The Attending Physician's Role in Hospice Care

We fully support the attending physician continuing to follow their patients on our hospice program and encourage them to take an active role in their hospice care.

The hospice medical director does not replace the primary physician, unless he or she wishes it so. Rather, the hospice medical director oversees hospice services and acts as a resource person for both the attending physician and the care team. The R.N. Case manager or the Patient Care Coordinator will contact the attending physician whenever a change in the patient's condition indicates a need for new orders or physician evaluation.

The patient's attending physician continues to bill Medicare, Medicaid or insurance companies for their services directly in the traditional manner. Hospice must identify the primary physician to Medicare with the physician's UPIN Number and Medicaid with the physician's Provider Number.

Within eight (8) days of admission to hospice, the attending physician must certify that patient as having a terminal illness. In addition, the attending physician must make an educated estimate as to the prognosis or life expectancy of the patient.

Of course, no one can predict absolute life expectancy for patients. But knowing the patient's history, and understanding the course that malignancies and chronic illnesses take, help determine the patient's eligibility for hospice care. It must be determined under medical guidelines that a patient has a life expectancy of six (6) months or less. Some patients may live beyond the six month estimate. That may be due to close monitoring and interventions by the hospice team. It may be because the patient has reached a plateau, not getting worse and not getting better. The patient continues to be closely monitored during each election period.

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Referring to Hospice in a timely manner is an important key to the success of providing services. "Death Bed" referrals in which the patient is unable to benefit from all hospice can provide are inappropriate. Many hospice patients are ambulatory and only require occasional assistance at the time they are admitted to the hospice program.

According to national statistics, the average length of stay for patients in a hospice program is about 50 days, and yet the benefit period is 6 months. The earlier the hospice team intervenes the more satisfaction is expressed by patients and families. Referring to hospice earlier provides access to the full scope of hospice services available to the patient and family.

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The following criteria must be met for a patient to be admitted into a hospice program:

• The patient is diagnosed with a terminal illness
• The patient's prognosis is limited to six months
• The patient refuses or is not eligible for aggressive care for the terminal illness
• The patient and family agree to participate in the Plan of Care

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Although hospice care is most often thought of in conjunction with cancer patients, there are other patients who may benefit, including those who suffer from congestive heart failure, Alzheimers, AIDS, end-stage liver, heart or lung disease, and other debilitating diseases. Additional diagnoses may include:

• Malignancies
  
• Neurological Diseases (ALS, MS MD, Parkinson’s)
  
• General Debility with Multi-System Failure
  
• Human Immunodeficiency Virus (HIV) or Opportunistic Infections
  
• End Stage Diabetes (with gangrene)
  
• End Stage Renal Disease (no dialysis)
  
• Circulatory System Diseases
  
• Alzheimer’s / Dementia
  
• Respiratory System Diseases

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In addition to meeting the diagnosis and performance criteria, patients referred to hospice also may manifest one or more of the following:

• Weight loss over the past 2-3 months
• Decrease activity tolerance over the past 2-3 months
• Decreased appetite/nutritional intake over the past 2-3 months
• Decreased cognitive abilities over the past 2-3 months
• Observable and documented change in condition in the past 2-3 months

Diagnosis alone may not be sufficient to classify a patient as a candidate for hospice care. Lack of response to treatment, situations in which disadvantages of treatment outweigh the potential benefits and situations where further active treatment prolongs the dying process and are rejected by the patient and family must be considered.

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Palliative Performance Scale (PPS)

PPS is a modification of the Karnofsky Performance Scale, which measured the patient's level of needs related to the disease process. It was developed to assist the care giver's assessment of the patient's status for referral to other services such as hospice.

PPS guides assessment of functional performance and provides a framework for measuring the progressive decline in palliative patients. Parameters for assessment include factors related to physical decline, such as intake, mobility, and level of consciousness.

AmHeart Hospice has developed an admission screen for each LMRP to assist in determining the appropriate time for referral. For your familiarization, a sample screen follows. (The form is adapted from Wellmark, Inc's LMRPs)

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Local Medical Review Policies (LMRP) for Non-Cancer Patients

We share a commitment with all physicians and facilities that admissions and recertifications will always be appropriate and supported. In our mutual evaluations, we will work diligently to make certain that the patient and family is truly ready for hospice. For non-cancer diagnoses, we use criteria listed in Local Medical Review Policies to assure that a process of evaluation is completed prior to a patient's enrollment in the program and prior to each certification period. The result of this assessment is completed and documented in the patient's Hospice Medical Record.

LMRPs were originally created to assist physicians and hospice programs in determining if patients suffering from non-cancer, end stage diseases had a prognosis of 6 months or less. LMRP's for some slowly-progressing cancers have also been developed.

Copies of LMRPs are available for:

• End Stage Heart Disease
• End Stage Pulmonary Disease
• Stroke and Coma
• Dementia
• Renal Disease and ALS
• Breast, lung, or prostate cancer

A sample LMRP for End Stage Heart Disease follows. Please call us for a complete package of LMRPs

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LMRP For End Stage Heart Disease

414.8 Refractory angina pectoris
428.0 Congestive heart failure
428.1 Left heart failure
428.9 Heart failure, unspecified (specific etiology for CHF may be documented also)

Patient will be considered to be in the terminal stage of heart disease (with a life expectancy of 6 months or less) when:

1. 1. At the time of certification or recertification for hospice, the patient is or has been optimally treated for CHF with diuretics and vasodilators usually including ACE inhibitors or have angina pectoris at rest, which is resistant to intensive medical therapy or are patients who are either not candidates for revascularization procedures or who decline procedures. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g. hypotension or renal disease.)
2. 2. The patient is classified as New York Heart Association (NYHA) Class IV and has significant symptoms of recurrent CHF at rest. Significant CHF may be documented by an ejection fraction of W 20%, but this criteria is not required if information is not already available.
   

• Treatment resistant symptomatic supra ventricular or ventricular arrhythmia
• History of Cardiac Arrest or resuscitation
• History of unexplained syncope
• Brain embolism of cardiac origin
• Concomitant HIV disease

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