Referral Guidelines

Texas – Hospice Referral Guidelines

Below are the Medicare/Medicaid approved diagnoses for hospice. Please call 281-570-4072 with any questions.

Cancer Diagnoses

  • Disease with metastases at presentation
  • Progression from early stage of disease to metastatic disease
  • Disease process stage III with or without lymph node involvement
  • Continued decline in spite of therapy
  • Patient declines further disease directed therapy

Note: Certain cancers with poor prognoses (e.g., small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria

End-Stage Pulmonary Disease (e.g. COPD)

  • Severe chronic lung disease
  • Corpulmonale/right-sided heart failure
  • Cardiogenic embolic disease
  • Recurrent pulmonary infections
  • Dyspnea at rest
  • Resting tachycardia > 100/min
  • p02 < 55 mmHg – or 02 sat < 88% on room air
  • FEV 1 < 30% after bronchodilators

End-Stage Renal Disease

  • Not seeking or a candidate for dialysis, renal transplant or discontinuing dialysis (prognosis < 6 months if on dialysis) • Serum Creatinine > 8 mg/dl (> 6 mg/dl for diabetics)
  • Creatinine Clearance < 10 cc/min (< 15 cc/min for diabetics) • Hyperkalemia (> 7.0 meq/l)
  • Signs of uremia/oliguria < 400 cc/24 hrs

End-Stage Neurologic Disease (ALS)

  • Critically impaired respiratory function
  • Severe nutritional insufficiency
  • Sleep disordered breathing
  • FVC < 40%
  • Dyspnea at rest/orthopnea
  • Use of accessory respiratory musculature
  • Weakened cough
  • Reduced speech/vocal volume

HIV

  • Karnofsky Performance Scale (KPS) < 50%
  • CD4+count < 25cells/mcl • Viral load > 100,000 copies/ml
  • CNS lymphoma, visceral Kaposi’s sarcoma
  • Recurrent infections unresponsive to therapies
  • Chronic persistent diarrhea > 1 year

End-Stage Heart Disease (e.g. CHF, CAD)

  • Functional Class IV NYHA Assessment
  • Symptomatic despite optimal medical management with diuretics and vasodilators
  • Not a candidate for or declining surgical procedures
  • Supraventricular/ventricular arrhythmias resistant to treatment
  • Angina at rest
  • Ejection fraction < 20% • History of; cardiac arrest or resuscitation, cardiogenic embolic disease, unexplained syncope

End-Stage Liver Disease

  • Not seeking or a candidate for liver transplant
  • Ascites refractory to treatment
  • Peritonitis
  • Hepatorenal syndrome
  • Encephalopathy
  • Recurrent variceal bleeding
  • Progressive malnutrition
  • PTT > 5 seconds above control
  • Serum albumin < 2.5g/dl

End-Stage Dementia/Alzheimer’s

  • FAST score > 7
  • Unable to walk, bathe or dress without assistance
  • Increasing urinary and fecal incontinence
  • No consistent meaningful verbal communication
  • Medical complications: aspiration pneumonia, septicemia, stage 3-4 decubiti, recurrent fever
  • Insufficient fluid/caloric intake
  • Weight loss >10% over previous six months
  • Serum albumin < 2.5g/dl

Stroke and Coma

  • Karnofsky Performance Scale (KPS) < 40%
  • Palliative Performance Scale (PPS) < 40%
  • Absent verbal response
  • Urinary and fecal incontinence
  • Dysphagia
  • Insufficient fluid/caloric intake
  • Weight loss > 10% over past 6 months
  • Serum albumin < 2.5g/dl
  • Medical complications: aspiration pneumonia
  • Stage 3-4 decubiti, recurrent fever
  • Life-limiting conditions (prognosis < 6months)
  • Karnofsky Performance Scale (KPS) < 70%
  • Palliative Performance Scale (PPS) < 70%
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