Hospice Referral Criteria

Max Diamond, M.D.

Refer member to Palliative/Supportive Care if Life Expectancy is greater than 6 months or does not meet hospice criteria

Clinical progression of any disease process that includes the following:

·  Frequent changes in condition requiring physician intervention;

·  Frequent Emergency Room visits and/or hospitalizations over the last 6 months; or

·  Sudden, major decline in functional status with no identified reversible causes. Typically with a Karnofsky Performance Status of ≤50:

o  50: Requires considerable assistance and medical care

o  40: Disabled; requires special care, unable to care for self, disease is progressive

o  30: Severely disabled

o  20: Very sick, active supportive treatment necessary

o  10: Moribund; fatal processes progressing.

Malnutrition, as supported by the following:

·  Unintentional weight loss ≥10% within six months; or

·  Serum albumin <2.4 g/dl.

Presence of any of the following medical complications:

·  Aspiration pneumonia;

·  Recurrent urosepsis;

·  Decubitus ulcers (multiple, stage III or IV);

·  Inability to maintain caloric needs (and declining a feeding tube); 

·  Recurrent falls;

·  Presence of dementia, such as end-stage Alzheimer’s or multi-infarction; or

·  Semi-comatose or comatose state with no identified reversible causes.

Congestive Heart Failure

·  Symptoms of CHF at rest – any Ejection Fraction (New York Heart Association class IV );

·  Ejection Fraction ≤ 20%;

·  Serum sodium level < 134 mmol/L or creatinine level > 2.0 mg/dL due to poor cardiac output; or

·  Intensive care unit admission for exacerbation.

Chronic Obstructive Pulmonary Disease

·  Cor pulmonale (right-sided heart failure associated with COPD);

·  New dependence in two activities of daily living (ADLs) due to COPD symptoms;

·  Chronic hypercapnia (PaCO2 > 50 mm Hg); or

·  Intensive care unit admission for exacerbation.

Dementia

·  Dependence in all ADLs, language limited to just a few words, and inability to ambulate;

·  Difficulty swallowing with recurrent aspiration;

·  Has feeding tube due to dementia or swallowing difficulty related to dementia; or

·  Acute hospitalization (especially for pneumonia or hip fracture).

Cancer

·  Poor physical performance status as a result of cancer (dependence in multiple ADLs);

·  Multiple tumor sites;

·  Metastatic cancer involving liver or brain;

·  Bowel obstruction due to cancer; or

·  Pericardial effusion due to cancer.

Sources: INTERACT Version 4.0 2015 (www.interact2.net) by Florida Atlantic University, End-of-Life Care Second edition 2011 by Barry M. Kinzbrunner MD and Joel S. Policzer MD.

How to Identify Patients Near the End-of-Life Provider Magazine November 2011 by M. Diamond MD.