Like so many other areas in hospice, the general inpatient level of care (GIP) is coming under increased scrutiny by the Department of Health and Human Services (HHS), Office of the Inspector General (OIG) and the Centers for Medicare and Medicaid Services (CMS). The OIG is currently conducting a series of studies and audits on the GIP level of care. Although the OIG’s most recent report Medicare Hospice: Use of General Inpatient Care, published May 3, 2013 provided no recommendations for hospices in terms of change in practice, it is a precursor for an upcoming audit report, which will be based on a medical review of GIP charts.
The May 3rd report noted that 33% of GIP stays in 2011 were longer than 5 days and 11% were longer than 10 days. According to the report, the average stay was 6.1 days in an inpatient unit, 4.1 days in a hospital, and 4.8 days in a skilled nursing facility. Interestingly, they also focused on underutilization, noting that 25% of hospice in 2011 provided little or no GIP, continuous home care, or respite care and suggested that CMS focus on whether hospices are providing access to all 4 required levels of care. In addition to this report, the 2012 OIG Work Plan indicated that they would focus on acute inpatient transfers to inpatient hospice care at the GIP level.
Implications for Providers
So what does this mean for you as a provider? It seems that if the OIG is “concerned” about the provision of GIP, we in the hospice industry should be concerned as well.
In our work with clients, Weatherbee sees a wide divergence in both the utilization of GIP and the conditions under which GIP is provided. In many instances, clinical record audits reveal that the patient is eligible for GIP (e.g., the patient's condition warrants the higher level of care as evidenced by pain or symptom management needs that cannot be met in the home setting); however, the documentation does not support payment for the higher level of care (e.g., the documentation does not evidence that a higher level of care was actually being provided).
We also have encountered hospice programs in highly saturated markets that are unable to obtain contracts with local hospitals and SNFs and, therefore, do not offer the GIP level of care. This places the hospice at risk of underutilization and its patients at risk of negative outcomes. Given that GIP is a requirement of the Medicare Hospice Benefit, its provision is not optional.
Common practices that we believe contribute to some of the current problems with GIP utilization include:
- Ineffective or untimely discharge planning (e.g., patients remaining on GIP for a prolonged period while waiting for a SNF bed to become available)
- Automatically admitting dying patients to the higher level of care regardless of their actual clinical needs
- Automatically admitting patients from an acute care hospital to the GIP level of care before going home (i.e., using GIP as a "step-down" or transitional level of care)
- Inadequate documentation evidencing the need for GIP
- Lack of involvement by the hospice team when the patient is placed on GIP in the SNF setting
- Inappropriately utilizing GIP for caregiver breakdown or respite
What Hospices Need to Know
1. What is GIP?
GIP is intended to be short-term care provided in an inpatient facility for the purpose of providing pain control or other acute symptom management that cannot be feasibly provided in other settings.
2. What are some of the criteria for admission to GIP?
- Evidence of a precipitating event and interventions that have been attempted to manage the pain/symptoms
- Documentation of the patient's skilled need and why there is no other appropriate setting in which to manage them
- Physician's order
3. What are some of the symptoms that would qualify for GIP?
- Uncontrolled pain requiring frequent medication adjustment, aggressive treatment, or complicated technical delivery of medication which requires an RN to do the calibration etc.
- Intractable nausea and vomiting
- Unmanageable respiratory distress
- Pathological fractures
- Severe agitated delirium
- Wounds requiring complex and/or frequent (skilled) dressing changes
- Imminent death if skilled needs are present
- Caregiver breakdown only if the patient has unmet skilled needs
4. What should hospices document?
- Changes in the plan of care that reflect the change in the patient’s condition and the new patient/family goals and interventions
- All of the symptoms being managed, how they are being managed, and with what frequency
- The patient’s response to interventions
- Evidence of patient/family education
- Evidence of discharge planning to return the patient to a lower level of care
- Evidence of coordination of care between the hospice team and the staff at the facility providing the care
- Documentation that shows that the hospice has remained responsible for the professional management of the patient’s care
- Ongoing documentation throughout each 8-hour shift. Again, the documentation should be as thorough and specific as possible noting the frequency of the interventions, the response to interventions, and any changes that have occurred in the patient’s condition.
Don’t be afraid to admit patients to the GIP level of care, just make certain the patient’s care needs justify the higher level of care and that the clinical record supports the team’s decision to provide it.
Patients are entitled, under their Medicare Hospice Benefit, to receive the GIP level of care. Hospice providers need to be prepared to offer this care to their patients. However, they need to do so in such a way that they adhere to the current guidelines for the provision of this level of care. Periodic staff education and the development of internal policies and procedures regarding the use of GIP are measures that can offer hospice programs a higher comfort level as scrutiny increases. Periodic pre-billing audits are also recommended. These audits should evaluate whether the higher level of care was both needed by the patient and provided by the hospice.
- Medicare Hospice: Use of General Inpatient Care
- 2012 OIG Work Plan - https://oig.hhs.gov/reports-and-publications/archives/workplan/2012/WP01-Mcare_A+B.pdf
- CoPs in a Book: The Final Edition - http://www.weatherbeeresources.com/cops.html
- Hospice Regulatory Policies and Procedures - http://www.weatherbeeresources.com/policies.html
Posted by: Sheila Flynn, RN, MSN, Senior Vice President, Consulting Services and Operations, Weatherbee Resources, Inc. & Hospice Education Network Inc.