Hospice Certification, Care
Planning and Documentation:
Created by: Created by:
Brenda Lovelady, Liberty Hospital Hospice Presented by:
Hospice Certification
Written certification statement is required
“I certify that _____ is terminally ill with a life
expectance of 6 months or less if the terminal illness runs its normal course.”
Local Coverage Determination for
“Determining Terminal Status
”
LCD for Hospice—”Determining
Terminal Status” by Medicare- Handout
Only a guideline
Written for specific diagnoses Must consider co-morbidities
Karanofsky Performance Status Palliative Performance Scale
Scales to assist in documenting the
status of a patient
Can be used to study functional level of
patients at time of admission, prior to death and prediction ability.
Coma/ Stroke
Karnofsky Performance Status (KPS) or
palliative Performance Scale (PPS) of 40% or less
Wt. Loss > 10% in last 6 month Serum albumin <2.5% gm/dl
Dysphagia severe enough to prevent
adequate nutrition
Coma/Stroke
Supports terminal prognosis
Aspiration pneumonia URI
Sepsis
Decubitus ulcers
Alzheimer’s-type Dementia
Unable to ambulate
Unable to dress without assistance Unable to bath without assistance Incontinence B & B
No meaningful verbal communication Recent (past 12 months) infections Stage 7 or beyond FAST-
End Stage Renal
Not seeking dialysis or renal transplant Creatinine Clearance < 10ml/min
Serum creatinine >8mg/dl Co-morbidities
Heart Disease
Failing optimal treatment
Symptoms of heart failure at rest Supportive factors
Treatment resistant SVT or VT Hx cardiac arrest
Unexplained syncope
ALS
Impaired breathing Dyspnea at rest Rapid progression Nutritional impairment InfectionsPulmonary Disease
Disabiling dyspnea at rest
Right heart failure secondary to
pulmonary disease
Resting tachycardia > 100/min
Hypoxemia at rest on room air O2 sat <
Liver Disease
INR >1.5 Serum albumin < 2.5 gm/dl Ascities Bacterial peritonitis Progressive malnutrition Muscle wastingDecline in Health
Recurrent infections
Wt. Loss-(wt., arm circumference, abdominal
girth) Dysphagia Dyspnea N/V Weakness PPS < 70%
Cancer
Distant metastases
Progression of disease Decline therapy
PPS < or = 70%
Assistance with 2 or more ADLs Co-morbidities
Process to Determine Eligibility
Use all information
Input all team members Assessment
Agency guidelines Decision
Developing the Plan of
Care
Begins with the referral
Providing transitional information to
patient and family
(Travis, 2001) Interdisciplinary assessments
Team sharing and collaboration
Overview of Care Plan Model
Initial POC
Identification of the problem
Problem List-
Further development of each problem
Initial Plan of Care
Patient’s name and numbers Admit date Diagnosis (s) Physician’s name Pharmacy Medications Allergies Initial Problems
Initial Plan of Care
Specific Treatment Orders Supplies/Equipment/Diet Frequency of Visits
DNR wishes
Attending sign death certificate Patient/family administer meds
POC reviewed by IDG every 2 weeks
Signature and verbal approval of nurse, social worker
(counseling), Chaplain, attending and medical director
Plan of Care Process
With IPOC identify the major problems These problems are then further
developed on the POC with interventions and goals
Remember…this is an ongoing process POC should be added to as time goes
Problem Areas
What areas are problematic to
document for you?
Physician Orders and
Plan of Care
Included as part of Plan of Care
If has medication orders, filed with
Medication Plan of Care
Order for equipment, filed with
Equipment Plan of Care
Flow of Documentation
Admission assessments
Problems identified
IDG conferences/summaries
Physician orders
Patient & family goals
Staff visit notes
Making it Work…Updating the
Plan of Care
Team takes ownership of POC
Any team member can update any
identified problem
Any team member can open a newly
Documentation
Medical Record is a legal document. Writing must be legible/readable
Statements must be factual and specific Patient and family quotes may be used
Identify time/date of entry with signature and
title
All telephone contact must be documented. All conversations with physicians and other
Documentation:
Support Prognosis
Summary from the physician or nurse that
identifies clinical symptoms, tests, treatments to show status of condition
Discharge Summary or H/P from hospital Changes in conditions
Date of diagnosis and course of illness
Patient’s desires for palliative, non-curative
Supportive Documentation:
Breast cancer pt. w/ new seizure onset.
Brain scan indicating brain metastases.
Prostate cancer pt. w/ recent fall resulting in
pathological fracture related to bone metastases.
Pt. w/ dementia for 11 years. Now in facility
for 2 years and has lost 10% of her body wt. Wt. 89 lbs and appetite 25%.
Supportive Documentation
Parkinson’s patient recently returned to care
facility following hospitalization for aspiration pneumonia with continuous swallowing
difficulties.
During a recent care conference, noted s/o
decline in long-term pt. with multiple dx. Skin breakdown,recurrent UTIs, low-grade fever and weakness. Albumin level 2.1.
Documentation:
Support Hospice
Change in wt.
Change in lab values Change in pain
Change in responsiveness Skin breakdown
Dependence on ADLs
Anthropomorphic measures
Documentation:
Support Hospice
Change in respirations Oxygen use Change in B/P Change in strength/weakness Change in orientation Change in intake/outputDocumentation: Level of Care
Routine Home Care
Patient in home setting, routine
treatment being provided
Paint a picture Clinical findings
Wt. Loss/gain, VS, wounds, eating Interventions
Documentation: Level of Care
Continuous Home Care
Provided in period of crisis to maintain
pt at home. Must include 8 hrs care in 24 hours to achieve palliation or
management of acute medical
symptoms. Primary services (at least
half) must be provided by RN/LPN, may be supplemented with
Documentation: Level of Care
Continuous Home Care
Pt. must require skilled services
Normal dying process, usually does not
Documentation: Level of Care
Continuous Home Care
Should document
Dates/times/reason for change in level of care (Pt in severe pain, caregiver unable to control. Cont. care to begin 7/7/09 1 pm.)
Interventions
Response of pt/family
Any adjustment medications/treatments Goals
Documentation: Level of Care
Inpatient Respite Care
To relieve caregivers, does not require
a change in pt’s condition
Caregiver needs rest so can resume
duties as caregiver
Caregiver is sick
Documentation: Level of Care
Inpatient Respite Care
Documentation Tips
Date respite started, reason, order
Date respite ended, order for change in
Documentation: Level of Care
General Inpatient Care
Short-term hospitalization for symptom
control
Requires 24 hour care by RN Examples:
Pain management requiring complicated technical delivery of medication
Freq. Evaluation by nurse/physician Sudden deterioration
Uncontrolled nausea/vomiting
Complex wound requiring complex dressing changes
Documentation: Level of Care
General Inpatient Care
Documentation Tips
Order change in level of care Date/Time of change
Reason for care Assessment
Tips to Make the Care
Planning Process Work
Not merely time-consuming, academic
exercise
But both documentation tool and
implementation plan for individualized
hospice care
Requires sharing and collaboration
Joint effort of members of team to
develop care plan model/tool which
reflects best practices of agency
References
Lovelady, B., & Sword, T. (2004). Hospice care planning: An interdisciplinary
roadmap.
Journal of Hospice and
Palliative Nursing, 6
(4), 223-230.Missouri Hospice Licensure Regulations. Medicare Hospice Regulations.
Travis, S. (2001). Palliative care: A way of thinking, a prescription for doing.
