Utilization of continuous home care has dropped precipitously during the past decade, with labor pressures, regulatory scrutiny and billing challenges as contributing factors.
Continuous home care (CHC) represented 0.9% of hospice care days during 2022, according to the National Hospice and Palliative Care Organization (NHPCO). This is down from 1.8% in 2013.
The widespread labor shortage in hospice is one of several barriers to patients’ receiving CHC, according to Sarah Simmons, director of quality at NHPCO.
“Continuous home care also requires that hospices have nursing staff available to provide this high-intensity, continuous, in-home care at all times,” Simmons told Hospice News in an email. “CHC cannot be planned in advance as it is provided in response to acute symptom management needs, so hospices need to maintain adequate staffing levels to respond to these needs emergently. This is a challenge for providers in light of the widespread health care staffing challenges that impact the hospice community.”
Patients can receive CHC during a period of crisis in which an individual requires continuous care to manage acute medical symptoms so that the individual can remain at home, according to the U.S. Centers for Medicare & Medicaid Services (CMS).
Medicare may cover CHC for as long as 24 hours a day. Each day, a patient in CHC must receive a minimum of 8 hours of nursing care or nursing and aide care.
CMS has been trying to identify issues that may be impeding patient access to the higher acuity levels of care, including CHC, general inpatient care and respite care. In 2020, the agency rebased the payment rates for those services in an effort to boost utilization.
More recently, CMS included requests for information (RFIs) in its proposed 2024 hospice rule around access barriers to these higher-acuity services, pointing towards claims data that reflected underutilization.
However, regulatory scrutiny of higher-cost, higher-acuity hospice care by CMS and its contractors is also a likely factor contributing to the decline in utilization. Claims and documentation for these services are frequently flagged for audits or medical reviews.
“Hospice providers are subject to a significant amount of scrutiny on continuous home care, among many other areas under the hospice benefit,” Patrick Harrison, senior director of regulatory and compliance for NHPCO told Hospice News. “For example, many medical review activities are focused on the reasonableness and necessity of CHC, and a hospice’s documentation and compliance with CHC requirements.”
In addition to these concerns, billing for CHC can be complex. A distinction exists between the provision of CHC and “billable” CHC, according to Simmons.
For CHC to be billable, the hospice must provide at least eight continuous hours of predominantly nursing care within a 24-hour period that begins and ends at midnight.
“This means that if a patient’s symptoms indicate the need for CHC beginning at 8 p.m. and the hospice provides continuous in-home care until 4 a.m., the care is not billable as CHC because the full eight hours were not within the midnight-to-midnight window,” Simmons said.