hospice continious home care

Monday, March 19, 2007

Hospice Continious Home Care

I have not talked much, if any, about the different levels of hospice care provided for by the Medicare Hospice Benefit. I’ll try to rectify that over the next few weeks.

First, I want to deal with Continuous Home Care, because it is the most misunderstood, confusing, or abused portion of the Medicare Hospice Benefit. The confusion comes from a bit of a vague description of what qualifies a patient for continuous care and the fact that continuous care doesn’t actually have to be continuous. Many hospices use CHC as a marketing tool to nursing homes, and that has only added to the problems within the hospice community. I’ll deal with the marketing portion more later. First, let me try to define and explain what Continuous Home Care is supposed to be.

In its most basic form, Continuous Home Care is used by the hospice for patients who need skilled nursing care to control acute symptoms. It allows the hospice to place appropriate staff members in the home setting for large chunks of time to get acute problems under control. It is the best weapon a hospice has to avoid a patient needing to be hospitalized.

The Hospice Training Manual from Palmetto GBA (one of the Medicare Intermediaries charged with processing hospice claims) gives these bullet points when discussing coverage of Continuous Home Care:

· Continuous home care should be provided only during a period of crisis as necessary to maintain the terminally ill individual at home.
· A period of crisis is defined as a period in which a patient requires predominately nursing care to achieve palliation or management of acute medical symptoms.
· If a patient’s caregiver has been providing a skilled level of care for the patient and the caregiver is unwilling or unable to continue providing care, this may precipitate a period of crisis because the skills of a nurse may be needed to replace the services that had been provided by the caregiver.
· The hospice must provide a minimum of 8 hours of care during a 24-hour day.
· When ensuring the 8-hour requirement has been fulfilled, remember that the 24-hour day begins and ends at midnight.
· The care need not be “continuous.” For example, 4 hours of care may be provided in the morning and 4 hours may be provided in the evening.
· Nursing care must be provided for more than half of the period of care and must be provided by either a registered nurse or licensed practical nurse.
· Nursing care in the hospice setting can include skilled observation and monitoring when necessary and skilled care needed to control pain and other symptoms.
· Homemaker or home health aide services may be provided to supplement the nursing care.

It actually doesn’t seem confusing when you read the manual, but, as they say, “there’s many-a-slip between a cup and a lip”. What seems easy to define becomes much harder when you add the business side to the equation. Hospices can make good money doing continuous care. The rough math is this: Medicare pays $30/hour for continuous care. A hospice pays a LPN $16/hour or an Aide $11/hour for working a continuous care case. Thus, there is money to be made here. Continuous care is also a popular benefit. It is done when families are at a place where they are not confident about their ability to care for their loved one. At that point, who wouldn’t want a nurse to come stay with them?

As a hospice owner/administrator it is easy to fall into the trap of thinking that Continuous Care is always justifiable. Make money – good! Make the family happy – good! Add to that, the possibility of marketing this service to nursing homes, and it’s almost hard to resist abusing this benefit. If there are two hospices “competing” for patients in one nursing home and one promises to do continuous care for all “actively dying” patients while the other says that continuous care must be evaluated on a case by case basis who do you think the nursing home will choose? They want the hospice that is going to put a staff member in the patients room, so they won’t have to do all the work that comes with a dying patient. It makes their life easier, so they want it.

The Palmetto manual says:

A period of crisis is defined as a period in which a patient requires predominately nursing care to achieve palliation or management of acute medical symptoms.

If a patient is dying peacefully, there are no acute medical symptoms to manage. Thus, I believe that symptom controlled death does not meet the standards of Continuous Home Care.

Palmetto provides a little wiggle room with this though:

If a patient’s caregiver has been providing a skilled level of care for the patient and the caregiver is unwilling or unable to continue providing care, this may precipitate a period of crisis because the skills of a nurse may be needed to replace the services that had been provided by the caregiver.

To me, this means that a caregiver freaking out because of the impending death of a loved one can justify continuous care, but, since a nursing home is seen as the primary caregiver, that could never apply to a patient in a nursing home.

There are a lot of people that disagree with me here. Their logic is what I explained above. If it makes good business sense and is good for the patient, then how can it be wrong? Because it is against the rules, that’s how. A hospice that provides continuous care for all dying patients has chosen to ignore the regulations which is convenient and illegal. Those that market their lack of good judgement as a selling point make it hard on everyone who values following the Medicare regulations. There are times where Continuous Care is appropriate, and those hospices who don’t do Continuous Care (or try to avoid it) because “it is hard to staff” are just as much guilty of wrong here as those who overuse it. Continuous Care is a very valuable tool that a hospice can use to help a patient/family, but it must be used in a responsible evenhanded manner. (If you are doing continuous care to help the nursing home instead of to help the patient, then you’ve clearly gone over the the dark side.)

I would guess that this is the first post on this blog where I have argued against giving a patient more help. This whole discussion goes against my most basic instinct of putting the patient first. I believe the logic above is correct, but it still feels wrong. That feeling in my gut is why this is such a misunderstood or abused level of care. If you break the rules for all the right reasons don’t the ends justify the means? I guess I’ll let you tell me.


Bob F

This seems a bit like setting up a straw man and then knocking him down. You’d be correct if every single patient were certified by a hospice for continuous care, but not every patient is — or else the hospice risks audits by Medicare, the state licensing authority, or both. Let’s face it — most nursing homes are not that great and really can’t meet the standard of continuous care when it’s needed the most.


