Timing the Hospice Conversation: A Case Management Perspective on GIP Level of Care and End-of-Life Decision Making
BY JENNY QUIGLEY-STICKNEY, MSN, MA, MHA, CCM, ACM-RN, CMAC, CPHM, FCM
WHEN IS THE RIGHT TIME TO BEGIN THE CONVERSATION ABOUT HOSPICE?
Is it at the onset of chronic illness, when future care planning can still be approached with clarity and foresight? Is it when curative options have been exhausted and prognosis becomes limited? Or does the conversation too often occur in the final days—or even hours—of life, when decisions are made under pressure and emotional distress?
In practice, the answer varies. Yet across care settings—particularly in acute care hospitals—case managers frequently encounter hospice discussions initiated at the most critical and compressed moments in a patient’s trajectory. These late-stage conversations often include decisions regarding Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, placing significant emotional and ethical weight on patients, families, and healthcare team members.
THE CHALLENGE OF TIMING AND READINESS
Despite increased emphasis on advance care planning, many patients and families remain unprepared—or unwilling—to engage in end-of-life discussions early in the disease process. Clinicians who attempt to introduce hospice prematurely may be met with resistance, discomfort, or even perceived insensitivity.
However, the absence of early dialogue often leads to a far more difficult reality: decision-making under duress.
Families who have not previously explored care goals may find themselves navigating complex medical decisions in crisis situations. Healthcare proxies, in particular, may struggle to balance the patient’s previously expressed wishes with the emotional needs of family members. This tension can lead to conflict, delayed decision-making, and, at times, care that is misaligned with the patient’s values.
For healthcare teams, these scenarios frequently present ethical dilemmas—especially when aggressive interventions continue despite limited clinical benefit and increasing patient discomfort.
THE ROLE OF CASE MANAGEMENT IN EARLY CONVERSATIONS
Case managers are uniquely positioned to bridge this gap. By initiating conversations earlier—through tools such as advance directives, “Five Wishes,” or structured frameworks like The Conversation Project—case managers can help normalize discussions around goals of care. These conversations are not about removing hope; rather, they are about redefining it in a way that aligns with patient values, dignity, and quality of life.
At the core of this work is education: ensuring that patients and families understand the full spectrum of care options available to them, including hospice services and the levels within that benefit.
UNDERSTANDING HOSPICE AND THE GIP LEVEL OF CARE
Hospice care is grounded in a philosophy of comfort, dignity, and holistic support for individuals facing life-limiting illness. While most hospice services are delivered in the home or long-term care setting, there are circumstances in which symptom burden exceeds what can be safely managed in those environments.
In these moments, General Inpatient (GIP) hospice care becomes an essential component of the continuum.
THE FOUR LEVELS OF HOSPICE CARE
Under the Centers for Medicare & Medicaid Services (CMS) hospice benefit (2024), four levels of care are defined:
- Routine Home Care
- Continuous Home Care
- Inpatient Respite Care
- General Inpatient (GIP) Care
GIP represents the most intensive level of hospice care, designed specifically for short-term management of acute, uncontrolled symptoms that cannot be addressed in other settings.
It is important to emphasize that GIP is not a transition away from hospice—it is an extension of hospice support during times of clinical crisis.
CLINICAL INDICATIONS FOR GIP CARE
Patients may require GIP level of care when experiencing complex symptom exacerbations such as:
- Intractable pain unresponsive to standard management
- Severe dyspnea requiring intensive monitoring
- Persistent nausea and vomiting
- Terminal agitation or delirium
- Seizure activity
- Complex wound or bleeding management
THE GOAL OF GIP IS STABILIZATION—NOT CURATIVE.
Once symptoms are effectively managed, patients typically transition back to their preferred setting, whether that be home, assisted living, or a skilled nursing facility.
DOCUMENTATION, COMPLIANCE, AND MEDICAL NECESSITY
Regulatory Criteria
GIP care requires rigorous documentation to support medical necessity. CMS 2024 guidelines mandate clear evidence of:
- Acute, uncontrolled symptoms
- Need for frequent skilled nursing intervention
- Inability to manage symptoms in a non-inpatient setting
- Daily reassessment of ongoing need
Failure to meet these criteria can result in compliance risks, including claim denials. Conversely, underutilization of GIP may lead to unmanaged suffering and avoidable hospitalizations.
For case managers, maintaining this balance is both a clinical and operational responsibility.
THE CASE MANAGER’S ROLE IN GIP COORDINATION
Case management professionals serve as critical navigators across the continuum of care. Their responsibilities in GIP hospice care include:
- Evaluating medical necessity and ensuring appropriate level-of-care determination
- Facilitating transitions between hospital, hospice, and community settings
- Ensuring regulatory compliance through accurate and timely documentation
- Educating patients and families about expectations and goals of care
- Advocating for patient-centered outcomes aligned with hospice philosophy
In many cases, case managers act as the bridge between acute care intensity and hospice intentionality—ensuring that escalation in care reflects an escalation in comfort, not in futile intervention.
COMMUNICATING GIP TO PATIENTS AND FAMILIES
Perhaps the most delicate aspect of GIP care lies in how it is communicated.
