VNA Hospice Care

Patient-Centered Care

The Visiting Nurse Association (VNA) is the oldest, most experienced and trusted hospice care provider in North Texas. As a nonprofit organization, our team is patient-centered and focused on ensuring patient goals are developed and coordinated with great care.

Since 1978, our experienced care team is one of the most sought after in the region. VNA participated in the Medicare pilot establishing the hospice benefit still available today.

How We Support Patients

  • Experienced care delivered wherever the patient calls home
  • Pain and symptom management
  • Care plan coordination
  • Medication management
  • Emotional, psychological and spiritual support for the patient and their family
  • Medical equipment and supply management
  • Medical social work services
  • Specialized care for Alzheimer’s and dementia, cancer, congestive heart failure (CHF), and pulmonary disease
  • Music and pet therapy
  • Volunteer support
  • Meals on Wheels (Dallas County)
  • Bereavement support

Four Levels of Care

All hospices are required to provide the same four levels of care in the United States. Which level of care a patient receives varies with each individual case, and it’s not uncommon for a patient to move from one level of care to another and back again as his or her needs change.

Patients at this level usually reside at home (a private residence or a facility) and their symptoms are well controlled; this accounts for 97% of all hospice care provided.

When symptoms have worsened to the point they can no longer be managed at home, patients may require inpatient care. The patient may be temporarily placed in a skilled nursing facility or an acute care hospital to stabilize and better control their symptoms. Once a patient stabilizes, he/she will return to the routine level of care.

Respite care occurs when a patient is moved from the home setting to a skilled nursing facility to provide up to five days of care to allow for caregiver relief.

If the patient’s symptoms worsen to the point they can no longer be controlled by the caregiver, and the patient chooses to stay at home, hospice nurses will provide continuous 24/7 nursing care until the symptoms are controlled.

Medical Guidelines

Critical Factors
Supporting Factors
  • Life-limiting conditions; prognosis < 6 months if the disease follows its normal progression
  • Progressive difficulty in many ADLs (a critical factor in determining prognosis)
  • Progression of disease(s) – Need for frequent medical care, hospitalization
  • Patients of any age with a BMI < 20 kg/m2 who are ill enough to be hospitalized, regardless of diagnosis, have significant morbidity within 6 months
  • Weight loss > 10% over past 6 months (one of the most critical indicators in the elderly)
  • Serum albumin < 2.5 g/dl
  • Cholesterol < 156 mg/dl
  • HCT < 41%
  • Two or more comorbid conditions
  • Family desires palliative care only
  • No longer pursuing aggressive medical treatment
  • CD4 < 25/mcl or viral load > 100,000/ml plus 1 of the following:
    1. Weight loss of at least 33% of lean body mass (wasting syndrome)
    2. CNS or systemic lymphoma, unresponsive to treatment
    3. PML (progressive multifocal leukoencephalopathy)
    4. Cryptosporidiosis
    5. MAC (mycobacterium avium complex)
    6. Visceral Kaposi’s Sarcoma, unresponsive to treatment
    7. Renal failure without anticipated dialysis
  • Karnofsky Performance Scale 5
  • Chronic diarrhea > 1 year
  • Persistent serum albumin < 2.5 g/dl
  • Advanced AIDS dementia complex
  • CHF, symptomatic at rest
  • Current substance abuse
  • Age > 50
  • Absence of antiretroviral, chemotherapeutic, or prophylactic drug therapy specifically for HIV disease
  • Progression differs markedly from patient to patient
  • The two factors most critical to survival (and prognosis) are ability to breathe, and to a lesser extent, the ability to swallow
  • At least one of the following:
    1. Critically impaired breathing capacity- VC < 30% of predicted
      – Dyspnea at rest
      – Requires supplemental oxygen at rest
      – Declines ventilator
    2. Rapid progression of ALS- Wheelchair or bed-bound
      – Barely intelligible speech
      – Requires pureed or liquid diet
      – Requires assistance with all ADLs
    3. Critical nutritional impairment- Oral intake of nutrients and fluids insufficient to sustain life
      – Dehydration or hypovolemia
      – Progressive weight loss
      – Declines feeding tube
    4. Both rapid progression of ALS and life-threatening complications- Life-threatening complications
      a. Recurrent aspiration pneumonia
      b. UTIs/pyelonephritis
      c. Sepsis
      d. Recurrent fever after antibiotic therapy
  • Exam by neurologist within 3 months of hospice evaluation
  • Certain cancer diagnoses with poor prognosis may be hospice eligible without fulfilling other criteria
    1. Small Cell Lung Cancer
    2. Brain Cancer
    3. Pancreatic Cancer

