Hospice Eligibility Criteria, Requirements & Diagnoses
On average, hospice patients live about two months after being given a six-month prognosis. It means most patients who come into hospice care were eligible for services months before the referral was made. Patients miss the benefits of hospice comprehensive services and support when the referral is made too late.
To start hospice care, patients must meet the hospice criteria established by the U.S. Centers for Medicare & Medicaid Services. While no specific number of symptoms is needed when qualifying for hospice, these hospice guidelines will help determine if an individual’s condition is or will soon be eligible for hospice care.
In This Article:
How do You Qualify for Hospice Care?
Only the primary care doctor and the hospice doctor can certify that patient is terminally ill, featuring a life expectancy of six months or less), states Medicare. A nurse practitioner, for example, can’t confirm that someone is terminally ill. There’s no age restriction when it comes to who qualifies for hospice – anyone in the last phases of life can be eligible. Other considerations that must be met are:
- The patient and family must understand the prognosis and agree to use palliative care instead of seeking a cure;
- Patient and family must provide informed consent;
- Patient and family must elect the hospice benefit through completing and signing an election form.
When it comes to determining hospice eligibility criteria, the doctors must first evaluate the patient for symptom and pain management, counsel the patient on hospice and any other options available to him/her, and inform the patient on advanced care planning.
It’s crucial to note, however, that a person who shows marked improvement throughout hospice may cancel hospice treatment at any time. Also, any patient who decides to re-visit the possibility of curative measures can do that at any time.
How to Meet Medicare Hospice Criteria?
To choose hospice under Medicare, a patient must be entitled to Medicare Part A and certified as terminally ill by a physician with a prognosis of 6 months or less if the disease runs its normal course.
Medicare Part A covers hospice services, even for individuals with a Medicare Advantage (Part C) plan. Medicare enables and reimburses for a one-time visit by a doctor who is either the medical director or employee of a hospice agency.
Hospice Eligibility Requirements
- Patient is diagnosed with a life-limiting condition with a prognosis of 6 months or less if terminal illness runs its typical course;
- Frequent hospitalizations in the past 6 months;
- Progressive weight loss;
- Increasing fatigue, somnolence, and weakness;
- A change in functional and cognitive abilities;
- Compromised ADLs such as dressing, toileting, bathing, transferring/walking, eating, and continence;
- Deteriorating mental;
- Recurrent Infections;
- Specific decline in condition;
- Skin breakdown.
Disease-Based Hospice Eligibility Criteria
There are also specific criteria for hospice care to consider based on the patient’s primary diagnosis. Below are applicable disease-specific requirements for hospice care.
Cancer hospice criteria
Since there are many different types of cancer, the following hospice cancer requirements are general rules used by physicians to determine if hospice is the best choice for a patient.
- Metastatic cancer;
- Decline in condition regardless of therapy;
- Karnofsky Score or Palliative Performance Score of 70 percent or less;
- Choosing to forgo further disease directed curative treatment.
Requirements for AIDS/HIV hospice
While no specific number of symptoms is necessary to fulfill the hospice eligibility requirements for HIV/AIDS patients, here are a few of the signs considered.
- Must have established HIV or AIDS diagnosis;
- Decision has been made to forego antiretroviral, antifungal, antibacterial, chemotherapeutic and prophylactic drug therapy related particularly to the AIDS diagnosis;
- Chronic, long-term diarrhea;
- Significant weight loss of 10% or more in the past 3 months;
- Persistent weakness;
- Frequent opportunistic infections;
- Congestive heart failure at rest;
- ADS (AIDS Dementia Complex);
- Generalized wasting;
- Substance abuse.
CVA hospice eligibility criteria
These are the requirements that should be met before a doctor recommends hospice care after a stroke or cerebrovascular accident.
- Mainly bed to chair bound;
- Karnofsky Score Palliative Performance Score of 40% or less;
- Changes in orientation status;
- Impaired functional status;
- Needs assistance with ADLs;
- Unintentional weight loss;
- Unable to maintain sufficient caloric and fluid intake.
CHF disease hospice criteria
In addition to general hospice guidelines, consider the following symptoms when determining hospice criteria for congestive heart failure.
- A poor response to diuretics and vasodilators;
- Tightness or dyspnea in the chest;
- Impaired sleep functions;
- Identification of specific structural and functional impairments;
- Chest pain;
- Inappropriate heart rhythms, contraction force of ventricular muscles and poor blood supply to the heart;
- Changes in appetite, progressive weight loss;
- Relevant activity limitations and or damaged mobility;
- Decline in physical endurance.
COPD hospice criteria
The slow decline of chronic obstructive pulmonary disease often has patients unsure of when they meet COPD hospice requirements. Consider the following criteria for chronic obstructive pulmonary disease patients.
- Recent visits to the ER or hospitalization for respiratory failure or pulmonary infections;
- Dyspnea or tightness in the chest;
- Identification of specific structural and functional impairments;
- Relevant activity limitations;
- Changes in appetite, unintentional weight loss;
- Impaired sleep functions;
- Decline in physical endurance;
- Needs oxygen some of the time or all of the time;
- Poor mobility;
- May have difficulty with eating or making conversations without becoming short of breath;
- May require the use of inhalers or breathing treatments.
