Medicare-certified hospice agencies must be prepared to provide care that matches a patient’s changing needs.
Most hospice patients receive care at home under Routine Home Care, but some patients may temporarily need more intensive services because of a medical crisis, uncontrolled symptoms, or caregiver needs.
CMS recognizes four levels of hospice care:
- Routine Home Care
- Continuous Home Care
- Inpatient Respite Care
- General Inpatient Care
Each level serves a different purpose. For hospice agencies delivering care primarily in patients’ homes, understanding when each level applies is essential for clinical care, staffing, documentation, billing, and survey readiness.
*This article was written in consultation with Mariam Treystman.
At The Home Health Consultant, we work with Medicare-certified hospice agencies on compliance, operations, billing, survey readiness, and ongoing regulatory requirements. This article explains the four Medicare hospice levels of care and what agencies need to know when determining which level is appropriate.
What Is Routine Home Care in Hospice?
Routine Home Care, or RHC, is the standard level of hospice care when a patient is at home and is not receiving another level of hospice care.
CMS describes Routine Home Care as the usual level of care for hospice patients who are not experiencing a crisis that requires Continuous Home Care or symptoms requiring inpatient treatment.
For patients living in private residences, hospice services are provided according to the individualized plan of care. This may include but is not limited to:
- Nursing
- Hospice aide services
- Social work
- Counseling
- Medications
- Medical equipment, supplies, and other services related to palliation and management of the terminal illness and related conditions.
Routine Home Care does not mean that hospice staff remain in the patient’s home continuously. Visits and services are based on the patient’s assessed needs and plan of care.
This is important to explain to patients and families during admission. Hospice care at home does not automatically include a hospice employee physically present around the clock.
What Is Continuous Home Care in Hospice?
Continuous Home Care, or CHC, is a higher level of hospice care provided during a brief period of crisis when increased care is necessary to maintain the patient at home.
CMS defines a crisis as a period in which the patient requires continuous care that is predominantly nursing care to achieve palliation or management of acute medical symptoms.
CHC is therefore not simply “more visits” or additional caregiver support.
To qualify for Continuous Home Care, CMS requires at least 8 hours of qualifying care during a 24-hour day that begins and ends at midnight. The eight hours do not have to be consecutive.
More than half of those hours must be provided by an RN, LPN, or LVN. Hospice aide and homemaker services may supplement the nursing care, but cannot replace it.
Examples of circumstances that may require intensive symptom management could include but are not limited to:
- Acute pain
- Respiratory distress
- Severe agitation
- Another rapidly changing clinical problem
The documentation must establish the actual crisis and why intensive care was necessary to keep the patient at home.
If fewer than eight qualifying hours are provided during the day, CMS pays the hospice at the Routine Home Care level rather than CHC.
Does Continuous Home Care Mean a Nurse Must Stay for Eight Hours Straight?
No, continuous home care does not mean a nurse must stay with a hospice patient for eight hours straight.
CMS does not require the eight qualifying hours to be consecutive.
For example, qualifying care could be provided during separate periods throughout the same midnight-to-midnight day when clinically appropriate.
However, an agency should never schedule services simply to reach eight hours.
The clinical record needs to support:
- The medical crisis being managed
- Why continuous care was necessary
- Who furnished the care
- The amount of qualifying direct-care time
- The interventions provided
- The patient’s response
CMS has specifically identified CHC medical necessity and documentation as an area subject to Medicare review.
Can Continuous Home Care Be Used Because the Caregiver Needs a Break?
No, continuous home care cannot be used simply because a hospice patient’s caregiver is tired or needs time away.
CHC is intended to manage a medical crisis requiring predominantly nursing care.
When the primary issue is that the usual caregiver needs temporary relief rather than the patient experiencing a qualifying medical crisis, another hospice level, Inpatient Respite Care, may be more appropriate.
This distinction is important because CHC and respite serve very different purposes.
What Is Inpatient Respite Care in Hospice?
Inpatient Respite Care, or IRC, provides short-term inpatient care when the family member or other person who normally cares for the hospice patient at home needs temporary relief.
The patient does not need to have uncontrolled symptoms to qualify for respite.
