In hospice, the question of 24-hour care is a complex one. The answer is “yes,” hospice provides continuous care in some circumstances, but other circumstances would require families to supplement the care of hospice.
Hospice Continuous Care
The hospice benefit entails primarily intermittent care. This means visiting the home a few times per week up to daily. These visits typically last less than an hour. However, the traditional Medicare hospice benefit also recognizes that there are times when patients require continuous care. Medicare allows for continuous care when patients present with an acute skilled need for nursing. This applies specifically to nursing related to palliation. While Medicare states that imminent death is not in and of itself a skilled need, the skilled need for continuous care often corresponds with the last hours of life. Examples of continuous care include frequent medication or care adjustments needed to control symptoms; monitoring and treatment for new onset seizures; and multiple visits in one day to monitor oxygenation problems.
Oddly, while provision of continuous care for a certain percentage of hospice cases emerges as a quality indicator, federal regulators are stepping up scrutiny of continuous care in a way that discourages it. Regulators seem to be concerned that hospices may be providing aide service and other services at a level that is not medically necessary to induce patients to enroll. Under federal law, giving away anything as an inducement for people to use federally insured services is illegal. Generally, this law is meant to apply to gifts, bribes, discounts, and coupons. Nevertheless, with much complexity, it can also apply to giving away services. Paradoxically for hospice agencies, providing continuous care can invite costly inspections.
Inpatient Hospice Care
Caring for a loved one with high personal care needs takes a physical and emotional toll on the caregiver. On occasion, the family caregiver will need more of a break than that provided by the visits of nurses, aides, and volunteers. In these cases, the hospice provider can check a patient into a 24-hour personal care home that is staffed for hospice patients. This is covered under the hospice benefit, so the Medicare-certified hospice agency will often have a particular home that it works with. Inpatient respite care is not needed in most cases, but the hospice benefit does make it available just in case.
Private-Pay Home Care
For the most part, the Medicare home hospice benefit is intended for patients and families that can handle a patient’s personal care needs with some intermittent support. Also, home hospice is only appropriate for patients whose medical needs can be satisfied by numerous home visits and 24/7 on-call nursing. This does not mean Medicare-funded home hospice and family caregivers are the only home care options, though. Private-pay home care as a supplement to hospice care presents as a third option. When families pay for at-home personal aide support and/or private-duty nursing, the complexities of Medicare regulations largely disappear. Some Medicare-certified hospice agencies provide private-pay services, but most do not. Managing the complexities of where Medicare benefits end and private-pay services begin can be problematically blurry. Fortunately, hospice agencies pride themselves on coordinating all the home care needed. Families can ask their hospice agencies what private-pay providers they recommend and work with well.