The four levels of hospice care

The four levels at a glance

The level of care is a clinical decision based on the person's needs on that day. It is not a package that a family picks, and a higher level is not a better kind of hospice.

Routine home care

Routine home care is hospice as most people experience it. The team visits on a schedule set by the plan of care. Nurses manage pain and other symptoms and teach family caregivers. Hospice aides help with bathing and personal care. The social worker and chaplain visit as wanted. Medicines, equipment and supplies related to the terminal illness are delivered to the home.

"Home" means wherever the person lives. That can be a house or apartment, a family member's home, a residential care facility for the elderly (RCFE), a board-and-care home or a nursing facility. A hospice nurse answers the phone 24 hours a day, 7 days a week, and can visit when needed. Family or hired caregivers provide the day-to-day care between visits. See what hospice provides.

Continuous home care

Continuous home care is provided only when medically necessary during a symptom crisis, when the goal is to keep the person at home. Examples are pain that is not responding to the usual medicines, severe shortness of breath, uncontrolled nausea or vomiting, or severe agitation.

Under Medicare rules, this level means at least 8 hours of care within a 24-hour day, and more than half of those hours must be nursing care from a registered nurse or a licensed vocational nurse. Hospice aides may provide the rest. The team reviews the need every day. When the crisis settles, care returns to routine home care.

Continuous home care is not a way to get a caregiver in the home, and it is not used because a family is tired or a death is near. Those are real needs, and the team has other ways to help with them, including respite care.

General inpatient care

General inpatient care, often shortened to GIP, is provided only when medically necessary during a symptom crisis that cannot be managed in any other setting. The person moves for a short time to a hospital, a hospice inpatient unit or a nursing facility that has a contract with the hospice and has a registered nurse on site at all hours.

Typical reasons are pain or other symptoms that need frequent medicine changes and close nursing observation, or complex wound or breathing care that cannot be done safely at home. The hospice team still directs the care. Once symptoms are controlled, the person returns home on routine home care.

When general inpatient or respite care is needed, the hospice team confirms a contracted facility with an available bed and arranges the clinical handoff and transport before any transfer.

Inpatient respite care

Respite care is for the caregiver. If the person caring for someone at home needs rest, becomes ill, or has to travel for a family event, the hospice can arrange a short stay in a contracted facility. Respite care lasts up to 5 days at a time and is meant to be occasional. The hospice arranges transport and continues the plan of care during the stay.

Respite care is the one level with a routine cost share under Medicare: 5% of the Medicare amount for each respite day. We tell you the amount before the stay. When general inpatient or respite care is needed, the hospice team confirms a contracted facility with an available bed and arranges the clinical handoff and transport before any transfer.

Who decides the level of care?

The level of care is decided by the hospice team, led by the hospice doctor, using Medicare's definitions. Families play a real part because they see changes first.

1. Step 1

   You call when something changes

   New or worse pain, breathing trouble, agitation, or a caregiver who cannot go on. A hospice nurse answers the phone 24 hours a day, 7 days a week, and can visit when needed.

2. Step 2

   A nurse assesses

   The nurse checks symptoms, adjusts medicines with the doctor, and sees whether the problem can be managed at the current level.

3. Step 3

   The team and doctor decide

   If the person's needs meet the rules for a higher level, the hospice doctor orders it and the team explains the plan to you. Nothing changes without the patient or their representative knowing.

4. Step 4

   The level is reviewed

   Continuous home care and general inpatient care are reviewed every day. When the crisis passes, care steps back down to routine home care.

What do the levels cost?

Medicare covers hospice care related to the terminal illness. Under Medicare, most people pay nothing for hospice care itself. There can be a copay of up to $5 per prescription for symptom medicines and 5% of the Medicare amount for inpatient respite care. Medicare does not pay room and board where you live.

Medicare pays the hospice a set daily rate for each level, and the rate is higher for the three short-term levels. You do not pay the difference. During general inpatient care and respite care, the facility stay is part of the hospice benefit for those days. Medi-Cal follows the same four levels. See paying for care.

Common questions about levels of care