11/2/2011 DOWNLOAD THE HANDOUTS OBJECTIVES. Determining Terminal Status: Dementia Due to Alzheimer s Disease and Related Disorders

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1 Determining Terminal Status: Dementia Due to Alzheimer s Disease and Related Disorders Joy Barry, RN, MEd, LNC Weatherbee Resources, Inc. Hospice Education Network, Inc. DOWNLOAD THE HANDOUTS Click on the Links button to download the handouts. The following handouts are available: The presentation slides A copy of the appropriate LCD guideline Determining Terminal Status (L25678) published by National Government Services (NGS); Determining Terminal Status (L13653) published by Cahaba Government Benefit Administrators (Cahaba); or LCD for Hospice Alzheimer's Disease & Related Disorders (L16343) published by Palmetto Government Benefit Administrators (Palmetto). OBJECTIVES At the end of this session, participants will be able to: 1. Identify the appropriate criteria to use when assessing initial and on-going hospice eligibility of patients. 2. Describe effective care planning the required team, tool, and technique. 3. Describe and document the value-added nature of hospice care as well as patient-level outcome measures. 4. Identify the unique needs of facility-based patients as well as compliance-related challenges inherent with this patient population. 1

2 RHHIs & LCDs Regional Home Health and Hospice Intermediary (RHHI) Local Coverage Determination (LCD) guidelines for Hospice: Determining Terminal Status (L25678) published by National Government Services (NGS); Determining Terminal Status (L13653) published by Cahaba Government Benefit Administrators (Cahaba); or LCD for Hospice Alzheimer's Disease & Related Disorders (L16343) published by Palmetto Government Benefit Administrators (Palmetto). TO LOCATE CURRENT LCD For Provider / Supplier, choose Home Health and Hospice as the Business Type, select your State then click on Go Click on accept (CPT) At Quick Links, Click on LCD Select RHHI (UGS or AHS) Click to accept the CPT again Click on View Active Policies (right-hand menu) Scroll down and click on Hospice Determining Terminal Prognosis DETERMINING TERMINAL STATUS Amended: January 28, 2008 Effective: February 1, 2008 A patient will be considered to have a life expectancy of six months or less if s/he meets the non-disease specific Decline in clinical status guidelines described in Part I. Alternatively, the baseline non-disease specific guidelines described in Part II plus the applicable disease specific guidelines listed in Part III will establish the necessary expectancy. 2

3 PART I DECLINE IN CLINICAL STATUS requires documented disease progression in the following 9 domains: 1. Clinical Status 2. Symptoms 3. Signs 4. Laboratory Findings (if available) 5. KPS Score 6. FAST Score 7. ADL Dependence 8. Pressure Ulcers (Stage III or IV) 9. ER / MD / Hospital Visits SHOULD The word should in the disease specific guidelines means that on medical review the guideline so identified will be given great weight in making a coverage determination. It does not mean, however, that meeting the guideline is required. The only requirement is that the documentation supports the beneficiary s prognosis of 6 months or less, if the illness runs its normal course. PART II Non-disease specific baseline guidelines both A and B should be met A. Physiologic impairment of functional status as demonstrated by: Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) < 70% (HIV Disease, Stroke and Coma establish a lower qualifying KPS or PPS). 3

4 PART II, cont d. B. Dependence on assistance for 2 or more activities of daily living (ADLs): Ambulation; Continence; Transfer; Dressing; Feeding; and/or Bathing. PART II, cont d. C. Co-morbidities Although not the primary hospice diagnosis, the presence of disease such as the following, the severity of which is likely to contribute to a life expectancy of 6 months or less, should be considered in determining hospice eligibility: PART II, cont d. 1. Chronic obstructive pulmonary disease (COPD) 2. Congestive heart failure (CHF) 3. Ischemic heart disease 4. Diabetes mellitus 5. Neurologic disease (CVA, ALS, MS, Parkinson s) 6. Renal failure 7. Liver Disease 8. Neoplasia 9. Acquired immune deficiency syndrome (AIDS) 10.Dementia 11.Acquired Immune Deficiency Syndrome (HIV) 12.Refractory severe autoimmune disease (e.g. Lupus or Rheumatoid Arthritis) 4

