Hospice Criteria and Eligibility

Hospice isn’t a topic that’s enjoyable to discuss, but it is important, especially if your loved one is an elderly dealing with a terminal illness and is expected to need hospice services in the near future. As a caregiver, you must familiarize yourself with the hospice criteria and eligibility requirements so that you can prepare your loved one. There are very specific hospice criteria and eligibility requirements that must be met for your senior loved one to receive benefits under Medicare. 

First off, what is hospice care?

Before you can understand the eligibility and criteria for hospice care, you need to understand what hospice care is. At its core, hospice focuses on the comfort and care of a person with a terminal illness who is approaching the end of their life. When a patient reaches the point where treatments of a disease are no longer effective, there is no known cure for the disease, or they decide to discontinue treatment, hospice care is generally the path they choose to take. 

Hospice care is reserved for patients who are expected to live no longer than 6 months, which is why it is necessary for doctors to carefully assess patients who are requesting hospice or who are resisting it. Patients don’t want to wait too long to enter hospice because they can suffer greatly without it, but they also cannot enter hospice too soon because not only won’t it be paid for, but there might still be effective treatments available.

General eligibility and criteria for hospice

Most hospice criteria and eligibility requirements are disease-specific because no two diseases have exactly the same life expectations. But, there are some requirements that are general in nature, so it’s important to first grasp the general hospice eligibility and criteria before moving into the disease-specific rules. Here are those requirements:

1. The patient has to have been diagnosed with a terminal condition that has a prognosis of 6 months or less without intervention (i.e. the disease is allowed to run its normal course).
2. The patient has had frequent hospitalizations in the past 6 months related to their terminal condition.
3. The patient has experienced progressive weight loss (not accounting water (edema) weight loss).
4. The patient is experiencing increasing weakness, fatigue, and sleepiness.
5. The patient has experienced a change in cognitive and functional abilities.
6. The patient is experiencing compromised activities of daily living (ADLs) like dressing, bathing, eating, walking/transferring, continence, and toileting.
7. The patient is experiencing deteriorating mental abilities.
8. The patient’s skin is beginning to break down.
9. The patient experiences a specific decline in their condition.
10. The patient has two or more chronic diseases or conditions, at least one of which is considered terminal.

No specific number of symptoms are required for hospice eligibility, but these 10 criteria help healthcare providers determine if a patient’s condition is or will soon be appropriate for hospice care. In addition to these general hospice criteria and eligibility requirements, there are disease-specific criteria that healthcare providers will take into account when assessing a patient’s need for hospice services. To help make their decision, they will most likely use the the Palliative Performance Scale.

Palliative Performance Scale (PPS)

Palliative care is the term for care that a patient with a terminal disease elects to receive that focuses on providing symptom relief rather than treatment. The goals of palliative care are to remove the stress of treating a terminal illness and improving the patient’s and caregiver’s quality of life. Once a patient with a terminal disease elects for palliative care, healthcare providers use the Palliative Performance Scale (PPS) to assess when a patient is eligible to transfer to hospice care. 

On the PPS, there are 5 areas of a patient’s life that are assessed on a 0% to 100% scale. These 5 categories are:

1. Ambulation
2. Activity level and evidence of disease
3. Self-care
4. Intake
5. Level of consciousness

If a patient scores 100% in all categories, they will not be eligible for hospice care. When they score low enough in certain categories (disease dependent), their healthcare provider will begin to assess their need and eligibility for hospice. 

Functional Assessment Scale (FAST)

The Functional Assessment Scale or FAST is used to diagnose dementia in patients who are suffering from a loss or decrease of specific functions. Since dementia is a common disease in elderly people, the FAST is a tool that healthcare providers use to determine the level of disease progression and the patient’s eligibility for hospice.

The scale is from 1 to 7, with 1 being normal functioning and 7 being advanced dementia. A level 2 would represent a patient who complains of forgetting the location of objects and has some work difficulties. At level 3, a patient has difficulty traveling to new locations, has decreased organizational capacity, and has difficulties with work that are noticeable to co-workers.

Level 4 patients demonstrate a decreased ability to perform complex tasks like planning dinner for guests or handling personal finances. At a level 5, a patient requires assistance with choosing the right clothing to wear for the season or occasion and may wear the same clothing repeatedly without intervention.

