Summary Of Evidence

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Analysis of Evidence

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This policy addresses a specific category of skilled nursing care currently available to Medicare home health (HH) beneficiaries with Alzheimer’s disease (AD) and behavioral disturbances – the category of skilled nursing care is called “teaching and training activities.” Teaching and training activities are defined in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual (see citation under CMS National Coverage Policy section of this policy) and in the case of the beneficiary population with AD and behavioral disturbances, could be part of a unique beneficiary-centered care plan directed at teaching the family or caregiver how to manage the behavioral disturbances. 

Skilled nursing services must be based on the patient's medical condition as described in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual Chapter 7 §40.1.1.
 
Behavioral disturbances often complicate the medical management of beneficiaries with AD. At baseline many individuals with AD manifest activity limitations in such domains as communication and self-care. The occurrence of behavioral disturbances, if not addressed in a comprehensive and systematic manner, may further compromise the activity limitations present at baseline resulting in sub-optimal clinical outcomes.

Each behavioral disturbance should be fully characterized and answers to the following questions should be documented in the patient’s medical records:

What is the specific behavioral disturbance being addressed?
What is the frequency of the behavior?
Are there specific situations or activities that “trigger” the behavior?
When does it occur?
Where does it occur?
Who is involved?
Are there other possible explanations for the behavior (e.g., pain, infection, change in medication, disruption in schedule, swallowing difficulties, catastrophic reaction induced by environment or personal interaction)?
What are the consequences of the behavior?
What interventions have been successful in addressing this behavior in the past?
What other techniques or interventions can be used to address the behavior?

Teaching and training interventions should be based on the answers to the above questions, the specific impairment(s) and activity limitation(s) identified for each beneficiary, as well as the ability of the family or caregiver to learn and implement the proposed interventions. Environmental factors impacting the identified behavior(s) and the resultant care plan must also be considered. Use of the World Health Organization’s International Classification of Functioning Disability and Health (ICF) would facilitate the identification and documentation of specific impairments, activity limitations, and environmental factors. 

The CMS Internet-Only Manual, Pub. 100-02, Chapter 7 §40.1.2.3 provides guidance in determining the reasonableness and necessity of the number of training visits and the appropriateness of re-teaching and re-training.

In the HH setting, skilled education services are no longer needed if it becomes apparent, after a reasonable period of time, that the patient, family, or caregiver could not or would not be trained. Further teaching and training would cease to be reasonable and necessary in this case, and would cease to be considered a skilled service. Notwithstanding that the teaching or training was unsuccessful, the services for teaching and training would be considered to be reasonable and necessary prior to the point that it became apparent that the teaching or training was unsuccessful, as long as such services were appropriate to the patient's illness, functional loss, or injury.