Hospice in Hospital GIP and Beyond Gregory Miller

Hospice in Hospital - GIP and Beyond Gregory Miller, MD

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

HOSPICE LEVELS OF CARE • Four levels of care – two home-care levels – two inpatient levels

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

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)

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

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)

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

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.

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.

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

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.

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

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

MR. RF • 90 yo male admitted to hospital for respiratory distress after an aspiration event. 4 th 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

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

MR RF continued • DAY 3: up in chair, always short of breath, morphine x 5/24 hrs, lorazepam x 2/24 hrs • DAY 4: fatigues with minimal exertion, rales at bases; 2+ BLE edema. Morphine x 4, lorazepam x 2. improved cardiovascular assessment. Discharge to home planned for next day.

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

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

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

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