Hospice Care
Hospice is a service provided by an interdisciplinary care team to any patient who is diagnosed with a terminal illness and certified by a physician that they have less than six months to live. While traditional medical care focuses on treating disease and illness, hospice care centers on improving the quality of life for the individual, in addition to providing support and education to the family. Hospice care provides a team-oriented approach to delivering medical care, pain management, and emotional and spiritual support individualized to the patient’s needs and wishes. The service is provided where the patient resides, at home or in a facility. At Care Dimensions Healthcare, our mission is to provide compassionate, quality care with respect and comfort to our patients and their families/caregivers.
Hospice Care
Hospice is a service provided by an interdisciplinary care team to any patient who is diagnosed with a terminal illness and certified by a physician that they have less than six months to live. While traditional medical care focuses on treating disease and illness, hospice care centers on improving the quality of life for the individual, in addition to providing support and education to the family. Hospice care provides a team-oriented approach to delivering medical care, pain management, and emotional and spiritual support individualized to the patient’s needs and wishes. The service is provided where the patient resides, at home or in a facility. At Care Dimensions Healthcare, our mission is to provide compassionate, quality care with respect and comfort to our patients and their families/caregivers.
Hospice Care Eligibility
One must satisfy the criteria developed by the Centers for Medicare and Medicaid services, as listed below, in order to be eligible for hospice care:
- The Hospice Care agency must be Medicare-certified.
- The attending physician (if they have one) and the hospice physician must certify the patient as terminally ill with a medical prognosis of 6 months or less to live if the illness runs its normal course.
- The patient must sign an election statement to elect the hospice benefit and waive all rights to Medicare payments for the terminal illness and related conditions.
- A physician or a healthcare professional that works with the doctor must document a face-to-face encounter within a specified time and the encounter must be related to the patient’s need for home health care.
-
- Palliative Performance Score (PPS) less than 70%
- Dependence on 2 or more Activities of Daily Living (ADLs)
- SOB at rest or with minimal exertion
- Multiple ER visits or hospitalizations
- Recurrent falls with injury
- Weight loss of 10% or more in last 6 months
- Presence of the following Comorbidities, the severity of which is likely to contribute to the life expectancy of 6 months or less:
- Cancer
- COPD
- CHF
- Liver Disease
- Ischemic Heart Disease
- Neurologic Disease (CVA, ALS, MS, Parkinson’s)
- Type 2 Diabetes Mellitus (DM)
- Renal Failure
- HIV/AIDS
- Dementia/Alzheimer’s
- Refractory severe autoimmune disease (Lupus or Rheumatoid Arthritis)
Palliative Performance Scale (PPS)
These guidelines are provided as a reference tool but do not take the place of a physician’s professional judgment. Use in conjunction with “Non Disease Specific Guidelines”.
- Patient declines further chemotherapy/immunotherapy
- Cancer has metastasized
- Continued decline in spite of therapy
- Certain cancers with poor prognosis may be hospice eligible without fulfilling the other criteria in this section
Neurological Diseases (Amyotrophic Lateral Sclerosis/ Lou Gehrig’s Disease (ALS), Multiple Sclerosis, Non-Alzheimer’s Dementia, Parkinson’s, Huntington’s disease, etc.).
Use in conjunction with “Non Disease Specific Guidelines”.
- Inability to swallow liquids or soft food without choking or coughing
- Inability to clear respiratory secretions, persistent cough, recurrent aspiration pneumonia, and severely compromised breathing
- Impaired communication marked by barely intelligible speech
- Patient/family declines to continuation of a feeding tube or ventilator/tracheostomy
Use in conjunction with “Non Disease Specific Guidelines”.
- All of the following characteristics present:
- FAST Stage of 7a or above
- Unable to dress without assistance
- Unable to bathe without assistance
- Unable to ambulate without assistance
- Urinary and Fecal incontinence
- Loss of basic motor skills
AND
- At least 1 of the following within the past year:
- Aspiration pneumonia
- Septicemia
- Pyelonephritis
- Decubitus Ulcer, Multiple stage 3‐4
- Fever, recurrent after a course of antibiotics
- 10% weight loss in 6 months or decreased serum albumin < 2.5 gm/dl
Heart Diseases (Congestive Heart Failure, CAD, Cardiomyopathy, Ischemic Heart Disease, Myocardial Infarction, Hypertensive Heart Disease, Valvular Heart Disease, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
- Optimally treated with vasodilators and diuretics
- For CHF and Angina ‐ New York Heart Association (NYHA) Class IV (Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increase)
- May need supportive documentation, but NOT required:
- EF of < 20%
- History of cardiac arrest or resuscitation
- Treatment resistant symptomatic supraventricular or ventricular arrhythmias
- History of unexplained syncope Brain embolism of cardiac origin
Use in conjunction with “Non Disease Specific Guidelines”.
