Hospice care has four levels, not stages of decline, but levels of service that adjust based on what a patient needs at any given time. These four levels are defined by Medicare: Routine Home Care, Continuous Home Care, General Inpatient Care, and Inpatient Respite Care. A patient can move between levels as symptoms change, and most people spend the majority of their time at the first level.
To qualify for any level of hospice, a physician must certify that the patient has a life expectancy of six months or less if the illness follows its expected course. The initial certification requires sign-off from both the hospice’s medical director (or a physician on the hospice team) and the patient’s own doctor, if they have one. After that first 90-day period, only the hospice physician needs to recertify. Starting at the third benefit period, a hospice doctor or nurse practitioner must see the patient face-to-face to confirm continued eligibility.
Level 1: Routine Home Care
This is by far the most common level of hospice. The patient lives at home, or in a place they consider home (which could be an assisted living facility or a family member’s house), and receives scheduled visits from the hospice team. Symptoms like pain, nausea, and breathing difficulty are being managed effectively, and the patient’s condition is relatively stable day to day.
Routine home care includes visits from nurses, aides, social workers, chaplains, and volunteers on a regular schedule. The hospice provides medications related to the terminal illness, medical equipment like hospital beds or oxygen, and supplies. A nurse is typically available by phone around the clock for questions or concerns, but someone isn’t stationed in the home continuously. Family members or other caregivers handle most of the daily care between visits.
Most patients remain at this level for the entirety of their hospice enrollment. The other three levels exist for specific situations when routine care isn’t enough.
Level 2: Continuous Home Care
Continuous home care kicks in during a medical crisis that would otherwise send the patient to a hospital or facility. The goal is to manage the crisis at home by providing intensive, nearly round-the-clock nursing and support.
To qualify, the patient must receive at least 8 hours of direct care within a 24-hour period (midnight to midnight), and nursing must make up at least half of those hours. Those 8 hours don’t have to be consecutive. A nurse might be present for 4 hours in the morning and 4 more in the evening, for example. The types of crises that trigger this level include uncontrolled pain, severe breathing difficulty, intense nausea or vomiting, seizures, or acute anxiety and agitation that can’t be managed with the patient’s current care plan.
Continuous home care can also be activated when a patient’s support system collapses, such as when a primary caregiver becomes unable to provide care during a period of rapid decline. Once the crisis is resolved and symptoms are back under control, the patient steps back down to routine home care.
Level 3: General Inpatient Care
General inpatient care (sometimes called GIP) is for symptoms so severe they cannot be managed in any other setting. This level moves the patient into a Medicare-approved hospital, a hospice inpatient facility, or a skilled nursing facility with an agreement with the hospice.
The most common reasons for this level are pain that hasn’t responded to treatments tried at home, severe shortness of breath requiring close monitoring, or other acute symptoms that need the kind of intervention only available in a clinical setting. This isn’t a permanent move. The purpose is to get symptoms under control and then transition the patient back home to routine care. Think of it as the intensive care version of hospice, focused entirely on comfort rather than cure.
Medicare requires that the need for inpatient-level care be documented and medically necessary. A patient can’t be placed at this level simply because their disease is progressing or because the family is worried. The symptoms must be actively unmanageable in a less intensive setting.
Level 4: Inpatient Respite Care
Respite care is the only level designed primarily for the caregiver rather than the patient. When the person providing daily care at home needs a break, whether from exhaustion, their own medical appointment, a family obligation, or simply emotional fatigue, the patient can temporarily stay in a Medicare-approved facility.
Each respite stay is limited to 5 consecutive days. After that, the patient returns home and routine care resumes. There’s no limit on how many times respite care can be used over the course of hospice enrollment, but each individual stay caps at 5 days. The patient goes to a nursing home, hospice facility, or hospital during this time and continues to receive their hospice services there.
How Patients Move Between Levels
These four levels aren’t a staircase. Patients don’t progress through them in order. Someone on routine home care might need a few days of continuous home care during a pain crisis, return to routine care for weeks, use respite care so their spouse can rest, and never need general inpatient care at all. Another patient might go directly from routine care to general inpatient care and back again multiple times.
The hospice team reassesses the patient’s needs regularly and adjusts the level of care accordingly. The patient and family have input in these decisions, especially around whether to manage a crisis at home with continuous care or move to a facility for inpatient care. The hospice nurse or medical director makes the clinical determination about which level is appropriate based on the severity and type of symptoms.
What Medicare Covers at Each Level
Medicare covers all four levels of hospice care with minimal out-of-pocket cost to the patient. For routine home care, continuous home care, and general inpatient care, Medicare pays the hospice directly and the patient typically owes nothing beyond small copays for prescription drugs (capped at $5 per medication). For respite care, Medicare requires the patient to pay 5% of the Medicare-approved amount for each day in the facility.
All hospice-related medications, equipment, and supplies are covered regardless of the level of care. What changes between levels is the intensity and location of the services, not the scope of what’s included. The hospice is responsible for managing all care related to the terminal diagnosis at every level.