HOSPICE CARE NURSING - all end-of-life concerns are addressed in a

holistic manner
An Introduction to Hospice and Palliative Care
- Patients receive skilled palliative care
- Hospice – healthcare dedicate to alleviating
interventions to ensure comfort
suffering in terminally ill patients. Has been in
- Care is mainly provided in the home (which may
the US for several decades. Large part is
include facilities, if this is where the patient
palliation of distressing symptoms.
resides; Coyle, 2015)
- Palliative care- considered a specialty distinct
- Hospice care is generally provided for patients
from hospice care.
who have a life expectancy of 6 months or less
without life-sustaining treatment.
- Goal: symptom management and support
- Beyond 6-month, a patient may continue to
throughout the disease process.
receive services provided that recertification
- Patient and family/caregivers – are the unit of
requirements are met.
care, their needs are addressed by members of - HC continues through the disease process,
the hospice interdisciplinary team. during the dying process and even after the
- Interdisciplinary team approach- to deliver patient’s death in the form of bereavement
medical, nursing, social, psychological, support for the patient’s family and caregivers.
emotional and spiritual services through a  Palliative care nursing should be
collaboration of professionals and caregivers. integrated into the nursing care of older
adults, with chronic illness to improve
- Goal: making the beneficiary as physically and quality of care and to promote physical,
emotionally comfortable as possible. spiritual and emotional comfort.
- Hospice is compassionate beneficiary and (Ferrell, 2019)
family/caregiver centered care for those who
CHARACTERISTICS OF PALLIATIVE CARE
are terminally ill (Centers for Medicare and
- National Institute on Aging 2017 defines
Medicaid Services, 2018 p. 38624
palliative care as “ a resource for anyone living
- Resources for hospice and palliative nurses
with a serious illness (HF, COPD, CA, dementia,
include: *
PD)
 American Nurses Association ANA - PC can be helpful at any stage of illness and is
 End-of-life Nursing Education best provided from the point of diagnosis.
Consortium ELNEC - It can be provided along with curative
 Hospice & Palliative Credentialing treatment and does not depend on prognosis.
Center HPCC - PC includes symptoms management such as
 Hospice & Palliative Nurses Association pain, dyspnea, NV, fatigue and others that
HPNA interfere with the patient’s ability to be
 National Hospice and Palliative Care comfortable.
Organization NHPCO - PC can take place in various settings in clinic,
 The City of Hope. hospital, long-term care facility.
- It can be distinguished from other medical
CHARACTERISTICS OF HOSPICE CARE specialties by its foci on:
- It is associated with terminality, fear on the part  Incorporation of interdisciplinary team
of patients and families when the term is used to address spiritual, psychosocial and
- Related with misperception, nearing death, all cultural needs of patients and families
hope is lost, patient will give up the will to live.  Integration with curative treatments
- The patient may fear his/her actual death, and  Symptom management in early stages
the family may fear the loss of their loved one of disease and throughout the disease
(El-Jawahri et al, 2017) process
- Hospice care focuses on physical, emotional and  Patient and family involvement in the
spiritual comfort of terminally ill patients plan of care (WHO 2019)
through interventions developed by IDT - * PC is not specified as Medicare benefit,
- Hospice nurses may have expertise in symptom Medicare Part B may cover some treatments
management and be well versed in HOW each and services that are considered palliative.
disease trajectory typically evolves. - PC nurses have expertise in managing
- Care is specifically tailored to issues related to symptoms that disrupt patients’ and their
the terminal illness families quality of life.
- The patient agrees to forgo curative treatments - Pharmacologic and non-P measures are used to
- Services are covered by the Medicare Hospice alleviate suffering, whether plan of care is
Benefit (if eligible) curative or promotion of comfort.
 - Some hospitals have embraced the need for - Dr. Elisabeth Kubler-Ross – a key researcher
palliative services and have gained certification who advanced end of life conversations by:
through The Joint Commission. www. capc.org.
