1. HOSPICE CRITERIA AND RECERTIFICATION
Paul Rozynes, M.D.
Medical Director
VITAS Broward

2. 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.

3. COMMON HOSPICE DIAGNOSES
1. Cerebral degeneration, dementia, Alzheimer’s disease
2. Parkinson,s disease
3. Cerebrovascular disease
4. Heart disease
a. Valvular heart disease
b. Coronary artery disease
c. Congestive heart failure
d. Arrhythmia
5. Chronic obstructive lung disease
6. Malignancies

4. COMMON HOSPICE DIAGNOSES
7. Failure to thrive
8. End stage renal disease
9. Cirrhosis
10. Peripheral vascular disease with gangrene
11. Abdominal or thoracic aortic aneurism
12. HIV

5. HOSPICE “TOOLS’
BMI-Body Mass Index. This is a ratio of height to weight.
See hand outs and go over how each are used.

7. 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.
See hand outs and go over how each are used.

9. HOSPICE “TOOLS’
3. PPS-Palliative Performance Scale. It reflects functional status.
See hand outs and go over how each are used.

10. Palliative Performance Scale Version 2

11. HOSPICE “TOOLS’
4. FAST Scale-Functional Assessment Stage. It is used to determine the functional and mental status of a patient with dementia.
See hand outs and go over how each are used.

12. Functional Assessment
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.

13. TYPICAL TIME COURSE OF ALZHEIMER’S DISEASE (AD)
Hospice Parameters:
"Minimum Magnitude of Severity"
Clinical Diagnosis:
Incipient or Questionable AD
Mild AD
Moderate AD
Moderate-Severe AD
Severe AD
FAST Stage: 3 4 5
FAST Substage: a b c d e f
Years:
10.5 13 19
Mini Mental
Status Exam
Usual Point of Death

14. HOSPICE “TOOLS’
5. NYHA Classification-New York Heart Association functional classification to determine the level of heart failure.
See hand outs and go over how each are used.

15. 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.

16. HOSPICE “TOOLS’ 6. Pain Scale (0-10) Determines level of pain.
See hand outs and go over how each are used.

17. Evaluating Physical Pain
Pain is evaluated during every visit using the scale. 2 10
Mild Moderate Severe
The 0-10 pain scale is to be used when asking a verbal patient to report their pain level. The numerical 0-10 scale is one of the most commonly used.
The Wong/Baker faces rating scale is a visual representation of the numerical scale. The faces were developed for pediatric patients, but this tool has proven to be useful in the elderly and for patients who have difficulty reading.
Wong D, Whaley L: Clinical Handbook of Pediatric Nursing, ed. 2. St. Louis: CV Mosby Co, 1986:373
The gold standard for assessing pain is to ask about the patient’s pain severity using this pain severity scale.

18. HOSPICE “TOOLS’ 7. Decubiti staging
See hand outs and go over how each are used.

19. Pressure Ulcer Staging
Stage I
Stage II
Stage III
Stage IV
Pressure ulcers are classified according to depth by using a staging system which is based on the work of Dr. Shea (1975).
Note: This system is recommended by the NPUAP (National Pressure Ulcer Advisory Panel), The Agency for Healthcare Research and Quality (AHRQ), formerly known as the AHCPR or Agency for Healthcare Policy and Research, and the WOCN (Wound Ostomy and Continence Nurses Society). It is the current methodology for monitoring wound status.
When the MDS is next modified, it will replace the Shea staging tool with the PUSH tool or “Pressure Ulcer Scale for Healing”. This tool utilizes not only the size of the wound but also amount of exudate and tissue type of the wound to arrive at a score. You can then track numerical scores over time. This has been an issue for LTC providers since reverse staging is no longer considered the current methodology. If a stage 4 wound heals to a very superficial ulcer, it is still considered a stage 4 and not a stage 2. If an ulcer heals, it is a healed Stage 4 ulcer.
When eschar is present in the wound, it often cannot be staged until the eschar has been removed. Also, it may be difficult to assess the stage of an ulcer when the resident has a cast or other orthopedic device.
Now, let’s look at examples of each ulcer stage.

20. HOSPICE “TOOLS’ 8. NHPCO Guidelines
See hand outs and go over how each are used.

21. Medical Guidelines for Determining Prognosis

22. SUPPORTIVE LABS AND DIAGNOSTIC STUDIES
1. Blood tests
2. X-Ray reports
3. 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%.

23. 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.

24. INTENSITY OF SERVICE 2. Document if patient has private duty care.
1. 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.

25. ADDITIONAL SYMPTOMS 1. Agitation, psychosis, and depression.
2. Weakness.
3. Bowel and urine incontinance.
4. Nausea.
5. Shortness of breath.
6. Congestion, cough, dysphagia.

26. 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.

27. 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.

30. 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.)

31. PARKINSON’S DISEASE PPS 10, 20, 30, or 40 Co-morbid conditions
FAST score if patient is demented

32. END STAGE CEREBROVASCULAR DISEASE
PPS 10, 20, 30, or 40
FAST score if demented.
Co-morbid conditions.
Non-ambulatory

33. 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.

34. 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.

35. Table 1. – Spirometric classification of COPD
Stage
FEV1/FVC (%)
FEV1 % predicted
Symptoms
At risk
>70
>=80
chronic symptoms (cough, sputum production)
Mild
<=70
with or without chronic symptoms (cough, sputum production)
Moderate
50-79
Severe
30-49
Very severe
< 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 #:

36. 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”.

37. 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.

38. 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).

39. 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).

40. 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.

41. 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.

42. 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.

43. Certification Medicare 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

44. Recertification Medicare 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

45. 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

46. 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

51. 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.