Eligibility GuideAdvocate Hospice

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Adm

ission Indicators

Admission IndicatorsAdmission criteria include:

• Lifelimitingillnesswithaprognosisof<6months• Patientandfamilydesirecomfortcare• Twophysiciansconfirmterminalcondition• Clinicalprogressionofterminaldisease

Admission indicators may include:• Patientlikelytodieifdiseaserunsitsnormalcourse• Recentdeclineinfunctionalstatusasdeterminedby:

– KarnofskyPerformanceStatus<50%(seescaleonpage2)– Dependenceinatleast3of6ADLs

• Impairednutritionalstatusevidencedbyeither:– Weightloss>10%overthepast6months– Serumalbumin<2.5gm/dl

• Hospitalizationsoremergencyroomvisits• InfectionssuchasUTI,URI,sepsis• Decubitusulcers

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Karnofsky Performance Scale

General Category Index Specific Criteria

Unabletocareforself,requiresinstitutionalorhospitalcareorequivalent,diseasemayberapidlyprogressing

50Requiresconsiderableassistancefromothersandfrequentmedicalcare

40 Disabled,requiresspecialcareandassistance

30Severelydisabled,hospitalizationindicated,deathnotimminent

20Verysick,hospitalizationnecessary,activesupportivetreatmentnecessary

10 Moribund,activelydying

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Adult Failure to T

hrive and Debility

Hospice Indicators for Adult Failure to Thrive and Debility*• Unexplainedweightloss• Malnutritionornutritionaldisability

– BMI<22kg/m2(BMI(kg/m2)=703x(wtinlbs)/(htininches)

– Mid-armmusclecircumference,incm,(ifBMIcannotbemeasured)thatisbelownorms(basedonageandgender)

• Declinesenteralorparenteralnutritionalsupportornotrespondingtonutritionalsupport

• DisabilitydemonstratedbyKarnofskyPerformanceScale(seepage2)orPalliativePerformanceScale(seepage4)value,or=40%

Somepatientsmaynotmeettheadmissioncriteria,yetstillbeappropriateforhospicecarebecauseofotherco-morbiditiesorrapiddecline.Thesepatientsareoftendescribedasfailingtothriveorhavingdebility.Coverageforthesepatientsmaybeapprovedonanindividualconsiderationbasis.

*Adult failure to thrive and/or debility should be used as a secondary diagnosis

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% AmbulationActivity and Evidence

of DiseaseSelf-Care Intake

Consciousness Level

100 FullNormalActivity

NoEvidenceofDiseaseFull Normal Full

90 FullNormalActivity

SomeEvidenceofDiseaseFull Normal Full

80 FullNormalActivitywithEffortSomeEvidenceofDisease

FullNormalorReduced

Full

70 ReducedUnabletodoNormalWorkSomeEvidenceofDisease

FullNormalorReduced

Full

60 ReducedUnabletodo

Hobby/HouseWorkSignificantDisease

OccasionalAssistanceNecessary

NormalorReduced

FullorConfusion

50MainlySit/

LieUnabletodoAnyWork

ExtensiveDisease

ConsiderableAssistanceRequired

NormalorReduced

FullorConfusion

40Mainlyin

BedUnabletodoAnyWork

ExtensiveDiseaseMainly

AssistanceNormalorReduced

FullorDrowsyorConfusion

30TotallyBed

BoundUnabletodoAnyWork

ExtensiveDiseaseTotalCare Reduced

FullorDrowsyorConfusion

20TotallyBed

BoundUnabletodoAnyWork

ExtensiveDiseaseTotalCare

MinimalSips

FullorDrowsyorConfusion

10TotallyBed

BoundUnabletodoAnyWork

ExtensiveDiseaseTotalCare

MouthCareOnly

DrowsyorComa

0 Death – – – –

Palliative Performance Scale*

*ThisscaleisamodificationoftheKarnofskyPerformanceScale.Ittakesintoaccountambulation,activity,self-care,intakeandconsciousnesslevel.

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Cancer

Hospice Indicators for Cancer• Treatmentsineffective• Treatmentishavingnegativeimpactonpatient’squalityoflife• Increasingpainand/orsymptoms• Multipletripstohospitalforsymptommanagement• Metastasisand/orStage3or4• Toxicityoutweighsbenefits• Poorperformancestatus

– ECOGof3–4– KarnofskyorPalliativePerformanceScalelessthan50%

• Exhaustedpatientandfamily/caregivers• Patient/familywantstostopcurativeorpalliativeradiation

and/orchemotherapy• Mayqualifyforpalliativeradiationand/orchemotherapytreatment

onanindividualizedbasisforcancersymptommanagement

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What is hospice?Hospiceisaprogramdesignedspecificallyforpeoplewhohavechosentochangetheplanofcareforalife-limitingillnessfromaggressivemedicaltreatment,focusedoncuringanillness,tocarethatmanagespainandsymptomssopatientscanmakethemostofeveryday.

Did you know?