- Nurses as the 1st HCP to identify EOL concerns - Conducting interviews with dying patients in the
among patients, PC skills are essential for mid 1960s
developing a trusting therapeutic relationship - Identifying that certain themes emerged over
with patient and conveying needs to IDT (Dahlin
and over
& Wittenberg, 2019)
- Publishing her groundbreaking work On Death
Differences Between Hospice and Palliative Care & Dying in 1969, with 5 stages: denial and
isolation, anger, bargaining, depression,
HOSPICE CARE PALLIATIVE CARE
for terminally ill and dying aimed promoting comfort acceptance.
patients for seriously ill whether
- Awareness of Dying book, Glaser and Strauss,
terminal or not
1965 offered how physicians and nurses had
bereavement services are bereavement services are
provided up to 1 year not always provided little skill in the care of dying patients. They
after death found that HCP:
care is primarily delivered care maybe in acute care,
 Were quiet uncomfortable working
at patient’s home long-term care, homes or
other settings with dying patients
patient chooses to forgo provided either curative  Tended to avoid dying patients because
curative treatment or end-of-life treatments
they felt ill-prepared to discuss death
covered by Hospice may or may not be
Medicare Benefit covered by Medicare or  Increased their own feelings of
other health insurance ineptitude and distress by avoiding and
plan
isolating dying patients.
life expectancy is 6 life expectancy is not a
months or less factor.  *Considered to be the model for
quality, compassionate care for people
HISTORY AND EVOLUTION OF HOSPICE IN USA facing a serious or life-limiting illness or
- It is rooted in the end-of-life movement that injury, hospice care involves a team-
came to US from Europe in the later half of 20th oriented approach to expert medical
century. care, pain management, and emotional
- Dame Cicely Saunders- an English nurse, social and spiritual support expressly tailored
worker and physician who is credited with
to the patient’s needs and wishes
founding the hospice movement. Her vision
involved: (National Hospice and Palliative Care
Organization NHPCO, 2019).
 Developing a humane and systematic
approach to end-of-life care, - Medical training was mainly focused on fighting
 Devising an interdisciplinary approach disease and prolonging life.
to patient care
 Supporting the spiritual growth of - However, the growing interest in death and
patients and hospice staff, dying was already creating perspective and
 Easing the pain and suffering involved driving changes in health care.
in dying
- 1974: the Connecticut Hospice, Inc. the 1st
- Saunders anticipated that hospice workers hospice to open in the US began to provide end
would be organized in a way similar to religious of life care (Simms, 2007)
orders. For expansive hospice movement,
Saunders and her colleagues developed - 1978: the National Cancer Institute provided
document “Aim and Basis”, outlined the 5 funding to the Connecticut Hospice, Inc.
premises of HC. Purposes: developing a national demonstration
- 1st hospice, St. Christopher’s in London, 1967 center for home care of terminally ill and their
families
- *Saunders’ passion for e-o-l care was fueled by
her deep religious convictions and her belief - By the end of 1978, there were 59 hospices in
that ministering to the dying is a religious calling the US. (Greer, Morris and Birnbaum, 1983)
(Wright & Clark, 2012) - 1979: the Health Care Financing Administration
funded an inquiry into the scope of hospice
 services and the costs associated with this type - 2001: The National Consensus Project, an
of care. interprofessional meeting to discuss end-of-life
care in the US, took place in NYC.
- 1982: Congress approved a provision that
covered hospice services under Medicare Part - 2004: National Quality Forum NQF released “A
B. the provision included a sunset clause, which national framework and preferred practices for
meant it would end in 1986 without palliative and hospice care quality: A consensus
congressional action. report”
 Fast Facts: the Hospice Medicare
- 2009: Updated clinical guidelines were created
Benefit covers services from doctors,
and released through a collaboration among
nurses, nurse practitioners, nurses’
the:
aides, therapists, social workers,
1. American Academy of Hospice & Palliative
chaplain and volunteers.
Medicine,
 Medical equipment, supplies and
2. The Center for the Advancement of
medications that are related to the
Palliative Care,
terminal illness are also covered.
3. The Hospice & Palliative Care Organization
 Respite care is available in an inpatient
4. National Hospice & Palliative Care
facility for up to 5 days each month
Organization.
(Centers for Medicare and Medicaid
- 2010: The Patient Protection & Affordable Care
Services, 2018)
Act included provisions for the delivery of high-
- 1983: US Senate report from the Committee of
quality palliative and e-o-l care.
Finance chaired by Sen Robert Dole, collected
data about hospice and reported hospice care - 2011: The Joint Commission launched Advanced
was more effective and cost efficient than end- Palliative Care Certification opportunities for
of-life care provided in the hospital setting. The qualifying healthcare organizations;
average savings were $2,485 per patient.
- 2015: The Centers for Medicare and Medicaid
Today’s terms would be $5,000 per patient.
