1. General Inpatient Level of Hospice Care “You, Too, Can GIP”

2. “We need to trust that our patients are the experts on their lives, culture, and experiences, and if we ask with respect and genuine desire to learn from them, they will tell us how to care for them.” Lipson, J. (1996)

3. Introduction Lori Kenyon, RN, BSN and Mary Gallien MSW with panel guests Hospice Physician, Dr. Arun Vijay and Clinical Manager, Krista Wassermann, RN, MSN
We are expecting to do about a 30-min presentation followed up with a panel for questions with our hospice physician Dr. Vijay and Clinical Manager Krista Wasserman, thank you in advance for attending.

4. What is Hospice General Inpatient Care? (GIP)
One of the 4 levels of Federal Medicare regulations require a hospice to provide as a condition of Certification. GIP is intended as a short term intervention for management of acute symptoms that cannot be managed in another setting.

5. When is Hospice General Inpatient Care? (GIP) considered
Initiated when other efforts for symptom management have not been successful.
For patients who cannot comfortably remain in a residential setting.
And who require skilled nursing care around the clock to attain/maintain comfort.

6. Patient Status That May Lead to GIP Eligibility
Uncontrolled pain requiring frequent evaluation by physician/nurse
Sudden deterioration requiring intensive nursing intervention
Titrations of IV medications
Pt’s admitted to transition from one IV medication to another.
Complicated technical delivery of medication requiring skilled nursing assessment
Frequent medication adjustment

7. Wounds requiring complex and/or frequent skilled dressing changes
Intractable GI symptoms, Uncontrolled nausea/vomiting     
Pathological fractures
Delirium, with behavioral issues
Unmanageable respiratory distress 

8. Imminent death – ONLY if skilled nursing needs are present
Skilled care required for unstable medical conditions may include
Management of Dehydration
Rapid onset of ascites or fluid retention causing pain not manageable in other settings
Recurrent Seizures
Frequent Suctioning
Imminent death – ONLY if skilled nursing needs are present

9. Joe Carson
Patient Joe C is a 70 year old male with advanced colon cancer; metastases with pulmonary and hepatic involvement.
Joe was rushed to ER/ED due to radiating leg pain, chest pain, persistent cough with hemoptysis, blood in stool, incontinence unable to be managed in home.
Family wants all care treatment options possible. Patient responding poorly to aggressive efforts, prognosis poor…

10. Joe Carson Unmanaged symptoms present Ongoing decline
Pt safety concerns, family uncertain what to expect, shocked at rapid decline.
Here is an example of GIP and why: Family reported pain medication not effective, fear around bloody sputum/blood noted in colostomy bag/brief which has increased over last 6 hours, patient. has become incontinent. Pt experiencing overall anxiety r/t family concerns and his new s/sx. Joe was started on a drip for pain management. Attempts to relive cough/minimize bloody sputum ineffective. Psychosocially and physically uncomfortable, goal of care to get patient and family more comfortable/adjusted to what they are seeing.

11. What is not covered under GIP
Care giver breakdown For care that can be provided in another setting Imminent death WITHOUT a need for aggressive symptom management
Examples of Ineligibility for GIP Status:
No care giver in the home, or caregiver is unable/unwilling to help the patient adequately, other arrangements can or should be made.
ER or ED arrival as a way to address unsafe living conditions in the patient’s home
An "automatic” level of care when a patient is imminently dying.

12. Betty Thompson – current Hospice patient just arrived in Emergency Room
Betty Thompson is an 82 year-old woman who lives in private home with twin sister Barbara and many cats. She was recently admitted to hospice with hospice diagnosis of dementia, chronic Hep C requiring increased level of care needs. Sister Barbara called 911 due to Betty’s increased weakness, refusal to take medications and not allowing assistance with care. Barbara is wheel chair bound and has trouble providing hands on care.
Barbara was met in ED by hospice RN to be evaluated for GIP admit and does not meet criteria.
Betty was stabilized, given appropriate medications, IV fluids and sent home with alert to Hospice Care Team to f/u on possible placement.
ELIDGABLE not Eligible? Can symptoms be managed/provided in an outpatient environment.

