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Hospice Eligibility

Hospice is at its best when services to address pain, symptoms, emotions and practical issues are provided over months rather than weeks or days. This ensures the patient and family receive the maximum benefit from the program and that all their care wishes and needs are fully addressed.

One of the ways Brookdale Hospice supports you in your practice is by helping you to identify hospice eligibility as soon as possible so your patients and their families can receive the full benefit of hospice care.

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Hospice Eligibility
Eligibility can vary depending on the patient. After making a referral, we will work with the patient to determine their eligibility.

In general, a patient is eligible for hospice care when life expectancy is six months or less, and aggressive curative treatment is no longer an option or desired.

 

Hospice eligibility may be met with the following:

  • One significant terminal diagnosis as your patient meets Medicare Disease Specific Criteria,

OR

  • Multiple comorbidities contribute to the terminal decline. Your patient exhibits multiple signs and symptoms that suggest a terminal progression but do not add up to a single terminal diagnosis. Often a combination of diagnoses is accelerating decline yet a patient does not have to meet all the criteria listed. Documenting your patient’s terminal trajectory, in this case, should include several areas of decline so that a clear picture of poor prognosis is evident.

Patients may be in the terminal stage of renal disease and eligible for hospice if they meet the following criteria:

 

Clinical Indicators 

  • Not seeking dialysis or renal transplant
  • Creatinine clearance <10ml/min (<15ml for diabetics/CHF)
  • Serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics)
  • Acute/Chronic renal failure

Supportive Factors for Eligibility

  • Advanced disease of heart, liver or lung
  • Malignancy (other organ system)
  • Sepsis
  • Oliguria: output <400 cc/24hrs
  • Cachexia or albumin <3.5 gm/dl
  • Immunosuppression/AIDS
  • Disseminated intravascular coagulation

Patients may be in the terminal stage of stroke or coma and eligible for hospice if they meet the following criteria:

 

Clinical Indicators
Palliative Performance Scale < 40 percent (mainly in bed, unable to work, requires maximal assistance to perform self-care, normal or reduced food/fluid intake, either conscious, drowsy or confused)

  • Inability to maintain hydration and caloric intake with one of the following:
    • Weight loss >10 percent during previous six months, or
    • Weight loss >7.5 percent during last three months or
    • Serum albumin <2.5gm/dl or
    • Current history of pulmonary aspiration not responsive to speech/language pathology intervention, or
    • Dysphagia severe enough to prevent the patient from receiving food/fluids necessary to sustain life in a patient who does not receive artificial nutrition/hydration, or
    • Calorie counts documenting inadequate caloric/fluid intake

Supportive Factors for Eligibility 

  • Aspiration pneumonia
  • Upper UTI (ex. Pyelonephritis)
  • Sepsis
  • Refractory stage 3 to 4 decubitus ulcers
  • Recurrent fever after antibiotic

Patients may be in the terminal stage of cancer and eligible for hospice if they meet the following criteria:

 

Clinical Indicators

  • Palliative Performance Scale score of <70 percent and
  • Dependency with two or more Activities of Daily Living and
  • Evidence of malignancy or metastases confirmed by pathology reports or
  • Progression from earlier stage of disease to metastatic disease with either continued decline in spite of therapy or patient declines further disease-directed therapy
  • No further treatment available or desired

Comorbidities or Supportive Factors for Eligibility 

  • COPD
  • CHF
  • Ischemic heart disease
  • Diabetes
  • Liver disease
  • Renal failure
  • Dementia
  • Neurological disease
  • Hypercalcemia >12
  • Cachexia or weight loss of 5 percent in previous three months
  • Requirement for transfusions
  • Malignant ascites or pleural effusion

Patients may be in the terminal stage of heart disease and eligible for hospice if they meet the following criteria:

 

Clinical Indicators

  • Patient is already optimally treated with diuretics and vasodilators (ACE inhibitors), not a candidate or declines invasive procedures, and
  • Class IV of NYHA (physical activity causes discomfort, symptoms of recurrent heart failure or angina at rest)

