The Plan

Members requiring short-term care or rehabilitation following hospitalization may be eligible for inpatient admission to a skilled nursing facility (SNF), also commonly called a subacute rehabilitation facility, depending on their plan. A SNF is a care center where nurses and nursing assistants are available to provide twenty-four hour care for patients to assist them with conditions in their transition between the hospital and a lower level of care such as the home. A SNF may also provide rehabilitation in order to improve the member's function and decrease the burden of care. These centers can be part of a nursing home or hospital but must be licensed by the state or governing body under which they operate. Admission to a skilled nursing facility is determined by the medical necessity for skilled services, such as therapy and rehabilitation. Disease severity alone is not an indication for skilled nursing care.

For clinical guidelines relating to home skilled care services, please refer to the appropriate guideline:

• The Plan Clinical Guideline: Home Care - Skilled Nursing Care (RN, LVN/LPN) (CG020)
• The Plan Clinical Guideline: Home Care - Physical Therapy/Occupational Therapy (CG021)

Definitions

Skilled Nursing Care is defined by the Center for Medicare and Medicaid Services (CMS) as skilled services that "require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists", and "must be provided directly by or under the general1supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result." Skilled nursing care can be delivered in the inpatient (SNF) or outpatient setting, depending on the individual needs of the patient.

Skilled Nursing Facilities (SNFs) are inpatient centers where skilled nursing care is delivered in an inpatient setting. Section 1819(a) of the Social Security Act outlines the specific criteria for designating a care center as a SNF. SNF services may include:

• Semi-private room
• Meals, inclusive of specialized dietary needs and administration
• Respiratory Care
• Durable Medical Equipment and Medical Supplies (e.g., wound care supplies, assistive devices)
• Medications and Pharmacy Supplies
• Case Management Services
• Social Services
• Laboratory Services
• Imaging
• Rehab therapies (Physical therapy, Occupational therapy, Speech language pathology)

Subacute Care Facilities are a level of rehabilitative care typically provided following an inpatient hospital admission. Subacute care facilities provide services similar to skilled nursing facilities; services include but are not limited to skilled nursing care, respiratory care, and rehab therapies.

General Supervision refers to the minimum level of supervision required at a SNF. This includes initial direction and periodic inspection of the actual activity but does not include the continuous (24-hour) presence of a licensed RN or physician.

Custodial Care refers to personal care and non-medical assistance with activities of daily living and can be safely delivered by non-licensed caregivers.

Adult Care Homes are non-skilled living settings where a custodial level of care is provided.

Home Health refers to care delivered in the outpatient setting, often at the residence of the patient. Home health care can be custodial or skilled in nature, depending on the provider, the patient's condition, and the specific program.

Hospice Care / End-of-Life Care are interdisciplinary and holistic care when curative or life-prolonging treatments are no longer beneficial and services may focus on symptom control, psychosocial and spiritual care, nursing, or short-term acute services. Trained clinicians and support staff support individual and family quality-of-life goals.

Hospice care can be provided in the home, skilled nursing facility, or hospital setting (for acute symptom management and stabilization to return to previous level of hospice care).²“Palliative Care” is interdisciplinary and holistic care that focuses on symptom management, relieving suffering in all stages of disease, supporting communication, assessing psychosocial, spiritual, social and economic resources. Members may receive curative or life-prolonging treatment, and may not choose to receive hospice care or end-of-life care. Furthermore, palliative care provides support for individual and family quality-of-life goals.

Clinical Indications

SNF Levels of Care

Please refer to the SNF contracts for reimbursement leveling based on the number of skilled hours, frequency of assessments, and clinical complexity. The appropriate level of care is subject to change as the member progresses or when acute changes in condition occur.

Initial Admission Criteria

The Plan considers skilled nursing facility (SNF) care medically necessary when ALL of the following criteria are met:

