FAST 7A, OR B with comorbid conditions (dysphagia, hear

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HOSPICE CRITERIA AND RECERTIFICATION

• Paul Rozynes, M.D.
• Medical Director
• VITAS Broward

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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.

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COMMON HOSPICE DIAGNOSES

• 1. Cerebral degeneration, dementia, Alzheimers
  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

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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

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HOSPICE TOOLS

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

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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.

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HOSPICE TOOLS

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

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Palliative Performance Scale Version 2
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HOSPICE TOOLS

• 4. FAST Scale-Functional Assessment Stage. It is
  used to determine the functional and mental
  status of a patient with dementia.

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TYPICAL TIME COURSE OF ALZHEIMERS DISEASE (AD)
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HOSPICE TOOLS

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

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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.

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HOSPICE TOOLS

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

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Evaluating Physical Pain

• Pain is evaluated during every visit using the 0
  -10 scale.

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0 1

2

3 4 5 6 7
8 9

Mild Moderate Severe
The gold standard for assessing pain is to ask
about the patients pain severity using this pain
severity scale.
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HOSPICE TOOLS

• 7. Decubiti staging

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Pressure Ulcer Staging
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HOSPICE TOOLS

• 8. NHPCO Guidelines

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Medical Guidelines for Determining Prognosis
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SUPPORTIVE LABS AND DIAGNOSTIC STUDIES

• 1. Blood tests
• 2. X-Ray reports
• 3. Tests
• Examples are BUN-100
• Hb-7.4, Albuminlt2.5
• CXR report-Metastatic cancer
• Pulmonary Function Test-FEV130
• Echocardiogram report-Severe Aortic
  Stenosis and Ejection Fraction of 15.

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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.

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INTENSITY OF SERVICE

• 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.

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ADDITIONAL SYMPTOMS

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

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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.

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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.

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CEREBRAL DEGENERATION, DEMENTIA, ALZHEIMERS
DISEASE

• FAST 7C
• PPS 10,20, 30, OR 40
• FAST 7A, OR B with comorbid conditions
  (dysphagia, heart disease, diabetes, cva, etc.)

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PARKINSONS DISEASE

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

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END STAGE CEREBROVASCULAR DISEASE

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

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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.

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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.

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Table 1. Spirometric classification of COPD
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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.

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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.

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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 lt10cc/min. If diabetic,
  lt15cc/min. (125cc/min is normal).

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CIRRHOSIS

• Sonogram or CAT scan shows cirrhosis.
• Abnormal liver enzymes.
• Ascites, hepatic encephalopathy, muscle wasting,
  weakness.
• Esophageal Varices.
• GI bleed.
• Prolonged prothrombine time (gt5 seconds).
• Low protein and albumin (2.5 or less).

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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.

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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.

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HIV

• 1. CD4 count below 25 cells/mcl.
• 2. HIV RNA (viral load) gt100,000 copies.
• 3.Opportunistic infections TB, Toxoplasmosis,
  Systemic Fungal infections.
• 4. Malignancies Lymphoma, Kaposis Sarcoma.
• 5. Complications Progressive multifocal
  leukoencephalopathy, wasting syndrom, HIV
  dementia, renal failure, CHF.
• 6.Patient decides to stop anti-viral drugs.

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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

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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

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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

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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

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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 patients
  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.