Supportive Factors for Eligibility 

  • Treatment-resistant symptomatic arrhythmias
  • Ejection fraction < 20 percent
  • History of cardiac arrest and CPR
  • Unexplained syncope
  • Brain embolism of cardiac origin
  • Concomitant HIV disease
  • Resistant to Nitrate Therapy
  • Decline in Palliative Performance scale to 50 percent or less
  • BMI less than 22
  • CHF or Cardiomyopathy with documented cardiomegaly
  • Ischemic Heart Disease, ASHD/ASCVD/CAD
  • Increase frequency of hospitalization or ER visits for symptom control
  • Current inotropic therapy dose unable to be reduced
  • Oxygen dependent

Patients may be in the terminal stage of pulmonary disease and eligible for hospice if they meet the following criteria: 

 

Clinical Indicators

  • Disabling dyspnea at rest
  • Increasing visits to ER or current or prior hospitalizations over previous six months and/or respiratory failure

Supportive Factors for Eligibility

  • Cor pulmonale/right heart failure secondary to pulmonary disease
  • Resting tachycardia > 100/min
  • Unintentional weight loss of 10 percent in previous six months
  • Poor response or unresponsive to bronchodilators resulting in decreased
  • functional capacity (bed to chair existence, fatigue, cough)
  • Documentation of Forced Expiratory Volume (FEV1) after bronchodilator < 30 percent of predicted
  • Hypoxemia at rest, pO2 < 55 mm Hg or
  • Oxygen saturation of 88 percent or less on room air or
  • Hypercapnia with pCO2 > 50 mm Hg

Patients may be in the terminal stage of liver disease and eligible for hospice if they meet the following criteria:

 

Clinical Indicators

  • End-stage cirrhosis and not a candidate for transplant, and PT > 5 sec over control, and INR > 1.5, and serum albumin < 2.5 gm/dl
  • At least one of the following:
    • Ascites, refractory to treatment or patient non-compliant
    • Hepatorenal syndrome
    • Spontaneous bacterial peritonitis
    • Hepatic encephalopathy despite treatment
    • Recurrent variceal bleed

Supportive Factors for Eligibility

  • Progressive malnutrition
  • Muscle wasting/loss of strength
  • Continued alcohol consumption
  • Hepatocellular carcinoma
  • Positive HBsAg
  • Hepatitis C refractory to Interferon

Patients may be in the terminal stage of ALS and eligible for hospice if they meet the following criteria:

 

Clinical Indicators
Patients are considered end-stage ALS when meeting criteria in one or two:

  1. Critically impaired breathing in the last 12 months as evidenced by
    • Vital capacity < 30 percent of normal
    • Dyspnea at rest
    • Declines artificial ventilation
    • External ventilation used for comfort measures only

  2. OR

  3. Rapid disease progression (as demonstrated by all of the following in the last 1 months) with either a. or b.
    • Bed-bound status
    • Barely intelligible or unintelligible speech
    • Pureed diet
    • Needing major assistance in all ADLs, and
    1. Critical nutrition impairment in the last 12 months as demonstrated by
      • Oral intake of nutrients and fluids insufficient to sustain life
      • Continued weight loss
      • Dehydration or hypovolemia
      • Absence artificial feeding methods
    2. Life-threatening complications in the last 12 months as evidenced by ONE of the following:
      • Recurrent aspiration pneumonia (with or without tube feedings)
      • Upper UTI
      • Sepsis
      • Recurrent fever after antibiotic therapy
      • Decubitus ulcers, multiple, Stage 3 to 4

The two crucial factors to consider in determining end-stage ALS are the patient’s ability to breathe and, to a lesser extent, the patient’s ability to swallow.

