Refer a Patient
Hospice Referrals
Patients and Families
Referring a loved one, a friend or a neighbor to hospice for evaluation of eligibility is a kind and loving act. InFinity Care of Tulsa is here to provide palliative care to patients and their families and to support the caregiver, family and other providers.
If you know someone who has the following care needs, please click here on the Referral for Evaluation Form and send to us. We will contact the patient, or the family, and the physician to schedule an evaluation. There is no cost for our evaluation to the patient or the family and it will provide valuable information regarding the eligibility of the patient for the Medicare Hospice Benefit and/or other services which might be available.
Other information for the caregiver or family related to Frequently Asked Questions, Information on How to Choose a Hospice Provider, and important helpful links are provided by simply clicking on these topics.
Functional Assessment Staging (FAST)
Reisberg, B. Functional Assessment Staging (FAST). Psychopharmacology Bulletin,
1988; 24:653-659.
| 1 | No difficulty either subjectively or objectively. | ||
| 2 | Complains of forgetting location of objects. Subjective work difficulties. | ||
| 3 | Decreased job functioning evident to co-workers. Difficulty in traveling to new locations. Decreased organizational capacity. * | ||
| 4 | Decreased ability to perform complex tasks, e.g., planning dinner for guests, handling personal finances (such as forgetting to pay bills), difficulty marketing, etc. | ||
| 5 | Requires assistance in choosing proper clothing to wear for the day, season or occasion, e.g., patient may wear the same clothing repeatedly unless supervised. * | ||
| 6 | a | Improperly putting on clothes without assistance or cueing (e.g., may put street clothes on over night clothes, put shoes on wrong feet, or have difficulty buttoning clothing) occasionally or more frequently over the past weeks. | |
| b | Unable to bathe properly (e.g., difficulty adjusting bath-water temperature) occasionally or more frequently over the past weeks. * | ||
| c | Inability to handle mechanics of toileting (e.g., forgets to flush the toilet, does not wipe properly or properly dispose of toilet tissue) occasionally or more frequently over the past weeks. * | ||
| d | Urinary incontinence (occasionally or more frequently over the past weeks). * | ||
| e | Fecal incontinence (occasionally or more frequently over the past weeks). * | ||
| Patient may be eligible for Medicare Hospice Benefit. Please call InFinity Care for more information. | |||
| 7 | a | Ability to speak limited to approximately a half dozen intelligible different words or fewer in the course of an average day or in the course of an intensive interview. | |
| b | Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview (patient may repeat the word over and over). | ||
| c | Ambulatory ability is lost (cannot walk without personal assistance). | ||
| d | Cannot sit up without assistance (e.g., the individual will fall over if there are not lateral rests [arms] on the chair). | ||
| e | Loss of ability to smile. | ||
| f | Loss of ability to hold up head independently. | ||
| * Scored primarily on the basis of information obtained from acknowledgeable informant and/or patient | |||
InFinity Care Foundation
The community we serve and our commitment to end of life care. InFinity Care Foundation
Long Term Care
Video Library
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