Scores and Scales: Understanding the Balance of Hospice Eligibility

You’re the healthcare professional treating a patient for a serious, life-limiting illness, such as cancer, liver disease, or a neurological condition. Of course you want to do what’s best for the patient. This includes considering hospice care. How can you determine if the patient qualifies for hospice? What are the rules for being deemed hospice eligible?

Let’s start with the basics. A common hospice myth is that a patient must be within a few weeks or even days of dying to qualify for hospice care. In truth, Medicare (which regulates hospice certification for patients over the age of 65) requires a patient be within six months of death to be considered appropriate for hospice.

A rolling six-month prognosis is used to make the hospice determination. Here’s how that works: A patient qualifies for hospice only when a physician has provided medical evidence to support the belief the person will live six months or fewer. After the patient is on hospice for three months, a certification must be made. If after the next three months the patient is still living, he/she must be recertified. Following the second three-month period, recertification is required every 60 days. The interdisciplinary group (consisting of the medical director, nurse practitioner, team leaders, volunteers, and others) must continue to make the case for why the patient remains appropriate for hospice.

Making the Case

Armed with an understanding of the hospice certification process, how can healthcare professionals then make an accurate-as-possible prognosis for life expectancy? While making an intelligent cast for hospice is imprecise, there are scores and scales designed to help.

The common Palliative Performance Score (PPS), for example, evaluates activity levels, ambulation, and mental status — and uses a chart to assign a PPS. The PPS paints a picture of the patient and provides an indicator of how he/she is doing compared to an otherwise well, functioning member of the population at that same age. In addition to having an assigned PPS, dementia patients are scored in seven categories of increasing debility through a Functional Assessment Staging Test (FAST), which helps confirm that diagnosis.Other diseases have their own specific tests.

While there are many scales and scores, using them is just part of the equation. “Evaluating a patient for hospice is a process, not a decision,” says Walter L. George, M.D., corporate medical director for Crossroads Hospice. There are tools available to assess the level of decline in functioning and for determining objective numerical estimates, but other things are also important to the big picture.

“Physicians must consider other diagnoses of the patient in determining hospice eligibility,” says Dr. George. A patient with end-stage kidney disease may have other issues happening concurrently. Does he/she have insulin-dependent diabetes? Heart failure or COPD? A blood disorder? Cancer? “Review all other conditions to ask these key questions: To what degree is the referral to hospice based on renal failure reduced by the presence of other diseases? How do these other diseases contribute?”

“Social history, medical history, family history — these are all part of the equation, too,” advises Dr. George. “A life-span prediction will be based on a synthesis of all the medical findings plus applicable performance scores.”

Best Practices

“Patients don’t come on to hospice soon enough, which is unfortunate for them and their families,” says Dr. George. “The longer patients receive hospice care, the more and better we can do for them.” Toward this end, what can healthcare professionals do to make the most informed evaluation?

“First and foremost, don’t try to figure this out yourself,” says Dr. George. He recommends attending physicians seek out an assessment from a hospice physician. “Hospice is a specialty. Let us do the work and tell you if your patient meets the criteria. You can’t be expected to know this and be conversant with all the tools and scores and skills. Err on the side of thinking the patient might be qualified and let us help you make the determination.”

Dr. George also reminds that hospice is a level of care for the living designed to enhance the quality of life. “Hospice is for the living, not the dying. If your patient qualifies, he or she should by all means come onto service. There is a lot to be gained through pain management and having emotional and spiritual support. Even if a patient qualifies, he or she can always decline. But we owe the patient the opportunity to benefit from all hospice care has to offer.”

Get more information on hospice eligibility criteria or call us at 1-888-564-3405.

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