🔲Patient requires short-term inpatient care for pain / other symptom management which cannot be controlled or treated appropriately in any other setting
🔲 Patient symptoms are not controlled in current setting. (also, qualifying Hospice
terminal diagnosis)
🔲 Place of care: Hospital / skilled Nursing facility / Hospice in patient place.
🔲 Aggressive pain control
🔲 Aggressive treatment of uncontrolled symptoms
🔲 Uncontrolled agitation / delirium / anxiety around end stage
🔲 Uncontrolled nausea / vomiting
🔲 Severe uncontrolled SOB severe shortness of breath
🔲 Uncontrolled seizures
🔲 Fracture with severe pain control
🔲 Uncontrolled S/S requiring skilled nursing care
🔲 Needs complex wound care
🔲 It is different than current care being provided
🔲 Documented : Why patient can not be taken care in any other place
🔲 Place of care is in-patient unit. (Hospital stay/SNF offered only if patient is on vent,
high flow O2, pressers, or requiring an enclosed bed, or specialty bed, excessive
loudness, behaviors not related to terminal diagnosis.
🔲 Uncontrolled symptoms is needed converting PO to IV and visa -versa
🔲 Uncontrolled end stage terminal agitation
🔲 Titration or starting long acting Opioids (patch, methadone)
🔲 Changing route (macy catheter)
🔲 Discharge planning documented:where is patient going after resolution of S/S
🔲 Bring down the level of care once problem resolved
🟥 NOT COVERED due to : General decline, actively dying, caregiver not available/
breakdown, supervision needed, for prevention of symptoms.
🔲 Allowed: Family training and education for new onset wounds/incontinence, med
administration. (Documentation of education documented fully)
🔲 Patient/family/DPOAagreedtosign.
🔲 Admit to GIP.


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