1. Hospice in Hospital - GIP and Beyond
Gregory Miller, MD

2. OBJECTIVES Document Hospice Levels of Care
Identify the regulatory requirements for general inpatient level of care
Describe patients who are eligible for and can benefit from higher level of care
Review options of providing multiple levels of hospice care within a hospital

3. HOSPICE LEVELS OF CARE Four levels of care two home-care levels
two inpatient levels

4. ROUTINE HOME CARE
Routine care provided in the patient’s place of residence, whether a private home, a nursing facility or prison
Benefit does not cover the cost of room and board

5. CONTINUOUS HOME CARE
Level of care intended for brief periods of crisis management of acute symptoms in a home setting
Patient must have a skilled-care need
Requires a minimum of 8 hours of direct care in a 24 hour period (50% of care provided by a licensed nurse)

6. GENERAL INPATIENT CARE (GIP)
This level is intended for control of acute pain or other symptoms that cannot be adequately managed in the patient’s home setting

7. RESPITE CARE For patients whose caregivers need relief
For no more that 5 consecutive days for each occurrence
Provided in a Medicare-approved facility (hospice inpatient facility, hospital, or nursing home)

8. LEVEL OF CARE DETERMINATION
Made by hospice interdisciplinary team
Reevaluated on a regular basis to assure appropriateness

9. MR. R.J.
54 yr. old male admitted to home hospice routine level of care with terminal diagnosis of progressive, heavily treated CNS lymphoma. Refractory head pain requiring repeated opioid dosing with ineffective titration of oral opioids. Pain poorly controlled, family distressed.

10. MR R.J. continued
Admitted to hospital under GIP level of care after family meeting, hospice team meeting.
Aggressive parenteral opioid titration, initiation of parenteral steroids, frequent monitoring by nursing and medical treatment team.

11. MR R.J. continued
On fourth hospital GIP days, after family and hospice team meeting, patient transferred home on morphine PCA with symptoms controlled.
Further titration of opioids occurred in home setting allowing a comfortable death 10 days later

12. GIP
The decision to change a patient’s care to the GIP level is based on the clinical condition of the individual
Requires the documentation of an acute change in the patient’s condition, requiring aggressive, intensive treatment for the management of symptoms
Documentation includes why the hospice was unable to manage at current level of care.

13. DISCHARGE PLANNING
Consideration of the discharge planning needs occurs the moment the patient transfers to the GIP level of care
The hospice (not the hospital discharge planners) is responsible for managing the discharge.
Documentation should show that the hospice is assessing the situation on a daily basis and planning for the transfer to another setting or level of care

14. GIP AT THE END OF AN ACUTE HOSPITAL STAY
Transfer to GIP hospice if there is a need for pain control or symptom management which cannot be feasibly provided in the home setting at hospital discharge

15. MR. RF
90 yo male admitted to hospital for respiratory distress after an aspiration event. 4th hospital admission in last year with history of advanced dementia and COPD.
Admitted to ICU
Palliative care consultation resulted in goal of care discussion with family: comfort care only

16. MR RF continued.
DAY 1: Patient transferred from hospital to hospice on GIP status for dyspnea. Use of accessory muscles, cough, increase in secretions, on morphine and lorazepam prn
DAY 2 : tachycardic, use of accessory muscles, coarse breath sounds, very short of breath with transfer to chair, requiring prn dosing of morphine and lorazepam

17. MR RF continued
DAY 3: up in chair, always short of breath, morphine x5/24 hrs, lorazepam x2/24 hrs
DAY 4: fatigues with minimal exertion, rales at bases; 2+ BLE edema. Morphine x 4, lorazepam x2. improved cardiovascular assessment. Discharge to home planned for next day.

18. GIP DOCUMENTATION Daily focused assessment on reason for GIP
24 hour summary includes intervention, orders, medication, procedures, diagnostics; outcome/results
Why this care cannot be provided in another setting

19. WHEN IS GIP NOT APPROPRIATE
Not intended for caregiver respite
Not intended as a way to address unsafe living conditions
Not an “automatic” level of care when a patient is imminently dying. There must be pain or symptom management and skilled nursing needs present

20. OFFICE OF INSPECTOR GENERAL OIG
2016 REPORT: Hospices inappropriately billed Medicare over $250 million for GIP
Hospices billed one-third of GIP stays inappropriately
Hospices commonly billed for GIP when the beneficiary did not have uncontrolled pain or unmanaged symptoms

21. OIG RECOMMENDATIONS TO CMS
Increase oversight of hospice GIP claims
Ensure physician involvement in GIP decision
Conduct prepayment reviews for lengthy GIP stays
Increase surveyor efforts to ensure hospice meets care planning requirements
Establish additional enforcement remedies
Follow up on inappropriate GIP stays