Eligibility and documentation

Under the Medicare hospice benefit, the patient must be terminally ill with a prognosis of six months or less if the illness runs its usual course. Two physicians must certify: the hospice medical director or a hospice physician, and either the attending physician or a second hospice physician.

The patient (or authorized decision-maker) must elect hospice, which means forgoing curative treatment for the terminal diagnosis and accepting comfort-focused care. Treatment for unrelated conditions and for symptom relief continues.

The six-month standard is a probabilistic judgment supported by clinical evidence of decline, not a fixed countdown. Patients are recertified at 90, 90, and then 60-day intervals.

Regardless of diagnosis, the documentation that most reliably supports eligibility describes a trajectory rather than a single data point:

• Progressive functional decline: the patient can do less this month than last.
• Unintentional weight loss, or a documented decline in nutritional intake.
• Recurrent hospitalizations or emergency department visits for the same condition.
• Decline in ability to perform activities of daily living, with specific examples.
• Skin breakdown, recurrent infections, or aspiration events.
• A documented decision to stop disease-directed treatment, and the reasoning.

A sentence like “patient is declining” is less useful than “patient now requires assistance to transfer from bed to chair, was independent two months ago, and has lost 12 pounds since March.”

• Cancer. Progression despite therapy, declining performance status, weight loss, and a documented decision to stop disease-directed treatment.
• Dementia. Advanced cognitive decline with inability to ambulate or communicate meaningfully, incontinence, and complications such as recurrent infection, inadequate oral intake, or pressure injury.
• Heart failure. Symptoms at rest, recurrent admissions, poor response to optimized therapy, and documented ejection fraction or functional class.
• COPD. Dyspnea at rest, frequent exacerbations, hypoxemia, weight loss, and declining functional status despite maximal therapy.
• Kidney disease. Advanced renal failure, particularly when dialysis is declined or discontinued. Receiving dialysis does not automatically rule out hospice; document whether dialysis is related to the terminal illness and how it will be covered.
• ALS and neurological disease. Rapid progression, respiratory decline, weight loss, and functional loss.

Eligibility depends on an individual clinical assessment. Two reasonable clinicians can disagree, and a hospice evaluation is a way to resolve that without obligating the patient.

In our experience, referrals most often stall on three things: the attending physician is unavailable for orders, the family has not been told the prognosis and needs a conversation before they can consent, or the patient’s location is outside the area a hospice can reliably reach.

We address the third honestly and immediately. For the first two, we can often help, including by having the hospice physician speak with the attending, or by arranging an educational visit with the family that does not assume admission.

Recertification requires documented continued decline or evidence that the prognosis remains six months or less. When a patient stabilizes or improves, the appropriate action is discharge from hospice, with the option to re-elect later. We do not keep patients on service to maintain census.

If a patient revokes the benefit to pursue treatment, we document the revocation and remain available for future referral.

Call (818) 351-5250 and the intake team will provide the current secure method for transmitting documentation. Please do not send protected health information through this website, and do not email records to a general inbox.

If you are coordinating a discharge, tell us the anticipated discharge date at the time of referral. Earlier coordination is the single biggest factor in a safe transition home.