I’d like to talk about the four levels of care that a hospice provides to its patients. In my experience with talking to doctors, discharge planners, and other hospices, there are two of the four levels of care that are seldom used, in fact, I have found that many doctors who refer patients to hospice are not aware of the four levels of care provided by hospice. I’ll discuss that in a moment. First, for those readers that may not be aware of what hospice care is, according to the National Hospice and Palliative Care Organization (NHPCO) Facts and Figures, 2020 Edition. Hospice is “Considered the model for quality compassionate care for people facing a life-limiting illness, hospice provides expert medical care, pain management, and emotional and spiritual support expressly tailored to the patient’s needs and wishes. Support is provided to the patient’s family as well.”
So, the four levels of care provided by hospices are
So, the four levels of care provided by hospices are
- Routine Hospice Care (RHC)
- Continuous Home Care (CHC)
- Inpatient Respite Care (IRC)
- General Inpatient Care (GIP)
98% of patients admitted to Aria Hospice are admitted under Routine Hospice Care which basically means that the patient will be receiving hospice care at his place of residence, the rest or 2% are admitted under Continuous Home Care.
When we are in the process of admitting a patient to Aria Hospice, we conduct a thorough review of the patient’s medical history as well as a physical examination which includes review of hospitalization records and the latest hospice consultation which is typically done at the hospital when the patient is being referred to hospice. Additionally, we consult with any nursing staff who taking care of the patient, in order to seek real-time information on the patient’s clinical status. We visit the patient at the hospital and also visit with the patient’s family and discuss their ability to provide basic bedside care to the patient, once he or she is home. Based on the type of information obtained, Aria Hospice makes a decision on the level of care that will be best suited for the patient, family and caregivers. As indicated above, 2% of patients admitted under our care, come in under Continuous Home Care. So, what is Continuous Home Care (CHC)?
Continuous Home Care is provided during a period of crisis. A period of crisis is a period in which the patient requires continuous nursing care to achieve palliation (pain control) or management of acute symptoms. Sometimes, the patient’s caregiver becomes unwilling or unable to continue providing care, is unable to understand the patient’s body language related to an increase in pain or other symptoms resulting in the caregiver being unable to provide care and a crisis develops that requires Continuous Home Care.
During Continuous Home Care, the hospice provides a minimum of 8 hours of nursing, hospice aide, and/or homemaker care during a 24-hour day, which begins and ends at midnight. Continuous Home Care does not need to be continuous, for example, 4 hours can be provided in the morning and another 4 or more hours in the afternoon or evening. The hospice must ensure that more than half of the hours of care are provided by a licensed RN. It is the policy of Aria Hospice that all Continuous Care will be initiated by the RN/Case Manager followed by Licensed Vocational Nurses (LVN’s). When providing Continuous Home Care, Aria Hospice practice is to provide at a minimum of 10 hours a day of Continuous Home Care.
Inpatient Respite Care (IRC) is a level of care available to provide temporary relief to the patient’s primary care provider, up to 5 days in a hospital, hospice facility, or a skilled nursing facility that has 24 hours licensed nursing personnel present. I find that this type of care, also known as ‘Respite Care’ can be tasking for the family and the patient because, under Medicare regulations, this type of care can only be provided up to 5 days for each Certification Period (a Certification Period is 90 days during the first and second period and 60 days thereafter). The reason I find this type of care tasking or inconvenient to the patient and the patient’s family is that the patient has to be moved to a skilled nursing facility, hospice facility, or a hospital for a 5 day period. The move can be tasking for the patient, very often is traumatic to the family and can be difficult for them to visit the patient as often as they would like due to problems with transportation as in the case of elderly spouses that are unable to drive or that visiting hours can be limited at the facility where the patient is residing. In addition, many skilled nursing homes find it difficult to release a bed for only 5 days because they may fear that in that period of time, they may lose a long-term care patient. And, currently, while we continue to suffer from the pandemic, this type of care is not the recommended care at this time. For those reasons, Respite Care is not used very frequently.
The fourth and last hospice level of care is General Inpatient Care (GIP), I see GIP as the next step after providing Continuous Home Care. It is a level of care provided for pain control or other acute symptom management that can not feasibly be provided in other settings. In order to provide the GIP level of care, the patient must be transported to a hospice or skilled nursing facility with whom the hospice has an agreement to provide this type of care. This level of care is mostly used when a patient is being discharged from a hospital and referred to hospice care but the patient continues to have symptoms that require daily nursing care that cannot be managed at home. In those cases, the patient is moved to a general medical surgical ward within the hospital, and the hospice nurse coordinates the care with the hospital nursing personnel. What I have found when dealing with this level of care with a hospital is that the hospice will have a signed agreement before providing the services and hospitals, typically are unable to execute an agreement immediately so they like to move the patient to a hospice with whom there is an existing agreement. This can cause a problem because when the patient and or family has already decided on a specific hospice to care for their loved one, the patient’s choice is not being honored.
As you can see, out of the four levels of hospice care, the most common is Routine Home Care and this is the care that most families and patients want to remain in, as the care is at home, or wherever the patient resides. Often, with the support of hospice, families are able to bring their loved one home, exactly where we all want to be, in the end. Home.
