Category: Metrics & Tools

Checklists, scores, visuals, and downloadable frameworks. Designed to be used in real-world clinical or caregiver settings.
Examples: PPS Explained, Checklist: Signs Someone Might Be Ready for Hospice, IDG Meeting Prep Guide

  • NYHA in Hospice: Turning Breathlessness into Shared Language

    NYHA in Hospice: Turning Breathlessness into Shared Language

    The NYHA Still Matters

    Every hospice nurse knows the moment: the patient gasps two steps after standing, already on oxygen, swollen despite diuretics, worsening each week. Families call it weakness. Hospitals call it criteria. We should name it New York Heart Scale (NYHA) Class IV with clinical clarity.

    “NYHA Class IV” alone in the chart invites denials, audits, and mistrust. It was never a checkbox. Paired with PPS ≤40% and functional decline, it tells a tale. Without context, it erases that story and costs patients’ care. Much like other metrics that matter, NYHA remains essential in hospice: not a number, but a narrative of breath and function. It’s all about the score plus the story.

    Case Example

    Mr. Lowe, 78, a retired truck driver, had severe heart failure. His EF sat near 30%. His daughter asked, “Does that number mean he qualifies for hospice?”

    What mattered wasn’t just a static EF. He became short of breath just pulling on his socks. He had two hospitalizations in 60 days. He had 10lbs of fluid gain, despite diuretics.

    EF didn’t tell that story. However, NYHA classified it as Class IV, with symptoms present at rest. Paired with PPS 40% and documented declines. The record was clear, defensible, and compassionate. His daughter finally understood: “his heart can’t get him through the day anymore.” She was right, it’s not just about numbers. 

    The Essentials

    Definition. NYHA is a four-class system quantifying functional limits in heart failure:

    • Class I: No symptoms with ordinary activity
    • Class II: Symptoms with ordinary activity
    • Class III: Symptoms with less-than-ordinary activity
    • Class IV: Symptoms at rest

    Nature. NYHA is subjective. It depends on clinician judgment, patient report, and observed capacity. It predicts mortality, but reproducibility suffers from interobserver variability.

    Theme. NYHA is essential but insufficient. Alone it misleads. In context it clarifies.

    Application. “Symptoms at rest” is the textbook line, but Class IV is broader:

    • Minimal effort counts. Even standing, dressing, or talking may trigger symptoms.
    • Not just dyspnea. Fatigue, palpitations, and angina also qualify.
    • Fluid symptoms count. Orthopnea, paroxysmal nocturnal dyspnea, bendopenia.
    • Dynamic status. Patients may fluctuate between III and IV; document the worst functional state.
    • Prognosis. Class IV signals poor survival, but hospice eligibility still requires PPS ≤40%, weight loss, or hospitalizations.

    At the bedside, Class IV means:

    • “Patient breathless pulling on socks.”
    • “Requires chair after 10–15 feet.”
    • “Needs 2–3 pillows to sleep.”

    NYHA IV should always be written as lived narrative, not just noted simply as “at rest.”

    History

    NYHA classification first appeared in 1928, refined in 1964 and 1994. Why has it lasted nearly a century? Not for perfection. It is subjective and inconsistent. It lasted because it is simple, human, and functional.

    Before PPS or ECOG, cardiology needed a way to say what patients could do and what they could not. NYHA gave that answer. Hospice inherits the same need: a language of limitation understood in the clinic, in the living room, and in audits.

    Clinical Relevance

    In advanced heart failure, NYHA still provides clarity:

    • Class IV signals serious limitation, usually with PPS <50%.
    • CMS LCDs cite NYHA IV plus decline markers: hospitalizations, EF <20%, weight loss.
    • Ejection Fraction (EF) is often a lagging indicator. Echo numbers may look stable or go unmeasured while patients continue to decline. Functional change over time always carries more prognostic weight.
    • Families and physicians outside hospice know the scale, making it a bridge between worlds.
    • Scope: Validated in HF and valvular disease, sometimes in congenital or right-sided failure. For non-cardiac illness, use tools like PPS or FAST.

    Used wisely, NYHA supports eligibility, teaches teams, and reassures families that what they see is real.

    Interdisciplinary Voice

    What each discipline brings to NYHA:

    • Nurse: Record distance and recovery. “Needs two rests in 15 feet.”
    • Social Worker: Capture role loss. “Stopped grocery shopping due to breathlessness.”
    • Chaplain: Note spiritual or community loss. “Unable to attend church after 50 years.”
    • Physician/NP/PA: Synthesize. “NYHA IV, PPS 40%, 5% weight loss, two CHF admissions, decline consistent with terminal heart failure.”

