Hospice care focuses on improving the quality of life for patients with life-limiting illnesses and their families. It provides physical, emotional, and spiritual support to help patients cope with their condition and prepare for the end of life. Hospice care can be provided in various settings, such as the patient’s home, a hospice facility, a nursing home, or a hospital.
However, sometimes hospice patients may experience severe pain or other symptoms that cannot be adequately controlled in their current setting. In such cases, they may need a higher level of care that can only be provided in an inpatient setting. This is called hospice general inpatient care, or GIP for short. GIP is a short-term level of care that aims to stabilize the patient’s condition and relieve their suffering. GIP is not a permanent placement but a temporary intervention that can be discontinued when the patient’s symptoms improve or they return to their previous setting.
GIP can offer many benefits for hospice patients and their families. It can help patients better manage pain and symptoms, enhancing their comfort and dignity. GIP can also help families reduce their stress and burden by allowing them to rely on the hospice team’s professional care and guidance. GIP can also allow families to spend quality time with their loved ones without worrying about their medical needs.
In this article, we will explain everything you need to know about GIP, including:
How to determine if a patient is eligible and meets the criteria for GIP
How GIP is paid for and covered by Medicare and other insurance plans
How GIP is billed and documented to ensure compliance and avoid audits
How to plan for the discharge and transition from GIP to another level of care
We hope this article will help you understand GIP better and make informed decisions for yourself or your loved one. If you have any questions or concerns about GIP, don’t hesitate to contact your hospice provider or refer to your hospice handbook for more information and support.
Eligibility and Criteria for GIP
Not every hospice patient is eligible for GIP. GIP is only appropriate for patients who have severe pain or other symptoms that cannot be managed in different settings, such as their home, a nursing home, or an assisted living facility. GIP is not a substitute for long-term care or custodial care. GIP is also not a choice that patients or families can make alone. GIP requires a medical justification and a written order from the hospice medical director or the patient’s attending physician.
GIP can be provided in one of the following three settings:
A hospice inpatient unit or facility is a Medicare-certified hospice that meets the standards for direct inpatient care, including staffing, physical environment and infection control.
A hospital that is a Medicare-certified facility that also meets the standards for providing 24-hour nursing services and appropriate patient areas
A skilled nursing facility (SNF) is a Medicare-certified facility that also meets the standards for providing 24-hour nursing services and appropriate patient areas.
The hospice must have a written agreement with the hospital or SNF to provide GIP care. The contract must specify the hospice’s and the facility’s roles and responsibilities, including admission and discharge procedures, billing and payment arrangements, quality assurance, and patient rights.
The common conditions and symptoms that may qualify a patient for GIP include, but are not limited to:
Pain crisis that is uncontrolled or poorly controlled by oral or subcutaneous medications
Nausea and vomiting that are unresponsive to oral or subcutaneous medications
Respiratory distress that requires oxygen, a nebulizer, or suctioning
Delirium, agitation, or confusion that are unmanageable or pose a safety risk
Severe bleeding that requires transfusion or intervention
Severe dehydration that requires intravenous fluids
Severe constipation or bowel obstruction that requires a nasogastric tube or enema
Wound care that requires frequent dressing changes or debridement
Seizures that are frequent or prolonged
Terminal restlessness that is distressing to the patient or family
The role of the hospice medical director and the interdisciplinary team is to determine and document the need for GIP. The hospice medical director or the patient’s attending physician must certify that the patient is terminally ill (with a life expectancy of six months or less) and that GIP is medically necessary for pain or symptom management. The hospice interdisciplinary team, which consists of the hospice medical director, the patient’s attending physician (if any), the hospice nurse, the hospice social worker, the hospice chaplain, and the hospice aide, must develop and update a written plan of care that specifies the goals, interventions, and expected outcomes of GIP. The hospice interdisciplinary team must also coordinate and communicate with the facility staff where GIP is provided and regularly monitor the patient’s condition and progress. The hospice interdisciplinary team must document the patient’s status, symptoms, medications, treatments, and response to GIP in the patient’s medical record. The hospice interdisciplinary team must also review the patient’s eligibility and appropriateness for GIP at least every 24 hours and discharge the patient from GIP when the patient’s symptoms improve or when the patient requests to return to another level of care.
