What are the criteria for recertification for hospice care in a patient with respiratory failure?

Hospice Recertification SOAP Note for Respiratory Failure

For hospice recertification with respiratory failure, you must document joint certification by both the treating physician and hospice medical director that the patient's prognosis remains terminal (more likely than not less than 6 months to live), along with evidence of continued decline through progressive symptoms, functional deterioration, increasing healthcare utilization, or new complications. 1

Subjective Documentation Requirements

Document disabling dyspnea at rest that significantly limits activity and responds poorly to bronchodilators - this is the cornerstone criterion for respiratory failure patients, particularly those with COPD. 1

Include the following subjective elements:

• Patient-reported dyspnea severity using standardized scales (Dyspnea Numerical Rating Scale or Dyspnea Categorical Scale), as these show moderate-to-strong correlation with objective measures 2
• Functional limitations - specifically document inability to perform activities of daily living due to breathlessness 1
• Symptom burden including anxiety associated with dyspnea, depression, and other distressing symptoms 1
• Patient/family understanding of terminal prognosis and goals of care 3

Objective Documentation Requirements

Document disease progression indicators - you must include at least one of the following for respiratory failure patients: 1

• Two or more exacerbations per year despite adequate treatment
• Previous hospitalizations for respiratory decompensation
• Severe airflow obstruction despite optimal therapy
• Hypoxemia or hypercapnia on ambient air

Additional objective findings to document: 4

• Right heart failure secondary to pulmonary disease (cor pulmonale)
• Unintentional progressive weight loss
• Resting tachycardia
• Declining Karnofsky or Palliative Performance Scale scores 5

For patients unable to self-report, use the Respiratory Distress Observation Scale (RDOS), which has good inter-rater reliability (ICC 0.947) and can identify moderate-to-severe dyspnea with 76.6% sensitivity and 86.2% specificity when RDOS ≥ 4. 2

Assessment: Terminal Prognosis Justification

State explicitly that the patient meets terminal prognosis criteria despite the known limitations of current prognostic tools. 1, 4

Address the following in your assessment:

• Acknowledge prognostic uncertainty - current hospice criteria for non-cancer respiratory illnesses have limitations in accurately predicting 6-month mortality, and the BODE index has not been validated for 6-month mortality determination 1, 4
• Do not delay recertification due to prognostic uncertainty - the combination of advanced respiratory failure with other comorbidities provides sufficient evidence of terminal illness 1
• Document continued decline through comparison with previous assessments showing worsening symptoms, functional status, or new complications 1

Critical pitfall to avoid: Many physicians delay hospice referral or recertification due to prognostic uncertainty or lack of awareness of eligibility criteria for non-cancer patients. 4 The requirement is "more likely than not" less than 6 months, not a guarantee of death within 6 months. 3

Plan: Symptom Management and Continued Hospice Care

Document the ongoing symptom management plan prioritizing quality of life: 1

• Dyspnea management with opioids as first-line treatment, oxygen therapy, positioning, and non-pharmacologic interventions (handheld fans directed at face) 1, 6
• Anxiety control with benzodiazepines when dyspnea is associated with anxiety 1
• Depression treatment with antidepressants as necessary for palliative respiratory patients 1
• Supplemental oxygen and medications for symptom control that improve quality of life 6

Confirm patient agreement that hospice care (not curative care) will continue to be used to treat their terminal illness. 3, 4

Document that the patient does not require a DNR order to remain in hospice - it is illegal under the Patient Self-Determination Act for Medicare-funded hospice programs to exclude patients who don't agree to forgo CPR. 3, 6

Note that if the patient's condition unexpectedly improves, they can be withdrawn from hospice, and conversely, if they survive beyond 6 months but still meet enrollment criteria, Medicare will continue reimbursement. 3, 4

Key Documentation Elements for Recertification

Your SOAP note must demonstrate: 1

• Progressive decline since last certification period
• Continued terminal prognosis despite any stabilization
• Ongoing symptom burden requiring hospice-level care
• Patient/family understanding and agreement with hospice care focus

The recertification does not "guarantee" death within 6 months - it certifies that death is more likely than not within this timeframe if the disease follows its expected course. 3 This distinction is critical for addressing the inherent prognostic uncertainty in respiratory failure patients compared to cancer patients. 4