    In IDG, NYHA language should not sit only in the physician’s note. When nurses, social workers, and chaplains mention the same functional language: dyspneic at rest, limited to 10 feet. Then whole record speaks with one voice.

    Number + Narrative

    NYHA should always be Number + Narrative.

    • Number: Class I–IV
    • Narrative: Functional loss proving the class

    Examples:

    • “NYHA IV, dyspneic at rest, PPS 40%, two CHF admissions, 5% weight loss in 3 months.”
    • “Paused twice in 10 feet, needed chair after 20 seconds standing.”

    Pair with PPS and weight trends to strengthen eligibility notes. Never rely on EF alone. Function carries more prognostic weight.

    Beyond Self-Report: Anchors That Hold

    NYHA is subjective. Frail or cognitively impaired patients may understate symptoms or forget limits. To anchor classification:

    • Use proxy reports from caregivers.
    • Document observed tasks: “Paused twice in 10 feet, needed chair after 20 seconds standing.”
    • Add objective tools: PPS, FAST, etc…

    Anchors improve reproducibility and strengthen eligibility notes.

    Blind Spots and Misuse

    • Equating EF with prognosis: Low EF alone does not qualify. Function drives prognosis.
    • Confusing PPS with NYHA: PPS is global; NYHA is disease-specific. They complement, not replace, each other.
    • Assuming Class IV is enough: Documentation must show decline over time.
    • Over-jargon in charting: “NYHA IV” without narrative is not defensible.

    Compliance pitfall: A chart that only says “NYHA IV” is not very helpful. In audits, NYHA without narrative is treated as noncompliant. Eligibility rests on narrative: distance, frequency, functional loss. Without it, coverage and credibility collapse.

    Say This / Not That

    Say ThisNot That

    “NYHA IV, dyspneic at rest; PPS 40%; unable to walk 10 feet; two hospitalizations this year.”
    		“NYHA IV.”

    “EF 25% with functional collapse, symptoms now daily at rest.”

    “Low EF, so hospice.”

    “Decline in activity and self-care, no longer dresses without stopping for breath.”
    		“PPS 40%, meets criteria.”

    “Observed dyspnea after 8–10 feet, accessory muscle use, needed chair after 20 seconds, PPS 30%.”
    		“Nonverbal patient, severe CHF.”

    Closing

    NYHA is essential but insufficient. Alone it risks becoming a checkbox that hides truth. Paired with PPS, weight loss, and hospitalizations, it tells a story of decline families and auditors can trust.

    Like PPS and FAST, NYHA follows our Hospice Synopsis rule: every metric must live through story. The number points. The story proves.

    When decline is measured, NYHA gives us the language. Our job is to add the narrative that makes hospice clear today.

    3 Key Insights

    • NYHA remains one of the oldest and clearest functional tools in heart failure, still vital in hospice.
    • It is subjective. Anchor it with PPS, weight loss, and observed decline.
    • A number alone fails. Narrative makes eligibility defensible and care plans clear.

    2 Actionable Ideas

    • Standardize CHF notes: always pair NYHA with PPS and recent hospitalizations.
    • Teach every IDG member how their notes shape NYHA class.

    1 Compassionate Call to Action

    Use NYHA not as a checkbox but as a bridge. Turn breathlessness into language that families, teams, and auditors can trust.

    “Breathless at ten feet tells a truer story than EF alone. NYHA gives us the words; PPS and trajectory make them matter.”

    Bibliography

    • The Criteria Committee of the New York Heart Association. (1994). Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels (9th ed.). Little, Brown & Co.
    • Centers for Medicare & Medicaid Services. (2025). Local Coverage Determination (LCD): Hospice – Heart Disease. https://www.cms.gov/medicare-coverage-database
    • Levy, W. C., Mozaffarian, D., Linker, D. T., et al. (2006). The Seattle Heart Failure Model: Prediction of survival in heart failure. Circulation, 113(11), 1424–1433. https://doi.org/10.1161/CIRCULATIONAHA.105.584102
    • O’Connor, C. M., & Whellan, D. J. (2005). Evolving role of functional classification in heart failure: NYHA and beyond. American Heart Journal, 149(2), 209–214. https://doi.org/10.1016/j.ahj.2004.03.010

    Glossary Terms

    • NYHA (new): The New York Heart Association classification—a four-stage functional system (I–IV) originally designed for heart failure, still used in hospice to document decline and support eligibility.
    • Class IV Heart Failure (new): The most severe NYHA stage, defined by symptoms at rest. In hospice, often paired with PPS <50% and recurrent hospitalizations to support eligibility.

