospice RN arrival confirmed
#11Day of DC·Case Managercost coverageIn progress
Write UB-04 Patient Discharge Status Code 50 (Hospice · home) to encounter.
Encounter billing closes once UB-04 is set; hospice transfer triggers post-acute care transfer rules.
NUBC UB-04 Patient Discharge Status Code list·Evidence: UB-04 50 on encounter

Post-discharge

2 of 3 done

#12T+1d·VendormedicalDone
Hospice IDT (interdisciplinary team) meeting within 5 days — MD, RN, MSW, chaplain, hospice aide, bereavement coordinator. Establishes plan of care.
IDT plan of care is a Medicare hospice condition of participation. Without it, hospice can't bill.
42 CFR §418.56 (interdisciplinary group)·Evidence: IDT meeting note + plan of care in hospice EHR
#13T+3d·Vendorpatient agreementBlocked
MSW + chaplain home visits — assess family coping, spiritual needs, anticipatory grief, financial concerns.
Family decompensation is the most common reason for hospice revocation. Early MSW + chaplain support prevents the bounce-back.
42 CFR §418.64 (core services) + NHPCO Family Support Standards·Evidence: MSW + chaplain visit notes
#15T+7d·VendormedicalHITLDone
Crisis-care escalation rule — continuous-care (CHC) or general inpatient (GIP) level if symptom crisis emerges. Hospice RN authorized to escalate without re-referral.
4 levels of hospice care: routine home, CHC, IPU/GIP, respite. Failing to escalate at crisis = patient suffering + ED bounce.
42 CFR §418.302 (four levels of hospice care)·Evidence: Level-of-care escalation note if triggered

Demo data · no PHI · mocked Epic + payer endpoints