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Cardiopulm

onary Disease

• Disablingdyspneaatrest,poorresponsetobronchodilators

• PersistentsymptomsofrecurrentCHFatrest

• Optimallytreatedwithdiureticsandvasodilators(ACEinhibitors)orunabletotolerate

• NewYorkHeartClassIV• Impairmentinthecontraction

forceofventricularmuscles• Supraventriculararrhythmias

thatareresistanttoarrhythmiatherapy

• Historyofunexplainedsyncope

• HistoryofcardiacarrestorMI• IncreasingvisitstotheER

orhospitalizationsforrespiratoryinfectionsand/orrespiratoryfailure– pO2<or=55mmHg– Oxygensaturation<or=to88%

• Restingtachycardia>100/minute

• Presenceofcorpulmonaleorrightheartfailure(RHF)

• Identificationoffunctionallimitation,suchas:– Declineinfunctionalstatus

Hospice Indicators for Cardiopulmonary DiseaseIdentificationofspecificstructural/functionalimpairments,alongwithrelevantactivitylimitationssuchas:

Examplesofsecondaryconditions:Delirium,pneumonia,stasisulcers,pressureulcers,failuretothriveanddebility

Exampleofco-morbidcondition:EndStageRenalDisease(ESRD)

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The timing of end-of-life conversations is critical.TheAmericanSocietyofClinicalOncologyrecommendsthatpatientsbetoldwhatend-of-lifecarechoicesareavailableearlierinthecourseoftheirdisease.Doingsoempowersthemtodefinehis/herfinalwishes.

Did you know?

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Dem

entiaHospice Indicators for DementiaIncludes diagnoses such as Alzheimer’s Disease, Parkinson’s Disease, Senile Degeneration of the Brain and Multi-Infarct Dementia

• Stage7orhigheronFASTscale(lossofspeech,locomotionandconsciousness)

7a: Abilitytospeakislimited(1to5wordsaday)7b: Speechisunintelligible7c: Non-ambulatory7d: Unabletositupindependently7e: Unabletosmile7f: Unabletoholdheadup

Co-morbidity,suchas:• CHD(CoronaryHeartDisease)• COPD

SecondaryConditions,suchas:• Delirium• Dysphagia• Aspirationpneumonia• Urinarytractinfection• Decubitusulcers

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Did you know?

Hospice is not a place.Rather,itisacomprehensiveservicethatisprovidedinthehome90percentofthetime.Sometimes,patientsaretemporarilymovedtoahospitalifapatient’spainorsymptomscanbemoreeasilymanagedbyhospicestaff.

Thehospiceteamcanalsoproviderespitecaresothatcaregiverscanhavealittletimeawayfromtheday-to-dayrequirementsofcaringforalovedoneinhospicecare.Thepatientcanbeplacedinanursinghomeforapredeterminednumberofdayswhilecontinuingtoreceivecarefromthehospiceteam.

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1. CD4+Count<25cells/mcLorpersistentviralload>100,000copies/ml,plusONEofthefollowing:a.CNSLymphomab.Untreated,ornotresponsive

totreatment,wasting(lossof33%leanbodymass)

c.Mycobacteriumaviumcomplex(MAC)bacteremia,untreated,unresponsivetotreatment,ortreatmentrefused

d.Progressivemultifocalleukoencephalopathy

e.Systemiclymphoma,withadvancedHIVdiseaseandpartialresponsetochemotherapy

f. VisceralKaposi’ssarcomaunresponsivetotherapy

g.Renalfailureintheabsenceofdialysis

h.Cryptosporidiuminfectioni.Toxoplasmosis,unresponsive

totherapy

2.Decreasedperformancestatus,asmeasuredbytheKarnofskyPerformanceStatus(KPS)scaleof<or=50

3.Documentationofthefollowingfactorssupporteligibilityforhospicecare:a.Chronicpersistentdiarrhea

foroneyearb.Persistentserumalbumin<2.5c.Concomitant,active

substanceabused.Age>50years

HIV

Disease

Hospice Indicators for HIV Disease

1 and 2 must be present; factors from 3 will add supporting documentation:

Eligibility factors continued on reverse

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Did you know?

A multi-disciplinary team cares for hospice patients.Theteamincludes:patient/caregiver;patient’sphysician;hospicephysician;registerednurse;certifiedhomehealthaide;socialworker;chaplain;griefcounselor;andvolunteers.

e.Absenceofantiretroviral,chemotherapeuticandprophylacticdrugtherapyrelatedspecificallytoHIVdisease

f.AdvancedAIDSdementiacomplexg.Toxoplasmosis

Hospice Indicators for HIV Disease (cont.)

