Many families searching for the four stages of hospice care are trying to understand what happens after a loved one enters Hospice and whether care becomes progressively more intensive over time.
The terminology can be confusing.
Hospice is not usually divided into four chronological stages that every patient progresses through. Instead, hospice care in the United States is generally organized into four levels of care, with each level designed to meet a different type of need.
The four levels are:
- Routine home care
- Continuous home care
- General inpatient care
- Inpatient respite care
A patient does not necessarily progress from Level 1 to Level 2, then to Level 3, and finally to Level 4. Instead, the hospice team determines which level is appropriate based on the patient’s symptoms, condition, care setting, and caregiver needs.
Understanding the four stages of hospice care—or, more accurately, the four levels of hospice care—can help families know what type of support may be available as a person’s needs change.
| Key Takeaway | What It Means |
|---|---|
| Hospice care has four recognized levels | The four levels are routine home care, continuous home care, general inpatient care, and inpatient respite care. |
| Routine home care is the most common. | Most hospice patients receive care where they live, including in a private home, an assisted living community, or a nursing facility. |
| Continuous home care is used during a crisis. | This temporary level provides more intensive nursing support when symptoms become difficult to manage at home. |
| General inpatient care is for uncontrolled symptoms | Patients may temporarily receive hospice care in an inpatient setting when symptoms cannot be effectively managed elsewhere. |
| Respite care supports family caregivers. | Short-term inpatient respite care can give an unpaid caregiver a temporary break from daily caregiving responsibilities. |
What Are the Four Stages of Hospice Care?
The four hospice levels are designed to provide the right amount of support at the right time.
| Hospice Level | Primary Purpose | Typical Setting |
|---|---|---|
| Routine home care | Ongoing comfort-focused hospice services | Home, assisted living, nursing facility, or other residence |
| Continuous home care | Intensive support during a temporary medical crisis | Usually the patient’s residence |
| General inpatient care | Management of symptoms that cannot be controlled in the current setting | Hospital, hospice inpatient unit, or qualified facility |
| Inpatient respite care | Temporary relief for a patient’s caregiver | Medicare-certified inpatient facility or other eligible setting |
Hospice care levels are not only based on proximity to death. Patients may primarily receive regular home care, but during a symptom crisis, they might switch to continuous or inpatient care until the crisis is managed, after which they can return to home care.
Stage 1: Routine Home Care
Routine home care is the most common level of hospice care.
Home care is generally provided when a patient’s symptoms are reasonably controlled, and around-the-clock skilled nursing care is not needed. Despite the term “home care,” the patient does not have to live in a private house.
Routine hospice care may be provided in:
- A private residence
- An assisted living community
- A nursing home
- A long-term care facility
- Another place the patient considers home
During routine home care, the hospice team creates an individualized plan based on the patient’s needs and goals.
What Does Routine Home Hospice Include?
Depending on the patient’s condition and plan of care, hospice support may involve professionals such as:
- Hospice physicians
- Registered nurses
- Hospice aides
- Social workers
- Chaplains or spiritual care providers
- Counselors
- Therapists
- Volunteers
The team may help manage symptoms such as pain, shortness of breath, anxiety, nausea, constipation, restlessness, or fatigue.
Hospice staff also educate family caregivers about what to expect and whom to contact when symptoms or needs change.
Is Someone With the Patient 24 Hours a Day?
Not usually.
Routine home hospice should not be confused with 24-hour custodial caregiving.
Hospice professionals make scheduled visits based on the patient’s care plan and remain available to address urgent concerns in accordance with the hospice provider’s procedures.
Day-to-day caregiving is often provided by family members, friends, privately hired caregivers, or staff at the patient’s residential facility.
Stage 2: Continuous Home Care
Continuous home care is a higher-intensity hospice level used during periods of acute medical crisis.
This level may be appropriate when a patient’s symptoms suddenly become difficult to control and more intensive nursing care is needed to help the person remain in their home environment.
Continuous home care is intended to be temporary rather than a permanent form of around-the-clock hospice care.
What Does Level 2 Hospice Mean?
