Table of Contents

This article is meant to help families and new hospice staff understand the four levels. According to Medicare guidelines, several levels of care govern in the United States of America, whether the patient uses Medicare or not.

Routine Care — the most usual form of is routine care. This is task-based care where a visiting nurse (LPN or RN) comes anywhere from once every literal 14 days to several times per week. All visiting staff (chaplains, social workers, certified nursing assistants, and nurses) are task-based in that they come to see the patient and family, complete tasks, and leave for the next patient until the end of their work day. Medicare guidelines state that the minimum visit time for routine care is 30 minutes. Most agencies have a maximum time for routine care, which is two hours. There is leeway in both directions, such that a visit might be 15 to 20 minutes or three or four hours. It's based on the current needs of the patient and family.

() Care — Along with Continuous Care, this is the most misunderstood level of care in hospice. care occurs in the hospital setting where the (1) patient has symptoms that can only be controlled in a hospital setting, such as frequent monitoring for medication dose (strength), frequency, and effectiveness. (2) The goal is to transition the patient from IV or injectable to oral medications. (3) There's a plan to discharge the patient from the hospital to a home setting, which can include a facility (just not a hospital). Number three (3) is the most misunderstood, even by hospital staff participating with GIP patients. Still, it is a Medicare requirement that the overall goal of GIP is to achieve a means of “at-home” symptom management. GIP requires the to send out a nurse daily to work with the hospital staff to meet the GIP goals for the patient.

Continuous Care — Continuous care is where hospice care is provided for eight hours or more during 24 hours, during which the nurse (LPN, RN) is present more than 50% of the time. Continuous care is remarkably similar to care, such that there are Medicare rules for what qualifies for continuous care. Since hospice at home requires that the family and I cannot stress this enough, the family is the primary caregiver for the patient — the situation must involve one that is in constant motion typically involving the titration of medication, which means frequent changing of doses and potential frequent changes of what medications are used to control comfort. The most common case for continuous care (at home) in my experience is uncontrolled terminal restlessness followed by uncontrolled pain. Once the nurse has achieved control of the symptoms and the medications and instructions for the family are in place, continuous care is ended, and routine care is resumed.

 — Where the patient is placed in a skilled facility within the operating area of the hospice (this may or may not be local to the family of the patient) with the first available bed for up to five days per benefit period. The family needs to supply the patient's medications and clothing.

Scheduled Visiting Frequencies as it relates to

  • Routine Care — daily if the patient is within two weeks of life or less or there are current symptoms that need once-a-day tweaks for a brief period. Otherwise, based on the patient and family needs, several times per week to every two weeks or less. Medicare's maximum spread is once every two weeks (a maximum of 14 days).
  • General Inpatient (GIP) — daily visits.
  • Continuous Care involves being on-site eight or more hours per day until symptoms resolve; a nurse must be present more than 50% of the time.
  •  : The same as routine care, based on the patient's needs, though at least one visit during the stay. It is expected to get a “tuck-in” visit or call the day the patient arrives and another when the patient returns home.

Always remember that your hospice provider should be available 24/7 for phone calls, including asking for any of the visiting staff to come sooner than “scheduled.”

Conclusion

As defined by Medicare, the levels of care in hospice include routine home care, general inpatient care, continuous home care, and respite care. These levels of care are designed to meet the varying needs of patients and their families as they navigate the end-of-life journey. Routine care is the most common form of hospice care, involving task-based visits by a hospice team. General inpatient care takes place in a hospital setting and is aimed at managing symptoms that require frequent monitoring or transitioning the patient to at-home symptom management. Continuous care provides hospice care for eight or more hours during 24 hours, typically for uncontrolled symptoms that require constant attention. Respite care allows the patient to stay in a skilled facility for up to five days per benefit period, providing a short break for the family caregivers. Families and caregivers need to understand these levels of care to ensure that the patient's needs are met effectively throughout the hospice journey. Always remember that the hospice provider should be available 24×7 for phone calls, including asking any visiting staff to come sooner than “scheduled.”

Resources

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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