The Plan

Members who are ready for discharge from the hospital will be assessed for the most appropriate setting for post-acute care. There are many factors that will be considered such as the level of medical care needed, potential for rehabilitation, and social needs of the member. Members who are appropriate for long-term acute care hospitals (LTACH) have complex care needs. Members who are admitted for LTACHs are expected to eventually recover to pre-hospitalization status under close observation and the typical average length of stay is ≥25 days.

Definitions

Long-Term Acute Care Hospitals

are defined by the Center for Medicare and Medicaid Services (CMS) as hospitals that have an average Medicare inpatient length of stay greater than 25 days. These hospitals typically provide extended medical and rehabilitative care for members who have multiple acute or chronic conditions with complex management. Services may include, but are not limited to: comprehensive rehabilitation, respiratory therapy for ventilator management, chest tube, wound care, cancer treatment, head trauma treatment and pain management.

Inpatient Rehabilitation Facilities

provide an intensive rehabilitation program and can be freestanding rehabilitation hospitals or rehabilitation units in acute care hospitals, i.e., acute rehabilitation units. Members who are admitted have complex nursing, medical, and rehabilitation needs. They must be able to tolerate 3 hours of intense rehabilitation services per day or 15 hours per week. There are measurable goals for improvement and managed by an interdisciplinary team.

Skilled Nursing Facilities

are defined by the 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 general supervision 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.

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.

Clinical Indications

General Indications

(Please check member's benefit plan for LTACH admission)

The Plan considers LTACH admissions medically necessary when ALL of the following criteria are met AND Condition Specific Indications are met:

1. Member is stable for transfer to LTACH defined by:
   • Cardiovascular status stable as indicated by MCG (GRG-050); and
   • Hypotension absent as indicated by MCG (GRG-050); and
   • Stable (respiratory) chest findings as indicated by MCG (GRG-050); and
   • Intake acceptable as indicated by MCG (GRG-050); and
   • Renal function acceptable as indicated by MCG (GRG-050), unless admitted for End-Stage Renal Disease and dialysis; and
   • Pain adequately managed as indicated by MCG (GRG-050); and
   • Member has no new, acute or unstable neurological/neuro-surgical abnormalities of one of the following. Or if the member has one of the following conditions, that the condition has been stabilized:
     1. Confusional state (e.g., disorientation, bewilderment, and difficulty following commands that persists for several hours despite treatment); or
     2. Lethargy (e.g., drowsiness, aroused by moderate stimuli, reduced self-awareness and environment for several hours despite treatment); or
     3. Obtundation (e.g., slowed responses and aroused with strong stimuli, sleep more than normal and drowsiness in between sleep states); or
     4. Stupor (e.g., vigorous and repeated stimuli to arouse, immediate lapse to unresponsive state); or
     5. Coma (e.g., unarousable unresponsiveness); or
     6. Acute psychotic condition (sudden and severe onset of hallucinations, delusions, or grossly disorganized thinking and/or behaviors that are not part of the member's baseline mental state);and
   • No new, acute or unstable hepatic dysfunction, unmanaged bleeding or clotting disorders; and
   • No need for respiratory isolation or other types of isolation, unless manageable at the LTACH; and
   • If needed, long-term feeding or peripheral access already established or to be placed at LTACH;
2. Member is expected to recover supported by:
   • Documentation that patient will benefit and improve during LTACH care; and
3. Member is managed by a multidisciplinary team as defined by at least 2 physician specialists and at least 3 skilled services (e.g., PT/OT, respiratory therapy, wound care):

Clinical management more frequently needed than provided at alternative levels of care.

Condition-Specific Indications

Member meets General Indications listed above AND criteria for the following conditions:

1. Member meets the criteria for ONE of the following conditions:
   • Complex Medical Management (see criteria below); or
   • Complex Wound Management (see criteria below); or
2. Member meets the criteria for TWO of the following conditions:
   • Cardiovascular conditions (see criteria below); and/or
   • End-Stage Renal Disease and Kidney Dialysis (see criteria below); and/or
   • Severe Infectious Disease Condition (see criteria below); and/or
   • Ventilator Management (see criteria below).
   (For extension requests/discharge criteria, please see pages 5-6)

Complex Medical Management

The Plan considers LTACH admission for complex medical management medically necessary when ALL of the following criteria are met (e.g., chest tube management for persistent air leaks, traumatic brain injury with polytrauma):

1. Requires daily 6 hours or more of skilled services; and
2. Daily healthcare practitioner monitoring; and
3. Requires at least 1 intravenous antibiotic; and
4. Requires invasive interventions and close observation (e.g., chest tube management, drainage tube management, serial bedside debridements); and
5. Does not require escalation of surgical services to a higher level of care (e.g., plastic surgery, surgical intervention at acute inpatient level of care); and
6. One of the below:
   • Dependent on high-level supplemental oxygen (e.g., high-flow nasal cannula, noninvasive ventilation) that is not able to be managed at a lower level of care; or
   • Member meets Ventilator Management criteria below.

