RoundsHospice and palliative care
The four levels of hospice care, explained
Medicare defines four levels of hospice care, from regular visits at home to nursing at the bedside through a crisis. What each one is, when it’s used and what it costs a family.
Listen to this note
Most families picture hospice as one thing: a nurse who visits. Medicare actually defines four levels of hospice care, and a family may need one of them, or all four in a single week. Knowing what each level is helps you ask for the right one when things change, often in the middle of the night. This note walks through each level with Medicare’s own rules.
The short answer
Medicare pays a hospice for four kinds of days.1
- Routine home care: regular visits from the hospice team wherever the person lives.
- Continuous home care: nursing at the bedside for long stretches during a crisis, so the person can stay home.
- General inpatient care: a short stay in a hospital, a skilled nursing facility or a hospice inpatient unit when pain or symptoms can’t be managed at home.
- Inpatient respite care: a short stay in a facility so the family caregiver can rest.
The level can change from one day to the next. A person isn’t placed in a level and left there. The hospice team moves them as their needs change, and back again when things settle.
Routine home care
This is the level most people are on most of the time. The hospice team comes to wherever home is: a house, an apartment, assisted living, a board and care home or a nursing home. The nurse visits on a schedule set in the plan of care, and the aide, social worker and chaplain come as the plan calls for them.
Between visits, the family isn’t on its own. Medicare requires a hospice to have nursing services, physician services, and drugs and biologicals routinely available 24 hours a day, 7 days a week.2 In practice that means a phone line answered at any hour, and a nurse who comes out when a call needs a visit.
Routine home care is not someone in the house around the clock, as our note on 24-hour care explains. Families give most of the day-to-day care, or arrange it with paid caregivers, and the hospice team supports them. If you’re worried about that gap, say so at the first visit. Many families share that worry, and the plan of care should answer it.
Continuous home care
Sometimes symptoms flare: pain that won’t come under control, breathing that becomes hard, sudden agitation, bleeding. Medicare calls this a period of crisis. During it, continuous home care brings nursing to the bedside, at home, for as much as 24 hours a day, so the person doesn’t have to go to the hospital to get through it.3
Medicare sets the terms. The care has to be mostly nursing, because the goal is to bring acute symptoms under control. Aides and homemakers can help alongside the nurse.3 And a day only counts as continuous care when at least 8 hours of care are given in that day.1
Continuous care is meant to be temporary. When the crisis passes, the person goes back to routine home care. If the symptoms can’t be brought under control at home, the next level is general inpatient care.
General inpatient care
General inpatient care is a short stay for pain control or symptom management that can’t be handled at home.4 It happens in a hospice inpatient unit, or in a hospital or skilled nursing facility that works with the hospice. The hospice stays in charge of the care, and the stay ends when the symptoms are under control and the person can safely go home.
Families sometimes worry that a hospital stay means hospice has ended. It doesn’t. A general inpatient stay is part of the hospice benefit, and it’s for comfort, not for treatment to cure the illness.
Inpatient respite care
Caring for someone at the end of life is exhausting, and Medicare plans for it. Respite care is a short inpatient stay that gives the family caregiver a break, given only when it’s needed to relieve the people doing the caring. Medicare pays for up to five days in a row.3
Respite can be used more than once, on an occasional basis.3 Use it before you reach the end of your rope, not after. A rested caregiver is better for the person they love.
Who decides, and how
The hospice team decides the level together with the hospice physician, based on what the person needs that day. Families can start that conversation. A call to the hospice line describing what you’re seeing is a good way to begin it. Say what you’re seeing, when it started and what you’ve already tried, and the nurse will take it from there.
Things worth calling about right away:
- Pain that the plan of care isn’t controlling
- Breathing that has become hard or fast
- New confusion, agitation or restlessness
- A fall, bleeding or a sudden change
- A caregiver who can’t keep going
Medicare also requires every hospice to offer the full set of services in the benefit, including short-term inpatient care and respite care.4 Ask any hospice how it handles each level before you choose it. HealthView provides all four.
What each level costs a family
With Original Medicare, there’s no deductible for hospice care, whichever level it is. Drugs for pain and symptoms are covered when they’re part of the plan of care, and there usually isn’t a co-pay for them. Inpatient respite care can cost 5% of the Medicare-approved amount.5 Room and board isn’t part of the hospice benefit for someone who lives in a facility, except during a short inpatient or respite stay.5
Medi-Cal and most health plans cover hospice too. Our intake team can check a family’s coverage when you call.
Questions families ask
Can my mom go from routine care to continuous care and back?
Yes. Levels change with need. Continuous care is for a crisis, and the person returns to routine home care when it passes.3
Does continuous care mean a nurse moves in?
For the length of the crisis, nursing care can be at the bedside for as much as 24 hours a day. It ends when the symptoms settle.3
If my dad goes to the hospital for his symptoms, does hospice stop?
Not if it’s a general inpatient stay arranged by the hospice for pain or symptom control. That stay is part of hospice care.4
How long can respite care last?
Up to five days in a row, from time to time.3
Sources
Sources 5 references
- 42 CFR 418.302, “Payment procedures for hospice care.” Legal Information Institute, Cornell Law School. law.cornell.edu (opens in a new tab)
- 42 CFR 418.100, “Condition of participation: Organization and administration of services.” Legal Information Institute, Cornell Law School. law.cornell.edu (opens in a new tab)
- 42 CFR 418.204, “Special coverage requirements.” Legal Information Institute, Cornell Law School. law.cornell.edu (opens in a new tab)
- 42 CFR 418.108, “Condition of participation: Short-term inpatient care.” Legal Information Institute, Cornell Law School. law.cornell.edu (opens in a new tab)
- Centers for Medicare & Medicaid Services, “Medicare Hospice Benefits,” Product No. 02154. medicare.gov (opens in a new tab)
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