Skilled Home Health Nursing Services

Skilled Home Health Care Nursing Services AHM

Clinical Indications

• Skilled home health nursing services is considered medically necessary when ALL of the following criteria are met • Skilled nursing care consists of those services that must be performed by a registered nurse or licensed practical (vocational) nurse, and meet ALL of the following criteria for skilled nursing services . Based on physician orders, the service(s) is so inherently complex that it can be safely and effectively performed only by, or under the supervision of, a licensed nurse to achieve the medically desired result . The skilled nursing care must be provided on an intermittent or hourly basis . The skilled nursing service is not custodial in nature . The skilled nursing service(s) must be reasonable and necessary for the treatment of the illness or injury, that is, the services must be consistent with the unique nature and severity of the patient's illness or injury, his or her particular medical needs, and accepted standards of medical and nursing practice, without regard to whether the illness or injury is acute, chronic, terminal, or expected to last a long time . Skilled home health nursing services is considered medically necessary when ALL of the following criteria are met • Member meets 1 or more of the following :

• The patient is homebound because of illness or injury (i.e., the patient leaves home only with considerable and taxing effort and absences from home are infrequent, or of short duration, or to receive medical care) • Patient is being case managed and cost effective therapy can be managed safely in the home setting . examples include include but are not limited to: Children that need scheduled care and also must attend school. Working adult who needs scheduled treatments, that cannot go to office or would not be

ActiveHealth Management Medical Management Guidelines

cost effective to go to ER or Urgent care center to receive care, and care could be safely administered at home. • The services are ordered by a physician and are directly related to an active treatment plan of care established by the physician. (Once the orders are received by the agency, it is reasonable to approve 1 visit for a nursing assessment and treatment plan to be developed) • The nursing services provided are not primarily for the comfort or convenience of the patient or custodial in nature • The services are provided in lieu of a continued hospitalization, confinement in a skilled nursing facility (SNF), or receiving outpatient services outside of the home • The skilled nursing care is appropriate for the active treatment of a condition, illness, disease, or injury to avoid placing the patient at risk for serious medical complications • The skilled nursing care is intermittent or hourly in nature • The treatment provided is appropriate for the patient's condition including the amount of time spent providing the service as well as the frequency and duration of the services • The use of a home health aide is considered medically necessary in selected cases when ALL of the following criteria are met • The services of a home health aide are rendered in conjunction with intermittent skilled home health care services provided by a licensed practical or registered nurse, occupational therapist, physical therapist, or speech therapist • The services delivered by the home health aide directly support skilled home health care services. These may include 1 or more of the following . Assisting with a prescribed exercise regimen . Assisting with activities of daily living . Changing non-sterile dressings that do not require the skills of a licensed nurse . Routine care of prosthetic and orthotic devices . Supervising the individual's adherence to prescribed, self-administered medication and/or special diets . Taking blood pressure and other health monitoring activities

Notes

• Skilled home health nursing care is the provision of intermittent skilled services to a patient in the home for the purpose of restoring and maintaining his or her maximal level of function and health. These services are rendered in lieu of hospitalization, confinement in an extended care facility, or going outside of the home for the service

ActiveHealth Management Medical Management Guidelines

• Intermittent or part time skilled home care nursing is defined as a visit of up to 4 hours in duration • Home health skilled nursing care is defined as a consecutive 4-hour period of time (i.e., an 8-hour shift equals 2 visits) • Custodial care is defined as services and supplies furnished to a person mainly to help him or her with activities of daily life. Custodial care includes the following services and supplies • Furnished mainly to train or assist the insured family patient in personal hygiene and other activities of daily living rather than to provide therapeutic treatment • That can be safely and adequately provided by persons without the technical skills of a health care provider (e.g., nurse) • A home health aide is a provider who assists a patient with non-skilled care to meet activities of daily living, thereby maintaining the individual in his or her home environment. Generally, the following services are considered NOT medically necessary • Babysitting services • House cleaning (except for maintaining the patient's immediate area) • Transportation Evidence Summary

Background

• Skilled nursing care is health care given when a person needs skilled nursing staff (registered nurse (RN) or licensed practical nurse (LPN)) to manage, observe, and evaluate care. Skilled nursing care requires the involvement of skilled nursing staff in order to be given safely and effectively. Care that can be given by non-professional staff is not considered skilled nursing care. The goal of skilled nursing care is to help improve the patient's condition or to maintain the patient's condition and prevent it from getting worse. • Custodial care is care that helps persons with usual daily activities like walking, eating, or bathing. It may also include care that most people do themselves, like using eye drops, oxygen, and taking care of colostomy or bladder catheters. References

1. U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Skilled nursing care. Home Health Agency Manual §205.1. HCFA Pub. 11. Baltimore, MD: HCFA; 2000.

