Members Skilled Care Guidelines

Members recently discharged from the hospital and/or those diagnosed with certain medical conditions may require short-term skilled care provided in the home setting. Skilled nursing care is delivered by licensed medical professionals including registered nurses (RN) and licensed vocational/practical nurses (LVN or LPN). When medically necessary, skilled nursing care is provided until the member’s condition has stabilized. Services are intended to restore or improve functional independence, and also to help train caregivers and family members in ongoing care of the member.

Guideline Overview

This guideline provides clinical criteria regarding the indications and exclusions for skilled nursing care.

Information about coverage and benefit limitations can be found in the member’s plan contract at hioscar.com/forms.

Definitions

• Homebound: refers to members who have normal inability to leave home without considerable and taxing effort (i.e. requires an assistive device or the assistance of another person to leave home) AND one of the following:
  1. Members who cannot leave home due to a medical condition, chronic disease, or injury; or
  2. Members advised by a treating provider not to leave home for various reasons (e.g., safety, ongoing medical treatment needs); or
  3. Members who need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, special transportation (when the member is unable to use common transportation such as private automobile, bus, taxi due to medical condition), or the assistance of others to leave their place of residence.
• When the member does leave home, the absence of the member from the home is infrequent or for short periods of time, such as to receive health treatment or adult daycare (non-residential program providing services during the day).
• Skilled Nursing Care: is care delivered by licensed, professional nurses (Registered Nurse [RN], Licensed Vocational/Practical Nurse [LVN/LPN]) for members who need a skilled level of care to safely manage, observe, evaluate recovery from an illness or injury, maintain member’s current condition or prevent deterioration. When services can be safely and effectively performed by the member or unskilled caregivers, such services do not require skilled nursing.
• Activities of Daily Living (ADLs): are defined as the routine activities that most healthy persons perform daily without requiring assistance: These include, but are not limited to: bathing, communication, dressing, feeding, grooming, mobility, personal hygiene, self-maintenance, skin management, and toileting.
• Instrumental Activities of Daily Living (IADLs): is defined as activities that may be performed daily but are not fundamental for daily functioning. These include, but are not limited to: the use of public transportation, balancing a checkbook, community living activities, meal preparation, laundry, leisure activities and sports, and motor vehicle operation.
• Custodial Care or Long-term Care are non-skilled, personal care to maintain the member’s ADLs or IADLS over a long-term duration and do not require oversight or skilled services by trained health professionals or technical personnel. These services are not part of a medical treatment plan for recovery, rehabilitation, habilitation, or improvement in sickness or injury. Custodial services may be provided in the home, assisted living facilities, or nursing homes, etc. This type of custodial or long-term care typically does not apply for plan benefits, please see the member’s plan benefit.
• 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).
• Palliative Care - are interdisciplinary and holistic care that focuses on symptom management, relieving suffering in all stages of disease, supporting communication, assessing psychosocial and spiritual resources, 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

Skilled Nursing Care in the home is considered medically necessary for initial requests when ALL of the following criteria are met:

1. The treatment plan is prescribed and monitored by a licensed provider (MD, DO, NP, or PA) as per individual state law, and requires the knowledge, skills, and clinical expertise of a licensed nurse (RN, LVN, or LPN); and
2. The member meets the definition of homebound and is evident in the medical record (see Definitions section above); and/or
3. The member is not homebound, but needs home infusion treatment with skilled nursing (see Home Infusion Criteria below); and/or
4. The services requested are not custodial in nature as defined by assistance for activities of daily living (see Definitions section above) that can be performed safely by non-professionals, unskilled caregivers, family members, or the member; and
5. Medical necessity criteria in the appropriate MCG Home Care Optimal Recovery Guidelines, MCG Home Care General Recovery Guideline, or for palliative (MCG Palliative Care PO-2020) or hospice care (MCG End-Of-Life Care PO-2006) is met; and
6. Without home skilled nursing care, the member would require hospitalization, Skilled Nursing Facility (SNF) placement, or outpatient skilled care; and
7. Services are intended for short-term or rehabilitative care with the ultimate goals of stabilization, independence, and/or modified independence with the support of a caregiver; and

Plan of Care Documentation

The individualized plan of care should be sufficiently documented to determine the medical necessity of treatment, including the following elements:

1. A medical evaluation has been conducted within 30 days of the service dates; and
2. The diagnosis, the date of onset or exacerbation of the disorder/diagnosis, the duration, the severity, the anticipated course (stable, progressive, or improving), and the prognosis; and
3. Prior level of functioning and current level of functioning; and
4. Long-term and short-term goals that are specific, quantitative, objective, and provide a reasonable estimate of when the goals will be reached; and
5. The frequency and duration of treatment; and
6. The specific skilled care to be provided; and
7. Discharge plan; and

Documentation of medical necessity should be reviewed when ANY of the following occur:

9. The plan of care exceeds the expected duration and/or estimated frequency of care; or
10. There is a change in the member’s condition that may impact the plan of care; or
11. The specific goals are no longer expected to be achieved in a reasonable or expected duration of time.

