Over the last few months we have receiveda lot of questions from readers of NSIDEM.D. about how hospice works. Interestinglyfor us, the questions we get from those whorefer to hospice regularly and from those whoonly occasionally or rarely refer to hospicetend to be the same.
What we are learning from you is thatthose of us in hospice have not always donea good job of helping our referral base trulyunderstand what hospice should provide,and how our different levels of service areaccessed.
In our debut article in M.D., we presenteda basic primer on what hospice is, how ithas grown, and some basic concepts aboutqualifying for hospice. But we did not havethe space to provide details about the differentlevels of service, and what criteria need toexist to access those levels of care.
This month we want to address these andhopefully answer some of the more commonquestions we are getting from our readers.
The starting point in hospice is recognizingthat the hospice benefit was designed withthe primary goal of keeping patients at homeand delivering all of their care in that setting.However, the framers of the legislation wereaware that that goal presented challenges attimes. In recognition of those challenges, fourdistinct levels of hospice care were incorporatedinto the legislation which produced theMedicare hospice benefit we have today.
The four levels of care are Routine HomeCare, Respite Care, Continuous Care andInpatient Care. Each one is designed to meeta specific need of the patient and the patient’scaregivers. Let’s look at each one in detail.
The first level of care is Routine Home Care(RHC). This is overwhelmingly the most utilizedlevel of hospice care. About 95 percentof all hospice days of care are RHC days. Aswe talk to our community about hospice,this is the level of care that most are familiarwith. It is the backbone of hospice, and is theprimary tool in Medicare’s hospice arsenal.
It provides the front line in accomplishingthe goal of allowing the terminally illto be cared for in their home setting. Thehospice brings all of its services to the placethe patient calls home. That may be a privateresidential setting, a nursing home or nursingfacility, an assisted living residence, or a smallgroup home.
In this setting the hospice supplies itsentire team, pharmacy, durable medicalequipment, supplies, and 24/7 response to thepatients needs. Most hospice patients comeonto hospice with RHC, and for most it is theonly level of service they ever receive. Theyeventually die comfortably and peacefully athome, as they wished, surrounded by familyand friends, in the intimacy that only a homecan provide.
The next level of care is Respite Care.Respite care is entirely unique to hospice. Noother segment of Medicare provides anythingsimilar. Respite Care is designed primarily forthe benefit of the caregiver. It recognizes theextreme physical, emotional, psychologicaland spiritual challenges that accompany caringfor those who are terminally ill.
It allows the hospice to place the patient ina hospice inpatient unit, contracted hospitalor skilled nursing facility, for up to fivedays. The hospice team remains intact andcontinues to manage the care, but does it ina setting where the caregiver is freed of thedemands of caring for their loved one. Respitecare aids in the goal of keeping the patient athome, by avoiding caregiver breakdown, andprotecting the valuable resource of those whomake RHC possible.
The least used level of hospice care is ContinuousCare. In some circles, particularlythe skilled nursing setting, it is commonlyreferred to as crisis care. That’s because it isusually a patient crisis that makes it appropriate.The crisis may be unmanageable pain orsymptoms that are beyond the ability of thelay caregiver to manage.
In some circumstances, though not all,active dying is accompanied by signs andsymptoms that allow the utilization of continuouscare. Continuous Care extends thegoal of keeping the patient at home, providingaround–the–clock care by skilled staff,in those circumstances where the patient’scondition would require admission to aninpatient unit, if continuous skilled care is notprovided in the home.
Last is General Inpatient Care (GIP). TheGIP level of care is a recognition that in somepatients, pain or other acute or chronic symptomssimply cannot be managed in any othersetting.
The GIP level of care may be provided ina licensed hospice inpatient unit, a hospitalor skilled nursing facility that meets the requirementsof 24–hour RN care and specificsregarding patient areas. The GIP benefit isintended to be a short term benefit.
The four levels of care, in combination,allow the hospice provider to cover everysituation that may face the terminally ill patient.They maximize the goal of keeping thepatient at home, allowing for respite for thecaregiver when necessary and around–theclockskilled care at home in some circumstances.
Even if an inpatient setting becomes necessary,the goal of the patient, who wants to beon hospice, is maintained because no matterwhere the patient is the hospice remainsresponsible for the overall professional managementof the patient.
Stay tuned for the next issue, where we willcontinue to uncover hospice.