- CD4+ <25 cells/mcl or Persistent viral load > 100,000 copies/ml plus any of the following:
- CNS Lymphoma (untreated/treatment resistant)
- Wasting (loss of at least 10% of lean body mass)
- Progressive multifocal leukoencephalopathy
- Mycobacterium avium complex bacteremia
- Systemic lymphoma with advanced HIV disease
- Visceral Kaposi’s sarcoma
- Renal failure in the absence of dialysis
- Cryptosporidium infection
- Toxoplasmosis
- Palliative performance scale (PPS) ≤ 50%
- May need supportive documentation, but NOT required:
- Chronic persistent diarrhea for 1 year
- Concomitant, active substance abuse
- Persistent serum albumin < 2.5 gm/dL
- Age > 50 years
- Advances AIDS dementia complex
- Absence/resistance to effective therapy
- Toxoplasmosis
- CHF, symptomatic at rest, NYHA Class IV
- Advance Liver Disease
Liver Disease (Chronic Hepatitis, Liver Cirrhosis, Biliary Cirrhosis, Hepatic Fibrosis, Hepatic Encephalopathy, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
- Patient should have both:
- PT prolonged > 5 secs over control or INR > 1.5
- Serum Albumin < 2.5 gm/dL
- And at least 1 of the following present:
- Ascites
- Spontaneous Bacterial Peritonitis
- Hepatic Encephalopathy
- Hepatorenal Syndrome
- Recurrent Variceal bleeding
- May need supportive documentation, but NOT required:
- Progressive malnutrition
- Muscle wasting with reduced strength and endurance
- Hepatocellular carcinoma
- Continued active alcoholism (> 80 gm Ethanol/day)
- HBsAG (Hepatitis B positivity)
- Hepatitis C refractory to interferon treatment
Pulmonary Disease (Chronic Bronchitis, COPD, Emphysema, Respiratory Failure, Pulmonary Fibrosis, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
- Patient should have both:
- Disabling dyspnea at rest, poorly or unresponsive to bronchodilators (Decreased FEV1 optional)
- Increasing visits to the ED or hospitalizations for pulmonary infections/respiratory failure
- Hypoxemia or Hypercapnia at rest and on room air (pO2 ≤ 55mm HG OR Oxygen saturation ≤ 88% OR pCO2 ≤ 55 mm Hg)
- May need supportive documentation:
- Right heart failure secondary to Cor Pulmonale
- Unintentional weight loss > 10% body weight in 6 months
- Resting tachycardia > 100/min
Use in conjunction with “Non Disease Specific Guidelines”.
- Patient is not seeking dialysis or renal transplant (Note: 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 condition.)
- And at least 1 of the following present:
- Creatinine level < 10 mL/min (<15 mL/min id with DM) or < 15 mL/min if with CHF (<20 mL/min if with DM)
- Serum Creatinine > 8.0mg/dL (>6.0 mg/dL if with DM)
- Estimated GFR <10 mL/min
- May need supportive documentation:
- 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
Stroke/CVA/Coma (Hemiplegia or Generalized Muscle Weakness with or without Dysphagia as a late effect of CVA, Thromboembolic Stroke, Intracerebral Hemorrhage, Subdural Hematoma, Aneurysmal Bleed, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
- PPS Score of < 40%
- And at least 1 of the following present:
- Weight loss > 10% in 6 months or > 7.5% in 3 months
- Pulmonary Aspiration
- Serum Albumin < 2.5gm/dL
- Inadequate intake by sequential calorie count
- Severe dysphagia
- Coma of any etiology or coma patient with any 3 of the following on day 3 of the coma:
- Abnormal brainstem response
- Absent verbal response
- Serum Creatinine > 1.5 mg/dL
- Absent withdrawal response to pain
- May need supportive documentation:
- Medical complications
- Progressive clinical decline for past 1 year
- Aspiration pneumonia
- Refractory Stage 3‐4 decubitus ulcers
- Pyelonephritis
One must satisfy the criteria developed by the Centers for Medicare and Medicaid services, as listed below, in order to be eligible for hospice care:
- The Hospice Care agency must be Medicare-certified.