Home Infusion Treatment

(Do not apply home health care visits by a skilled nurse towards the benefit limit for home infusion treatments. Home-bound status is not required for the member to meet medical necessity)

Skilled Nursing Care for home infusions is considered medically necessary when ALL of the following criteria are met:

1. The treatment plan is prescribed and monitored by a licensed provider (MD, DO, NP, or PA) with current DEA (Drug Enforcement Agency) licensure as per individual state law, and requires the knowledge, skills, and clinical expertise of a licensed nurse (RN, LVN, or LPN); and
2. The infusion treatment in the home setting with skilled nursing services is most appropriate for the member (homebound or not homebound) based on previous response to treatment, toxicity of medication, monitoring required, member’s comorbidities, and infusion needed overnight or the weekend when the outpatient clinic is closed; and
3. The administration of the drug is required through intravenous, intraosseous, intraspinal, or subcutaneous; and
4. The member’s home environment is safe and appropriate for medication administration. The medication is neither hazardous nor does it require close observation with acute intervention needed by a medical practitioner; and
5. The nurse provides member and caregiver education on safe storage, maintenance, disposal of solutions, supplies, and equipment; furthermore, education on troubleshooting the infusion device, recognizing signs and symptoms of adverse effects, and preventing complications.

Duration of Therapy

The duration of therapy is dependent on the treatment plan of care and the severity of the member’s condition. The Plan utilizes MCG home care criteria for the recommended visits per episode.

Note: Postnatal newborn care visits must be made within 2 weeks of delivery.

Private Duty Nursing

Subject to the terms, conditions, and limitations of a member's benefit plan policy, private duty nursing is considered medically necessary when MCG criteria (PDN-2001) are met.

Extension Requests

A Plan member who requires continued Skilled Nursing visits, beyond the original treatment plan of care, may receive extended treatment when the follow criteria are met:

1. A medical evaluation has been conducted within 30 days of the service dates; and
   • The appropriate MCG Home Care Optimal Recovery Guidelines with the Extended Visits criteria are met; or
   • The appropriate MCG Home Care General Recovery Guideline is reviewed and the member is still in General Treatment Course Stage 2 or has not met all of the milestones in Stage 3.
2. For an extension request/recertification for hospice or palliative care, please see plan benefits and requirements.

Members meet medical necessity for extension requests when they continue to meet for palliative (MCG Palliative Care PO-2020) or hospice care (MCG End-Of-Life Care PO-2006) in Extended Visits criteria or in General Treatment Course Stage 2 or have not met all of the milestones in Stage 3.

Experimental or Investigational / Not Medically Necessary

Skilled care, and thus nursing care, should be discontinued when one of the following is present:

• Homebound status is no longer met; or
• The member reaches the predetermined goals or skilled treatment is no longer required; or
• The member’s condition is stable or predictable; or
• The member can safely and effectively continue in a non-skilled care program; or
• The member’s medical condition prevents further therapy; or
• The member is transferred to an inpatient or other skilled setting; or
• The member no longer meets medical necessity criteria; or
• The family or caregiver has been taught and adequately demonstrated skills of care; or
• The member refuses treatment.

Skilled nursing services are not considered medically necessary for the following:

• Skilled care is not necessary, or care is not provided for a specific illness or injury; or
• Chronic illness / chronic flare-ups or exacerbations that did not result in a decline in function or related to an acute exacerbation, or
• Long-term maintenance therapy, as it is aimed to preserve the present level of function or to prevent regression below an acceptable level of functioning; or
• Custodial care or Long-term care services; or
• No expected improvement or achievable goals in functioning over a reasonable and predictable period of time; or
• Respite care, or to allow family or caregivers to go to work, school, or other obligation; or
• Duplicative therapy services or programs; or
• Treatment modalities can safely be conducted by the member alone or with the help of family or caregivers and therefore do not require a licensed nurse;or
• Ongoing and routine care including, but not limited to:
• Services to prevent injury or illness; or
• Administration of medications, including oral medications, topical ointments, eye drops, intramuscular injections, intravenous infusions, and subcutaneous medications (e.g., insulin); or
• Enteral feedings; or
• Suction unless specifically covered otherwise; or
• Routine ostomy care; or
• Intermittent straight catheterization for chronic conditions or foley care; or
• Emotional support or counseling; or
• Non-skilled tasks that are typically performed by the member or caregiver; or
• If solely for long-term or non-skilled assistance with ADLs; or
• If solely for long-term or non-skilled assistance with IADLs.