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Liver Disease

Hospice Indicators for Liver DiseaseCriteria in 1 and 2 must be present; factors from 3 will lend supporting documentation:

1.INR>1.5(orProthrombintimeprolongedmorethan5secondsovercontrol).SerumAlbumin<2.5gm/dl

2.Documentationofendstageliverdisease,andpatientshowsatleastoneofthefollowing:• Ascites,refractoryto

treatment,orpatientnon-compliant

• SpontaneousBacterialPeritonitis

• HepatorenalSyndrome(elevatedcreatinineandBUNwitholiguria(<400ml/day)andurinesodiumconcentration<10mEq/l)

• HepaticEncephalopathy,refractorytotreatment,or

patientnon-compliant• Recurrentvaricealbleeding

despiteintensivetherapy

3.Progressivemalnutrition• Musclewastingwithreduced

strengthandendurance• Continuedactivealcoholism

(>80gmethanol/day)• Hepatocellularcarcinoma• HBsAg(HepatitisB)positivity• HepatitisCrefractoryto

interferontreatment

PatientsawaitinglivertransplantwhootherwisefittheabovecriteriamaybecertifiedfortheMedicarehospicebenefit.Butifadonororganisprocured,thepatientmustbedischargedfromhospice.

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Did you know?Hospice is affordable.MedicareandMedicaidprovidecoverageforhospiceservicessotherearenoout-of-pocketexpenses.Hospiceservicesandmedicationsusedtomanagethelife-limitingillnessarecoveredat100%.

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Neurological C

onditionsIncludes diagnoses such as CVA, Parkinson’s Disease, ALS and MS

• Neurologicalconditionsareassociatedwithimpairments,activitylimitationsanddisability

• Identificationofspecificstructural/functionalimpairments,togetherwithanyrelevantactivitylimitations,shouldserveasthebasisforpalliativeinterventionsandcare-planning

SecondaryConditionssuchas:• Dysphagia• Pneumonia• Pressureulcers

Co-morbidconditions,suchasCOPD,maybedistinctfromtheprimaryconditionitself.Howeverservicesaimedattheco-morbidconditionmayberelatedtopalliationandmanagementoftheterminalcondition.

Hospice Indicators for Neurological Conditions

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Did you know?

Patients can dis-enroll from hospice at any time.Theyjustsimplysignaform.Patientsmayfeeltheserviceisnotrightforthem.Or,thepatient’slife-limitingillnessmayimprove,andtheycomeoffofhospice.Patientscanalsore-enrolliftheychangetheirmindagainandwanttogobackonhospice.Ahospicestayoflongerthansixmonthsisalsopossibleifthediseaserunsitsusualcourseandsurpassesthetimeframe.

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Renal C

areHospice Indicators for Renal CareThepatientisnotseekingdialysisorrenaltransplant

• Creatinineclearance< 10ml/min(< 15fordiabetes)• Serumcreatinine> 8.0mg/dl(> 6.0mg/dlfordiabetes)

SupplementalPresenceofco-morbidconditionsinacuterenalfailureishelpful

• Coronaryheartdisease(CHD),i.e.dyspnea,orthopnea,chestpain,peripheralvasculardisease(PVD),vasculardementia

Secondary conditions, directly related to the primary condition:• Secondaryhyperparathyroidism• Calciphylaxis• Nephrogensystemicfibrosis• Electrolyteabnormalities• Anorexia• Fluidoverload

Presenceofsignsandsymptomsinchronicrenalfailureishelpful:• Examplesincludeuremia,oliguria(< 400ml/day),hyperkalemia(> 7.0)

notresponsivetotreatment,hepatorenalsyndrome,etc.

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Did you know?

After a patient dies, Advocate Hospice offers family and loved ones a 13-month bereavement program.Griefsupportcanbeprovidedindifferentways:Daybreakmonthlynewsletter;individualgriefsupport;griefsupportgroups;workshops;andeducation.

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How Advocate Hospice Helps Patients and Families• Enhancesqualityoflife• Consultationsavailable24hoursaday,7daysaweekby

professionalstaff(ie.,RN,psychosocialandphysician)• Painevaluatedoneveryvisit• Expertiseinpainandsymptommanagement• Provides4LevelsofCare• Treatsinfectionsandwoundstopromotepatientcomfort• Providesmedications,suppliesandequipmentrelatedto

symptommanagementoftheterminalillness,anxietyanddepression

• Educatesregardingnutritionandhydrationissues,withafocusonpatientcomfortandgoals;evaluationforswallowingconcernscanbeorderedifneeded

• PersonalizedplanofcareforADLs• Reducesphysicianofficecalls,911calls,ERvisitsand

hospitalizations• Provideshigherlevelofcareforchangeincondition

(continued on reverse)

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• Helpwithendoflifeplanning– Prepareadvancedirectives,obtainaLimitationofEmergencyTreatment(LET)orderandassistwithfuneralplanningarrangements

• Anticipatesneedsofpatientandfamily;mayrefertoavailablecommunityresources

• Useofnon-pharmacologicaltherapy(ie.,massagetherapy)• Increasespatientandcaregiversupport• Visitsprovidedbypsychosocialandspiritualstaffwithongoing

follow-upforpatients,familiesandstaff• Communicateswithfamiliesregardingpatient’scondition• Communicationandpatientupdatesasdeterminedbythe

referralsource• Attendandconfirmdeaths• 13monthsofbereavementservices

How Advocate Hospice Helps Patients and Families (cont.)

8/14MC1572

To learn more about Advocate Hospice or to make a referral, call:

Chicagoland Area:630.963.6800Normal, IL Area:309.268.5930