- The attending physician (if they have one) and the hospice physician must certify the patient as terminally ill with a medical prognosis of 6 months or less to live if the illness runs its normal course.
- The patient must sign an election statement to elect the hospice benefit and waive all rights to Medicare payments for the terminal illness and related conditions.
- A physician or a healthcare professional that works with the doctor must document a face-to-face encounter within a specified time and the encounter must be related to the patient’s need for home health care.
If a patient meets at least 2, consider Hospice:
- Palliative Performance Score (PPS) less than 70%
- Dependence on 2 or more Activities of Daily Living (ADLs)
- SOB at rest or with minimal exertion
- Multiple ER visits or hospitalizations
- Recurrent falls with injury
- Weight loss of 10% or more in last 6 months
- Presence of the following Comorbidities, the severity of which is likely to contribute to the life expectancy of 6 months or less:
- Cancer
- COPD
- CHF
- Liver Disease
- Ischemic Heart Disease
- Neurologic Disease (CVA, ALS, MS, Parkinson’s)
- Type 2 Diabetes Mellitus (DM)
- Renal Failure
- HIV/AIDS
- Dementia/Alzheimer’s
- Refractory severe autoimmune disease (Lupus or Rheumatoid Arthritis)
These guidelines are provided as a reference tool but do not take the place of a physician’s professional judgment.
Use in conjunction with “Non Disease Specific Guidelines”.
Patient declines further chemotherapy/immunotherapy
Cancer has metastasized
Continued decline in spite of therapy
Certain cancers with poor prognosis may be hospice eligible without fulfilling the other criteria in this section
Neurological Diseases (Amyotrophic Lateral Sclerosis/ Lou Gehrig’s Disease (ALS), Multiple Sclerosis, Non-Alzheimer’s Dementia, Parkinson’s, Huntington’s disease, etc.).
Use in conjunction with “Non Disease Specific Guidelines”.
Inability to swallow liquids or soft food without choking or coughing
Inability to clear respiratory secretions, persistent cough, recurrent aspiration pneumonia, and severely compromised breathing
Impaired communication marked by barely intelligible speech
Patient/family declines to continuation of a feeding tube or ventilator/tracheostomy
Use in conjunction with “Non Disease Specific Guidelines”.
- All of the following characteristics present:
- FAST Stage of 7a or above
- Unable to dress without assistance
- Unable to bathe without assistance
- Unable to ambulate without assistance
- Urinary and Fecal incontinence
- Loss of basic motor skills
AND
- At least 1 of the following within the past year:
- Aspiration pneumonia
- Septicemia
- Pyelonephritis
- Decubitus Ulcer, Multiple stage 3‐4
- Fever, recurrent after a course of antibiotics
- 10% weight loss in 6 months or decreased serum albumin < 2.5 gm/dl
Heart Diseases (Congestive Heart Failure, CAD, Cardiomyopathy, Ischemic Heart Disease, Myocardial Infarction, Hypertensive Heart Disease, Valvular Heart Disease, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
- Optimally treated with vasodilators and diuretics
- For CHF and Angina ‐ New York Heart Association (NYHA) Class IV (Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increase)
- May need supportive documentation, but NOT required:
- EF of < 20%
- History of cardiac arrest or resuscitation
- Treatment resistant symptomatic supraventricular or ventricular arrhythmias
- History of unexplained syncope Brain embolism of cardiac origin
Use in conjunction with “Non Disease Specific Guidelines”.
