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
- Review all 5 domains (ambulation, activity, self-care, intake, consciousness).
- Choose the best-fit score using 10% increments only. Never average or use ranges.
- Anchor the score to time and context (e.g., “PPS 40 on 7/3/25 due to <25% intake and assist for transfers”).
- 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 Level | Key Indicators | Story 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?
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