Hospice Eligibility Criteria for Common Diagnosis
Hospices must present a medical justification for a patient to qualify for hospice benefits. Americare Hospice has adopted the following guidelines in determining terminal prognosis, in order that we may admit patients to hospice who will appropriately benefit from our services. Some individuals may not meet the following criteria, but may be appropriate for hospice due to co morbid conditions or a rapid decline suggesting a 6 month prognosis.
Patient Eligibility for Medicare Benefits
- Patient must be eligible for Medicare A (the hospitalization benefit)
- Patient must have a terminal illness, the prognosis being 6 months or less certifiable by the hospice medical doctor and the patient’s primary physician. (The patient will not lose hospice benefits if he/she does not die within this time period, but the patient must show persistent decline during this time.)
- Patient /decision maker must give informed consent.
- Patient/decision maker must desire palliative approach rather than urative focus
Benefit Periods
Hospice benefit periods run for two periods of 90 days followed by an unlimited number of 60 day periods at the end of each period, the patient has benefits renewed if there is a continued decline in condition with a prognosis of 6 months or less.
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Amyotrophic Lateral Sclerosis (ALS)
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Rapid progression of ALS (w/ch or bedbound,ack of intelligible speech, pureed diet, ADL dependence and
- Critical nutritional impairment, Or
- Critically impaired breathing capacity (Vital capacity less than 30% of normal, Significant dyspnea at rest requiring supplemental oxygen at rest,declines artifical ventilation) Or
- Life-threatening complications (aspiration pneumonia, pyelonephristis, Sepsis)
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Heart Disease
- Optimally treated with diuretics and vasodilators or angina at rest, resistant to nitrate tx and declines invasive procedure
- Symptoms of CHF at rest
- Ejection fraction of less than equal to 20%
- Treatment resistant symptomatic supra-ventricular or ventricular arrhythmias
- History of cardiac arrest or resuscitation
- History of unexplained syncope
- Concomitant HIV disease
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Alzheimer’s Disease/Dementia
- FAST level greather than or equal to 7A
- Requires assistance with bathing/dressing
- ncontinence, urinary or fecal, intermittent unresponsive to or constant
- Unable to ambulate without assistance
- Unable to speak or communicate meaningfully
- One of the following within the past 12 months:
- Aspiration pneumonia
- Pyelonephristis or other UTI concomitant
- Septicemia
- Decubitus Ulcers
- Fever recurrent after antibiotics
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HIV Disease
- CD4+Count less than 25cells/mcl or persistent viral load greather than 1000.000c/ml
- Loss of 33% lean body mass
- CNS lymphoma
- Mycobacterium avium compex bacteremia,untreated, unresponsive to treatment, or treatment refused Progressive multifocal leukoencephalopathy
- Visceral Kaposi’s sarcoma therapy
- Renal failure in the absence of dialysis
- Cryptosporidium infection
- Toxoplasmosis
- Supporting conditions: Chronic diarrhea for one year; persistent serum albumin < 2.5; active substance abuse; CHF symptoms at rest
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Cancer
- Clinical finding of malignancy with widespread,aggressive, or progressive disease
- ncreasing symptoms
- Palliative Performance Scale of =70%
- No longer seeking curative treatment
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Renal Diseases
- Patient is not seeking dialysis or renal transplant
- Creatinine clearance < 10cc/min ( <15cc/min for diabetes)
- Serum Creatinine > 8.0mg/dl (>6.0mg/dl for
- Clinical s/s of renal failure
- Comorbid conditions: Mechanical ventilation; malignancy; lung disease; advanced cardiac disease;advanced liver disease sepsis;albumin 75
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Stroke and/or Coma
- Palliative Performance Scale of ? 40% (mainly unable to do self care, reduced po intake, fully conscious or drowsy/confused)
- Inability to maintain hydration and caloric (weight loss > 10% in 6 mos. Or serum albumin < 2.5gm/dl
- History of aspiration pneumonia, pyelonephritis stage 3-4 decubitus ulcer, fever
- Comatose with any of following on day three of
- Abnormal brain stem response
- absent verbal response
- absent withdrawal response to pain
- serum creatinine >1.5mg/dl
- age > 70
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Pulmonary Disease
- Disabling dyspnea at rest, poorly or unresponsive in bed, to brochodilators; with Decreased functional capacity (bed to chair existence, fatigue) And
- Increasing visit to MD, ER or hospital for intake pulmonary infections and/or respiratory failure,
- Hypoxemia at rest on supplemental O2 (pO2 ? 55 mmHg) Or oxygen saturation 50mmHg)
- Supporting conditions; cor pulmonale and right sepsis,heart failure 2º pulmonary disease; weight loss > 10% recurrient after antibiotics in past 6 months; Resting tachycardia > 100/min coma;
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Failure to Thrive
- Palliative Performance Scale ? 40% (mainly in requires asst. w/ADL)
- Underweight (BMI ? 22)
- General decline in condition despite treatment
- Declines enteral/parenteral support or has not responded to such nutritional support
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Note
If the patient has a diagnosis that is not listed above or does not meet the criteria listed for these diagnoses, he or she may still be eligible for hospice if the physician determines the life expectancy to be 6 months or less.
