SUMMARY OF GUIDELINES ONE TO THREE MONTHS Withdrawal from the world and people Decreased food intake Increase in sleep Going inside self Less communication ONE TO TWO WEEKS Disorientation Agitation Talking with the unseen Confusion Picking at clothes Physical Decreased blood pressure Pulse increase or decrease Skin color changes: pale, bluish Increased perspiration Respiration irregularities Congestion Sleeping but responding Complaints of body tired and heavy Not eating, taking little fluids Body temperature: hot, cold 12DAYS OR HOURS Intensification of one to two weeks’ signs Surge of energy Decrease in blood pressure Eyes glassy, tearing, half open Irregular breathing: stop, start Restlessness or no activity Purplish, blotchy knees, feet, hands Pulse weak and hard to find Decreased urine output May wet or stool the bed MINUTES “Fish out of water” breathing Cannot be awakened 13Coverage for hospice care depends on certification by two pl wysicians 7 that an individual has a prognosis of six months or less if the terminal illness runs its normal course. The criteria contained in this brochure are based on information from CMS and our fiscal intermediary/Medicare Administrative Contractor. The general guidelines apply to all disease entities. Listed are general comorbidities that may contribute to the likelihood that a specific disease has a limited prognosis. Specific disease categories are listed with the criteria that support a prognosis of < 6 months. With each specific category there are secondary conditions, that worsen the patient’s prognosis. Do not consider these to be exact or exclusive criteria for determining hospice appropriateness. Use this information as a guide for determining a prognosis of six months or less. General Guidelines for Hospice Referrals Progression of disease: ¢ Physician’s serial assessments documenting Clinical progression of disease, with significant structural and/or functional impairment. ¢ Multiple ER, hospital or home visits Decline in functional or nutritional status: ¢ Kamofsky or Palliative Performance scale of < 50% (requires considerable assistance and frequent medical care) © Dependence in at least 3 of 6 ADLs (ambulating, bathing, dressing, feeding, transferring, toileting) e Reduced BMI or mid-arm circumference; weight loss of > 10% in 6 months or serum albumin < 2.5 gmv/dl. General Comorbidities (with significant structural/functional impairments, such as): e AIDS e Hematologic or malignant disease e Diabetes e Liver disease © Gastrointestinal disorders ¢ Lung disease e Heart disease e Neurologic disease