Routine Home Care vs. Continuous Home Care in Hospice

Routine Home Care (RHC) is the everyday level of hospice: the team visits on the schedule in the plan of care, and a nurse can be reached 24/7 by phone. Continuous Home Care (CHC) is the crisis level: at least 8 hours in a day, and up to 24, of mostly nursing care where the patient lives, only during a brief period of acute symptoms. Almost all hospice care is routine: in fiscal 2025, 98.8% of Medicare hospice days were RHC and about 0.1% were CHC (CMS Hospice Monitoring Report, April 2026).

	Routine Home Care	Continuous Home Care
When used	Everyday care, including stable symptoms	Brief period of crisis with acute medical symptoms
Care pattern	Intermittent scheduled visits	At least 8 hours in a midnight-to-midnight day, up to 24
Who provides it	Nurse, aide, social worker, chaplain, and others, per the plan of care	More than half the hours must be nursing (RN, LPN, or LVN); aides and homemakers can add hours
Location	Where the patient lives: home, assisted living, or nursing home	Where the patient lives, including assisted living or a long-term nursing home stay, but not a hospice inpatient unit, hospital, or skilled nursing facility
Duration	Ongoing	Until the crisis resolves; no set number of days
Cost to the family	Up to $5 per prescription for symptom drugs	Same; no extra charge for the higher level

Routine Home Care: the default level

RHC is what people usually mean by "hospice at home." A nurse, aide, social worker, and chaplain visit on a schedule tailored to the patient's needs, and the on-call line is available 24/7 for questions and after-hours problems. Visit frequency is written into the plan of care and changes with need. This level does not mean someone is in the home at all times: the visits are intermittent, and family or other caregivers handle day-to-day care between visits.

Continuous Home Care: crisis support at home

CHC is for a period of crisis, when a patient needs continuous, predominantly nursing care to manage acute medical symptoms (42 CFR 418.204). The point is to bring intensive support to the patient so they do not have to be moved to a facility. It is short-term by design and ends when symptoms are stabilized. Medicare's test is specific (Medicare Benefit Policy Manual, ch. 9, sec. 40.2.1):

• At least 8 hours in a day. The day runs midnight to midnight. With fewer than 8 hours of care, the day counts as routine care.
• The hours do not have to be in a row. Four in the morning and four in the evening count. As many as 24 hours a day can be covered.
• More than half the hours must be nursing. An RN, LPN, or LVN provides them. If aide hours exceed nursing hours, it is not CHC.
• Only direct patient care counts. Paperwork, phone calls to order medications, and updating the plan of care do not count. Neither do social worker or chaplain hours, though those services should still happen if needed.

What qualifies for Continuous Home Care

CHC is a clinical decision, not something a family can simply request for convenience. The hospice assesses whether the patient is in a genuine crisis that needs at least 8 hours of predominantly skilled nursing to stay safely at home. Common triggers include pain that the current regimen is not controlling, severe breathlessness, frequent seizures, sudden agitation or terminal restlessness, or uncontrolled nausea and vomiting. Being close to death does not qualify by itself, and neither does caregiver exhaustion alone. CHC is meant to be a bridge: the team stabilizes the symptoms, then steps the patient back down to Routine Home Care once the crisis passes.

CMS's manual gives these examples, and says they are illustrations rather than a checklist:

Situation	CMS's call	Why
New seizures and vomiting; nurse stays 4 hours and returns for 5 more, aide gives 8 hours; the wife, who had been giving skilled care, cannot continue	Qualifies	Medical crisis; 9 of the 17 hours are nursing
Rapid decline near death with air hunger, continuous vomiting, and increasing pain; nurse gives 6 hours, aide gives 4	Qualifies	Nursing is most of the 10 hours
Exhausted caregiver; patient needs 9 hours of help with bathing, walking, and meals	Does not qualify	Little of it needs a nurse; inpatient respite fits instead
Breathing worsens; nurse gives 3 hours, aide and homemaker give 8	Does not qualify	Not predominantly nursing
Nurse teaches IV medications and visits for 3 hours, aide gives 3, nurse spends 2 more on calls and paperwork	Does not qualify	Only 6 of the 8 hours are direct patient care

How to ask for Continuous Home Care

Call the hospice's on-call line, describe what is happening, and ask directly: “Does this qualify for continuous home care?” The hospice decides; you cannot order it yourself, and it is not a way to arrange ongoing daily help or a live-in caregiver. If your need is custodial rather than a crisis, the social worker can discuss other options, which hospice does not pay for. But CHC is not optional for the hospice when the need is there. CMS tells state surveyors to check whether a hospice offers continuous home care for symptom management when indicated, and failure to provide it can be cited as a deficiency. If you believe your loved one needed it and did not get it, see what to do if you're unhappy with your hospice.

Continuous Home Care vs. General Inpatient: how they differ

Both CHC and General Inpatient (GIP) care exist for symptom crises. The key distinction is location and intensity. Continuous Home Care keeps the patient where they live and brings mostly nursing hours to them; it works when the crisis can be safely controlled there and the family wants to avoid a move. General Inpatient care relocates the patient to a hospital, hospice house, or contracted nursing facility where staff can manage symptoms around the clock, used when home control is not realistic — for example, when complex medication titration or close monitoring is needed. Neither is permanent; both aim to stabilize the patient and, where possible, return them to Routine Home Care. The hospice team, including the hospice physician, weighs the severity of symptoms, the home environment, and caregiver capacity to recommend one over the other.