Myths about GIP Care
GIP care is limited to a certain number of days
False: The GIP level of care is intended for “short-term” interventions. However, there is no limit to the number of days. This level of care can persist as long as necessary to achieve the goals of palliation. CMS closely scrutinizes GIP care lasting longer than 5 days to ensure appropriate use.
GIP is for anyone who is actively dying.
False: GIP is not an automatic level of care when a patient is imminently dying. There must also be pain or symptom management, and skilled nursing needs must be present that cannot be managed at home.
GIP can be used when a caregiver would prefer to stay in the hospital longer
False: It is not intended for caregiver respite, to address unsafe living conditions, or to address the lack of a caregiver. A skilled nurse must manage the symptoms.
Where and How is GIP Hospice Provided?
GIP hospice is a level of care that can help hospice patients who have severe pain or symptoms that cannot be managed in other settings. GIP Hospice is not a place to live but a place to get better. GIP hospice is only for a brief time until the patient’s condition improves or they choose to go back to their home or another setting.
GIP hospice can be provided in one of the following three types of facilities:
A hospice inpatient unit or facility is a place specially designed for hospice care. It has a comfortable, home-like environment and is staffed by hospice nurses, doctors, and other professionals who provide 24-hour care and support.
A hospital is a place that can provide medical care and treatment for many kinds of illnesses and injuries. It has various types of equipment and technology, and it is staffed by hospital nurses, doctors, and other professionals who can work with the hospice team to provide GIP hospice care.
A skilled nursing facility (SNF) provides nursing care and rehabilitation for people who need more help than they can get at home. It offers a range of services and activities and is staffed by SNF nurses, doctors, and other professionals who can work with the hospice team to provide GIP hospice care.
The hospice team and the inpatient staff have different roles in coordinating GIP hospice care. The hospice team is responsible for:
Determining and documenting the need for GIP hospice care based on the patient’s condition and symptoms.
Developing and updating a written plan of care that outlines the goals, interventions, and expected outcomes of GIP hospice care.
Communicating and collaborating with the inpatient staff ensures that the patient receives the best care and support.
Monitoring and reviewing the patient’s progress and response to GIP hospice care and deciding when to discharge the patient from GIP hospice care.
The inpatient staff is responsible for the following:
Providing the patient with a safe and comfortable room and board, and allowing the patient to receive visitors at any time.
Following the hospice plan of care and providing the patient with the necessary medications, treatments, and services.
Reporting any changes or concerns about the patient’s condition and symptoms to the hospice team.
Respecting the patient’s rights and preferences and honoring the patient’s dignity and privacy.
GIP hospice care in a hospital setting can have both benefits and challenges. Some of the benefits are:
The patient can access more advanced medical care and equipment, which can help manage their pain or symptoms more effectively.
The hospital staff can monitor the patient more frequently and closely, which can help prevent or treat complications or emergencies.
The patient can have more opportunities to consult with specialists or experts who can offer more advice or options for their care.
Some of the challenges are:
The patient may feel more stressed or anxious in a hospital setting, which can affect their comfort and well-being.
Patients may have less privacy or autonomy in a hospital setting, affecting their sense of control and dignity.
Patients may have less continuity or consistency in their care as they encounter different hospital staff or policies.
Key Requirements for GIP
The following are essential requirements to remember for GIP:
GIP care must be provided in a facility setting that has an RN present around the clock.
The best practice is to conduct daily nursing visits from the hospice provider.
Discharge planning must begin when GIP care is initiated.
Documentation must support the need for increased care, including efforts to manage symptoms before initiation.
Cues that GIP care may be needed
Many different scenarios would meet the requirements for GIP care. Each situation is unique and should be discussed with the case manager, clinical supervisor, medical director, and other IDG members to determine if GIP care is appropriate.
Worsening of symptoms in the home that cannot be managed in the home setting.
