General Inpatient (GIP) Level of Care for Hospice Explained

Published on September 25, 2021

Updated on December 25, 2023

Hospice, often abbreviated as , is a crucial but frequently misunderstood aspect of . This level of care is provided to patients in an inpatient setting, typically in a Medicare-certified hospital, inpatient unit, or skilled nursing facility. It is designed for short-term, acute situations that require intensive management by skilled nursing care. In this article, we will clarify the basics of for hospice, including eligibility requirements, settings, doctor's orders, plan of care, documentation, and education. Additionally, we will provide real-life cases to illustrate the application of GIP in .

Misunderstandings about GIP in Hospice

GIP, or Hospice, is an often-misunderstood aspect of hospice care. Both hospital staff and families sometimes have misconceptions about GIP. Families may assume it's readily available upon request, while hospital professionals may believe it allows patients to remain in the hospital indefinitely, even when death is weeks away. In this article, we will clarify the basics of GIP for hospice, including eligibility requirements, doctor's orders, plan of care, documentation, and education. We'll conclude with two real-life cases to illustrate these points.

Eligibility Requirements (for the patient)

Idg Gip Criteria
GIP criteria explained
Source: Implementing a floating hospice
  1. Hospice Appropriateness: The patient must have a prognosis of six months or less to live, certified by a medical provider via a certificate of terminal illness (CTI).
  2. Symptoms Requiring Hospital Setting: The patient should have symptoms that necessitate a hospital environment. These may include:
    • Uncontrolled pain not managed by oral or topical medications.
    • Intractable nausea/vomiting requiring IV medications and fluids.
    • Advanced open wounds needing specialized care.
    • Respiratory distress requiring BiPap, intubation, or high-flow oxygen.
    • with behavior issues demanding frequent medication adjustments.
    • Sudden decline necessitating intensive nursing intervention.
    • Imminent death, but only if skilled nursing care is required.

A patient is not eligible for GIP if it's solely for caregiver respite, the patient lives in an unsafe environment, or simply because they are expected to pass away soon. GIP is reserved for situations requiring intensive management by skilled nursing care.

GIP Settings

The setting for GIP is typically a Medicare certified hospital or a certified inpatient unit (IPU).

Doctor’s Order for GIP

Once eligibility for GIP is confirmed, orders must be obtained from the attending physician at the GIP location and the hospice medical director, who addresses the level of care.

Plan of Care Requirements

GIP is designed for acute situations, so a plan must be in place to discharge the patient to a lower level of care. This plan includes:

  • Daily visits by one or more members of the Interdisciplinary Group (IDG) team.
  • The hospice (RN CM) oversees the patient's care and works with the hospital team to transition the patient to a home setting. The RN CM collaborates with the family and ensures that necessary equipment (DME) is set up in the patient's target environment.
  • The assists with discharge planning and transportation.
  • Daily nursing notes from the GIP location are crucial to track adjustments and progress toward discharge.

Documentation Requirements

Gip Documentation Requirements
Gip Documentation Requirements Additional

All IDG members involved in the patient's care should document their actions and their results. Frequent documentation is essential to demonstrate progress toward discharge.

Education Recommendations

Education is a crucial part of hospice care. Every interaction with the patient's family should include educational moments. If a family requests GIP in a home setting, but it's not appropriate, educate them on managing the situation and explore their needs. If GIP is appropriate, ensure the family and hospital staff understand the GIP requirements regarding a discharge plan to home.

Real-Life Case Examples

These are cases that I personally managed.

Case 1: Respiratory distress

The patient was on a 45-liter high flow BiPap at the hospital with attending at the hospital and the family desiring the patient to be on hospice, and to start GIP. Since home DME's typically don't provide such high flow devices at a reasonable cost, there is a go for GIP if the team can provide a pathway to discharge.

The hospital respiratory therapist was consulted to investigate options that would work in a home setting (priceless pearl: you don't need to be an expert in all areas, remember to use your resources!). Given the goal of 10 to 15 liters for DME equipment, the respiratory therapist was able to produce a solution that involved a specialty canula which they provided.

The main barrier to GIP was the family initially thought the patient would remain in the hospital until death; this was resolved via education and providing options such as local skilled nursing homes (SNF).

Case 2:

The family wanted hospice for their loved one who was in the hospital with extreme for which the hospital care team was not sure how to manage effectively. Hospice was called in to evaluate, admit under GIP, provide recommendations to treatment and to work on a discharge plan home.

Medication recommendations were given, applied, and in 12 hours the patient was comfortable and ready for discharge home. The patient expired several hours after coming home in the presence of their loving family.

Conclusion

Understanding GIP in hospice is vital for providing appropriate end-of-life care. By meeting eligibility requirements, obtaining doctor's orders, developing a plan of care, maintaining documentation, and offering education, we can ensure that GIP serves its intended purpose effectively.

Resources

What are the levels of care in hospice?

General Inpatient Care Compliance Guide

Hospice General Inpatient (GIP) Level of Care Frequently Asked Questions

42 CFR § 418.108 — Condition of participation: Short-term inpatient care

42 CFR § 418.110 — Condition of participation: Hospices that provide inpatient care directly

Providing Comfort During the Last Days of Life with Barbara Karnes RN (YouTube Video)

Preparing the patient, family, and caregivers for a “Good Death”

Velocity of Changes in Condition as an Indicator of Approaching Death (often helpful to answer how soon? or when?)

The Dying Process and the End of Life

The Last Hours of Life

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Gone from My Sight: The Dying Experience

The Eleventh Hour: A Caring Guideline for the Hours to Minutes Before Death

By Your Side , A Guide for Caring for the Dying at Home

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