APPENDIX A Certificatin f Advanced Disease: Name: DOB: Member ID: Name f Palliative Care Prgram: A. General Criteria: Check each f the fllwing that apply (All needed fr eligibility). Patient wh is likely t r has started t use the hspital and/r emergency rm as a means t manage their advanced stage disease. Patient is in the advanced stage f illness with cntinued decline in health, and is nt eligible r has declined hspice. Patient has received apprpriate patient-desired medical therapy with n further traditinal therapy ptins available, is intlerant r declines further therapy, r decmpensates due t severe nn-cmpliance. Life expectancy f abut 2 years r less based n clinical status. Patients and, if applicable, family/patient-designated supprt persn agree t bth f the fllwing: a. Willing t attempt in-hme, residential-based, r utpatient disease management instead f first ging t the emergency department b. Willing t participate in Advance Care Planning (ACP) B. In additin, ne f the fllwing diagnses must be selected, and assciated severity criteria met: 1. Cngestive Heart Failure (CHF) Any patient wh is hspitalized due t CHF as the primary diagnsis. N further invasive interventins planned althugh access t curative care is maintained, NYHA III classificatin r higher (definitin f NYHA III: Patients with cardiac disease resulting in marked limitatin f physical activity. They are cmfrtable at rest. Less than rdinary activity causes fatigue, palpitatin, dyspnea r anginal pain.) ne f the fllwing: Ejectin Fractin < 30 fr systlic failure
Significant cmrbidities: e.g. renal disease, diabetes, dementia, r pr bimarkers including rising BNP, pr-bnp, hscrp, BUN/ Creatinine (patient is in their best cmpensated state), and CAD. 2. Chrnic Pulmnary Disease (e.g. COPD, Cystic Fibrsis, Pulmnary Fibrsis): Severe airflw bstructin: FEV1 < 35 % predicted 24-hur xygen dependent 3. Advanced Cancer: Any Stage III r IV cancer, lcally advanced r metastatic cancer, leukemia r lymphma ne f the fllwing: Palliative Perfrmance Scale (PPS) scre < r equal t 70% (PPS 70% = Cares fr self; unable t carry n nrmal activity r d active wrk) Failing tw lines f standard f care therapy (chemtherapy r radiatin therapy). 4. Liver Disease: Irreversible Liver Damage as evidenced by ne f the fllwing: Ascites Subacute bacterial peritnitis Hepatic encephalpathy Hepatrenal syndrme Recurrent esphageal bleeds Mdel fr End Stage Liver Disease (MELD) scre f greater than 19 T calculate MELD Scre: https://ptn.transplant.hrsa.gv/resurces/allcatin-calculatrs/meld-calculatr/ Meld Scre: 5. End Stage Renal Disease: GFR < 15
Patient refusing dialysis, has pr cmpliance, and is nt seeking renal transplant Declining status with multiple ther c-mrbidities, such as CHF, ESLD, COPD 6. Dementia: Functinal Assessment Staging Scale (FASS) scre f 5 with high risk f using the hspital t manage their disease with dcumentatin f reasn fr high risk status: FASS 6 t 7 Any demented patient wh has been institutinalized r required hspitalizatin primarily due t their dementia, plus Had an apprpriate metablic wrkup (CMP, Thyrid Functin Tests, B12) and neur imaging (r dcumented refusal) 7. Neurlgic Disease (e.g. Parkinsn s, ALS, Multiple Sclersis): Impaired breathing capacity requiring xygen Rapid disease prgressin as evidenced by decline in ambulatin status frm independent t wheelchair/ bed bund, r decline in speech t unintelligible, r decline in ral intake t pureed fds, r decline in ADLs t requiring md/max assistance Nutritinal impairment assciated with weight lss Life threatening cmplicatin event in past 12 mnths such as aspiratin pneumnia, sepsis, stage 3 r 4 pressure ulcers
8. AIDS: Palliative Perfrmance Scale (PPS) <= 50% CD4 cell cunt < 25 r viral lad >100,000 WITH either nn-cmpliance, refusal, intlerance, failure, r resistance t antiretrviral therapy Presence f ANY f the fllwing: 1. Opprtunistic infectins (e.g. multidrug-resistant M. tuberculsis, MAC, CMV, Cryptspridium, Txplasmsis, Prgressive Multifcal Leukencephalpathy) 2. AIDs related malignancy (e.g. Nn-Hdgkin s r CNS lymphma, visceral Kapsi s sarcma) 3. HIV-assciated dementia 4. HIV wasting syndrme (>10% unintentinal weight lss ver 12 mnths, 33% lss f lean bdy mass r BMI <20) 5. Declining status with presence f multiple c-mrbidities (e.g. advanced liver disease, CHF, ESRD) 9. Other advanced illness (psychiatric r substance abuse related diagnses are excluded as primary qualifying diagnses fr prgram): ICD-10: Clinical dcumentatin supprting the patient is advanced stage f disease:
C. Prgram acuity type: Lw High - requires clinical justificatin criteria includes: ACG scre = CCM level and PHU > 50% Mre than 2 inpatient admissins in the past 3 mnths Mre than 3 ER visits in the past 3 mnths Palliative Perfrmance Scale (PPSv2) 60% r less Presence f c-mrbid uncntrlled significant mental health disrder (e.g. Biplar, Schizphrenia) and marked with pr functinality (Glbal Assessment f Functining scale (GAF) <= 50) Hmeless r pr scial supprt C-mrbid active alchl and/r drug abuse Prvider Signature Date