Continuous care is in place, but it does not provide the care required to palliate symptoms.
Patients are ready for discharge from the hospital, but their symptoms require skilled care interventions that cannot be managed in the home setting.
Examples of appropriate GIP care
The symptoms below require a nurse to observe, intervene, and monitor them to achieve palliation or resolution. Management of the symptoms should not be something that could be provided in the home setting.
Severe, uncontrolled symptoms:
Pain
Unmanaged respiratory distress
Agitation/Delirium/Anxiety
Nausea/Vomiting/Diarrhea
Bowel obstruction
Bleeding/hemorrhaging
Seizures
Advanced open wound
Pathological fractures
Transfusions for relief of symptoms
Traction/frequent re-positioning requiring more than one staff member)
Symptoms related to imminent death – ONLY if can’t be managed at home
Severe/uncontrolled symptoms require the following for management:
Technical delivery of pain medication
Frequent dosing changes
Frequent evaluation
Frequent medication adjustment
Aggressive treatment to control pain
Equipment/support/interventions that could not be provided in the home setting
When is GIP care NOT appropriate?
Please remember there are specific times when GIP is not appropriate, such as:
GIP care is NOT intended to be time for respite for the caregiver or family.
GIP care is NOT designed to provide extra time to address unsafe living arrangements.
GIP care is NOT an automatic level of care assigned to those who are imminently dying.
How Long Does GIP Hospice Last and What Happens Next?
GIP hospice is a level of care that can help hospice patients who have severe pain or symptoms that cannot be managed in other settings. GIP Hospice is not a place to live but a place to get better. GIP hospice is only for a brief time until the patient’s condition improves or they choose to go back to their home or another setting.
One of the most frequent questions patients and families have about GIP hospice is: how long does it last? The answer is that it depends. GIP Hospice does not have a fixed or predetermined length of stay. GIP hospice is individualized to each patient’s needs and preferences. Some patients may need GIP hospice for only a few days, while others may need it for longer. The average length of stay in GIP hospice is about six to twelve months, but it can vary depending on the disease, the patient’s ability to fight off the disease, and any treatments the patient is receiving.
The hospice team and the inpatient staff assess the patient’s condition and symptoms daily. They also review the patient’s plan of care and treatment goals. They check if the patient is still eligible and appropriate for GIP hospice or ready to be discharged to another level of care. The hospice team and the inpatient staff regularly communicate with the patient and family, involving them in decision-making. They also document the patient’s status, progress, and response to GIP hospice in the patient’s medical record.
The hospice team and the inpatient staff also plan the patient’s discharge and transition from GIP hospice to another level of care. They consider the patient’s wishes, comfort, safety, and quality of life. They also consider the availability and readiness of the patient’s caregivers, as well as the resources and support they may need. The hospice team and the inpatient staff coordinate with the patient, the family, and the receiving facility or agency to ensure a smooth and safe transfer. They also educate the patient and family about continuing hospice care at home or in another setting.
After GIP hospice, the patient and the family have different options and resources to continue hospice care. The most common option is to return to the routine home care level of hospice, which is provided in the patient’s home or other residence. The hospice team will visit the patient and the family regularly and provide nursing, hospice aide, and other services as needed. The hospice team will also be available 24/7 by phone for any questions or concerns. The patient and the family can also access other hospice services, such as social work, chaplaincy, grief, and volunteer support.
Another option is to receive a continuous home care level of hospice, which is provided in the patient’s home or other residence when the patient has a crisis or emergency that requires more intensive care. The hospice team will provide continuous nursing care for at least eight hours a day and may also offer other services as needed. The hospice team will stay with the patient and the family until the crisis or emergency is resolved or until the patient is stable enough to return to the routine home care level of hospice.
A third option is to receive respite care at the level of hospice, which is provided in an inpatient facility for up to five days at a time when the patient’s caregivers need a break or relief from the stress and burden of caregiving. The hospice team will arrange for the patient’s admission and transportation to the inpatient facility and will continue to oversee the patient’s care and care plan. The hospice team will also coordinate with the patient’s caregivers and the inpatient facility to plan for the patient’s discharge and return to the routine home care level of hospice.
