What are the key considerations for evaluating a patient's eligibility for hospice care under F2F (Face-to-Face) non-certifying criteria, particularly in terms of their terminal illness prognosis, symptoms, and quality of life?

Face-to-Face Non-Certifying Hospice Criteria

The face-to-face (F2F) encounter is required by CMS for patients entering their third certification period (after 180 days in hospice) to verify continued hospice eligibility, and must be performed by a hospice physician or nurse practitioner to document that the patient remains terminally ill with a prognosis of 6 months or less if the disease runs its normal course. 1

When F2F Encounters Are Required

• F2F assessments are mandatory when patients reach their third benefit period (180 days after initial hospice enrollment), not at initial certification or first recertification 1
• The encounter must occur before the hospice medical director can recertify continued eligibility 1
• This regulation was implemented January 1,2011, to address concerns about patients with extended hospice stays 1

Who Performs the F2F Encounter

• Must be conducted by either a hospice physician or a nurse practitioner employed by or under contract with the hospice 1
• The hospice medical director then uses this assessment to recertify eligibility 2
• Both the treating physician and hospice medical director must jointly certify that the patient's prognosis remains terminal 3

Documentation Requirements for F2F Recertification

Subjective Clinical Findings

Document progressive functional decline and symptom burden that demonstrates continued terminal trajectory:

• Disabling symptoms at rest (such as dyspnea, pain, or fatigue) that significantly limit activity and respond poorly to treatment 3, 4
• Inability to perform activities of daily living due to disease progression 3
• Progressive dependence in most activities of daily living with physical and mental decline 5
• Anxiety, depression, or other distressing symptoms associated with terminal illness 3
• Patient/family understanding of terminal prognosis and goals of care 3

Objective Clinical Findings

Document measurable evidence of disease progression:

• Frequent hospitalizations or emergency visits for disease decompensation despite optimal treatment 5, 3
• Unintentional progressive weight loss or cardiac cachexia 5, 4
• New complications such as right heart failure, infections, sepsis, or altered mental status 5, 4
• Disease-specific markers (e.g., hypoxemia/hypercapnia for pulmonary disease, severe refractory symptoms despite optimal therapy) 3, 4
• Electrolyte imbalances or other metabolic derangements 5

Assessment and Plan Documentation

• Explicitly state that the patient continues to meet terminal prognosis criteria despite known limitations of prognostic tools 3
• Compare current status with previous assessments showing worsening symptoms, functional status, or new complications 3
• Document the ongoing symptom management plan prioritizing quality of life over curative treatment 3
• Confirm patient agreement that hospice care will continue to be used to treat their terminal illness 3
• Note that patients do not require a DNR order to remain in hospice 2, 3

Patient Populations Most Likely to Require F2F

Patients with dementia/debility are 3.35 times more likely to require F2F recertification compared to cancer patients (OR=3.35, p<0.001), as they frequently survive beyond 6 months in hospice 1. Key characteristics include:

• Primary diagnosis of dementia or debility rather than cancer 1
• Presence of serious comorbidities (OR=2.84, p<0.001) 1
• Older age 1
• Admission from facility care settings rather than home 1

Critical Pitfalls to Avoid

The 6-month prognosis requirement creates significant access barriers because current prognostic criteria for non-cancer illnesses have poor accuracy:

• For advanced lung disease, 53-70% of patients meeting Medicare hospice criteria survive longer than 6 months 4
• The BODE index provides prognostic information for COPD but has not been validated for determining 6-month mortality 2
• Broad inclusion criteria identify patients with 70% surviving beyond 6 months; even narrow criteria have 53% surviving beyond 6 months 6

Common misconceptions that delay appropriate care:

• Many physicians incorrectly believe hospice is only for the last hours to days of life, when earlier referral improves outcomes 2
• Prognostic uncertainty serves as a barrier to timely referral, with physicians reluctant to discuss hospice due to lack of communication skills 2
• Physicians are often unaware of hospice eligibility criteria for non-cancer patients 2
• Fear of financial and legal repercussions from CMS audits causes hesitancy to certify patients unless clearly dying 7

Key clinical realities:

• Patients can be withdrawn from hospice if their condition unexpectedly improves 2
• The physician certifying hospice eligibility does not guarantee death within 6 months 2
• Hospice care itself may improve prognosis, creating a paradox where effective symptom management extends survival 7
• Only 12-15% of Medicare beneficiaries' days during the last year of life are spent in hospice, reflecting systematic underutilization 7

Disease-Specific Considerations

For pulmonary disease patients requiring F2F:

• Severe chronic lung disease with disabling dyspnea at rest 4
• Hypoxemia at rest on ambient air or hypercapnia 4
• Two or more exacerbations per year despite adequate treatment 3
• Right heart failure secondary to pulmonary disease 4

For heart failure patients requiring F2F:

• Severe HF symptoms with poor quality of life despite optimal pharmacological and non-pharmacological therapies 5
• Frequent admissions for decompensation despite optimal treatment 5
• Heart transplantation and mechanical circulatory support ruled out 5
• Progressive functional decline and dependence in most activities of daily living 5