Quick Guide and Medicare Guidelines for admission for medical professionals
Unity Hospice has included the Medicare Guidelines for admission and a Hospice Quick Guide as a reference when evaluating a patient for hospice admission.
Quick Guide--questions for hospice appropriateness
This is designed as a quick guide for healthcare professionals to help determine if a patient is appropriate for hospice care. More detailed information is contained in the tabs below.
Has the patient’s appetite decreased over the last weeks or months?
• May only now be eating 25 to 50% of meals in many cases.
• Refusal of meals or no interest in eating.
Has there been weight loss over the last 3-6 months?
• If there has been weight gain, could it be due to edema/fluid retention?
• Patient may present as having weight loss of 10% or more, consistent over last 3-6 months.
o Patient weighs so little that she/he is very fragile.
Has the patient required frequent doctor visits or hospitalizations in the past few months?
Does it appear as though the patient is declining in spite of treatment?
Has the patient/family refused treatment?
Does the patient have multiple diseases contributing to their symptoms/decline?
Is the person incontinent of bowel or bladder?
• Patient may present as being incontinent of one or both.
• May be a recent change.
How much assistance is required?
• Total assist? Some assistance? Independent?
• Patient may present as requiring nearly total or total assist with feeding, dressing, bathing and mobilization.
Is patient’s mobility limited?
• Patient may present as wheel chair or bed bound.
Is there any notation or observation of weakness, lethargy, pain, or frequent skin breakdown?
• Patient often presents as having weakness, tiredness, and limited mobility due to these things leaving him/her prone to skin breakdown.
Is the person on oxygen?
• How often and how much?
• Patient may present as requiring oxygen for symptom relief.
• Does the patient need oxygen but refuses?
Does the person have limited verbalization?
• Patient may present as confused/disoriented.
• Has limited verbalization or is incoherent.
Change in patient’s mental status?
• Patient may present as confused, disoriented.
To begin the referral process, please click on the "Make a Referral" button, or call Unity Hospice at 888 494-1188 24/7/365.
Medicare Guidelines for Hospice Criteria
• Must have a terminal illness with a life expectancy of six months or less to live should the disease follow its normal course.
• Active therapies refused, discontinued or not appropriate for the stage of the disease.
• Frequent hospitalizations or emergency room visits.
• Progressive unintentional weight loss (10% or more the past six months) for no apparent reason.
• Karnofsky scale <50%.
• Aggressive progression of the disease process and/or significant co-morbidities.
Hospice Eligibility Criteria
Prognosis: The patient must continue to have a prognosis of less than 6 months at the time of certification and at each recertification (90 days, 180 days, and every 60 days thereafter).
Initial certification: Patient may meet criteria for one diagnosis or have several conditions that together result in a prognosis of 6 months or less.
Recertification: Patients must show decline/instability during each certification period or a status such that any further decline would result in death.
General (non-specific Terminal Illness)
• The terminal condition cannot be attributed to a single specific illness and
• The rapid decline over the past 3-6 months as evidenced by the progression of disease evidenced by symptoms, signs and test results. Decline in PPS to <50%; Involuntary weight loss > 7.5% in previous 3 month period and/or Albumin<2.5.
• Advanced disease (typically stage IV).
• The patient chooses not to pursue aggressive treatment or the patient continues to decline in spite of definitive therapy.
• Evidence of functional decline despite therapy or patient refusing therapy.
• Cancers with extremely poor prognosis.
• Karnofsky <70%: considerable assistance with ADL’s and frequent medical care.
Alzheimer's, dementia and related disorders
The following should be present:
o Inability to walk, dress, bathe without assistance.
o Urinary and fecal incontinence.
o In Alzheimer’s disease: no consistently meaningful speech or inability to speak more than 1-5 words daily.
o Plus one of the following in the past 12 months:
Aspiration pneumonia, pyelonephritis, septicemia.
Unintentional weight loss: 10% in last 6 months, 7.5% in 3 months.
o Serum albumin<2.5mg/dl.
o Presence of stage 3 or 4 pressure ulcers.
• Stage 7a or below on FAST scale
• Significant co-morbidities causing structural/functional impairments.
• Optimally treated; not a candidate for surgical procedure.
• NYHA Class IV symptoms (angina or dyspnea at rest)
• Inability to carry out even minimal physical activity.
• Increased symptoms with minimal exertion.
• Ejection Fraction of < 20% (if available). Supporting information:
• Patient history of cardiac or unexplained syncope.
• Embolic stroke.
• Patient history of cardiac arrest.
• Patient history of cardiac arrest.
Neurologic disease (chronic degenerative conditions such as ALS, MS, Parkinson’s, Multiple Sclerosis, Muscular Dystrophy)
The patient must meet the criteria in at least one of the following:
• Critically impaired breathing capacity, with all:
o Dyspnea at rest.
o Vital capacity <30%.
o Supplemental Oxygen at rest.
o The patient refuses artificial ventilation.
• Rapid disease progression from:
o Independent ambulation to wheelchair or bed-bound status.
o Barely intelligible speech.
o Pureed diet.
o Dependent for most ADL’s.
• Critical nutritional impairment – continued weight loss (5%), dehydration and/or intake of food and fluids insufficient to maintain life.
• Continuing weight loss.
• Dehydration or hypovolemia.
• Absence of artificial feeding methods.
• Life-threatening complications in the past 12 months as demonstrated by:
o Recurrent aspiration pneumonia.
o Recurrent Fever.
o Stage 3 or 4 pressure ulcer(s).
Severe chronic lung disease as documented:
• Disabling dyspnea at rest.
• Poor response to bronchodilators.
• Steroid dependent.
• Progression of the disease as evidenced by increased ER visits/hospital admits.
• O2 saturation < 88% on room air. • Resting tachycardia > 100/min.
• Unintentional weight loss of 10% in six months.
• Oxygen dependence or refusal.
Renal Failure/Kidney Disease
• The patient is not seeking dialysis or transplant.
• Creatinine clearance is <10 mg/dl (>6 with diabetes).
• Serum Creatinine >8 mg/dl (>6 mg/dl for diabetics).
• Intractable hyperkalemia.
• Uremic pericarditis.
• Hepatorenal syndrome.
• Intractable fluid overload.
• GI bleeding.
• Palliative Performance Scale (PPS < 40).
• Inability to maintain hydration & caloric intake with one of the following:
o Weight loss > 10% during previous 6 months.
o Serum albumin < 2.5 gm/dl.
o Current history of pulmonary aspiration with ineffective intervention to prevent.
o Calorie counts documenting inadequate caloric/fluid intake.
Must present with any three of the following on day three of the coma:
• Abnormal brain stem response.
• Absent verbal responses.
• Absent withdrawal responses to pain.
• Serum creatinine >1.5 gm/dl.
Patients will be considered to be in the terminal stage of their illness if they meet the following criteria:
HIV disease (1 and 2 must be present; factors from 3 will aid supporting documentation).
1. Clusters of differentiation 4 (CD4)+ Count 100,000 copies/ml, plus one of the following:
• CNS lymphoma.
• Untreated or not responsive to treatment, wasting (loss of 33% lean body mass).
• Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment or treatment refused.
• 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.
• Cryptosporidium infection.
• Toxoplasmosis, unresponsive to therapy.
2. Decreased performance status KPS of < 50.
3. Documentation of the following will support hospice eligibility:
• Chronic persistent diarrhea for one year.
• Persistent serum albumin <2.5. • Concomitant, active substance abuse. • Age > 50 years.
• Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy related to HIV disease.
• Advanced AIDS dementia complex.
• Congestive heart failure, symptomatic at rest.