FAST scale in patients with dementia as hospice diagnosis

[elsbets]

I've been working on a QI project assessing documentation of decline in dementia patients and I wanted to reach out to people at other organizations about their use of the FAST staging tool in patients with dementia their hospice diagnosis. At my institution, the FAST is currently recorded by the RN and the provider for every certification period. My work auditing charts here has shown that the documented FAST is often not supported by clinical notes and that providers and nurses often score the same patient differently. I wanted to ask you if your organization uses the FAST, and if so, is it used for all dementia patients or only those with Alzheimer's? How often is it tabulated? Have you noticed discrepancy between provider and nurse scoring? Are there other measures of decline in dementia patients that you find yourself referring to or weighing more heavily than the FAST for recertification purposes?

Thank you for your feedback!!!

[coffeetalker]

FAST was specifically designed for Alz. dementia. If RNs and MDs are not scoring the pt the same, perhaps more education is needed for them. Generally it is used at the end of every certification period. At my organization I rarely see differences in MD/RN scoring. Other measures of decline that I like to use are- weight loss/falls/ UTIs/ Respiratory infections-but these generally occur more with 'expected' decline in Alz. pts- and are really just supportive info for recert.

[elsbets]

Thank you for your for your feedback! Do you often see FAST scores that are contradicted by clinical notes (i.e., a clinical note stating something like "spoke at length with patient in regards to their time in the Navy and their world travels" in a patient who is described elsewhere as having a FAST of 7B)? This is something I have been coming across. I've also noticed it tends to be used for all dementia types due to lack of a better tool. Is there something else you or your institution uses for non-Alzheimer's dementia?

Thanks again!

Elsbet

[nutella, MSN, RN]

I have done hospice eligibility evaluations in the past, which includes dementia as the main dx.

Personally, I always went through specific steps :

1. complete chart review if patient in facility for longterm care - the majority of requests for hospice care for pat with dementia comes from assisted living and longterm care. In the chart review I look specifically for information about weight to determine objective weight loss, and other information regarding infections (UTI,PNA, etc), pressure ulcers, other relevant medical problems.

2. face-to-face assessment - always! and document including the relevant items for the FAST scale. Obviously, if the patient is still speaking in full sentences and able to walk or speaking in full sentences they are not at a FAST of 7 c

http://geriatrics.uthscsa.edu/tools/FAST.pdf

http://geriatrics.uthscsa.edu/tools/Hospice_elegibility_card__Ross_and_Sanchez_Reilly_2008.pdf

3. discuss with staff if in facility and family to get more information

4. discuss with medical director hospice

When I started doing evals I got initial push back from facilities especially assisted living. Medicare has become strict, which is good, and AL was still used to hospice agencies catering to AL disregarding that patients are not declining or no objective weight loss is present.

And - it also happened that staff would say "the patient qualifies for hospice" because they really want a hoyer lifter, broda chair and a HHA (I get it - it is AL...) and told me that the patient does not talk, walk, and so on but my assessment did not match their assessment. For example patient unable to walk but otherwise talking in full sentences, still continent and able to feed himself.

At times staff would be confrontational and say "our usual hospice agency says the patient qualifies" .

In the time I worked for that specific hospice agency, I have not seen documentation that contradict a FAST scale per se. But what sometimes happens is that a patient at time of evaluation has an additional problem like UTI or pneumonia and is in worse shape - hence may not speak at all, incontinent, bedbound. But 2 weeks later, po antibiotics and the attention from hospice with getting pat out of bed into broda chair and so on make her "better" and now the assessment is different. Patient gains weight perhaps - and has to get discharged from hospice in another 2 weeks. That scenario can be prevented by not admitting in this situation and re-eval in 2 weeks after antibiotics are done.

The FAST is used for alzheimer - for other dementia it is usually a multifactorial assessment that includes determining if there is another illness that determines hospice eligibility - example vascular dementia with documented weight loss of 5 % and functional decline is decreased but now the patient is also dx with lung cancer stage 4 and will not undergo treatments.

My experience is that providers who are palliative and hospice certified MDs will typically score the same way experienced hospice nurses do because the score is based on an objective assessment.

Another important thing is this :

Hospice means that the patient is going to die, estimated by the physician 6 months or less, which is not an absolute rule but a very good indicator. So it is also good to overall keep the "surprise question" in mind. At times, when it was not really clear if a patient with dementia meets criteria the MD would say "looking at this patient, do you think she will die within the next 3 months?". The goal of hospice is to provide 100% comfort at the EOL - so EOL = dying is an essential part and being on hospice for extended periods - for example 1 year - is questionable in my opinion.

Having said all of this, it also points to the bigger problems we are facing in our society, which comes from our aging population and the fact that people can live longer while sicker - which often leads to a significant decline in functional ability but not necessarily dying. And custodial care is expensive, not covered my Medicare. Nowadays, families are not always able or willing to provide care at EOL at home but also patients do not want to spend their money on care.

[makeitwork, BSN, RN]

I hope the nurse that charted is not the same one that documented the FAST of 7b. If so, and you see this often, it sounds like a training issue for this nurse and/or the nursing staff.