Description

This policy provides criteria to determine medical necessity of extended hours skilled nursing services in the home when such services are a covered benefit under the member’s benefit plan.

Definitions

Skilled Nursing:

• Skilled nursing is a service that can be safely and effectively performed only by or under the direct supervision of licensed nursing personnel and under the direct supervision of a Professional Health Care Provider.  A skilled nursing visit is intermittent in nature.
• Skilled treatments and procedures include, but are not limited to: administering medications that cannot be self-administered, wound care, continuous or near continuous IV infusion, and catheter insertion.
• Teaching and training activities that require skilled nursing personnel to teach a patient, the patient’s family, or caregivers how to manage the treatment regimen would constitute skilled nursing services. The teaching and training relates to the skill required to teach and not to the nature of what is being taught. Teaching and training should be appropriate for the member’s functional loss, illness, or injury. Teaching and training are no longer appropriate if, after a reasonable period of time, the member, family, or caregiver will not or is not able to be trained.

Intermittent Skilled Nursing Care is defined as services of up to two consecutive hours per visit in the member’s home provided by a licensed registered nurse (RN) or licensed practical nurse (LPN) under the supervision of an RN who are employees of an approved home health care agency.

Extended Hours Skilled Nursing Services (skilled nursing services) are continuous and complex skilled nursing services greater than two (2) consecutive hours per date of service in the member’s home.

Extended hours skilled nursing care services provide complex, direct, skilled nursing care to develop caregiver competencies through training and education to optimize the member’s health status and outcomes. The frequency of the nursing tasks is continuous and temporary in nature and is not intended to be provided on a permanent, ongoing basis.

Two hours per day of intermittent skilled nursing services in the home, are generally adequate to meet the skilled care needs of most members. Extended hours skilled nursing care may be necessary in limited situations. Examples include:

• Transition of a member from an inpatient setting to home;
• When a member experiences an acute change in condition and additional skilled nursing care will prevent a hospital admission; or
• When transition to a skilled nursing facility is indicated, but no skilled nursing facility (SNF) bed is available.

Medically Complex Home Care means care of a patient, in the home setting that would otherwise be provided in a hospital, skilled nursing facility, or other active inpatient setting. Reasons for medically complex home care are high severity or life-threatening nature of illness or technology dependence.

Ventilator Dependent refers to a member who receives mechanical ventilation for life support at least six hours per day and is expected to be or has been dependent on a ventilator for at least 30 consecutive days.

Custodial or Supportive Care means care that BCBSND determines is designed essentially to assist the patient in meeting the activities of daily living and not primarily provided for its therapeutic value in the treatment of an illness, disease, injury or condition.  Examples of custodial care include giving medicine that can usually be taken without help, preparing special foods, helping someone walk, get in and out of bed, dress, eat, bathe and use the toilet. These services do not seek to cure, are performed regularly as part of a routine or schedule, and do not need to be provided directly or indirectly by a health care professional.

Respite Care is short-term patient care provided to the member only when necessary to relieve the family member or other persons caring for the individual.

Criteria

I. Extended Hours Skilled Nursing

• Extended Hours Skilled Nursing in the home may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:
  • The member has a skilled nursing care need that would otherwise be provided in a hospital or other active inpatient setting;
  • The member has a condition that requires frequent (multiple times each day) nursing assessments and monitoring that result in changes in the plan of care and treatment goals in accordance with the individual’s condition;
  • The member’s skilled care needs cannot be met through an intermittent Skilled Nursing visit;
  • The complexity of the member’s treatment plan requires the skills of a registered nurse (RN) or licensed practical nurse (LPN) working under the supervision of an RN;
  • The required services are appropriate for the treatment of the illness or injury;
  • The services are ordered by a physician, in accordance with his/her scope of practice (e.g., MD, DO) who has approved the written plan of care which includes all of the following:
    • Disciplines providing care;
    • Frequency and duration of all services;
    • Demonstration of the need for services supported by all pertinent diagnoses;
    • Member’s functional level, medications, treatments, and clinical summary;
    • Goals of care based on individualized needs of the member.
  • The services are not provided in an inpatient or skilled nursing facility.
  • Extended Hours Skilled Nursing in the home is provided to meet the skilled needs of the member only, not for the convenience of the family or caregiver.

II. Extended Hours Skilled Nursing – Ventilation Assistance/Ventilator Dependent

• Extended Hours Skilled Nursing in the home may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:
  • The member meets all criteria in section I;
  • The member is Ventilator Dependent at home for respiratory insufficiency;
  • Mechanical ventilation for life support is needed for at least 6 continuous hours per day;
  • Member is expected to be or has been Ventilator Dependent for 30 consecutive days;
  • Member’s physician has approved the home care plan;
  • Member would otherwise require confinement to a skilled nursing or inpatient facility.

III. Ongoing Authorization

• Continued Extended Hours Skilled Nursing in the home may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following are met:
  • All the criteria in section I or II continue to be met;
  • Plan of care is updated at least each 60 days, which includes the following for patients age 18 or above:
    1. A statement of goals including long and short-term goals and need for continuing Medically Complex Home Care;
    2. The nursing and other adjunctive therapy progress notes indicating that necessary interventions or adjustments have been made;
    3. Expected course of the underlying disease and rehabilitation potential;
    4. Identification of current and potential ongoing Medically Complex Home Care needs;
    5. Reassessment and documentation of family or caregiver education and training including a review of the living environment and functionality with the goals of making the member and family or caregiver as independent as possible and gradually decreasing nursing care hours as the member’s medical condition improves and/or the family or caregiver have been taught and demonstrate the skills and ability necessary to carry out the plan of care.
  • A review of the developmental progress for neonates and pediatric patients must be reviewed in addition to meeting all elements of the care plan included in the criteria directly above (i.e., under Plan of care update) and criteria in section I or II.

IV. Discharge Criteria

• Extended Hours of Skilled Nursing in the home is considered NOT MEDICALLY NECESSARY AND APPROPRIATE when ONE OR MORE of the following have been met:
  • The goals of treatment have been reached and the member no longer requires Extended Hours of Skilled Nursing care in the home.
  • The family/caregiver have been taught the nursing services and have demonstrated the ability to carry out the plan of care.
  • Medical and nursing documentation supports that the condition of the client is stable/predictable.
  • Care becomes Custodial or Supportive including but not limited to the following:
    1. Routine patient care such as changing dressings, periodic turning and positioning in bed, administering oral medications
    2. Care of a stable tracheostomy (including intermittent suctioning)
    3. Care of a stable colostomy/ileostomy
    4. Care of a stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings
    5. Care of a stable indwelling bladder catheter (including emptying/changing containers and clamping tubing)
    6. Watching or protecting a member
    7. Respite care, adult (or child) day care, or convalescent care
    8. Institutional care, including room and board for rest cures, adult day care and convalescent care
    9. Help with the daily living activities, such as walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or preparing foods
    10. Any services that a person without medical or paramedical training could be trained to perform
    11. Any service that can be performed by a person without any medical or paramedical training
  • The plan of care does not require an RN or LPN to be in continuous attendance.
  • Due to changes in the member’s condition, care in an inpatient or skilled nursing facility, hospice, long-term acute care hospital or other facility is more appropriate.

V. Ineligible for Coverage as Extended Hours Skilled Nursing in the Home

• Member, family, and/or caregiver are unable or unwilling to comply with the plan of care, placing the member at risk of harm.
• Care provided solely for Respite of the family or caregiver.
• Care provided outside the home including but not limited to medical care in a clinic, outpatient facility, hospital, or skilled nursing or intermediate care facility, or licensed residential care facility except as stated in the benefit chart.
• Nursing care provided by the member’s spouse, natural or adoptive child, parent, foster parent, brother, sister, grandparent or grandchild. This includes any person with an equivalent step or in-law relationship to the member.
• Care that is non-skilled in nature such as that performed by a companion or home health aide.

Documentation Submission

Written documentation by the physician specifying the medical necessity, according to the criteria above, is required. Requested documentation may include, but is not limited to:

• A completed Form CMS-485 – Home Health Certification and plan of care.
• Current physician’s order:
  1. Renewed at least every 60 days if member’s condition is not stable (i.e., member’s status requires frequent changes in assessment or care plan); or
  2. Renewed at least every 6 months if the member’s condition is stable.
• Home care records.
• Supporting documentation that describes the complexity and intensity of the member’s care and the number and frequency of skilled nursing interventions needed