  • Decline by the Numbers: How BMI, MAC, and Weight Trends Defend Hospice Eligibility

    Decline by the Numbers: How BMI, MAC, and Weight Trends Defend Hospice Eligibility

    I. Introduction

    In prior blogs [Metrics That Matter] we traced hospice metrics from Graunt’s mortality tables to [PPS] and [FAST]. Now we turn to frontline numbers that can make or break eligibility: BMI, MAC, and weight trends.

    II. Decline by the Numbers

    She hadn’t eaten more than a few bites in days. The scale still read 116 pounds. Her daughter thought that meant stability. Then we measured her mid-arm circumference: 20.6 cm, down 2 cm in four weeks. Beneath the fluid, her body was fading. That number anchored the case and redirected the plan.

    Her daughter closed her eyes and whispered, “I knew something was wrong.” Without the MAC, the muscle loss might have stayed hidden.

    Auditors demand the story told in numbers. And families feel the same, because metrics anchor the truth. Without them, decline may seem invisible. Metrics are frontline tools. They prove eligibility, track decline, and sharpen decisions. In hospice, they separate a chart that tells the story from a chart that collapses under review.

    III. When Numbers Conflict

    BMI may look steady. Weight may rise. But if MAC falls, that is signal—not noise. Edema, diuresis, and fluid shifts distort the picture. Our job is not just to record numbers but reconcile them.

    One patient’s MAC was listed at 28 cm one month and 23.9 the next. He had not wasted that fast. The first was measured over the maximum R sided bicep; the second, correctly at the midpoint of the L arm as prior. His weight still read 130, but he was cachectic. If the error had stood, his eligibility might have been questioned.

    When numbers clash, name the cause. Document the context. Accuracy shields the patient’s true condition. Clarity equips the IDG to act on reality.

    “In hospice, MAC is the metric that may save the story from obscurity. The tape tells the truth. Measure well.” — Brian H. Black, D.O.

    IV. The Consequence of Missing It

    An IDG nurse was distraught when her patient was recommended for discharge. She had seen visible wasting, but the chart said “weight stable” and “no changes.” We reviewed the case, documented decline, and the patient stayed on service.

    Metrics protect patients, not payors. Without them, the story is left untold. Families lose trust, and auditors deny care. Both are preventable with accuracy, context, and consistent measurement.

    V. The Principle of Clarity

    Metrics are clarity at the bedside. 

    • For families, they explain what the eye cannot see.
    • For clinicians, they turn impressions into evidence.
    • For auditors, they defend eligibility without apology.

    Aides notice sleeves hanging looser. Social workers hear, “She doesn’t dine with us anymore.” Chaplains hear prayers grow shorter. Caregivers see meals pushed away. These are metric moments too. Train every team member to document comparison decline, because what is first seen must be measured.

    Metrics feel optional until denial comes. Leaders must treat it as mission work, because what feels optional today decides tomorrow.

    VI. Common Barriers at the Bedside

    • Families may resist weighing or measuring, fearing it adds burden. Explain that metrics protect eligibility and keep care in place.
    • Staff may avoid MAC because they haven’t practiced since school. Train and validate technique in IDG.
    • Equipment variation (bed scales, hoyer lifts, home bathroom scales) creates drift. Document source every time.

    VII. Toolbox: Audit Anchors and CTI Language

    Think of BMI, MAC, and weight as the three anchors of eligibility.

    MetricEligibility TriggerDocumentation TipRisk Flag
    BMI <22Common LCD thresholdTrack percent change and dateNone
    MAC <22 cmSignals undernutritionRecord side, method, and patient position>2 cm change between visits without reason
    Weight trend>5% in 30 days or >10% in 6 monthsDocument source (bed, hoyer, scale type)Discrepant with BMI or MAC

    Metric conflict    		___Explain divergence clearly in CTI>10% mismatch between MAC and BMI

    CTI Language Examples

    • Weight + BMI drop: “BMI declined from 21.8 to 18.6 over 90 days, with 12-lb loss and diminished intake. MAC dropped 2.1 cm. No diuretic use.”
    • Edematous patient: “MAC fell from 26.4 to 23.9 in 3 months. Weight stable. Edema persists with CHF. Trend reflects depletion.”
    • Multimodal loss: “Weight dropped from 142 to 128 lbs over 4 months. BMI 19.4. MAC 21.7 cm. These confirm terminal decline.”

    MAC in 3 Steps (Teach at IDG)

    1. Pick one arm—use the same side every time.
    2. Seat or lay patient flat, sleeve off.
    3. Wrap tape at midpoint between shoulder and elbow. Record to 0.1 cm.

