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Hospice Patient Referral Form

Same-Day Admissions / 24 hours-7 Days/Week

We encourage you to call our RNs 24/7 to find out how we can help with your patient’s needs.
(800) 229-8183

Quick Links To Referral Criteria

daughter embracing her mom and smilingHospice – Routine Level of Care | Hospice – Inpatient Level of Care  | Palliative MedicinePrimary Care at Home

Hospice by Diagnosis: ALS | Cancer | Dementia | Heart Disease | HIV Disease | Kidney Disease | Liver Disease | Lung Disease | Stroke

 

Fill out this patient referral form to refer a patient or to learn more.

Person Submitting Form

Patient Information


Hospice Care

  • Frequent hospitalizations and/or emergency department visits over the last six months
  • Declining functional status as determined by: dependence in 3 of 6 Activities of Daily Living (ADLs)
  • Patient chooses comfort care rather than curative treatment
  • Would you be surprised if the patient survived beyond 6 months?

Inpatient Services

  • Pain or symptom crisis not managed by changes in treatment in the current setting or that requires frequent medication adjustments and monitoring
  • Intractable nausea/vomiting
  • Advanced open wounds requiring changes in treatment and close monitoring
  • Unmanageable respiratory distress
  • Intractable delirium with behavior issues
  • Sudden decline necessitating intensive nursing intervention

Other services offered at Inpatient Centers

  • High-flow oxygen option for more comfortable and timely transfer
  • Routine level of hospice care – private-pay option
  • Respite level of hospice care to relieve family caregiver

ALS

  • Rapidly progressing disease
  • Dyspnea at rest
  • Needs O2 at rest
  • Poor oral intake of food or fluid
  • Weight loss
  • Recurrent infection (such as pneumonia, pyelonephritis or sepsis) or recurrent fever after antibiotics
  • Decubitus ulcers
  • Vital capacity < 40% of normal
  • Desire not to be intubated
  • Desire not to be hospitalized
  • Other comorbid disease that may shorten survival
  • Difficulty with feeding, ambulation, continence, transfer, bathing, or dressing

Cancer

  • Weight loss
  • Metastatic disease
  • Progression from an earlier stage despite therapy
  • Desire to no longer pursue curative treatment (palliative radiation may be continued)
  • Desire not to be hospitalized if the illness worsens
  • Other comorbid disease that may shorten survival
  • Difficulty with feeding, ambulation, continence, transfer, bathing, or dressing

Dementia

  • Difficulty speaking intelligibly
  • Difficulty sitting up
  • Difficulty smiling or holding up the head
  • Decubitus ulcers
  • Infection during the past year (such as pneumonia, pyelonephritis or sepsis) or recurrent fever after antibiotics
  • Weight loss
  • Poor oral intake of food or fluid or dysphagia
  • Desire not to be hospitalized if the illness worsens
  • Other comorbid disease that may shorten survival
  • Difficulty with feeding, ambulation, continence, transfer, bathing, or dressing

 

Heart Disease

  • Symptomatic CHF despite diuretics and vasodilators
  • Angina at rest despite medical management
  • Angina at rest and not a surgical candidate or refuses surgery
  • New York Heart Association Class IV disease
  • Increased need for supplemental O2
  • Refractory symptomatic SVT or ventricular arrhythmia
  • History of cardiac arrest
  • Unexplained syncope
  • Cardiogenic brain embolism
  • Desire not to be hospitalized if the illness worsens
  • Other comorbid disease that may shorten survival
  • Difficulty with feeding, ambulation, continence, transfer, bathing, or dressing

HIV Disease

  • CD4 count < 25 cells/mcL or viral load > 100,000 copies/mL
  • Weight loss
  • Debility
  • Chronic diarrhea
  • Serum albumin < 2.5 gm/dL
  • Antiretroviral therapy no longer effective or too toxic
  • Cancer such as CNS or systemic lymphoma, visceral Kaposi’s sarcoma
  • AIDS dementia or progressive multifocal leukoencephalopathy
  • Infection such as Mycobacterium avium complex bacteremia, toxoplasmosis, Cryptosporidium
  • Ongoing substance abuse
  • Other comorbid disease such as CHF, liver disease or renal failure that may shorten survival
  • Not to be hospitalized if the illness worsens
  • Difficulty with feeding, ambulation, continence, transfer, bathing, or dressing