Other Criteria:

  • Patient meets ALL of the following:
    1. Clinical findings of malignany with widespread, aggressive or progressive disease as evidenced by increasing symptoms, worsening lab values and/or evidence of metastatic disease
    2. Palliative Performance Scale (PPS) < 70%
    3. Refuses further life-prolonging therapy or continues to decline in spite of definitive therapy
    4. Karnofsky < 70%

Documentation includes:

  • Hypercalcemia > 12 mg/dL
  • Cachexia or weight loss of 5% in the past 3 months
  • Recurrent disease after surgery, radiation or chemotherapy
  • Tissue diagnosis or reason why tissue diagnosis is not available
  • Signs of advanced disease (e.g., nausea, requirement for transfusions, malignant ascites or pleural effusion, increased pain, etc.)

Acute Phase

  • Had at least one of the following:
    1. Myoclonus and/or persistent vegetative state persists 3 days post anoxic event– Abnormal brain stem response
      – Absent speech or meaningful verbal response
      – 6 intelligible words in 24 hours
      – Absent pain response
      – Serum creatinine > 1.5 mg/dl
      – Bed-bound, unable to care for self

Chronic Phase
Both of the following or documentation of severe comorbidities and rapid decline:

  • FAST Scale ≥ Stage 7 or Karnofsky ≤ 40
    1. Dependence in most ADLs, paralysis, incontinence, aphasia
  • Inability to maintain hydration and nutrition
    1. Decreased nutritional status despite tube feeding, if present
    2. Weight loss > 7.5% in past 3 months
    3. Serum albumin < 2.5 g/dl
    4. Current history of pulmonary aspiration without effective response to speech therapy
  • Increased medical complications
  • Diagnostic imaging supports poor prognosis
  • Functional Assessment Staging Scale 7 (does not affect the impact of comorbid conditions)
  • Unable to walk, bathe, dress without assistance
  • Dual incontinence
  • Speaks 6 spontaneous words/day
  • Had at least one of the following in the past 12 months:
    1. Medical complications (aspiration pneumonia or other URI, UTI, sepsis, Multiple Stage 3-4 decubiti)
    2. Dysphagia
    3. Poor nutritional status (despite tube feedings, if present)
    4. Fever, recurrent after antibiotics
  • Weight loss > 10% during previous 6 months
  • NYHA Class IV:
    1. Symptomatic at rest despite maximum therapy and not pursuing therapy
    2. Angina at rest
    3. Ejection fraction < 20%
  • Recurrent CHF and/or angina
  • Increased discomfort with minimal activity
  • Arrhythmias resistant to treatment
  • History of cardiac arrest
  • Cardiogenic embolic CVA
  • Concomitant HIV disease
  • Hx unexplained syncope
  • Oxygen dependent
  • PTT > 5 sec above control or PT/INR > 1.5 sec
  • Serum albumin < 2.5 g/dl
  • One or more of the following:
    1. Ascites despite optimum diuretics
    2. Peritonitis
    3. Hepatorenal syndrome
    4. Encephalopathy with asterixis, somnolence, coma
    5. Recurrent variceal bleeding
  • Liver transplant either not anticipated or would discharge from hospice if it is scheduled
  • Progressive malnutrition, muscle wasting, reduced strength and endurance
  • Active ETOH abuse
  • Hepatocellular carcinoma
  • + for Hepatitis B
  • Hepatitis C refractory to treatment
  • Disabling dyspnea at rest, unresponsive to bronchodilators
  • Recurrent pulmonary infections and/or respiratory failure
  • Frequent ER visits, hospitalizations
  • pO2 < 55 mg Hg or O2 sat < 88% on O2 or pCO2 50 mm Hg
  • FEV 1 < 30% after bronchodilators
  • Cor Pulmonale/right heart failure not secondary to left heart failure
  • Weight loss > 10% in 6 months
  • Resting tachycardia > 100/min
  • Age > 70
  • Progression differs markedly from patient to patient
  • Severely impaired breathing capacity such as:
    1. Dsypnea at rest
    2. Requires supplemental oxygen at rest
    3. The patient declines artificial ventilation
  • Rapid disease progression and (one of the below):
    1. Progression from independent ambulation to w/ chair or bed-bound
    2. Severe muscle weakness affecting speech, chewing or swallowing
    3. Progression from independence in most or all ADLs to needing major assistance
  • Severe nutritional impairment evidenced by:
    1. Weight loss > 10%
    2. Dehydration or hypovolemia
    3. No desire to implement artificial feedings
    4. Poor nutritional status (despite tube feedings, if present)
  • Life-threatening complications demonstrated by one or more of the following:
    1. Recurrent aspiration pneumonia
    2. Upper UTI
    3. Sepsis
    4. Recurrent fever after antibiotic therapy
  • Exam by neurologist within 3-6 months of hospice evaluationIn the absence of one or more of the above findings, rapid decline or comorbidities may also support eligibility for hospice care.
  • Creatinine clearance < 10 cc/min (< 15 cc/min if diabetic)
  • Creatinine > 8 mg/dl ( > 6 mg/dl if diabetic)
  • Not seeking dialysis or renal transplant
  • Signs of uremia (confusion, nausea, pruritus, restlessness, pericarditis)
  • Oliguria < 400 cc / 24 hrs
  • Uremic pancreatitis
  • Hepatorenal syndrome
  • Hyperkalemia > 7 mEq/L
  • Intractable fluid overload, not responsive to treatment
  • Weight loss
  • Decline in ADLs
Clinical Excellence

