Background     In the United States, modern hospice care is guided by the Medicare Hospice Benefit (MHB), which pays for 80% of all hospice care (see Fast Facts #82, 87, 90).  Because most of hospice care is in the form of routine home care, clinicians may not be aware that the MHB specifies four different levels of hospice services to meet the diverse needs of dying patients and their family.   

1.  Routine Home Care:

• The most common type of hospice services in the United States.
• Hospice interdisciplinary team provides core services (see Fast Fact  #82) in the patient’s home.
• The patient’s home may be a private home, an assisted living facility, a boarding home, or a long-term care facility – wherever the patient lives.   

2.  Respite Care:

• Respite care is short-term inpatient care to relieve the family/primary caregiver.  Caregivers often schedule respite in order to travel or tend to their own healthcare needs.
• Respite is limited to 5 consecutive days. 
• The hospice agency may provide respite in a variety of contracted settings (e.g. inpatient facility, local nursing home, etc.).

3.  General Inpatient Hospice Care (GIHC):  The MHB provides for care to be provided in an acute care hospital or other setting where intensive nursing and other support is available outside of the home.  Criteria for this level of care include: 

• Uncontrolled distressing physical symptoms (e.g. uncontrolled pain, intractable nausea, respiratory distress, severe wounds, etc.).
• Psychosocial problems (e.g. unsafe home environment or imminent death where family can no longer cope at home).
• GIHC may be provided in a variety of settings
• Dedicated inpatient hospice facilities, where the patient is cared for by dedicated hospice staff.
• Contract beds, where the facility (hospital/nursing home) staff provides routine care, with supplemental services provided by hospice personnel.

4.  Continuous Home Care:  For hospice patients who qualify for GIHC, but desire to remain in their own home, continuous care (CC) intends to support the patient and their caregiver through brief periods of crisis. There is some published data that patients who did not have access to continuous care were more likely to be transferred from their home prior to death. 

• CC provides care for 8-24 hours a day. 
• Home health aide and homemaker services or both may be used to cover the care needs.
• Care must be primarily provided (more than 50%) by an LPN or RN.   

Under the MHB patients may be admitted into a hospice program at any level of care as determined by their individual needs and the patient may transfer between the levels of care as needed.  For patients whose hospice care is covered by a pay source other than Medicare, there may be limitations or specifications for the different levels of care. 

References

1. NHPCO Facts & Figures, 2014.  Alexandria, VA: National Hospice and Palliative Care Organization; 2014.  Most current version is available at:  http://www.nhpco.org/sites/default/files/public/Statistics_Research/2014_Facts_Figures.pdf Accessed July 10, 2015.
2. Kinzbrunner BM, et al.  20 Common Problems in End-of-Life Care.  New York, NY: Mc-Graw Hill; 2002.
3. Code of Federal Regulations, Title 42 – Public Health.  Chapter IV – Health Care Financing Administration, Department of Health and Human Services.  Subchapter B – Medicare Program, Part 418 – Hospice Care.
4. Barclay JS, Kuchibhalta M, et al. Association of hospice patients’ income and care level with place of death. JAMA Intern Med. 2013; 173(6):450-456

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in August 2005. Version re-copy-edited in April 2009; then again by Sean Marks MD in July 2015 — reference web-links updated and reference #4 added and incorporated into the text.