When people ask, “What does Level 2 on hospice mean?”, they are usually referring to continuous home care. This level may be considered when a patient experiences symptoms such as:
- Severe uncontrolled pain
- Significant breathing difficulty
- Persistent vomiting
- Severe agitation or restlessness
- Sudden worsening of symptoms
- Other acute problems requiring intensive symptom management
The exact services provided depend on the patient’s clinical needs and hospice plan of care.
How Is Continuous Home Care Different From Routine Hospice?
The primary difference is intensity.
| Routine Home Care | Continuous Home Care |
|---|---|
| Used when symptoms are relatively stable | Used during a temporary crisis |
| Hospice staff make intermittent visits | Care is provided for extended periods during the crisis |
| Family or other caregivers often provide ongoing daily support | Skilled hospice support becomes substantially more intensive |
| May continue for extended periods | Generally lasts only as long as the crisis requires |
Once symptoms are controlled, a patient may return to routine home care.
Stage 3: General Inpatient Hospice Care
General inpatient hospice care is designed for patients experiencing symptoms that cannot be adequately managed in their current environment. The purpose is not necessarily long-term placement.
Instead, general inpatient care provides access to intensive symptom management until the patient’s condition becomes stable enough to return to a lower level of hospice care.
When Might General Inpatient Care Be Needed?
A hospice team may consider inpatient care when a patient experiences problems such as:
- Pain that remains uncontrolled despite treatment
- Severe respiratory distress
- Persistent nausea or vomiting
- Complicated medication management
- Severe agitation
- Symptoms requiring frequent skilled assessment
- Other acute problems that cannot be effectively controlled in the current care setting
The decision is based on the individual’s clinical situation.
Where Is General Inpatient Hospice Provided?
Depending on available services and the hospice provider’s arrangements, general inpatient care may take place in:
- A dedicated hospice inpatient unit
- A hospital
- A skilled nursing facility
- Another qualified inpatient setting
The goal is intensive symptom control. Once the crisis has been addressed, the patient may transition back to routine hospice care.
Stage 4: Inpatient Respite Care
The fourth level is inpatient respite care.
Respite care serves a different purpose than continuous home care or general inpatient care; it is not mainly designed to address a medical crisis. Instead, its goal is to support the caregiver caring for the patient.
Caring for someone with a serious illness can be both physically and emotionally demanding. Even the most dedicated family caregivers may need a short break to recharge.
Inpatient respite care allows a hospice patient to temporarily reside in an approved facility while their regular caregiver takes some time off.
Why Might a Family Use Respite Care?
Respite care may be helpful when a caregiver:
- Is physically exhausted
- Needs time to attend to personal health needs
- Has an important family obligation
- Needs temporary relief from continuous caregiving
- Is experiencing significant caregiver stress
Hospice respite care is intended to be temporary. After the respite period, the patient generally returns to their usual residence and resumes the appropriate level of hospice services.
Are the Four Levels of Hospice Care Sequential?
No.
This is one of the most important things to understand about the four stages of hospice care. They are not four steps that every patient must complete.
A patient may receive routine home care for several months but experience a temporary pain crisis that requires general inpatient care before returning home to routine hospice services.
Another patient might receive only routine home care throughout their entire hospice experience without needing additional services.
A third patient could use respite care to give their caregiver a temporary break, even if the patient’s medical condition is not worsening.
Example Hospice Care Journey
- Routine home care: Symptoms are stable, and hospice professionals visit regularly.
- Temporary crisis: Pain or breathing problems suddenly become difficult to control.
- General inpatient or continuous care: More intensive services are provided.
- Symptoms improve: The patient returns to routine home care.
The appropriate level can change more than once.
What Is the Most Common Level of Hospice Care?
Routine home care is the level most commonly associated with Hospice.
One reason is that hospice philosophy emphasizes allowing patients to receive comfort-focused care in familiar surroundings whenever possible.
For many people, that means staying at home surrounded by family, personal belongings, pets, and familiar routines.
Routine care can still involve substantial clinical support.
Hospice nurses and other team members monitor the patient’s condition, recommend symptom-management strategies, provide caregiver education, and adjust the plan of care as needs change.
How Does a Hospice Team Decide Which Level of Care Is Needed?
The decision is based on clinical need rather than simply on a patient’s diagnosis or how long they have been enrolled in Hospice.
