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.
- 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.