Can Ontario Health Authority (OHA) care coordinators initiate hospice referrals for patients?

Can Ontario Health Authority Care Coordinators Initiate Hospice Referrals?

Yes, care coordinators can and should initiate hospice referrals for appropriate patients—this is a core function of case management and care coordination, particularly for patients with advanced illness and an estimated prognosis of 6 months or less.

Role of Care Coordinators in Hospice Referrals

Care coordinators are explicitly positioned to facilitate hospice referrals as part of their comprehensive care coordination responsibilities. Patients with complex palliative care needs, including those requiring advance care planning and coordination of end-of-life services, warrant case management referral and subsequent hospice enrollment when appropriate 1. The care coordination role includes identifying patients who would benefit from hospice services and ensuring timely referral to hospice agencies 2, 3.

When Care Coordinators Should Initiate Hospice Referrals

Primary Triggers for Hospice Referral

• Patients with an estimated prognosis of ≤6 months who have comfort-oriented goals should receive immediate referral to hospice 2, 3
• Advanced heart failure patients with ≥2 hospitalizations, dependence on intravenous inotropes, or end-organ dysfunction require case management involvement and hospice consideration 2, 1
• Cancer patients with stage IV disease (particularly lung, pancreatic, or glioblastoma) benefit from early palliative care and hospice referral when prognosis indicates 6-12 months 2
• Cirrhosis patients with Child-Pugh Class C, MELD-Na trending upward, or CLIF-C ACLF scores >70 should be referred to hospice when goals align with comfort care 2, 3

Functional and Clinical Indicators

Care coordinators should initiate hospice referrals when patients demonstrate:

• Decreased performance status (ECOG ≥3 or Karnofsky ≤50) 2
• Progressive functional decline in activities of daily living despite treatment 3
• Refractory symptoms including uncontrolled pain, dyspnea, or other distressing symptoms 2
• Recurrent hospitalizations or emergency department visits for the same condition 1

The Referral Process

Documentation Requirements

Before initiating hospice referral, care coordinators should ensure:

• Documented advance directive or surrogate decision-maker is in place 2
• Goals of care discussions have occurred and are documented, ideally within 1 month of advanced disease diagnosis 2
• Patient/family understanding of prognosis and comfort-focused goals is confirmed 3
• DNR/DNI status is clarified and documented 3

Operational Steps

1. Assess prognostic awareness and readiness for hospice discussions 2, 3
2. Identify local hospice agencies and their specific referral criteria 2
3. Coordinate with the primary physician or specialist to confirm eligibility 2
4. Ensure goals of care documentation transfers with the patient to the hospice agency 3
5. Facilitate the transition by providing the hospice team with comprehensive medical and psychosocial information 1

Common Pitfalls and How to Avoid Them

Timing of Referral

The most critical error is late referral—nationally, median hospice length of stay is only 17.4 days, with 36% of patients dying within 7 days of admission 2. To avoid this:

• Refer when prognosis is 6-12 months rather than waiting until weeks remain 2
• Use sentinel events (new CNS metastases, ICU admission, initiation of mechanical ventilation, start of high-dose opioids) as triggers for immediate hospice discussion 2
• Do not delay referral until end-organ dysfunction or cardiogenic shock develops, as this may preclude benefit from hospice services 2, 1

Misconceptions About Hospice

• Patients and families often equate hospice with hastening death—care coordinators must clarify that hospice focuses on comfort and quality of life, not accelerating death 2
• Physicians may avoid hospice discussions due to prognostic uncertainty—care coordinators can bridge this gap by using validated prognostic tools (MELD-Na, Child-Pugh, functional assessments) to support the conversation 2

Access Barriers

• In Ontario, hospice availability varies by region, with medical wards being the most common location for palliative care, particularly in rural areas 4
• Faith-based facilities may refuse to allow hospice services on-site, requiring patient transfer—care coordinators should identify these barriers early and plan accordingly 5
• Financial and human resource limitations are common barriers—care coordinators should connect patients with available community resources and support services 4

Coordination with the Interdisciplinary Team

Care coordinators do not work in isolation—they facilitate referrals in collaboration with physicians, palliative care specialists, and hospice agencies 2. Specifically:

• Primary physicians or specialists retain medical oversight and must agree the patient meets hospice eligibility criteria 2
• Specialist palliative care consultation may be needed for patients with refractory symptoms, complex decision-making, or challenging family dynamics before hospice enrollment 2
• Hospice agencies conduct their own eligibility assessments, but care coordinators expedite the process by ensuring documentation and communication are complete 6

Evidence Supporting Care Coordinator-Initiated Referrals

Multiple guidelines explicitly recommend that referrals to hospice be made as needed by the interdisciplinary care team, which includes case managers and care coordinators 2. The American Heart Association, NCCN, and AGA all emphasize that timely referral to hospice improves quality of life and ensures patients receive care aligned with their values 2. Care coordinators are uniquely positioned to identify eligible patients, facilitate advance care planning, and ensure seamless transitions to hospice services 1, 3.