The hospice team may consider factors such as:
- Severity of symptoms
- Whether symptoms are controlled
- Frequency of nursing intervention needed
- Safety of the patient’s current environment
- Ability of caregivers to provide necessary support
- Whether a temporary medical crisis is occurring
- Whether the family caregiver needs respite
- Whether symptoms require inpatient management
Hospice care is individualized, so two patients with the same diagnosis may need very different levels of support.
Who Provides Care at Each Hospice Level?
Hospice uses an interdisciplinary team approach.
Rather than relying on a single physician or nurse, different professionals contribute according to the patient’s needs.
Hospice Physicians
Physicians help oversee the hospice plan of care and provide guidance regarding symptom management and the patient’s terminal illness.
Hospice Nurses
Nurses assess symptoms, administer or coordinate medications, educate caregivers, monitor changes in the patient’s condition, and communicate with the rest of the hospice team.
Hospice Aides
Hospice aides may assist with personal care activities such as:
- Bathing
- Grooming
- Dressing
- Repositioning
- Other approved personal care needs
Social Workers
Hospice social workers can help patients and families address emotional, practical, family, financial, and care-planning concerns.
Spiritual Care Providers
Chaplains or other spiritual care professionals may provide support consistent with the patient’s beliefs, values, and preferences. Spiritual care is typically optional and does not require a patient to follow any particular religion.
Bereavement Professionals
Hospice support often extends to family members through bereavement services after the patient’s death. However, bereavement care is generally considered a hospice service rather than one of the four formal levels of hospice care.
Are Bereavement Care and Palliative Care Hospice “Stages”?
Not in the same sense as the four recognized hospice levels.
This is where many explanations of Hospice become confusing. Palliative care, hospice care, and bereavement services are related, but they are not simply consecutive stages that everyone passes through.
Palliative Care
Palliative care focuses on improving quality of life and relieving symptoms associated with serious illness. It may be available before someone qualifies for Hospice and can sometimes be provided while a patient continues disease-directed treatment.
Hospice Care
Hospice care is a specific form of comfort-focused care for patients who meet hospice eligibility requirements and elect hospice services.
Bereavement Care
Bereavement support is provided to help loved ones cope with grief following a patient’s death. Therefore, describing primary care, palliative care, Hospice, and bereavement as the “four stages of hospice” can be misleading.
The more accurate description of the four hospice levels is:
- Routine home care
- Continuous home care
- General inpatient care
- Inpatient respite care
Does a Higher Hospice Level Mean Death Is Closer?
Not necessarily.
A higher-intensity level of Hospice may indicate that the patient is experiencing a temporary symptom crisis. Still, it does not provide an exact prediction of how much time the person has left.
For example, a patient might require general inpatient care because of severe pain. Once the pain is controlled, they may return home and continue routine hospice care.
Likewise, respite care does not mean the patient’s health suddenly became worse at all. It is primarily intended to provide relief for caregivers.
The hospice team is the best source of information about an individual patient’s condition and expected trajectory.
Does Hospice Provide 24-Hour Care?
This depends on what is meant by “24-hour care.”
Hospice programs offer access to clinical support; however, routine hospice care typically does not assign a nurse or caregiver to provide care 24 hours a day. During a qualifying crisis, continuous home care can provide more intensive bedside assistance for a limited time.
General inpatient care, on the other hand, offers around-the-clock facility-based clinical support for managing symptoms that require that level of attention. Families needing permanent custodial assistance or full-time personal caregiving may need additional services beyond what routine hospice care provides.
How Long Does Each Level of Hospice Care Last?
There is no single duration that applies to every patient.
| Level | Typical Duration |
|---|---|
| Routine home care | Can continue as long as the patient remains eligible and this level remains appropriate. |
| Continuous home care | Temporary, generally during an acute symptom crisis |
| General inpatient care | Temporary, until symptoms can be managed at a lower level |
| Inpatient respite care | Short-term caregiver relief |
A patient’s hospice level is determined by current needs rather than a predetermined schedule.
Can Someone Move Back to a Lower Level of Hospice Care?
Yes.
Moving from intensive hospice care back to routine care is common when symptoms become controlled.
For example:
- A patient develops uncontrolled pain.