Complex Wound Management

The Plan considers LTACH admission for complex wound management medically necessary when ALL of the following criteria are met:

1. Member has complex wound lesions as defined ONE of the following:
   • Stage IV, large necrotic, non-healing wounds, or post-operative wound complications being assessed for possible bedside surgical intervention; or
   • Large wound with high output fistula, delayed closures, tunneling, draining; or
   • Non-healing amputations; or
   • Management after emergency phase for necrotizing fasciitis; or
   • Severe burns (admitted to burn centers) who still require ONE of the following:
     1. Late burn wound complications (e.g., graft loss, late contractures); or
     2. Frequent evaluation and surgical management of burn wound contractures that have not been responsive to rehabilitation; or
     3. Need continual nutritional support with extended hypermetabolic response; and
2. Requires daily 6.5 hours or more of extensive wound management by skilled services that cannot be provided at lower levels of care; and
3. Daily healthcare practitioner monitoring; and
4. Requires invasive interventions (e.g., serial bedside debridements); and
5. Does not require escalation of surgical services to a higher level of care (e.g., plastic surgery, surgical intervention at acute inpatient level of care).

The member must meet criteria for TWO of the following conditions for medical necessity for LTACH admissions:

Cardiovascular Conditions

The Plan considers LTACH admission for cardiovascular conditions medically necessary when ALL of the following criteria are met AND one other condition as listed in Condition-Specific Indications:

1. Heart failure with pulmonary hypertension requiring long-term IV vasodilator therapy; or
2. Heart failure with need for intravenous vasoactive drugs (e.g., dobutamine); and
3. Continued support needed with high-concentration oxygen (greater than 40%); and
4. Daily adjustment and monitoring of diuretic therapy, fluids, and electrolytes needed.

End-Stage Renal Disease (ESRD) and Kidney Dialysis

The Plan considers LTACH admission for kidney dialysis for ESRD (eGFR <15 mL/min/1.73 m2) stage 5 medically necessary when the following criteria are met AND one other condition as listed in Condition-Specific Indications:

1. Acute medical conditions related to ESRD such as uremic bleeding, uremic pericarditis, uremic neuropathy, uncontrolled hypertension, metabolic disturbances, and pulmonary edema.

Severe Infectious Disease Conditions

The Plan considers LTACH admission for severe infectious disease medically necessary when ONE of the following criteria are met AND one other condition as listed in Condition-Specific Indications:

1. Infective endocarditis, native valve endocarditis, prosthetic valve endocarditis, or peritonitis requiring long-term intravenous antibiotics; or
2. Acute care and monitoring for recurring embolic phenomenon or other instabilities; or
3. Meningitis, encephalitis; or

Sepsis Management

e.g., Candidemia (i.e., invasive Candida species in the blood), multidrug resistant bacteria entering the bloodstream.

Ventilator Management

The Plan considers LTACH admission for acute/chronic respiratory failure on ventilator management medically necessary when the following criteria pathway questions lead to approval AND one other condition as listed in Condition-Specific Indications:

1. Has the member been on respiratory ventilation for 21+ days OR tracheostomy placement for at least seven days?
   • If no, deny
   • If yes, go to next question
2. Has the member been securely and safely trached with ALL of the following:
   • Positive end-expiratory pressure requirement 10 cm H2O (981 Pa) or less; and
   • Adequate oxygenation (oxygen saturation 90% or greater) on FIO2 60% or less; and
   • Oxygen levels stable during suctioning and repositioning
     • If no, deny
     • If yes, go to next question
3. Has the member had at least 2 reasonable weaning trials or spontaneous breathing trials within the past four days or three weaning trials or spontaneous breathing trials within the past seven days?
   • If no, deny
   • If yes, go to next question
4. Confirmed detailed note from pulmonology, critical care, or attending physician stating this member has good weaning potential and will eventually come off the ventilator? (E.g., Tidal volume, respiratory rate, FIO2)
   • If no, deny
   • If yes, Approve.

Extension Requests

The Plan considers LTACH extension requests medically necessary when the member continues to meet admission criteria, clinical status is improving during LTACH stay, and is not ready to be transitioned to an alternative or lower level of care. Extension requests should be based on medical records of progress and not be approved by more than 7 days at a time.

Discharge Criteria

The Plan members are ready for discharge to alternative or lower level of care when the following criteria are met:

1. The member meets all of the clinical indications and milestones under Clinical Status and Interventions in Stage 3 and Discharge Criteria in the following:
   • MCG Ventilator Management Long-Term Acute Care Hospital (LTACH) Guideline (GRG-049) for a member on a ventilator; or
   • MCG Long-Term Acute Care Hospital (LTACH) Level of Care Guideline (GRG-050) for other members;
2. The member no longer meets all the criteria listed in each Condition-Specific Indications listed above; and/or
3. The member’s condition has changed and no longer needs LTACH level of care:
   • The member requires a higher level of care due to deterioration or new illness; and/or
   • Current services preserve a present level of function or prevent regression of function for condition that has stabilized; and/or
   • The member is no longer expected to recover and needs palliative care;
4. The member’s condition can safely and effectively be managed at an alternative level of care.