Levels of Hospice Care

Hospice evolved in the United States with the intention to provide comprehensive services to patients at the end of life in the most comfortable environment possible. This is usually the patients own residence, whether the patient is living in their own home, in a family members home, or in a nursing care facility. There are times, however, that patients require more care than is possible to deliver with the usual scope of services provided by hospice. Adding to the problem is that under the Medicare Hospice Benefit a patient is no longer entitled to hospitalization benefits under Medicare Part A. Because of this, hospice provides four levels of care to address patient needs.

Routine Home Care

Routine home care is the basic level of care under the hospice benefit. If a patient resides in a nursing home, it can also be called routine nursing home care. It includes:

• Nursing services – A nurse usually visits 1-3 times per week based on patients needs. Can be more often if needed.
• Physician participation – attending physician, following physician, hospice physician, and specialists as necessary
• Medical social services
• Home health aide services – A home health aide usually visits 2-3 times per week based on patients needs
• Counseling services (pastoral, spiritual, bereavement, dietary, and others as necessary)
• Medications
• Medical equipment
• Medical supplies
• Lab and diagnostic studies related to terminal diagnosis
• Therapy services (physical, occupation, speech) if needed

Continuous Home Care

If a patient develops physical or emotional symptoms that aren’t easily managed with routine care, continuous care may be an option. Continuous care provides more intense care in the patient’s home environment. A nurse and/or a home health aide will remain in the patients home environment for a minimum of 8 up to 24 hours per day to administer medications, treatments, and support until the symptoms are under control. Some examples of symptoms requiring continuous care would be unrelieved pain, severe nausea and vomiting, severe shortness of breath, anxiety or panic attacks, or a breakdown in the primary caregiver support system. Continuous care is considered a short term level of care and is reevaluated every 24 hours.

General Inpatient Care

Some patients may have symptoms so severe that they cannot get adequate treatment at home or they may feel more comfortable getting treatment at an inpatient facility. For these patients, inpatient care may be an option. Some patients may already be living in a facility that offers inpatient level of care and can benefit from its services. Others would have to be admitted to an inpatient facility.

Symptoms requiring inpatient care are the same as those requiring continuous care (above), only the setting of care may be different. With inpatient care, nurses are available around the clock to administer medications, treatments, and emotional support to make the patient more comfortable. There are three types of facilities that may offer inpatient hospice services:

1. Free standing facility – These are owned and operated by a hospice company and are staffed with hospice trained staff. There is a limited supply of these types of facilities and may not be an option for everyone in need.
2. Hospital – A hospice company may lease a unit in the hospital to provide inpatient care. In this case, hospice trained staff would provide around the clock care. A company may also have a contract with a hospital which would allow hospital staff to provide 24 hour care with hospice staff supplementing care.
3. Long term care facility – As with a hospital, a hospice company may lease a unit in a nursing home or contract with the nursing home to provide care.

As with continuous care, inpatient care is considered short term and would be discontinued once a patient's symptoms were under control and they were comfortable. If the patient was admitted to an inpatient unit, they may then be discharged back home.

Respite Care

This level of care is used more for the family than for the patient. If the patient does not meet criteria to qualify them for continuous care or inpatient care but the family is having a difficult time, respite care may be an option. If a patient’s family is the primary source of care and cannot meet the patients needs due to caregiver stress or other extenuating circumstances, a patient may temporarily be admitted to an inpatient environment to give the family a needed break or respite. Respite care is limited to five consecutive days at a time. Once that period expires, the patient would be discharged back to home.

Determining Level of Care

A patient can be admitted to hospice on any level of care that is necessary at that time. A patient may also be transferred between levels of care as their needs change. For example, a patient may be admitted to hospice on continuous care because they are in a great deal of pain. After 12 hours the pain is under control and the family has been well prepared to treat the patient's pain themselves. The patient is then transferred to routine care. A few weeks later, the patient’s family experiences a crisis that leaves them unable to cope with caring for the patient. The patient is then admitted to an inpatient facility for respite care but is discharged back home after 3 days when the family feels ready to resume care. The idea of having four levels of care is to never leave the patient or their family to deal with a crisis situation on their own.