HIV: Disease Trajectory and Hospice Eligibility

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1 HIV: Disease Trajectory and Hospice Eligibility Terri L. Maxwell, PhD, APRN VP, Strategic Initiatives Weatherbee Resources Inc Hospice Education Network Inc Course Handouts & Post Test To download presentation handouts, click on the attachment icon Presenter discloses no financial relationships with a commercial entity producing healthcare-related products and/or services. Conflict of interest disclosure and resolution statement is on file with HEN. This presentation is for educational and informational purposes only. It is not intended to provide legal, technical or other professional services or advice. Course Objectives At the end of this session, participants will be able to: 1. Describe clinical documentation criteria that supports clinical eligibility for HIV Disease based upon LCD Guidelines 2. Describe the importance of secondary and comorbid disease(s) conditions on the terminal trajectory of HIV Disease. 3. Describe secondary and comorbid disease(s) conditions associated with HIV. 1

2 HIV (Human Immunodeficiency Virus) HIV is a virus that attacks and destroys key components of the body s immune system, T cells or CD4 cells. Destruction of large numbers of CD4 cells leads to AIDs AIDS (Acquired Immune Deficiency Syndrome) is the final stage of HIV infection. Patients with AIDs are at risk for opportunistic infections. HIV Prevalence CDC estimates that more than one million people are living with HIV in the U.S. One in five living with HIV is unaware of their infection Gay and bisexual men are most severely affected By race, African Americans face the most severe HIV burden More than 17,000 people with AIDs died in % of hospice admissions are those with HIV Symptoms Associated with HIV/AIDs Fatigue Diarrhea Nausea/vomiting Fever, chills, night sweats Wasting syndrome Affective Disorders Dementia Cough/dyspnea Mouth sores Pressure ulcers Rash/pruritus 2

3 Secondary Conditions Associated with HIV/AIDs Kaposi s sarcoma Lymphoma Renal failure Opportunistic infections such as cryptosporidium or toxoplasmosis AIDs dementia Wasting syndrome LCD Guidelines for Hospice Eligibility and Recertification for HIV NGS LCD Number L25678 CGS LCD Number L32015 NHIC LCD Number L29881 Part III Disease-Specific Guideline Note: These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II of the LCD A. KPS / PPS < 50% B. Two or more ADL dependence C. Co-morbidities that contribute to life expectancy of 6 months or less 3

4 HIV Disease LCD Guidelines Per the LCD 1 and 2 must be present; 3 is used to add supporting documentation: 1. CD4+ Count <25 cells/mclor persistent viral load > 100,000 copies/ml, plus one of the following: CNS lymphoma Untreated, or not responsive to treatment, wasting (loss of 33% lean body mass) Mycobacterium aviumcomplex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused Progressive multifocal leukoencephalopathy HIV Disease LCD Guidelines cont d Systemic lymphoma with advanced HIV disease and partial response to chemotherapy Visceral Kaposi s sarcoma unresponsive to therapy Renal failure in the absence of dialysis Cryptosporidum infection Toxoplasmosis, unresponsive to therapy HIV Disease LCD Guidelines cont d 2. Decreased performance status: KPS of < Documentation of the following support eligibility: Chronic persistent diarrhea for one year Persistent serum albumin <2.5 Concomitant, active substance abuse Age > 50 years No antiretroviral, chemotherapeutic & prophylactic drug therapy specifically related to HIV disease Advanced AIDS dementia complex Toxoplasmosis CHF, symptomatic at rest Advanced liver disease 4

5 Documentation example: Eligibility Thomas is a 57 yrold Caucasian male diagnosed with HIV/AIDS several years ago. Soc. Hx: Pt is homeless and an active substance abuser (heroin and cocaine). He was treated with antiretrovirals, but adherence was poor. He now has AIDs-related dementia and was recently hospitalized with a cryptosporidium infection and pneumonia. He has lost 60 lbsin the past 6 mos. (wt137 lbs, 6 1 ). He is dependent in 6/6 ADLs, KPS 40. He is incontinent of frequent loose stool. Appetite poor; requires hand feeding. He is not oriented to place or time. He was transferred to Sunshine Nursing Home and referred to hospice for supportive care. Family requests DNR and no hospitalization. Summary HIV/AIDs is now viewed as a chronic condition but patients still die secondary to AIDs-related complications LCD guidelines outline the clinical criteria for patients considered in the terminal phase of their illness. Documentation of concomitant secondary and co-morbid conditions support burden of illness and hospice eligibility. Course Handouts & Post Test Thank you for viewing this course on the Hospice Education Network The course evaluation and post test are available from your course catalog page 5

6 THANK YOU! Terri Maxwell PhD, APRN VP, Strategic Initiatives Weatherbee Resources Inc. & Hospice Education Network 6

HIV: Disease Trajectory and Hospice Eligibility

HIV: Disease Trajectory and Hospice Eligibility Terri L. Maxwell PhD, APRN VP, Strategic Initiatives Weatherbee Resources/HEN Course Materials & Disclosure Course materials including handout(s) and conflict