“Live discharge” is the term Medicare uses to describe hospice disenrollment before death. In the past, it was common for clinicians to refer to these patients as “hospice graduates.” However, that term implies that hospice is no longer needed. In many live discharges, the patient may not qualify for hospice but continues to need home-visiting clinician services as well as affordable palliative care medications, supplies, and equipment. For this reason, there is a movement to change the language such that clinicians differentiate between hospice graduates, disenrollment, and revocation. More importantly, any live discharge suggests a need for transitional care management, management that is often overlooked. Nearly one in five hospice patients experience a live discharge, making how well this is managed an important hospice program differentiator.1
Hospice Graduate: Decertification typically occurs because a patient’s prognosis changes to something longer than six months. Some patients and families welcome such news.2
Decertification: Almost three out of ten decertified hospice patients die within six months.2 Some caregivers describe the discharge as distressing and abrupt.2
Revocation: Revocation means the patient ended hospice, often by pursuing life-saving care not covered under the hospice benefit. Forty-six percent of these patients die within six months.3 Many of these patients would have preferred to keep their hospice services while also receiving other medical care, but Medicare regulations often lead to hospice ending when other types of care begin.
Alongside clinicians, hospice has an important role to play in transition management for live discharges. Unfortunately, this transition is not well recognized, and how individual hospice agencies manage live discharges varies. At Avatar Home Health & Hospice, we recognize that not all live discharges are hospice graduations. Combining hospice, home health, and caregiver services, Avatar is better positioned to provide a continuum of care for your patients even when Medicare benefits may be structured in a way that contributes to care interruptions. The following important services are part of well-managed live discharges. If needed:
- Making sure the patient is reconnected with their primary care doctor.
- Helping patients establish direct connections to the pharmacy and medical supplies providers.
- Transitioning patients to our Medicare-certified home health services for continuity of care.
- Identifying patients at risk for revocation and develop plans for emergent situations.
- Providing anticipatory guidance about the possibility of a live discharge if a patient is stabilizing.
- Providing opportunity for patients and families to process their feelings and experience when a live discharge is pending.
Doctors and other care planners can help in many ways, but there is one task for which doctors are uniquely positioned. Patients need to be informed that they have freedom of choice among Medicare hospice providers.4 Decertifications can be appealed through a different hospice. Additionally, one out of three decertified patients die without hospice.5 This can be influenced by a sense that the hospice abandoned them. Offering a referral to a hospice with a commitment to live-discharge transitions management can provide the reassurance some patients need to reenroll for needed services.
References
- Medicare Payment Advisory Commission. Health Care Spending and the Medicare Program: A Data Book. Section 11: Other Services. 2023. Available from: https://www.medpac.gov/wpcontent/uploads/2024/07/July2024_MedPAC_DataBook_SEC.pdf
- Wladkowski SP. Dementia caregivers and live discharge from hospice: what happens when hospice leaves?. Journal of Gerontological Social Work. 2017 Feb 17;60(2):138-54.
- LeSage K, Borgert AJ, Rhee LS. Time to death and reenrollment after live discharge from hospice: a retrospective look. American Journal of Hospice and Palliative Medicine®. 2015 Aug;32(5):563-7.
- Wladkowski SP, Hunt LJ, Luth EA, Teno J, Harrison KL, Wallace CL. Top ten tips palliative care clinicians should know about hospice live discharge. Journal of Palliative Medicine. 2025 Oct 1;28(10):1385-92.
- Kutner JS, Meyer SA, Beaty BL, Kassner CT, Nowels DE, Beehler C. Outcomes and characteristics of patients discharged alive from hospice. Journal of the American Geriatrics Society. 2004 Aug;52(8):1337-42.