Level 6 patients occasionally or more frequently over the past week:

• Have improperly put on clothes without intervention or assistance
• Have been unable to bathe properly
• Have been unable to handle toileting (flushing, wiping, disposing of toilet paper, etc.)
• Have urinary incontinence
• Have fecal incontinence

At a level 7, patients meet all of the above criteria plus:

• Are limited in their speech (less than or equal to six intelligible words in the course of an average day)
• Cannot walk without assistance
• Cannot sit up without assistance
• Have lost their ability to smile
• Have lost their ability to hold their head up independently

Hospice criteria and eligibility for different conditions

Cancer

Cancer is one of the most common diseases in elderly patients, and sometimes, these patients tire of treating cancer, especially if it has metastasized. Here are the hospice criteria and eligibility requirements for cancer patients.

1. The cancer must be malignant and widespread, aggressive, or progressive
2. The patient’s PPS is 70% or less in all categories
3. The patient refuses life prolonging treatment OR continues to decline despite treatment
4. The patient has hypercalcemia (high calcium blood levels) levels of 12 or greater
5. The patient has lost greater than 5% of their weight in the past three months
6. The patient has signs of advanced disease (nausea, the requirement of transfusions, the presence of cancer in the organs, water on the lungs, etc.)

Renal failure

Renal failure is the name for loss of kidney function and is a common disease in people over the age of 60. In fact, almost 40% of adults in this population suffer from chronic renal failure, which is the result of a coexisting disease that gradually damages the kidneys. As this damage continues, eventually the kidneys stop functioning. Here are the hospice criteria and eligibility requirements for renal failure patients.

1. The patient has refused dialysis or a kidney transplant, OR the patient requests to discontinue dialysis
2. The comparison level of creatinine in the patient’s urine and blood is less than 10 or less than 15 in diabetics
3. The patient’s serum creatinine is greater than 8 or greater than 10 in diabetics
4. The patient’s urine output is less than 400 cc in 24 hours
5. The patient has high potassium levels that are greater than 7. 
6. A patient who is also on mechanical ventilation, has a malignancy in another organ system, has chronic lung disease, has advanced cardiac disease, or has advanced liver disease in combination with renal failure should also be considered eligible for hospice

Dementia

With 1 in 7 adults over the age of 70 suffering from some level of dementia, it is likely someone you love will have a disease that affects their mental function by the time they pass away. As such, it is critical to understand the hospice criteria and eligibility for dementia patients so that you can help them determine when they are ready to discontinue treatment and enter hospice before they get to that point.

1. The patient must score a 7 or higher on the FAST scale (cannot stand without assistance), AND
2. The patient has had one or more of the following conditions within the last 12 months:
   • Aspiration pneumonia
   • Pyelonephritis (a bacterial infection of the kidney)
   • Septicemia (a bacterial infection of the blood)
   • Multiple pressure ulcers (stage 3-4)
   • Recurrent Fever
   • Inability to maintain sufficient fluid and calorie intake in past 6 months (they have lost 10% or more of their weight)
   • Other significant condition that suggests limited prognosis

Neurological disease

While less common, neurological diseases like ALS, muscular dystrophy, multiple sclerosis, and Parkinson’s can be extremely difficult to live with in their advanced forms. Here are the hospice criteria and eligibility requirements for a patient with a neurological disease.

1. The patient is suffering from critically impaired breathing capacity with labored breathing at rest and a vital capacity reading of less than 30%, AND the patient needs oxygen at rest and refuses artificial ventilation, OR
2. The patient is suffering from rapid disease progression from being able to walk independently to being wheelchair or bed bound, from being able to speak normally to having unintelligible speech, from eating normally to requiring pureed food, or from being independent with ALS to needing major assistance, AND
3. The patient is unable to orally intake enough nutrients or fluids to sustain life (past 12 months), has continued weight loss, is suffering from dehydration or decreased blood volume, and is not using artificial feeding methods, OR
4. The patient has suffered life threatening complications within the last 12 months, including recurrent aspiration pneumonia, pyelonephritis (kidney infection), sepsis (blood infection), recurrent fever, or stage 3 or 4 pressure ulcers

Heart disease

Heart disease is not only common in the elderly, with 75% of people between the ages of 60 and 79 and up to 86% of people ages 80 and older suffering from this condition, but it’s also the leading cause of death in the United States. As such, it’s vital that everyone understand the hospice criteria and eligibility for heart disease.

1. The patient has multiple symptoms of heart disease while at rest, AND
2. The patient is unable to carry out minimal physical activity without chest pain or labored breathing, AND
3. The patient is being treated with diuretics, vasodilators, ACEI, hydralazine, and nitrates, OR
4. The patient has chest pain at rest, is resistant to nitrates, and has either been determined not to be a candidate for or has declined invasive procedures
5. The patient may also have an ejection fraction of 20% or less (the heart is operating at about one-third of its normal function), treatment-resistant symptomatic dysrhythmias (irregular heartbeat), a history of cardiac related syncope (fainting or dizziness), suffered a cardiac embolism, a history of cardiac resuscitation, or concomitant HIV disease

Liver disease

Less common in the elderly than many other diseases, liver disease is still present in about 40% of people over the age of 60. Here are the hospice criteria and eligibility requirements for patients with liver disease.