ActiveHealth Management Medical Management Guidelines

2. Suddarth DS. Lippincott Manual of Nursing Practice. Philadelphia, PA: J.B. Lippincott Co.; 1991. 3. Bernstein LH, et al. Primary Care in the Home. New York, NY: J.B. Lippincott Company; 1987. 4. Corkery E. Discharge planning and home health care: What every staff nurse should know. Orthopaed Nurs. 1989;8(6):18-27. 5. American Medical Association, Council on Scientific Affairs. Home care in the 1990s. JAMA. 1990;263(9):1241-1244. 6. Maguire GH, ed. Care of the Elderly: A Health Team Approach. Boston, MA: Little, Brown and Co.; 1985. 7. Martinson IM, et al. Home Health Care Nursing. Philadelphia, PA: W.B. Saunders Co.; 1989. 8. Olson HH. Home health nursing. Caring. 1986;Aug:53-61. 9. Cartier C. From home to hospital and back again: Economic restructuring, end of life, and the gendered problems of place-switching health services. Soc Sci Med. 2003;56(11):2289-2301. 10. Stein J. Medicare and long-term care. Issue Brief Cent Medicare Educ. 2003;4(4):1-6. 11. Kadushin G. Home health care utilization: A review of the research for social work. Health Soc Work. 2004;29(3):219-244. 12. Office of the Secretary, Department of Defense. TRICARE; Sub-acute care program; Uniform skilled nursing facility benefit; Home health care benefit; Adopting Medicare payment methods for skilled nursing facilities and home health care providers. Final rule. Fed Regist. 2005;70(204):61368-61379. 13. Vincent HK, Vincent KR. Functional and economic outcomes of cardiopulmonary patients: A preliminary comparison of the inpatient rehabilitation and skilled nursing facility environments. Am J Phys Med Rehabil. 2008;87(5):371-380. 14. Birmingham J. Understanding the Medicare "Extended Care Benefit" a.k.a. the 3- midnight rule. Prof Case Manag. 2008;13(1):7-16. 15. U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). HCFA Publication No. 10969. Baltimore, MD: HCFA; updated December 10, 1996. 16. Boland P. Making Managed Healthcare Work: A Practical Guide to Strategies and Solutions. New York, NY: McGraw Hill; 1991 17. Kongstvedt P, The Managed Health Care Handbook. Gaithersburg, MD: Aspen; 1993. 18. Marrelli TM, Handbook of Home Health Standards. St. Louis, MO: Mosby Year Book; 1991. 19. Portnow J. Assistive technology in the home. Caring. 1994;13(9):58-61. 20. Harris MD. The home health aide as a member of the home healthcare team. Home Healthc Nurse. 1997;15(11):773-775 21. Najera LK, Heavey BA. Nursing strategies for preventing home health aide abuse. Home Healthc Nurse. 1997;15(11):758-767; quiz 769-770. 22. Hays BJ, Willborn FH. Characteristics of clients who receive home health aide service. Public Health Nurs. 1996;13(1):58-64.

ActiveHealth Management Medical Management Guidelines

23. No authors listed. Medicare program; Medicare coverage of home health services, Medicare conditions of participation, and home health aide supervision--HCFA. Final rule. Fed Regist. 1994;59(243):65482-65498. 24. Grieco AJ. Physician's guide to managing home care of older patients. Geriatrics. 1991;46(5):49-55, 59-60. 25. Scharf JH, Lindner MK, Gordon J, et al. Making the relationship work. Management of a hospital-based home health agency and hospital for-profit home health aide service. Caring. 1990;9(4):62-65. 26. Cayla JS. The nurse, the nurses' aide, the practical nurse and the home health aide. Soins. 1989;525:59-60. 27. Aalberts N. Training home care paraprofessionals. Areas for consideration. Caring. 1989;8(2):26-27. 28. Najera LK. Enhancing home health aide training. Home Healthc Nurse. 1988;6(5):39-41. 29. Boies AH. Role of the home health aide in the rehabilitation process. Home Health Nurse. 1987;5(6):44-45. 30. Joseloff AW. The home health aide. A member of the hospice team. Caring. 1986;5(10):36-38. 31. Ferrell BR, Borneman T. Community implementation of home care palliative care education. Cancer Pract. 2002;10(1):20-27. 32. Murashima S, Asahara K. The effectiveness of the around-the-clock in-home care system: Did it prevent the institutionalization of frail elderly? Public Health Nurs. 2003;20(1):13-24. 33. Cucinotta D, Savorani G, Piscaglia F, et al. The chronically ill elderly patients discharged from the hospital: Interim report from a controlled study of home care attendance. Arch Gerontol Geriatr Suppl. 2004;(9):103-108

Reviewed by a Board Certified Internist Reviewed by David Evans, MD, Medical Director, Active Health Management- May 2016 Copyright 2016 ACTIVEHEALTH MANAGEMENT No part of this document may be reproduced without permission. Codes

CPT® or HCPCS: 99500, 99501, 99502, 99503, 99504, 99505, 99506, 99507, 99509, 99510, 99511, 99512, G0154, G0156, G0162, G0163, G0164, S5108, S5109, S5110, S5111, S5115, S5116, S9098, S9122, S9122, S9123, S9123, S9124, S9124, S9474, T1000, T1001, T1002, T1003, T1004, T1021, T1030, T1031