13. How is GIP different from Routine Hospice Care?
Crisis stabilization in a Medicare certified Hospital, Skilled Nursing Facility, or inpatient hospice unit
 Routine
Standard level of hospice care provided in patients place of residence -- home, long term care facility, assisted living setting, or adult family home
Who what when where?
GIP
Includes care team
Acute symptom management
Expected transition to hospice routine level of care in another setting. Home, SNF, assisted living etc..
Requires a safe discharge plan for continued symptom management in another setting. Is the patient able to go home on continuous IV? Goal to transition to oral medications/patches for ease of administration.
CT visit, may/may not use HA
Routine
 Includes Care Team
 24 hour on call nursing support

14. GIP Referrals from hospital may include:
Hospitalized patient with deteriorating health status and unmanaged symptoms
Pt is no longer a candidate for further treatment, but presents with skilled needs for symptom management
Pt may have had an event (stroke, HA, seizures, embolism, etc..) that has precipitated acute symptom management needs
Rapid decline
Patient can no longer tolerate radiation/chemotherapy at this time, but is having acute ASE to recent therapies.
Pt may be experiencing ongoing seizure activity, unable to be managed in home
Pt may be on hi-flow O2 to be able to maintain adequate saturation for comfort/short period of time.
Continuity of care – Grief support services and hospice Care Team able to support patient and family.

15. Referral To Inpatient Hospice – GIP not met
If Hospice Criteria is met but GIP Criteria is not met, then admission to Hospice can be scheduled for the day patient discharges from hospital to home or skilled facility.
If not on hospice, no further treatment available/patient is done w/treatment and wants to live out their lives in comfort and no unmanaged symptoms. Patient can be admitted in hospital on day of discharge form hospital. Coordination of DME prior to discharge.

16. Hospice Consults & Admitting Criteria

17. Already in the bed -------------------- Hospital in-patient to Hospice GIP status.
Referral comes from attending physician, requesting evaluation for GIP status.
Hospice responds with GIP evaluation. . .
Hospice admit nurse coordinates admit visit with family.
Once admitted, patient, family, physician, and Hospice Care Team initiate plan of care.
2. Referral comes from attending;
s/sx seen; a UTI can look like terminal agitation, SOB requiring high O2, etc..
Hospice physician may be contacted to review patient chart challenges with symptom management to ensure criteria for GIP is met prior to admission.
3. Clarification of hospice services both in and out of the hospital, determine goals of care and potential discharge plan.
As noted before if patient does not meet criteria under GIP status but meets Hospice criteria patient admit can be scheduled for the day patient discharges from hospital.

18. Hospice Community patient admitting to GIP in hospital setting.
Pt determined to have intractable symptoms unmanaged in the home setting.
Hospice may arrange transport as needed, POLST to accompany patient.
Hospice Triage or Care Team RN, contacts hospital ER/ED Physician
Process and give report as soon as possible, fax clinical.

19. Hospice Community patient admitted to GIP in hospital setting.
Preliminary measures toward comfort are addressed in the ER, and fully assessed by a Hospice RN, preferably Care Team RN.
Determination made that GIP criteria is met by Hospice RN.
Then patient is admitted to hospital through ED/ER.

20. Getting into the GIP Bed Community Patients to GIP
Confirm Insurance coverage for inpatient care
Confirm Hospice Contract with hospital of choice
Notify patient’s Attending Physician for Hospice
Notify Hospice Clinical Manager and Administrator On-Call (AOC)

21. Getting into the GIP Bed At the Hospital…..
Confirm Attending Physician in agreement to admit patient to GIP level of care.
Confirm patient’s hospice diagnosis is related to the hospital admitting diagnosis.
Hospice diagnosis must appear among the first 3 admitting diagnosis
Care coordination with MD, hospital staff and family to determine to plan for symptom management.