Services introduced 2 new billing codes for
- 1984: The Joint Commission began accrediting advance care planning provided for Medicare
hospice organizations beneficiaries;

- 1986: Recognizing the benefits of care of the - 2016: The Centers for Medicare & Medicaid
dying patients, Congress voted to make the Services introduced a two-tiered payment
Hospice Medicare benefit permanent. system for routine home care, decreasing
payment for routine visits after the 60th day of
- 1991: Hospice care was recommended for
hospice service.
inclusion in veterans benefits NHPCO
 However, a service intensity add-on was
- 1993: Hospice care became a nationally introduced, increasing payments to
guaranteed benefit, and President Clinton hospice organizations caring for
recognized November as National Hospice patients during the last 7 days of life
Month. (National Association for Home Care &
Hospice, 2017)
- 1994: The 1st certification examination for
- 2018: Passage of the Medicare Patient Access
hospice nurses was administered through the
to Hospice Act enabled physician assistants to
Hospice and Palliative Credentialing Center
serve as attending physicians for hospice
(HPCC, 2019)
patients (American Academy of Physician
- 1997: The Balanced Budget Act included several Assistants, 2018)
provisions for hospice care, such as an updated
- Numerous national and international efforts to
payment structure, revised benefit periods and
improve care for terminally ill patients continue
expanded coverage.
each year.
- 2000: the end-of Life Nursing Education - Today, HC is available in every state in America,
Consortium Nursing ELNEC developed to hospice and palliative certification is available
provide training for RN. Today, over 24,000 for both RN and advance practice nurses
nurses and other HCP have attended ELNEC (Hospice & Palliative Credentialing Center,
courses (American Association of Colleges of 2019).
Nursing, 2019).
 - For the past 50 years, e-o-l care has been - Most often hospice referrals are obtained late
rapidly expanding in the US in the course of patient’s illness and
- Aided by pioneers in the field and numerous conversations regarding e-o-l care and wishes
legislative changes. can be influenced by emotion and fear, cultural
- Hospice Medicare Benefit ensures access to HC and religious beliefs, and individual’s
for all Americans at the EOL acceptance (or lack) of diagnosis (Candrian et al,
2017).
- For nurses providing e-o-l care, certification is
available and HC is now a recognized specialty. - The initial visit is an opportunity for the hospice
team to explain services, gain trust, alleviate
You can differentiate and elaborate between Hospice fears and clear up any misconceptions about
& Palliative Care hospice services.

You can demonstrate & identify an understanding of - To initiate hospice services, the patient must
HC, its turning points, how research helped shape EOL, sigh a Notice of Election NOE, which the hospice
and the legislative changes that supported HC in the must file with Medicare within 5 calendar days
US. of the admission date to prevent inappropriate
payment to nonhospice providers.

- NOE must include:

HOSPICE ADMISSION AND 1. Name of the hospice that will provide
LEVELS OF CARE care to the patient.
2. the patient’s or patient representative’s
- Using the hospice eligibility criteria discussed acknowledgement of understanding of
previously, hospice nurses assess prospective hospice services and waiver of certain
patients’ eligibility for hospice services Medicare benefits.
- If appropriate he/she may be admitted 3. the date of election of hospice care,
- Level of hospice care will be determined by IDT must be the 1st day of the hospice care
in collaboration with the patient and family or later, but not earlier.
- Nurses assessment skills and knowledge of 4. the name of the physician, nurse
hospice levels of care are integral to the hospice practitioner, or physician assistant who
admission process and ongoing determination will serve as the attending physician as
of the patient’s and family’s needs. well as provider’s contact information
and National Provider Identifier NPI
THE HOSPICE ADMISSION 5. acknowledgement that the provider
- Upon receiving a referral, hospice nurse and a serving as the attending physician is the
hospice social worker will visit the patient to choice of the patient. (Centers for
conduct an initial assessment and to discuss Medicare and Medicaid Services, 2018)
- The election of services is valid as long as the
whether hospice care is warranted
- Nurse and SW will review information regarding patient remain under the care of a hospice,
hospice transition with patient and family: does not revoke hospice benefits and is not
1. patient and family goals, (comfort and discharged from hospice.
treatment) - The patient has the right to change hospice
2. hospice philosophy and revocation providers once during each benefit period.
options - Such a change is considered transfer not a
3. services provided by hospice and those revocation of hospice benefits.
that are not provided ORIENTATING PATIENTS AND FAMILIES TO
4. availability of inpatient and respite HOSPICE SERVICES
services - At the initial hospice visit, nurse and SW should
5. fees or co-pays (if applicable) establish rapport with the patient and family.
