What is a comprehensive assessment and plan for an elderly frail woman requiring assistance with activities of daily living, who has aged out of breast and colon cancer screening and is enrolled in hospice (routine home care G9709 and skilled nursing G9710)?

Comprehensive Assessment and Plan for Elderly Frail Woman on Hospice with ADL Dependence

Assessment

Functional Status and Frailty

This patient requires comprehensive documentation of her frailty status using a validated multidimensional frailty instrument, with specific assessment of each activity of daily living (ADL) and instrumental activity of daily living (IADL) impairment. 1

• Document specific ADL limitations: Record whether she requires "some help," "unable to perform," or can perform independently for bathing, dressing, toileting, transferring, continence, feeding, and grooming 2, 1
• Document IADL limitations: Assess using transportation, managing money, taking medications, shopping, preparing meals, doing laundry, doing housework, and using telephone 2, 1
• Frailty assessment: Use validated tools such as Clinical Frailty Scale or FRAIL Scale to quantify her frailty level 1, 3
• Gait and mobility: Assess 4-meter gait speed (≥4 seconds indicates impairment) and document fall history in the last 6 months 1

Hospice Status Documentation

The patient is enrolled in Medicare hospice with routine home care (G9709) and skilled nursing facility care (G9710), indicating terminal prognosis with life expectancy of 6 months or less. 1

• Homebound status: Document that she is confined to home except for medical purposes, which is mandatory for Medicare coverage 2, 4
• Terminal diagnosis: Record the primary hospice diagnosis and estimated prognosis 1
• Hospice level of care: Clarify whether she is receiving routine home care, continuous home care, or general inpatient care 1

Cancer Screening Status

This patient has appropriately aged out of both breast and colon cancer screening given her hospice enrollment and limited life expectancy. 1

• Breast cancer screening (G9709): Document that screening mammography is not indicated due to hospice status and estimated life expectancy of less than 10 years required to benefit from screening 1
• Colon cancer screening (G9710): Document that colonoscopy or other colon cancer screening is not indicated due to hospice enrollment and limited life expectancy 1
• Rationale: In patients with multimorbidity and limited life expectancy, preventive services with long time-to-benefit should be discontinued to focus on quality of life and symptom management 1

Nutritional Assessment

Assess for malnutrition risk, which is substantially elevated in frail elderly patients and directly impacts quality of life. 1

• Weight history: Document weight loss in past 3 months (>3 kg indicates high risk) 1
• Dietary intake: Assess whether she consumes adequate calories (minimum 1500 kcal/day) and protein requirements 1
• Hydration status: Ensure daily fluid intake of 1.6 L for women, as individuals with cognitive decline often forget to drink 1
• Swallowing assessment: Screen for dysphagia using Eating Assessment Tool-10 (positive if score ≥3) 1
• Sarcopenia screening: Assess for disproportionate loss of muscle mass and strength following European Working Group on Sarcopenia in Older People 2 guidelines 1

Medication Review

Conduct comprehensive medication review to discontinue medications with limited benefit that do not improve quality of life or relieve symptoms in the hospice setting. 5, 1

• Identify limited benefit medications (LBMs): Review for anti-hyperlipidemics (statins), anti-hypertensives (if not for symptom control), oral anti-diabetics, anti-platelets, anti-dementia medications, anti-osteoporotic medications, and proton pump inhibitors 5
• Discontinuation rationale: 29.8-30.5% of hospice patients inappropriately continue LBMs after hospice admission; these should be stopped unless directly addressing symptoms 5
• Medication management support: Designate a family member to fill weekly pillboxes and provide written instructions for remaining medications 1

Home Environment and Safety

Document home safety evaluation findings and environmental barriers that impact her care needs. 2, 1

• Fall risk assessment: Ask "Do you have trouble with stairs inside or outside of your home?" and assess for hazards with bathtubs, rugs, or lighting 1, 2
• Environmental modifications needed: Document need for handrails, adequate lighting, removal of loose rugs, and adaptive equipment 2, 4
• Assistive devices: If mobility impairment present, prescribe walker with specific type (standard, two-wheeled, or four-wheeled) based on functional limitations 4

Social Support and Caregiver Assessment

Identify and document all available caregivers and assess their capacity to meet her care needs. 2, 1

• Primary caregivers: List identified persons in the medical record who can help in case of illness or emergency 1, 2
• Caregiver capacity: Document whether caregivers demonstrate anxiety, confusion, forgetfulness, or poor coping skills 2
• Living situation: Record whether she lives alone or has inadequate support systems 2, 1
• Decision-making: Document who is involved in medical decision-making and establish documented health care proxy 1

Psychological and Spiritual Assessment

Address psychological, social, cultural, and spiritual needs as core components of end-of-life care. 1

• Emotional health screening: Use PROMIS Anxiety 4-item scale (raw score ≥11 indicates need for intervention) 1
• Depression screening: Assess for history of major depression and current mood symptoms 1
• Spiritual needs: Offer access to clergy or spiritual support to foster communication with congregation of worship 1

Plan

Hospice Services Coordination

Ensure comprehensive interdisciplinary hospice team involvement to address all dimensions of end-of-life care. 1

• Skilled nursing: Registered nurse with end-of-life expertise visits as needed with 24-hour on-call availability 1
• Medical social services: Social worker provides counseling, bereavement support, and care coordination 1
• Home health aide services: Personal care assistance with ADLs (bathing, dressing, toileting) is covered only when concurrent skilled nursing or therapy services are justified 2, 1
• Therapy services: Physical therapy for gait/assistive device evaluation, strength, and balance training; occupational therapy for home safety evaluation and functional impairment treatment 1, 2
• Hospice medical director: Provides consultation and oversight of care plan 1
• Volunteer services: Trained hospice volunteers offer friendly visits, compassionate listening, and companionship 1

