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General Eligibilty

General Eligibility

ALS Eligibility

ALS Eligibility

Alzheimer's . Dementia Eligibility

Alzheimer's / Dementia Eligibility

Eligibility Heart Disease

Heart Disease Eligibility

COPD and lung disease eligibility

COPD and lung disease eligibility

Cancer eligibility

Cancer eligibility

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General Eligibility

Early identification of hospice eligible patients increases the likelihood that they and their families will benefit from hospice care. Physicians must certify that patients meet guidelines determined by CMS to be eligible for admission to a hospice provider.

General Eligibility Guidelines

For a patient to be eligible for hospice, the physician should consider the following guidelines:

  • The illness is terminal (a prognosis of ≤ 6 months) and the patient and/or family has elected palliative care.
  • The patient has a declining functional status as determined by either:
    • Palliative Performance Scale (PPS) rating of ≤ 50% for non-cancer diagnoses or ≤for cancer diagnoses
    • Dependence in 3 of 6 Activities of Daily Living (ADLs)
  • The patient has alteration in nutritional status, e.g., > 10% loss of body weight over last 4-6 months
  • The patient has a documented deterioration in overall clinical condition in the past 3-6 months, as manifested by at least one of the following:
    • ≥ 3 hospitalizations or ED visits
    • Decrease in tolerance to physical activity
    • Decrease in cognition
  • Other comorbid conditions are likely to contribute to the life expectancy of 6 months or less
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ALS Eligibility

Patients are considered to be hospice eligible for amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease) when a physician makes a clinical determination that life expectancy is six months or less if the disease runs its normal course and they meet the following guidelines:

  • Both rapid progression of ALS and critically impaired ventilatory capacity or
  • Both rapid progression of ALS and critical nutritional impairment with a decision not to receive artificial feeding or
  • Both rapid progression of ALS and life-threatening complications such as:
    • Recurrent aspiration pneumonia
    • Decubitus ulcers, multiple, stage 3-4, particularly if infected
    • Upper urinary tract infection, e.g., pyelonephritis
    • Sepsis
    • Fever recurrent after antibiotics


In end-stage ALS, two factors are critical in determining prognosis: ability to breathe and ability to swallow. ALS may be complicated by secondary and co-morbid conditions. Secondary conditions, such as dysphagia, pneumonia and pressure ulcers, are a direct result of the impairment of respiratory functions, swallowing, muscle power and muscle tone that are common in ALS. Co-morbid conditions, which often accompany the rapid progression of ALS, include chronic obstructive pulmonary disease (COPD), pyelonephritis or upper urinary tract infection, septicemia and fever after recurrent antibiotics. While feeding tubes may be a normal part of treatment in ALS, G-tubes and ventilator support prolonged life expectancy. Hospice eligible patients are those who have chosen to forego supportive ventilation, artificial hydration and nutrition.

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Alzheimer's Dementia Eligibility

Alzheimer’s disease and other progressive dementias are life limiting conditions for which curative therapy is not available. Patients with dementia or Alzheimer’s are eligible for hospice care when they show the following characteristics:

  • Unable to ambulate without assistance
  • Unable to dress without assistance
  • Unable to bathe properly
  • Incontinence of bowel and bladder
  • Unable to speak or communicate meaningfully (ability to speak is limited to approximately a half dozen or fewer intelligible and different words)
 

Patient should be at least stage 7 on the FAST scale 


Secondary diagnoses associated with advanced dementia include:

  • Aspiration pneumonia
  • Pyelonephritis or upper urinary tract infection
  • Septicemia
  • Decubitus ulcers, multiple, stage 3-4
  • Fever recurrent after antibiotics
  • Impaired Nutritional Status as evidenced by one or more of the following:
    • Difficulty swallowing or refusal to eat
    • If receiving artificial nutritional support (NG or G-tube, TPN), patient must be exhibiting continued weight loss despite the feedings
    • Protein calorie malnutrition as evidenced by:
    • Weight loss over 11% or
    • BMI<18 or
    • Albumin <3.1
 

Co-morbid conditions that might significantly impair the dementia patient’s health and functionality:

  • Congestive heart disease or cardiovascular disease
  • COPD or restrictive lung disease
  • Cerebrovascular disease, including stroke
  • Diabetes mellitus
  • Renal insufficiency
  • Malignancy
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Hospice Eligibility for Heart Disease

Patients are eligible for hospice care when a physician makes a clinical determination that life expectancy is six months or less if the disease runs its expected course. 

