CONTENTS. I. Introduction CONTENTS

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2 I. Introduction CONTENTS II. Definition III. BMI/Mid-Arm Circumference IV. PPS V. FAST VI. NYHA Classification VII. PAINAD Scale VIII. Norton Pressure Sore Risk Assessment IX. Fall Risk Assessment X. Four Ways to Document Eligibility XI. Disease-Specific Guidelines for Determining Eligibility XI. A. General Guidelines XI. B. ALS XI. C. Alzheimer s Disease & Related Disorders XI. D. Cancer XI. E. Cardiopulmonary Conditions XI. F. HIV XI. G. Liver Disease XI. H. Renal Disease XI. I. Stroke and Coma XI. J. Adult Failure to Thrive XI. K. Other Terminal Illnesses XII. Bereavement Risk Assessment CONTENTS

3 INTRODUCTION WHAT THIS TOOLBOX IS: A collection of tools and guidelines intended to facilitate: Gathering of information by clinicians to improve documentation of symptoms and assessment findings that demonstrate hospice eligibility Providing guidance for Hospice Medical Directors/Associate Medical Directors to utilize in exercising their medical judgment in determining prognosis and documenting hospice eligibility An ever-evolving guide that was created and distributed by KAH and its predecessors, and will continue to be updated as guidelines and their interpretations change. This edition is felt to be current on the date it was published, subject to change with new regulations. WHAT THIS TOOLBOX IS NOT: A definitive or authoritative listing of criteria for determination of prognosis and hospice eligibility Medical judgment should always be used for each case in determining prognosis and hospice eligibility. I. INTRODUCTION

4 DEFINITION As part of its Conditions of Participation, CMS addresses eligibility for the Medicare Hospice Benefit in : In order to be eligible to elect hospice care under Medicare, an individual must be I. Entitled to Part A Medicare; and II. Certified as being terminally ill in accordance with states: The certification must specify that the individual s prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course. The above applies to Medicare patients Medicaid is determined by state statutes / regulations, but will generally follow this definition Other insurers may have their own definition of eligibility determination of who qualifies for hospice care II. DEFINITION

5 BMI Formula BMI = (weight in pounds x 703) Height* in inches 2 *Maximum Adult Height is necessary to calculate BMI (Body Mass Index). If the exact height is unknown, ask for a best estimate. MID-ARM CIRCUMFERENCE Measuring the Mid Arm Circumference provides an indication of skeletal muscle mass, bone and subcutaneous fat. It is used as a baseline for all patients, for future reference, and for a patient who cannot be weighed. Consistency in measurement is key. Position patient lying down. Place the non-dominant arm flat on the bed with the palm up. Measurement is taken on the non-dominant arm. Identify the acromial process (top of the shoulder) and the olecranon process (point of the elbow). Measure the distance between the 2 points and mark the half way point on the arm. Place the measuring tape perpendicular to the long axis length of the arm at the marked midpoint. The measurement should be in centimeters to the nearest millimeter. The tape must be neither too loose nor too tight. III. BMI/MAC

6 (See available job aid for further instruction on appropriate usage of the PPS) IV. PPS

7 Functional Assessment STaging (FAST) (See available job aid for further instruction on appropriate usage of the FAST) FAST score is the highest consecutive level of cognitive disability: 1. No difficulty either subjectively or objectively. 2. Complains of forgetting location of objects. Subjective work difficulties. 3. Decreased job functioning evident to co-workers. Difficulty in traveling to new locations. Decreased organizational capacity.* 4. Decreased ability to perform complex, tasks, e.g., planning dinner for guests, handling personal finances (such as forgetting to pay bills), difficulty marketing, etc.* 5. Requires assistance in choosing proper clothing to wear for the day, season, or occasion, e.g., patient may wear the same clothing repeatedly unless supervised.* 6. a) Improperly putting on clothes without assistance or cueing (e.g., may put street clothes on over night clothes, put shoes on wrong feet, or have difficulty buttoning clothing) occasionally or more frequently over the past weeks.* b) Unable to bathe properly (e.g. difficulty adjusting the bath water temperature) occasionally or more frequently over the past weeks.* V. FAST

8 V. FAST c) Inability to handle mechanics of toileting (e.g. forgets to flush the toilet, does not wipe properly or properly dispose of toilet tissue) occasionally or more frequently over the past weeks.* d) Urinary incontinence (occasionally or more frequently over the past weeks).* e) Fecal incontinence (occasionally or more frequently over the past weeks).* 7. a) Ability to speak limited to approximately 1-5 intelligible different words or fewer, in the course of an average day or in the course of an intensive interview. b) Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview (the person may repeat the word over and over). c) Ambulatory ability is lost (cannot walk without personal assistance). d) Cannot sit up without assistance (e.g., the individual will fall over if there are not lateral rests [arms] on the chair). e) Loss of ability to smile. f ) Loss of ability to hold head up independently. *Scored primarily on the basis of information obtained from knowledgeable informant and / or observation. Reisberg, B. Functional assessment staging (FAST). Psychopharmacology Bulletin 1988; 24:

