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Updates to CMS Hospice Eligibility Guidelines – What Health Care Providers Need to Know

Posted 8/2/2013 Categories: dementia, hospice, alzheimer's

A pivotal requirement for hospice eligibility is a prognosis of six months or less (following the normal course of a disease). CMS has provided a number of clinical guidelines to help identify when a patient with terminal illness is clinically eligible for hospice. These guidelines are very useful when looking at disease processes that are known and when disease trajectory is more predictable.

However, oftentimes we recognize that elderly patients undergo what is indiscriminately referred to as “the slow dwindles”. In many cases a combination of a number of chronic illnesses is the culprit and the progressive functional and clinical decline associated with these illnesses is indicative of poor prognosis in and of itself. A common practice in these instances has been to consider the use of Debility or Adult Failure to Thrive (FTT) as a primary hospice diagnosis.

Over concerns that Debility and Adult FTT have become “catch all” diagnoses that do not accurately reflect a terminal illness, CMS has recently provided clarification on the use of these two particular diagnoses.

Effective immediately, hospices are no longer allowed to use Debility or Adult FFT as a primary diagnosis.

Instead, hospices are advised to determine the cause of the debility or Adult FFT that they are witnessing. In effect, hospices must now provide a specific diagnosis that has resulted in the debility or FTT, using these two diagnoses in question as a secondary diagnosis further describing the clinical picture that has resulted in the determination of six month prognosis.

For example, consider a patient recently hospitalized for pneumonia who has underlying COPD, Alzheimer’s disease, and renal disease. Clearly all of these diagnoses combined contribute to a poorer prognosis than would one condition by itself. Prior to hospitalization this patient was experiencing symptoms suggestive of adult FTT as evidenced by progressive functional decline, incontinence, weight loss and spending much of the day in bed. The determination must be made which of the underlying diagnoses (e.g., COPD, Alzheimer’s, renal disease) has primarily resulted in the failure to thrive. In this instance, Adult FTT will become a secondary condition.

CMS is also reviewing the use of “dementia” as a primary diagnosis. To be clear, CMS will likely be looking for greater definition related to the specific type of dementia identified as the primary hospice diagnosis. As we all know, there a numerous types of dementia, each with its own disease trajectory and clinical presentation. Although there is no specific requirement issued by CMS at this time, hospices would be well advised to avoid the non-specific diagnoses such as “dementia with behaviors” or “dementia without behaviors” as a primary diagnosis.

Amedisys will be moving forward in a proactive manner, working closely with physicians and medical directors to identify the specific type of dementia that will be listed as the primary diagnosis. The most common forms of dementia seen in hospice today include: Alzheimer’s disease, Vascular dementia, Lewy Body dementia, Parkinson’s Disease dementia, and Frontotemporal dementia.

Hospice Eligibility Kit

Determining prognosis indicative of hospice eligibility is not always easy. If you’d like more details, download our Hospice Eligibility Kit. It includes eligibility criteria for common conditions (like Alzheimer’s, cardiopulmonary disease and liver disease) and guidance on how to have the hospice conversation with a patient, an important part of helping patients receive the right care at the right time.

About the Author

Corrine Connors is a Family Nurse Practitioner and Certified Hospice Administrator with 13 years of experience in hospice and palliative care. Corrine currently works for Amedisys as Chronic Care Program Manager focusing on the development of disease specific programs, trainings and educational materials in support of hospice.
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Recognizing the Important Role of Family Caregivers

Posted 2/9/2012 Categories: chronic care, home health, caregiving, dementia, hospice, respite, alzheimer's

Guest post by Stien Vandierendonck, Manager of Programs and Communications at the National Alliance for Caregiving.

Did you know that over 65.7 million Americans provide care for a family member, friend or neighbor? That’s nearly three in ten people age 18 or older1. Family caregivers nevertheless remain under-recognized and under-resourced.

Most American caregivers are female and on average 48 years old. They typically take care of a relative, most often a parent, for an average period of 4.6 years.1 The estimated economic value of their unpaid contribution was on average $450 billion in 2009.2

In addition to helping the care recipient with everyday activities, surveys reveal that many family caregivers also provide financial assistance. A study the National Alliance for Caregiving published on caregiving out-of-pocket costs indicates that caregivers spend on average $5,531 each year on caregiving responsibilities. Since the annual median household income is $43,026, you realize that this is a significant burden for many. The highest costs are related to medical, food, and household expenses. For caregivers with limited incomes, it is even harder to cope.3 Another study suggests that caregiving for an older relative is an important factor in the health, medical care expense, and productivity of employees across all age groups. The additional health cost to employers is 8 % more compared to non-caregivers.4

Besides the financial costs, the health of the family caregiver is also a subject of concern. There are studies that indicate that the health of family caregivers (most often a spouse) may be adversely affected, especially as their caregiving continues for an extended period of time and becomes more intense. A study we released in November on caregivers of people with Alzheimer’s disease (AD) shows a significant decrease in family caregiver health over time as their care recipient’s dementia increases. This study also specifically examined the use of formal health services in a large sample of AD caregivers. The strain of caring for someone with AD can cause family caregivers to use health care services (ER visits, hospital visits and doctor visits) at higher rates than non-caregivers of the same age, at an average annual cost increase of $4,766 per caregiver in personal healthcare expenses.5

The expenses of the impact to personal health of the caregiver, combined with the expenses of caregiving responsibilities, shows the significant economic impact of caregiving on personal costs in this country – especially for older caregivers on fixed incomes.