Choosing the right level: a simple decision path

Hospice has four levels of care. Think of them as a ladder the team moves up and down with the patient:

• Symptoms stable, manageable with scheduled visits? Routine Home Care is the right level, and where most patients stay most of the time.
• Acute crisis, but it can be handled in the home with intensive nursing? Continuous Home Care brings the hours to the bedside so the patient does not have to move.
• Crisis too severe to control at home even with CHC? General Inpatient care in a facility provides round-the-clock management until things settle, with the aim of returning the patient home.
• No crisis, but the caregiver is exhausted and needs a break? Inpatient respite (up to 5 consecutive days at a time) gives the family rest — it is not a treatment level.

You don't have to diagnose the level yourself. Your job is to call the on-call line when something changes; the hospice determines which level fits.

The misconception to correct

Families sometimes expect that signing onto hospice means continuous, round-the-clock care at home from day one. It does not. The default is Routine Home Care with scheduled visits. Continuous Home Care is reserved for genuine short crises and is not a way to obtain a permanent live-in caregiver. If you need ongoing 24-hour custodial help, that is a separate arrangement hospice does not pay for; see does hospice pay for 24-hour care.

What this means for cost

Moving between routine home care, continuous home care, and General Inpatient care does not cost the family more, and all four levels are covered under the Medicare hospice benefit. You pay nothing for hospice care itself except up to $5 per prescription for symptom drugs and, for inpatient respite, 5% of the Medicare-approved amount. Under both Routine and Continuous Home Care, hospice does not pay for room and board if the patient lives in a nursing home or assisted living; only the General Inpatient and inpatient-respite levels cover a bed, and even then for limited purposes. For dual-eligible patients, Medicaid may cover the nursing-home room separately.

What Medicare pays the hospice differs by level. These are payments from Medicare to the hospice, not bills to you. The national base rates below run from October 1, 2026 to September 30, 2027, apply to hospices that report the required quality data, and are adjusted for local wages:

Level	Medicare base rate
Routine Home Care, days 1 to 60	$236.33 per day
Routine Home Care, day 61 onward	$186.33 per day
Continuous Home Care	$71.92 per hour ($1,726.16 for a full 24 hours)

The routine rate is paid for each day regardless of how many visits happen that day, and only one level can be paid for a given day. In the last 7 days of life, Medicare also pays extra for RN and social worker visits on routine days, up to 4 hours a day, so more visits near the end do not by themselves mean the level changed to CHC.

Frequently asked questions

How many hours is Continuous Home Care?

At least 8 hours in a midnight-to-midnight day and as many as 24, with more than half of them nursing. The hours can be split up, so “continuous” does not mean a nurse stays without a break.

How long does Continuous Home Care last?

Federal rules set no fixed number of days. They limit it to “brief periods of crisis” and only as necessary to keep the patient at home, so it lasts until the crisis is controlled, and each day must meet the 8-hour test on its own. Once symptoms stabilize, the patient steps back down to Routine Home Care. If a crisis cannot be controlled at home, the team may shift to General Inpatient care instead.

Can Continuous Home Care be provided in a nursing home or assisted living?

Yes, if the patient lives there as a long-term resident. CMS says CHC can be given when a patient resides in a long-term care facility, and the HHS Inspector General lists it as allowed in assisted living. It cannot be given in an inpatient facility, which CMS defines as a hospice inpatient unit, a hospital, or a skilled nursing facility. Some nursing homes are certified as both a long-term nursing facility and a skilled nursing facility, so ask the hospice which applies to the patient's stay.

Does an exhausted caregiver qualify for Continuous Home Care?

Not by itself. If the caregiver has been doing skilled care and can no longer do it, that can create a crisis because a nurse is needed to take over. If the care is help with bathing, meals, and walking, CMS points to inpatient respite instead. Tell the team either way.

Do hospice aides stay overnight under Routine Home Care?

No. Aide visits under RHC are intermittent and scheduled, not 24-hour custodial care. Families and other caregivers handle day-to-day needs between visits, with the 24/7 on-call line available for problems and guidance.

Is Continuous Home Care available from every hospice?

CMS says hospices must be able to provide it, but many go a whole year without providing any. In CMS's analysis of Medicare claims, 72.2% of hospices provided no CHC in fiscal 2022 (FY 2024 Hospice proposed rule, Figure 1). Over eight quarters of claims from fiscal 2019 to 2021, a CMS technical report found that 18.3% of hospices with at least 20 claims did not provide a single day of either CHC or General Inpatient care. Providing at least one day of either is one of the 10 indicators behind the Hospice Care Index score on Care Compare, so that point alone does not show a hospice provides CHC. When you compare providers, ask how many CHC days the hospice provided last year and how quickly it can get a nurse to the home for a multi-hour stay at night.

Your next step

If symptoms are escalating at home, call the hospice on-call line right away; that is exactly when the team evaluates whether CHC or a higher level is needed. If you are still choosing a provider, ask each one how quickly they can mobilize continuous care during a crisis. You can compare hospices near you and then request a hospice evaluation to discuss your specific situation; ask whether there is any charge.