Health Care Resources

Hospice Eligibility Conditions

A guide to some of the common criteria for hospice-eligible patients

A patient will be considered to have a life expectancy of six months or less if he/she meets the following:

Criteria 1 = patient meets guidelines in Part 1 – “Decline in clinical Status”
OR
Criteria 2 = patient meets Disease Specific Guidelines in Part 3 plus non-disease specific guidelines in Part 2

Criteria 1

Part I – Decline in Clinical Status

  1. Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results.
    • Clinical Status
      1. Recurrent / intractable serious infections (pneumonia, sepsis or pyelonephritis)
      2. Progressive inanition:
        1. Weight loss of at least 10% body weight in the prior six months;
        2. Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth);
        3. Observation of ill-fitting clothes, decrease in skin turgor, increasing skin folds or other observation of weight loss in a patient without documented weight;
        4. Decreasing serum albumin or cholesterol;
        5. Dysphagia leading to recurrent aspiration and/or inadequate oral intake;
    • Symptoms
      1. Dyspnea with increasing respiratory rate;
      2. Cough, intractable;
      3. Nausea/vomiting poorly responsive to treatment;
      4. Diarrhea, intractable;
      5. Pain requiring increasing doses of major analgesics more than briefly.
    • Signs
      1. Decline in systolic blood pressure to below 90 or progressive postural hypotension;
      2. Ascites;
      3. Venous, arterial or lymphatic obstruction due to local progression or metastatic disease;
      4. Edema;
      5. Pleural/pericardial effusion;
      6. Weakness;
      7. Change in level of consciousness.
    • Laboratory Results
      1. Increasing pCO2 or decreasing pO2 or decreasing SaO2;
      2. Increasing calcium, creatinine or liver function studies;
      3. Increasing tumor markers (e.g. CEA, PSA);
      4. Progressively decreasing or increasing serum sodium or increasing serum potassium.
  2. Decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) due to progression of disease.
  3. Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST).
  4. Progression to dependence on assistance with additional activities of daily living (see Part II, Section 2).
  5. Progressive stage 3-4 pressure ulcers in spite of optimal care.
  6. History of increasing ER visits, hospitalizations, or physician visits related to the hospice primary diagnosis prior to election of the hospice benefit.

Criteria 2 – Part II and Part III should be met

Part II – Disease-Specific Guidelines in Conjunction with Non-Disease Specific Guidelines

Note: Presence of trach and/or g-tube does not disqualify patients, however, patients are considered eligible for hospice care if they do not elect tracheostomy and invasive ventilation, along with the following:

  1. Impaired respiratory function: Criteria A OR B
    1. Signs/Symptoms = ANY 3 OF THE FOLLOWING:
      • Dyspnea at rest OR Orthopnea
      • Use of accessory muscle of respiration OR RR > 20
      • Paradoxical abdominal respiration
      • Reduced speech OR vocal volume
      • Weakness cough OR unexplained nausea
      • Symptoms of sleep-disordered breathing
      • Frequent awakening
      • Daytime somnolence OR excessive sleepiness
      • Unexplained headaches OR confusion OR anxiety
    2. FVC < 40% predicted PLUS 2 OR MORE OF THE ABOVE
  2. Severe nutritional insufficiency
    Dysphagia with progressive weight loss of at least 5% of body weight with or without election for Gastrostomy tube insertion.

Note: Criteria 1 AND 2 required, Criteria 3 will lend supporting documentation.

  1. Optimally treated with vasodilators & diuretics
  2. For CHF & Angina – New York Heart Class IV
  3. Supportive documentation, but not required
    • EF of < 20%
    • Treatment-resistant symptomatic supraventricular or ventricular arrhythmias
    • History of cardiac arrest or resuscitation
    • History of unexplained syncope
    • Brain embolism of cardiac origin
    • Concomitant HIV disease

NYHA Classification of Heart Failure/Angina
Class IV—Severe

  • Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

Source: The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown & Co; 1994:253-256

Note: Criteria 1 AND 2 required; Criteria 3 will lend supporting documentation.

