Hospice Eligibility Criteria
In order to begin hospice care, patients must meet the hospice eligibility requirements established by the U.S. Centers for Medicare & Medicaid Services. While no specific number of symptoms is required when qualifying for hospice, these guidelines can help determine if a patient’s condition is, or will soon be, appropriate for hospice care.
Hospice eligibility requirements:
While there is no one diagnosis that qualifies a patient for hospice, a combination of symptoms can qualify a patient for end-of-life care. Consider the following criteria to determine if a patient is eligible for a hospice referral:
- Diagnosis of a life-limiting condition with a prognosis of six months or less based on the natural course of the disease
- Frequent hospitalizations within the past six months
- Progressive weight loss,, accounting for factors such as edema
- Increasing weakness, fatigue, and drowsiness
- Changes in cognitive and functional abilities
- Compromised Activities of Daily Living (ADLs) such as eating, bathing, dressing, toileting, transferring/walking, and continence
- Deteriorating mental abilities
- Recurrent infections
- Skin breakdown
- Specific decline in condition
- Other comorbid conditions
Disease-specific requirements for hospice care.
When metastatic cancer is present, there’s a decline in condition despite therapy, and the patient is no longer receiving curative treatment, they may qualify for hospice.
Stroke patients may be ready for hospice if they experience a significant decline in functional abilities, recurrent complications, and are mainly bed to chair bound.
The identification of specific structural/functional impairments, a poor response to diuretics and vasodilators, and declined general endurance are all signs that hospice may be appropriate.
Some hospice eligibility criteria for COPD patients include severe respiratory symptoms, frequent exacerbations, and dyspnea or tightness in the chest.
When dementia or Alzheimer’s patients experience significant decline in cognitive functional abilities or, difficulties swallowing, or have a diagnosis of pneumonia or sepsis, they may be eligible for hospice.
Low CD4 counts, high viral loads, and generalized weakness are some signs that an HIV/AIDS patient is eligible for hospice care.
Liver disease patients may be ready for hospice if they experience recurrent variceal hemorrhage, hepatic encephalopathy, peritonitis and more.
Patient’s with conditions like non-Alzheimer’s dementia, Parkinson’s disease, MS, ALS, and Huntington’s disease may be ready for hospice with symptoms including structural/functional impairments, activity limitations, and increased pain.
Once a patient in end-stage renal failure has chosen not to have renal dialysis for any reason and experiences significant decline in kidney function, they may be eligible for hospice care.
Insurance requirements for hospice.
Generally, insurance requires a prognosis of six months or less and certification of terminal illness by a physician. View various insurance program’s hospice eligibility criteria:
Patients benefit from hospice by receiving comprehensive care focused on comfort, symptom management, and emotional support during their end-of-life journey. If you have any doubt about whether the requirements for hospice care have been met, please contact us using the Help Bar above for a hospice consultation.