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COVID-19: documenting for hospice change in level of care

Link Healthcare Advantage and MatrixCare have teamed up to help give insight into what is happening within the industry and hopefully address some of those unanswered questions, that maybe you didn’t even know to ask.

Hospice conditions of participation require that four levels of care be provided to patients: Routine Home Care, Continuous Home Care, General Inpatient Care, and Respite Care. CMS data from the 2020 Wage Index identifies that less than 2% of hospice claims include days for continuous home care and general inpatient care. This has led me to wonder why is that such a low percentage? Is it because patients are well managed in the home and thus don’t need a higher level of care? Or is it because clinicians and agencies are unsure of what qualifies for the level of care? Along with qualifying the patient for care, the clinician must also document care provided that supports the need for a higher level of care.

Continuous Home Care (CHC) is provided for a period of crisis time requiring continuous care in the home that is a minimum of 8 hours in a 24-hour time frame (midnight to midnight). At least ½ of the time is provided by a nurse and the remaining hours can be provided by an aide. The goal of continuous care is to achieve symptom management and maintain the patient at home.

General Inpatient Care (GIP) is provided for symptoms or care that cannot be provided in the home. The care is provided in a Medicare-certified inpatient facility that has an RN on duty 24/7. Most GIP stays are less than three days.

The types of symptoms that may require CHC or GIP may include uncontrolled pain, uncontrolled nausea/vomiting, unmanageable respiratory distress, sudden deterioration of care requiring frequent skilled nursing interventions, complex wound care, agitation, or delirium.

Documentation must reflect the patient’s needs for a higher level of care. Prior to starting GIP or CHC, the interdisciplinary team should agree with the change and a physician order should be obtained for the higher level of care including in the order the reason for the change. The clinician that initiates GIP or CHC should complete a patient assessment and include in the documentation the symptom management issue and what has led up to the need for GIP or CHC.

During the GIP or CHC stay, documentation should be written more frequently than is done for a routine level of care. The documentation needs to demonstrate the need for more frequent interventions, medications, or nursing care needs. The following are suggestions for documentation to support a higher level of care.

  1. Each note should identify the symptom or need that the patient is experiencing that requires the level of care
  2. Clearly document the symptoms, interventions, and outcome of the intervention that was provided during that hour
    • Document medication, dosage and the time given and follow up with documentation if the medication worked (example 1:00 pm patient states their pain is now at level 8 -Morphine 10mg po given. 1:15 pm pain at level 6 per patient)
  3. Document non-pharmacologic care provided such as positioning, elevating the head of the bed, calm environment, or cool compresses.
  4. Document any caregiver issues that prevent the caregiver from providing care – this is part of the discharge planning process
  5. Document any education provided to caregivers
  6. Document updates and new orders from the physician
  7. At the change of shift – document handoff to oncoming hospice staff
  8. Oncoming hospice staff should perform assessment and continue with the documentation

Once a patient’s symptoms have improved then the patient should be transitioned back to routine home care level. Documentation should reflect that the caregiver understands any changes in care or medications and discuss the plan for the next visit. A physician order should be obtained indicating to resume the routine level of care.

Hospices are challenged with providing palliative symptom management and ensuring that the documentation reflects the care provided.  I recommend that any patient on a higher level of care have a 100% review of documentation each day to ensure that the patient is receiving symptom management and that the documentation supports the level of care.

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Disclaimer: we are not endorsing this information for the accuracy or validity of the content. We encourage you as appropriate, to verify clinical and regulatory content with your own trusted sources.

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