1. Medical necessity criteria in MCG Recovery Facility Care Guidelines are met; or
2. For members requesting hospice care/end-of-life care or palliative care at a SNF (please check plan benefits to verify hospice or palliative care benefit timeframes), the following criteria must be met to meet medical necessity:
   • The member is terminally ill, presenting with functional decline, and certified by a medical practitioner for life expectancy less than twelve months for palliative care and less than six months for hospice/end-of-life care and meets all of the criteria in one of the following MCG Guidelines:
     1. MCG End-Of-Life Care (PO-5006); or
     2. MCG Palliative Care (PO-5020);
3. The member was admitted to an inpatient hospital within 30 days of the requested SNF admission; and
4. The written plan of care includes an initial evaluation and is sufficient to determine the necessity of therapy, including ALL of the following elements:
   • The diagnosis, the date of onset or exacerbation of the disorder/diagnosis, the duration, the severity, the anticipated course (e.g. stable, progressive, or improving), and the prognosis of the illness or injury; and
   • Prior functioning level; and
   • Plan of care: Long-term and short-term goals are specific, quantitative, objective, and can reasonably be considered attainable; and
   • Daily documentation of progress; and
   • Discharge plan.
5. The member requires a skilled level of care meeting the following requirements:³
   • a. Skilled care is performed by or under the supervision of an authorized provider (e.g., speech therapist, registered nurse, physical therapist, etc. ); and
   • b. The level of care could not be provided by non-skilled providers; and
   • c. The skilled care can only be performed on an inpatient basis in a skilled nursing facility; and
   • d. The skilled care is required by the member at least daily, as defined by:
   • 7 days per week for most cases of standard SNF care; or
   • At least 6 days per week when the member requires skilled restorative nursing ii. care; or
   • At least 5 days per week when the member’s inpatient needs are solely for skilled rehabilitation.
   • e. The level of care required is reasonable and necessary for:
   • Treatment of the member’s specific illness and/or injury; and
   • ii. The duration and quantity of care needed.
   • These requirements are documented and ordered by the treating physician.

Discharge Criteria

The Plan considers skilled nursing facility services no longer medically necessary when ANY of the following criteria are met:

1. Services no longer meet ALL of the criteria above; or
2. The member’s condition has changed such that skilled care or rehabilitation is no longer needed (i.e., the member has reached a functional plateau, maximal mobility is met with or without assistance or an assistive device, and current orthopedic precautions are not expected to change in the next week); or

4. The member is not progressing with goals of therapy within a reasonable and defined period of time or has met therapy goals; or
5. When services are provided solely to preserve a present level of function or prevent regression of function for a condition that has stabilized; or
6. The member refuses to participate in the ongoing treatment plan; or
7. The member requires a higher level of care due to deterioration or new illness; or
8. Care was initially or has become custodial in nature; or
9. Services can safely and effectively be performed by non-medical personnel or self-administered by the member in a home setting; or
10. Rehabilitative goals can safely and effectively be met in the home setting, outpatient setting, or at a custodial level; or
11. Discharge from SNF level of care would not be expected to result in a deterioration of the member's condition.

Experimental or Investigational / Not Medically Necessary

Duplicate Services

Diagnostic imaging or testing is not considered medically necessary in the SNF when duplicate services were performed prior to admission.

Delays in Discharge

Discharge planning is expected to begin at admission and continue at regular intervals throughout the member's stay. Any delays in discharge due to inappropriate discharge planning such as the failure to make appropriate DME or home health referrals are subject to denial.

Not Medically Necessary Indications

The following conditions are generally not indications for inpatient skilled nursing unless documented to meet criteria as above:

• ADL assistance or custodial care;
• Administration of suppositories or enema;
• Care of confused or disoriented patients who are under an established medication regimen
• Care solely for the administration of oxygen, nebulizer treatments, or for individuals on established levels of ventilatory support;
• Care solely for the treatment of stage 1-2 pressure ulcers
• Emotional support or counseling;
• Heat treatment – wet or dry:
  • Whirlpool baths, paraffin baths or heat lamp treatments do not qualify an individual for care in an acute inpatient rehabilitation or SNF.
  • There may be a rare instance when a severely compromised individual with desensitizing neuropathies or severe burns requires skilled observation during the above treatments. These cases are to be reviewed on an individual consideration basis. Documentation must support the medical necessity for such observation.
• Passive range of motion exercises, unless there are complex wound care, co-morbid orthopedic or neurological conditions that require the services of a skilled therapist;
• Routine care for colostomy, enteral feedings, or foot and nail;
• Routine or maintenance medication administration. Admissions solely for the administration of routine or maintenance medications, including daily IV, IM and SQ medications are not considered skilled. Parenteral medication administration in medically stable individuals is most often managed in the home setting by a home health or home infusion therapy provider;
• Routine or maintenance therapy;
• Routine services directed toward the prevention of injury or illness;
• Suctioning of the nasopharynx or nasotrachea. Suctioning daily or PRN less frequently than every 4 hours PRN is not considered skilled;
• Urinary catheters. The presence of a stable indwelling or suprapubic catheter, the need for routine intermittent straight catheterization, catheter replacement or routine catheter irrigation does not qualify an individual for acute inpatient rehabilitation or SNF placement unless other skilled needs exist.