I Want a SNF Please…Dr Maria Johar, MD 75 year old patient with Medicare Advantage came to the hospital for a procedure. Post-operatively the family states they are unable to care for the patient and both family and patient desire placement in a skilled nursing facility for rehabilitation. Social workers get the paperwork together for submission after a choice for an in-network facility has been made. Physical therapy and occupational therapy provide assessments and recommend a SNF as well. Therapy Assessment: Social worker sends paperwork to MA Plan for approval on Monday, it is reviewed on Wednesday and denied, Peer to Peer is offered by 12pm on Thursday. Attending is busy so seeks the physician advisor’s help. As a physician advisor the first step is to review the case:
Let’s tackle these one by one. If recommending home with home health, the patient must be homebound. To leave their home, they must need help, including the help of another person, crutches, a walker, a wheelchair, or special transportation. Patients must need skilled nursing care on intermittent basis. Patients must need physical, speech-language, or occupational therapy or nursing services on an intermittent basis. Home health care makes sense when the patient is recovering from an injury or illness and doesn’t need 24-hour care. It also makes sense when the type of care required is custodial, although custodial care is not covered. Home health care is most often provided by a visiting nurse, therapist, or home health aide. Often, several visits to the home are made each week to provide the appropriate care. Home health care can include a wide range of services, including, but not limited to, respiratory therapy, cleaning and bandaging of wounds, monitoring health, and assistance with bathing and dressing. If recommending a skilled nursing facility, this is usually a short term placement with the goal of allowing the patient to return home at baseline. The change between baseline and current state generally needs to have an expectation of improvement. Clear and current information needs to be sent to the payor for approval. Skilled nursing is typically used for short-term rehabilitation to allow patients to improve their functioning and regain independence. It can also help patients learn how to better take care of themselves in the face of their ongoing health challenges or prevent decline with some chronic conditions. The best skilled nursing programs take a well-rounded and integrative approach to care. Overall, a patient who requires daily care for any health condition is qualified for skilled nursing care. Individuals who require ongoing medical care after an injury, rehabilitation or other highly effective medical treatment qualify for skilled nursing care. Those recovering from a stroke, a surgery, an accident, or significant illness are typical skilled nursing facility patients. Patients in need of intensive wound care or those requiring physical and occupational therapy also qualify for skilled nursing facilities. If recommending long-term care services, we are seeking care for someone who is at baseline and needs full care which is not possible elsewhere. Medicare and Medicare Advantage do not cover long term care. Services that include medical and non-medical care for people with chronic illnesses or disability. Long-term care helps meet health or personal needs. Most long-term care services assists people with Activities of Daily Living, such as dressing, bathing, and using the bathroom. Long-term care can be provided at home, in the community, or in a facility. For purposes of Medicaid eligibility and payment, long-term care services are those provided to an individual who requires a level of care equivalent to that received in a nursing facility. Medicaid: Does pay for the largest share of long-term care services, but to qualify, your income must be below a certain level, and you must meet minimum state eligibility requirements. Some other options are also available: Adult Day Care Adult day-care centers provide care in a group setting for aged or disabled people who live at home, and/or may need help with the basic activities of daily living due to physical or mental impairment. Often, these people live with a relative who works and cannot take care of them during the day. Adult day-care centers usually provide an elderly person with social interaction, therapeutic activities, preventive health services, and nutritional meals. Hospice Care Hospice care is quality compassionate care for those terminally ill patients nearing their end of life. Hospice can take place in a care facility that provides comfort and care, or it can be administered in the home. Respite Care Respite care provides some time off for the caregiver (usually a relative) who regularly provides care for an elderly or disabled person. It can be offered in a local community center, nursing home or at home through the services of a home health aide. Case Follow-up: This 75 year old Medicare Advantage patient wants a short term SNF, however pt does NOT qualify for a short term SNF because the pt is able to walk household distances. Typically, pts walking 50 -75 ft are not eligible for care at a SNF. We would communicate with the treating doctor and ancillary team to find a suitable discharge option. In this case the team had provided multiple options to the patient and family and the patient finally agreed to go home with home health. Payor did approve home health services. How Physician advisors Can Assist: Participating in regular rounds or having a great line of communication with the bedside team will assist in identifying the right discharge destination for the patients in need. Contacting the treating physician and having a dialogue with them on the possibilities and assisting them with an optimal discharge will help in the recognition of the physician advisor as a valuable member of the team. The hospital administrators and leaders see the value of a well-informed physician advisor as they prevent avoidable delays by helping with the right discharge disposition with complex cases. Performing peer to peers for any discharge denial is another feature that can prove very valuable for the hospitals if they have a strong physician advisor. Reducing length of stay, educating the team of case managers, social services, physical therapists to seek the right disposition is key to ensure appropriate utilization of healthcare resources. Tips to remember:
Dr Maria Johar is Lead Physician Advisor for Ensemble Health Partners |