General Inpatient (GIP) Eligibility &

Documentation

Presented By

Hospice of Southern Illinois

www.hospice.org • 1-800-233-1708

GIP: Related Policies and SOP’s

• C-2: Levels of Care

• C-14: Transfer to Contracted Facility

• C-SOP: Transferring a Patient From Medicare/Medicaid Routine Home Care to Medicare/Medicaid Inpatient Facility

• C-SOP: Transferring a Patient From Medicare/Medicaid Inpatient Facility to Medicare/Medicaid Routine Home Care

GIP:

Retrieved from: https://www.nhpco.org/sites/default/files/public/Statistics_Research/2015_Facts_Figures.pdf

(OIG Report for 2012)

Retrieved from: https://www.nhpco.org/alerts/oig-publishes-report-hospice-general-inpatient-care

GIP:

OIG Recommendations:

• Level of care eligibility: DOCUMENT the reasons that GIP is appropriate for each patient. Evaluate continued

eligibility for GIP EVERY DAY with documentation in the medical record that can be easily reviewed and evaluated.

• Review GIP length of stay regularly: Review use of GIP and the length of stay for each patient at the GIP level of care on a

monthly basis. Internal chart reviews for length of stay of more than 2-3 days should be carefully analyzed for continuing eligibility.

Retrieved from: https://www.nhpco.org/alerts/oig-publishes-report-hospice-general-inpatient-care

HSI Standards: GIP Eligibility Form (GIP-CC Eligibility) completed daily for each patient receiving GIP level of

care

GIP patient records audited daily by the Regulatory Compliance Department. Audit includes assessing for presence and content of GIP Eligibility Form and assessing length of stay.

GIP Level of Care (Inpatient Care [Acute])

• For acute medical management of pain and symptoms.

• Available at contracted facilities for patients covered by the Medicare/Medicaid hospice benefit or for patients covered by third-party payers.

• The hospice provides the inpatient facility information related to the patient’s condition and coordinates the inpatient services to be furnished.

• The hospice is financially responsible for acute inpatient care for the Medicare/Medicaid Hospice Patient as approved in the Plan of Care. The third-party payer is financially responsible for patient under Private Insurance Benefit.

• GIP may be provided at the end of an acute hospital stay if there is a need for pain control or symptom management which cannot be feasibly provided in the home setting at hospital discharge.

Retrieved From: P:/Public/Policies/ClinicalPolicies/C-02 Levels of Care.doc

When is GIP Appropriate?

1. Need for aggressive treatment to control pain or other uncontrolled

symptoms such as nausea, vomiting or respiratory distress

2. Frequent need for evaluation and re-assessment by physician/nurse

3. Frequent need for medication changes and titration due to sudden clinical

deterioration

4. Pathological fractures requiring medication adjustments for pain control

and multiple caregivers for repositioning of patient

5. Advanced open wounds requiring frequent treatment changes and close

monitoring

6. Severe agitated delirium or acute anxiety with behaviors, secondary to the

end-stage disease process requiring intensive intervention

Retrieved from: O:\StandardsofPerformance\C-sop transfer - rhc to inpatient facility.doc

When is GIP Not Appropriate?

• It is not intended for caregiver respite

• It is not intended as a way to address unsafe

living conditions in the patient’s home

• It is not an “automatic” level of care when a

patient is imminently dying

Retrieved from: NHPCO Compliance Tip Sheet: Managing General Inpatient Care for Symptom Management, 2012

GIP-CC Eligibility Form

GIP-CC Eligibility Form (cont.)

Multi-select field:

Select all options

that apply.

Patient Care Requirements for GIP

• Complicated technical delivery of medication requiring skilled nursing care

unable to be provided by caregivers – (IV-SQ-rectal)

• Frequent evaluation and re-assessment by physician or nurse

• Aggressive treatment to control pain or other uncontrolled symptoms

• Frequent medication adjustment

• Sudden clinical deterioration requiring intensive nursing intervention

• Uncontrolled nausea and vomiting

• Pathological fractures requiring medication adjustments for pain control and multiple

caregivers for repositioning of patient

• Refractory respiratory distress

• Transfusions for relief of symptoms

• Wound care requiring complex and/or frequent dressing changes

• Severe agitated delirium or acute anxiety or depression secondary to the end-stage disease

process requiring intensive intervention

• Other (See Comments)

The Hospice of

Southern Illinois

staff are amazing!

We wouldn’t know

what to do without

them.

GIP-CC Eligibility Form (cont.) Free text field. Document

how the patient became

eligible for GIP level of

care.

Multi-select field: Select

all options that apply.

• Hospice is aggressively working to develop and provide a plan for safe discharge to lower level of

care

• Uncontrolled pain or other symptoms and/or ongoing clinical deterioration related to the terminal

diagnosis continues to require active treatment and frequent physician/nurse assessment

• Acute symptoms have stabilized but death is imminent within a short period of time as evidenced by

clinical deterioration such as mottling of the skin, change in respiratory status and level of

consciousness

• Symptomatic condition not conducive for transport

GIP-CC Eligibility Form (cont.)

