Background: The most common level of hospice care under the Medicare Hospice Benefit (MHB) is routine home care, wherein the interdisciplinary team cares for the patient in their home via scheduled visits and round-the-clock phone access to nursing care. Crisis situations may arise in hospice care, however, where a patient’ s comfort, safety, or clinical needs cannot be managed by routine home care. Continuous home care (CHC) is an option under the MHB that can help patients remain in their home even if there is an acute care crisis. This Fast Fact summarizes CHC and distinguishes it from general inpatient (GIP) (Fast Fact #415) and other levels of hospice care (see Fast Fact #82, Fast Fact #87, Fast Fact #90, Fast Fact #139, and Fast Fact #140).

​​​​​​​​​What is continuous home care (CHC)? CHC is one of the four levels of MHB care that all Medicare-certified hospice entities must provide (others being routine home care, GIP, and respite) (1). Published data suggest around 11% of hospice patients receive CHC, but there is significant regional and cultural variability (2,3). CHC is meant to address a period of clinical crisis where a patient requires an escalation in nursing care to keep them comfortable at home. A CHC day is defined as a midnight-to-midnight 24-hour period in which at least 8 hours of direct patient care core services are provided, which can be split up throughout the day (e.g., 4 hours in the morning, 4 hours in the evening). Nursing care must be predominant, but it can be supplemented by a hospice aid and/or homemaker care (4,5).

What clinical circumstances qualify for CHC? There is no definitive or exhaustive list of circumstances that automatically qualify for CHC, and each patient scenario is evaluated on a case-by-case, day-by-day basis. Determining CHC qualification is complex and involves multiple care factors. Not every patient on MHB qualifies for CHC. In general, the hospice agency, not the clinician of record, will ultimately determine CHC eligibility. Still, it is helpful for clinicians to be aware of the general CHC requirements:  

• ​​​​​Skilled nursing monitoring of distressing symptoms and acute clinical status changes;
• Skilled nursing care to administer medications and/or other interventions for distressing symptoms;
• AND the patient/family are aiming to avoid a hospital, nursing home, or hospice facility admission.

​​​​​This escalation in care needs can be driven by a change in medication(s), rapid clinical deterioration, and/or a collapse in the patient’s support system (1). Nursing care is required for at least 50% of the direct patient service hours. CHC is not intended as respite care for caregiver fatigue with non-skilled nursing care (such as bathing, ambulation assistance or meal preparation), or as a solution to patient placement difficulties. However, if a patient’s caregiver(s) was providing a skilled level of care that would otherwise require the skills of a nurse (RN, LPN or LVN), and the caregiver(s) is now unable or unwilling to provide this care, CHC could be considered (1). Clinical examples include:  

• A patient with brain metastases experiences new-onset seizures and refractory vomiting. Their spouse is unable to assess and intervene in the patient’s symptomatology, and at least 8 hours/day of direct skilled nursing care is required at bedside.
• A patient suffers an aspiration event, becomes acutely dyspneic, and is clinically deteriorating. Their spouse/primary caregiver is hospitalized, and nursing level of care is required in the home.
• Other scenarios associated with CHC – terminal hemorrhage, hyperactive delirium, severe pain crisis.

What if a patient does not qualify for CHC? The patient would either continue with routine home care or be evaluated for GIP, hospitalization, or respite care. They could also be considered for routine hospice care in a care facility (e.g., long term care facility, free standing hospice), though this usually involves a facility room and board fee that may not be covered by hospice (4). 

Where can CHC be provided? For how long? CHC is provided at the patient’s home, which can be a private home, assisted living facility, or non-skilled long-term care facility. CHC cannot be provided in a hospital, inpatient hospice facility, or skilled nursing facility (5). It should be provided only as long as necessary for the patient’s clinical crisis to subside. Depending on the clinical course, the patient should be transitioned back to routine home hospice care, respite care (e.g., caregiver fatigue), or GIP.

Is CHC effective? Retrospective studies suggest that CHC initiation decreases the odds of dying in an inpatient setting by 70%, hospice disenrollment by 80% decrease, and hospitalization by 60% (3,6).

Challenges with CHC Among the four MHB levels of care, CHC is the most staffing-intensive and expensive. It places a significant burden on hospice resources, which is exacerbated by nationwide nursing shortages. Many hospices do not have the staffing to provide CHC routinely and may have to contract staff as emergency supplementation if CHC is needed (7). Variable use of CHC by hospice agencies contributes to varying levels of experience and comfort with providing CHC to patients.

Summary: Most patients with terminal illness desire to die at home; however, acute care crises can make it challenging to keep patients in their home even with the support of hospice care. Clinicians should be aware of CHC as an option in select cases to manage end-of-life crises in the patient’s home.

References  

1. Centers for Medicare and Medicaid Services. Electronic Code of Federal Regulations. Title 42, Chapter IV, Subchapter B, Part 418 – Hospice Care. Available at: https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418?toc=1. Accessed 12/15/2024.
2. Medicare Benefit Policy Manual. Chapter 9 – Coverage of Hospice Services.
3. Lee EJ, Lee NR. Factors associated with place of death for terminal cancer patients who wished to die at home. Medicine (Baltimore). 2022;101(39):e30756. doi:10.1097/MD.0000000000030756.
4. Wang SY, Aldridge MD, Canavan M, Cherlin E, Bradley E. Continuous Home Care Reduces Hospice Disenrollment and Hospitalization After Hospice Enrollment. J Pain Symptom Manage. 2016;52(6):813-821. doi:10.1016/j.jpainsymman.2016.05.031.
5. Under Hospital Insurance. Revision 12696, 2024. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf. Accessed 12/15/2024.
6. Medicare Claims Processing Manual. Chapter 11 – Processing Hospice Claims. Revision 12847, 2024. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c11.pdf. Accessed 12/15/2024.
7. Casarett D, Harrold J, Harris PS, et al. Does Continuous Hospice Care Help Patients Remain at Home?. J Pain Symptom Manage. 2015;50(3):297-304. doi:10.1016/j.jpainsymman.2015.04.007.

Author’s Affiliation: University of Iowa, Sioux City, IA
Conflicts of Interest: The author has declared no relevant conflicts of interest.
Version History: First electronically published in April 2025; originally edited by Sean Marks MD.