About the Medicare hospice benefit

The four levels of hospice care

98.6% of Medicare hospice patients receive their hospice care at their “residence.” Residence includes their personal home or that of a family member or friend. It also includes a skilled nursing or assisted living home.

Here’s the breakdown for the four levels,

• 93.8% of Medicare hospice patients receive what’s known as Routine Home Care.

• 4.8% receive Continuous Home Care. This is hospice care consisting predominantly of licensed nursing care on a continuous basis at the residence. This is only furnished during brief periods of crisis and only as necessary to maintain the patient at home (out of the hospital).

• 1.0% receive General Inpatient Care in an inpatient facility (hospital) for pain control or symptom management that cannot be managed elsewhere.

• 0.4% receive Respite Care in a facility on a short-term basis to provide respite (relief) for the family or other caregiver.

Source: National Palliative Care and Hospice Organization, NHPCO Facts and Figures (2015 Edition)

Hospices are visiting services

Normally we all think of “hospice” as a place, so this can be confusing. Here in the South Bay and elsewhere, hospices under Medicare are normally visiting services, not places.

Hospice teams visit their patients where the patients reside. So your hospice team can visit you at your home or at a nursing home or assisted living home.

Skilled care vs. personal care

Keep in mind the distinction between skilled (aka medical or nursing) care and personal care.

• Skilled care is care provided by a physician, nurse, rehabilitation therapist or other licensed medical professional.

• The primary job of the hospice team is to provide skilled care.

• Personal care does not require a licensed medical professional.

​Medicare hospice vs. home health care benefit

If you’re using the Medicare hospice benefit, you won’t use the Medicare home health care benefit. Between the two, the hospice benefit provides more complete services.

​Personal care that you might need

Personal care includes help with a broad range of tasks and activities. Your needs will depend on your individual circumstances. You may need personal care so that you can live at home safely.

• You’ve likely heard of ADLs (activities of daily living). Those are routine self-care tasks that healthy people tend to do every day without assistance. The ADLs are eating, bathing, dressing, toileting, transferring (walking) and continence.

• Not as well known are IADLs (instrumental activities of daily living). They go beyond routing self-care. They’re part of being able to live independently in a community. The IADLs are housework, preparing meals, taking medications as prescribed, managing money, shopping for groceries or clothing, use of the telephone or other form of communication, and transportation within the community.

• There are additional tasks to handle for someone with an illness. These include monitoring the person’s condition to help make care adjustments, scheduling appointments, and interacting and advocating with care providers, agencies and professionals.

Who will provide the personal care?

Men and women dealing with illness receive a remarkable amount of help from unpaid family and friends. An estimated 34.2 million American adults served as an unpaid caregiver to a person age 50 or older in a recent year.  And 88% of that care was provided in the person’s own home or the home of a family member or other connected person. Source: Caregiving in the U.S. – 2015 by the National Alliance for Caregiving and the AARP Public Policy Institute.

Members of a hospice team will normally visit their patient for a few hours each week (e.g., five). Their focus is managing symptoms and medications, and on comfort. Other than help with bathing and tasks a hospice volunteer might take on (e.g., limited shopping), the hospice team generally does not help with personal care.

Goals of care

An important part of assessing your needs is to look at your goals of care. When you ask “what are we trying to accomplish?” you’re talking about setting a goal. Goal setting is a crucial part of making appropriate treatment and care decisions for yourself (or anyone else).

The goals of care you select will depend on your circumstances, and goals often change when the circumstances change. Based on the goals you select, different treatment (and care location) choices will be appropriate.

Possible goals of care include

• curing the illness, or stopping or slowing down its progress

• maintaining or improving function

• prolonging life

• being clear-headed or in control

• allowing a natural death, and

• relieving pain and suffering.

When you need more help

Unfortunately, many don’t have family or friends available to help. Or to the full extent needed. And available family and friends can become overwhelmed providing and arranging care.

When you need more help than is available from family and friends, the options to focus on are

• Hiring home care help (to come to your home)

• Moving and receiving care outside your home at a

  • Nursing home,

  • Large assisted living facility or

  • Board and Care (small assisted living home).

Additional Information

​Where do patients receive hospice services?

