Aligning Intake Conversations, Code Status Documentation, and the Ongoing Plan of Care

Advance care planning (ACP) in hospice is not a one-time discussion or a completed form. It is a longitudinal process that aligns a patient’s values, goals, and preferences with the care they receive over time.

For hospice administrators, the priority is not just ensuring these conversations happen, but building processes that connect what is discussed at intake, what is documented as code status, and what is carried through the plan of care. When these elements are aligned, agencies are better positioned to deliver consistent care while reducing compliance risk.

Why Alignment Matters

Hospice admissions often occur during periods of rapid decline or care transitions, when decisions are made quickly and documentation may not reflect current preferences.

According to CMS, ACP is a voluntary discussion that includes identifying a surrogate decision-maker, clarifying goals of care, and documenting preferences for treatment. It extends beyond completing forms and requires ongoing communication as conditions change.

When alignment is missing, agencies may see:

• Conflicting or outdated code status documentation
• Unclear direction during emergencies
• Unwanted or non-beneficial interventions
• Gaps in documentation that do not support the clinical record

ACP helps close these gaps by connecting conversation, documentation, and care delivery.

Aligning Hospice Intake Conversations

The intake process is the foundation for effective ACP. It is often the first structured opportunity to explore goals of care in the context of hospice.

Starting early, ideally during pre-admission or at the beginning of intake, allows for more thoughtful decision-making. Rather than leading with forms, conversations should focus on what matters most to the patient, including values, fears, and goals for the time ahead.

Plain language is critical. Terms like DNR or full code may not be clearly understood, especially in emotionally complex situations. Framing questions in a more direct and relatable way supports informed consent and reduces confusion.

Key elements to consistently capture during intake include:

• Patient goals, values, and understanding of their condition
• Preferences around life-sustaining treatment
• Identification of the healthcare proxy or surrogate decision-maker
• Confirmation that the surrogate understands and is willing to act

National guidance reinforces that advance directives are living documents, meaning they should be revisited and updated as a patient’s condition or preferences change.

Code Status Documentation: From Conversation to Action

Once preferences are discussed, they must be translated into clear, consistent documentation that can guide care in real time.

Code status should always be reconfirmed at admission rather than assumed from prior records. Preferences often change after hospitalization or clinical decline.

To reduce risk, documentation should be aligned across:

• The Hospice EHR
• The hospice plan of care
• POLST or MOLST forms when applicable
• Paper documentation kept in the home

Accessibility also matters in the home setting. Families should know where documents are located and how to present them in an emergency.

It is equally important to clarify what code status decisions mean. A DNR order does not mean no care. It reflects a shift toward comfort-focused treatment, with continued emphasis on symptom management and quality of life.

Integrating ACP into the Plan of Care

Advance care planning does not end at admission. As a patient’s condition evolves, the plan of care should continue to reflect their current goals.

ACP should be revisited at key points, including:

• Interdisciplinary team (IDT) meetings
• After hospitalizations or significant clinical changes
• Changes in cognitive status or decision-making capacity

The interdisciplinary team plays a central role in maintaining this alignment utilizing tools such as hospice software to stay well ahead of the curve. Nurses reinforce goals during visits, providers translate preferences into medical orders, and social workers often lead or support deeper ACP discussions. Research shows that hospice social workers are highly involved in educating patients and documenting these conversations, reflecting the team-based nature of ACP in hospice.

When ACP is integrated effectively, the plan of care becomes a direct reflection of patient preferences, guiding decisions around symptom management, hospital transfers, and overall care approach.

Operational Considerations for Administrators

For ACP to be consistent, it must be built into workflow rather than handled case by case.

Focus areas for hospice administrators include:

• Standardization: Clear expectations for intake conversations, documentation, and when ACP should be revisited
• Documentation practices: Ensuring conversations are thoroughly captured, not just noted as completed
• Reimbursement awareness: ACP may be billable under CPT codes 99497 and 99498 when criteria are met
• Cultural awareness: Supporting teams in navigating cultural, spiritual, and family dynamics that influence decision-making

A structured approach allows teams to remain consistent across different care settings while still adapting to individual patient needs.

Impact on Patient Outcomes

Advance care planning has a measurable impact on both care quality and utilization.

Patients who engage in ACP are more likely to:

• Receive care aligned with their preferences
• Avoid unnecessary hospitalizations
• Experience fewer unwanted interventions
• Remain in their preferred setting at end of life

In hospice settings, ACP has also been associated with fewer hospital days and a higher likelihood of achieving the preferred place of death.

The Takeaway

Advance care planning is a core component of hospice care. It ensures that patient preferences are not only discussed, but also documented, understood, and carried forward.

By aligning intake conversations, code status documentation, and the ongoing plan of care, hospice organizations can reduce variability, strengthen compliance, and improve the patient and family experience.

The goal is not just to have the conversation, but to build a process that supports it throughout the entire course of care.

References

1. Centers for Medicare & Medicaid Services. Advance Care Planning (MLN Booklet).
2. Hospice Foundation of America. Advance Care Planning.
3. The Conversation Project, Institute for Healthcare Improvement.
4. National Institute on Aging. Advance Care Planning: Advance Directives for Health Care.
5. American College of Physicians. Principles of Effective Care Transitions Between Settings (2023).
6. Florida Atlantic University. Advance Care Planning Communication Guide (2021).
7. Abel, J., et al. The impact of advance care planning on place of death, hospital use, and costs: A hospice retrospective cohort study.
8. Journal of Palliative Medicine. Social Work Involvement in Advance Care Planning in Hospice and Palliative Care Settings.

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