Eligibility

To qualify for Hospice Care, a patient’s attending physician and the hospice Medical Director certify that the patient’s prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course.

Review guidelines

Medicare guidelines

Simple guidelines were designed by Medicare to help medical professionals identify patients who may be eligible for hospice care

  • Hospice eligibility is determined by prognosis or expected length of life
  • Medicare expects to see specific clinical events associated with a terminal diagnosis
  • Patients may have a terminal prognosis without meeting all disease specific guidelines and some patients may experience events related to multiple diagnoses
  • Documentation is needed to support the patient’s prognosis and eligibility
  • The physician’s clinical judgment, evidence of swift decline and a patient’s comorbidities are also considered when determining hospice eligibility

 

Eligibility by Illness

General Signs and Symptoms

Rapid decline over the past 3-6 months evidenced by:

  • Dependence for two or more activities of daily living (ADLs): feeding, ambulation, toileting, transferring, bathing or dressing
  • Increasing ER visits, hospitalizations or physician oversight
  • Inability to tolerate artificial nutrition or refusal of nutrition by mouth
  • Dysphagia leading to inadequate nutritional intake
  • Recurrent aspiration
  • Weight loss of 10% of body weight and/or declining serum albumin levels
  • Body Mass Index(BMI) less than 22 (this tool is under Tools and Resources)
  • Multiple progressive Stage 3-4 pressure ulcers despite optimal care
  • Progressive orthostatic or postural hypotension (drop in systolic blood pressure due to a change in body position)
  • Specific disease progression as evidenced by signs, symptoms and test results
  • Overall clinical decline as evidenced by a combination of signs, symptoms and test results
  • Decline in Palliative Performance Scale (PPS)
  • Decline in Functional Assessment Staging Tool (FAST)


Cardiopulmonary Disease

International Classification of Functioning, Disability and Health (ICF) related categories that allow for comprehensive description of an individual’s health status and service needs (ranked no/mild/moderate/severe/ complete impairment)

  • Structures of cardiovascular system
  • Structures of  respiratory system
  • Communication
  • Mobility
  • Self-care

AND identification of specific structural/functional impairments and relevant activity limitations:

  • Heart Valve Stenosis
  • Ambulation
  • Class IV NYHA
  • Incontinence
  • Transfers
  • Severely reduced EF
  • Impaired self-care
  • Abnormal lab values
  • Abnormal O2 saturation
  • Irregular lung sounds

AND at least one of the specific, secondary or comorbid conditions listed in the last 12 months:

  • Secondary Conditions
  • Delirium
    • Pneumonia
    • Stasis ulcers or Pressure ulcers
    • Falls
    • Weight loss
    • Oxygen dependence
    • Other infections
  • Comorbid conditions unrelated to Cardiopulmonary Disease but, contributing to terminal prognosis

 In the absence of one or more of these findings, rapid decline or unrelated comorbid conditions may also support hospice eligibility

 

Alzheimer’s Disease

  • Score of 7a on FAST Scale

The highest consecutive level of disability

  1. a.  Ability to speak limited to approximately half a dozen or fewer different intelligible

words in the course of an average day or in the course of an intensive interview.

  1.  Speech ability is limited to the use of a single intelligible word in an average day or in

the course of an intensive interview (the person may repeat the word over and over).

  1.  Ambulatory ability is lost (cannot walk without personal assistance).
  2.  Cannot sit up without assistance (e.g., the individual will fall over if there are not

lateral armrests on the chair).

  1.  Loss of ability to smile.
  2.  Loss of ability to hold head up independently.

 

AND Identification of structural/function impairments and relevant activity limitations:

  • Ambulation
  • Continence/toileting
  • Transfer
  • Dressing
  • Eating
  • Bathing

 

AND at least one of the specific, secondary conditions listed in the last 12 months:

  • Recent falls
  • UTIs (pyelonephritis)
  • Other infections
  • Pressure ulcers
  • Weight loss
  • Delirium

In the absence of one or more of these findings, rapid decline or unrelated comorbid conditions may also support hospice eligibility

 

Cancer

Clinical findings of malignancy that has spread to distant parts of the body and one or more of the following:

  • Evidence of aggressive disease such as worsening lab values and diagnostic tests AND
  • Palliative Performance Scale (PPS)≤ 70% AND
  • Refuses further curative/life-prolonging treatment  OR continues to decline AND
  • Has a prognosis of 6 months or less despite treatment
  • Cancers with poor prognoses (small cell lung cancer, brain cancer or pancreatic cancer) may be hospice-eligible without fulfilling these criteria

Additional supporting documentation for patients with a primary cancer diagnosis includes:

  • Poor appetite, cachexia or significant weight loss in past 3-6 months
  • Recurrent disease after treatment such as surgery, radiation or chemotherapy
  • Other symptoms such as exhaustion, nausea, vomiting, increased need for blood transfusions, malignant ascites, pleural effusion or pain
  • Hypercalcemia > 12

 In the absence of one or more of these findings, rapid decline or unrelated comorbid conditions may also support hospice eligibility

 

Neurological Conditions

International Classification of Functioning, Disability and Health (ICF) related categories that allow for comprehensive description of an individual’s health status and service needs (ranked no/mild/moderate/severe/ complete impairment)

  • Structures of the nervous system
  • Mental functions, communication, mobility and  self-care
  • Consciousness
  • Attention Sequencing complex movements
  • Ingestion
  • Muscle power
  • Muscle tone
  • Endurance

AND at least one of the specific, secondary or comorbid conditions listed in the last 12 months:

  • Secondary Conditions
  • Dysphagia
  • Pnuemonia
  • Pressure ulcers
  • Falls
  • Infections
  • Comorbid Conditions