​NHPCO Facts and Figures reports that nationally at the time of death hospice care was received:

• 35.7% at the patient’s residence (includes residence of family or friend)

• 14.5% in a Nursing Home

• 8.7% in a Residential Facility (includes assisted living)

• 9.3% in Acute Care Hospital

• 31.8% in Hospice Inpatient Facility (a dedicated inpatient unit or facility located by a hospice service) [we are not aware of any Hospice Inpatient Facility located in the South Bay]

Source: National Palliative Care and Hospice Organization, NHPCO Facts and Figures (2015 Edition)

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Hiring home care help

You can hire individuals directly or through a home care agency.

Here’s a summary of the tasks involved with hiring and using home care help and protecting yourself and the helpers in the process:

1. Determine what help is needed (needs assessment)

2. Find, interview and select caregivers

3. Create and sign a written agreement

4. Create a care plan and supervise that it’s followed

5. Create and follow a care log (tracks caregiving activities as done)

6. Create and follow a medications log (tracks medications, dosages, timing, who prescribed, etc.)

7. Have list of contact information

8. Create and follow a money and costs log

9. Inventory belongings

10. Supervise, communicate and problem-solve

11. Deal with homeowners insurance, workers compensation insurance, employee taxes and eligibility to work.

Healthcare and Elder Law Programs Corporation (H.E.L.P.) has created a free plain language Home Care Toolkit that includes sample needs inventory, care plan, care log, medications log, money log and other tools. You can download it at www.help4srs.org/home-care-toolkit .

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Hiring individuals directly

Here you take on the 11 tasks listed above (or have family or friends handle them). This is typically less expensive (vs. an agency) from an hourly rate viewpoint. The trade-offs: you spend more time managing your care and you take on much more responsibility and potential liability if something goes wrong (e.g., a caregiver is injured in your home).

The CA Department of Social Services maintains a public online registry for home care aides who have been background checked.

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Minimum Wage and Overtime Rules

This section was updated May 2, 2018.

In the South Bay the basic minimum wage in 2018 for a household employee (caregiver) is $10.50 per hour ($12 per hour in the City of Los Angeles).

• For 24-hour care at the minimum wage, the cost would be $252 per day ($288 per day in the City of Los Angeles).

The overtime rules require additional compensation for household employees. In general, they require pay at least 1.5 times the regular hourly rate (time-and-a-half),

• for all hours worked over 40 in a workweek and

• for all hours worked over 8 in a workday.

An example: Mrs. Jones hires 2 caregivers to provide round-the-clock care in her home. Each caregiver works 12 hours per day, 7 days per week. She pays minimum wage and complies with the overtime rules. She would owe each caregiver $147 per day (8 hours times $10.50 per hour; plus 4 times $10.50 per hour times 1.5). For the two caregivers the total would be $294 per day (or $336 in the City of Los Angeles).

The rules are more complicated than described above. For more information, see this California Tax & Labor Law Summary.

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Hiring through a home care agency

When you hire through a home care agency, you do it so the agency will take the responsibility for the tasks listed above, including supervising the caregivers. You sign an agreement with the agency, and you deal with the agency to resolve difficulties and concerns.

California law requires home care agencies to be licensed with the CA Department of Social Services.  

This is typically much more expensive (vs. hiring individuals directly) from an hourly rate viewpoint. The trade-offs: you spend less time managing your care and you take on much less responsibility and potential liability if something goes wrong.

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Moving and receiving care outside your home

The first step in selecting care outside your home is to determine what help you need (needs assessment). Based on the needs assessment, you then choose between three categories of care home. Check to be sure the prospective home has the necessary license, staffing and experience to meet your needs.

• Nursing homes (skilled nursing facilities) are licensed and staffed to provide skilled nursing care and skilled rehabilitation services. They have nurses on duty 24/7 and the focus of care is medical plus personal.

  • A person on hospice can receive care in a skilled nursing facility. The person’s selected hospice service will visit them at the facility.

• Large assisted living facilities are not licensed to provide skilled nursing care or rehabilitation services. They are not required to have nurses on duty. The focus of care is personal.

  • A person on hospice can receive care in a large assisted living facility if the facility has the needed “hospice waiver.” The person’s selected hospice service will visit them at the facility.

