Continuous Home Care (CHC)
Continuous home care may be provided only during a period of crisis. A period of crisis is a period in which a patient requires continuous care which is primarily nursing care to achieve palliation or management of acute medical symptoms. If a patient’s 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 is in a long term care facility.
The hospice must provide a minimum of eight hours of care during a 24-hour day, which begins and ends at midnight. This care need not be continuous, e.g., four hours could be provided in the morning and another four hours in the evening. But a need for an aggregate of 8 hours of primarily nursing care is required. The care must be predominately nursing care provided by either a registered nurse (RN) or licensed practical nurse (LPN). Services provided by a nurse practitioner that, in the absence of a nurse practitioner, would be performed by a registered or licensed practical nurse, are nursing services and are paid at the same continuous home care rate. This means that at least half of the hours of care are provided by RN or LPN. Homemaker or home health aide services may be provided to supplement the nursing care.
NOTE: When fewer than eight hours of nursing 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 therapy visits, drugs, supplies and equipment, and the average daily cost of the hospice interdisciplinary group (IDG). The computation of the required 8 hours for the CHC level of care applies only to direct patient care provided by a nurse, a homemaker, or a home health aide and, in general, assumes that one hourly payment would be made per hour. While in the majority of situations, one individual would provide continuous care during any given hour, there may be circumstances where the patient’s needs require direct interventions by more than one covered discipline resulting in an overlapping of hours between the nurse and home health aide. In these circumstances, the overlapping hours would be counted separately. 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 care that is needed and required. This means that all nursing 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 continuous 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 it qualify as necessitating the services of more than one provider. In addition, the services provided by other disciplines such as medical social workers or pastoral counselors are an integral part of the care provided to a hospice patient, however, these services are not included in the statutory definition of continuous care and are not counted towards total hours of continuous care. However, the services of social workers and pastoral counselors 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.
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