Guidelines in determining patient eligibility under the Medicare/Medicaid Hospice Benefit are helpful by identifying those persons that may have a life expectancy of approximately six months or less. A patient will need to meet all of the following criteria to be eligible for hospice:

• The patient's condition is life limiting , and the patient and/or family has been informed of this determination. A "life limiting condition" may be due to a specific diagnosis, a combination of diseases, or there may be no specific diagnosis defined.


• The patient and/or family has elected treatment goals directed toward relief of symptoms , rather than cure of the underlying disease. Or patient may have one of the following:


• Documented clinical progression of a disease, which may include:

1. Progression of the primary disease process as listed in disease-specific criteria and documented by a physician assessment, laboratory, radiology or other studies.
   
   
2. Multiple Emergency Department visits or inpatient hospitalizations over the prior six months.



3. For homebound patients receiving home health services, nursing assessment may be documented. For patients who do not qualify under 1, 2 or 3, a recent decline in functional status may be documented.

• Documented recent impairment of nutritional status relating to the terminal process.

1. Unintentional, progressive weight loss of greater than 10% over the prior six months.
   
   
2. Serum albumin less than 2.5 gm/dl may be a helpful prognostic indicator, but should not be used in isolation from other factors in I-III above.

• Coverage of hospice care depends upon a physician's certification that a person's life expectancy is six months or less if the illness runs its normal course. Recognizing that determination of life expectancy during the course of a terminal illness is difficult, the National Hospice and Palliative Care Organization has published medical criteria for determining prognosis of certain diagnoses. These guidelines form a reasonable approach to the determination of life expectancy based on available research.


• If a patient meets the medical criteria, they are, by definition, eligible to receive hospice services. Some patients may not meet the criteria, but may still be eligible for hospice care because of other co-morbidities or rapid functional decline. It is the physician's clinical judgment regarding the normal course of the individual's illness determines a prognosis of six months or fewer.