For discharge planners and case managers

When should you make the hospice referral?

The useful trigger is the first goals-of-care conversation in which comfort-focused care comes up, or the point where the team expects that further hospital treatment will not change the course of the illness. A referral at that point is a request for an informational visit. It does not commit the patient. Late referrals are the usual cause of discharge delays, because consent, certification, equipment and medicines all take time to line up.

What to send

Send what you have. We will ask for the rest. Use the fax number or secure options on the referral page. Do not send protected health information by ordinary email.

• Face sheet with demographics, insurance and the name and phone number of the decision maker.
• History and physical, recent progress notes and any palliative care consult.
• Current medication list and the medication administration record for the last 24 to 48 hours, especially opioids and anxiolytics.
• Recent labs, imaging and pathology that support the prognosis.
• Code status, POLST and advance directive if available.
• Hospice order or referral from the physician, and the name of the physician who will follow as attending, if any.
• Expected discharge date, destination address and who will be there to receive the patient and equipment.
• Oxygen needs, wounds, drains, lines, isolation status and transport needs.

What happens after you refer

1. Step 1

   Intake

   We confirm receipt, check benefits and contact the family to set a time. Referrals get a response within two hours, 24 hours a day, including nights and weekends.

2. Step 2

   Informational visit

   A hospice nurse or other licensed hospice staff member meets the patient and family, in the hospital when possible, explains the benefit and answers questions. Only the patient or legal representative can elect hospice. We can complete the informational visit and consents at the hospital bedside the same day.

3. Step 3

   Eligibility

   Our medical director reviews the record and, with the attending physician if there is one, decides whether the patient can be certified.

4. Step 4

   Equipment and medicines

   We order the hospital bed, oxygen and other equipment in the plan of care for delivery to the home, and arrange comfort medicines through ASAP Pharmacy. In-stock equipment and medicines are delivered within two hours of the order, and for a hospital discharge we coordinate delivery so essential equipment is in place when the patient arrives; non-stock items and delivery timing are verified individually. Before the patient leaves, we confirm orders, medication availability, the delivery destination and caregiver instructions.

5. Step 5

   Transport and first visit

   We provide hospital-to-home transport and coordinate timing with you so a nurse sees the patient after arrival. Hospital-discharge admissions typically happen the same day unless otherwise requested, and we agree on pickup, arrival and the first nursing visit with the patient, family and discharging team before departure.

6. Step 6

   Report back

   We tell you the outcome: admitted, declined, not eligible or still deciding.

Home hospice or general inpatient care?

General inpatient care is provided only when medically necessary during a symptom crisis. When general inpatient or respite care is needed, the hospice team confirms a contracted facility with an available bed and arranges the clinical handoff and transport before any transfer. See levels of care criteria.

Hospice and readmissions

Many patients and families choose hospice because they want to stop cycling through the hospital. Hospice gives them a nurse who answers the phone 24 hours a day, 7 days a week, and can visit when needed, plus medicines and equipment at home for expected symptoms. That gives families an alternative to calling 911 when symptoms change. We do not promise readmission results. A patient on hospice can still choose to go to the hospital, and can revoke hospice at any time.

Patient choice and your provider list

Federal discharge planning rules at 42 CFR 482.43 require hospitals to respect patient and family preferences and the patient's freedom to choose among participating providers, and to disclose any financial interest in a provider they refer to. If your hospital gives patients a list of hospices, we ask only to be on it accurately. If the patient chooses another hospice, we will help you hand off cleanly.

Common questions