Clinical Excellence

The experienced team at VNA Hospice Care is focused on ensuring our patients receive the highest quality care at every stage of their journey.

Learn more about our clinical quality measures.

Certifications & Licensing

VNA has been Community Health Accreditation Partner (CHAP) accredited since 2010. All hospice organizations are required to meet state and federal regulations in order to operate. However, obtaining CHAP accreditation requires meeting higher standards of care and going above and beyond Centers for Medicare and Medicaid Services (CMS) guidelines. VNA was recently audited by CHAP (standard for all CHAP-accredited agencies) and was found to have no deficiencies.

The National Institute for Jewish Hospice (NIJH) provides accreditation to hospices that testifies to a hospice’s ability to serve Jewish clients in a culturally sensitive way. Accreditation includes training on Jewish culture and religion and is reviewed annually.

The Care Team

Our interdisciplinary care teams are composed of trained professionals and volunteers whose main goal is to ensure we are caring for the whole patient and their loved ones. The teams proactively communicate with each patient’s doctor(s), ensuring the care plans are followed and patient needs are met. Our teams are available to coordinate care 24 hours a day, seven days a week.

Hospice staff prepare, train, guide and support the caregiver(s) throughout the hospice experience to keep the patient as comfortable as possible.

Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs) are the patient’s main medical caregiver(s) and report ongoing health conditions directly to the doctor. The patient’s dedicated RN also serves as the Care Coordinator and is responsible for overseeing the patient’s overall plan of care. VNA RNs are trained in the art of symptom management and provide compassionate, hands-on care as well as education to caregivers on how to provide care to their loved one at home.

A medical social worker will be your family’s connection to accessing any needed community resources and offer emotional support and counseling throughout the process.

Certified Hospice Aides may help with bathing, grooming or other personal care services. Their role is to help provide support to the patient’s family and caregiver(s).

These hospice specialists often help patients improve or recover basic life skills they may have lost over time, such as walking, dressing, eating or speaking.

Spiritual counselors are available to provide comfort and support. VNA Hospice Care is able to provide spiritual counseling for all faiths and creeds. If requested, the VNA Chaplain can work directly with the patient’s clergy to provide additional support.

The Hospice Physician is an invaluable member of the interdisciplinary hospice team. Physicians provide the medical expertise to manage care at the end of life.

*In addition to the VNA Hospice Physician, the patient is able to choose any attending physician to oversee their care if desired.

After completing the VNA Hospice Training Program, VNA volunteers offer compassionate support and companionship for patients and their families. Volunteers can serve in multiple roles including: providing caregiver respite, reading and/or listening to music with the patient, documenting patient stories and memories, running light errands, and providing emotional support.

VNA nurses are available around the clock including evenings and weekends to address any needs of the patient and family. Expert clinicians will be dispatched any time day or night as the need arises.

Palliative Care or Hospice

Palliative Care or Hospice?

Selecting the right care at the right time for your patient is an important decision.

The National Hospice and Palliative Care Organization (NHPCO) provides this helpful guide to navigate these options: