When a loved one is living in a nursing home and hospice is mentioned, families often feel two opposing things at once: relief that there may be more support, and confusion about how hospice works when a facility is already providing care. It is a reasonable question. If the nursing home has nurses and aides, what does hospice add? Who is “in charge”? What is covered by Medicare, and what will the family still be responsible for?
This guide is designed to answer those questions in plain English. It explains how hospice functions alongside nursing home care, how roles are typically divided, what Medicare covers under the hospice benefit, how room and board usually works, and what to ask so your family is not guessing during a stressful time. This article is educational and not medical or legal advice. Your hospice and facility teams can explain what applies to your loved one’s diagnosis, payer situation, and facility policies.
Start With the Core Idea: Hospice Is a Layer of Support, Not a Replacement for the Facility
Hospice is a model of comfort-focused care for someone approaching the end of life, and it can be provided in several settings, including nursing homes. Medicare’s hospice coverage page explains that hospice care can be provided in your home and in other settings and outlines eligibility and coverage basics.
When hospice is provided in a nursing home, it does not “take over” the facility’s responsibilities. Instead, hospice becomes an additional layer of specialized comfort care and care coordination related to the terminal illness and related conditions. The nursing home continues to provide room, board, and the kind of daily custodial and nursing services it normally provides. Hospice focuses on symptom management, comfort planning, and family support.
In real life, this can feel like a relief because it adds a team whose full job is end-of-life comfort—medication adjustments, symptom planning, education, and guidance—while the facility continues to provide the daily care infrastructure.
Who Qualifies for Hospice in a Nursing Home?
The eligibility rules are the same whether someone is at home or in a facility. Medicare explains that hospice eligibility requires a hospice doctor and the person’s regular doctor (if they have one) to certify terminal illness with a life expectancy of six months or less if the illness runs its normal course, and it requires the person to choose hospice (comfort care) instead of curative treatment for the terminal illness and related conditions under Medicare’s standard pathway.
Many nursing home residents have conditions with unpredictable trajectories, such as dementia, heart failure, COPD, or general frailty. Hospice can still be appropriate in these situations when clinicians believe the person is in the last months of life and the goals have shifted toward comfort.
How Hospice and Facility Care Divide Responsibilities
Families often worry that hospice will conflict with facility care, or that “everyone will assume someone else is handling it.” That is a valid fear, and it is one reason you should ask very direct questions early. In healthy collaborations, the division of responsibilities is clear.
As a general rule, hospice typically provides:
- Comfort-focused symptom management for the terminal illness and related conditions, including medication planning and adjustments.
- Hospice nurse oversight, including assessment, coaching, and coordination with the hospice physician or medical director.
- Equipment and supplies tied to comfort and safety related to the hospice diagnosis, when appropriate.
- Social work and emotional support for the resident and the family.
- Spiritual support if desired, without requiring a particular faith tradition.
- Bereavement support for the family after death.
The nursing home typically continues to provide:
- Room and board and facility-based daily care routines.
- Daily nursing and aide care within the facility’s staffing model, including assistance with toileting, bathing, repositioning, and basic needs.
- Facility policies and safety processes that shape how care is delivered on-site.
CMS describes hospice as a comprehensive program intended to provide palliative care and symptom management, including interdisciplinary services under a plan of care. In a nursing home setting, that hospice plan of care works alongside the facility’s care plan, and communication between the teams matters a great deal.
Medicare Coverage: What Hospice Covers and What It Typically Does Not
Coverage is often the biggest source of stress, so it helps to be very concrete. Medicare’s hospice coverage page explains what hospice includes and emphasizes that hospice focuses on comfort rather than cure for the terminal illness. The Medicare Hospice Benefits booklet provides a more detailed overview written for beneficiaries and families.
One important point for nursing home families is room and board. Medicare notes that hospice does not cover room and board when you live in a nursing home or hospice facility, except in limited situations. The hospice benefit focuses on hospice services related to the terminal illness, not the cost of living in the facility. This is why families may continue to see facility charges while hospice is providing additional services.
This is also why families should ask a simple question early: “What costs are the facility’s responsibility, and what costs are the hospice benefit’s responsibility?” The answer often reduces anxiety immediately, because it separates what you are paying for the bed and daily care from what hospice is adding for comfort and end-of-life support.
What About Medicare Advantage Plans?
Families often worry that a Medicare Advantage plan will complicate hospice. The Medicare Hospice Benefits booklet explains that when someone starts hospice, Original Medicare covers hospice care even if the person stays enrolled in a Medicare Advantage plan. The Medicare Advantage plan may continue to cover services not related to the terminal illness and may provide extra benefits, depending on the plan. This is a key reason to ask hospice to explain coordination and billing in your loved one’s specific coverage situation.
How Medication and Treatment Decisions Change Under Hospice in a Facility
Families sometimes fear that hospice means “stopping all treatment,” especially if their loved one is already in a structured care environment. Medicare explains that electing hospice means choosing hospice care instead of other Medicare-covered treatments for the terminal illness and related conditions. In practical terms, this means the plan shifts away from cure-focused interventions for the terminal illness and toward comfort-focused symptom relief.
