The Hospice Plan of Care: Demystifying the 15-Day Requirement

Guest Blog Written by: Jennifer Kennedy, EdD, MA, BSN, RN, CHC

Hospice care is an important component of the U.S. healthcare continuum, distinguished by its dedication to personalized, end-of-life support. At the heart of this care is the hospice plan of care (POC), a dynamic and individualized roadmap designed to address the patient’s medical, emotional, spiritual, and personal needs. The Centers for Medicare and Medicaid Services (CMS) considers the POC the most important tool in a hospice team’s toolkit, essential for delivering high-quality, coordinated care. As patients approach the end of life, their needs often change rapidly, necessitating flexible and responsive care. Recognizing this, CMS mandates a minimum 15-day interval for POC updates, ensuring that care evolves in step with the patient’s journey. It is a common misconception that care should be aligned with the certification period as in home health. Instead, the hospice 15-day unique requirement underscores the adaptive nature of hospice care and its unwavering focus on providing meaningful support to patients and their families.

The hospice plan of care (POC) is more than a document that fulfills a federal regulatory requirement. It is the roadmap for the hospice team to deliver care based on the patient’s medical status, the patient’s and family’s emotional and spiritual needs, and the patient’s/representative’s wishes for end-of-life care.  The Centers for Medicare and Medicaid Services (CMS) considers the hospice plan of care as the most important tool in a hospice team’s tool chest and key to providing high-quality coordinated care. To understand how to use this tool optimally, you need to understand the rationale of the regulatory text.

The Plan of Care Overview

The plan of care is established by the hospice interdisciplinary team/group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver per the patient’s needs if any of them so desire.  The hospice team provides education and training to the patient and the primary caregiver(s) as appropriate to their responsibilities for the care and services identified in the plan of care.  The rationale for this requirement is that the outcomes of the initial and ongoing comprehensive assessment process drive the initial development of an individualized plan of care and its ongoing update.  It is a continuous cycle that ensures patient, and family needs are evaluated and addressed, and the goals of care are developed and achieved (if possible).  The patient, family, and primary caregiver(s) are active participants in developing their plan of care at all stages of the process and they need to be educated related to the hospice team interventions, patient/family responsibilities, and achieving goals of care that are created via shared decision-making.

The Plan of Care Content

The content of the plan of care is designated by CMS and integrated into your electronic medical record (EMR) by your vendor.  While most EMRs design their documents to be a point-and-click process for the user, the hospice team must go beyond that and include free text information to truly individualize the plan of care.  Clicking a box in a plan of care does not necessarily provide a personalized description of the item addressed. It is particularly important to include free text information related to the following plan of care content:

  1. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs
    • This means what clinical service will be provided and how often will it be provided
    • In hospice care, frequencies at the most, are developed for 15 days at a time and more frequently per the patient’s status
    • The rationale is to demonstrate that the patient and family unit are receiving continuous hospice care that meets the changing status of that unit, and minimally the hospice team collaborates every 15 days to ensure the scope and frequency of services meet the current needs
    • Note: Hospice is not home health care where scope and frequency are written for a certification period
  2. Measurable outcomes from implementing and coordinating the plan of care
    • Measurable goals are required on a hospice plan of care and should be developed with the patient and family/caregivers’ input
    • The rationale is to evidence realistic goal establishment that is collaborative with the patient and family and is not nebulous related to projected completion
    • Measurable goals should have an outcome to be achieved, a timeframe, and a quantifiable metric
    • Goals should be updated when they are achieved, and the hospice team minimally reviews every 15 days
    • Developing measurable goals for social work and spiritual care services can be less concrete or quantifiable than developing medical goals. However, with some adaptation, these disciplines in the team can develop goals that can be measured with quantifiable or qualifiable descriptors
  3. The interdisciplinary group’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the plan of care, per the hospice’s policies, in the clinical record
    • The rationale for this content is documentation that evidences how a patient and family are involved, understand, and agree with the plan of care. Documenting free text beyond point-and-click for each of these items on the POC provides a better picture of the patient and family to an objective reviewer
    • For example, if the patient did not understand the concept of the POC and their responsibility, the conversation and specific issues should be documented. If the patient and family pushed back on measurable goals or interventions in the plan of care, the conversation and specific issues should be documented

Review of the plan of care

The regulations require the hospice team to review and revise a patient’s POC as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. A revised plan of care must include information from the patient’s updated comprehensive assessment and must note the patient’s progress toward outcomes and goals specified in the plan of care.  The rationale for the requirement is to ensure POCs are continuously updated by hospice clinicians providing care as the patient’s status changes and is minimally reviewed by the hospice team every 15 days.  Depending on the patient’s status, changes to the POC will be happening in the 15-day interval.  In this instance, the clinician updates the POC and alerts the other team members of the update. The scope and frequency of services are very likely to change as the patient declines, which is why CMS designated the minimal 15-day interval for the POC update.  Again, hospice is not home health, and practices from home health should not be applied to hospice care planning.  Hospice care planning occurs minimally every 15 days but is most likely more frequent than that interval.

Your hospice team members need to understand the concept and value of the hospice plan of care. The plan of care is not just a document in your EMR, it is an important working tool in your hospice care delivery process to ensure that any staff member who cares for the patient and family understands the roadmap to their individualized care.

References

Centers for Medicare and Medicaid Services. Title 42: Public Health: PART 418—HOSPICE CARE https://www.federalregister.gov/citation/73-FR-32204

Centers for Medicare and Medicaid Services. State Operations Manual Appendix M – Guidance to Surveyors: Hospice. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf

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