22. Getting into the GIP Bed At the Hospital….cont.
Questions to Consider:
What is the most appropriate symptom management to return patient to previous level of care?
Is this symptom management consistent with patient’s previous and current Plan of Care and Goals?

23. AT THE HOSPITAL – The most important non-clinical notification
Financial Responsibility – Notify the admissions/billing department of decision to admit patient. GIP and forward any need forms to confirm financial responsibility to billing office.
Clarity around financial responsibility is critical to a smooth admit and transition to GIP in a hospital or a Skilled Nursing Facility setting.

24. Hospice Team for General Inpatient Care

25. Hospice Team - GIP  Hospice Physicians
 Experienced Hospice Clinicians
 Hospice Physicians
 End of Life teaching/education to staff, patient,
and family members.
Maintains family goals toward developing Plan of Care
The GIP Hospice Team consists of: A nurse, MSW, CH, hospice physician, pharmacist, and an aide, who initiate and guide the POC. Care coordination takes place with staff in hospitals or SNF toward POC goals of comfort, symptom management or toward successful discharge planning.
Education: CG, family, what are they seeing/what does it mean.
Discharge planning begins on day of admit and continues throughout the GIP stay. The RN case manager visits daily to assess the patient and make recommendations for improved pain and symptom control. Access to hospitalist, hospice physician, pharmacy and family included in determining what may help patient going forward.

26. Hospice Team - GIP Symptom management, emotional and spiritual support
 Comfort care protocols in an acute environment.
 Discharge planning discussion with patient/family initiated upon admission.
Hospice ensures that families can get formal hospice bereavement services for 13 months after the event of the patient’s death.
Remember people are not always comfortable in a hospital. Normalize with explanations on what you see r/t patient decline. Encourage them to advocate for themselves PRN, explain structure. “You are in hospital but staff will err on side of privacy unless we request more routine checks as patient is on hospice. Please use call light when needed. Ask for their perspective of what comfort is to them.

27. Guidelines for Attending Physician
Orders for hospice inpatient stay written by Attending Physician Comfort Care order set initiated in EMR by physician/hospitalist Routine follow up by Attending Physician during hospice admission
Community---Usually entry through ED, evaluated for unmanaged symptoms by RN/Hospice, Orders written by hospitalist for GIP Admission?
Inpatient Admit

28. Guidelines for Attending Physician
Signs Hospice Plan of Care Daily contact with hospice team Hospice team member(s) will visit patient daily Hospice Medical Director/Hospice physician will be available as a resource

29. Hospice Physician
Provides onsite hospital consultations for; Goals of care, Disposition recommendations, Care Coordination and Symptom Management
PR/Consults for hospice as well as liaison for hospice.
Coordinates with hospice pharmacists, Care Team and staff around symptom management challenges.

30. Care Team Management/Support Initial Encounter
Enter room together as a team when possible
Ask what family and patient understands about disease process and prognosis?
Explain how addition of hospice care team to Hospital team can benefit patient to provide best care.
Main Concerns
Goals of care
Patient assessment
I would like to hear your perspective on how things are going right now – what do you see as your future?
What is important to you – this will allow us to take the best care of you.
Too personal? Appropriate to speak in front of the patient. Let me know.
Mary?

31. Registered Nurse GIP role Assessment
GIP: Head to toe assessment with focus on;
Psycho/social how is patient participating in conversation interaction with RN, what are they saying, how they are saying it. Assess Pain levels, SOB, unmanaged symptom concerns and changes since hospitalized. What has worked/not worked.
Request to further assess, Nero, CV RRR, Lungs CTAB, work of breathing, discomfort, signs and symptoms of anxiety, agitation – determine baseline and goals
Is our patient eating, bowel care, mobility and independence, desire for help/support, skin integrity
Active needs: increased suctioning, bolus dosing of medication, etc..
REVIEW WHAT I AM SEEING WITH FAMILY/THOSE PRESENT IF APPROPTIATE. Discuss review, what is changing.
Listen to patient
Continued assessment of (symptom) Pt sates improve (symptom) management with (treatment)
Interventions effective in managing (symptom)
Care needs being managed by (intervention)
Increased need for care AEB.