The hospice team will provide the patient and the family with information and guidance on the different options and resources for hospice care after GIP hospice. The hospice team will also respect the patients’ and the families’ choices and preferences and honor their rights and dignity. The hospice team will support the patient and the family throughout the hospice journey and help them cope with the physical, emotional, and spiritual challenges of the end of life.
GIP Documentation Requirements
Documentation must support the need for the level of care. This means the documentation must show that the patient’s condition could NOT be managed in the home setting. Documentation for the GIP level of care should paint a picture of the patient’s appropriateness for hospice and the increased level of care.
What failed interventions took place to manage symptoms before initiation of GIP?
Why can’t the caregiver manage the patient’s care in the home setting?
Why are the adjustments/treatments necessary for the patient?
Documentation must include:
A physician’s order for the GIP level of care.
A plan of care update reflecting the need for the change in level of care.
Precipitating factors and failed interventions to manage symptoms led to the initiation of the GIP level of care.
A change in symptoms or interventions required to manage symptoms should be noted at every visit.
Communication between IDG members and facility staff members.
Discharge planning efforts.
Medication changes, number of doses of breakthrough medications needed in the last 24 hours.
Non-pharmacologic measures are implemented to control symptoms.
Oxygen flow rate increases or delivery changes.
Family/caregiver/patient education and counseling.
GIP Documentation Tips
Discharge and Transition from GIP
GIP is a level of care that can help hospice patients with severe pain or symptoms that cannot be managed in other settings. It is not a place to live, but a place to get better. GIP is only for a limited time until the patient’s condition improves or they choose to return home or another setting.
One of the most important things to remember about GIP is that it is intended to be a short-term intervention, not a permanent placement. GIP is not a substitute for long-term care or custodial care. GIP is also not a choice that patients or families can make alone. GIP requires a medical justification and a written order from the hospice medical director or the patient’s attending physician.
The goal of GIP is to stabilize the patient’s condition and relieve their suffering so that they can return to their home or another setting where they can receive routine hospice care. GIP is not meant to prolong the patient’s life or cure their illness, hasten the patient’s death, or cause them harm. GIP is intended to enhance the patient’s comfort and dignity and support the patient’s and the family’s wishes and preferences.
The hospice team and the inpatient staff work together to plan the patient’s discharge and transition from GIP to another level of care. They consider the following criteria for discontinuing GIP:
Symptom improvement: The patient’s pain or symptoms have improved to a level that can be managed in another setting, such as at home, in a nursing home, or in an assisted living facility.
Patient preference: The patient desires to return to home or another setting where their pain or symptoms can be managed.
Change in prognosis: The patient’s condition changes in a way that affects their eligibility or appropriateness for GIP, such as a significant improvement or decline in their health status.
The hospice team and the inpatient staff regularly communicate with the patient and family, involving them in decision-making. They also document the patient’s status, progress, and response to GIP in the patient’s medical record. They also educate the patient and the family on continuing hospice care at home or in another setting.
The hospice team and the inpatient staff also provide tips and resources for ensuring a smooth and safe transition from GIP to home or another level of care. Some of the tips and resources are:
Before the discharge date, arrange transportation and equipment, such as a wheelchair, oxygen, or a bed.
Review the patient’s medications and treatments, and ensure the patient and the family have enough supplies and know how to use them correctly.
Please coordinate with the patient’s primary care provider and other health care professionals and inform them of their discharge and care plan.
Schedule follow-up visits or phone calls with the hospice nurse or social worker, and ensure the patient and family know how to contact the hospice team 24/7 for any questions or concerns.
Provide the patient and the family with emotional and spiritual support and connect them with other hospice services, such as chaplaincy, bereavement, and volunteer support.
Hospice Nursing GIP Checklist
The hospice IDG is responsible for the professional management of the patient’s care by the hospice plan of care. To ensure effective management and continued eligibility for the GIP level of care, consider the following:
Check the report from the previous day/shift. Look for unmanaged symptoms and what changes have been implemented since the last visit.