1. The patient has end-stage liver disease as evidenced by a PT greater than five or an INR greater than 1.5, AND
2. The patient has a serum albumin (a protein produced by the liver) of less than 2.5, AND
3. The patient has one or more of the following conditions:
   • Refractory ascites
   • A history of spontaneous bacterial peritonitis (an infection of the liver)
   • A history of hepatorenal syndrome (decreased kidney function)
   • refractory hepatic encephalopathy (a brain condition common among people with liver disease)
   • A history of recurrent variceal bleeding
4. The patient may also have progressive malnutrition, muscle wasting with decreased strength, ongoing alcoholism (drinking more than 80 grams of ethanol per day), chronic hepatitis B, or hepatitis C that is resistant to treatment

Pulmonary disease

Pulmonary or lung disease affects about 15% of elderly Americans, so even though it is less common than some of the other conditions mentioned here, it is still common enough to know the hospice criteria and eligibility requirements for this disease.

1. The patient has disabling labored breathing while at rest, is not responding to bronchodilators, has decreased functional capacity (is basically only living in a chair and bed), has fatigue, and has a cough, AND
2. The patient has experienced the progression of the disease as evidenced by increasing office, home or emergency room visits, and/or hospitalizations for lung infections, and/or hospitalizations for respiratory failure, AND
3. The patient has had an arterial hypoxia reading of p02 <55 by ABG, an oxygen saturation reading of less than 88%, or a hypercapnia reading of pC02 >50 within the last three months
4. The patient may also have right-side heart failure or unintentional progressive weight loss

Stroke or coma

Stroke and coma are unfortunately relatively common in older people, especially those who have high blood pressure. In fact, about 66% of the people hospitalized for stroke are over the age of 65. Knowing the hospice criteria and eligibility requirements for stroke and coma can help you make the right medical decisions for your loved ones if they suffer from one of these conditions.

1. The patient has a PPS of 40% or less in all categories, AND
2. The patient has poor nutritional status with the inability to maintain sufficient calorie or fluid intake and has one of the following:
   • A 10% or greater weight loss over the past six months
   • A 7.5% or greater weight loss over the past three months
   • A serum albumin reading of less than 2.5
   • A history of pulmonary aspiration and no response to speech therapy treatments to improve swallowing problems to reduce aspiration
3. The patient may also be in a coma for three days and three of the following conditions:
   • Abnormal response of the brain stem
   • No verbal responses
   • No pain withdrawal response
   • A post-anoxic stroke, which occurs when the brain doesn’t receive enough oxygen

Conclusion: Discuss the options before a disease progresses

Even though it’s an unpleasant topic, if you have a loved one who is a senior citizen, whether they have any specific medical condition or not, you should discuss the criteria and hospice options before they’re in the position of possibly needing hospice care. This is because most of these conditions must be advanced before Medicare will pay for hospice services, and your loved one may not be able to make their own medical decisions by that time.

Understanding how your loved one wants to live out the remainder of their life is one of the most loving things you can do for them. So, despite your uncomfortable feelings around this topic, it’s vital for you to bring up the subject and document their wishes ahead of time.

Sources:

1. Hypercalcemia, Mayo Clinic, www.mayoclinic.org
2. Hospice Care Coverage, Medicare.gov, www.medicare.gov 
3. Pleural Effusion Causes, Signs & Treatment, Cleveland Clinic, my.clevelandclinic.org
4. Creatinine clearance test, UCSF Health, www.ucsfhealth.org
5. Kidney infection, Mayo Clinic, www.mayoclinic.org
6. Septicemia, Johns Hopkins Medicine, www.hopkinsmedicine.org
7. The Burden of Cardiovascular Disease in the Elderly: Morbidity, Mortality, and Costs, National Institutes of Health, www.ncbi.nlm.nih.gov
8. What is Ejection Fraction?, University of Rochester Medical Center, www.urmc.rochester.edu
9. Syncope, Cleveland Clinic, my.clevelandclinic.org
10. Albumin – blood (serum) test, Mount Sinai, www.mountsinai.org
11. What Are Palliative Care and Hospice Care?, National Institute on Aging, www.nia.nih.gov