The Medicare Hospice Benefit (MHB) is the most common way to fund hospice care provided in nursing homes. Non-Medicare (e.g., private insurance and Medicaid) hospice programs are also available and will offer services unique to their respective plans. Coverage must be individually determined prior to initiating care.
The information below is provided to delineate the levels of care available to those residents enrolled in MHB.
By funding a wide range of services, MHB enables hospice programs to provide comprehensive care in the home or place of residence (including nursing homes, adult family homes, and alternative home settings) whenever possible. The MHB provides four levels of care to its beneficiaries. The following is a description of each level of care available to MHB participants:
Routine home care: provides basic hospice care in the home. If the patient resides in a setting other than a private residence, hospice does not cover room and board. The hospice team, including nurse, social worker, home care aide, chaplain, volunteer, and other disciplines, visits routinely and is available 24 hours a day to respond to urgent changes. The routine home care level of services also includes coverage of medications, medical equipment and supplies as necessary for the individual’s comfort care.
Continuous home care: during a brief, acute crisis that requires enhanced care to manage uncontrolled symptoms, nursing care may be provided on a continuous basis in order to meet the patient’s goal of staying at home. The care provided must be primarily skilled nursing in focus, with a minimum of 8 hours and maximum of 24 hours per day. Home health aide services may in some situations be utilized to provide a portion of this care; however, a licensed nurse must provide 50% or more of the continuous care.
General inpatient care: in a crisis or acute episode that cannot be managed at routine home level, a patient can be admitted to an inpatient setting as contracted and arranged by the Hospice. Patients who elect MHB waive their Medicare Part A benefits to cover an acute-care hospitalization for the care related to their terminal condition. Patients are not admitted to the acute-care setting in a traditional manner, but are “transferred” to a different level of hospice care. Hospice continues to direct and provide care during the general inpatient stay. Regulations require 24-hour access to registered nursing services at this level of care.
Examples of symptoms or conditions which may precipitate the transfer of a patient to continuous or general inpatient levels of hospice care, include:
Uncontrolled pain
Acute respiratory distress
Intractable nausea, vomiting or diarrhea
Severe pressure sores or hemorrhaging skin lesions
Acute and uncontrolled psychosocial problems, such as severe depression mandating a change in environment or acute breakdown in family dynamics
Inpatient respite care: is available to provide caregivers relief from day-to-day caregiving activities they provide at home, on a time-limited basis. This inpatient level of care is available in a Medicare-approved facility with which the hospice has a contract, and can be utilized for up to five days at a time.
Information adapted from: Center for Medicare Education, available at www.MedicareEd.org, and Kinzbrunner, BM. The Medicare Hospice Benefit. AAHPM Bulletin. Vol 1, #3, Spring 2001.