(Medicare Benefit Policy Manual)

CMS Conditions of Participation define a qualified homemaker as an individual who meets the requirements described in 42 CFR 418.202(g)  and who has successfully completed hospice orientation addressing the needs and concerns of patients and families coping with a terminal illness.  Homemaker services may include assistance in maintenance of a safe and healthy environment and services to enabl e the individual to carry out the plan of care.  40.1.8 - Physical Therapy, Occupational Therapy, and Speech-Language Pathology  (Rev. 141, Issued: 03- 02-11, Effective: 01 -01-11: Implementation: 03- 23-11)  Physical therapy, occupational therapy, and speech -language pathology services may be provided for purposes of symptom control or to enable the individual to maintain activities of daily living and basic functional skills.  Also, see 40.5 regarding waivers available under certain conditions for provision of these services.   40.1.9 - Other Items and Services  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  Any other item or service which is included in the plan of care and for which payment may otherwise be made under Medicare, in accordance with title XVIII of the Social Security Act, is a covered service under the Medicare hospice benefit.  The hospice is responsible for providing any and all services indicated in the plan of care as reasonable and necessary for the palliation and management of the terminal illness and related conditions.  The hospice Interpretive Guidelines for 42 CFR 418.54(a) , published via a Survey and Certification letter (S & C 09 -19, Advance Copy- Hospice Program Interpretive Guidance Version 1.1), require that the initial assessment be conducted in the location where hospice services will be provided.  The plan of care is developed from that initial assessment and from the comprehensive assessment.  Ambulance transports to a patients home which occur on the effective date of the hospice election (i.e., the date of admission), would occur prior to the initial assessment and therefore prior to the plan of cares development.  As such, these transports are not the responsibility of the hospice.  Medicare will pay for ambulance transports of hospice patients to their home, which occur on the effective date of hospice election, t hrough the ambulance benefit rather than through the hospice benefit.  Ambulance transports of a hospice patient, which are related to the terminal illness and which occur after the effective date of election, are the responsibility of the hospice.   EXAMPLE:   A hospice determines that an existing patients condition has worsened and has become medically unstable.  An inpatient stay will be necessary for proper palliation and management of the condition.  The hospice adds this inpatient stay to the plan of care and decides that, due to the patients fragile condition, the patient will need to be transported to the hospital by ambulance.  In this case, the ambulance service becomes a covered hospice service.   40.2 - Special Services  (Rev. 1, 10- 01-03) A3-3143.2, HO -230.3  40.2.1 - Continuous Home Care (CHC)  (Rev.  12400; Issued: 12- 06-23; Effective: 01 -01-24; Implementation: 01- 02-24) Continuous home care may be provided only during a period of crisis as necessary to maintain an individual at home. A period of crisis is a period in which a patient requires continuous care which is predominantly nursing care to achieve palliation or mana gement of acute medical symptoms. If a patients caregiver has been providing a skilled level of care for the patient and the caregiver is unwilling or unable to continue providing care, this may precipitate a period of crisis because the skills of a nurse  may be needed to replace the services that had been provided by the caregiver. This type of care can also be given when a patient resides in a long term care facility. However, Medicare regulations do not permit CHC to be provided in an inpatient facility (a hospice inpatient unit, a hospital, or SNF).  The hospice must provide a minimum of 8 hours of nursing, hospice aide, and/or homemaker care during a 24- hour day, which begins and ends at midnight. This care need not be continuous, e.g., 4 hours could be provided in the morning and another 4 hours in t he evening. In addition to the 8 hour minimum, the services provided must be predominantly nursing care, provided by either an RN, an LPN, or an LVN. Services provided by a nurse practitioner that, in the absence of a nurse practitioner, would be performed  by an RN, LPN, or LVN, are nursing services and are paid at the same continuous home care rate. This means that more than half of the hours of care are provided by an RN, LPN, or LVN. Homemaker or hospice aide services may be provided to supplement the nursing care.  NOTE:  When fewer than 8 hours of care are required, the services are covered as routine home care rather than continuous home care.  Nursing care in the hospice setting can include skilled observation and monitoring when necessary, and skilled care needed to control pain and other symptoms.  The development of the CHC rate included the daily costs of nursing, hospice aide, social worker, and therapy visits; drugs; supplies and equipment; and the average daily cost of the hospice IDG. However, the statute limits the billable CHC hours of direct  patient care to care provided by a nurse, a homemaker, or a hospice aide. Medicare regulations require that an hourly payment be made. While in the majority of situations, one individual would provide continuous care during any given hour, there may be circumstances where the patients needs require direct interventions by more than one covered discipline resulting in an overlapping of hours between the nurse and hospice aide. In these circumstances, the overlapping hours would be counted separately. The total hours paid cannot exceed 24 hours per day.  