    VII. Threshold Evidence

    Recent OIG audit reports confirm that missing weight or MAC documentation remains a top cause of hospice denials (OIG, 2021). Consistent measurement is not optional—it is compliance protection. Here are some numbers to know:

    • BMI <22: Appears in LCDs and audits for cancer, CHF, COPD (ESPEN, 2015; CMS LCDs; NHPCO, 2023).
    • MAC <22 cm: Marker of undernutrition, especially with dementia, edema, immobility (WHO, 2012; Kaiser et al., 2020; Powell-Tuck & Hennessy, BMJ, 2003).
    • Weight loss >5%/30 days or >10%/6 months: Clinically meaningful (Fearon et al., Lancet Oncology, 2011; NIA audit standards).
    • CHF + edema: MAC more reliable than BMI or weight when fluid overload distorts the picture (Anker & Coats, Lancet, 1999).
    • CMS/NHPCO compliance: LCDs cite BMI, weight, and nutrition as eligibility anchors. Especially for frailty and organ failure trajectories where fluids shifts may make loss. NHPCO (2024) emphasizes consistent documentation as key.

    VIII. Legacy

    Metrics are the language of decline, the defense of eligibility, and the bridge between what families feel and what clinicians prove.

    If every admission carried BMI, MAC, and weight trends, families would see decline before crisis, teams would align, and auditors would find charts that hold.Numbers do not just save the chart, they save trust. That clarity is care.

    Three Takeaways

    1. MAC, BMI, and weight trends are frontline metrics.
    2. Method matters. Drift creates denials.
    3. Document decline. Defend it with the charting.

    Two Quotes

    • “Metrics don’t protect payors, they protect patients.”
    • “You are not just charting numbers. You chart charting defensible decline.”

    One Question

    When the numbers don’t match, what story do you tell?

    Bibliography

    • Kaiser, M. J., et al. (2020). Validation of the Mini Nutritional Assessment Short-Form (MNA-SF) for use in older adults. Journal of Nutrition, Health & Aging, 24(6), 601–606.
    • National Hospice and Palliative Care Organization (NHPCO). (2023). Facts and Figures: Hospice Care in America. Alexandria, VA.
    • NHPCO. (2024). Standards of Practice for Hospice Programs. Alexandria, VA.
    • ESPEN. (2015). ESPEN guidelines on nutrition in older adults. Clinical Nutrition, 34(6), 1052–1079.
    • World Health Organization. (2012). Guidelines on Nutritional Assessment in Older Adults.

    Glossary

    • BMI (Body Mass Index): Height–weight calculation. In hospice, <22 signals decline; <18.5 often supports eligibility.
    • MAC (Mid-Arm Circumference): Measure of body mass and nutrition. Clinically significant below 22 cm. Requires consistent side, position, and method.
    • Weight Trend: Decline over time carries more weight than a single snapshot.
    • Measurement Drift: Inconsistent technique that corrupts MAC trends.
    • Audit Anchor: A stable, consistent metric (BMI, MAC) that defends eligibility.
    • MAC Method Standard: Side, patient position, tape type, and arm choice.
    • CTI (Certification of Terminal Illness): Physician document certifying life expectancy of six months or less, built on clear evidence of decline.

    Sparks

    • “BMI isn’t a diet metric in hospice. It’s a decline metric.”
    • “MAC without method is malpractice.”
    • “When the scale lies, the tape tells the truth.”
    • “You don’t chart weight. You chart decline.”
    • “If decline isn’t documented, eligibility crumbles. The metrics tell that story—or no one will.”
  • FAST Isn’t a Memory Test: It’s a Map of Decline

    FAST Isn’t a Memory Test: It’s a Map of Decline

    Picture of a map with text overlay, "Fast isn't a memory test: It's a map of decline."

    Introduction

    FAST is a staircase you only go down. Each step lost, never regained. It marks the body’s slow surrender to Alzheimer’s disease (Reisberg, 1988)

    Every team member knows FAST. But few master documenting it well enough to protect patients and recertifications. This guide explains dementia staging, documenting decline, and using FAST to identify hospice eligibility, while addressing its limitations for equitable care. Identify eligibility before it’s too late.

    The Forgotten Scale That Built the Frame

    The FAST Scale—Functional Assessment Staging Tool—was developed in 1984 by Dr. Barry Reisberg to stage Alzheimer’s disease progression for research, not hospice.

    Decades later, it’s a cornerstone of hospice eligibility, defining the threshold of irreversible functional decline, often at stage 7c. However, while FAST is critical, research highlights limitations in its prognostic accuracy and applicability, prompting ongoing debates in palliative care. Clinicians should use it as part of a broader assessment to ensure equitable and accurate decisions.

