HOSPICE CRITERIA AND

RECERTIFICATION

Paul Rozynes, M.D.

Medical Director

VITAS Broward

GOALS OF THIS LECTURE

1.To understand common diagnoses used to admit a patient to Hospice and what criteria are used for each diagnosis.

2. To understand the “tools” used to evaluate whether a patient is Hospice appropriate.

COMMON HOSPICE DIAGNOSES

1. Cerebral degeneration, dementia, Alzheimer’s disease

2. Parkinson,s disease3. Cerebrovascular disease4. Heart disease a. Valvular heart disease b. Coronary artery disease c. Congestive heart failure d. Arrhythmia 5. Chronic obstructive lung disease6. Malignancies

COMMON HOSPICE DIAGNOSES

7. Failure to thrive8. End stage renal disease9. Cirrhosis10. Peripheral vascular disease with

gangrene11. Abdominal or thoracic aortic aneurism12. HIV

HOSPICE “TOOLS’

1. BMI-Body Mass Index. This is a ratio of height to weight.

HOSPICE “TOOLS’

2. MMA-Mid Muscle Area. This is a ratio of mid arm circumference (mc) and tricep skin fold (ts). It is used if patient cannot be weighed.

HOSPICE “TOOLS’

3. PPS-Palliative Performance Scale. It reflects functional status.

Palliative Performance Scale Version 2

HOSPICE “TOOLS’4. FAST Scale-Functional

Assessment Stage. It is used to determine the functional and mental status of a patient with dementia.

Fast Stage Functional Assessment

1 No difficulties, either subjectively or objectively.

2 Complains of forgetting location of objects; subjective word finding difficulties only.

3 Decreased job functioning evident to coworkers; difficulty in traveling to new locations.

4

Decreased ability to perform complex tasks (e.g., planning dinner for guests; handling finances; marketing).

5 Requires assistance in choosing proper clothing for the season or occasion.

6a Difficulty putting clothing on properly without assistance.

6b

Unable to bathe properly; may develop fear of bathing. Will usually require assistance adjusting bath water temperature.

6c Inability to handle mechanics of toileting (i.e., forgets to flush; doesn't wipe properly).

6d Urinary incontinence, occasional or more frequent.

6e Fecal incontinence, occasional or more frequent.

7a Ability to speak limited to about half a dozen words in an average day.

7b Intelligible vocabulary limited to a single word in an average day.

7c Nonambulatory (unable to walk without assistance).

7d Unable to sit up independently.

7e Unable to smile.

7f Unable to hold head up.

Hospice Parameters:

"Minimum Magnitude of Severity"

Clinical Diagnosis:

Incipient or Questionable

ADMild AD

Moderate AD

Moderate-Severe AD   Severe AD  

FAST Stage: 3 4 5    

FAST Substage:       a b c d e a b c d e f

                             

Years: 0 7 9   10.5       13         19  

Mini Mental 29 25 19 14 5 5

Status Exam

Usual Point of Death

TYPICAL TIME COURSE OF ALZHEIMER’S DISEASE (AD)

HOSPICE “TOOLS’

5. NYHA Classification-New York Heart Association functional classification to determine the level of heart failure.

The Stages of Heart Failure – NYHA Classification

• In order to determine the best course of of therapy, physicians often assess the stage of heart failure according to the New York Heart Association (NYHA) functional classification system. This system relates symptoms to everyday activities and the patient's quality of life.

• ClassPatient Symptoms– Class I (Mild)No limitation of physical activity. Ordinary

physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath).

– Class II (Mild)Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.

– Class III (Moderate)Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.

– 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.

HOSPICE “TOOLS’

6. Pain Scale (0-10) Determines level of pain.

Evaluating Physical Pain• Pain is evaluated during every visit using the 0 -10

scale.

0 1 2 3 4 5 6 7 8 9

10

Mild Moderate Severe

The gold standard for assessing pain is to ask about the patient’s pain severity using this pain severity scale.