CD4+ <25 cells/mcl or Persistent viral load > 100,000 copies/ml plus any of the following:
CNS Lymphoma (untreated/treatment resistant)
Wasting (loss of at least 10% of lean body mass)
Progressive multifocal leukoencephalopathy
Mycobacterium avium complex bacteremia
Systemic lymphoma with advanced HIV disease
Visceral Kaposi’s sarcoma
Renal failure in the absence of dialysis
Cryptosporidium infection
Toxoplasmosis
Palliative performance scale (PPS) ≤ 50%
May need supportive documentation, but NOT required:
Chronic persistent diarrhea for 1 year
Concomitant, active substance abuse
Persistent serum albumin < 2.5 gm/dL
Age > 50 years
Advances AIDS dementia complex
Absence/resistance to effective therapy
Toxoplasmosis
CHF, symptomatic at rest, NYHA Class IV
Advance Liver Disease
Liver Disease (Chronic Hepatitis, Liver Cirrhosis, Biliary Cirrhosis, Hepatic Fibrosis, Hepatic Encephalopathy, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
Patient should have both:
PT prolonged > 5 secs over control or INR > 1.5
Serum Albumin < 2.5 gm/dL
And at least 1 of the following present:
Ascites
Spontaneous Bacterial Peritonitis
Hepatic Encephalopathy
Hepatorenal Syndrome
Recurrent Variceal bleeding
May need supportive documentation, but NOT required:
Progressive malnutrition
Muscle wasting with reduced strength and endurance
Hepatocellular carcinoma
Continued active alcoholism (> 80 gm Ethanol/day)
HBsAG (Hepatitis B positivity)
Hepatitis C refractory to interferon treatment
Pulmonary Disease (Chronic Bronchitis, COPD, Emphysema, Respiratory Failure, Pulmonary Fibrosis, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
Patient should have both:
Disabling dyspnea at rest, poorly or unresponsive to bronchodilators (Decreased FEV1 optional)
Increasing visits to the ED or hospitalizations for pulmonary infections/respiratory failure
Hypoxemia or Hypercapnia at rest and on room air (pO2 ≤ 55mm HG OR Oxygen saturation ≤ 88% OR pCO2 ≤ 55 mm Hg)
May need supportive documentation:
Right heart failure secondary to Cor Pulmonale
Unintentional weight loss > 10% body weight in 6 months
Resting tachycardia > 100/min
Use in conjunction with “Non Disease Specific Guidelines”.
Patient is not seeking dialysis or renal transplant (Note: 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 condition.)
And at least 1 of the following present:
Creatinine level < 10 mL/min (<15 mL/min id with DM) or < 15 mL/min if with CHF (<20 mL/min if with DM)
Serum Creatinine > 8.0mg/dL (>6.0 mg/dL if with DM)
Estimated GFR <10 mL/min
May need supportive documentation:
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
Stroke/CVA/Coma (Hemiplegia or Generalized Muscle Weakness with or without Dysphagia as a late effect of CVA, Thromboembolic Stroke, Intracerebral Hemorrhage, Subdural Hematoma, Aneurysmal Bleed, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
PPS Score of < 40%
And at least 1 of the following present:
Weight loss > 10% in 6 months or > 7.5% in 3 months
Pulmonary Aspiration
Serum Albumin < 2.5gm/dL
Inadequate intake by sequential calorie count
Severe dysphagia
Coma of any etiology or coma patient with any 3 of the following on day 3 of the coma:
Abnormal brainstem response
Absent verbal response
Serum Creatinine > 1.5 mg/dL
Absent withdrawal response to pain
May need supportive documentation:
Medical complications
Progressive clinical decline for past 1 year
Aspiration pneumonia
Refractory Stage 3‐4 decubitus ulcers
Pyelonephritis
One must satisfy the criteria developed by the Centers for Medicare and Medicaid services, as listed below, in order to be eligible for hospice care:
- The Hospice Care agency must be Medicare-certified.
- The attending physician (if they have one) and the hospice physician must certify the patient as terminally ill with a medical prognosis of 6 months or less to live if the illness runs its normal course.
- The patient must sign an election statement to elect the hospice benefit and waive all rights to Medicare payments for the terminal illness and related conditions.
- A physician or a healthcare professional that works with the doctor must document a face-to-face encounter within a specified time and the encounter must be related to the patient’s need for home health care.
If a patient meets at least 2, consider Hospice:
- Palliative Performance Score (PPS) less than 70%
- Dependence on 2 or more Activities of Daily Living (ADLs)
- SOB at rest or with minimal exertion
- Multiple ER visits or hospitalizations
- Recurrent falls with injury
- Weight loss of 10% or more in last 6 months
- Presence of the following Comorbidities, the severity of which is likely to contribute to the life expectancy of 6 months or less:
- Cancer
- COPD
- CHF
- Liver Disease
- Ischemic Heart Disease
- Neurologic Disease (CVA, ALS, MS, Parkinson’s)
- Type 2 Diabetes Mellitus (DM)
- Renal Failure
- HIV/AIDS
- Dementia/Alzheimer’s
- Refractory severe autoimmune disease (Lupus or Rheumatoid Arthritis)
These guidelines are provided as a reference tool but do not take the place of a physician’s professional judgment.
