Hospice episode · 60_day_unlimited
election 2025-11-10
Currently at: Routine Home Care (RHC)
RHC days
171
$218/day
CHC days
0
$1,626/day
IRC days
5
$525/day
GIP days
4
$1,145/day
Episode revenue
$44,483
case-mix-adjusted
Audit risk
low
live-discharge classifier
Dx category
respiratory
Hospice Item Set (HIS)
Pain (F2014)
Dyspnea (F2030) · Opioid (F1010)
Spiritual / clinical context
Diagnoses
J44.9
Chronic obstructive pulmonary disease, unspecified
F32.1
Major depressive disorder, single episode, moderate
J96.10
Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
I50.32
Chronic diastolic (congestive) heart failure
I10
Essential (primary) hypertension
E11.9
Type 2 diabetes mellitus without complications
Visit notes
Urgent psychosocial and bereavement support visit. Mr. Garza's son arrived from out of state yesterday. Family gathered at bedside. Patient unresponsive to verbal stimuli; death appears imminent per RN assessment. Facilitated family meeting in the living room — son expressed guilt about not being present throughout illness. Normalized his feelings and provided emotional support. Discussed what to expect in the final hours of COPD-related respiratory decline, including Cheyne-Stokes breathing and extended pauses. Funeral home contact confirmed; family has arrangements in place. Chaplain visit coordinated for this afternoon per family request. Family reports feeling supported by the hospice team. Social worker available by phone around the clock. Documentation of anticipatory grief counseling completed. Follow-up bereavement services offered to family post-death per hospice program protocol.
Follow-up skilled nursing visit. Mr. Garza appears more somnolent than prior visit, arousable to voice. Respiratory rate 20, more shallow in character. Oral intake markedly decreased over past 48 hours per Maria — patient accepting only sips of water. Skin integrity intact; repositioning schedule reinforced with caregiver. Oral care performed and demonstrated to family. Mottling noted to bilateral knees. Patient no longer reporting dyspnea verbally; monitored for nonverbal signs of air hunger — none noted at this time. Comfort medications being administered as scheduled by family appropriately. Discussed with Maria that these changes are consistent with the natural progression of end-stage COPD and that death may be approaching within days. MSW and chaplain referral re-offered; Maria accepted both. Bereavement resources provided. Family encouraged to be present and speak to patient. Will visit again in 24 hours.
Acute dyspnea crisis reported by caregiver Maria at approximately 1600. On-call RN arrived within 30 minutes. Mr. Garza was found sitting upright in bed, diaphoretic, RR 32, O2 sat 78%, in severe respiratory distress secondary to advanced COPD exacerbation. Morphine 4mg SL administered per standing PRN order with repeat dose at 20 minutes; lorazepam 0.5mg SL given concurrently. Dyspnea improved to moderate level within 40 minutes; RR decreased to 24, patient reported air hunger as 5/10 from 9/10. Patient and family declined emergency transport, consistent with documented DNR/DNI and goals of care. MD notified; medication regimen reviewed and standing morphine frequency increased as ordered. Maria provided reassurance and hands-on teaching for future acute episodes. Hospice aide visit arranged for AM. Situation stabilized; will reassess tomorrow morning.
Face-to-face encounter with patient Ruben Garza per hospice certification requirements. Patient has end-stage chronic obstructive pulmonary disease, unspecified (J44.9). On exam: cachectic male in moderate respiratory distress at rest, RR 26, accessory muscle use noted, O2 sat 81% on 4L NC. Bilateral diminished breath sounds with prolonged expiration. No reversible acute process identified; patient declines hospitalization consistent with goals of care. Morphine sulfate dose adjusted to 4mg SL q4h PRN and scheduled q6h for baseline dyspnea management. Lorazepam 0.5mg SL q6h PRN anxiety added. Prognosis consistent with six-month terminal trajectory given current functional decline and hypoxemia refractory to supplemental oxygen. Patient and family counseled. Goals of care reaffirmed — comfort, home death preferred. Recertification documentation completed.
Psychosocial visit with Mr. Garza and his daughter Maria. Patient is adjusting to hospice election and reports mixed emotions — relief at having a plan, but grief over declining functional status related to end-stage COPD. Maria is primary caregiver and expressed caregiver fatigue and tearfulness. Explored family support system; son lives out of state and has been contacted. Discussed advanced directive status — POLST on file, DNR/DNI confirmed and in chart. Chaplain referral offered; patient declined at this time but stated he may reconsider. Community resources discussed including respite care options for Maria. Patient's goals remain comfort-focused at home. Will follow up next week and reassess need for chaplain or bereavement support.
Initial skilled nursing visit following hospice election on 11/10. Patient is Ruben Garza, 74-year-old male with primary diagnosis of chronic obstructive pulmonary disease (COPD), unspecified. Presented with dyspnea at rest, RR 24, O2 sat 84% on 3L nasal cannula. Lung sounds with diffuse expiratory wheezing bilaterally. Patient reports increased air hunger and anxiety with minimal exertion. Comfort medications reviewed; morphine sulfate 2mg SL q4h PRN dyspnea ordered by MD and discussed with patient and daughter Maria. HOB elevated to 60 degrees. Fan placed at bedside per patient preference. Patient verbalizes understanding of hospice goals. Family educated on symptom management and when to call the on-call nurse. Will return in 48 hours.