Eli's Hospice Insider

Don't get so caught up in ambulation that you miss other key criteria.

Question: In reading the new local coverage decision (LCD) on Alzheimer's disease, our hospice is confused about how we should determine an Alzheimer's patient's eligibility. The LCD seems to say that a patient who can ambulate in any way -- whether it's moving a wheelchair with her feet, shuffling her feet under the guidance of an aide, or just putting one foot in front of another -- does not meet the eligibility requirement. Is this correct?

Answer: No, ambulation is not the only criteria that would determine an Alzheimer's patient's hospice eligibility, Palmetto GBA clarifies in a set of questions and answers from the Nov. 17 Hospice Coalition meeting, which was released this month.

The LCD (L16343, Hospice Alzheimer's Disease & Related Disorders) states that "to be eligible for hospice the individual should have a [Reisberg Functional Assessment Staging (FAST)] level of greater than or equal to 7" -- which is the stage that identifies an activity limitation that would support the six-month prognosis for hospice.

Alzheimer's patients classified as Stage 7 have loss of speech, locomotion, and consciousness that includes limited ability to speak, loss of intelligible vocabulary, no ambulation, and inability to sit up independently, smile, or hold the head up.

Key: An Alzheimer's patient's ability to ambulate isn't the deciding factor for whether that patient meets the FAST criteria for Stage 7. Any loss of speech, locomotion, or consciousness caused as a direct result of the disease would be enough.

However, Palmetto's goal was to "make the LCD more descriptive, rather than prescriptive," the regional home health and hospice intermediary (RHHI) says -- especially because of the complex decision-making required when making hospice referrals for such a "heterogeneous population."

Crucial: The RHHI emphasizes that hospice eligibility is based on FAST staging plus "relevant secondary and/or co-morbid conditions," Palmetto says. While the FAST Scale is meant to measure the functional impact of the disease, these secondary conditions allow for a more holistic picture of the patient.

"The combined effects of the Alzheimer's disease (stage 7) and any co-morbid condition should be such that most beneficiaries with Alzheimer's disease and similar impairments would have a prognosis of six months or less," Palmetto explains. Secondary conditions such as delirium and pressure ulcers would also meet this requirement.

The bottom line: A patient's ability to ambulate isn't the key to determining an Alzheimer's patient's hospice eligibility, Palmetto says. Look for loss of speech and consciousness as well as locomotion -- and those comorbid/secondary conditions -- when you're not sure whether a patient should qualify.