HOSPICE CRITERIA AND RECERTIFICATION

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.

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.

9. HOSPICE “TOOLS’ 3. PPS-Palliative Performance Scale. It reflects functional status.

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.

13. TYPICAL TIME COURSE OF ALZHEIMER’S DISEASE (AD)

14. HOSPICE “TOOLS’ 5. NYHA Classification-New York Heart Association functional classification to determine the level of heart failure.

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.

17. Evaluating Physical Pain • Pain is evaluated during every visit using the 0 -10 scale. 10 0 1 2 3 4 5 6 7 8 9 Mild Moderate Severe 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

19. Stage I Stage II Stage III Stage IV Pressure Ulcer Staging

20. HOSPICE “TOOLS’ 8. NHPCO Guidelines

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 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

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