5 PART II, cont d. NOTE: The baseline guidelines (Part II) do not independently qualify a patient for hospice coverage. PART III Disease Specific Guidelines These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II. DISEASE SPECIFIC GUIDELINES Cancer Diagnoses Non-cancer Diagnoses 1. Amyotrophic Lateral Sclerosis (ALS) 2. Heart Disease 3. Dementia due to Alzheimer s Disease and Related Disorders 4. HIV Disease 5. Liver Disease 6. Pulmonary Disease 7. Renal Disease 8. Stroke and Coma 5

6 PART III, cont d. This section is specific for Alzheimer s disease and Related Disorders, and is not appropriate for other types of dementia. DEMENTIA DUE TO ALZHEIMER S DISEASE AND RELATED DISORDERS Patients will be considered to be in the terminal stage of dementia if they meet the following criteria: DEMENTIA, cont d. 1. Patients with dementia should show all the following characteristics (in addition to meeting Part II): a. Stage 7 or beyond according to the Functional Assessment Staging (FAST) scale b. Unable to ambulate without assistance; c. Unable to dress without assistance; d. Unable to bathe without assistance; e. Urinary and fecal incontinence, intermittent or constant; f. No consistently meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to six or fewer intelligible words. 6

7 FAST SCORING 7a - Speech ability limited to about a half-dozen intelligible words 7b - Intelligible vocabulary limited to a single word 7c - Ambulatory ability lost 7d - Ability to sit up lost 7e - Ability to smile lost 7f - Ability to hold up head lost DEMENTIA, cont d. 2. Patients should have had one of the following within the past 12 months: a. Aspiration pneumonia; b. Pyelonephritis; c. Septicemia; d. Decubitus ulcers, multiple, stage 3-4; e. Fever, recurrent after antibiotics; f. Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin < 2.5 gm/dl. SOME TYPES OF DEMENTIA Alzheimer s Disease (prognosis ~8 years) Lewy Body (prognosis ~7 years) Vascular (prognosis ~3 years) Frontal Lobe Dementia Traumatic Dementia Dementia secondary to other diseases, such as: Parkinson s Alcoholism HIV-related Viral (CJD / Mad Cow Disease) 7

8 PATIENT ELIGIBILITY Discern what type of dementia the patient has. Use LCD-based admission and recertification criteria. Ensure that PART II (both A & B) and PART III of the LCD guidelines are met. If not met, consider using Decline in Clinical Status (Part I) instead. WHOSE PATIENT IS IT ANYWAY? Perhaps better questions to ask are: What is the goal of care? and Who s goal is it? What does the patient want for his/her end-of-life? Are the family and facility in agreement? Does the attending and/or consulting physician concur? Is the hospice IDT including the medical director in alignment? Patient/ Family TEAM Include the patient, family, caregivers, facility staff, and physicians in the care planning process. This is a crucial step to ensure that the goals of care are mutual and palliative. Ensure that the right members of the Interdisciplinary Team (IDT) are involved and working on the right problems, interventions, and goals (PIGs). 8

9 TOOL Provide a copy of the hospice Plan of Care (POC) to the facility and obtain a copy of the facility POC to ensure the alignment of PIGs. Review the facility POC at each visit and monitor for changes. Discuss PIGs with facility staff to discern whether the goal of care is hospice appropriate, etc. TECHNIQUE Participate in the facility s care plan meetings. Consistently collaborate and communicate with the entire team. Schedule case conferences to discuss inconsistent PIGs and make informed decisions about ongoing hospice. appropriateness whenever conflicts arise. Document all collaboration / communication. CARE PLANNING What are the goals of hospice care and who s goals are they? Is the treatment: Palliative or curative / life prolonging in nature? Related or unrelated to the terminal diagnosis? Included in, or excluded from, the hospice POC? 9

10 NURSING FACILITY POC Problems The facility can be cited on survey for negative patient outcomes (e.g., skin breakdown / wounds, infections, falls, physical / chemical restraints, etc.). Interventions Usually aggressive in order to prevent negative patient outcomes. Goals Typically restorative / rehabilitative in nature; designed to maintain or improve current level of function. HOSPICE POC Problems Based on comprehensive assessment of patient / family needs. Interventions Related to terminal diagnosis, palliative in nature. Goals Designed to eliminate futile / unwarranted treatment, keep patient at home, assure comfort and pain / symptom management. NURSING FACILITY POC, cont d. PROBLEM INTERVENTION GOAL Potential alteration in skin integrity due to immobility and incontinence. Megace, MVI, Ensure, double portions, T&P, special skin care after incontinence, air mattress. Skin will be free of breakdown. 10