Get a report from the facility staff. Evaluate how many times breakthrough medications were needed to control symptoms.
Review facility orders to see if any new orders were written.
During the nursing assessment, evaluate if the patient’s symptoms have changed. Are they worse/better/managed/the same? Did the previous interventions work?
Make changes to the patient’s current regimen if needed. This can include medication changes, oxygen adjustments, positioning, dimming lights, adding fans, additional consults, etc.
Communicate any changes in condition, interventions, and discharge planning to facility staff.
Communicate any changes in condition, interventions, and discharge planning to the IDG. In your emailed report, include details from your visit, any changes over the last 24 hours, new orders, etc. This will ensure that ANY staff member who sees the patient after you will be up to date on symptoms and the treatment plan for continuity of care.
Conclusion
In conclusion, Hospice General Inpatient Care (GIP) is a crucial level of care that aims to stabilize a patient’s condition and relieve their suffering when severe pain or symptoms cannot be managed in other settings. This article has provided comprehensive information on GIP, including eligibility criteria, the role of the hospice team, myths about GIP care, where and how GIP hospice is provided, documentation requirements, and the discharge and transition from GIP. It emphasizes the temporary nature of GIP and the importance of patient preference, symptom improvement, and changes in prognosis in determining the transition from GIP to another level of care.
The article underscores the collaborative approach between the hospice team and inpatient staff in coordinating GIP care and planning for the patient’s discharge. It also highlights the options available for continuing hospice care after GIP, such as routine home care, continuous home care, and respite care, with a focus on respecting the patient’s and family’s choices and preferences.
This article addresses the essential requirements and considerations for GIP to empower families and nurses to make informed decisions and ensure a smooth and safe patient transition. It emphasizes the compassionate and person-centered approach of hospice care, aligning with the values of empathy and compassion that are fundamental to end-of-life care.
For further information or support regarding GIP, readers are encouraged to contact their hospice provider or refer to their hospice handbook. This article is a valuable resource for those navigating the complexities of hospice care, with the aim of enhancing the quality of life for patients with life-limiting illnesses and their families.
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Compassion Crossing Academy — Free and paid online courses are available to teach caregivers, nurses, social workers, chaplains, end-of-life advocates, and educators, including death doulas, how to confidently coordinate complex care.
The Death Deck is often a wonderful conversation starter.
Compassion Crossing, LLC, via Peter M. Abraham, BSN, RN, EOLD, offers on-site services in Madison County, KY, as well as in the seven nearby counties—Clark, Estill, Fayette, Garrard, Jackson, Jessamine, and Rockcastle—and provides virtual options when no local provider is available.
Hospice Buddy: Although Jamie Haberman, RN, CHPN, isn’t a certified end-of-life doula, her virtual services are highly valuable.
Currently, no official organization regulates end-of-life doulas (EOLDs). Remember that some EOLDs listed in directories may no longer be practicing, so it’s important to verify their current status.
End-of-Life Doula Schools
Before you consider a death doula school, please volunteer for a local hospice provider as a “companion volunteer” to gain experience with strangers who are dying, family dynamics, and staff dynamics. The author also recommends reading the article Economic rant: The death doula crisis we aren’t talking enough about, as most death doula schools do not emphasize that being a death doula is a calling rather than a career.
The following are end-of-life (aka death doula) schools for those interested in becoming an end-of-life doula:
Compassion Crossing Academy: Although it isn’t a dedicated death-doula school, it offers unique classes that can help death doulas expand their practice. It serves as an important resource for individuals looking to deepen their understanding and grow in this meaningful profession.
Remember that there is no official accrediting body for end-of-life doula programs. Certification simply shows you’ve completed an unaccredited course and received a certificate of completion. It’s advisable to have discovery sessions with any death doula school you’re considering — even if it isn’t listed here — to see if it meets your needs. Also, ask questions and reach out to references, such as former students, to assess whether the school provided a solid foundation for launching your own death doula practice.
