Clinical Liaison

1. Referral Intake and Clinical Screening

The Clinical Liaison will:

- Receive referrals from hospitals, physicians, skilled nursing facilities, assisted living facilities, case managers, health plans, families, and community providers.

- Respond to new referrals promptly and acknowledge receipt.

- Obtain all available records necessary for clinical review, including:

  - Face sheet and insurance information.

  - History and physical. 

  - Recent physician and nursing notes.

  - Hospital discharge summary.

  - Medication list.

  - Laboratory and diagnostic results.

  - Code status, POLST, or advance directive.

  - Functional and cognitive status.

  - Weight loss and nutritional decline.

  - Recent hospitalizations and emergency-department visits.

  - Wounds, infections, oxygen needs, falls, and symptom burden.

  - PPS, KPS, FAST, NYHA, or other disease-specific information when available.

- Identify missing information and follow up with the referral source.

- Conduct an in-person, bedside, telephone, or virtual informational evaluation when appropriate and permitted by agency policy.

- Identify urgent symptoms or unsafe discharge concerns and immediately escalate them to the clinical team.

- Prepare a concise clinical summary for review by the hospice Medical Director, physician designee, or physician member of the interdisciplinary group.

- Document whether the referral was accepted, declined, placed on hold, or requires additional records.

The Clinical Liaison may collect and organize information, but cannot independently approve a patient for hospice admission. A hospice may admit a patient only upon the recommendation of the Medical Director, physician designee, or physician member of the hospice interdisciplinary group, with input from the attending physician when applicable. eCFR

2. Hospice Eligibility Coordination

The Clinical Liaison will:

- Recognize common indicators of hospice appropriateness, such as progressive functional decline, nutritional decline, recurrent hospitalizations, increasing dependence, disease progression, and worsening symptom burden.

- Present the patient’s individualized clinical circumstances rather than relying only on diagnosis or checklists.

- Obtain the name and contact information of the patient’s attending physician.

- Assist the clinical team in obtaining supporting documentation and physician certifications.

- Follow up on unsigned or incomplete certifications, orders, and referral documents.

- Communicate the clinical decision to the referral source and family in a professional and compassionate manner.

- Refer patients who are not currently eligible to appropriate community or palliative-care resources when available.

The physician—not the liaison—determines whether the prognosis supports a life expectancy of six months or less if the illness runs its normal course. Initial certification generally involves the hospice physician and the attending physician when the patient has one. eCFR

3. Patient and Family Education

The Clinical Liaison will provide clear, neutral, and compassionate education regarding:

- The hospice philosophy and comfort-focused approach.

- The patient’s right to choose a hospice provider.

- The hospice interdisciplinary team.

- Nursing, physician, social-work, spiritual-care, hospice-aide, volunteer, bereavement, medication, equipment, and supply services.

- Availability of hospice support 24 hours a day.

- What services, medications, equipment, and supplies may be related to the terminal illness.

- The role of the attending physician and hospice Medical Director.

- The patient’s right to participate in the plan of care.

- The patient’s right to refuse treatment.

- Election, revocation, transfer, and discharge from hospice.

- Complaint and grievance procedures.

- Advance directives and code-status choices.

- The responsibilities of the patient, family, facility, and hospice.

Education must be provided without pressure, coercion, misleading promises, or guarantees of admission. The patient or representative must receive understandable notice of hospice rights and responsibilities, and the patient retains the right to participate in care planning, refuse treatment, and choose an attending physician. eCFR

4. Admission and Transition Coordination

Once the patient is clinically approved, the Clinical Liaison will coordinate with intake and admissions to confirm:

- Election date and requested start-of-care date.

- Discharge date and time.

- Patient’s destination and physical address.

- Responsible caregiver and emergency contacts.

- Transportation arrangements.

- Admission-nurse availability.

- Medication needs and pharmacy arrangements.

- Durable medical equipment needs.

- Oxygen, hospital bed, wheelchair, commode, suction, or other equipment delivery.

- Wound-care or treatment supplies.

- Comfort-medication needs.

- Facility room number and facility contact person.

- Attending physician and primary pharmacy.

