General Inpatient Level of Care Requirements When I first considered this column’s theme, I was concerned that this topic would only be of interest to members who work in hospice programs. But because we are one specialty and need to understand the different areas in which we practice, I decided to move forward with this discussion regarding requirements for the general inpatient (GIP) level of care under the Medicare Hospice Benefit.

It’s important for physicians working in either hospice or non-hospice palliative care to understand the requirements for GIP so that appropriate patients are admitted, whether they are referred from their hospice program or an outside palliative care program. Misunderstandings about the GIP benefit often lead to complicated patientfamily dynamics when the expectations are not realistic. They can also lead to improper billing issues when ineligible patients are managed under the GIP level of care.

Both the general public and healthcare professionals often share a common misconception that a “hospice house” or “inpatient hospice facility” is a place where patients go to live until their death. On the contrary, the majority of patients in these facilities are admitted under the GIP benefit, defined by Medicare as “general inpatient care, which is for pain control and symptom management…that cannot feasibly be provided in other settings.”

So, there needs to be (a) a symptom present and (b) evidence that this symptom could not be managed at another level of care. For example, a home hospice patient in pain may have symptoms that are uncontrolled by escalating oral opioids, and the family caregiver cannot be taught to administer subcutaneous medications. Or, a patient with advanced lung disease who is admitted directly from the acute care hospital may have shortness of breath requiring frequent nebulizer treatments, and the caregiver is neither educated nor capable of delivering these treatments. Both of these examples meet the basic requirements for the GIP level of care.

These examples also point to an important aspect of the required documentation: there should always be a plan to move the patient to another setting when the symptoms are controlled or when the caregiver has been taught to deliver the needed treatments. Unfortunately, these goals usually fall under the heading of discharge planning, a term that often terrifies family caregivers who cannot imagine that their loved one will be able to return home. It takes great skill to communicate this goal with patients and families and to involve them in delivering bedside care. Even if these goals are not accomplished, they should be part of the plan of care and attempted. Documentation must include these attempts to move toward another care setting.

What about caregiver breakdown? Does the abrupt loss of a competent caregiver at home make a patient eligible for GIP admission? The inpatient stay is GIP eligible only if there is a symptom requiring skilled nursing care. I often find that caregiver breakdown is really a consequence of subtle but progressive patient symptoms, perhaps unidentified by the healthcare professionals. GIP care is needed to treat these symptoms that can no longer be managed by the current caregiver. The symptoms, not the caregiver breakdown, should be documented as the reason for GIP admission. Once admitted, one of the goals must be the transfer of the patient to a lower level of care, either to return home with additional caregiver education or placement in a long-term care facility where the required treatments can be safely delivered. Finally, imminent death is not a reason for GIP admission.

If the patient has developed uncontrolled symptoms related to dying that cannot be managed at home or in the nursing facility, then GIP admission should be considered. Again, it is the symptoms that support GIP eligibility, not imminent death.

Documentation is key. There is a large difference between “resting comfortably” and “pain currently controlled by a continuous subcutaneous morphine infusion at 3 mg/hour but still requiring two breakthrough doses overnight to maintain comfort.” There should be documentation of caregiver education and consideration of the options to move the patient to a lower level of care. Be sure that the patient and family’s psychosocial needs are also addressed and documented—hospice is more than a skilled nursing benefit!

In summary, the GIP level of hospice care requires the presence of a symptom that cannot be managed at a lower level of care. Once admitted to the GIP benefit, there should be an attempt to return the patient to a lower level of care, either by controlling the symptoms or educating the caregiver to deliver the needed treatments. Even an imminently dying patient must have an uncontrolled symptom to support GIP admission and stay.