Wednesday, June 1, 2011

The Hospice Navigator Crazy Busy Tip: 4 important assessment tools

Medicare regulatory requirements for hospice care include proving how patients with life limiting disease meet hospice eligibility requirements. These guidelines known as the local coverage determinations (LCD's) are issued by Medicare Administrative Contractors (MAC's). The LCD's are approved by the Center for Medicare and Medicaid Services (CMS) and are used to determine ongoing eligibility for hospice care. Visit CMS's Hospice Center to view the LCD's in your state.

Proving hospice eligibility is a grey area since prognostication is a "best guess" scenario supported by many variables. At the very least, hospice clinicians need to document the guidelines cited in the LCD's for disease specific evidence of decline in clinical status where applicable in addition to non-disease specific indicators. Thereafter, comorbid conditions and other factors that add to the clinical picture can be highlighted in addition to the unique patient specific factors that influence each patient's trajectory of illness. Graphing the decline in clinicals status over time may be helpful to the clinical team in focusing assessments and evaluating the meaning of findings in the bigger picture.

The next step in documenting patient eligibility is to quantify the severity of disease or symptoms experienced. Hospice clinicians can best support these requirements by utilizing standardized assessment scales and tools. These tools are required in the LCD's but are also indicative of the extent of disease and add to the probability of decline in the coming weeks and months. In this crazy busy issue, we will cover 5 scales listed in the local coverage determinations that help to prove hospice eligibility. At the very least, hospice clinicians should be using these scales where appropriate:

Crazy Busy Tip #1: The Palliative Performance Scale

The palliative performance scale is a modification of the Karnofsky performance scale specifically for patients receiving palliative care. The scale uses 5 observer rated domains to assess functional status. Results correlate with actual survival and median survival time in cancer patients. Lower scores are indicative of poor performance and poor prognosis. Using the palliative performance scale to determine care needs is useful as the patient's disease progresses.

Hospice Eligibility: A palliative performance scale (PPS) of 70% or less is required for hospice eligibility. Further requirements depend on the terminal disease. Median survival of patients with a palliative performance scale of 70% is 145 days. A palliative performance scale of 40% or less is indicative of a poor prognosis in patients with stroke. The trajectory of decline towards death is different depending on the terminal disease. Differences that we must be mindful of include for example: Cancer patients tend to be functional with a higher PPS for a longer period of time & when decline occurs, the decline is rapid. Dementia patients on the other hand will decline slowly over a longer period of time and therefore, attention to small changes from one week to the next is needed.

How to: Nurses and physicians should document the palliative performance scale routinely during assessment visits and interdisciplinary team discussions. The initial assessment provides the baseline for which the patient's decline in clinical status is measured. Decline in the palliative performance scale over time is indicative of hospice eligibility in conjunction with disease specific findings. Documenting the hospice's and clinical teams response to care needs highlighted by the palliative performance score constitutes a specialist level use of the scale. Nurses and physicians who document the scale as a matter of course are instrumental in helping build the case for hospice eligibility in addition to describing the patients functional state.

Caution: Inconsistencies in the palliative performance score across disciplines and over time is indicative of inaccurate assessment and use of the palliative performance scale. Patient's whose palliative performance scale improves over time should be assessed for continued hospice eligibility. Staff training is indicated if the palliative performance score is variable depending on which team member is assessing the patient.

Crazy Busy Tip #2: The Functional Assessment Staging Tool (FAST) score

The FAST score was developed by Barry Reisberg, MD at New York University Medical Center's Aging and Dementia Research Center. The FAST score measures the stages of Alzheimers disease. In the absence of a definitive Alzheimers diagnosis, the FAST score is used to assess dementia however, other types of dementia do not follow the decline trajectory as defined in the FAST score. Late stage dementia is characterized by severe cognitive decline, loss of verbal skills and loss of psychomotor skills.

Hospice Eligibility: A FAST score of 7 is required for hospice eligibility per the local coverage determinations. Further to the requirement, the patient must also be "unable to ambulate" which correlates with a FAST score of 7C. Additional requirements include inability to dress without assistance (6A), inability to bathe without assistance (6B), urinary and fecal incontinence (6D & E) and no consistent meaningful verbal communication (7A) with either stereotypical phrases only or 6 or fewer intelligible words. Bear in mind that the duration of each stage can be 12-18 months, clearly showing that the FAST score in itself is not a definitive indicator of hospice eligibility. Comorbid conditions add significant value to proving eligibility when they affect day to day functioning, cause complications and further decline. Focusing on attributing decline to the dementia or to the comorbid condition should not be undertaken as it does not paint a clear picture of the patient's condition if relevent clinical information is not assessed and documented based on association with a disease process.

How to: Patients with a hospice diagnosis of dementia or related disorders should have the FAST score assessed routinely. Nurses and physicians should document the FAST score on admission, during assessment visits and interdisciplinary team discussions. The initial assessment provides the baseline for which the patient's decline in status is measured. To complete the FAST score, the score is the highest consecutive level of disability. Decline in the FAST score is expected over time. Nurses and physicians who document the scale as a matter of course are instrumental in helping build the case for hospice eligibility in addition to describing the patients cognitive and functional state.

Caution: Do not complete the FAST score in clinical documentation if the patient does not have dementia or alzheimers disease. In these cases, the FAST score does not offer any value or information that supports the terminal condition. Inconsistencies in documentation of the FAST score across disciplines or over time raise a red flag as far as credibility of the scoring. If the hospice diagnosis is Dementia & the patient is ambulatory without assistance, the patient is most likely not eligible for hospice care. Consideration of all comorbid conditions and determination of the hospice diagnosis that best suits the patients status is recommended.