6. process of discharge and/or revocation - If admitted the family should be oriented to the
 The hospice admission is a pivotal types of services that will be provided such as:
experience for the patient and 1. durable medical equipment
family and sets the tone for future 2. medication related to terminal illness
hospice care experiences (Moon, 3. 24-hour availability of hospice staff and
2017). 4. care from the IDT team
- Information shared at the initial meeting with
the patient and family should be accurate and
clear to the patient and family.
 - Families should also be aware that hospice care LEVELS OF HOSPICE CARE
does not encompass: - Hospice nurses must work with the IDG to
1. curative treatment of the terminal determine which level of care is most
illness appropriate for the patient.
2. emergency services - For some, home care is the most appropriate
3. live-in caretakers level of care. There is a caregiver present and
4. long-term inpatient services or
the patient prefers to stay at home rather than
5. ongoing individual counseling
transfer to an inpatient facility.
 Family caregivers should be advised
- In other cases, inpatient care may be most
that respite care is available in an
appropriate due to lack of a caregiver or it is in
inpatient facility for up to 5 days each
month. line with the patients preferences.
- The decision-making process for determining
CERTIFICATION AND RECERTIFICATION OF the appropriate level of care is complex and
REQUIREMENTS involves a series of questions and decisions
- Patients can be admitted to hospice provided regarding the goals and care needs.
that the eligibility requirements are met.
- The initial hospice certification period is six Box 1 ASSESSING THE PATIENT’S GOALS
months, which Medicare defines as two 90-day
1. What is the most important to the
certification periods.
patient right now?
- Following the first 90-day period, the hospice
2. if the patient’s condition were to
medical director must certify the patient’s
change, would they want to stay at
terminality using his/her knowledge of the home or go to an inpatient setting?
patient’s condition along with the assessment 3. what symptoms or conditions would
information gathered from all members of the make the patient or family consider a
hospice. hospital admission?
- Following the 2nd 90-day certification period, 4. does the patient have a Living Will? Is a
recertification of the terminal illness is required POLST order written and accessible?
every 60 days for as long as the patient receives Pennsylvania Orders for Life-Sustaining
hospice services. Treatment Form
- Patients who continue to meet eligibility
Box 2 ASSESSING CARE NEEDS
requirements can continue to receive hospice
services for an unlimited number of 60-day 1. Is there a reliable caregiver at home?
periods. 2. Is the home environment safe?
- A NP or physician provide a face-to-face visit 3. Can the patient symptoms be managed
with the patient during the 3rd and subsequent at home by the caregiver with the
support of the hospice team?
benefit periods
4. Is the patient experiencing acute
symptoms? Can the symptoms be
FACE-TO-FACE ENCOUNTERS managed most effectively in an
- As a result of the Patient Protection and inpatient hospice setting?
Affordable Care Act of 2010, patient must be 5. Does the patient already reside in a
seen by a NP or physician prior to the 3rd long-term care facility? Is the staff able
benefit( after the first 180 days of service). to comanage e-o-l concerns with the
- If the NP conducts the f2f visit, he/she must be hospice team?
an employee of the hospice organization. 6. Can the patient’s symptoms be
- The purpose of the encounter s to verify managed in the home with continuous
continued eligibility for hospice services. care from the hospice staff?
- Following the encounter, the provider must - After completing the assessment, and in
document the clinical findings that rationalize a consultation with the patient and family, the
6-month life expectancy. hospice team may recommend one of the
- This documentation becomes part of the following hospice level:
evidence that is shared by the IDG to determine
1. Routine home care: care in the home
whether hospice services are appropriate for
with regularly scheduled visits from the
the patient and whether the appropriate level
hospice team
of hospice care is being provided.
2. Continuous home care: continuous care
is provided in the home, predominantly
 by nurses, but can be supplemented HOSPICE PATIENT DISCHARGE
with hospice aides. This type of care is - Hospice services are reserved for those facing
intended to support patient and terminal conditions.
families through crises on a short-term - However, prognostication is an inexact science
basis in order to allow the patient to with some hospice patients living well beyond
stay at home. the anticipated 6-month estimate.
3. Inpatient Respite Care: care is provided
- Although the number of very lengthy hospice
within an approved facility for a short
stays has decreased in recent years, the number
period of time to allow respite for the
of live discharges has steadily increased.
caregiver.
(MedPac, 2016; Russel et al, 2017)
4. General Inpatient Care GIP: care is
provided in an inpatient facility to - Patients maybe discharge due to revocation of
achieve pain control or symptom hospice benefit, change of hospice provider,
management that cannot be improvement in medical status, for cause or
accomplished at home. through death.
