Hospice and Palliative Care Program Structure, Quality Improvement, and Reimbursement
Benefit structure
The Medicare hospice benefit covers two 90-day periods followed by unlimited 60-day periods, each requiring physician certification and recertification. The interdisciplinary group - physician, nurse, medical social worker, chaplain, aide, volunteer coordinator, and bereavement counselor - reviews each plan of care at least every 15 days. Volunteers must provide at least 5% of patient-care hours, and bereavement support extends up to 13 months after death. A face-to-face encounter is required before the third benefit period and each subsequent recertification.
Levels of care
Routine home care is the default. Continuous home care requires at least 8 hours of primarily nursing care in a 24-hour period for acute crisis. Inpatient respite is limited to 5 consecutive days to relieve caregivers. General inpatient care is for symptoms that cannot be managed in another setting - it is not for convenience or caregiver exhaustion alone, a classic trap. Election of hospice waives curative treatment for the terminal diagnosis but not for unrelated conditions.
Quality improvement
Know the Model for Improvement and PDSA cycles, run charts and control charts (to separate signal from common-cause variation), and balancing measures that catch unintended harm. Reported measures include the Hospice Item Set and its successor tool, the Hospice CAHPS survey, and publicly reported quality and star ratings. Structure, process, and outcome measures are distinct categories.
Palliative care outside hospice
Community palliative care bills through advance care planning codes and chronic care management; documentation must support time and medical necessity.
Worked example: a family requests general inpatient care because they are exhausted. That is a respite indication, capped at 5 days. GIP requires documented symptoms unmanageable in the home.