What are the criteria for specialty palliative care referral and disease-specific guidelines for hospice referral according to Medicare and the Center to Advance Palliative Care (CAPC)?

Criteria for Specialty Palliative Care Referral and Disease-Specific Guidelines for Hospice Referral

According to Medicare and the Center to Advance Palliative Care (CAPC), specialty palliative care referrals should be made for patients with complex or uncontrolled care needs, including pain or other symptoms requiring significant adjuvant medications or interventions, or those with complex psychosocial or spiritual needs. 1

Specialty Palliative Care Referral Criteria

Primary Criteria for Specialty Palliative Care Referral

1. Symptom-Based Criteria:

   • Severe physical symptoms despite optimal medical therapy 1
   • Severe emotional symptoms requiring intervention 1
   • Complex pain or other symptoms requiring significant adjuvant medications 1
   • Uncontrolled symptoms affecting quality of life 1

2. Disease Complexity Criteria:

   • Patients with advanced cancer, especially within 3 months of diagnosis for cancers with median survival ≤1 year 2
   • Progressive disease despite second-line therapy 2
   • Multimorbidity, frailty, or cognitive impairment 1
   • Patients with hematologic malignancies (specific recommendation) 1

3. Decision-Making Criteria:

   • Patients facing major medical decisions (e.g., left ventricular assist device implantation) 1
   • Request for assistance with decision-making or care planning 2
   • Goals-of-care discussions needed 3
   • Spiritual or existential crisis 2

4. Utilization Patterns:

   • Frequent hospital admissions or emergency department visits 1
   • Prior hospitalization within the last 30 days 1
   • Hospitalization longer than 7 days 1

Disease-Specific Guidelines for Hospice Referral

Heart Failure Hospice Criteria (Medicare)

• NYHA Class IV symptoms despite optimal treatment
• Ejection fraction <20%
• Multiple hospitalizations for heart failure
• Additional criteria:
  • Progressive functional decline and dependence in activities of daily living 1
  • Cardiac cachexia 1
  • Heart transplantation and mechanical circulatory support ruled out 1

COPD Hospice Criteria (Medicare)

• Severe airflow obstruction
• Oxygen dependence
• Multiple hospitalizations for respiratory exacerbations
• Disease progression with:
  • Decreased functional capacity
  • Hypoxemia or hypercapnia 4

Advanced Cirrhosis Hospice Criteria (Medicare)

• Complications of end-stage liver disease
• Ineligibility for liver transplantation
• Hepatorenal syndrome
• Progressive malnutrition and muscle wasting 4

Neurodegenerative Conditions Hospice Criteria (Medicare)

• Progressive decline in functional status
• Complications such as aspiration pneumonia, pyelonephritis, sepsis
• Difficulty swallowing or refusal of artificial nutrition/hydration
• Decreased consciousness 4

Implementation Considerations

Primary vs. Specialty Palliative Care

• Primary palliative care should be provided by all healthcare professionals as part of routine care 1
• Specialty palliative care should be reserved for patients with more challenging needs beyond the capabilities of the primary team 1

Timing of Referral

• Early referral is recommended, especially for patients with advanced cancer 1
• The "surprise question" can be used as a trigger: "Would you be surprised if the patient dies within the next six months?" If "no," consider hospice evaluation 4

Barriers to Appropriate Referral

• Confusion about eligibility criteria
• Communication barriers between providers
• Lack of advance care planning
• Underutilization for non-cancer diagnoses 4

Practical Approach to Screening

• Implement systematic screening at admission and during daily rounds 5
• Screen for uncontrolled symptoms, moderate to severe distress, serious comorbidities, limited life expectancy, and patient/family concerns 4
• Use automated screening systems to identify high-risk patients 6

Benefits of Appropriate Referral

• Improved quality of life
• Reduced symptom burden
• Potentially improved survival
• Enhanced patient understanding of prognosis and goals of care
• Benefits extending to caregivers 4
• Cost savings of approximately $6,000 per person at end-of-life 1

By implementing these criteria systematically, healthcare providers can ensure timely and appropriate referrals to specialty palliative care and hospice services, ultimately improving patient outcomes and quality of life.