- Cancer
Use in conjunction with “Non Disease Specific Guidelines”.
- Patient declines further chemotherapy/immunotherapy
- Cancer has metastasized
- Continued decline in spite of therapy
- Certain cancers with poor prognosis may be hospice eligible without fulfilling the other criteria in this section
- Neurological Diseases (Amyotrophic Lateral Sclerosis/ Lou Gehrig’s Disease (ALS), Multiple Sclerosis, Non-Alzheimer’s Dementia, Parkinson’s, Huntington’s disease, etc.).
Use in conjunction with “Non Disease Specific Guidelines”.
- Inability to swallow liquids or soft food without choking or coughing
- Inability to clear respiratory secretions, persistent cough, recurrent aspiration pneumonia, and severely compromised breathing
- Impaired communication marked by barely intelligible speech
- Patient/family declines to continuation of a feeding tube or ventilator/tracheostomy
- Alzheimer’s Disease
Use in conjunction with “Non Disease Specific Guidelines”.
- All of the following characteristics present:
- FAST Stage of 7a or above
- Unable to dress without assistance
- Unable to bathe without assistance
- Unable to ambulate without assistance
- Urinary and Fecal incontinence
- Loss of basic motor skills
AND
- At least 1 of the following within the past year:
- Aspiration pneumonia
- Septicemia
- Pyelonephritis
- Decubitus Ulcer, Multiple stage 3‐4
- Fever, recurrent after a course of antibiotics
- 10% weight loss in 6 months or decreased serum albumin < 2.5 gm/dl
- Heart Diseases (Congestive Heart Failure, CAD, Cardiomyopathy, Ischemic Heart Disease, Myocardial Infarction, Hypertensive Heart Disease, Valvular Heart Disease, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
- Optimally treated with vasodilators and diuretics
- For CHF and Angina ‐ New York Heart Association (NYHA) Class IV (Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increase)
- May need supportive documentation, but NOT required:
- EF of < 20%
- History of cardiac arrest or resuscitation
- Treatment resistant symptomatic supraventricular or ventricular arrhythmias
- History of unexplained syncope Brain embolism of cardiac origin
- HIV/AIDS
Use in conjunction with “Non Disease Specific Guidelines”.
- CD4+ <25 cells/mcl or Persistent viral load > 100,000 copies/ml plus any of the following:
- CNS Lymphoma (untreated/treatment resistant)
- Wasting (loss of at least 10% of lean body mass)
- Progressive multifocal leukoencephalopathy
- Mycobacterium avium complex bacteremia
- Systemic lymphoma with advanced HIV disease
- Visceral Kaposi’s sarcoma
- Renal failure in the absence of dialysis
- Cryptosporidium infection
- Toxoplasmosis
- Palliative performance scale (PPS) ≤ 50%
- May need supportive documentation, but NOT required:
- Chronic persistent diarrhea for 1 year
- Concomitant, active substance abuse
- Persistent serum albumin < 2.5 gm/dL
- Age > 50 years
- Advances AIDS dementia complex
- Absence/resistance to effective therapy
- Toxoplasmosis
- CHF, symptomatic at rest, NYHA Class IV
- Advance Liver Disease
- Liver Disease (Chronic Hepatitis, Liver Cirrhosis, Biliary Cirrhosis, Hepatic Fibrosis, Hepatic Encephalopathy, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
- Patient should have both:
- PT prolonged > 5 secs over control or INR > 1.5
- Serum Albumin < 2.5 gm/dL
- And at least 1 of the following present:
- Ascites
- Spontaneous Bacterial Peritonitis
- Hepatic Encephalopathy
- Hepatorenal Syndrome
- Recurrent Variceal bleeding
- May need supportive documentation, but NOT required:
- Progressive malnutrition
- Muscle wasting with reduced strength and endurance
- Hepatocellular carcinoma
- Continued active alcoholism (> 80 gm Ethanol/day)
- HBsAG (Hepatitis B positivity)
- Hepatitis C refractory to interferon treatment
- Pulmonary Disease (Chronic Bronchitis, COPD, Emphysema, Respiratory Failure, Pulmonary Fibrosis, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
- Patient should have both:
- Disabling dyspnea at rest, poorly or unresponsive to bronchodilators (Decreased FEV1 optional)
- Increasing visits to the ED or hospitalizations for pulmonary infections/respiratory failure
- Hypoxemia or Hypercapnia at rest and on room air (pO2 ≤ 55mm HG OR Oxygen saturation ≤ 88% OR pCO2 ≤ 55 mm Hg)
- May need supportive documentation:
- Right heart failure secondary to Cor Pulmonale
- Unintentional weight loss > 10% body weight in 6 months
- Resting tachycardia > 100/min
- Renal Disease
Use in conjunction with “Non Disease Specific Guidelines”.