Medication Management Plan

Optimize medication regimen by discontinuing non-palliative medications and focusing on symptom relief and quality of life. 5, 1

• Discontinue limited benefit medications: Stop statins, anti-osteoporotic medications (if taking >5 years, fracture protection persists up to 5 additional years), and other medications not addressing symptoms 1, 5
• Continue symptom-directed medications: Maintain medications that directly relieve pain, dyspnea, nausea, anxiety, or other distressing symptoms 1
• Simplify regimen: Consolidate dosing schedules to once daily when possible to improve adherence 1
• Family medication management: Designate responsible family member to fill weekly pillboxes and store medications (except as-needed medications) in family member's home 1
• Written instructions: Provide detailed written medication list with indications and monitoring instructions 1

Nutritional Support Plan

Implement individualized nutritional interventions to maintain quality of life without imposing dietary restrictions. 1

• Liberalize diet: Avoid dietary restrictions; weight-reducing diets are contraindicated in frail elderly hospice patients 1
• Protein and calorie supplementation: Recommend nutritional supplements to meet protein-calorie requirements; for intake <1500 kcal/day, add daily multivitamin supplementation 1
• Small frequent meals: Provide high-protein/high-calorie snacks throughout the day 1
• Hydration monitoring: Ensure 1.6 L daily fluid intake with consistent monitoring to prevent dehydration 1
• Dietitian referral: Consult dietitian to tailor recommendations to her specific needs and preferences 1
• Vitamin supplementation: Consider vitamin D, B12, and folate supplementation if deficiencies identified 1

Functional Support and Rehabilitation

Provide targeted interventions to maximize functional independence and prevent complications. 1, 2

• Physical therapy: Request gait/assistive device evaluation, lower-extremity strength training, and balance training for fall prevention 1, 2
• Occupational therapy: Request home safety evaluation and treatment for functional impairments affecting ADLs and IADLs 1, 2
• Fall prevention: Check orthostatic blood pressure, adjust medications if low or low-normal, and provide falls prevention education 1
• Adaptive equipment: Provide walker, raised toilet seat, shower chair, and other assistive devices as needed 4

Symptom Management and Palliative Care

Prioritize alleviation of pain and other physical symptoms using palliative care paradigm. 1

• Pain assessment: Regular pain screening with appropriate analgesic management including opioids as needed 1
• Dyspnea management: Address respiratory symptoms with oxygen, opioids, and positioning 1
• Skin integrity: Implement pressure ulcer prevention strategies given her frailty and limited mobility 6
• Bowel and bladder management: Prevent constipation from opioids; minimize urinary catheter use to reduce infection risk 1

Communication and Decision-Making

Respect patient dignity and family wishes while maintaining clear communication about goals of care. 1

• Shared decision-making: Ensure patient and family understand hospice philosophy and make informed choices consistent with patient preferences 1
• Communication modality: If communicative impairments develop, identify and maintain assistive devices to allow continued communication with family and caregivers 1
• Advance care planning: Confirm documented health care proxy and POLST/MOLST forms are in medical record 2
• Family education: Provide education about disease progression, what to expect, and how to contact hospice team 24/7 1

Caregiver Support

Provide comprehensive support to family caregivers to prevent burnout and ensure sustainable care. 1

• Respite care: Arrange periodic respite admissions to skilled nursing facility to provide caregiver relief 1
• Caregiver education: Train family in proper positioning, range of motion exercises, and use of assistive devices 2
• Counseling services: Offer adjustment-to-death support and bereavement counseling (available up to 1 year after death) 1
• Social work support: Address financial concerns, community resources, and psychosocial needs 1

Cancer Screening Documentation

Document rationale for discontinuation of cancer screening given hospice status. 1

• Breast cancer screening (G9709): Document that patient has aged out of screening due to hospice enrollment and limited life expectancy insufficient to benefit from screening (requires >10 years) 1
• Colon cancer screening (G9710): Document that patient has aged out of screening due to hospice enrollment and focus on quality of life rather than preventive services with long time-to-benefit 1
• Shared decision-making: Confirm patient and family understand and agree with discontinuation of screening 1

Monitoring and Follow-Up

Establish regular monitoring schedule with hospice team to assess symptom control and adjust care plan. 1

• Nursing visits: Schedule frequency based on symptom burden and caregiver needs (typically 1-3 times weekly for routine home care) 1
• Physician oversight: Hospice medical director reviews care plan regularly with attending physician 1
• Crisis management: Ensure family knows how to access 24-hour hospice nurse for urgent symptom management 1
• Level of care adjustments: Reassess need for continuous home care or general inpatient care if symptoms become uncontrolled 1

Documentation for Medicare Coverage

Ensure all documentation meets Medicare requirements for home health and hospice services. 2, 4

• Homebound status: Explicitly document that patient is confined to home except for medical purposes 2, 4
• Skilled service justification: Document specific skilled nursing or therapy needs that justify home health aide coverage for ADL assistance 2, 1
• Functional limitations: Record exact level of assistance required (standby, minimal, moderate, maximal, total) for each ADL 2
• Medical necessity: Document unstable medical status, multiple comorbidities, or high risk of complications requiring close supervision 2, 1