Knowledge Base

A homemaker or hospice aide services or both may be covered on a 24-hour continuous basis during periods of crisis, but the care must be predominantly nursing care. The purpose of continuous home care is to achieve palliation and management of acute medical symptoms. Continuous home care is only furnished during brief periods of crisis as described in Sec. 418.204(a) and only as necessary to maintain the terminally ill patient at home.

To document CHC in Hospice Tools use the CHC documentation provided within the Nurse Chart section of the EMR. 

Suggested Work Flow: 

1.  Complete a Change in Level of Care form: to document that the patient transitioned from one level of care to another, this will also establish the official date in which the level of care changed. The Change in level of care form will go to internal MD for signature via the dashboard
2.  Update the Level of Care on the Patient's Intake Screen: The patient's level of care should be immediately updated on the intake screen. ex: If the patient was a Routine Home Care, update to Continuous Home Care)
3.  Recommended Documentation for CHC: 
   • Recommend process for documentation at least hourly
   • Reason for continuous home care
   • Vital signs (as appropriate)
   • Observations of the patient’s condition
   • Interventions used to achieve palliation of physical or emotional symptoms
   • Services provided to the patient
   • Medications given and the patient’s response
   • Treatments completed and the patient’s response
   • Contacts made to the hospice and/or attending physician
   • New or changed orders received
   • Family response to care (as indicated)
   • Detailed discharge planning to transfer the patient back to routine home care as soon as the
   crisis subsides.
   • There is no specified frequency of documentation for CHC in the regulations or guidance. However, since CHC is for acute symptom management or some other crisis and billing occurs in15-minute increments, the best practice standard is to document at least every hour.
   • Suggest an MAR and narcotic count at each nursing staff shift change

Hospice Tools Documentation for CHC: 

1. Continuous Initiation sheet: This document is used to provide specific details such as co-morbidities, team members assigned, state of crises, & specific orders
2. Continuous Care Specific Instructions :(this can be combined with the CHC Initiation sheet)  email support@hospicetools.com for this document modification
3. Continuous Care Flow Sheet: This is used to take the patient's vitals, (this can be combined with the Continuous Care Hourly Documentation) email support@hospicetools.com for this document modification
4. Continuous Care Hourly Documentation: This should be completed every hour in which the patient is seen the RN,LVN,LPN, or Hospice Aides

* If the documentation is not assessable by the appropriate discipline please contact support to remove the nurse specific credential tie to the CHC documentation 

Hospice Tools Billing:

In order to bill for CHC hours, the hours will need to be entered in the ebilling module on the Patient's General Tab. If you do not have access the ebilling module, this will need to be completed by the employee who has access. 

1. Click Patients, Find the patient. In the General tab scroll down to the to the level of care
2. Click on CHC Hours Covered hyperlink- A side panel will appear to enter the hours and dates applicable. The dates and hours entered should match the documentation completed in edocs

Additional Resources

Medicare Chapter 9

NHPCO Compliance Guide on CHC

Help Guides:

Ebilling CHC Hours

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GIP is intended to be a short-term intervention (similar to the duration of an acute hospital stay). However, GIP under the Medicare hospice benefit is not equivalent to a hospital level of care under the Medicare hospital benefit.  The federal regulations, at §418.302(b)(4), also state GIP is “for pain control or acute or chronic symptom management which cannot be managing in other settings.” GIP may be initiated when other efforts to control symptoms are ineffective. There is no specified disease, condition, or symptom that qualifies a patient to receive GIP. Each patient and his or her symptoms will differ; GIP may be helpful to one patient and not to another with the same disease. GIP care carries specific requirements regarding where the services may be provided, as well as types and levels of staffing.

Suggested Work Flow Transitioning to GIP Level of Care:

1. Complete a Change in Level of Care form: to document that the patient transitioned from one level of care to another, this will also establish the official date in which the level of care changed. The Change in level of care form will go to internal MD for signature via the dashboard
2. Update the Patient's Location information in the Contact Tab: Patient's location is no longer their home. Update the address to reflect accurately where the patient is receiving their Inpatient Care eCFR :: 42 CFR Part 418 -- Hospice Care*GIP care cannot be provided in the home, in an assisted living facility, a hospice residential facility, or in a long-term care nursing facility (NF). These environments are not equipped to provide skilled nursing and medical care to manage an acute symptom crisis
3. Update the Level of Care on the Patient's Intake Screen: The patient's level of care should be immediately updated on the intake screen. ex: If the patient was a Routine Home Care, update to General Inpatient Care)
4. Charting in Hospice Tools: Complete the GIP Evaluation Assessment- This document is located within the nurse chart section. Documentation to support Admission to GIPLC: Complete to indicate the specific intervention necessary, symptom changes, psychological and social problems, patient/family teaching, immanent death, and additional information text box to indicate the reason this care cannot be provided in the home.
5. GIP Nurse Visit Note: Used to document scheduled or PRN visits. Comprised of a physical assessment, wound assessment, medication dashboard, care plan dashboard, & discharge planning
6. Medications: Update any current or submit new medication orders using the comfort kit, single medication form, or multiple medication form s
7. IDG Updates: Using the applicable discipline progress notes, nurses need to address symptom management, observations, medications initiated and changes in medications, other changes in treatment, etc. Other IDG members need to document what they see in terms of symptom management, patient and family coping, discharge planning discussions, options for returning to the routine home care or another level of care, etc. All IDG members should document to paint a complete picture of the patient, including the pain and symptoms not adequately managed and why GIP is necessary each day the patient receives this
   level of care.

*Refer to the NHPCO GIP Inpatient Compliance Guide below on documentation during this specific level of care, including documentation pertaining to IDG

For more information: NHPCO General Inpatient Compliance Guide 

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Respite care is short-term inpatient care provided to the individual only when necessary to relieve the family members or other persons caring for the individual at home. Payment for respite care is for a maximum of 5 continuous days at a time including the date of admission but not counting the date of discharge.

To document Respite Care in Hospice Tools you can use the documentation specific to each discipline to chart for patient visits. 

Suggested Work Flow: 

1.  Complete a Change in Level of Care form: to document that the patient transitioned from one level of care to another, this will also establish the official date in which the level of care changed. The Change in level of care form will go to internal MD for signature via the dashboard

2. Update the Patient's Location within the Contact Tab: The patient's location is no longer their home. Proceed to change the address of the location in which the patient is receiving their care ( Medicare Certified Inpatient hospice facility, contracted Medicare-certified Hospice or SNF which has 24 hour care).
3.  Update the Level of Care on the Patient's Intake Screen: The patient's level of care should be immediately updated on the intake screen. ex: If the patient was a Routine Home Care, update to Inpatient Respite Care)
4.  Documentation for Respite Care: A patient’s plan of care during an inpatient respite stay would be the same as if the patient were receiving care in their home. The established plan of care visit frequency is followed by the hospice interdisciplinary group (IDG) and the facility staff would give care that the caregiver would provide in the home setting.

For more information: NHPCO Respite Care Tip Sheet

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