Your are reading Part 2 of my series, “What to expect from your hospice nurse.” To gain full perspective, I encourage you to start from the beginning by visiting the series landing HERE.

Medicare Guidelines for Hospice Nursing Care

Hospice in the United States is regulated by Centers for Medicare & Medicaid Services also known as CMS. While some of the rules that regulate hospice care can be very specific, there are also A LOT of gray areas. Today, I will address some of the regulations that will guide some of your nurse’s behavior and your overall care.

This is NOT an exhaustive review of the CMS guidelines for hospice care. I will cover some of the most important guidelines. At least what I think is most important.

Your case manager is an RN (Probably)

In general, hospice nurses have 3 types of assessments. They are The Initial Comprehensive Assessment, the Comprehensive Assessment and the Focused Assessment.

Only an RN can complete the Initial Comprehensive Assessment and the Comprehensive Assessment. An RN or LPN/LVN can complete a focused assessment.

It is a CMS requirement that the Initial Comprehensive Assessment be completed within the first 48 hours of admission into hospice care. This is completed by an RN. This RN may or may not be your case manager depending on agency policy.

Once the Initial Comprehensive Assessment is completed, you are on a specific schedule. That schedule is mandated by CMS. CMS requires that, at a minimum, a Comprehensive Assessment is completed every 15 days. This is the trigger to assign you an RN Case Manager.

Some agencies will use an LPN/LVN as a case manager. This can be done, but an RN will still have to make a visit at least every 15 days to complete the Comprehensive Assessment.

The IDG/IDT

The nurse is not the only member of the hospice team. The CMS guidelines designate 4 required members of the Interdisciplinary Group/Interdisciplinary Team. Also known as IDG/IDT.

This group is made up of a Medical Director that is either an MD or DO, an RN, a Medical Social Worker and a Chaplain. Without these 4 members, a hospice agency is non-compliant and subject to disciplinary action.

The IDG/IDT is required to meet every 15 days to review all the patients on service. During this meeting the Medical Director will hear from the RN, Chaplain and Social Worker. They work together to create and adjust the overall plan of care for each patient.

As a patient or caregiver, you do have the right to attend this meeting. I would only recommend such action in the most extreme of situations. Your nurse, social worker and Chaplain are perfectly capable of handling whatever needs that may arise. Still, it is not widely known that you have a right to attend this meeting, so now you do.

Hospice includes 4 levels of care

Routine: Most patients enter hospice on routine level of care. This care is provided wherever the patient calls home. This includes nursing homes, assisted living facilities and residential care facilities.

Respite: Caring for a loved one who is on hospice can be exhausting. Due to caregiver fatigue, hospice providers are required to provide respite services. To provide the caregiver with a break, the patient is placed into a Medicare or Medicaid certified facility for 5 nights.

Continuous Home Care: Sometimes, symptoms can get out of control. When this happens, your hospice agency can initiate Continuous Home Care. Continuous can include a nurse and a nurse aid, but the majority of Continuous Home Care is provided by a nurse per Medicare regulations. Once the patient’s symptoms are back under control, the patient will return to Routine Care.

General Inpatient Care (GIP): When symptoms cannot be managed at home, Inpatient Care can be provided by the hospice agency. Inpatient Care, like Respite, must be provided in a Medicare or Medicaid certified facility. This can include long-term-care facilities as well as a hospital or a hospice owned facility like a Hospice House. It should be noted that the GIP level of care is not for patients when they are dying. Hospice Houses and other GIP facilities are for uncontrolled symptoms. Once those symptoms are under control, the patient could be returned back home for Routine care. Even if they are in their final days of life.

Certification and benefit periods

There is one person, and one person only who determines your eligibility for hospice services. It is the hospice Medical Director. The IDG/IDT will discuss your case during the 15 day meetings, and the Medical Director will use this information to make his decision, but ultimately, he is the one who will write and sign the Certificate of Terminal Illness (CTI). This document is ultimately what allows you to remain on hospice.

There are benefit periods with hospice care. You do not have to do anything to manage the benefit periods. Still, I think it is helpful for you to know about them.

The hospice benefit periods are broken into 2 ninety-day benefit periods and then unlimited sixty-day benefit periods. Prior to each benefit period, your hospice case manager will gather data from your case and present it to the Medical Director for review. The Medical Director will then write the next CTI so you can remain on hospice.

Sometimes, patients do get discharged from hospice for being deemed no longer terminally ill. This is rare in hospice, and the national rate is around 20%. There are a lot of factors that play into this. Rather than try to address live discharges here, I recommend you discuss this with your hospice provider.

I could go on for quite a while trying to explain all of the CMS guidelines for hospice care. What I have provided above should be adequate for this series. Should you have any questions please feel free to ask them in the comments. I will answer them as best as possible.

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James

James worked on-and-off as an LPN for over 20 years. In 2014 he completed a bridge program and became an RN. James became a hospice nurse in January 2015. He lives in the Kansas City area with his wife of over 30 years, 4 daughters and 2 sons in law.