9 NEW YORK HEART ASSOCIATION NEWnEW (NYHA) YOURL FUNCTIONAL CLASSIFICATION (Class & Description) I Patients with cardiac disease, but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, dyspnea, palpitations or anginal pain. II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, dyspnea, palpitations or anginal pain. III Patients with limitations of physical activity. They are comfortable at rest. Less than ordinary physical activity causes fatigue, palpitations, dyspnea or anginal pain. IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased. VI. NYHA

10 Item 0 Points 1Point 2 Points Score Breathing independent of vocalization PAIN ASSESSMENT IN ADVANCED DEMENTIA (PAINAD) SCALE Normal Occasional labored breathing. Short period of hyperventilation. Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations. VII. PAINAD Negative vocalization None Occasional moan or groan. Low-level speech with a negative or disapproving quality. Repeated trouble calling out. Loud moaning or groaning. Crying. Facial expressions Smiling or inexpressive Sad. Frightened. Frown. Facial grimacing. Body language Relaxed Tense. Distressed pacing. Fidgeting. Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out. Consolability No need to console Distracted or reassured by voice or touch. Unable to console, distract or reassure. Total

11 VII. PAINAD PAIN ASSESSMENT IN ADVANCED DEMENTIA (PAINAD) SCALE (CONTINUED) Breathing 1. Normal breathing is c characterized by effortless, quiet, rhythmic (smooth) respirations 2. Occasional labored breathing is characterized by episodic bursts of harsh, difficult or wearing respirations. 3. Short period of hyperventilation is characterized by intervals of rapid, deep breaths lasting a short period of time. 4. Noisy labored breathing is characterized by negative sounding respirations on inspiration or expiration. They may be loud, gurgling or wheezing. They appear strenuous or wearing. 5. Long period of hyperventilation is characterized by an excessive rate and depth of respirations lasting a considerable time. 6. Cheyne-Stokes respirations are characterized by rhythmic waxing and waning of breathing from very deep to shallow respirations with periods of apnea (cessation of breathing). Negative Vocalization 1. None is characterized by speech or vocalization that has a neutral or pleasant quality. 2. Occasional moan or groan is characterized by mournful or murmuring sounds, wails or laments. Groaning is characterized by louder than usual inarticulate involuntary sounds, often abruptly beginning and ending. 3. Low level speech with a negative or disapproving quality is characterized by muttering, mumbling, whining, grumbling or swearing in a low volume with a complaining, sarcastic or caustic tone 4. Repeated trouble calling out is characterized by phrases or words being used over and over in a tone that suggests anxiety, uneasiness or distress. 5. Loud moaning or groaning is characterized by mournful or murmuring sounds, wails or laments much louder than usual volume. Loud groaning is characterized by louder than usual inarticulate involuntary sounds, often abruptly beginning and ending. 6. Crying is characterized by an utterance of emotion accompanied by tears. There may be sobbing or quiet weeping. Facial Expression 1. Smiling is characterized by upturned corners of the mouth, brightening of the eyes and a look of pleasure or contentment. Inexpressive refers to neutral, at ease, relaxed or blank look. 2. Sad is characterized by an unhappy, lonesome, sorrowful or dejected look. T here may be tears in the eyes. 3. Frightened is characterized by a look of fear, alarm or heightened anxiety. Eyes appear wide open.

12 PAIN ASSESSMENT IN ADVANCED DEMENTIA (PAINAD) SCALE (CONTINUED) Facial Expression continued 4. Frown is characterized by a downward turn of the corners of the mouth. Increased facial wrinkling in the forehead and around the mouth may appear. 5. Facial grimacing is characterized by a distorted, distressed look. The brow is more wrinkled, as is the area around the mouth. Eyes may be squeezed shut. Body Language 1. Relaxed is characterized by a calm, restful, mellow appearance. The person seems to be taking it easy 2. Tense is characterized by a strained, apprehensive or worried appearance. The jaw may be clenched (exclude any contractures). 3. Distressed pacing is characterized by activity that seems unsettled. There may be a fearful, worried or disturbed element present. The rate may be faster or slower. 4. Fidgeting is characterized by restless movement. Squirming about or wiggling in the chair may occur. The person might be hitching a chair across the room. Repetitive touching, tugging or rubbing body parts can also be observed. 5. Rigid is characterized by stiffening of the body. The arms and / or legs are tight and inflexible. The trunk may appear straight and unyielding (exclude any contractures). 6. Fists clenched is characterized by tightly closed hands. They may be opened and closed repeatedly or held tightly shut. 7. Knees pulled up is characterized by flexing the legs and drawing the knees up to- ward the chest. An overall troubled appearance (exclude any contractures). 8. Pulling or pushing away is characterized by resistiveness upon approach or to care. The person is trying to escape by yanking or wrenching him or herself free or shoving you away. 9. Striking out is characterized by hitting, kicking, grabbing, punching, biting or other forms of personal assault. Consolability 1. No need to console is characterized by a sense of well being. The person appears content. 2. Distracted or reassured by voice or touch is characterized by a disruption in the behavior when the person is spoken to or touched. The behavior stops during the period of interaction with no indication that the person is at all distressed. 3. Unable to console, distract or reassure is characterized by the inability to soothe the person or stop a behavior with words or actions. No amount of comforting (verbal or physical) will alleviate the behavior. Warden V. Hurley AC, Volicer L. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. J Am Med Dir Assoc. 2003; 4;9-15 Excerpted from Frampton K. Vital Sign #5. Caring for the Ages 2004; 5(5): & copy; 2004 Lippin- cott Williams &amp Wilkins. All rights reserved. Reprinted with permission.