5. Last 7 days: this service intensity add on
(SIA) provides additional REVOCATION OF HOSPICE BENEFIT
reimbursement for care of a patient - Patient may revoke the hospice benefit any
during the last week of life, which is time
intense and costly. In order to receive - She/he must sign a revocation form the
reimbursement in addition to the per specifies the date of termination for hospice
diem routine rate, following criteria
services.
must be met:
- It should not be back dated.
a. The patient’s level of care is
- Once signed, patient’s care is no longer covered
“routine home care”
under the Medicare hospice benefit and
b. the date of care is within the
last 7 days of the patient’s life Medicare coverage that was previously waived
c. Direct patient care is provided may resume.
by a registered nurse or - Private insurance coverage varies and
licensed social worker. individuals should be counseled regarding their
benefits.
- With the appropriate level of care determined,
- Most commonly patient revoke care to seek
the nurse coordinates the plan of care for the
disease modifying treatments.
patient with the IDT.
- Roughly 7% of all hospice discharges are due to
- The IDT may update the plan of care as often as
revocation.
necessary, but no less frequently than every 15
- Patients who choose to withdraw actually have
days.
a higher 6-month mortality rate than those who
- A documentation checklist may be useful for
are discharge for other reasons.
the hospice IDG in ensuring that all
- Therefore, the hospice IDG should carefully
documentation is complete.
counsel patients and families who revoke
- Sample documentation checklist is available at
hospice benefits in favor of aggressive
https:www.
treatment regarding their rights to reenroll in
cgsmedicare.com/hhh/education/materials/pdf
hospice any time.
/j15_hospice_doc_checlistre.pdf/
- Currently, only about 1 quarter of those who
- The hospice nurse’s role in determining the
disenroll from hospice reenroll prior to death.
appropriate level of care for a patient and
(LeSage & Rhee 2015, Russel et al 2017)
coordinating care with the IDT during
transitions was reviewed.
- CHANGE IN HOSPICE PROVIDER
Let us evaluate: - A patient may choose to change hospice
- Conduct a hospice admission agencies once in each hospice benefit period.
- Orient a patient and family to hospice services - The patient is not required to revoke benefits,
- Assess ongoing eligibility for hospice care rather the change is considered a transfer of
- Identify the levels of hospice care. services.
- The hospice from which the patient transfers
must discharge the patient into the care of the
newly designated hospice.
 - Discharging hospice agency must obtain a (the patient’s primary care provider
signed statement from the patient indicating should be informed of the discharge)
the effective date of transfer. 5. Provide appropriate counseling
- Names of both discharging and receiving regarding medical care options
hospice must be included  when a patient is discharge
- Receiving hospice must file a new NOE but the from hospice for cause,
benefits remained unchanged. alternative services s.a.
- If the transfer takes place in the 3rd benefit palliative care and community
period or later, a f2f encounter is required support services should be
unless the discharging hospice agency provides offered.
verification that one has taken place. - If discharge for a cause but still hospice eligible,
care may be transferred to another agency.
IMPROVEMENT IN MEDICAL STATUS - In such cases, discharge code 50 or 51 is used,
- In instances wherein a patient is no longer and the receiving hospice agency must submit a
eligible due to health improvement, patient will transfer of the NOE.
be discharged from hospice services - If a transfer of services occurs, the patient’s
- Patient may also initiate if seeking curative hospice benefit is not terminated.
treatment - However, a patient discharge for a cause may
- In this case, patient will revoke the hospice also choose to revoke benefits rather than
benefit. transfer to another hospice provider.
- A discharge order must be written by the
Hospice Medical Director DISCHARGE DUE TO PATIENT DEATH
- Hospice team must include the patient and - When a patient dies under the hospice care, the
family in the discharge planning process. hospice nurse pronounces the death and
(National Hospice and Palliative Care provides family support. At the time of death,
Organization, 2016) the nurse must:

1. Maintain a calm approach

DISCHARGING FOR CAUSE
2. Properly identify the patient
- Effective Jan 1, 2009, new condition code H2 3. Asses the patient for breathing,
was added to identify patient discharge from motion, or other signs of life.
hospice service “for cause” 4. Assess for lack of pupillary
- Indicates that a patient was discharge from the response, absent carotid pulses and
care of agency because safety (patient/staff) apical pulses, (auscultate for a full
was compromised. minute in most situations)
5. Provide respectful, culturally
- The Code of Federal Regulations for Hospice
appropriate postmortem care
Care further specifies that for cause discharges
(Berry and Griffie, 2015)
may occur when “the patient’s (or other
person’s in the patient’s home) behavior is - To determine state regulations that govern the
disruptive, abusive or uncooperative to the RN practice visit the National Council of State
extent that delivery of care to the patient or the Boards of Nursing. Nurse Practice Act.