    What FAST Is—and Isn’t

    FAST stages Alzheimer’s disease—not all dementias. Apply it cautiously to related disorders (e.g., vascular, Lewy body, or frontotemporal dementias). In vascular dementia, decline may be stepwise with plateaus; in Parkinson’s, early motor and speech losses can mimic 7c or 7d without matching Alzheimer’s trajectory. Critics note that FAST’s assumption of sequential, irreversible decline can exclude up to 41% of patients whose progression is nonlinear—such as those with comorbidities like strokes—making staging challenging. For these cases, supplement FAST with tools like the Palliative Performance Scale (PPS) or Advanced Dementia Prognostic Tool (ADEPT) for better prognostication.

    For non-Alzheimer’s dementias, use FAST language (e.g., loss of ambulation, speech, self-care) to describe decline without forcing a score. FAST tracks function—mobility, toileting, speech—not memory or cognition. Even at 7f, a patient may flinch at a name or glance toward music. Their body may be silent, but they’re not gone. FAST’s focus on function is valuable, but its limitations in predicting short-term survival mean it should not stand alone.

    Think of FAST as a staircase you only descend. Each step is lost in order, from stage 1 (normal function) to 7f (bedbound, mute, incontinent). Regression is rare and must be documented. The clinical tipping point is FAST 7c—loss of independent ambulation—requiring all prior stages (6, 7a, 7b).

    Critics note that FAST’s assumption of sequential, irreversible decline can exclude up to 41% of patients whose progression is nonlinear…” Kiely et al. 2009

    FAST 7c: The Line in the Sand

    FAST is one of the foundational hospice metrics. 7c is more than a score. It’s the pivot point that can unlock hospice support, or delay it until crisis. CMS criteria begin at 7a—full dependence for dressing. But in practice, auditors and hospices often hold the line at 7c, loss of ambulation. That gap leaves families stranded in months of decline that qualify by regulation but not by culture.

    FAST 7c isn’t occasional standby help—it’s total loss of independent walking or transferring. No walker with assist. No shuffle to the commode. If a patient needs full hands-on help to move, they’re 7c. We’ve seen patients denied hospice because teams didn’t document this shift. FAST makes decline visible, preventing falls, wounds, or crises.

    FAST 7c Observation Examples:

    • No longer walks to meals, even with a walker
    • Needs hands-on assist for toilet transfers
    • Cannot bear weight during pivot
    • No longer propels wheelchair independently

    “We noticed it during morning care. She stopped pivoting and started sliding. Transfers became two-person. That’s when we named 7c.”

    Documenting FAST with the Story

    Without a dated narrative linking stage to function, it’s a guess—not evidence. 

    How to Write a FAST 7c Narrative (3 Things):

    • Use a specific date
    • Name a functional loss (e.g., ambulation, transfer)
    • Describe irreversibility or progression

    Example CTI Phrasing: “As of 3/12/25, patient meets FAST 7c—requires hands-on assist for all mobility and no longer transfers without 2-person support. Functional decline is permanent and progressive.”

    Social workers can note when families describe loss of shared meals. Chaplains may hear when prayer groups stop visiting because the patient no longer leaves bed. These details support the FAST narrative and protect eligibility.

    FAST 7c typically aligns with PPS 40–50 and near-total ADL dependency. Anchor FAST 7c to PPS and ADL trends so the IDG and auditors see the same picture you do.

     Score FAST based on sustained observations or caregiver reports—isolated moments don’t define eligibility.

    Teachable Moment Prompt: If a nurse says, “He’s walking less lately,” reply: “Let’s assess for FAST 7c today and document if he’s crossed that threshold.”

    Common Misunderstandings

    Families and clinicians often misinterpret FAST:

    • “She smiles at me. How can she be 7f?” Smiles don’t mean someone can stand. FAST measures sustained functional loss, not cognition or emotion.
    • “He says a few words. Isn’t that stage 6?” Speech at 7b is one word daily; occasional words don’t change staging.
    • “She’s in memory care. Doesn’t that mean FAST 7?” Facility placement doesn’t define FAST stage—function does.

    FAST is a map of functional decline, not memory or personality. Clear documentation prevents these errors from delaying care.

    Controversies and Limitations of FAST

    While FAST is a cornerstone in dementia staging, it’s not without debate. Research highlights limitations that clinicians should navigate for accurate, equitable care.

    1. Poor Prognostic Value for 6-Month Mortality: FAST 7c, a common hospice threshold, has low accuracy in predicting 6-month survival (c-statistic ~0.51, near chance), risking delays or denials. Only ~22% of nursing home residents with advanced dementia who die within 6 months meet 7c criteria.
    2. Assumption of Linear Progression: FAST assumes sequential decline, but up to 41% of patients cannot be staged due to nonlinear progression from comorbidities (e.g., strokes, infections).
    3. Limited Validation for Non-Alzheimer’s Dementias: Designed for Alzheimer’s, FAST lacks validation for types like vascular or Lewy body dementia, risking misapplication.
    4. Lack of Empirical Basis and Equity Issues: Dementia prognostic tools, including FAST, underperform across racial and ethnic groups [Harrison et al., 2019, CAPC, 2023] risking later referrals for those already underserved. This underscores the need for holistic documentation to promote equity.