- Patient is not seeking dialysis or renal transplant (Note: 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 condition.)
- And at least 1 of the following present:
- Creatinine level < 10 mL/min (<15 mL/min id with DM) or < 15 mL/min if with CHF (<20 mL/min if with DM)
- Serum Creatinine > 8.0mg/dL (>6.0 mg/dL if with DM)
- Estimated GFR <10 mL/min
- May need supportive documentation:
- 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
- Stroke/CVA/Coma (Hemiplegia or Generalized Muscle Weakness with or without Dysphagia as a late effect of CVA, Thromboembolic Stroke, Intracerebral Hemorrhage, Subdural Hematoma, Aneurysmal Bleed, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
- PPS Score of < 40%
- And at least 1 of the following present:
- Weight loss > 10% in 6 months or > 7.5% in 3 months
- Pulmonary Aspiration
- Serum Albumin < 2.5gm/dL
- Inadequate intake by sequential calorie count
- Severe dysphagia
- Coma of any etiology or coma patient with any 3 of the following on day 3 of the coma:
- Abnormal brainstem response
- Absent verbal response
- Serum Creatinine > 1.5 mg/dL
- Absent withdrawal response to pain
- May need supportive documentation:
- Medical complications
- Progressive clinical decline for past 1 year
- Aspiration pneumonia
- Refractory Stage 3‐4 decubitus ulcers
- Pyelonephritis
Stage
Characteristics
1-6
Not eligible
7a
Speaks <= 6 words during the day
7b
Speaks one intelligible word during the day
7c
Ability to ambulate is lost
7d
Not able to sit up without assistance
7e
Ability to smile is lost
7f
Ability to hold up head independently is lost
PPS Level
Ambulation
Activity & Evidence of Disease
Self Care
Intake
Conscious Level
100%
Full
Normal Activity & work. No evidence of disease.
Full
Normal
Full
90%
Full
Normal Activity & work. Some evidence of disease.
Full
Normal
Full
80%
Full
Normal Activity with Effort. Some evidence of disease.
Full
Normal or Reduced
Full
70%
Reduced
Unable to work Normal job. Significant disease.
Full
Normal or Reduced
Full
60%
Reduced
Unable hobby/house work. Significant disease.
Occasional assistance necessary
Normal or Reduced
Full or Confusion
50%
Mainly Sit/Lie
Unable to do any work. Extensive disease.
Considerable assistance required
Normal or Reduced
Full or Confusion
40%
Mainly in bed
Unable to do most activity. Extensive disease.
Mainly assistance
Normal or Reduced
Full or Drowsy +/- Confusion
30%
Totally Bed Bound
Unable to do any activity. Extensive disease.
Total Care
Normal or Reduced
Full or Drowsy +/- Confusion
20%
Totally Bed Bound
Unable to do any activity. Extensive disease.
Total Care
Minimal to sips
Full or Drowsy +/- Confusion
10%
Totally Bed Bound
Unable to do any activity.
Totally Bed Bound
Mouth Care only
Drowsy or Coma +/- Confusion
Stage
- 1-6
- 7a
- 7b
- 7c
- 7d
- 7e
- 7f
Characteristics
- Not eligible
- Speaks <= 6 words during the day
- Speaks one intelligible word during the day
- Ability to ambulate is lost
- Not able to sit up without assistance
- Ability to smile is lost
- Ability to hold up head independently is lost
Disease Specific Guidelines
- Heart Diseases (Congestive Heart Failure, CAD, Cardiomyopathy, Ischemic Heart Disease, Myocardial Infarction, Hypertensive Heart Disease, Valvular Heart Disease, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
- Optimally treated with vasodilators and diuretics
- For CHF and Angina ‐ New York Heart Association (NYHA) Class IV (Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increase)
- May need supportive documentation, but NOT required:
- EF of < 20%
- History of cardiac arrest or resuscitation
- Treatment resistant symptomatic supraventricular or ventricular arrhythmias
- History of unexplained syncope Brain embolism of cardiac origin
- HIV/AIDS
Use in conjunction with “Non Disease Specific Guidelines”.