32. Registered Nurse GIP role Charting
Clinical Note, EMR Note
“GIP Day 1, Day 2, Day 3 etc.…”
Supportive Data that the symptoms are ongoing:  Pt continues to meet GIP eligibility for… “state the uncontrolled symptom(s)”
Ongoing Issues:
Patient response to current interventions; if any
Measureable outcome: pain ratings and quotes from patient family
Providing recommendations to manage symptoms and education provided to staff and family.
Discharge plan: TBD
Coordinated care with: i.e.... Name Care Givers involved in development of POC for comfort.
Please contact your Hospice Agency for symptom management needs, changes in condition, or at time of death
Recommendations: Turning/mouth care Q2-4H for comfort, lip balm, music, scents, stuffed animals photos. TCs from friends/family etc..
Cool compresses to forehead. Courtesy tray for vigiling family.
Coordinated Care: Hospice Care Team, Clinical Manager, Hospice Pharmacist, Hospitalist, Family members, SN, Specialists, Attending
We are responsible for managing POC while patient is in the hospital. Show patient and family involvement in care planning, document interventions/outcomes and if effective.

33. MSW/GIP: Assessment, Documentation, and Beyond
Precipitating Event prior to GIP status
Location/ Who is Present at this Visit
Initial MSW Assessment—or SW Assessment
 Ideally the Initial Assessment includes the RN and MSW in joint visit…
1.) have a good understanding prior to consult with RN/Hospital, or meeting the family.
2.) includes family members and their relationship to decision-making, POA, etc.
3.) includes physical status, with attribution to team members who offer information “per RN/CT or per hospitalist Dr. XXX
4.) sometimes chaplain too, it is beneficial to the family if care team stays sensitive to overwhelm of family members

34. MSW-GIP Assessment Documentation, and Beyond
Social Hx/Support Network
Neuro/Emotional/Behavioral Status
Communication Capacity/Ability–
Code Status (if in question or not completed)
1.) essential to determine assets/resources for emotional support or hands on care giving if discharge is a potential
2.) Assess for anxiety and/or depression in patient and in family members, understanding that anxiety and or depression may be conditional due to circumstance, health status.
3.) Is patient able to participate in LTC planning? Does Family seem to be absorbing information about Plan of Care for patient
4.) Often a discussion after patient has consented to hospice, can be an emotional discussion in light of hospitalization and rapid decline of patient. Important to have the POLST in place for discharge purposes and to ensure that patient wishes are respected.

35. MSW---GIP Assessment, Documentation, and Beyond
Funeral Home –
Financial Concern/Insurance
Resource/Counseling Provision
 emotional adjustment counseling
 reflective inquiry with patient and/or family members
 Written information given to go over in a quiet moment at the bedside
1.) provide resource lists that include names/addresses/phone numbers/websites so that patient/family can “shop around” if they need to. When the decision is made, find a way to communicate the Funeral Home choice to hospital staff so it is handy to staff at the time of need.
2.) Clarify the payor source for hospice, explore family willingness to use financial resources/assets for R&B in a SNF or AFH, or if pts are in need of a Medicaid application for R&B) 
3a.) for patient and family—normalize feelings of shock at sudden change in patient health status
3b.) listening for meaning and avenues for emotional support
4.) info given about GSS follow up, SC info, anticipatory counseling by MSW/GIP; also includes information on EOL provided like S&S of approaching death, Gone From My Sight, etc..)

