SPECIALIZED CARE

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SPECIALIZED CARE

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1. SPECIALIZED CARE Presented by Arleen Johnson RN Health Care Compliance Specialist II

2. OUTLINE Introduction Criteria Preauthorization Process Documentation Requirements Question and Answer Period

3. Specialized Care In Virginia The Department of Medical Assistance Services (DMAS) implemented ?Specialized Care? as a Medicaid reimbursement program in 1991 for high acuity nursing facility residents. The Adult Specialized Care program (12VAC30-60-320) addresses the needs of individuals who require mechanical ventilation and individuals with a complex tracheostomy.

4. Specialized Care In Virginia The Pediatric Specialized Care program (12VAC30-60-340) addresses the needs of pediatric individuals who require Mechanical Ventilation, Comprehensive Rehabilitation or have Complex Health Care needs.

5. General Criteria Must meet nursing facility level of care for admission and continued stay. The Uniform Assessment Instrument (UAI) is used for admission and the Minimum Data Set (MDS) is used for continued stay Must require physician visits at least weekly (every 7 days). The initial Physician visit must be made by the physician personally and subsequent required physician visits may alternate between the physician, a physician assistant or nurse practitioner.

6. General Criteria Skilled registered nursing services 24 hours a day A coordinated multidisciplinary team approach to meet needs. Infection control Ancillary services related to plan of care Respiratory therapy services by a board-certified therapist (these services must be available 24 hours a day)

7. General Criteria Psychology services by a licensed clinical psychologist, licensed clinical social worker, licensed professional counselor, or licensed clinical nurse specialist-psychiatric related to a plan of care Necessary durable medical equipment and supplies as required by the plan of care

8. General Criteria Nutritional elements as required A plan to assure that specialized care residents have the same opportunity to participate in integrated nursing facility activities as other residents Non emergency transportation Discharge planning and Family or caregiver training

9. Adult Criteria Must require Mechanical ventilation or Have complex tracheostomy that meets all of the following criteria. The resident must Have a tracheostomy with the potential for weaning or documentation of attempts to wean with subsequent inability to wean;

10. Adult Criteria Require nebulizer treatments followed by chest PT (physiotherapy) at least 4 times per day or nebulizer treatments at least 4 times a day, provided by a licensed Nurse or Licensed Respiratory Therapist; Require pulse oximetry monitoring at least every shift due to demonstrated unstable oxygen saturation levels;

11. Adult Criteria Require respiratory assessment and documentation every shift by a Licensed Respiratory Therapist or Trained nurse; Have a Physician?s order for oxygen therapy with documented usage; Require tracheostomy care at least daily; Have a Physician?s order for suctioning as needed; AND

12. Adult Criteria Be deemed to be at risk to require subsequent mechanical ventilation.

13. Pediatric Criteria The recipient must be age 21 or under. The nursing facility must coordinate with appropriate agencies to provide the educational and habilitative needs of the child.

14. Pediatric Criteria Comprehensive Rehab Must require two out of three of the following rehab services: Physical Therapy, Occupational Therapy, and Speech-pathology Must be provided at a minimum of 6 therapy sessions per day (minimum of 15 minutes per session), 5 days per week. Child must demonstrate progress in the overall rehabilitative plan of care on a monthly basis.

15. Pediatric Criteria Pediatric Special Equipment Must require special equipment such as mechanical ventilators, respiratory therapy equipment (that has to be supervised by licensed nurse or respiratory therapist), monitoring device (respiratory or cardiac) kinetic therapy;

16. Pediatric Criteria Complex Medical Care Must require at least one of the following special services: Ongoing administration of intravenous medications or nutrition (i.e. TPN, antibiotic therapy, narcotic administration, etc) Special infection control precautions Dialysis treatment that is provided within the facility (i.e. peritoneal dialysis)

17. Pediatric Criteria Complex Medical Care Daily respiratory therapy treatments that must be provided by a skilled nurse or respiratory therapist Extensive wound care requiring debridement, irrigation, packing, etc. more that two times a day (i.e., grade IV decubiti; large surgical wound that cannot be closed, second or their degree burns covering more than 10% of the body)

18. Pediatric Criteria Complex Medical Care Ostomy care requiring services by a licensed nurse Care for terminal illness.

19. Preauthorization Medicaid Specialized care program is available to individuals who are Medicaid eligible and meet the Medicaid specialized care criteria The nursing facility (NF) must check the recipients eligibility through the Automated Response System (ARS) or through Medicall to determine if the individual is Medicaid eligible.