  • A large assisted living facility cannot admit a person who has a “prohibited condition.” These include a serious infection, communicable tuberculosis, certain behavior/mental disorder issues, stage 3 or 4 pressure sores and (depending on the facility’s hospice waiver status) various types of tubes and devices.

• Board and care homes (small assisted living homes) are not licensed to provide skilled nursing care or rehabilitation services. They are not required to have nurses on duty. The focus of care is personal.  

  • A person on hospice can receive care in a small assisted living facility if the facility has the needed “hospice waiver.” The person’s selected hospice service will visit them at the facility.

  • A small assisted living facility cannot admit a person who has a “prohibited condition.” These include a serious infection, communicable tuberculosis, certain behavior/mental disorder issues, stage 3 or 4 pressure sores and (depending on the facility’s hospice waiver status) various types of tubes and devices.

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Moving to a nursing home

A nursing home (skilled nursing facility) is licensed to provide skilled nursing and rehabilitation services. There are medical conditions and care needs that skilled nursing facilities can meet that assisted living homes cannot meet.

Nursing homes in the South Bay overview:

• Setting: a medical facility, appearance and amenities vary.

• Typically larger facilities (average is 83 residents).

• Normal goals of care are rehabilitation, longevity and return home.

• Allowed to serve residents who are on hospice; hospice service will visit.

• California staffing requirements call for 24/7 awake staff; 1 caregiver for 5 patients (days), 1 for 8 patients (evenings), 1 for 13 patients (nights).

• Caregivers are mostly CNAs led by a staff RN/LVN.

• Typically 2 or 3 patients per bedroom.

• Licensed by the California Department of Public Health. Certifications by U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services (CMS).

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Moving to a large assisted living facility

Large assisted living facilities are licensed to provide personal care. There are medical conditions and care needs that a large assisted living facility cannot meet. The conditions and needs they can meet can be expanded if they have the necessary hospice waiver.

Large assisted living facilities in the South Bay overview:

• Setting: a large facility, appearance and amenities vary.

• Typically larger facilities (range from 51 to 202 residents).

• Normal goals of care are rehabilitation and longevity.

• Allowed (if they obtain a hospice waiver) to serve a resident who is on hospice; hospice service will visit.

• Staffing is 24/7 awake staff.  No specific California staffing requirements.

• Caregivers are led by the administrator; RN/LVN might be present.

• Typically 1 or 2 patients per bedroom.

• Licensed by the California Department of Social Services as Residential Care Facility for the Elderly.

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Moving to a board and care home (small assisted living home)

Board and care homes are licensed to provide personal care. There are medical conditions and care needs that a board and care home cannot meet. The conditions and needs they can meet can be expanded if they have the necessary hospice waiver.

Board and care homes in the South Bay overview:

• Setting: a private home, appearance and amenities vary.

• Typically small facilities (up to 6 residents).

• Normal goals of care are rehabilitation and longevity.

• Allowed (if they obtain a hospice waiver) to serve a resident who is on hospice; hospice service will visit.

• Staffing is typically 1 or 2 caregivers for up to 6 residents, with 24-hour shifts (staff sleeping allowed at night).  No specific California staffing requirements.

• Caregivers are led by the administrator.

• Often 2 patients per bedroom.

• Licensed by the California Department of Social Services as Residential Care Facility for the Elderly.

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Where Caring House fits in

Caring House is a board and care home (small assisted living home). There are medical conditions and care needs that we cannot meet. We do have hospice waivers for all bedrooms.

Caring House overview

• Setting: a private home.

• Up to 5 residents.

• Goal of care is peace, comfort and support at end-of-life.

• Allowed to serve residents who are on hospice; hospice service will visit.

• A maximum of 5 residents. 24/7 awake care by 1 or 2 caregivers; strong volunteer support. No specific California staffing requirements.

• Caregivers and volunteers are led by experienced resident care manager.

• All private bedrooms.

• We depend on residents and family members to help cover the cost of care to the best of their ability. If a resident or family is unable fully to cover the cost, we depend on donations from the community to cover the shortfall.

• Licensed by the California Department of Social Services as Residential Care Facility for the Elderly. License Number: 198602078.

This report gives general information not specific advice on individual matters. Information about facilities, staffing and programs is taken from sources believed by us to be reliable. If you have updates or corrections please share them with us by emailing contact@yourcaringhouse.org