HOW SHOULD THE IDG DOCUMENT GIP LEVEL OF CARE?
Documentation during GIP level of care must be thorough and reflect the need and intensity of care for this level at all phases of care. Implementation of the plan of care must be directed to stabilizing the acute or chronic symptom management, obtaining a positive palliative outcome (did the care make a difference), and moving the patient to a lower level of care at the appropriate time.
When transferring a patient to GIP level of care, documentation should include:
- The skilled nursing interventions being provided to the patient and the patient’s response
- A Plan of Care that reflects the change in level of care and interventions to stabilize the patient’s acute pain and symptom crises
- Collaboration with the facility colleagues if in a contracted facility
- Discharge planning (remember: GIP is short-term)
The precipitating event (onset of uncontrolled symptoms or pain) which prompted the need to change to GIP level of care should be evident in the comprehensive assessment documentation. Pain and symptom management interventions that were implemented in the home prior to initiating GIP level of care should be documented and available to the inpatient colleagues.
Documentation should be updated daily and clearly describe why the patient still requires inpatient level care. If GIP level care is no longer needed, then documentation should include a plan for discharge from the facility back to home hospice.
All IDG members should document to paint a complete picture of the patient, including the pain and symptoms not adequately managed and why the GIP level of care is necessary. Physicians and nurses need to address symptom management, observations, medications initiated and changes in medications, other changes in treatment, etc. Other IDG members need to document what they see in terms of symptom management, patient and family coping, discharge planning discussions, options for returning to the routine home care level, etc. Copies of facility documentation to support the LOC is a required element.
When the patient’s symptoms are managed and the GIP level of care is no longer medically necessary, the patient’s level of care should be returned to Routine Home Care and the patient transferred back to the residential setting as appropriate. In some cases, the patient may die while in GIP care. In this situation, the inpatient facility would facilitate transfer of the deceased patient to the mortuary and often furnish the death certificate. The IDG members will continue to provide support to the family.
Examples of Documentation
Case A
85 y.o. M on GIP hospice for metastatic prostate cancer. On morphine drip. Incontinent. Has dementia and confused. Discussed care changes with nursing. Will discuss with family when available. Remains hospice appropriate.
Case B
85 y.o. M admitted GIP for intractable pain from metastatic prostate cancer, mets to bone with multiple thoracic and lumbar compression fractures. Comorbid dementia, HTN. Now tachycardic in the 120-140 range {now irregular) and hypotensive, BP 85/45. Morphine drip titrated overnight from 1mg/hour to 4mg/hour with 3 bolus doses of morphine given as well as 2 doses of haloperidol for agitation. Pt continues to move frequently in bed, occasional moans. Mildly combative with cares including changing linens and depends on when incontinent.
Confused and not recognizing family causing emotional distress. Chaplain at bedside. Distal extremities cool and mottled. Discussed with nursing plan for drip titration this morning, continued bolus doses of morphine and haloperidol and frequent reassessments. Will continue to monitor closely and provide family further education on signs of impending death when available.
Observation:
Case A & B illustrate the differences in quality of documentation for GIP patients. Both cases provide documentation about the same patient, but Case 8 clearly demonstrates why the patient continues to require GIP level care. Examples of improved documentation in Case B includes documentation of changes in vital signs, titration of the morphine drip and bolus doses needed (dose amounts included), additional non-pain symptoms experienced by the patient, description of nursing cares required, interdisciplinary support needed (chaplain) and education given by the physician, as well as a plan for further monitoring and change of medications.
FAQ
General inpatient (GIP) care is one of four levels of hospice care required to be available under the Medicare Hospice Benefit. This level of care is for patients with medical conditions that warrant a short-term inpatient stay to manage severe pain or acute or chronic symptoms that cannot be feasibly coordinated in a residential setting. GIP care is a step up from routine home hospice care.
GIP can be provided in a Medicare-certified hospital, a Medicare-certified nursing facility, or in a special Medicare-certified hospice inpatient facility. The change to a facility-based setting for this level of care ensures the availability of nurses around the clock to best manage the patient’s symptoms and assist in returning the patient to a level of comfort prior to returning to a routine level of care at home.
Patients requiring GIP level of care often have symptoms that are challenging or difficult to control. The patient often requires increased levels of nursing care that cannot be provided by nonclinical support in a residential setting. A patient must first be eligible for hospice before they are eligible for GIP care. Only a hospice clinician should complete the evaluation for eligibility, which includes an assessment, labs, diagnostic imaging, medication review, discharge planning information, advance care planning, goals of care documentation and more.
GIP care may be initiated when the interdisciplinary group (attending physician and/or hospice medical director) determines the patient’s pain and symptoms cannot be effectively managed in the patient’s home or other residential setting.
The following examples of patient status triggers may lead to deciding on GIP care:
– Pain or symptoms not managed by changes in treatment in the current setting or that requires frequent medication adjustment and monitoring
– Intractable nausea/vomiting
– Advanced open wounds requiring changes in treatment and frequent monitoring
– Unmanageable respiratory distress
– Delirium with behavior issues
– Sudden decline in condition necessitating intensive nursing intervention
– Imminent death, but only if skilled nursing needs are present
• When death is imminent, not “automatic” level of care
• Lack of caregiver support in home
• When the caregiver needs respite
• To address unsafe living conditions in the patient’s home
GIP care patient transfer documentation should include:
• Skilled nursing interventions provided to the patient and the patient’s response
• Plan of care reflecting change in level of care and interventions to stabilize the patient’s acute pain and symptom crisis
• Indication of collaboration with facility colleagues if in a contracted facility
• Discharge planning (GIP is short term)