ability of hospice to operate effectively is - Documentation of the patient’s death should
seriously impaired” include:
- When a hospice agency is considering 1. Patient’s name
discharging a patient for cause, the hospice 2. Time of the call (if the nurse was called
must: to a patient’s home), who called, who
1. Determine that the problem is not was present at the time of death
related to the use of hospice services. 3. Physical exam findings
2. Inform the patient and family that 4. Who made the pronouncement of
discharge for cause is being considered death, and the time of pronouncement.
by the hospice team 5. Who was notified of the patient’s death
3. Clearly document the problems, take 6. To whom the patient’s body was
mitigatory steps and document such released
efforts in the patient’s medical record
4. prepare the discharge order and have it - When death occurs at home setting, the nurse
signed by the hospice Medical Director disposes of medications using the following
 recommendations (Nathan & Deamant, 2015; with daily tasks, nutritional and therapeutic
US FDA 2013, 2018) services. Intermittent care based on patient’s
needs.
1. Remove medications from their 2. CONTINOUS HOME CARE “crisis care”,
containers, mix with cat litter or used experiencing medical crisis, when symptoms
coffee grounds, and place in a plastic require more intensive management. RTC
bag or tub prior to trash disposal. nursing or extended periods of support.
 Drug deactivation can be used 3. INPATIENT HOME CARE maybe necessary if a
according to package patient’s symptoms can no longer be managed
instruction at home. Goal: for the control of severe pain
 Some medications may be and stabilize symptoms so he can return home
flushed down the toilet if possible. Some prefer to spend their final days
in inpatient center as a neutral, safe space with
2. When disposing of fentanyl patches,
loved ones.
fold the patch in half with the sticky
4. RESPITE CARE- much needed break for loved
side inward and flush the patch down a ones providing care at home while allowing
toilet patients to receive appropriate RTC symptom
3. Remove labels from patient medication management.
bottles and then throw the empty
bottles in the trash or recycle as - Your physician or hospice team will guide
appropriate. throughout the e-o-l journey, and determine
the appropriate level of HC for your loved one.
- If the patient death occurs while a patient is in
restrains or seclusion, or within 24 hours of the - Philosophy remains the same: to offer expert
removal of restraints, medical care and emotional support that
respects the unique wishes of the patient.
- the patient’s death must be reported to the
Centers for Medicare and Medicaid Services by - Understanding where and when HC is offered is
telephone by the end of the following business the 1st step to understanding the choices your
day and love has when it comes to the e-0-l journey.
(Laura Marion, RN, BSN, Asst VP of Allied
- Such notification must be documented in the
Services Hospice and Palliative Care)
patient’s medical record.
- In addition, the nurse should document that VITAS healthcare:
medications were properly disposed of, 1. Home HC- team ensure comfort and dignity.
following all agency policies and procedures. Diagnosis-specific equipment, supplies and
- Further, the nurse should adhere to all federal medication are provided at no cost.
laws regarding the disposal of opioid 2. Continuous- Intensive Comfort Care 24/7.
medications and manage acute symptoms and avoid
- Federal, state, tribal and local laws regarding hospitalization
“on site” drug disposal (Gregory, 2018). 3. Inpatient HC- cozy inpatient HC offers the
support of an acute-care facility with homelike
amenities.
Let us evaluate: 4. Respite Care- patients spend short time in a
- Discuss how to discharge a hospice patient Medicare-certified inpatient hospice setting so
- Describe discharge documentation
their primary caregivers can take a break. To
- Identify steps to be taken when a patient dies.
avoid burnout and provide care more
efficiently.
Levels of Hospice Care - How VITAS can help: with 40 years of leadership
4 Levels of Hospice Care: they offer personalized care plans by patient’s
As defined by Medicare: diagnosis, IDT, therapy, emotional and pastoral
1. Routine home care support, grief and bereavement services
2. Continuous home care - Medicare benefit includes: IDT, medication,
3. General inpatient care home medical equipment (wheelchair)
4. Respite care

A hospice patient may experience all 4 or only 1,

depending on their needs and wishes.
1. ROUTINE HOME CARE. Pain management,
symptom management, emotional and spiritual
counseling for patient and family, assistance