Patients and families often misunderstand hospice as a singular service rather than a flexible continuum. Introducing GIP requires reframing expectations with clarity and compassion.
A patient-centered explanation may sound like:
“Hospice care is usually provided wherever you live. However, if symptoms become difficult to control, we can provide a higher level of support in a hospital or hospice facility for a short time to help get those symptoms comfortable.”
This approach reinforces three essential messages:
- GIP is temporary
- It is focused on comfort
- It is part of the same hospice philosophy
ADDRESSING EMOTIONAL BARRIERS
When symptoms escalate, fear often follows. Families may interpret the transition to inpatient hospice as a sign of imminent death or loss of control.
Case managers can help reframe this perception by emphasizing:
- GIP is not “giving up”—it is intensifying comfort
- The interdisciplinary team remains actively involved
- The goal is to restore stability and dignity
Clear, compassionate communication—free of medical jargon—can significantly reduce anxiety and improve decision-making.
ETHICAL CONSIDERATIONS AND THE IMPORTANCE OF EARLY GOALS OF CARE PLANNING
When hospice discussions occur late, the burden of decision-making often shifts to families under stress. This can lead to choices driven by emotion rather than alignment with the patient’s wishes.
Ethics committees are increasingly engaged in these situations, reflecting the growing complexity of end-of-life care. However, many of these conflicts can be mitigated through earlier, proactive conversations.
Patients who engage in advance care planning are more likely to experience:
- Care aligned with their goals
- Reduced unnecessary interventions
- Greater comfort at end of life
- Improved family satisfaction and closure
A CALL TO ACTION FOR CASE MANAGERS
Hospice is not about the final days of life—it is about the quality of those days.
GIP hospice care, when utilized appropriately, represents the healthcare system at its most compassionate: responding swiftly to suffering, prioritizing dignity, and supporting both patient and family through life’s most vulnerable moments.
For case managers, the responsibility is clear: The Conversation Project 2026
- Start the conversation earlier
- Educate with clarity and empathy
- Advocate for patient-centered care
- Ensure access to the right level of care at the right time
Because in the end, the question is not just when we start the hospice conversation—It is how well we prepare patients and families for the journey.
REFERENCES
Aging with Dignity. (2023). Five Wishes. https://www.fivewishes.org
Case Management Society of America. (2022). Standards of practice for case management. https://www.cmsa.org
Centers for Medicare & Medicaid Services. (2025). Medicare program; FY 2026 hospice wage index and payment rate update and hospice quality reporting program requirements (CMS-1835-F). U.S. Department of Health & Human Services.
Centers for Medicare & Medicaid Services. (2024). Medicare program; FY 2025 hospice wage index and payment rate update final rule (CMS-1810-F). Federal Register. https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2025-hospice-payment-rate-update-final-rule-cms-1810-f
Centers for Medicare & Medicaid Services. (2024). Medicare benefit policy manual: Chapter 9—Coverage of hospice services. https://www.cms.gov/regulations-and-guidance/guidance/manuals
Centers for Medicare & Medicaid Services. (2024). Hospice outcomes and patient evaluation (HOPE) tool: Hospice quality reporting program.
Conversation Project. (2023). The Conversation Project. Institute for Healthcare Improvement. https://theconversationproject.org
National Hospice and Palliative Care Organization. (2024). NHPCO facts and figures: Hospice care in America. https://www.nhpco.org
National Hospice and Palliative Care Organization. (2023). Standards of practice for hospice programs.
National Coalition for Hospice and Palliative Care. (2024). Clinical practice guidelines for quality palliative care (5th ed.).
Hospice and Palliative Nurses Association. (2023). Scope and standards of hospice and palliative nursing practice (5th ed).
Jenny Quigley-Stickney, RN, MSN, MHA, MA, CCM ACM-RN, CPHM FCM, Professional case manager, Cape Cod Healthcare, has been active with CMSA/CMSNE for over 25 years serving currently as CMSA President-Elect 2025-2026 and prior to this role, served as CMSA Treasure, Board of Director for CMSA from 2021-2023. Prior to working for CMSA National she served as the President of CMSNE & Chair for both CMSA and CMSNE Public Policy Committees.
Jenny is active in the CMSNE New England states serving as co-chair for Public Policy promoting the advancement of the Nurse Licensure Compact, and Telehealth legislation for health care professionals. She has a passion for public policy and believes that legislation helps advance the field of professional case management. Jenny expanded her role, working on the National Board to becoming a member of CMSA Editorial Board 2021-current, CMSA Strategic planning committee for organizational development, Chair CMSA Finance Committee 2023-2026 and CMSA Sponsorship Committee 2022-current.
Jenny has been employed at all levels of the transitions of care, working with traumatic brain Injury, stroke and spinal cord for over 25 years in acute rehabilitation hospitals, hospital at home program and Outpatient Program Director for traumatic brain injury. She recently has shifted her work in professional case management back to her first love, acute care, focusing on vascular and trauma care in ICU and step-down unit for Cape Cod Healthcare. Bottom of Form