HOSPICE “TOOLS’

7. Decubiti staging

Pressure Ulcer Staging

Stage Stage II Stage Stage IIII StageStage III III Stage Stage IVIV

HOSPICE “TOOLS’

8. NHPCO Guidelines

Medical Guidelines for Determining Prognosis

SUPPORTIVE LABS AND DIAGNOSTIC STUDIES

1. Blood tests2. X-Ray reports3. Tests Examples are: BUN-100 Hb-7.4, Albumin<2.5 CXR report-Metastatic cancer Pulmonary Function Test-FEV1=30% Echocardiogram report-Severe Aortic

Stenosis and Ejection Fraction of 15%.

SUPPORTIVE NUTRITIONAL STATUS

1. Appearance: cachectic, temporal wasting, peripheral muscle wasting, loose garments, measurements.

2. Quantitate oral intake by percent of meal.

3. Document need for or use of food supplement and appetite stimulants such as: Megace, Prednisone, Periactin, antidepressants, and vitamins.

4 Dysphagia-aspiration risk.

INTENSITY OF SERVICE1. Document the number of RN and CNA

visits per week.2. Document if patient has private duty

care.3. Note if the patient has had additional

physician visits or chaplain and social worker visits.

4. Note why the services above were needed.

5. More visits imply higher intensity of service and greater needs.

ADDITIONAL SYMPTOMS

1. Agitation, psychosis, and depression.

2. Weakness.

3. Bowel and urine incontinance.

4. Nausea.

5. Shortness of breath.

6. Congestion, cough, dysphagia.

CO-MORBID CONDITIONS

• Other medical problems:

• Diabetes, hypertension, CVA, decubiti, psychosis, peripheral vascular disease, weight loss, and anorexia.

• Infection, antibiotics, URI, UTI.

• Risk for infection-immunosuppression, incontinence of bowel and bladder.

APPLY HOSPICE “TOOLS” TO DIAGNOSIS TO ASSESS

CRITERIA• This helps your documentation.• This helps you understand why the

patient is on a Hospice program.• This helps you follow the progress of your

patient.• This helps you explain to others why the

patient is on Hospice.

CEREBRAL DEGENERATION, DEMENTIA, ALZHEIMER’S

DISEASE

• FAST 7C• PPS 10,20, 30, OR 40• FAST 7A, OR B with comorbid conditions

(dysphagia, heart disease, diabetes, cva, etc.)

PARKINSON’S DISEASE

• PPS 10, 20, 30, or 40• Co-morbid conditions• FAST score if patient is demented

END STAGE CEREBROVASCULAR

DISEASE

• PPS 10, 20, 30, or 40• FAST score if demented.• Co-morbid conditions.• Non-ambulatory

END STAGE CARDIOVASCULAR DISEASE

• Severe valvular heart disease such as Aortic Stenosis or

• Low cardiac output state as documented by echocardiogram with an ejection fraction of about 20% or less or

• Pulmonary hypertension on echocardiogram or• Severe coronary artery disease as documented by

cardiac catheterization or recent MI or positive stress test or

• Congestive heart failure with NYHA Class 4 (see handout with NYHA Classes) or

• Severe arrhythmia such as ventricular tachycardia, sick sinus syndrome, or a non-functioning pacemaker.

END STAGE COPD• Must use Oxygen chronically.• Must use steroids either oral or inhaled

chronically.• Must have marked limitation of activity

due to dyspnea on exertion.• FEV1 (Forced expiratory volume in I

second) 30% or less. • Weight loss.• Abnormal CXR. • Pulmonary hypertension and or right

heart failure, tachycardia or atrial fibrillation.

• Elevated pCO2 on ABG.

Table 1. – Spirometric classification of COPD

Stage FEV1/FVC (%) FEV1 % predicted Symptoms

At risk >70 >=80chronic symptoms (cough, sputum

production)

Mild <=70 >=80with or without chronic symptoms (cough,

sputum production)

Moderate <=70 50-79with or without chronic symptoms (cough,

sputum production)

Severe <=70 30-49with or without chronic symptoms (cough,

sputum production)

Very severe <=70

<30 Or <50

plus chronic

respiratory failure

Quality of life is impaired; exacerbations may be life-threatening.