Crazy Busy Tip #3: The New York Heart Association (NYHA) Classification

The NYHA Classification, published in 1928, is a functional classification system for heart disease. It is based on clinical severity, prognosis and relates symptoms to everyday activities and quality of life.

Hospice Eligibility: If the hospice diagnosis is heart disease, the NYHA classification should be stage IV to meet the criteria for hospice eligibility. Stage IV heart disease is charachterized by symptoms of heart failure or anginal syndrome at rest. Symptoms include chest pain, dyspnea, weakness and inability to tolerate activity without discomfort. Additional criteria necessary for hospice eligibility with a terminal diagnosis of heart disease includes optimal treatment of heart disease, the patient declines or is ineligibility for surgical intervention, an ejection fraction of ≤ 20% and a history of a one of the following in the last 12 months: Treatment resistent SVT or ventricular arrhythmia, unexplained syncope, cardiac arrest, brain embolism of cardiac origin and / or concomitant HIV disease. If the patient is not symptomatic at rest and does not require routine use of medications to alleviate symptoms, the hospice team should evaluate 1. hospice eligibility 2. comorbid conditions 3. the appropriateness of the hospice diagnosis.

How to: When assessing the patient at rest, symptoms related to heart disease must be present. If patient is aided by oxygen, clinicians should evaluate if the patient is symptomatic on room air. Assessment of the presence of chest pain, dyspnea at rest and ability to tolerate activity is vital. Additionally, the use of medications to alleviate chest pain, manage other symptoms and the frequency of discomfort experienced should be documented as these medications show a requirement for treatment and resulting improvement in the experience of symptoms. If not documented, the presence of symptoms may not be accurately reported and give a contradictory account of the patient's status. Don't forget to ask about how the patient is at different times of the day, with activity and look for patterns in their symptom profile. The NYHA classification should not be documented unless the patient has documented heart disease.

Caution: Documentation of the patient's condition must support evidence of stage IV heart disease and the patient is expected to be symptomatic at rest. Documentation that shows independence & lack of symptoms does not support class IV disease. Medications for the management of symptoms associated with heart disease must be documented if symptoms are well controlled. If the patient does not have heart disease, do not complete the NYHA classification.  If evidence of end stage heart disease is not present at rest, the hospice team must consider 1. the patient's eligibility for hospice care 2. the correct hospice diagnosis. Evidence of the severity of disease is supported by the results from an echocardiogram or MUGA scan. Every effort should be made to obtain a copy of these results to support the prognosis. If the ejection fraction is not 20% or less, the hospice team should consider the patient's clinical status and document how their condition meets hospice eligibility criteria.

Crazy Busy Tip #4: Body Mass Index (BMI)

While BMI is not an indicator of terminal disease, significant changes to the BMI over time assist in painting a picture of decline in clinical status. Evidence of weight loss is most often a strong predictor of decline in clinical status. The terminal illness offers information about whether weight loss is a factor that impacts the prognosis. For example, a patient with lung cancer with usual body weight of 140 lbs who lost 16 lbs in the past 6 months is a strong indicator of decline in clinical status. Alternatively, a weight loss of 16 lbs for a patient with heart disease and who is obese may be indicative of an improvement in their clinical status. Having a baseline reading and a history or progressive weight loss over the previous year is important to document in addition to the impact the weight loss has on the patients overall health. Even if the baseline was not obtained at the time of admission, a reading within the past year is helpful.

Hospice Eligibility: Weight alone is not a determinant of hospice eligibility however, weight loss of 10% of usual body weight in the past 6 months is an indicator of poor prognosis. An accurate account of exact weight loss is very helpful in evaluating decline over time and assisting in proving eligibility when there are only small changes that support decline in status. Establishing the BMI on admission, whether the BMI is within a normal range for the patient, weight loss over the previous 6 months and the relationship between the weight loss and the terminal diagnosis is advised and should be documented. Further development would include information about the patient's appetite, fluid intake and hydration status, type of food / nutritional intake, amount tolerated and other signs and symptoms that may influence the patient's ability to maintain their intake and weight.

How to: If possible, obtain a baseline height and weight on admission. Weight loss or gain in the past year should be documented and the patient's account of their usual body weight. If bodyweight is below normal for weight and height, this should be highlighted in addition to weight loss of 10% or more. Of note is weight loss that occurs rapidly with no explanation other than advancing disease. Use the formula above to calculate the BMI or you may download a free BMI calculator to your phone that will calculate the BMI for you. When documenting BMI, make sure also to document the height and weight.

Caution: BMI alone will not be sufficient to show the patient's decline in clinical status. The history and impact of weight loss on the patients clinical status is important to document. If the BMI is normal or the patient is obese, weight loss may not be significant in the clinical picture. If the BMI increases over time, the hospice team should evaluate the reason for weight gain and whether the patient continues to be eligible for hospice care. If the BMI increases as a result of weight gain associated with the terminal diagnosis such as fluid accumulation in patients with liver disease or heart disease, the hospice team should be vigilant about documenting why this increase has occurred. Often, hospice care and assistance in feeding provided by the hospice team may assist in weight gain. An important point to highlight when there is an improvement is whether hospice interventions have been effective in bringing about this positive result. If weight and BMI cannot be measured and documented, the hospice team should be descriptive about signs of weight loss or gain that they observe.

Documentation in the clinical record may be aided by the availability of assessment scales and tools through electronic medical records, through forms and tools available at each hospice organization or through self study and use of reference documents. Clinicians should use scales and tools where possible to standardize documentation of assessment observations and findings as approved by their hospice. Pocket guides and portable reference guides are most useful to facilitate the use of multiple scales during patient assessment.

In our next crazy busy tip of the week, we will explore non-disease specific evidence of decline in clinical status.

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