  1. CD4+ < 25 cells/mcL OR Persistent viral load > 100,000 copies/mL plus ANY:
    • CNS Lymphoma (untreated/treated-resistant)
    • Wasting (loss of at least 10% of lean body mass)
    • Mycobacterium Avium Complex bacteremia
    • Progressive Multifocal Leukoencephalopathy
    • Systemic Lymphoma, with advanced HIV disease
    • Visceral Kaposi’s Sarcoma
    • Renal failure in the absence of Dialysis
    • Cryptosporidium infection
    • Toxoplasmosis
  2. Palliative Performance Scale (PPS) ≤ 50%
  3. Supportive documentation, but not required:
    • Chronic persistent diarrhea for one year
    • Persistent Serum Albumin < 2.5 g/dL
    • Absence/resistance to effective antiretroviral/chemotherapeutic/prophylactic drug therapy
    • Advanced AIDS Dementia Complex
    • Toxoplasmosis
    • CHF, symptomatic at rest; NYHA Class IV
    • Advanced liver disease

Note: Criteria 1 AND 2 required, Criteria 3 will lend supporting documentation.

  1. Patient should show BOTH A & B:
    1. PT prolonged > 5 secs over control OR INR > 1.5
    2. Serum Albumin < 2.5 dm/dL
  2. And at least 1 of the following present:
    1. Ascites
    2. Spontaneous Bacterial Peritonitis
    3. Hepatorenal Syndrome (elevated Creatinine, BUN, with Oliguria (<400 mL/Day) and Urine Sodium concentration < 10 mEq/L)
    4. Hepatic Encephalopathy
    5. Recurrent Variceal bleeding
  3. Supportive documentation, but not required:
    1. Progressive malnutrition
    2. Muscle wasting with reduced strength and endurance
    3. Continued active alcoholism (> 80 gm Ethanol/day)
    4. Hepatocellular carcinoma
    5. HBsAg (Hepatitis B) positivity
    6. Hepatitis C refractory to interferon treatment

Examples: Chronic Bronchitis, Emphysema, COPD, Respiratory Failure, Pulmonary Fibrosis

Note: Criteria 1 AND 2 required; Criteria 3-5 will lend supporting documentation.

  1. Severe chronic disease documented by BOTH A & B:
    1. Disabling dyspnea at rest, unresponsive to bronchodilators. Optional: FEV1 < 30% predicted
    2. Increasing visits to ED or hospitalizations for pulmonary infections/respiratory failure. Optional: serial decrease of FEV1 > 40mL/year
  2. Hypoxemia OR Hypercapnia at rest on room air:
    1. pO2 < 55 mm Hg OR Oxygen Saturation < 88% OR pCO2 > 50 mm Hg
  3. Right Heart Failure (Cor pulmonale) secondary to Pulmonary disease
  4. Unintentional progressive weight loss > 10% body weight in 6 months
  5. Resting Tachycardia > 100/min

Note: Criteria 1 AND EITHER 2, 3 or 4 required; Criteria 5 will lend supporting documentation.

  1. Patient not seeking dialysis or renal transplant
    • ESRD benefit is separate from Hospice benefit; Patients can avail of both the Hospice benefit and the ESRD benefit when the need for dialysis is not related to the patient’s terminal illness.
  2. Creatinine clearance
    < 10 mL/min (< 15 mL/min if with DM)
    OR
    < 15 mL/min if with CHF (< 20 mL/min if with DM)
  3. Serum Creatinine
    > 8.0 mg/dL ( > 6.0 mg/dL if with DM)
  4. Estimated GFR < 10mL/min
  5. Comorbid conditions supportive, but not required:
    • Mechanical ventilation
    • Malignancy of other organ system
    • Chronic lung disease
    • Advanced cardiac or liver disease
    • Immunosuppression/AIDS
    • Albumin < 3.5 gm/dL
    • Platelet count < 25,000
    • Disseminated Intravascular Coagulation
    • Gastrointestinal bleeding

Note: Criteria 1 AND EITHER 2, 3 or 4 required; Criteria 5 will lend supporting documentation.