- Code status and advance-directive documents.

- Insurance authorization or payer requirements when applicable.

- Language, interpreter, cultural, hearing, vision, or communication needs.

- Immediate safety concerns in the home or facility.

The liaison should complete a warm handoff to the admission nurse that includes the patient’s diagnosis, symptoms, functional status, caregiver situation, medication concerns, equipment needs, discharge timing, and family expectations.

After the hospice election is completed, a hospice RN must complete the initial assessment within 48 hours unless an earlier assessment is requested. The interdisciplinary group must complete the comprehensive assessment within five calendar days. eCFR

5. Hospital and Facility Coordination

The Clinical Liaison will:

- Develop working relationships with hospital case managers, discharge planners, physicians, SNF staff, assisted-living staff, board-and-care operators, and community providers.

- Attend discharge-planning meetings when appropriate.

- Help resolve barriers that may delay a safe hospice admission.

- Coordinate delivery of equipment and medications before or immediately after discharge.

- Ensure that the facility understands which services are provided by hospice and which remain the facility’s responsibility.

- Communicate changes and concerns to the hospice clinical team.

- Verify that required hospice-facility agreements are in place before services begin when applicable.

- Avoid directing facility staff to change treatments or medications without proper hospice and physician authorization.

For patients residing in a SNF, NF, or ICF/IID, the hospice retains responsibility for professional management of hospice services, must have a written agreement with the facility, and must coordinate the hospice plan of care with facility representatives. eCFR

6. Referral-Source Relationship Management

The Clinical Liaison will:

- Maintain professional contact with existing referral partners.

- Introduce hospice services to new hospitals, physician offices, facilities, health plans, and community programs.

- Provide educational presentations and in-services on:

  - Hospice eligibility.

  - Disease-specific decline.

  - Goals-of-care discussions.

  - Hospice versus palliative care.

  - Pain and symptom management.

  - Avoidable hospital transfers.

  - End-of-life care planning.

- Follow up with referral sources regarding referral status when permitted.

- Identify referral barriers, service gaps, and community needs.

- Maintain an organized outreach schedule and referral-partner list.

- Represent the hospice professionally at meetings and community events.

- Coordinate outreach activity with business-development and clinical leadership.

The relationship must be based on service quality, responsiveness, education, and patient needs—not gifts, payments, entertainment, free labor, or anything offered to induce referrals. The federal anti-kickback statute prohibits remuneration intended to induce or reward referrals involving federal healthcare-program business. HHS Office of Inspector General

7. Documentation and Communication

The Clinical Liaison will document referral activity on the same business day, including:

- Date and time the referral was received.

- Referral source and contact information.

- Patient and representative information.

- Clinical records received and requested.

- Clinical findings reported or observed.

- Education provided.

- Patient or family questions and concerns.

- Physician and Medical Director communications.

- Admission decision.

- Reason for non-admission, delay, or patient choice.

- Equipment, medications, transportation, and discharge arrangements.

- Handoff to the admission nurse.

- Follow-up activity.

The liaison must use secure, approved communication systems and comply with HIPAA and agency privacy policies. Patient information may generally be exchanged for treatment and care coordination with appropriate safeguards, but using PHI for marketing purposes is subject to stricter authorization requirements. HHS.gov

8. Quality and Compliance Responsibilities

The Clinical Liaison will:

- Follow Medicare hospice Conditions of Participation, California requirements, payer contracts, and agency policies.

- Maintain complete, accurate, and timely referral records.

- Participate in orientation, annual education, competencies, and compliance training.

- Report suspected abuse, neglect, exploitation, unsafe conditions, discrimination, or patient-rights violations.

- Report complaints and grievances immediately according to agency policy.

- Participate in QAPI activities involving:

  - Delayed admissions.

  - Failed or incomplete transitions.

  - Hospital readmissions.

  - Referral-processing errors.

  - Equipment or medication delays.

  - Communication failures.

  - Patient and family complaints.

- Help identify patterns behind lost referrals without pressuring staff to accept clinically inappropriate patients.

- Maintain professional boundaries with patients, families, physicians, and referral sources.

- Facility Inservices