Health professionals can play an important role in identifying caregivers at risk of having their own health decline, by using assessments that may help mediate costs. These assessments look at the caregiver’s health, ability and willingness to do what tasks may be required, as well as the caregiver’s need for support. For example, when an initial diagnosis of dementia is confirmed, it is recommended to conduct a caregiver assessment at the same time as an initial diagnosis of dementia. That way the family caregiver is integrated into the caregiving team, right from the beginning. As the care recipient’s health declines or dementia increases, the family caregiver assessments should be repeated to ensure that the caregiver is getting the support he or she needs. In addition, such assessments can serve to identify potential stress or even physical strain. The “Caregiver Self-Assessment” is such a tool, which can be downloaded from the American Medical Association or from the National Alliance for Caregiving. A caregiver assessment can also be integrated into the new annual Medicare Wellness Visit.

The efforts that family caregivers make are tremendous and the impact on different aspects of their lives is significant. That’s why we emphasize the importance of supporting the family caregiver, by integrating them from the beginning in the professional caregiving team as a part of the patient centered care – a relatively new, but vitally important, concept in health care. Employers can serve the best interest of their employees by anticipating and responding to the challenges of eldercare for their employees by offering eldercare benefits and wellness programs.4 For the family caregiver themselves, they need information, education and training. Information about the medical condition of the care recipient; coping skills and other relationship issues; better communication; community services; and long-term care planning. Education and training can be given through video, audio, workshops, and one-on one sessions.6

Last but not least, family caregivers want and need respite care so that they can be relieved from the extraordinary and intense demands of ongoing care, thereby strengthening the family’s ability to provide care. It doesn’t have to mean going on a vacation. Taking a break before extreme stress and crisis occurs, can also be simply going to a movie or concert or listening to your favorite music, while someone else cares for your loved one.7


  1. National Alliance for Caregiving. Caregiving in the U.S., 2009.
  2. AARP Public Policy Institute Report: Valuing the Invaluable: 2011 Update, The Growing Contributions and Costs of Family Caregiving.
  3. National Alliance for Caregiving. Evercare® NAC Caregiver Cost Study, 2007.
  4. National Alliance for Caregiving. The MetLife Study of Working Caregivers and Employer Health Care Costs, 2010.
  5. National Alliance for Caregiving. Alzheimer’s Caregiver’s Healthcare Costs Increase as Person with Dementia Declines, 2011.
  6. Schmall, VL, Family Caregiver Education and Training: enhancing self-efficacy, Journal of Case Management, 1995 Winter, 4 (4): 156-62.
  7. Family Caregiving 101. Respite.

About the National Alliance for Caregiving

Established in 1996, The National Alliance for Caregiving is a non-profit coalition of national organizations focusing on issues of family caregiving. Recognizing that family caregivers provide important societal and financial contributions toward maintaining the well-being of those they care for, the Alliance’s mission is to be the objective national resource on family caregiving with the goal of improving the quality of life for families and care recipients.

If you are a part of a caregiving coalition and would like to join NAC’s efforts or share information, please contact stien@caregiving.org or if you are a professional with an interest in family caregiving issues, please join the Caregiving Coalition Listserve to receive the Caregiving Exchange Newsletter and information on caregiving events, research, public policy and programs.

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Holistic Palliative Care for Alzheimer's/Dementia Patients

Posted 1/3/2012 Categories: chronic care, palliative care, dementia, hospice, webinar, alzheimer's

Alzheimer’s disease is the sixth leading cause of death in the United States and accounts for the largest percentage of dementia cases. For patients with end-stage Alzheimer’s disease and other forms of dementia, palliative and hospice care professionals can achieve optimal results by providing holistic end-of-life care services.

As part of their interdisciplinary topics series, the National Hospice and Palliative Care Organization (NHPCO) is hosting a webinar to discuss the importance of interdisciplinary team collaboration in assessing and holistically treating these patients and supporting their families.

Amedisys Chief Medical Officer, Dr. Kevin Henning, and China Phillips, Nurse Practitioner at Columbus Hospice, will:

  • identify pharmacological and non-pharmacological treatment options
  • discuss behavioral issues associated with patients with dementia
  • offer strategies with a focus on nursing and other interdisciplinary team member interventions to help families adapt to the day-to-day challenges of caring for a loved one with advanced dementia.

For more info and registration:

January Interdisciplinary Topic Holistic Palliative Care for Alzheimer/Dementia Patients
January 12, 2012 - 2:00 pm - 3:30 pm ET
CE/CME Offered: Counselor, Nurse, Physician, and Social Work

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