  1. Patient not seeking dialysis or renal transplant
    • ESRD benefit is separate from Hospice benefit; Patients can avail of both the Hospice benefit and the ESRD benefit when the need for dialysis is not related to the patient’s terminal illness.
  2. Creatinine clearance
    < 10 mL/min (< 15 mL/min if with DM)
    OR
    < 15 mL/min if with CHF (< 20 mL/min if with DM)
  3. Serum Creatinine
    > 8.0 mg/dL ( > 6.0 mg/dL if with DM)
  4. Signs & Symptoms of Renal Failure
    • Uremia
    • Oliguria (7.0 mmol/L)
    • Uremic pericarditis
    • Hepatorenal syndrome (elevated Creatinine, BUN, with Oliguria (less than 400 mL/24 hours) and Urine Sodium concentration less than 10 mEq/L)
    • Intractable fluid overload
  5. Estimated GFR < 10mL/min

STROKE/CVA: Hemiplegia or Generalized Muscle Weakness with or without Dysphagia as a late effect of CVA; Thromboembolic Stroke, Intracerebral Hemorrhage; Subdural Hematoma, Aneurysmal Bleed

  1. PPS Score of < 40%
  2. And at least 1 of the following:
      • Weight loss > 10 % in 6 months OR > 7.5 % in 3 months
      • Serum Albumin < 2.5 gm/dL
      • Pulmonary Aspiration
      • Inadequate intake by sequential caloric count
      • Severe dysphagia

COMA OF ANY ETIOLOGY:

  1. Coma patient with any 3 of the following on day 3 of coma:
    • Abnormal brain stem response
    • Absent verbal response
    • Absent withdrawal response to pain
    • Serum Creatinine > 1.5 mg/dL
  2. Medical complications due to progressive clinical decline within the previous 12 months:
    • Aspiration pneumonia
    • Pyelonephritis
    • Refractory Stage 3-4 Decubitus Ulcers
    • Fever recurrent after antibiotics
  3. Documentation of diagnostic imaging factors which support poor prognosis after stroke include:
    1. For non-traumatic hemorrhage stroke:
      1. Large-volume hemorrhage on CT:
        1. Infratentorial greater than or equal to 20 ml.;
        2. Supratentorial greater than or equal to 50 ml.
      2. Ventricular extension of hemorrhage;
      3. Surface area of involvement of hemorrhage greater than or equal to 30% of cerebrum;
      4. Midline shift greater than or equal to 1.5 cm.;
      5. Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt.
    2. For thrombotic/embolic stroke:
      1. Large anterior infarcts with both cortical and subcortical involvement;
      2. Large bihemispheric infarcts;
      3. Basilar artery occlusion;
      4. Bilateral vertebral artery occlusion.

Palliative Performance Scale

  1. Disease with metastases at presentation OR
  2. Progression from an earlier stage of disease to metastatic disease with either:
    Continued decline in spite of therapy OR patient declines further disease-directed therapy

Note: Certain cancers with poor prognoses may be hospice eligible without fulfilling the other criteria in this section.