Patients may be in the terminal stage of Alzheimer’s disease and eligible for hospice if they meet the following criteria: 

 

Clinical Indicators
Patients are considered to be in the terminal stage of Alzheimer’s disease if they meet indicators 1 and 2:

  1. Stage 7 on the FAST Scale
    • Unable to speak more than six intelligible words in the course of a day
    • Speech ability is limited to the use of a single intelligible word in the course of a day
    • Cannot walk without assistance
    • Cannot sit up without assistance
    • Loss of ability to smile
    • Loss of ability to hold head up independently

  2. AND
     

  3. One of the following in the last 12 months
    • Aspiration pneumonia
    • Recurrent or intractable infections (such as pneumonia or other URI)
    • Pyelonephritis (or other upper UTI)
    • Septicemia
    • Multiple, progressive Stage 3 to 4 decubiti
    • Fever after antibiotics
    • Delirium
    • 10 percent weight loss in last six months/albumin < 2.5 gm/dl

Co-Morbid Conditions or Supportive Factors for Eligibility 

  • Malignancies
  • COPD
  • Renal Failure
  • Liver Disease
  • CHF
  • Cancer

Patients may be in the terminal stage of an autoimmune disease and eligible for hospice if they meet the following criteria:

 

Clinical Indicators

  • Specific organ system involved: CHF/Ischemic heart disease, advanced kidney disease, and/or advanced liver disease
  • Recurrent infections: pneumonia, sepsis, pyelonephritis, urinary tract infections
  • Symptoms poorly responsive to treatment: pain, dyspnea, cough, nausea, vomiting, diarrhea, agitation
  • Progressive weight loss > 10 percent in prior six months not attributable to reversible cause
  • Multiple hospital or ER visits, increasing MD visits
  • Palliative Performance Score <70 percent

Supportive Factors for Eligibility 

  • Significantly decreased intake, artificial nutrition/hydration declined, dysphagia
  • Dependence or assistance required in two or more of the following ADLs: continence, transfers, dressing, bathing, feeding, chair bound/bedbound status
  • Non-healing pressure ulcers (Stage III or IV) despite wound care
  • HGB<10; Albumin <2.5 when available
  • Ascites or edema
  • Systolic BP below 90 or progressive postural hypotension
  • Unexplained or refractory fevers
  • Changes in level of consciousness
  • Labs (when available): increasing pCO2 or decreasing pO2 or decreasing SaO2, increasing calcium, creatinine or liver function studies, increasing tumor markers (CEA, PSA), progressively decreasing/increasing serum sodium or increasing potassium
  • Co-morbid conditions such as dementia, COPD, diabetes, neurological disease, malignancy

Patients may be in the terminal stage of Parkinson’s disease and eligible for hospice if they meet the following criteria: 

 

Clinical Indicators
Patients are considered end-stage Parkinson’s when meeting criteria in 1 or 2:

  1. Critically impaired breathing in the last 12 months as evidenced by
    • Vital capacity < 30 percent of normal
    • Dyspnea at rest
    • Declines artificial ventilation
    • External ventilation used for comfort measures only

  2. OR
     

  3. Rapid disease progression (as demonstrated by all of the following in the last 12 months) with either a. or b.
    • Wheelchair or bed-bound status
    • Barely intelligible or unintelligible speech
    • Pureed diet
    • Needing major assistance in all ADLs and
    1. Critical nutrition impairment in the last 12 months as demonstrated by:
      • Oral intake of nutrients and fluids insufficient to sustain life
      • Continued weight loss
      • Dehydration or hypovolemia
      • Absence artificial feeding methods
    2. Life-threatening complications in the last 12 months as evidenced by ONE of the following:
      • Recurrent aspiration pneumonia (with or without tube feedings)
      • Upper UTI
      • Sepsis
      • Recurrent fever after antibiotic therapy
      • Decubitus ulcers, multiple, Stage 3 to 4

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Referring eligible patients to Brookdale Hospice sooner enables us to continue and augment the care you have been providing. If you have questions about eligibility, we can help. We are available by phone for a consultation or patient assessment.