    Practical Advice: Combine FAST with PPS (broader applicability) and/or ADEPT (better mortality prediction). Document comorbidities and discuss in IDG meetings to advocate for patients. This fosters trust and equity.

    ToolStrengthsLimitations in Dementia
    FASTTracks functional declinePoor prognosis accuracy, linear assumption
    PPSBroad applicabilityLess specific to dementia
    ADEPTBetter 6-month predictionMore complex to score

    What FAST Tells Us Before the Family Can

    Families track emotion, not erosion. Hospice must name when decline becomes permanent—the shift from moment to pattern. FAST provides structure to document this, turning subtle changes into evidence. When FAST is missing or misapplied—due to its limitations in nonlinear cases—it’s often the most vulnerable who suffer: those without documentation, advocacy, or English as a first language. Getting FAST right isn’t just compliance—it’s equity.

    Who Notices What:

    • CNA: Transfer changes, sliding, two-person assist
    • RNCM: ADL changes, narrative alignment
    • MSW: Family perceptions of change
    • Chaplain: Emotional withdrawal, social silence
    • MD/NP: Assigns FAST, confirms progression

    No metric stands alone. FAST confirms what trajectory, BMI, PPS, and narrative support. Documenting FAST well protects eligibility and trust across families and audits.

    Documenting FAST correctly isn’t just eligibility. It’s stewardship. It shows the family—and the system—that we saw the slope, not just the silence.

    3 Key Insights

    • FAST tracks function, not memory.
    • Hospice eligibility often begins at FAST 7c.
    • Every FAST score needs a date and narrative.

    Two Common Mistakes

    • Waiting for 7f to initiate hospice.
    • Documenting scores without describing loss.

    One Takeaway

    FAST marks the line before the silence—not just after.

    Glossary

    • FAST — Functional Assessment Staging Tool: A 7-stage framework for Alzheimer’s, reflecting permanent functional loss. Use scores only for Alzheimer’s; for other dementias, use FAST language. Limitations: assumes linear progression, poor prognostic accuracy.
    • FAST 7c: Loss of independent ambulation, often the first hospice eligibility marker. Requires prior stages (7a, 7b) and aligns with PPS 40–50 and full ADL dependence.
    • Permanent Functional Decline: A steady, ongoing loss of daily abilities (e.g., walking, eating) that cannot be improved with treatment. Validates hospice eligibility.
    • ADEPT — Advanced Dementia Prognostic Tool: A scale with better sensitivity for predicting 6-month mortality in advanced dementia.
    • Nonlinear Progression: Dementia decline that doesn’t follow sequential stages, often due to comorbidities, limiting tools like FAST.

    The clinical point at which physical dependency justifies hospice services based on regulatory standards.

    Bibliography

    • Reisberg, B. (1988). Functional Assessment Staging (FAST) in Alzheimer’s Disease. International Psychogeriatrics, 1(1), 11–28. https://doi.org/10.1017/S1041610288000027
    • Reisberg, B. (2007). FAST Scale for Alzheimer’s Disease. NYU Aging and Dementia Research Center. Internal PDF resource.
    • NHPCO. (2024). Dementia and Hospice Eligibility: Best Practices. https://www.nhpco.org
    • CMS LCD L33548. Local Coverage Determination: Hospice – Alzheimer’s and Related Disorders. https://www.cms.gov
    • Mitchell SL, Kiely DK, Hamel MB. (2004). “Dying with advanced dementia in the nursing home.” Arch Intern Med.
    • Mitchell SL, et al. (2010). “The Advanced Dementia Prognostic Tool (ADEPT).” J Pain Symptom Manage.
    • CAPC. (2023). Dementia Prognostication in Hospice.

    Educational Image Prompt

    Note: This visual is for training use only. It should not be used as a standalone eligibility guide.

    Create a stepped slope graphic showing FAST stages 6–7f.
    Label each stage with 2–4 word descriptors.
    Highlight 7c–7f as the “Hospice Eligibility Range.”
    Include icons: fading speech bubble, walker, transfer assist, bed, mute symbol.
    Use neutral, educational tones—no dramatization.

    Sparks

    • Audit five current dementia charts today: Do they have a FAST score? Is it dated? Does it match the narrative?
    • Add to new-hire orientation modules: not policy—it’s protection.
    • “FAST isn’t a memory test. It’s a functional map. Document what they can’t do—and when it changed.”
    • “You can be FAST 7f and still smile. That’s not contradiction—it’s hospice.”
    • Pair with Blog 10B Getting PPS Right in Hospice for dual-metric fluency.
    • Visual Tool: Create a FAST + LCD cheat card for IDG and F2F documentation.
    • Use the narrative script prompt in admissions and CTI/F2F training.