That can look like fewer hospital transfers that don’t improve quality of life and more targeted symptom control in the facility. It can also look like more proactive medication adjustments, which is often why families experience hospice as “more care,” not less.
If you want a deeper explanation of what Medicare means by comfort care and why the hospice election changes how treatment is framed, Funeral.com’s companion article Does Choosing Hospice Mean “Stopping Treatment”? is designed to address that fear directly.
Hospital Transfers, Emergencies, and “Who Do We Call?”
One of the most practical reasons families choose hospice in a nursing home is to reduce crisis-driven decisions. If symptoms escalate and the situation is related to the terminal illness, hospice is usually the first call. Medicare cautions that if you go to the hospital and the hospice didn’t arrange it, you might have to pay the entire cost of the hospital care.
That does not mean “never go to the hospital.” It means coordinate with hospice. If the transfer is necessary for symptom control and hospice determines inpatient care is needed, hospice can arrange appropriate inpatient support. The key is to make sure the hospice team is involved before decisions are made in panic.
To reduce confusion, ask both the nursing home and hospice to spell out a simple protocol: in what situations should the family be called, when should the facility call hospice, and when does the facility call emergency services? The best systems are the ones where everyone knows the order of operations.
How Hospice Levels of Care Apply When Someone Lives in a Facility
Even in a nursing home, hospice care can shift levels depending on what is needed. Medicare describes four hospice levels of care, including general inpatient care for symptom management that cannot be managed elsewhere and inpatient respite care to give caregivers a break. Families should not feel they have to memorize the categories, but it is useful to understand that hospice has structured ways to escalate support during crises.
If your loved one’s symptoms become very difficult to manage in the nursing home setting, hospice can explain whether inpatient symptom management is appropriate and how transitions work. If your family is struggling to decide between home hospice and inpatient support more broadly, Funeral.com’s companion guide In-Home Hospice vs Inpatient Hospice can help you understand the practical factors families use when the home environment changes.
Family Communication: How to Stay Informed Without Becoming Overwhelmed
One reason nursing home hospice can feel stressful is the flow of information. Families may not be present for daily changes, and different staff members may give different impressions. This is where a simple communication structure helps.
Many families benefit from naming one point person who receives updates from hospice and the facility and then communicates to the rest of the family. This reduces misinterpretation and reduces the emotional burden on the resident, who may be exhausted by repeated “How are you doing?” conversations. If your family struggles to talk about end-of-life choices, Funeral.com’s guide Talking About End-of-Life Wishes with Family can help you frame conversations around values rather than conflict.
Advance planning documents also matter here, because they clarify who can make decisions and what the resident would want if they cannot communicate. The National Institute on Aging explains that advance directives provide instructions for medical care and take effect if a person cannot communicate. For those who are seriously ill or frail, clinicians may also discuss POLST forms, which are portable medical orders intended to guide care during emergencies.
What to Ask the Nursing Home and Hospice on Day One
Families feel calmer when expectations are explicit. You do not need to ask these questions in a confrontational way. You can ask them as an act of care.
- Who is our primary contact at hospice, and who is our primary contact at the facility?
- How often will hospice visit, and what triggers an extra visit?
- How will symptom changes be communicated to the family?
- Which medications and supplies are handled under hospice, and which remain under the facility?
- If symptoms escalate, who calls whom first, and what is the plan for preventing a crisis transfer?
- What does the plan look like if the family wants to be present at the end?
These questions do not make you difficult. They make the plan clearer, which makes the experience safer.
Planning for the “After” Without Turning This Into a Checklist of Grief
Even when death is expected, the “after” can feel disorienting. Many families benefit from having a simple plan for what happens when death occurs in a facility, including who the facility contacts, when the family is notified, and which funeral home will be called.
If you need a calm reference for the broader steps families face after death, Funeral.com’s guide How to Plan a Funeral in 7 Steps provides a grounded walkthrough. For paperwork, Death Certificates: Why You Need Them helps families understand why multiple certified copies are often needed.
And if the family is choosing cremation, it may help to know there are options that fit different comfort levels. Some families choose a central memorial urn with cremation urns for ashes. Others prefer shared memorial options with keepsake urns. Some prefer a discreet wearable keepsake through cremation jewelry. These decisions do not have to be rushed, but knowing the options exist can reduce stress when the time comes.
A Plain-English Summary
Hospice in a nursing home usually works as an added layer of comfort-focused support alongside facility care. The nursing home continues providing room, board, and daily care routines. Hospice provides symptom management, care planning, and family support related to the terminal illness and related conditions under the Medicare hospice benefit. Medicare notes that hospice generally does not cover room and board in a nursing home, so families may still see facility charges while hospice provides additional hospice services.
If you’re navigating this right now, the most stabilizing move is to ask both teams to put roles in plain language: who provides what, who you call first when symptoms change, what the coverage boundaries are, and how the family will be updated. When those answers are clear, hospice and nursing home care can work together in the way they were meant to—reducing suffering, supporting dignity, and helping families feel less alone.
