Heart Failure

• Hospitalization for moderate to severe symptomatic heart failure (HF), NYHA (New York Heart Association) Class III or IV with three or more of the following:
  • Age > 70
  • Left Ventricular Ejection Fraction (LVEF) 20% or less
  • Beta-type Natriuretic Peptide (BNP) > 950
  • Cardiac troponin I > 0.4
  • C-reactive protein > 3.5
  • 4th hospitalization for CHF or repeat hospitalization within 2 months
  • Dependency of 3 or more ADL (activities of daily living) or need for home care
  • Weight loss of 2.3 kg or greater in 2 months or albumin< 2.5
  • History of:
    • Cardiogenic shock
    • Ventricular or supraventricular arrhythmia
    • Cardiac arrest
    • Cardiopulmonary resuscitation or
    • Mechanical ventilation
  • Systolic blood pressure < 110
  • Creatinine > 2 or BUN > 40
  • Sodium < 135
  • Cardiovascular disease:
    • Ischemic cerebrovascular disease or
    • Peripheral vascular disease
  • Other comorbid illness:
    • Diabetes
    • Mellitus
    • Dementia
    • COPD
    • Cirrhosis
    • Cancer

Dementia

• Advanced dementia with dependency in all activities of daily living, bedbound status, urinary and bowel incontinence, decreased ability to communicate verbally, AND admission to a hospital or skilled nursing facility with one or more of the following:
  • BMI < 18.5, decreased oral intake, or significant weight loss
  • Presence of at least one pressure ulcer
  • Evidence of at least one comorbid illness
  • Male sex and age > 90
  • Placement of a feeding tube due to inability to eat or history of aspiration

Geriatric Failure-to-Thrive

• Age > 75, albumin < 3.5, dependency in 2 or more activities of daily living, AND admission to a hospital or skilled nursing facility with one or more of the following:
  • Dependency in all activities of daily living with malnutrition (weight loss >10% or albumin < 3)
  • Evidence of heart failure
  • Creatinine > 3
  • Evidence of delirium during hospitalization

End-Stage Renal Disease (ESRD)

• ESRD on dialysis with age > 70 and 2 or more of the following:
  • KPS < 50
  • Significant comorbid condition such as
    • Coronary artery disease
    • Peripheral vascular disease
    • Heart failure
    • Cancer
  • Malnutrition
    • BMI < 19.5 or albumin < 2.2
  • Residence in a skilled nursing facility
  • Admission to an intensive care unit for an acute illness
  • Hip fracture with inability to ambulate
• ESRD without dialysis with age > 70 and 1 or more of the following:
  • Dialysis withheld due to decreased performance status and significant comorbidity
  • Dialysis withdrawn due to advanced age, functional dependence, and comorbidity

Cirrhosis

• Decompensated hepatic cirrhosis and 1 or more of the following:
  • Child-Pugh 12 or greater
  • MELD 21 or greater
• Decompensated hepatic cirrhosis with hospitalization for an acute illness related to liver disease and 1 or more of the following:
  • Child-Pugh 10 or greater
  • MELD 18 or greater
  • Child-Pugh 9 or greater AND dependency in 3 or more ADL AND malnutrition (significant weight loss and albumin < 2.5
  • Hospitalization in an intensive care unit related to severe decompensation of liver disease, with hypotension requiring the use of vasopressors, creatinine > 1.5, OR evidence of jaundice
  • Evidence of hepatopulmonary syndrome or rapidly progressive hepatorenal syndrome

Chronic Obstructive Pulmonary Disease (COPD)

• Hospitalization for a severe COPD exacerbation with hypoxemia (paO2 < 55), hypercapnia (pCO2 > 50), dependence on supplemental O2, and 3 or more of the following:
  • Age > 70
  • Evidence of cor pulmonale
  • Repeat hospitalization within 2 months
  • History of intubation/mechanical ventilation
  • KPS < 60
  • Need for home care after discharge
  • Malnutrition (weight loss > 2.3 kg, albumin < 2.5, or BMI < 18)
  • Creatinine > 2