Hospice Care: Evidence-Based Interdisciplinary Support for Patients with Life-Limiting Illness

Hospice represents a fundamental shift in care goals—from curative intent to comfort-focused interdisciplinary support for patients with a prognosis of six months or less. Evidence demonstrates that appropriate hospice utilization improves clinical outcomes, enhances patient and family satisfaction, and reduces healthcare costs. At Ohio’s Hospice, our evidence-based approach throughout Ohio has consistently demonstrated that timely referrals significantly impact quality of life and care outcomes.

Clinical Framework

Hospice care operates through a Medicare-certified interdisciplinary team model that addresses the full spectrum of patient and family needs. The core team composition includes:

• Hospice Medical Directors: Board-certified in hospice and palliative medicine, providing expert symptom management and collaborating with attending physicians
• Registered Nurses: Hospice-certified professionals conducting comprehensive assessments and skilled interventions.
• Personal Care Specialists:
• Licensed Social Workers: Addressing psychosocial needs, facilitating care transitions, and coordinating community resources.
• Chaplains: Providing non-denominational spiritual support aligned with patient and family values.
• Additional Disciplines: Including physical therapists, occupational therapists, and speech therapists.
• Volunteers as indicated by the patient’s plan of care.

This interdisciplinary approach ensures comprehensive biopsychosocial-spiritual care tailored to individual patient and family needs.

Collaborative Care Model

Hospice programs operate under a collaborative model that maintains continuity with existing providers:

• Attending physicians may continue following patients with hospice medical director consultation
• Specialists can remain involved for symptom management expertise
• Facility staff partner with hospice teams for coordinated care delivery
• 24/7 clinical support ensures seamless communication and crisis management

Where is hospice care provided?

The hospice team provides care in the comfort of the patient’s home, extended care facility or assisted living center. Patients also can receive care in a hospital or one of our Hospice Houses. At Ohio’s Hospice, our mission is to celebrate the lives of those we have the privilege of serving by providing superior care and superior services to each patient and family.

Ohio’s Hospice Levels of Care

Hospice programs provide four distinct levels of care to meet varying patient needs:
1. Routine Home Care

• Comprises 93.8% of hospice days nationally.
• Intermittent visits based on patient needs and plan of care
• Delivered in patient’s residence, including private homes, assisted living, and skilled nursing facilities.

2. Continuous Home Care

• Minimum 8 hours of continuous nursing/aide presence in 24-hour period.
• Utilized during periods of acute medical crisis requiring intensive symptom management.
• Maintains patient in home setting during crisis episodes.

3. General Inpatient Care

• Short-term admission for acute symptom management not manageable in other settings.
• Requires daily physician assessment and documentation of continued need.
• Average length of stay 5-7 days.

4. Respite Care

• Maximum 5 consecutive days of inpatient care.
• Provides temporary relief for primary caregivers.
• Available on occasional basis.

How does hospice care work?

When a patient with a life-limiting illness or injury decides that curative measures are no longer appropriate, effective or desirable, hospice care becomes a compassionate, dignified and beneficial option for end-of-life care.

The patient receives care wherever they call home. Family and friends function as the patient’s primary caregivers. Each of our team members visit our patients on a regular basis and guides them, their caregivers and families through the process of the terminal illness or condition.

The patient’s primary care provider continues to provide care for non-hospice related conditions and collaborates with our medical director and hospice team on hospice care issues. The hospice medical director assists in the development of the patient’s hospice plan of care and approves any changes made to the plan by the hospice team.

Hospice care is covered by Medicare and most private insurers. Ohio’s Hospice does not bill a patient for any services not covered by these payers.

Hospice care services are available on a 24/7/365 basis. We stand side-by-side with our patients and their families during their entire stay under our hospice care.

Deciding when to call hospice is difficult, but those who have used our services often say they wish they had the benefit of hospice care earlier. Here are some things to consider  when trying to decide when to call hospice.

Communication Best Practices

Evidence-based communication approaches facilitate successful transitions to hospice care:

• Frame discussions around patient values and goals rather than specific interventions.
• Address prognostic awareness while maintaining appropriate hope.
• Include interdisciplinary team members in family meetings.
• Document goals-of-care discussions comprehensively in medical records.

Quality Differentials: Not-for-Profit Advantage

Peer-reviewed research consistently demonstrates measurable quality advantages of not-for-profit hospices:

• 10% more nursing visits per patient.
• 35% more social work visits.
• Double the therapy visits.
• Higher staffing ratios across all disciplines.
• More comprehensive bereavement programs.
• Greater community benefit activities.

As a not-for-profit provider, Ohio’s Hospice exemplifies these quality advantages while offering specialized programs and education.

Optimizing Hospice Utilization

Research indicates median hospice length of stay remains suboptimal at 17-18 days, with 28% of patients enrolled for ≤7 days. Early referral enables:

• Comprehensive symptom assessment and management.
• Time for relationship building between hospice team and patient/family.
• Adequate psychosocial and spiritual support.
• Advance care planning discussions.
• Caregiver education and support.
• Better bereavement outcomes

As healthcare systems focus on value-based care and patient-centered outcomes, hospice remains the gold standard for end-of-life care delivery. The evidence clearly supports hospice’s role in improving clinical outcomes, enhancing patient and family experience, and reducing healthcare costs. Timely referral to high-quality hospice programs represents best practice for patients with life-limiting illness.

For referrals or clinical consultations, Ohio’s Hospice maintains a 24/7 clinical support line at 888.449.4121, staffed by experienced hospice nurses who can assist with eligibility determinations and facilitate admissions.