    To Do

    • Design downloadable FAST narrative scripting tool
    • Integrate into Module 2H educational unit
    • Produce explainer video with slope visual + narration

    Plan follow-up blog: When FAST and PPS Don’t Match: How to Document Both

  • Getting PPS Right in Hospice, From Score to Story

    Getting PPS Right in Hospice, From Score to Story

    Image of a woman comforting someone with an overlay of text, "Getting PPS Right in Hospice" by Hospice Synopsis.

    PPS Unchanged? The Score + Story Approach

    We hear ‘PPS unchanged’ in IDG and recert reviews. But is that the whole story?

    The Palliative Performance Scale (PPS), adapted from the Karnofsky scale in the 1990s and refined in 2020 (PPSv2), became a standard eligibility tool. Validated in cancer cohorts (Anderson et al., 1996) and confirmed across diagnoses (Lau et al., 1997; Ho et al., 2008), PPS was widely adopted by U.S. hospice programs by the 2000s.

    PPSv2 is concise and accessible. It is even used as the “Patient Performance Scale” in ICU and nonhospice settings. But it is easy to misinterpret.

    Between benefit periods, the score may stay the same—but the patient doesn’t. That’s why Score + Story pairs every metric (PPS, FAST, BMI, ECOG, NYHA) with time-anchored clinical context.

    PPS reflects the patient’s predominant functional baseline, not just a single moment in time. PPS correlates with survival: 10–20% predicts days to weeks; 40–50% may suggest weeks to months in cancer patients (Ho et al., 2008).

    Use these values to anticipate decline trajectories like the terminal illness or frailty paths outlined in our metrics origins blog. We are about putting the score in context. What’s true most of the time, not what the patient shows during a brief surge or decline.

    How to Score PPS in Practice

    1. Review all 5 domains (ambulation, activity, self-care, intake, consciousness).
    2. Choose the best-fit score using 10% increments only. Never average or use ranges.
    3. Anchor the score to time and context (e.g., “PPS 40 on 7/3/25 due to <25% intake and assist for transfers”).
    4. Pair with the story that explains what changed since last scoring.

    The Score + Story method starts with one truth: the PPS may hold steady, but the patient doesn’t. “She’s still a PPS 40, but now needs full assist to transfer. Her daughter says she can’t leave her alone.” Those lived changes matter as much as the number. 

    The PPS gives a score. The story gives us fuller truth. And that’s where hospice lives, in the gap between metrics and meaning. 

    The PPS is where aides, chaplains, and social workers expand the to create the narrative.

    Common Missteps in PPS Use

    • Score from a patient’s best or worst moment of the day
    • Write “no change” despite subtle functional decline
    • Fail to anchor scores with dates (e.g., “PPS 40 on 7/3/25 due to worsening transfers and <25% intake”)
    • Dismiss interdisciplinary input, such as CNA ADL reports or chaplain notes on alertness
    • Ignore team insights:
      • CNA: “Patient now needs full assist with feeding.”
      • Chaplain: “Patient less alert during prayer, nods off mid-visit.”
      • MSW: “Daughter reports exhaustion from daily transfers.”

    These aren’t side notes — they refine the score.

    • Average PPS scores across visits or team members
    • Record scores outside 10% increments (e.g., “PPS 45”) — PPSv2 requires strict 10% steps for reliability
    • Document score ranges instead of a single best-fit value (e.g., “PPS 40–50 today”)

    Document what you observe, not what you assume. 

    PPS LevelKey IndicatorsStory Example
    50%Mainly sit/lie, considerable assistance needed“Patient spends mornings in chair but requires two-person assist; intake 50% of normal. Trending down from last month’s 60%.”
    40%Mainly in bed, total care for most ADLs“Now bed-dominant with one-person assist for transfers; <25% intake over the week, down from 50% two weeks ago.”
    30%Totally bedbound, extensive care“Unable to assist in any movement; minimal intake, drowsy most days. Was able to assist to chair occasionally last period.”

    Example: Pt admitted at PPS 40, Cannot get out of bed one visit (PPS 30), but is not bedbound most of the time—per CNA reports of daily patterns and chaplain notes on alertness surges. Document PPS of 40 and explain which pattern defines the period and how the patient is changing (not being able to get out of bed some days).