11 HOSPICE POC, cont d. PROBLEM INTERVENTION GOAL Potential alteration in skin integrity due to immobility and incontinence. T&P, special skin care after incontinence, air mattress. Skin will be free of breakdown. NURSING FACILITY POC, cont d. PROBLEM INTERVENTION GOAL Weight loss due to dementia. Prednisone, MVI, Ensure when <50% intake, health shakes 3X/D, cal diet, wkly weights. Patient will gain 1 pound per week X 10 weeks. HOSPICE POC, cont d. As weight loss is an expected outcome for hospice patients, it would not be identified as a problem on the POC. However, any related issues would be addressed. For example: Honoring patient s food choices and preferences; Assisting with feeding-related needs; Skin breakdown (potential or actual); Aspiration precautions; etc. 11

12 HOSPICE POC, cont d. As certain negative outcomes may be unavoidable at the end of life, facilities are not cited on survey when hospice patients experience weight loss, skin breakdown, etc. It is important to communicate this information to facility staff. END-STAGE DEMENTIA Typical causes of death in patients with dementia are: Aspiration Pneumonia Malnutrition / Failure to Thrive Fracture-related complications Urosepsis Therefore, the goals of care become real issues in terms of maintaining eligibility over time. VALUE-ADDED How is the value-added nature of hospice care evidenced? Supporting, not supplanting, the facility in patient care; Providing care in addition to what is required by the facility s POC; Meeting or exceeding the goals of care; Monitoring, measuring, and improving patient outcomes; etc. 12

13 DOCUMENTATION All certification (admission) and recertification documentation must contain enough information to support the patient s terminal status upon review (by an outside party such as the RHHI). All clinical indicators of decline that form the basis for certifying / recertifying the patient should be documented. DOCUMENTATION, cont d. Recertification for hospice care requires the same clinical standards be met as for initial certification. Documentation should paint a picture of why / how the patient is appropriate for hospice as well as the level of care being provided. Documentation should include observations and measurable data, not merely conclusions. DOCUMENTATION, cont d. Patients with long term survival in hospice, or apparent stability, can still be eligible for hospice benefits. If this is the case, sufficient justification for a less than 6-month prognosis should appear in the record. Inconsistent documentation should be specifically addressed and explained, including findings suggestive of a > 6- month prognosis. 13

14 DOCUMENTATION, cont d. There are patients for whom a particular LCD guideline does not match; and/or An LCD may be inadequate to predict the terminal prognosis of an individual patient who meets the guideline at the SOC and continues to do so over a prolonged period (> than 6 months). In such cases, it is important to document all factors that support the terminal prognosis. HOSPICE ASSESSMENT TOOLS KPS / PPS FAST NYHA ECOG Assessment Frequency (KPS / PPS, FAST, NYHA, ECOG) All patients Alzheimer s and Related Disorders (i.e., Dementia, Parkinsonian Dementia, etc.) Cardiac (Note: May also be useful for Pulmonary patients) Lung Cancer Minimum: At admission and prior to every recertification. Recommended: Monthly and upon any change in condition, including but not limited to level of care changes. WEIGHT AND INFECTION HISTORY Document the weight and infection history on all patients upon admission and throughout the course of care (including hospitalization history, reason, outcome, etc.). Weight: Not less than monthly; some patients may require weekly weights. Infection: Per occurrence regardless of type and/or site. CONSIDER USING S.O.A.P.I.E.R. DOCUMENTATION FORMAT SUBJECTIVE OBJECTIVE ASSESSMENT PLAN INTERVENTION EVALUATE REASSESS What do others tell you? What do you see, hear, read, observe? What do you make of it all? What actual and/or potential problems do you identify? Who is going to do what, where & when? What are the goals of patient, of the IDG? Take discipline-specific action that supports IDG problem oriented approach. Was outcome as expected? If not, why? What happens next? 14