Unrelated to neurological conditions but, contributing to terminal diagnosis

In the absence of one or more of these findings, rapid decline or unrelated comorbid conditions may also support hospice eligibility

 

Renal Disease

International Classification of Functioning, Disability and Health (ICF) related categories that allow for comprehensive description of an individual’s health status and service needs (ranked no/mild/moderate/severe/complete impairment):

  • Urinary function
  • Water, mineral and electrolyte function
  • Endocrine gland functions
  • Blood pressure functions
  • Exercise tolerance functions

Identification of specific structural/functional impairments to relevant activity limitations:

  • Ambulation
  • Incontinence
  • Transfers
  • Dressing
  • Eating
  • Bathing

AND at least one of the specific, secondary or comorbid conditions listed in the last 12 months:

  • Secondary Conditions
  • Secondary hyperparathyroidism
  • Hyperkalemia
  • Fluid overload
  • Access site infections
  • Comorbid conditions: unrelated to End Stage Renal Disease but, contributing to terminal prognosis

In the absence of one or more of these findings, rapid decline or comorbidities may also support hospice eligibility

 

Liver Disease

The patient should show both A and B:

  1. Prothrombin time prolonged more than 5  seconds over control or International Normalized Ratio (INR) > 1.5
  2. Serum albumin <2.5 gm/d1

AND the patient shows at least one of the following:

  • Ascites, refractory to treatment or patient  non-compliant
  • Spontaneous bacterial peritonitis
  • Hepatorenal syndrome (elevated creatinine and  BUN with oliguria (<400ml/day) and urine  sodium concentration <10 mEq/l)
  • Hepatic encephalopathy, refractory to treatment or patient non-compliant
  • Recurrent variceal bleeding, despite intensive therapy

 

Documentation of secondary and comorbid conditions contribute to poor prognosis of liver disease:

  • Progressive malnutrition
  • Muscle wasting with reduced strength and endurance
  • Continued active alcoholism (> 80 gm ethanol/day)
  • Hepatocellular carcinoma
  • HBsAg (Hepatitis B) positivity
  • Hepatitis C refractory to interferon treatment

In the absence of one or more of these findings, rapid decline or comorbidities may also support hospice eligibility

 

HIV DISEASE

CD4+ count <25 cells/mcL or persistent viral load >100,000 copies/ml, plus one of the following:

  • CNS lymphoma
  • Wasting untreated/unresponsive to treatment
  • Mycobacterium avium complex (MAC) bacteremia, untreated/unresponsive to treatment
  • Progressive multifocal leukoencephalopathy
  • Systemic lymphoma, with advanced HIV disease  and partial response to chemotherapy
  • Visceral Kaposi’s sarcoma, unresponsive to therapy
  • Renal failure in the absence of dialysis
  • Toxoplasmosis, unresponsive to therapy
  • Decreased performance status, measured by the Palliative Performance Scale (PPS)

 

Documentation of the following will support eligibility for hospice care:

  • Chronic persistent diarrhea for one year
  • Persistent serum albumin <2.5
  • Concomitant, active substance abuse
  • Age > 50 years
  • Absence of treatment related specifically to  HIV disease
  • Advanced AIDS dementia complex
  • Congestive heart failure, symptomatic at rest

 

International Classification of Functioning, Disability and Health (ICF) related categories that allow for comprehensive description of an individual’s health status and service needs (ranked no/mild/moderate/severe/ complete impairment)

  • Urinary function
  • Water, mineral and electrolyte function
  • Endocrine gland functions
  • Blood pressure functions
  • Exercise tolerance functions

In the absence of one or more of these findings, rapid decline or comorbidities may also support eligibility  for hospice care

 

TOOLS AND RESOURCES

Clinical tools to assist our professional partners in determining hospice eligibility.

  • Functional Assessment Scale Tool (FAST) – Neurological conditions
  • NYHA Functional Classification – Cardiopulmonary conditions
  • BMI scale
  • Palliative Performance Scale (PPS)
  • ICF Categories

FUNCTIONAL ASSESSMENT STAGING TOOL (FAST)

Identify the highest consecutive level of disability:

  1. No difficulty either subjectively or objectively
  2. Complains of forgetting of location of objects; subjective work difficulties
  3. Decreased job functioning evident to co-workers; difficulty in traveling to new locations; decreased organizational capacity.
  4. Decreased ability to perform complex tasks (e.g., planning dinner for guests, handling personal finances such as forgetting to pay bills, difficulty going shopping, etc.).
  5. Requires assistance in choosing proper clothing to wear unless supervised.
  6. Improperly putting on clothes without assistance or cueing (e.g., may put street clothes on top of overnight clothes, put shoes on the wrong feet, have difficulty buttoning clothing) occasionally or more frequently over the past weeks.
  1. Unable to bathe properly occasionally  or more frequently over the past weeks.
  2. Inability to handle mechanisms of toileting (e.g., forgets to flush the toilet, does not wipe properly or properly dispose of toilet tissue) occasionally or more frequently over the past weeks.
  3. Urinary incontinence occasionally or more frequently over the past weeks.
  4. Fecal incontinence occasionally or  more frequently over the past weeks.
  5. a. Ability to speak limited to approximately half a dozen or fewer different intelligible words in the course of an average day or in the course of an intensive interview.
  6. Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview (the person may repeat the word over and over).
  7. Ambulatory ability is lost (cannot walk without personal assistance).
  8. Cannot sit up without assistance (e.g., the individual will fall over if there are not lateral armrests on the chair).
  9. Loss of ability to smile.
  10. Loss of ability to hold head up independently.