Dementia hospice eligibility criteria
For patients with dementia, it may be time to consider hospice when the patient’s physical condition starts to decline. Some key factors to look for include:
- A diagnosis of other conditions as cancer, CHF, and COPD;
- Frequent hospitalizations and visits to the doctor, and/or trips to the ER;
- A diagnosis of sepsis or pneumonia;
- Weight loss or dehydration due to challenges in drinking/eating;
- Speech limited to 6 words or less per day;
- Difficult swallowing or choking on food or liquids;
- Fecal and urinary incontinence;
- No longer able to smile;
- Unable to walk without assistance like a walker or requiring a wheelchair;
- Unable to sit up without assistance.
Hospice eligibility criteria for liver disease
Patients are able to receive hospice care for liver disease when they meet the following hospice requirements. If an individual meets the liver disease hospice eligibility requirements, you should consider scheduling a hospice consultation.
- Weakness and decreased ability perform activities of daily living;
- Hepatic encephalopathy;
- Recurrent variceal hemorrhage;
- Muscle wasting.
Neurological hospice eligibility requirements
Patients with an end-stage neurological condition including Non-Alzheimer’s dementia, MS, Huntington’s disease, Parkinson’s, ALS, and other neurological conditions are eligible for hospice care. Check the symptoms for end-stage neurological symptoms below.
- Structural and functional impairments;
- Compromised mental function;
- Impaired neuromusculoskeletal and movement functions;
- Impaired sensory function and pain;
- Poor communication;
- Decreased mobility;
- Activity limitations;
- Self-care deficit.
Renal disease hospice criteria
End-stage renal/kidney disease patients have the right qualification for hospice care. Read the list below to view the renal failure hospice c requirements.
- Uremia with obtundation;
- Nausea and vomiting;
- Patient has chosen not to receive renal dialysis;
- Hepatorenal syndrome;
- Intractable hyperkalemia;
- Structural/functional impairments;
- Comorbid/secondary conditions contribute to terminal prognosis;
- Self-care deficits;
- Activity limitations;
- Uremic pericarditis.
What is the most Common Hospice Diagnosis?
The NHPCO has shown data revealing the primary diagnosis of hospice patients. Relying on that data, here are the 4 most common hospice diagnoses.
Cancer – Regardless of the gradual decline in the number of admissions due to hospice, cancer still dominates the ranking. Early diagnosis and advancement in treatments/early diagnosis and cure have decreased the number of cancer patients worldwide. Patients who are facing a continued decline in health despite of receiving therapy are eligible for hospice care. Some types of cancers with bad prognosis are also qualified for hospice care;
Dementia – The second most common diagnosis in hospice is dementia. Hospice care for dementia requires that the patient has detailed care since he/she might not be able to do the essential functions of life without help. They’re also susceptible to infections and care is needed for managing symptoms;
Heart disease – There has been an increase in the percentage of patients with heart disease. The individual will be taken in hospice if they meet the following requires: the patient has been optimally treated for their condition; the patient is either not suitable for a surgical procedure or they have declined the procedure; the patient has Angina or congestive heart failure, and due to physical activity, their discomfort has increased;
Lung disease – The most common lung disease for patients entering hospice care had been a COPD. Patients with stage 4 chronic obstructive pulmonary disease have a shorter life expectancy and therefore, they’re likely to get hospice care.
What are the Main Levels of Hospice Care?
Patients in hospice care may require differing hospice levels of care, as the illness progresses, or their health condition worsens. These levels are:
- Routine hospice care – This most common level of hospice care includes care of the patient at his/her residence, whether a private residence, nursing facility or assisted living facility;
- General inpatient care – Includes pain control or other acute symptom management that requires an inpatient setting. It typically starts when other efforts to address symptoms become inefficient. This care can be given in a Medicare-certified hospital, hospice inpatient facility, or nursing facility that has registered nursing staff available 24 hours per day for direct patient care;
- Continuous home care – It provides between 8 and 24 hours per day to manage pain and different acute symptoms. These services must be mostly nursing care, supported with caregiver and hospice aide services to help a terminally ill patient stay at home during a symptom or pain crisis;
- Inpatient respite care – This care provides temporary relief to a primary caregiver and can be received in a hospital, hospice facility, continuum care hospice, or a long term care facility that has nursing staff present on all shifts to meet a patient’s needs. Respite care could be provided for a maximum of 5 consecutive days.
While every patient’s case is sui generis, some requirements to look for are listed below.
One symptom is that the patient has received optimal treatment for his/her disease and isn’t a candidate for further medical or surgical intervention. Still, there are other signs such as advanced congestive heart failure, abnormal heart due to disease, and more.is text.
Two main requirements are – the patient can say only a few words, and has been through several years of decline. Others include – the patient can no longer walk and may be bed-bound; the individual is completely dependent on others for dressing, eating, and grooming; the patient shows signs of severe anxiety.
Ineffective treatment and rapid weakening are two signs, and there are others. They include – the patient is quickly weakening, and the cancer is progressing; the treatment intervention isn’t fully effective; the burden of treatment on the patient and family outweighs the benefits.
They include coma, continuous decline in function, severely reduced level of consciousness, persistent vegetative state, and a significant compromise in breathing and/or swallowing.