6
Establishing Hospice Eligibility
At the time of admission, and on an ongoing basis, the hospice nurse is responsible for assessing the patient’s condition and documenting that the patient continues to meet established criteria for hospice care. This chapter discusses several guidelines and prognostic tools.
After reading this chapter, you will be able to:
■ Identify hospice eligibility guidelines
■ Discuss tools used to support the need for end-of-life care
■ Determine eligibility for hospice services
Question: What if my patient is not Medicare-eligible?
Answer: The hospice social worker will work closely with individuals who have private insurance or no insurance to establish how care will be covered and to connect patients and their families with needed resources.
GUIDELINES AND ASSESSMENT TOOLS
Most commonly, patients utilize the Hospice Medicare Benefit to cover hospice services. According to the Centers for Medicare & Medicaid Services (2015b), to receive this benefit, patients must be eligible for Medicare Part A and:
■ Accept hospice care instead of curative treatments
■ Sign a statement choosing hospice care and revoking Medicare benefits for curative treatment of the terminal condition
■ Receive certification of terminality (life expectancy of 6 months or less) from both the primary care physician and the hospice medical director
Question: Where can my patients find reliable information about the Hospice Medicare Benefit?
Answer: Patients and their families can go to Medicare.gov and search for “hospice” in the search bar.
Other criteria are also used to support terminality and eligibility for services and should be documented in the patient’s record. For example, Local Coverage Determination (LCD) is used by the National Government Services to determine eligibility for hospice care (Jones, Harrington, & Mueller, 2013). These guidelines (Centers for Medicare & Medicaid Services, 2015a) specify criteria for:
■ Decline in clinical status
■ Nondisease-specific baseline guidelines
■ Disease-specific guidelines
A summary of Medicare’s LCD for hospice service eligibility is shown in Table 6.1.
The LCD guidelines reference several other tools that are used to determine terminality. Some of these tools include:
■ The Functional Assessment Staging Test (FAST©) Scale: This scale was developed as an evaluation tool for patients who have dementia (Reisberg, 1987). Health care professionals use the FAST Scale to document a patient’s functional status according to the seven stages included in the scale. A score of 1 indicates no impairment; 2 to 5 indicates mild to moderate impairment; 6 to 7 indicates moderately severe to severe impairment (Reisberg et al., 1996). FAST Scale scores of 6 to 7 have been associated with increased mortality (Sampson, Leurent, Blanchard, Jones, & King, 2013). Patients who have dementia must be at Stage 7 to be eligible for hospice services. (The FAST Scale is included in the Appendix.)
■ The Karnofsky Scale: This scale was first developed in the 1940s as a way to measure a patient’s status throughout cancer treatment (Karnofsky & Burchenal, 1949; Timmerman, 2012). It has been extensively tested and is a reliable and valid measure of performance status. This scale is also useful for prognostication purposes (Abernethy, Shelby-James, Fazekas, Woods, & Currow, 2005); a low score is associated with a poor prognosis. However, the scale indicates that a patient with a score of less than or equal to 30 requires hospitalization (see Appendix for Karnofsky Scale). Most hospice and palliative clinicians do not use the scale to determine the need for hospitalization, but rather, to assess and document declining health status. Another tool, the Palliative Performance Scale (PPS), is a modified version of the Karnofsky Performance Scale and is widely used in hospice and palliative settings.
■ The Palliative Performance Scale© (PPS): This scale is based on the Karnofsky Performance Scale and is meant to be used to develop a clinical snapshot of the patient’s status at a given time. Reassessment of the patient’s condition over time allows clinicians to monitor changes in the patient’s status using a standardized tool that helps establish prognosis. As scores decrease from 100% (no evidence of disease) to 0% (death), the patient’s mortality risk increases (Anderson, Downing, Hill, Casorso, & Lerch, 1996).
The PPS has been modified (Victoria Hospice Society, 2001), and the second version is a useful clinical tool for prognostication (Chan, Wu, & Chan, 2013). For nonspecific terminal illness, a PPS score of less than or equal to 70% supports hospice admission. For patients who have a diagnosis of cerebrovascular accident (CVA) or HIV, a score of less than or equal to 50% supports hospice admission (Jones et al., 2013). (The PPSv2 [PPS version 2] is included in the Appendix.)
■ The Eastern Cooperative Oncology Group (ECOG) Performance Scale: This scale is used to determine the progression of a patient’s disease on a scale from 0 (no restriction) to 5 (dead). Although an ECOG score is not specifically required for hospice admission, a score of more than or equal to 2 is predictive of a prognosis of 6 months or less (Wright & Kinzbrunner, 2011).
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