CMS provides examples such as allowing a caregiver time to rest, attend an important family event, or recover from illness.
Medicare pays for Inpatient Respite Care for up to five consecutive days at a time. Respite is intended to be used on an occasional basis.
Respite must be provided in an approved inpatient setting, such as an appropriate hospice inpatient facility, hospital, or qualifying nursing facility.
For hospices that primarily care for patients in private homes, this means having appropriate inpatient arrangements available before a caregiver suddenly needs respite.
What Is General Inpatient Care in Hospice?
General Inpatient Care, or GIP, is short-term inpatient hospice care for pain control or symptom management that cannot feasibly be provided in another setting.
The defining issue is not simply that the patient is seriously ill.
Hospice patients are, by definition, terminally ill. GIP requires a need for a level of symptom management that cannot feasibly be provided in the patient’s current setting.
CMS guidance identifies examples such as situations requiring intensive medication adjustment, observation, stabilizing treatment, or other interventions necessary to bring uncontrolled symptoms under control.
Once the symptoms are sufficiently controlled and GIP is no longer necessary, the patient should transition back to the appropriate lower level of care.
Does a Patient Qualify for GIP Simply Because They Are Actively Dying?
No, being close to death does not automatically qualify a hospice patient for General Inpatient Care.
CMS bases GIP eligibility on the need for pain control or acute or chronic symptom management that cannot feasibly be provided elsewhere.
Many hospice patients remain at home through the final days of life under Routine Home Care, with Continuous Home Care used when the CHC crisis criteria are met.
How Can Agencies Tell the Difference Between CHC, Respite, and GIP?
The easiest way to distinguish the levels of hospice care is to focus on why the patient needs additional support.
Continuous Home Care:
The patient is experiencing a medical crisis, requires at least eight hours of qualifying care, and can remain at home with predominantly nursing care.
Inpatient Respite Care:
The patient’s usual caregiver needs temporary relief, even though the patient may not have uncontrolled symptoms.
General Inpatient Care:
The patient has pain or other symptoms that cannot feasibly be managed in the current setting and requires short-term inpatient care.
These are different clinical situations and should not be treated interchangeably.
Does the Hospice Plan of Care Need to Support the Level of Care?
Yes, the hospice plan of care must support the level of care.
CMS requires hospice services to be furnished according to the patient’s individualized plan of care. When the patient’s needs change, the level and intensity of services should reflect those changes.
This becomes especially important when a patient moves to CHC or GIP.
The clinical record should explain:
- What changed in the patient’s condition
- What symptoms or circumstances required the new level
- What interventions were provided
- Why that level of care was necessary
- When the higher level was no longer required
The documentation should allow someone reviewing the record later to understand why the level of care billed was appropriate on those specific days.
How Can Hospice Agencies Stay Compliant With Medicare Levels of Care?
The four Medicare hospice levels are easiest to remember by focusing on their purpose:
Routine Home Care: the patient's usual hospice care at home when another level is not required.
Continuous Home Care: intensive, predominantly nursing care during a brief medical crisis so the patient can remain at home.
Inpatient Respite Care: short-term inpatient care, generally up to five consecutive days, to provide relief to the patient's usual caregiver.
General Inpatient Care: short-term inpatient care for pain or symptoms that cannot feasibly be managed elsewhere.
For Medicare-certified hospice agencies, the most important compliance principle is consistency.
The patient's
- Condition
- Assessment
- Plan of care
- Staffing
- Documentation
- Location of services
- Level billed should all support the same clinical story
At The Home Health Consultant, we help hospice agencies review Medicare compliance, clinical documentation, billing practices, inpatient arrangements, and survey readiness.
If your agency is unsure whether it is identifying, documenting, staffing, or billing hospice levels of care correctly, schedule a consultation with The Home Health Consultant to review your current process before it becomes a survey or payment issue.
*Disclaimer: The content provided in this article is not intended to be, nor should it be construed as, legal, financial, or professional advice. No consultant-client relationship is established by engaging with this content. You should seek the advice of a qualified attorney, financial advisor, or other professional regarding any legal or business matters. The consultant assumes no liability for any actions taken based on the information provided.
Topics:
