Subsequent nursing facility care, per day, for the evaluation and management of a new or established patient, which requires at least two of these three key components: an expanded problem focused interval history; an expanded problem focu... (Deprecated)
CPT4 code
Name of the Procedure:
Subsequent Nursing Facility Care, per Day, for the Evaluation and Management of a New or Established Patient (Deprecated)
Common name(s): Follow-up Nursing Home Visit, Daily Nursing Facility Care
Summary
Subsequent nursing facility care is a daily follow-up visit provided by healthcare professionals to evaluate and manage the health of patients residing in nursing facilities. This service is aimed at both new and established patients and involves a thorough check-up and updating care plans.
Purpose
The purpose of subsequent nursing facility care is to monitor and manage the ongoing health conditions of patients in nursing facilities. The goals include ensuring the patient's health is stable, managing chronic conditions, and quickly addressing any new issues that arise.
Indications
- Chronic diseases needing constant management (e.g., diabetes, hypertension).
- Post-acute care and rehabilitation.
- Long-term care for patients with disabilities or severe health conditions.
- Regular medical updates and care adjustments based on patient’s progress.
Preparation
No specific preparation is generally required for the patient. Healthcare providers might review the patient's current medical records and care plans before the visit.
Procedure Description
- The healthcare professional reviews the patient’s medical history and current health status.
- They conduct an expanded problem-focused interval history and physical examination.
- Medical assessments, which may include vital signs, medication reconciliation, and laboratory test reviews, are performed.
- Updates to the patient's care plan are made based on findings.
- Communication with other facility staff to ensure care consistency and coordination.
- Documentation of the visit and any changes in the patient’s medical records.
Duration
Typically, the entire process takes about 15-30 minutes per patient, depending on complexity.
Setting
This procedure is performed in nursing facilities, such as skilled nursing homes or long-term care facilities.
Personnel
- Primary Care Physicians
- Nurse Practitioners
- Physician Assistants
- Registered Nurses
Risks and Complications
There are minimal risks associated with the procedure itself. However, there is the general risk of:
- Miscommunication leading to inappropriate care.
- Potential for missing subtle changes in a patient’s health condition.
Benefits
- Ensures ongoing monitoring and management of chronic conditions.
- Timely detection and treatment of new health issues.
- Enhanced coordination of care leading to improved patient outcomes.
Recovery
There is no specific recovery necessary as this is a routine evaluation and management service. Follow-up care and monitoring continue as part of the patient’s care plan.
Alternatives
- Telehealth consultations: May provide remote monitoring but lack the hands-on examination.
- Home health visits: For patients who can move to a home setting but still need regular nurse visits.
- Outpatient clinic visits: Require the patient to travel to a healthcare facility for follow-up care.
Patient Experience
Patients can expect brief and routine assessments during which a healthcare professional checks their health status, updates their care plan, and discusses any concerns. Most patients find these visits reassuring and helpful for managing their long-term health. Comfort measures include respectful and attentive care, ensuring the patient's dignity and privacy. Pain and discomfort are usually minimal, limited to necessary physical examinations.