Improving Policy and Practices of Hospice Live Discharge: A Historical Exploration of the Medicare Hospice Benefit.

Hospice care in the US is heavily regulated to ensure access to the Medicare Hospice Benefit (MHB) for individuals with serious illness. Policy changes to the MHB, many of which intended to minimize potential fraud (e.g. focused medical reviews; documentation requirements for certifications, recertifications, and discharges; requirements of physician narratives and face-to-face visits), directly impact current hospice discharge practices and experiences. When patients revoke hospice or are unable to be recertified due to a stabilized condition, they lose access to the holistic philosophy of care and experience additional stressors with increased potential for burdensome transitions. Patients with chronic conditions, such as Alzheimer's disease or related dementias, Chronic Obstructive Pulmonary Disease, or heart failure are more likely to have longer length of stays and are more often discharged alive from hospice. Few policy changes have been made to account for growing incidents of patients dying of chronic illness though the policy was originally created primarily for cancer patients, reflecting a time when most patients were dying of cancer. This manuscript describes the uniquely American phenomenon of a hospice live discharge, reviews relevant and historical policies, and provides recommendations for future research, policy, and practice to better support patients and families during this critical healthcare transition.