The hospice would need to ensure that these direct patient care services are clearly documented and are reasonable and necessary. Computation of hours of care should also reflect the total hours of direct care provided to an individual that support the car e that is needed and required. This means that all nursing and aide hours should be included in the computation for CHC and when the aide hours exceed the nursing hours, CHC would be denied and routine payment will be made. The statutory definition of cont inuous home care is meant to include the full range of services needed to achieve palliation and management of acute medical situations. Deconstructing what is provided in order to meet payment rules is not allowed. In other words, hospices cannot discount  any portion of the hours provided in order to qualify for a continuous home care day.  Documentation of care, modification of the plan of care, and supervision of aides or homemakers would not qualify as direct care nor would these activities qualify as necessitating the services of more than one care provider. In addition, while the service s provided by other disciplines such as medical social workers , pastoral counselors , MFT or MHCs are  an integral part of the care provided to a hospice patient, these services are not included in the statutory definition of continuous care and are not coun ted towards total hours of continuous care. However, the services of social workers , pastoral counselors , MFT or MHCs  would be expected during these periods of crisis, if warranted as part of hospice care, and are included in the provisions of routine hospice care.  The following are used to illustrate circumstances that may qualify as CHC. This list is not all -inclusive nor does it indicate that if a patient presents with similar situations, that it would constitute CHC.  1. Frequent medication adjustment to control symptoms/collapse of family support system   Situation A:  The patient has had a central venous catheter inserted to provide access for continuous Fentanyl drip for pain control and for the administration of antiemetic medication to control continuous nausea and vomiting. The nurse spends 2 hours teaching the fam ily members how to administer IV medications. She returns in the evening for 1 hour. The hospice aide provides 3 hours of care. The nurse spends 2 hours phoning physicians, ordering medications, documenting and revising the plan of care.   Determination:  Despite 8 hours of service, this does not constitute CHC since 2 of the 8 hours were not activities related to direct patient care.   Situation B:  The patient experiences new onset seizures. He continues to have episodes of vomiting. The nurse remains with the patient for 4 hours (10 AM  2 PM) until the seizures cease. During that time she provides skilled care and family teaching. The patients wi fe states she is unable to provide any more care for her husband. A hospice aide is assigned to the patient for monitoring for 24 hours, beginning at 2:00 PM, with a total of 8 hours of direct care in the first day. The nurse returns intermittently for a total of an additional 5 hours to administer medications, assess the patient and to relieve the aide for breaks. The social worker provides 3 hours of services to work with the patients wife in identifying alternative methods to care for the patient.   Determination:  This qualifies as a continuous home care day. This constitutes a medical crisis, including collapse of family structure. The caregiver has been providing skilled care and the change in the patients condition requires the nurses interventions. Since ther e is no overlap in nursing care, 17 hours of care (i.e., 9 hours of nursing care and 8 hours of aide care) would be computed as CHC. The social worker hours would not be incorporated. If the caregiver had been providing custodial care and his  medical crisis resolved within a short time frame, this situation would not have qualified as CHC.   2. Symptom management/rapid deterioration/imminent death   Situation A:  77-year-old patient with lung cancer whose caregiver is 80 years old. The caregiver has been caring for this patient for 4 months and is now exhausted and scared. The care provided consists of assisting with bathing, assisting the patient to ambulate, pre paring meals, housekeeping and administering oral medications. Since the patient is dyspneic at rest, she requires assistance in all ADLs, which equates to 9 hours of assistance within a 24- hour period.   Determination:  This would not qualify as CHC since there is little nursing care that requires a nurse. The patient would however be a candidate for an inpatient respite level of care.   Situation B:  The patients condition deteriorates. The patient now has circumoral cyanosis, respiratory rate of 44 and labored with intermittent episodes of apnea. The nurse performs a complete assessment and teaches the caregiver on methods to make the patient comfor table. The nurse returns twice within the 24 -  hour period to assess the patient. She revises the plan of care after conferring with the patients attending physician and with the hospice physician. The homemaker and hospice aide are sent to assist the caregiver. Within the 24 -hour period, the direct care provided by the nurse equates to 3 hours, homemaker with 2 hours, and hospice aide of 6 hours.   Determination:  Since only 3 of the 11 hours were skilled care requiring the services of a nurse, this would not constitute CHC. In this situation, the care required is not predominantly nursing but are comprised of services provided by a hospice aide. In addition, it would not be correct to discount any portion of the hospice aides hours or to provide these services gratis in order to qualify for the CHC benefit.   Situation C:  The next day, the patients condition deteriorates further. She has increased periods of apnea and air hunger. In addition she is experiencing continuous vomiting and increasing pain. Her blood pressure is beginning to decrease and her respirations are increasing. The nurse remains at the patients bedside for 4 hours while attempting to control her pain and symptoms. The hospice aide provides care during 1 hour of this period. The nurse leaves and the hospice aide remains at the bedside for 3 hours. The s ocial worker comes and talks with the caregiver and remains for 1 hour. The nurse returns while the aide leaves. The nurse remains with the patient for 2 hours until she dies. The social worker returns and stays with the caregiver for 1 hour until the mort uary arrives.