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Hospice Eligibility Criteria for Providers

To be eligible for hospice care, a patient must meet three core criteria: 

  • A terminal diagnosis with a life expectancy of six months or less
  • A shift in focus from curative treatment to palliative and comfort-focused care
  • Physician certification of these conditions. 
 
Physicians & Providers: Please refer your patients as soon as they are eligible so that they have optimal quality of life, their family and caregiver have the support they need, and you and your team are supported by our team. You are still eligible for reimbursement, and the support of our team may significantly help improve your efficiency and quality metrics scores.
 
While a specific diagnosis is required, physicians also look for general signs of decline and disease-specific markers to determine if a patient is ready for hospice. If the primary terminal diagnosis is unclear, our Board Certified Hospice Physicians can help determine the most appropriate terminal diagnosis for your patient Your patient may be ready for hospice if they meet several of the following indicators: 
 

Core Hospice Eligibility Indicators

  • Terminal Prognosis: A physician certifies that the patient likely has six months or less to live if the illness follows its natural course.
  • Shift in Care Goals: The patient or their family chooses to stop curative treatments. 
  • Worsening symptoms, including pain, shortness of breath, or nausea that are no longer controlled despite medical treatment.
  • Decline in physical or cognitive function
  • Nutritional Decline: Unintentional weight loss of > 10% in the last 6 months (or 5% in one month). Other indicators are a reduction in appetite or not responding to nutritional support despite adequeate caloric intake.
  • BMI < 22 and/or decreasing mid-arm circumference
  • Non-Healing Wounds – Stage III or Stage IV
  • Functional Decline: Increased dependence for at least 3/6 of the Activities of Daily Living:
    • Bathing
    • Dressing
    • Feeding
    • Toileting/Continence
    • Transferring
    • Walking/Ambulation
  • Recurrence of at least one of the following within the last 12 months:
    • Life-threatening complications
    • Recurrent pneumonias or UTIs
    • Sepsis
    • Recurrent fevers after antibiotics
    • Frequent ED visits or hospitalizations related to primary diagnosis or co-morbidities including:
    • COPD, CHF/Heart disease, Diabetes Mellitus, Neurologic diseases, severe autoimmune diseases, dementia
Unable to care for self; requires equivalent of institution or hospital care; disease progression may be rapid 
40
Disabled; requires special care & assistance
 
30
Severely disabled; hospital indicated; death not imminent
 
20
Very sick; hospital admit necessary; active active supportive treatment necessary.
10

Moribund; fatal processes progressing rapidly

Unable to care for self; requires equivalent of institution or hospital care; disease progression may be rapid 
40
Disabled; requires special care & assistance
 
