hospice-eligibility-criteria

name

hospice-eligibility-criteria

description

Veteran playbook for EDUCATING referral sources on hospice eligibility — the Medicare Hospice Benefit structure, the non-disease-specific decline guidelines, the diagnosis-specific LCD criteria, and the PPS/FAST/NYHA scales. Teaches recognition, never certification. Consulted by hospice-eligibility-educator. Every output ends with 'the attending physician and medical director certify eligibility.'

Hospice Eligibility Criteria Skill

Purpose: help hospice-eligibility-educator teach a referral source to recognize a potentially hospice-eligible patient. This skill is education, not a certification or determination tool.

The hard line (applies to everything below)

The representative educates; the physician certifies. Hospice eligibility — a prognosis of six months or less if the disease runs its normal course — is certified by the attending physician and the hospice medical director on clinical judgment. Nothing in this skill, and nothing the agent produces from it, tells anyone that a specific patient "qualifies," "is eligible," or "is covered." Every deliverable ends with the physician-certifies line. (../CLAUDE.md §3 #1, §5.)

When to use

• Preparing eligibility education for a diagnosis or a mixed population.
• Doing a de-identified, educational read of whether a profile warrants a physician conversation.
• Correcting a referral source's eligibility misconception.

1. The Medicare Hospice Benefit (structure, not a coverage promise)

• For a patient with a terminal prognosis of six months or less if the disease runs its normal course, who elects the benefit and forgoes curative treatment for the terminal illness.
• Benefit periods: two 90-day periods, then unlimited 60-day periods, each requiring recertification; a face-to-face encounter is required before the third and each subsequent period. (Confirm the current CMS rule — [example — verify].)
• The benefit is revocable — a patient can leave hospice and resume curative care at any time. This fact matters enormously in the goals-of-care conversation.

2. The non-disease-specific decline guidelines (teach this first)

The most useful teaching tool, because it catches the multi-morbidity and failure-to-thrive patients that single-diagnosis LCDs miss. The decline picture:

• Functional decline — falling Palliative Performance Scale (PPS), increasing dependence in activities of daily living, mostly bed/chair-bound.
• Nutritional decline — unintentional weight loss, falling BMI, declining albumin, decreasing intake.
• Recurrent acute events — repeated infections (aspiration pneumonia, UTIs, sepsis), repeated hospitalizations / ED visits.
• Progressive symptoms — dyspnea, pain, or other symptoms worsening despite optimal treatment.

Teach the clinician to see the trajectory, not a single number.

3. The scales

Scale	Measures	Hospice-relevant signal
PPS (Palliative Performance Scale)	Functional status 0–100%	Lower PPS (often ≤ 40–50%) supports a decline picture — [example — confirm against the LCD]
FAST (Functional Assessment Staging)	Dementia progression	FAST stage 7 (plus a recent complication) is the dementia LCD anchor
NYHA (New York Heart Association)	Heart-failure functional class	Class IV (symptoms at rest), optimally treated, anchors the cardiac LCD

4. Diagnosis-specific LCD criteria (as education)

The detailed per-diagnosis decline indicators live in resources/lcd-quick-reference.md and ../../knowledge/hospice-eligibility-lcd-reference.md. Covered: heart disease, pulmonary, dementia, renal, liver, stroke/coma, ALS/neuromuscular, cancer, HIV, and adult failure-to-thrive. Each is dated and sourced to the published LCD, and each is teaching content — the recognition picture, not a checklist that certifies.

5. Correcting the common myths

Myth	The accurate framing
"You need a DNR for hospice."	False — a DNR is not required to elect hospice.
"Hospice is cancer-only."	False — the majority of hospice patients have non-cancer diagnoses (cardiac, dementia, pulmonary, etc.).
"You have to stop all treatment."	The patient forgoes curative treatment for the terminal illness; comfort and symptom treatment continue, and unrelated conditions are still treated.
"Hospice is the last 48 hours."	Hospice is for a six-month-or-less prognosis — earlier election gives the full benefit.

6. The educational screen (never a certification)

When reading a de-identified profile, list which decline indicators are present, what is missing to know, and recommend routing to the attending physician for the clinical conversation. The output is "these published indicators are present; this warrants a physician discussion," never "this patient is eligible." The eligibility-indicators subcommand of scripts/hospice_calc.py tallies indicators with the same discipline.

Hand-offs

• The conversation framing once a patient is identified → goals-of-care-conversations skill / goals-of-care-conversation-coach.
• Turning the education into a territory in-service → referral-territory-development skill / referral-development-strategist.
• The current text of a revised LCD → ravenclaude-core deep-researcher.
• The actual certification → the attending physician / medical director (always).