Top 10 Cancer Incidence by Mortality:

  1. Lung and Bronchus
  2. Female Breast
  3. Prostate
  4. Colorectal
  5. Pancreas
  6. Ovary
  7. Liver & Biliary Tree
  8. Urinary
  9. Non-Hodgkin Lymphoma
  10. Kidney and brain

Source: 2015 Top Ten Cancers, United States Cancer Statistics 

  1. Impaired respiratory function: Criteria A OR B
    • No meaningful verbal conversation (FAST Stage 7 or beyond)
    • Unable to ambulate without assistance
    • Unable to dress without assistance
    • Unable to bathe without assistance
    • Urinary and Fecal incontinence
  2. And at least 1 characteristic within the past 12 months:
    • Aspiration pneumonia
    • Pyelonephritis
    • Septicemia
    • Decubitus Ulcer, multiple, Stage 3-4
    • Fever, recurrent after antibiotics
    • 10% weight loss in 6 months
    • Decreased Serum Albumin < 2.5 gm/dL

Part III – Non-Disease Specific Guidelines

  1. Physiologic Impairment
    Palliative Performance Score (PPS) less than 70%
  2. Dependence on 2 or more Activities of Daily Living (ADLs)
    Ambulation, Transfer, Dressing, Feeding, Bathing, Toileting
  3. Comorbidities
    Presence of the following, the severity of which is likely to contribute to a life expectancy of six months or less:

    Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure, Ischemic Heart Disease, Diabetes Mellitus (DM) Type 2, Neurologic disease (CVA, ALS, MS, Parkinson’s), Renal Failure, Liver Disease, Neoplasm, HIV / AIDS, Dementia, Refractory severe autoimmune disease (e.g. Lupus or Rheumatoid Arthritis)

Hospice Levels of Care

All the ways Remita Health cares for you

General Inpatient Care (GIP)
Provided only when the beneficiary requires an intensity of care directed towards pain control and symptom management that cannot be managed in any other setting. It is not intended to be custodial or residential.

Routine Home Care
Paid for each day the patient is under the care of the hospice and not receiving one of the other categories of hospice care.

Inpatient Respite Care
Provided only when necessary to relieve the family members or other persons caring for an individual at home.

Continuous “Crisis” Care
Provided only during periods of crisis to maintain the beneficiary at home. Not intended to provide routine or respite care for a patient who cannot be left alone.

Remita Hospice Team

Our hospice Interdisciplinary Group (IDG) meets regularly to address the unique needs of each patient and his or her family. We work together to create a community of compassionate care centered around the patient.

Remita Hospice Team Chart

Hospice Physician

  • Oversees patient care
  • Works collaboratively with the patient’s attending physician and the team

RN Case Manager

  • Manages the care delivery team and is the patient and family’s main point of contact
  • Supervises patient’s medical care; highly skilled in assessing and managing pain, and other symptoms that may occur at the end of life
  • Educates and trains caregivers to provide hands-on care
  • Educates the patient about their illness and what to expect as their condition changes
  • Maintains communication with the entire team

Certified Hospice Aide/Homemaker

  • Helps with personal care, such as bathing, dressing and oral/mouth care and feeding
  • May assist with feeding when assigned to do so by an RN
  • Performs light housekeeping around the patient’s area to assist with maintaining the patient’s safety

Social Worker

  • Helps provide emotional support to the patient and family
  • Assists patient and/or family with resources to help resolve any identified financial concerns
  • Assists with end-of-life preparation, such as funeral and mortuary arrangements
  • Helps to identify any pre-bereavement needs of the patient and those involved in the care of the patient
  • Helps to identify the bereavement needs of the patient’s loved ones after the patient’s passing

Spiritual Counselor

  • Works with the patient’s community clergy to ensure the spiritual needs of the patient and his/her loved ones are met
  • Available to provide spiritual support for the patient and family
  • Available to assist with memorial or funeral services

Hospice Volunteer

  • Specially trained volunteers are available to provide companionship and support to the patient and his/her loved ones
  • Can provide a short period of relief for the caregivers when pre-arranged with the hospice team

Bereavement Counselor

  • Assists patient and loved ones with support through provision of anticipatory grief counseling
  • Provides community resource referrals as needed for grief and loss support if needed
  • Works collaboratively with the interdisciplinary team to identify support needs of the patient and loved ones

To learn more about partnering with us or joining our team, please call the nearest Remita Health office.

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