    Audit Red Flags

    • Documenting ‘no change’ despite fluctuation.
    • Insufficient physician narratives on prognosis for long-stay patients (e.g., >90 days), as  audits increasingly demand detailed trend explanations beyond scores to justify continued eligibility. The OIG’s 2024 report highlighted PPS as a frequent weak point: ‘In many cases, documentation did not adequately justify continued hospice eligibility despite prolonged lengths of stay’ (OIG, 2024)
    • PPS unsupported by ADL, intake, or cognition.
    • Lack of integration with other metrics like ADLs or MAC from IDG inputs, leading to isolated PPS entries that fail to show overall decline slopes as emphasized in our metrics evolution discussion
    • Score and narrative conflict (e.g., “bedbound” but PPS listed as 50)

    Clarify when you see these. PPS use is not mandated, but most hospice agencies and Medicare Administrative Contractors (MACs) use it as a key component of recertification documentation. With recent heightened OIG focus on hospice integrity, MACs are emphasizing PPS trends in CTI and addendum reviews. Use the Score + Story to reconcile the record, reflect reality, and show comparison declines outside the metric score alone. This method extends to all metrics like FAST or NYHA from our Measure What Matters blog, ensuring cohesive documentation across trajectories.

    Scoring PPS is not paperwork. It is stewardship of the hospice benefit, patient trust, and the story behind the numbers. Done well, PPS honors decline with clarity and equips teams to defend eligibility with integrity.

    Three Things to Remember


    – PPS is scored in 10% increments using best-fit domains and leftward precedence.
    – A stable PPS score doesn’t mean there are no changes. Document the full pattern.
    – Dates, details, and narrative show decline better than numbers alone.

    Two Common Mistakes


    – Averaging the score across days or different disciplines
    – Leaving the score without the story

    One Takeaway


    If the score is the same, the story must explain the existing changes.

    Bibliography

    Anderson, F., Downing, G. M., Hill, J., Casorso, L., & Lerch, N. (1996). Palliative Performance Scale (PPS): A new tool. Journal of Palliative Care, 12(1), 5–11.

    Victoria Hospice. (2020). Palliative Performance Scale (PPSv2). Retrieved from https://victoriahospice.org/wp-content/uploads/2022/05/PPSv2.pdf

    Harrold, J., & Harris, P. (2015). Fast Fact #263: Palliative Performance Scale. Palliative Care Network of Wisconsin. Retrieved from https://www.mypcnow.org/fast-fact/palliative-performance-scale/

    Office of Inspector General (OIG), U.S. Department of Health and Human Services. (2024). Vulnerabilities in Hospice Care: Recent Findings and Recommendations. Retrieved from https://oig.hhs.gov/reports-and-publications/featured-topics/hospice/

    Ho, F., Lau, F., Downing, M. G., & Lesperance, M. (2008). A reliability and validity study of the Palliative Performance Scale. BMC Palliative Care, 7, 10. https://doi.org/10.1186/1472-684X-7-10

    Lau, F., Downing, G. M., Lesperance, M., Shaw, J., Kuziemsky, C. (1997). Use of the Palliative Performance Scale in end-of-life prognostication. Journal of Palliative Care, 13(4), 17–23.

    OIG 2024 direct quote.

    Sparks

    • “PPS unchanged” is never the full story.
    • Chart the decline you observe—even if the number doesn’t drop.
    • The IDG doesn’t need more data. It needs clearer truth.

    Glossary Terms:

    Score + Story
    A hospice documentation method that pairs any clinical metric—such as PPS, FAST, BMI, ECOG, or NYHA—with a real, time-anchored clinical narrative. This approach ensures that stable scores are not misinterpreted as stable patients. Used to align IDG decisions, clarify decline, and prepare defensible recertification records. Originated in PPS scoring and has expanded to support broader documentation integrity across hospice metrics.

    Benefit Period
    A Medicare-defined interval used to review and determine ongoing hospice eligibility. The first two benefit periods are 90 days each, followed by unlimited 60-day periods. Documentation, including tools like PPS, must reflect the patient’s status and decline during each period.

    Predominant Functional Baseline
    The functional status that best represents how the patient performs most of the time during a benefit period. PPS should reflect this baseline, not an isolated high-functioning day or temporary fluctuation. It is the basis for defensible hospice certification.

    Recertification
    The process of reviewing and confirming a hospice patient’s eligibility for continued care at each benefit period boundary. Requires documentation of ongoing decline or persistent eligibility based on clinical tools (like PPS) and narrative evidence. Must meet regulatory and ethical standards.

    To Do

    • Add cross-links to “The Shape of Dying,” “Hospice Meds + Labs,” and “Expectation Mapping”
    • Create optional one-page “PPS Documentation Quick Guide” for IDG packets
    • Consider follow-up blog:  “Mythbusters: Does Standing Once Reset the ADL score?” What about a pt who uses a Hoyer lift to get out of bed? What is the PPS?