I totaly agree with you on this one. I work with a local hospice agency here in Milwaukee and were recently surveyed by state. We asked about the apropriateness of CHC in Skilled nursing homes where 24 hour nursing care is available. The response was “This type of care is not meant for facitilies that already have 24 hour skilled nursing care”. Hospice providers that market CHC to skilled nursing facilities are not only opening themselves up for a state audit but also risk being fined for offering inducements.


In response to continuous care you are exactly right on the billing side and regulations. But, no where in the medicare regulations does it say that you as a hospice can’t provide continuous care for free(that means not billing). I would not want to die alone or be a scared family member because I was not billable. Would you? The problem with the hospice community is everyone is worried about what everyone else is doing instead of thanking god you can help his people.


I find this blog so informative… and i find it interesting that while i have a father dying in the last stages of ALS in a paralized state… hospice has offered us 20 hours of nursing a WEEK!!! that is the time each day it takes to clean and feed an invalid and doesnt begin to address his breathing issues… i hope the ALS community takes care to read this blog as they assumed we would get all the care we needed from the hospice they recommended and we are fighting for every inch we *know* we can ask for.


As a hospice nurse of five years I agree with you about CHC being abused if the patient is dieing comfortably. When CHC is initated for this type of patient, the nurse is getting paid to sit there because there are no symptoms to manage. I also believe that Nursing homes look at CHC as a way to replace their staff. It is supposed to be additional care, not replacement care. Isee CHC being abused more and more as hospices try to make a profit.

Kristi, CHPN

I’m director of a hospice in Norman Oklahoma and have been in the hospice industry for 12 yrs. In that time I have watched many hospice struggle with this issue. CHC has been abused, overbilled and even used as a marketing tool by some agencies to lure patients to thier agency. CHC is a very important and wonderful service hospice can offer but only in a true crisis. The reality is that if hospice care has been provided well throughout the course of service, the patients needs have been anticipated and addressed and the families well prepared, there are very few true crisis situations. I am very proud to say that we seldom provide CHC because we dont need to. Our patients are well maintained and in the event issues do arise, we can almost always resolve the mini-crisis in less than 8 hours – the required time for CHC. I also think the fact that our RN’s are CHPN’s greatly impact the level of care we provide.


Being “in the field” w/ these pt’s and their families, I know that most often we are considered a god-send, both for the pt w/ sx’s out of control and to their families who are distraught and heartbroken watching their loved ones suffer. It is very difficult for me to explain to these families why we are discontinuing crisis care, despite the fact that I now understand the administrative side of what I do. It’s a double-edged sword, really…. you have to have empathy, compassion, you have to be a very caring individual to do this work sucessfully, but you must also not care too much, and guard against family members convincing you that you need to stay.


I also work with a hospice that abuses this continuous care blessing. I believe it looks bad to have so many patients on cont. care because it means that symptoms are out of control. I try to stand up for what I believe in but it’s like fighting an army. Medicare needs to audit more and crack down on the abusers of cont. care. In the end those with strong ethical values will win the fight! It should truly be about the patients not the PAYCHECK!!!!!!!!!


OK, here's my question. I was TOLD by a hospice here in Illinois (trying to get my business), that because my father was w/i 2 weeks of dying (we ended dialysis), they would provide two 12 hour shifts of continuous care (one CNA in the AM hours, and one LPN in the pm hours). However, as you might imagine, it is not the same individual, but, I was just told that after only 4 days of continuous care that I should be charting and giving medications. I don't understand? I would have opted to have my father go to a hospice wing of a hospital vs. coming home because I have so very limited experience with end of life care. The hospice LPN last night made a medication error, and this morning neglected to give a much needed medication. Now, we have to wait for the Hospice RN because my father has a G-Tube & the CNA is not authorized to give medications. Is this the kind of standard of care that Hospice provides? Please tell me it's not so…. Karen in IL

Hospice Guy

I have created a post about your comment where I give an answer and hope others will answer also. You can find that post at: http://www.hospiceblog.org/2009/02/continuous-care-issues.html


help in ma

We just brought my 90 yr old dad home (to my 78 year old mother who is not strong with myself who lives 60 miles away helping) with hospice from rehab – he has had CHF 4x this year…we are having issues with his INR and switch from lasix to bumex – he is not eating or drinking much at all, and difficulty managing nights. I am confused as to what we are able to receive from hospice…we were advised by them that they provide a health worker 2 hours day 5 days week and a volunteer – not sure yet what hours are for volunteer, and a nurse and caseworker checking in. In the short run while we deal with what his future ability will be, is there anything else we are entitled to? He has medicare and medex BCBS bronse


Any care provider service is welcome. People need to know that they have someone to turn to when they need care or help.


…ok, here's my two cents. I've been combing through the actual Federal Regulations (42 CFR Part 418) that govern Hospice…

As far as I can tell, this very well intended program simply falls flat and converts patients into cash cows for Hospice providers.

In my own case -my mom is currently in the hospital and will likely die by the time anyone reads this- my mom is being sent home to die and hospice will not provide a daily service of having suction her before she drowns in phlegm.

The Dr says I can do it myself after they show me how to do it.

Can you imagine that? Your 82 year old mother gasping/gurgling as phlegm chokes her last breath and you have to shove a plastic tube down through her nose…

You would think the hospice provider could send an RT once a day to perform the needed service which is plainly obvious.

At any rate, I'm very disappointed in the cold, calculated manner of this hospice program and the Fed.

Fortunately for my mom and my sanity, I'm able to hire someone to fill in this gap. But it saddens me to know that so many lone elderly are out there with no one to fend for them.