Kidney Disease

  • Desire to stop or forego dialysis
  • Creatinine clearance < 15-20 cc/min orserum creatinine > 6 mg/dL
  • Cachexia or serum albumin < 3.5 gm/dL
  • Uremia
  • Hyperkalemia
  • Uremic pericarditis
  • Fluid overload or oliguria
  • Hepatorenal syndrome
  • GI bleeding, DIC or platelets < 25,000
  • Infection such as HIV or sepsis
  • Other comorbid disease such as heart, liver or chronic lung disease that may shorten survival
  • Desire not to be hospitalized if the illness worsens
  • Difficulty with feeding, ambulation, continence, transfer, bathing, or dressing

Liver Disease

  • Protime > 5 seconds over control or INR > 1.5
  • Serum albumin < 2.5 gm/dL
  • Ascites
  • Spontaneous bacterial peritonitis
  • Hepatorenal syndrome
  • Hepatic encephalopathy
  • Recurrent variceal bleeding
  • Malnutrition or muscle wasting
  • Ongoing alcoholism
  • Hepatitis B antigen positive
  • Refractory hepatitis C
  • Hepatocellular carcinoma
  • Not a liver transplant candidate
  • Other comorbid disease that may shorten survival
  • Desire not to be hospitalized if the illness worsens
  • Difficulty with feeding, ambulation, continence, transfer, bathing, or dressing

Lung Disease

  • Dyspnea at rest despite bronchodilators
  • Declining functional status
  • FEV1 < 30% predicted
  • Falling FEV1 (by > 40 mL/year)
  • O2 saturation < 88% or pO < 55 mmHg on room air
  • pCO > 50 mmHg
  • O2 dependency
  • Cor pulmonale (right heart failure)
  • Weight loss
  • Resting tachycardia
  • Desire not to be hospitalized if the illness worsens
  • Other comorbid disease that may shorten survival
  • Difficulty with feeding, ambulation, continence, transfer, bathing, or dressing

Stroke

  • Weight loss
  • Serum albumin < 2.5 gm/dL
  • Dysphagia or aspiration
  • Poor intake of food or fluid
  • Infection (such as pneumonia, pyelonephritis, or sepsis) or recurrent fever after antibiotics
  • Decubitus ulcers
  • Large-volume hemorrhage, ventricular extension of hemorrhage, midline shift, or obstructive hydrocephalus by CT
  • Large infarcts
  • Basilar or bilateral vertebral artery occlusion
  • Other comorbid disease that may shorten survival
  • Desire not to be hospitalized if the illness worsens
  • Difficulty with feeding, ambulation, continence, transfer, bathing, or dressing

Palliative Medicine

  • Two or more hospital admissions in the past year for chronic illness
  • Length of stay > 7 days without evidence of improvement
  • Patients with one or more visits per month to the Emergency Department for the same or similar diagnosis
  • Admission of 3 or more days to ICU in one hospitalization
  • Patients/families who would benefit from education and support regarding goals of care and medical decisions
  • Patients whose primary diagnosis is complicated by additional co-morbidities
  • Patients with multi-system organ failure
  • Patients with uncontrolled pain or symptoms such as nausea, vomiting, anxiety, constipation or depression associated with serious illness, such as cancer, COPD, CAD, CHF, renal disease, liver failure, advanced dementia or failure to thrive
  • Patients from long-term care facilities with multiple chronic conditions
  • Patients with neurological or neuromuscular diseases where feeding tubes are being considered
  • Patients with unexplained weight loss; increased fatigue; increasing need for assistance with Activities of Daily Living; frequent falls; declining mental status

Primary Care at Home

More information coming soon.