- The hospice team determines general inpatient care is necessary.
- Medications and symptom-management strategies are adjusted.
- The patient’s pain becomes manageable.
- The patient returns home under routine hospice care.
This does not mean Hospice has stopped.
Only the level of hospice care has changed.
What Happens During Routine Hospice Visits?
Routine visits vary based on the patient’s needs. A hospice nurse’s duties and responsibilities are:
- Check pain and other symptoms
- Assess breathing
- Review medications
- Monitor changes in consciousness or mobility
- Evaluate skin condition
- Educate caregivers
- Discuss changes in eating or drinking
- Coordinate medications or medical equipment
- Update the hospice plan of care
Other members of the hospice team may visit separately according to the patient’s plan. The frequency of visits can also change as the patient’s condition changes.
What Families Should Ask About Hospice Levels
Families do not need to memorize every hospice regulation. However, they should understand the care being provided and the steps to take if the patient’s condition changes.
Helpful questions include:
- What level of hospice care is my loved one currently receiving?
- What symptoms should we report immediately?
- Who should we call at night or on weekends?
- What would qualify someone for continuous home care?
- When is general inpatient hospice appropriate?
- Where would inpatient care be provided?
- Is respite care available for our family?
- How does the Hospice determine when a patient can return home?
- What services are included in the current plan of care?
- What additional caregiving support might our family need?
These conversations can help families prepare before a crisis occurs.
Four Stages of Hospice Care at a Glance
| Stage/Level | When It Is Used | Main Goal |
|---|---|---|
| 1. Routine Home Care | Patient’s symptoms are adequately managed | Provide ongoing comfort-focused care in the patient’s residence |
| 2. Continuous Home Care | Temporary crisis requiring intensive support | Control acute symptoms while helping the patient remain at home |
| 3. General Inpatient Care | Symptoms cannot be effectively managed in the current setting | Stabilize complex or uncontrolled symptoms |
| 4. Inpatient Respite Care | Family caregiver temporarily needs relief | Give caregivers a short break while the patient remains safely cared for |
Understanding the Four Stages of Hospice Care
The phrase four stages of hospice care can make Hospice sound like a predictable sequence, but the reality is much more flexible.
The four recognized hospice levels—routine home care, continuous home care, general inpatient care, and inpatient respite care—exist so the amount and setting of care can change as the patient’s needs change.
Routine home care supports patients whose symptoms can be managed at home. Continuous home care provides temporary intensive assistance during a crisis. General inpatient care addresses symptoms that cannot be adequately controlled in the current setting, while respite care offers short-term relief to family caregivers.
Rather than thinking of these levels as milestones that predict how close someone is to death, families can think of them as different tools within hospice care. The hospice team selects the level that best supports the patient’s comfort, safety, dignity, and current clinical needs.
Frequently Asked Questions About the Four Stages of Hospice Care
What Are the Four Stages of Hospice Care?
The four recognized levels of hospice care are routine home care, continuous home care, general inpatient care, and inpatient respite care.
Although people commonly refer to them as the “four stages of hospice care,” they are more accurately described as levels, as patients do not necessarily progress through them in order.
What Is Level 1 Hospice Care?
Level 1 generally refers to routine home care.
It is the standard level used when a patient’s symptoms can be appropriately managed in their usual residence.
What Is Level 2 Hospice Care?
Level 2 is commonly referred to as continuous home care.
It is used temporarily during a crisis when a patient needs more intensive hospice nursing support in the home.
What Is Level 3 Hospice Care?
Level 3 generally refers to general inpatient hospice care.
It is used when symptoms become difficult to manage in the patient’s current setting and require inpatient-level symptom management.
What Is Level 4 Hospice Care?
Level 4 refers to inpatient respite care.
It allows an eligible patient to receive short-term care in an approved inpatient setting so their usual caregiver can have temporary relief.
Which Hospice Level Is Most Common?
Routine home care is the most common level of hospice service.
Many patients can remain in their home environment while receiving regular visits and support from an interdisciplinary hospice team.
Do Patients Go Through All Four Levels?
No.
Some patients remain at the routine home care level throughout their Hospice care. Others temporarily move to continuous or inpatient care and then return to routine services. Respite care may be used when caregivers need temporary relief.