Free text field. Document why the patient remains eligible for GIP level of care. Be specific.

Free text field. Document any plans to change to lower level of care or why there are no plans.

Advance Beneficiary Notice of Noncoverage (ABN)

• An ABN is issued when hospice has

determined that the patient no longer

meets criteria for GIP level of care and

the patient/family wish to remain at the

hospital.

• The family may be billed for the

additional cost of room and board in the

inpatient facility above the Medicare

allowable rate for routine home care.

• Estimated cost can be determined by

speaking with HSI Finance Manager.

• All blanks must be filled in.

• Seek guidance from your supervisor

before issuing an ABN.

GIP Eligibility Documentation

Like

GIP-CC Justification: Staff nurse, Nancy Smith RN, reported increasing patient’s Morphine

twice so far her shift. Patient was having s/s of pain/restlessness during visit and Nancy

increased Morphine again. Morphine drip currently at 5mg/hr, which was at 1mg/hr yesterday.

Spoke with patient’s physician, Dr. Johnson and obtained order to increase Ativan to 1mg

every 6 hours routinely due to uncontrolled restlessness.

GIP-CC Justification: Patient with severe pain. Constant crying, facial grimacing and

whimpering, grabbing/holding body parts, very restless/anxious, hypoxic with oxygen

saturation 83% despite supplemental oxygen, refractory respiratory distress. Patient requiring

frequent medication titration to manage symptoms. Transport of patient would

likely result in acute medical crisis and/or hasten death.

Events precipitating transfer to GIP-CC:

Patient admitted to hospital yesterday r/t UTI.

Patient treated with broad-spectrum IV

antibiotics and IV fluids with marginal

improvement, hospitalist determined patient

with very poor prognosis. Patient was to

transfer back to nursing home with hospice

services, but when EMT's arrived patient had

a significant change in condition (labored

respirations, severe restlessness) and

determined she was not appropriate to be

transferred out of hospital.

Events precipitating transfer to GIP-CC: Patient admitted post fall, surgical repair of left

hip.

GIP-CC Justification: Patient has declined since yesterday and is now non-verbal and

unable to maintain SPO2 stat, 70%RA

GIP-CC Justification: Patient's condition has deteriorated and requiring frequent

medication adjustments to help manage patient's symptoms.

Events precipitating transfer to

GIP-CC: Patient initiated on

morphine drip for pain and

respiratory distress. Patient

requiring frequent nursing

assessment for symptom

management as well as medication

titration.

Plan of Care

**The admission nurse will add this PIO to the patient’s POC if patient is admitted to GIP level of care.

**The case manager/RN designee will add this PIO to the patient’s POC if patient is transferred to GIP

level of care from routine home care.

**The case manger/RN designee will discontinue this PIO from the patient’s POC if patient

transfers from GIP level of care to routine home care.

Other Documentation Related to GIP Patients

• If patient is changing locations due to transferring into or transferring out of GIP level of care, complete the following documentation:

Discharge/Transfer Checklist

Change of Attending Physician form and change of status for physician change (if applicable)

Physician’s modified order for change in level of care and change in location

Change of status for change in level of care

Change address and phone number on face sheet

Communication

• Who needs to know

Medical Director

Attending Physician

Hospice staff: Case Manager, Social Worker, Hospice Aide, Volunteer (if applicable)

Patient Care Supervisor

Hospital staff: Nurse, Social Worker, Case Manager, Admissions, Billing

Home DME and medication providers (if applicable)

Questions

Quiz (Answer True or False)

1. HSI has 1 Standard of Performance (SOP)

that relates to GIP patients.

2. The GIP Eligibility form should be completed

daily for each patient receiving GIP level of

care.

3. The hospice is financially responsible for

acute inpatient care for all patients, regardless

of their pay source.

Quiz (Answer True or False)

4. GIP level of care can be provided at the end of an acute hospital stay.

5. Eligibility for GIP level of care includes: uncontrolled pain, uncontrolled nausea, and symptom controlled imminent death.

6. GIP level of care is not intended for caregiver respite.

7. A patient whose symptoms are controlled can remain on GIP level of care as long as they are on continuous IV pain medications.

Quiz (Answer True or False)

8. Planning for transfer to a lower level of care should begin upon admission to the GIP level of care.

9. An ABN is issued when hospice has determined that the patient no longer meets criteria for GIP level of care and the patient/family wish to remain at the hospital.

10.The Continuity of Care PIO should be added to the POC only if the patient transfers from routine home care to GIP level of care.

Your Community Not-For-Profit Hospice

1-800-233-1708 • www.hospice.org Belleville 618-235-1703 • Marion 618-997-3030