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Clinical Indicators of Hospice Eligibility

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Exploring the Clinical Indicators of Hospice Eligibility: Is your patient eligible for hospice care, or do they need palliative care instead? Patients are eligible for hospice if they receive a terminal diagnosis from an MD, with a life expectancy determination of six months or less. Discover the crucial criteria in this guide for healthcare professionals.

There are also several condition-specific indicators of hospice eligibility for a list of terminal conditions, including ALS, muscular dystrophy, MS, stroke, cancer, Alzheimer’s, Parkinson’s, heart disease, renal disease, HIV/AIDS liver disease, protein-calorie malnutrition, COPD, and associated conditions.

See the full list of criteria for hospice eligibility for these and other medical diagnoses below. This article is intended for use as a diagnostic aid and can’t take the place of a full determination by a physician.

A quick reference guide, Clinical Indicators of Hospice Eligibility, is available for download [PDF].


Lou Gehrig Disease (ALS) / Muscular dystrophy
Myasthenia gravis / Multiple sclerosis

  1. Dyspnea at rest, O2 dependent, vital capacity 30%, dysphagia, no BiPAP/ventilator, bed/chair bound, assist with all ADL’s, O2 88% on RA.
  2. Recent progression to: Bed/chair bound, barely intelligible or unintelligible speech, assist with all ADL’s, pureed diet, documented weight loss, NO feeding tube, documented hypovolemia and dehydration
  3. Recent progression to: bed/chairbound, barely intelligible or unintelligible speech, assist with all ADL’s, pureed diet, sepsis, recurrent aspiration PNA, pyelonephritis, recurrent fevers, stage 3 or 4 pressure ulcers.

ALL ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.


Cerebrovascular Accident (CVA) / Stroke

  • * Decreased LOC
  • * PPS score ≤ 40%
  • Albumin ≤ 2.5
  • No artificial hydration or nutrition without decline or weight loss
  • Weight loss of 10% in past 6 months or 7.5% in the last 3 months
  • Unable to intake adequate nutrition
  • Recurrent infections
  • Assist with all ADL’s
  • Post stroke dementia

* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.


Cancer

  • * Metastasis to multiple sites
  • * Choosing palliative care and to stop chemotherapy/radiation
  • Small cell lung, brain and pancreatic cancers do not require metastasis
  • Weight loss
  • Karnofsky ≤ 70%

* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.


Dementia / Alzheimer’s

  • * FAST 7A or beyond
  • * Unable to walk without physical assistance
  • * Assist with bathing, dressing and ambulating
  • * Less than 6 intelligible words, or no consistent meaningful conversation
  • * At least 2 of the following complications within last 12 months: PNA, UTI, sepsis, pyelonephritis, stage 3 or 4 pressure ulcers, recurrent fevers
  • * Urinary and fecal incontinence, either intermittently or constantly
  • Difficulty swallowing
  • Albumin ≤ 2.5

* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.


Parkinson’s Disease

  • Tremors in extremities
  • Dysphagia
  • Garbled speech
  • Ambulation decline
  • Dyspnea at rest
  • Increased assistance with ADL’s

* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.


Heart Disease / Coronary Artery Disease (CAD) Chronic Heart Failure (CHF)

  • * NYHA Class IV (for pts w/CHF or angina)
  • * Arrhythmias resistant to treatment
  • * No BiPAP unless will DC in near future
  • EF 20% or less
  • Physical symptoms at rest
  • Inability to tolerate vasodilators
  • BNP ≥ 1000
  • Symptomatic despite max medical tx
  • Hx of syncope or cardiac arrest
  • Cardiogenic embolic CVA

* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.


Protein Calorie Malnutrition

  • * Albumin ≤ 2.5
  • * Extreme, unintentional weight loss
  • * Weakness/Falls
  • * Assist with all ADLs
  • * Bed/chair existence
  • * NO feeding tube without continued decline and weight loss
  • * Recent documented infections
  • BMI of 22 or less
  • Recent ER visit/hospitalizations

* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.


Renal Disease

  • * Plan for discontinuing dialysis
  • * At least 2 of the following: serum creatinine ≥ 8.0 or ≥6.0 for Diabetics, uremia (confusion, nausea, pruritus, restlessness), oliguria (< 400cc/day), uremic pericarditis, hepatorenal syndrome, intractable fluid overload, or creatinine clearance of ≤ 10cc/min or 15cc/min for diabetics, hyperkalemia (Potassium ≥ 7.0)
  • GFR ≤ 10mL/min

* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.


Human Immunodeficiency Virus (HIV)
Acquired Immunodeficiency Syndrome (Aids)

  • * Wasting syndrome
  • * CNS lymphoma/Kaposi’s sarcoma
  • * Viral load ≥ 100,000
  • PPS ≤ 50%
  • Co-morbidities/severe infections
  • Albumin ≤ 2.5
  • CD4 + ≤ 25

* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.


Liver Disease

  • * PT ≤ 5 or INR ≥1.5
  • * Albumin ≤ 2.5
  • * At least 2 of the following: ascites, peritonitis, hepatorenal syndrome, (elevated BUN & Creatinine with oliguria 400mL/day & urine sodium concentration ≤ 10 mEq/L), recurrent variceal bleeding, hepatic encephalopathy with somnolence
  • Malnutrition, continued active alcoholism, Hep B positive, hepatocellular carcinoma, Hep C refractory to interferon treatment

* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.


Pulmonary Disease
Chronic Obstructive Pulmonary Disease (COPD)

  • * O2 dependent
  • * Poor response to bronchodilators
  • * O2 ≤ 88% on room air
  • * Recurrent pulmonary infections
  • * Resting tachycardia
  • * Hypercapnia/hypoxemia
  • * Dyspnea at rest
  • * Bed-to-chair existence
  • * Increased ER visits/hospitalizations
  • * No BiPAP unless will DC in near future
  • Weight loss of 10% in past 6 months
  • Cor Pulmonale/Right Heart Failure

* ALL STARED ITEMS MUST BE PRESENT FOR ADMITTING DIAGNOSIS
Coverage for hospice care may still be appropriate for patients not meeting these determinants due to co-morbidity or rapid decline.


For more information or to make a referral:

For the full criteria guidance on the factors influencing hospice eligibility, please contact us or see the complete LCD guide on the CMS website. You can also make a hospice referral using the contact information below.

The Sage Family of Companies provides hospice services in:

Sage Hospice
Arizona

Sage Hospice
Tucson

Elevation Hospice
Colorado

Elevation Hospice
Utah

Agape Hospice Georgia

Sage Hospice
Arizona

Sage Hospice
Tucson

Elevation Hospice
Colorado

Elevation Hospice
Utah

Agape Hospice Georgia

Robert LaBarge is the Director of Digital Marketing and Corporate Communications for the Sage Family of Companies. Robert has spent nearly three decades creating healthcare marketing communications for Eli Lilly, Merck, the Jewish Home and Hospital – New York City, the Cleveland Clinic – Cleveland, and the Medical University of South Carolina – Charleston.