13 VIII. NORTON PRESSURE SORE RISK

14 VIII. NORTON PRESSURE SORE RISK

15 IX. FALL RISK ASSESSMENT

16 FOUR WAYS TO DOCUMENT ELIGIBILITY X. FOUR WAYS TO DOCUMENT ELIGIBILITY

17 X. FOUR WAYS TO DOCUMENT ELIGIBILITY FOUR WAYS TO DOCUMENT ELIGIBILITY

18 Local Coverage Determinations (LCDs) LCDs are published by each Medicare Administrative Contractor as guidelines to aid in the documentation of hospice eligibility. The guidelines in this Toolbox are derived from the three different MAC s LCDs, generally choosing the strictest version. Therefore, it is important to be familiar with the actual LCDs for the MAC covering your geographic practice area. At this time this Toolbox is published, there are three MACs: CGS Administrators LLC National Government Services, Inc Palmetto GBA (see next page for their geographic coverage) The actual LCDs can be accessed online at: Choose Local Coverage Determinations Select the geographic area (usually your state) Enter hospice as a keyword Click Search by type LCDs are updated at irregular intervals, so it is worthwhile checking this periodically.

19 Home Health & Hospice A/B MACs As of April 2015

20 XI. A. GENERAL GUIDELINES

21 XI. A. GENERAL GUIDELINES

22 ALS Terminal Stage ALS Guidelines (Patients are considered eligible if 1, 2a & 2b or 2a & 3 are documented) (1) Critically impaired breathing capacity as evidenced by: Vital Capacity < 30% of normal Dyspnea at rest Declines artificial ventilation; external ventilation used for comfort measures only (2a) Rapid progression of disease as demonstrated by progression (within the 12 months preceding initial hospice certification) of: ambulation to w/c or bed-bound status Speech normal to barely or unintelligible Diet normal to puréed Independence in ADL s to needs major assistance with ADL s (2b) Critical nutritional impairment as demonstrated by: Oral intake of nutrients and fluids insufficient to sustain life Continued weight loss Dehydration or Hypovolemia Absence of artificial feeding methods XI. B. ALS

23 XI. B. ALS Remember to document your clinical judgment!

24 XI. C. ALZHEIMER S & RELATED DISEASES

25 XI. C. ALZHEIMER S & RELATED DISEASES Co-morbid conditions (cont d): Cardiopulmonary disease Renal disease Liver disease Rapid decline Remember to document your clinical judgment!

26 Remember to document your clinical judgment! XI. D. CANCER

27 XI. E. CARDIOPULMONARY CONDITIONS

28 XI. E. CARDIOPULMONARY CONDITIONS Hypercapnia with CO2 > 50mm Hg Remember to document your clinical judgment!

29 HIV HIV Disease Guidelines (Patients are considered to be eligible if 1 & 2 are present) (1) CD4 + count <25 cells/mcl or persistent (tested twice, at least one month apart) viral load >100,000 copies/ml, plus one of the following: CNS Lymphoma Untreated/unresponsive wasting (loss of lean body mass =10% - 33%) MAC infection (untreated/unresponsive to treatment, or treatment refused) Progressive multifocal leukoencephalopathy Systemic lymphoma Visceral Kaposi s Sarcoma, unresponsive to tx Renal failure without dialysis Cryptosporidium infection Toxoplasmosis, unresponsive to tx (2) PPS < 50% Supplemental: Chronic, persistent diarrhea for 1 year Persistent serum albumin <2.5gm/dL Concomitant active substance abuse Age >50 years Absence/resistance of antiretroviral, chemotherapeutic or prophylactic HIV tx Advanced AIDS dementia complex CHF, symptomatic at rest Toxoplasmosis Advanced liver disease XI. F. HIV

30 XI. F. HIV Remember to document your clinical judgment!

31 LIVER DISEASES Liver Disease Guidelines (Patients will be considered to be eligible if 1 & 2 are present) XI. G. LIVER DISEASES

32 XI. G. LIVER DISEASES Note: 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. Remember to document your clinical judgment!

33 Patients will be considered to be in the terminal stage of renal disease if 1 & 2 are present or 1 & 3 are present XI. H. RENAL DISEASE

34 XI. H. RENAL DISEASE Remember to document your clinical judgment!

35 Stroke 1 & 2 should be present XI. I. STROKE & COMA

36 XI. I. STROKE & COMA Remember to document your clinical judgment!

37 Remember to document your clinical judgment! XI. J. ADULT FAILURE TO THRIVE

38 Remember to document your clinical judgment! XI. K. OTHER TERMINAL ILLNESSES

39 XII. BEREAVEMENT RISK ASSESSMENT

40 XII. BEREAVEMENT RISK ASSESSMENT