36. MSW---GIP Assessment, Documentation, and Beyond
Care Coordination
Disposition
Discharge to home setting
Discharge to SNF or AFH,
Timing of Discharge
Placement efforts
1.) Also included efforts made to coordinate community supports (includes names of hospital staff for care coordination, RNs, MSWs, doctors, PHOS/Clinicians)
2a) Also includes reason that patient continues to meet GIP criteria, referencing RN/CT or consults with hospital staff that are patient and disease specific.
2d) may or may not be assisted by hospital personnel, depending on disposition.
MSW arranges transports helps coordinate DME in new setting and gives report to community Care Team SW.

37. MSW---GIP Assessment, Documentation, and Beyond
Should patient die in hospital setting
 reassure family of care taken with transition to mortuary care
 Check with hospital staff to see if there is a limit on time spent with patient after death
Help family understand the role of the Funeral Home for post-death tasks
Grief Support accessibility and follow up
2) Especially in regard to Death Certificate to be signed by Hospitalist/Attending, special arrangements for veterans
3) Length of time of support, whether or not young children are supported by grief counselors, how to enlist school counselors for kids.

38. Challenges
Family does not want patient to leave hospital – no matter what
Family unavailable
Placement challenges, lingering, high acuity of medication delivery, vent
Families not willing to try different medications easily given in other environments.
Discharge back to hospital

39. Chaplain GIP role: supports patient, family, hospital staff, and Providence care team throughout GIP hospitalization.
Assesses and identifies religious/spiritual goals, challenges, and strengths
Provides supportive spiritual and emotional presence
Facilitates sacramental rites, faith community visits as requested

40. Chaplain GIP role: supports patient, family, hospital staff, and Providence care team throughout GIP hospitalization.
Coordinates with hospital chaplain on handoff of spiritual plan of care to hospice chaplain
Provides increased availability and prioritization of GIP patients as needed
Ensures discharge handoff of spiritual plan of care to hospice community team chaplain

41. Patient ready for discharge – Home
Obtain orders for change to hospice routine level of care
Update community attending physician responsible for medication orders after discharge.
Durable medical equipment; OT referral for safety

42. Patient ready for discharge – Home
Coordinate with infusion as needed, have hospital physician write orders for medications x1 week.
Provide needed education to a willing family member on; care of drains, medication administration, basic care as needed.
Provide Tuck-in visit
Education: Medication onset, frequency, orders
Tuck-in: medications present in home, DMEs working well, update charting, LOC order changed

43. Patient ready for discharge – Skilled Facility (SNF)
Obtain orders for change to hospice routine level of care
Update community attending physician responsible for medication orders after discharge.
Durable medical equipment; OT referral for safety

44. Patient ready for discharge – Skilled Facility (SNF)
Coordinate with infusion as needed, have hospital physician write orders for medications x1 week.
Provide REPORT to SN around patient care needs, Goals of Care, DPOA, patient and family challenges. Routine that has been effective. Patient likes dislikes if known.
Provide Tuck-in visit, check in with facility RN

45. Paint the Picture (The picture you paint is the picture Medicare will use to determine whether this level of care is appropriate and reimbursable).
Pt with end stage pancreatic caner continues to meet GIP criteria for pain poorly managed at home. Unable to take PO medications due to nausea/vomiting. Requires frequent nursing interventions and assessment to ensure comfort. Pain was 9/10 when arrived to HCC, now reports improved at 6/10 with ongoing titration of dilauded infusion and Q4H doses of SQ Haldol effective patient. denies nausea at this time.
Brief history/story of what brought patient into hospital.
Documentation must support GIP or Medicare can reduce payment to routine Home care. The reason for higher level of care must be noted – what prompted change? All levels of care require ongoing documentation to show the patient is appropriate for hospice care. The precipitation event that prompted need/must be evident.
Discharge planning begins on day of admit – have we introduced topic? Family understanding
Note = Bill to Medicare and remember each note must stand alone.

46. Thank You

47. References
National Hospice and Palliative Care Organization, A Clinical Guide to Hospice General Inpatient Care (GIP) (2018)
Documenting to support General Inpatient (GIP) Hospice Level of Care. (2018) P_Tip_GIP_Sheet.pdf
Check-Lists: Admit, Discharge, Transfer