Characteristics of end-stage congestive heart disease:

  • New York Heart Association (NYHA) Class III if any of the following symptoms are present during any activity:
    • Fatigue
    • Palpitations
    • Angina or dyspnea with activity
  • NYHA Class IV as manifested by any of the following symptoms:
    • Dyspnea and/or other symptoms at rest or with minimal exertion
    • Inability to carry out physical activity without dyspnea and/or other symptoms
    • Dyspnea and/or other symptoms worsen with physical activity
  • The patient is being optimally treated for congestive heart failure with diuretics and vasodilators, such as ACE inhibitors, or they are maximally medically managed and have no available surgical options.

Characteristics of end-stage coronary artery disease:

  • Patient has frequent or recurrent bouts of angina pectoris at rest or with minimal activity.
  • Patient is symptomatic despite standard nitrate therapy.
  • Patient is not a candidate for (or declines) invasive procedures, such as percutaneous angioplasty or coronary artery bypass surgery.

Comorbid factors:

  • Symptomatic supraventricular arrythmias despite antiarrhythmic therapy
  • History of cardiac arrest
  • History of syncope from any cause
  • Cardiogenic brain embolism
  • Concomitant HIV disease
  • Renal failure
  • COPD
  • Cardiovascular accident (CVA, or stroke)
  • Liver failure
  • Cancer
  • Dementia
  • Smoking
  • Diabetes
  • Hypertension
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Hospice Eligibility Guidelines for COPD and Lung Disease

Major factors
  • Disabling dyspnea at rest or with minimal exertion
  • Dyspnea unresponsive or poorly responsive to bronchodilator therapy
  • Progression of chronic pulmonary disease as evidenced by one or more of the following:
    • Frequent hospitalizations, ED visits and/or physician outpatient visits for infections or respiratory failure
    • Frequent episodes of bronchitis or pneumonia
    • Unintentional weight loss of ≥ 10 percent body weight over the preceding six months
    • Progressive inability to independently perform various activities of daily living (ADLs) or increasing dependency with ADLs, resulting in a progressively lower performance status.

Other contributing factors

  • Cor pulmonale
  • Continuous chronic oxygen therapy
  • Resting tachycardia > 100/minute
  • Steroid dependent
  • Cyanosis

Abnormal laboratory findings

While these laboratory studies may be helpful to the clinician when considering patient eligibility for hospice services, they are not required for patient admission.
  • FEV1 ≤ 30 percent predicted post-bronchodilator
  • Serial decreases in FEV1 of at least 40 ml/year over several years
  • PO2 ≤ 55 on room air
  • O2 saturations ≤ 88 percent on room air
  • Persistent hypercarbia (PCO2) ≥ 50 mm HG
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Hospice Eligibility Guidelines for Cancer

To be eligible for hospice a patient should meet the following guidelines:

1. Disease with metastases at presentation OR;
2. Progression of disease to metastatic disease with either:

  • Continued decline in spite of therapy such as chemo or radiation and patient is discontinuing therapy OR;
  • Patient refuses aggressive therapies

OR

3. Patient is diagnosed with a cancer that is known to have a poor prognosis such as small cell lung cancer, brain cancer, or pancreatic cancer.

Palliative Performance Scale for Functional Status

In general, a cancer patient who scores 70% or lower on the Palliative Performance Scale may be eligible for hospice. These patients typically:

  • Are unable to carry on normal activity or do normal work
  • Spend more than 50% of their time in a bed, chair or a single room
  • Exhibit evidence of significant disease
  • Can provide only limited self-care
  • Have reduced nutritional intake


ECOG Score for Functional Status

The biggest predictor of hospice eligibility in oncology, is the patient’s functional status using the Eastern Cooperative Oncology Group (ECOG) scale. If your patients have decreased functional status and are spending an increasing amount of time sitting or lying down, a rough estimate of the prognosis is three months or less.

Using the ECOG scale, a median survival of three months roughly correlates with a score of >3. An ECOG score of 2 is generally supportive of being eligible for hospice services.

  • 0: Asymptomatic
  • 1: Symptomatic but completely ambulatory
  • 2: Symptomatic, <50% in bed during the day
  • 3: Symptomatic, >50% in bed but not bedbound
  • 4: Bedbound
  • 5: Death
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Contact us

  • 2301 FM 1187, Suite 203 Mansfield, TX 76063-6139
  • Toll Free: 877-469-6739
  • Local: (817) 469-6739
  • Fax: 817-801-3486