FEV1: forced expiratory volume in one second; FVC: forced vital capacity #:

MALIGNANCIES

• Any cancer not treated, or treated but not cured and no further aggressive care possible or requested.

• Monitor the progression of the disease by hospice “tools”.

FAILURE TO THRIVE

• BMI (Body Mass Index) 22 or less and patient has lost weight. This must be recorded on admission to use this diagnosis.

• Must document weight loss, BMI, and or MMA if patient cannot be weighed.

• Must note % of oral intake, dysphagia if present, appearance such as cachexia, special meals such as puree diet, thickened liquids, and food supplements.

• Also add co-morbid conditions.

END STAGE RENAL DISEASE

• Creatinine greater than 8 (Greater than 6 if diabetic).

• Symptoms of uremia: confusion, lethargy, weakness, nausea, constipation.

• Additional supporting information: Refuses dialysis, electrolyte disorder- (hyperkalemia, hypocalcemia).

• Oliguria• Creatinine Clearance-Measures the amount

of creatinine cleared by the kidneys in a 24 hour urine collection: <10cc/min. If diabetic, <15cc/min. (125cc/min is normal).

CIRRHOSIS

• Sonogram or CAT scan shows cirrhosis.• Abnormal liver enzymes.• Ascites, hepatic encephalopathy, muscle

wasting, weakness.• Esophageal Varices.• GI bleed.• Prolonged prothrombine time (>5

seconds).• Low protein and albumin (2.5 or less).

PERIPHERAL VASCULAR DISEASE WITH GANGRENE

• Stenosis and occlusion of a major artery or arteries to an extremity or extremities.

• Gangrene and or ischemic ulcers.• Pain to the extremity or extremities due to

vascular insufficiency.

ABDOMINAL AND THORACIC AORTIC ANEURISM

• Large and expanding aneurism of the aorta and patient refuses surgery or surgery is not feasible.

• Patient has pain due to dissection of the aneurism or expansion of the aneurism.

• Size usually greater than 4cm and has evidence by CAT scan, sonogram or XRAY of increase in size over time.

HIV

1. CD4 count below 25 cells/mcl.

2. HIV RNA (viral load) >100,000 copies.

3.Opportunistic infections: TB, Toxoplasmosis, Systemic Fungal infections.

4. Malignancies: Lymphoma, Kaposi’s Sarcoma.

5. Complications: Progressive multifocal leukoencephalopathy, wasting syndrom, HIV dementia, renal failure, CHF.

6.Patient decides to stop anti-viral drugs.

CertificationMedicare Hospice Regulation• Initial Certification of Terminal Prognosis

– Attending and hospice medical director– Medical prognosis of 6 months or less if illness

runs its normal course– LMRP modified by Clinical Judgment– May be up to 2 weeks prior, no later than 2 days

after care begins– If certification is verbal than written MUST be

obtained before billing

RecertificationMedicare Hospice Regulation• Recertification of Terminal Prognosis

– Hospice medical director or physician member of IDG– Statement that physician certifies prognosis of 6

months or less if illness runs its normal course– May be completed up to 5 days prior to recert date,

no later than 2 days after beginning of benefit period– Verbal recertification MUST be followed by written

before billings

VITAS Recertification Procedure• Recert report

– Tickles clinical team of those patients in need of recert in the coming 3 weeks.

• Clinical team case discussion– Explore need for labs, visit, conversation with

attending MD• Questionable prognosis

– Team Physician consults with Program Medical Director and committee

– Program Medical Director Consults with National Medical Director as needed

VITAS Recertification Procedure• Documentation of prognosis

– Recertification note / form– Collaborating chart documentation– Visit note, if applicable

• Discharge Plan– Communication with Attending– Communication with Team members– Communication with patient / family– Referral if necessary to other services– Follow up plan

CONCLUSION• Our knowledge of the hospice “tools” as

well as our knowledge of what criteria is used to make a patient Hospice appropriate will improve our documentation and help us follow our patient’s progress while on our program.

• We can see a pattern of decline or lack of improvement.

• We may also see improvement and need for referral to the discharge committee if criteria is no longer met.