30
Severely disabled; hospital indicated; death not imminent
 
20
Very sick; hospital admit necessary; active active supportive treatment necessary.
10

Moribund; fatal processes progressing rapidly

Disease Specific Criteria

  • Decline in condition despite treatment
  • Palliative Performance Scale (PPS) score ≤ 70%
  • Diagnosis confirmed through pathology or radiology
  • Patient is no longer receiving curative treatment/care
  • There is evidence of end-stage disease/rapid progression and/or metastasis.
  • Recent lab/diagnostic studies that support disease progression
  • Functional Status documentation or decline in functional status over time
  • Decline in Nutritional Status or > 10% weight loss over the past 6 months
  • Co-morbidities: cardiopulmonary disease, liver disease, heart disease, Type II DM, gi bleed, chronic infectious processes, anorexia, cachexia
  • A FAST Score of 7 or greater
  • Dependent in ADLs
  • Weight loss > 10% in last 6 months
  • Serum Albumin 2.5 or less
  • Impairments in body function, mental function and movement function
  • Life Threatening Complications:
    • Recurrent pneumonias
    • Recurrent UTIs
    • Sepsis
    • Recurrent fevers after antibiotics
    • Stage III or IV decubitus ulcers
  • Optimally treated with diuretics & blockers, vasodilators & blood thinners
  • NYHA Class IV Heart Failure
    • Unable to carry on any physical activity without discomfort. 
    • Symptoms of heart failure at rest. 
    • If any physical activity is undertaken, discomfort increases.
  • Ejection Fraction = < 20%
  • History of cardiac arrest, unexplained syncope, tachyarrhythmias
  • Treatment-resistant arrhythmias
  • Angina that increases with activity
  • Dyspnea at rest
  • Edema
  • Debilitating fatigue
  • Oxygen dependence
  • Oral Steroid dependence
  • O2 Sat = or < 88% on room air
  • PCO2 > 50
  • FEVI < 30%
  • Resting tachycardia > 100/min
  • Recurrent pulmonary infections and/or exacerbations
  • Unintentional weight loss
  • CD4 + count < 25 cells/mcl or Persistent Viral load > 100,000 copies/ml
  • At least one of the following:
    • CNS Lymphoma
    • Wasting (33% loss)
    • Mycobacterium avium complex bacteremia (MAC)
    • Progressive multi-focal leukoencephalopathy
    • Systemic Lymphoma with advanced HIV
    • Visceral Kaposi’s sarcoma unreponsive to therapy – Renal failure in the absence of dialysis
    • Crytosporidium infection
    • Toxoplasmosis unresponsive to therapy
  • Decreased performance status (KPS </= 50)
  • Supporting documentation:
    • Persistant diarrhea > 1 yr.
    • Serum albumin < 2.5
    • Active substance abuse
    • Age > 50
    • Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy
    • Advanced AIDS dementia complex
    • CHF, symptomatic at rest
  • End-stage liver disease as evidenced by BOTH of the following:
    • Prothrombin time prolonged more than five seconds over control or international normalized ratio (INR)>1.5
    • Serum albumin < 2.5 gm/dl.
  • AND The patient shows at least one of the following:
    • Ascites, refractory to treatment, or patient non-compliant
    • Spontaneous bacterial peritonitis
    • Hepatorenal syndrome (elevated creatinine and BUN with oliguria (<400ml/day) and urine sodium concentration
    • Hepatic encephalopathy, refractory to treatment, or patient non-compliant
    • Recurrent variceal bleeding, despite intensive therapy
  • Documentation of the following factors will support Hospice eligibility:
    • Progressive malnutrition
    • Muscle wasting with reduced strength and endurance
    • Continued active alcoholism (>80 gm ethanol/day)
    • Hepatocellular carcinoma
    • HBsAg (Hepatitis B) positivity
    • Hepatitis C refractory to interferon treatment
  • Patients awaiting liver transplant who otherwise fit the above criteria may be certified for the Medicare Hospice Benefit, but, if a donor organ is procured, the patient must be discharged from hospice.
  • Critically impaired breathing capacity
    • VC < 30%
    • Dyspena at rest
    • Supplemental O2
    • Declines Ventilation
  • Rapid disease progression compared to preceeding 12 months
    • From independent ambulation to wheel chair or bed bound status
    • From normal speech to barely intelligible or
      unintelligble speech
    • From independence in most ADLs to
      requiring major assistance with all
  • Critical nutrition impairment
    • Insufficient oral intake
    • Difficulty swallowing
    • Weight loss > 10% in past 6 months
    • Dehydration
    • Declines artificial feeding
  • Life-threatening complications
    • Recurrent pneumonia
    • Recurrent UTIs
    • Sepsis
    • Recurrent fevers after antibiotics
    • Stage III or IV decubitus ulcers
  • Severe chronic lung disease as evidenced by BOTH of the following:
  • Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased functional capacity, FEV1 after bronchodilator is less than 30% of predicted.
  • Progression of end stage pulmonary disease, as evidenced by:
    • Increasing visits to the emergency department or hospitalizations for pulmonary infections and/or respiratory failure or increasing physician home visits prior to initial certification.
    • Serial decrease of FEV1>40 ml/year
    • Hypoxemia at rest on room air, as evidenced by pO2 ≤55 mmHg; or oxygen saturation ≤88%, determined either by arterial blood gases or oxygen saturation monitors.
    • OR Hypercapnia, as evidenced by pCO2 ≥50 mmHg.
    • Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy).
    • Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months.
    • Resting tachycardia >100/min.
  • Patient has discontinued dialysis
  • Creatinine clearance < 10cc/min
  • Serum Creatinine > 8 mg/dl, < 6 mg dl in DM
  • Hyperkalemia > 7
  • Uremia, Oliguria
  • Hepatorenal Syndrome
  • Uremic Pericarditis
  • Intractable fluid overload
  • Hyperparathyroidism
  • Calciphylaxis
  • Nephrogenic systemic fibrosis
  • Electrolyte imbalance
  • Co-morbidities including;
    • Mechanical ventilation
    • Malignancy (other organ system)
    • Chronic lung disease
    • Advanced cardiac disease
    • Advanced liver disease
    • Sepsis
    • Immunosuppression/AIDS
    • Albumin
    • Cachexia
    • Platelet count <25,000
    • Disseminated intravascular coagulation
    • Gastrointestinal bleeding

Please note – patients awaiting kidney transplant who otherwise fit the above criteria may be certified for the Medicare Hospice benefit, but, if an organ donor is procurred, the patient must be discharged from hospice.

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