20. Preauthorization All individuals who are being considered for admission into the specialized care program must be preauthorized. Preadmission screening packages must be submitted to DMAS. Once the packet is received at DMAS, a decision will be made to either pend it for additional information, approve, or deny the request. If the packet is pended for additional information, providers will have 3 business days to submit the additional information to DMAS. If the additional information is not received within the time frame, the request for Medicaid specialized services will be denied.

21. SPEC 100

23. Preauthorization New admissions from the hospital or community SPEC 100 with original physician signature and date Uniform Assessment Instrument (UAI) MI/MR Assessment (Level I and II if needed) Preadmission Screening Authorization (screened for nursing facility level of care) the DMAS 96. Other pertinent information DMAS may request a copy of the H&P, progress notes, flow sheets etc. (to verify the recipient meets the specialized care criteria)

24. Preauthorization In-house Transfer SPEC 100 with current physician certification UAI or MDS Other pertinent information ? signed physician orders and/or information requested specifically by DMAS which may include H&P, flow sheets, etc.

25. Preauthorization Nursing facility to nursing facility SPEC 100 with original physician signature and date Updated MDS Signed Physician Orders Other pertinent information requested specifically by DMAS which may include H&P, flow sheets, etc.

26. Preauthorization If a resident is Medicaid Pending or will be Medicaid eligible within 180 days Submit complete screening package Will be denied because the resident is not Medicaid eligible A denial letter with appeal rights will be sent to the facility

27. Preauthorization When the Resident becomes Medicaid Eligible Resubmit the entire screening package with a note on the cover sheet indicating the package is being resubmitted Include the letter from the eligibility worker indicating the resident is Medicaid eligible

28. Preauthorization If a Resident is admitted under private insurance or Medicare and Is Medicaid eligible Submit a completed screening package for preauthorization upon initial admission. Do not include the admit date on the Spec 100 If approved for Medicaid specialized care, you will have 3 business days to submit the Spec 100 with the admission date once the Medicare or private insurance benefits are exhausted.

29. Preauthorization Readmissions Occur when resident is discharged from the specialized care program directly to the hospital or home on therapeutic leave and return directly to the specialized care program from the hospital or home. Requires a new SPEC 100 with original physician signature and date Current, signed physician orders Must be submitted within 3 days of the resident?s return to the facility

30. Documentation Requirements Physician History and Physical Admission Notes Progress notes weekly (every 7 days) Must reflect resident was seen and examined by physician The initial visit must be made by the physician and subsequent visits may alternate between physician and visits by the physician assistant of nurse practitioner. Must address why resident continues to meet criteria

31. Documentation Requirements Nursing Admission assessment by Registered Nurse Nursing plan of care with measurable goals and realistic time frames

32. Documentation Requirements Nursing Weekly comprehensive nursing summaries which must address the following: Reason or category resident meets the specialized care criteria Medical status Functional status in ADL?s Elimination and mobility Emotional or mental status Special therapies, Nutritional status Special nursing procedures and Identification and resolution of acute illnesses or episodes

33. Documentation Requirements Social Services Evaluation and social history Care plan with measurable objectives with realistic time frames Care plan updated monthly Progress notes at least monthly Discharge planning

34. Documentation Requirements Activities Evaluation Care plan with measurable objectives with realistic time frames Care plan updated monthly Progress notes at least monthly

35. Documentation Requirements Dietary Services Dietary evaluation by the registered dietitian Plan of care with measurable objectives within a realistic time frame Plan of care updated as needed but at least monthly. To be completed by RD Progress notes at least monthly by RD

36. Documentation Requirements Rehabilitative Therapy Documentation (Physical and Occupational Therapy or Speech Pathology or other health care professionals - Psychologist, Respiratory Therapy etc) Initial Assessment Plan of care with measurable goals and realistic time frames Plan of care updated as needed but at least monthly Progress notes at least monthly

37. Documentation Requirements Pharmacist Medication Review Must review medications monthly Review must be documented, dated and signed statement of the appropriateness of the drug therapy and whether there are potential problems with the therapy

38. Documentation Requirements Interdisciplinary Care Plan Resident specific with measurable goals within realistic time frames At a minimum, the nurse, social worker, registered dietitian and the activities, rehab or other direct health care staff must review and update the plan of care as needed but at least monthly

39. Documentation Requirements Must identify those attending care plan meeting Must identify any changes in goals and approaches, and the progress made toward meeting established goals and discharge Must specifically note how the resident continues to meet the criteria for Specialized Care reimbursement.

40. Other 12VAC30-60-320. Adult ventilation/tracheostomy specialized care criteria 12VAC30-60-340. Pediatric and adolescent specialized care criteria 12VAC30-60-40. Utilization control: Nursing facilities Medicaid Nursing Facility Provider Manual Chapter VI DMAS Long Term Care Division ? Telephone number- 804 - 225-4222 FAX number ? 804 - 612-0040


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