Clinical Indicators for Providers
Minnesota Hospice wants to help make the transition to hospice care easy and stress-free for patients, families, and medical professionals. We understand determining hospice eligibility can be challenging. Our goal is to provide you with the clinical information you need regarding eligibility, along with a simple referral process, and forms at your fingertips, to ensure the best possible outcomes for your patients with advanced life-limiting illnesses and their loved ones.
Referral is Fast and Easy
Referral for Physicians and Nurse Practitioners
- Print out Physician Evaluation and Treatment Order under Forms.
- Fill-out Physician Evaluation and Treatment Order.
- Fax order to Minnesota Hospice at 952-898-4006.
If an emergency admission is required, please fax Physician Evaluation and Treatment Order and call our 24/7 main line at 952-898-1022.
Referral for Facilities
- Print out Fax Referral Form.
- Fill-out Fax Referral Form.
- Fax form to Minnesota Hospice at 952-898-4006.
- Call Minnesota Hospice 24/7 main line at 952-898-1022.
If an emergency admission is required, please fax the Fax Referral Form and call our 24/7 main line.
General Clinical Guidelines
Hospice-appropriate individuals may exhibit some or all the general indicators for disease progression. If 3 or more of these indicators are present, it may be time to refer to hospice.
- Recurrent or intractable serious infections (i.e. pneumonia, sepsis or pyelonephritis)
- Significant weight loss of at least 10% body weight in the past 6 months (Learn about Body Mass Index here)
- Weight loss cannot be due to reversible causes such as depression or diuretic use
- A documented decrease in anthropomorphic measurements (mid-arm circumference or abdominal girth)
- Observation of ill-fitting clothes, decreased skin turgor, increasing skin folds or other observation of weight loss without documented weight
- Decreasing serum albumin or cholesterol
- Dysphagia with recurring aspiration and/or inadequate oral intake documented by a decrease in food consumption
- Dyspnea with an increase in respiratory rate
- Intractable cough
- Nausea or vomiting poorly responsive to treatment
- Intractable diarrhea
- Pain requiring more than brief increases in major analgesics
- Decline in systolic blood pressure to below 90 or progressive postural hypotension
- Venous, arterial or lymphatic obstruction due to local progression or metastatic disease
- Pleural / pericardial effusion
- Changes in levels of consciousness
- Increasing pCO2 or decreasing pO2 or SaO2
- Increasing calcium, creatinine or liver function studies
- Increasing tumor markers (i.e., PSA or CEA)
- Progressively decreasing or increasing serum sodium or increasing serum potassium
- Frequent hospitalizations, ER visits, or physician visits related to primary hospice diagnosis within the past 6 months
- A decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) due to disease progression
- Progressive decline in Functional Assessment Staging (FAST) for dementia of at least 7A
- Dependence on assistance for two or more activities of daily living (ambulation, continence, transfer, dressing, feeding, and/or bathing)
- Progressive stage 3-4 pressure ulcers despite optimal care
- Co-morbidities—although not the primary hospice diagnosis, but the severity of which is likely to contribute to a life expectancy of 6 months or less
- Chronic obstructive pulmonary disease (COPD)
- Congestive heart failure
- Ischemic heart disease
- Diabetes mellitus
- Neurological disease (Parkinson’s, CVA, ALS, MS)
- Renal failure
- Liver disease
- Acquired immune deficiency syndrome
- Acquired Immune Deficiency Syndrome/ HIV
- Refractory severe autoimmune disease (i.e. Lupus or Rheumatoid Arthritis)
Renal Disease Indicators (Chronic)
All people deserve love, compassion, and dignity at end-of-life. At Minnesota Hospice, we strive to empower people to live life as fully as possible on their terms. Our team is filled with experienced professionals dedicated to walking with you during this part of life’s sacred journey. We provide the highest level of hospice care possible to help people find meaning, purpose, love, and beauty in living before departing life peacefully.