- CD4+ <25 cells/mcl or Persistent viral load > 100,000 copies/ml plus any of the following:
- CNS Lymphoma (untreated/treatment resistant)
- Wasting (loss of at least 10% of lean body mass)
- Progressive multifocal leukoencephalopathy
- Mycobacterium avium complex bacteremia
- Systemic lymphoma with advanced HIV disease
- Visceral Kaposi’s sarcoma
- Renal failure in the absence of dialysis
- Cryptosporidium infection
- Toxoplasmosis
- Palliative performance scale (PPS) ≤ 50%
- May need supportive documentation, but NOT required:
- Chronic persistent diarrhea for 1 year
- Concomitant, active substance abuse
- Persistent serum albumin < 2.5 gm/dL
- Age > 50 years
- Advances AIDS dementia complex
- Absence/resistance to effective therapy
- Toxoplasmosis
- CHF, symptomatic at rest, NYHA Class IV
- Advance Liver Disease
- Liver Disease (Chronic Hepatitis, Liver Cirrhosis, Biliary Cirrhosis, Hepatic Fibrosis, Hepatic Encephalopathy, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
- Patient should have both:
- PT prolonged > 5 secs over control or INR > 1.5
- Serum Albumin < 2.5 gm/dL
- And at least 1 of the following present:
- Ascites
- Spontaneous Bacterial Peritonitis
- Hepatic Encephalopathy
- Hepatorenal Syndrome
- Recurrent Variceal bleeding
- May need supportive documentation, but NOT required:
- Progressive malnutrition
- Muscle wasting with reduced strength and endurance
- Hepatocellular carcinoma
- Continued active alcoholism (> 80 gm Ethanol/day)
- HBsAG (Hepatitis B positivity)
- Hepatitis C refractory to interferon treatment
- Pulmonary Disease (Chronic Bronchitis, COPD, Emphysema, Respiratory Failure, Pulmonary Fibrosis, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
- Patient should have both:
- Disabling dyspnea at rest, poorly or unresponsive to bronchodilators (Decreased FEV1 optional)
- Increasing visits to the ED or hospitalizations for pulmonary infections/respiratory failure
- Hypoxemia or Hypercapnia at rest and on room air (pO2 ≤ 55mm HG OR Oxygen saturation ≤ 88% OR pCO2 ≤ 55 mm Hg)
- May need supportive documentation:
- Right heart failure secondary to Cor Pulmonale
- Unintentional weight loss > 10% body weight in 6 months
- Resting tachycardia > 100/min
- Renal Disease
Use in conjunction with “Non Disease Specific Guidelines”.
- Patient is not seeking dialysis or renal transplant (Note: 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 condition.)
- And at least 1 of the following present:
- Creatinine level < 10 mL/min (<15 mL/min id with DM) or < 15 mL/min if with CHF (<20 mL/min if with DM)
- Serum Creatinine > 8.0mg/dL (>6.0 mg/dL if with DM)
- Estimated GFR <10 mL/min
- May need supportive documentation:
- 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
- Stroke/CVA/Coma (Hemiplegia or Generalized Muscle Weakness with or without Dysphagia as a late effect of CVA, Thromboembolic Stroke, Intracerebral Hemorrhage, Subdural Hematoma, Aneurysmal Bleed, etc.)
Use in conjunction with “Non Disease Specific Guidelines”.
- PPS Score of < 40%
- And at least 1 of the following present:
- Weight loss > 10% in 6 months or > 7.5% in 3 months
- Pulmonary Aspiration
- Serum Albumin < 2.5gm/dL
- Inadequate intake by sequential calorie count
- Severe dysphagia
- Coma of any etiology or coma patient with any 3 of the following on day 3 of the coma:
- Abnormal brainstem response
- Absent verbal response
- Serum Creatinine > 1.5 mg/dL
- Absent withdrawal response to pain
- May need supportive documentation:
- Medical complications
- Progressive clinical decline for past 1 year
- Aspiration pneumonia
- Refractory Stage 3‐4 decubitus ulcers
- Pyelonephritis