15 CONSIDER USING LONGITUDINAL DATA COLLECTION TOOLS - KPS/PPS WEIGHT / BMI LOG INFECTION HISTORY 15

16 FAST SCALE RECERTIFICATION CASE EXAMPLE # 1 Dx: Alzheimer s Dementia Recert: 2nd benefit period recert due in 2 wks. Measure Baseline Current Change Weight % KPS 50% 30% 20% ADLs 2 assist transfer Hoyer lift required Total dependence RECERTIFICATION CASE EXAMPLE # 2 Dx: Alzheimer s Dementia Recert: 6 th benefit period recert due in 2 wks. Measure Admit 5th Current Change Weight lbs in 90 days KPS 50% 40% 50% At baseline FAST 7A 7A 7A No change Other Recent UTI none Stage II on heels Skin changes 16

17 COMPLIANCE AND OTHER CHALLENGES Facilities and/or local competition can pressure hospices to: Consider admitting patients that do not meet LCD guidelines Keep otherwise stable patients on hospice Provide GIP to patients who do not meet the criteria for this level of care Provide continuous care to all dying patients regardless of patient need Act as staff extenders by assigning HHAs: 5-7 days/week regardless of patient need To assist with the care of non-hospice patients SUMMARY Patients needing custodial care are NOT necessarily hospice appropriate / terminal. Conduct a census analysis to identify problem prone patient populations and other risk areas (NCLOS, facility-based, etc.). If questionable patients are identified, conduct and document a Baseline Assessment to assess eligibility and take action accordingly. Initiate discharge planning in anticipation of ineligibility. SAMPLE ADMISSION NOTE I Pt admitted on 4/17/08 with a diagnosis of Alzheimer s. Fully and completely meets LCD guidelines as evidenced by (AEB): Part II: KPS 40% Dependent on caregivers for 6 of 6 ADLs Co-morbid diagnosis of COPD Part III: FAST 7C (unable to ambulate without assistance) Dependent on caregivers for 6 of 6 ADLs Stage III decubs on (R) heel, (R) scapula, and (R) hip 17

18 SAMPLE ADMISSION NOTE II Pt admitted on 4/17/08 with a diagnosis of Alzheimer s. Partially meets LCD guidelines AEB: Part II: KPS 40% Dependent on caregivers for 2 of 6 ADLs No significant / symptomatic co-morbid conditions Part III: FAST 7C (unable to ambulate without assistance) Dependent on caregivers for 2 of 6 ADLs No documented issues within last 12 months MD / IDT decision to admit was based on family report of: Significant weight loss over past 6 mo (smaller clothing needed) Suspected aspiration pneumonia 2 mo ago when pt began choking on liquids and had temp, congestion, and productive cough (untreated) Reduced PO intake (100% 6 mo ago down to 30-40% now) SAMPLE ADMISSION NOTE III Pt admitted on 4/17/08 with a diagnosis of General Decline in Health Status. Partially meets part I of the LCD guidelines AEB: 1. Clinical Status: Aspiration pneumonia 2 mo ago when pt began choking on liquids and had temp, congestion, and productive cough 2. Symptoms: None at present time 3. Signs: Weakness & change in level of consciousness ( sleeping) 4. Laboratory: Serum albumin pending (drawn 4/17/08) 5. KPS: 40% 6. FAST: N/A (no dementia diagnosis) 7. Dependent on caregivers for 2 of 6 ADLs 8. Pressure ulcers: None at present time 9. ER / MD / Hospital visits: Yes (2 mo ago w/aspiration pneumonia) SAMPLE ADMISSION NOTE III, cont d. MD / IDT decision to admit was based on: History of confusion w/probable dementia but not yet at stage 7 on FAST History of cardiac disease but not yet NYHA Class IV; no oxygen therapy needed at this time Family reports significant decline in past 2-6 months ; suspected weight loss; and decreased PO intake Plan: Draw baseline serum albumin; monitor skin, weight, and PO intake; safety & aspiration precautions; obtain hospital and MD records 18

19 THANK YOU Joy Barry, RN, M.Ed., LNC Principal WEATHERBEE RESOURCES, INC HOSPICE EDUCATION NETWORK, INC 259 North Street Hyannis, MA