Managing Post-Acute Care and Other Extended Care Services

Published by: Apollo Managed Care Consultants

Published: Jan. 1, 2009 - 602 Pages

Table of Contents

Preface including important notes and disclaimer - please review

Copyright and proprietary protection, other

Table of Contents

Quotes

Introduction (update 3-07)

Utilization Management

Subacute care programs

Medical necessity defined

Provider requirements for health plan contracts

Medicaid coverage (New 11-06)

Notes

Post-acute and Extended Care Requirements

Selecting the most appropriate setting

Evaluation definitions

Chronic pain assessment

Outcome management, factors for success

Functional Independence Measures (FIM)

Improve the identification and monitoring of ECS Patients: Cost Factors

Improve operational efficiencies and communication

Length of stay benchmarks

ECS Facility Network

Telephone Encounter Guidelines and form

After hours care triage of nursing home calls

Preadmission Screening (PAS) by the ECF

Preadmission Screening Tool

OASIS

Notes

Case or Care Management

Nursing Home Case Management (New 7-05)

Case Management process

Case Management Program

Case Management Referral Indicators

Target Diagnoses for CM Services

COPD care links - refer to Pulmonary Rehabilitation in vol. II. (New 4-05, update 2-09)

Parkinson’s Disease links (New 4-05)

Heart Failure - admission, discharge criteria guidelines

Diabetic Care - Case Management (added 10-03, update 1-04, 4-05)

End-of-life/Palliative care/Hospice: CM, guidelines, billing (New 3-06, update 12-06, 3-07, 4-08, 1-09)

Heparin-Coumadin Conversion Program (New 04)

HIV - Case Management (updated 2-02)

Hip Fracture - Case Management (added 10-03)

Mental Health Case Management Services (New 2-05, update 4-05)

CM: Behavioral Healthcare - Policy example (New 4-05)

Depression Case Management (New 2-04)

Obstetrical Case Management (Added 3-05)

Case Loads - 2001 survey data from MCOL (added 08-02)

Case Management Screens

Case Management - New patient screens/triggers

High risk screen examples

Catastrophic conditions report

Planning the continuum of care

Hospitalist program post-discharge transitional management of care - example (New 11-05)

CM Planning sheets

Director of Case Management Services, position description

Case Manager, position description

Discharge Planner, position description

Post-acute Care Coordinator (New 1-09)

CM Candidate Screen

Case Management Department staff responsibilities

Case Management Credentialing Resources

CM Resources, References

Case or Care Management Web Links (update 12-06)

Skilled Nursing Facility (SNF)TCU and Hospice Services

Skilled Nursing Facility (SNF) Services - UM (Update 8-04, 6-05, 6-07, 6-08)

SNF admission, tests, services and continued stay - medical necessity criteria and LOS guidelines (New 8-04, update 6-05, 5-07)

Coverage of services, procedures in a SNF (New 12-01, update 11-05)

Glucose monitoring coverage in a SNF (New 1-07)

Centralized extended care service resource and care management

SNF Case Management (New 7-05)

ECS Resource Center Staff Forums and Grand Rounds

Skilled Nursing Facility (SNF) Spell of Illness Quick Reference Chart (New 2-07)

Tracking sheet

Strategic Initiative to Improve Triage Decisions

SNF Guidelines: Level of Care assignment

SNF Levels of Care for payment

Skilled Service Reimbursement, example language for agreements

Skilled Services; Scope of services by level

Transitional Care Unit Guidelines

Hospice (New 5-05, update 11-06)

Educational handout re: SNF care concerns

Defining Skilled Services

Skilled vs. unskilled nursing services (Updated 4-00, 3-05, 11-06, 3-07)

Physical Therapy Skilled Services - criteria

Skilled vs. unskilled physical therapy services

Occupational Therapy Services - example criteria

Skilled vs. unskilled occupational therapy services

Skilled vs. unskilled speech-language therapy services

Speech and Voice Therapy; guidelines (update 4-05, 11-05)

Skilled vs. non-skilled services criteria, examples

Custodial care (New 5-05)

Notes

Managing Extended Care Services

Service Standards and Procedures

Hospital Admission Review; LOS, Level of Care

Direct Admissions

Admission process for Extended Care Facility Patients

Voluntary Placement of Custodial Patients; admission from home

ECS ‘Against Medical Advice’ policy/procedure

Transfer from ECF to Acute Level of Care

ECS Clinicians ‘best practices’ for continuing care

Transitional Continuity of Care Plan

Discharge Planning, form (update 5-08)

Hospitalist program transition management (New 5-08)

Discharge planning resources (New 5-08)

ECF Discharge - home or residential care facility - also refer to form in Forms chapter

Acute Care to ECF - P & P

Podiatry services - foot and ankle care (update 1-09)

Chiropractic services (updated 12-01)

Notes

Acute Inpatient Rehabilitation

Introduction

Criteria for admission

Preadmission review for rehabilitation

Rehab criteria

Continued stay review

Discharge status review and criteria - refer to form in Forms chapter that follows

Case Mix, Severity Indices and Complexity of Care

Notes

Authorization/Continued stay criteria

Stroke/CVA

Spinal Cord Injury w. paraparesis/paraplegia; dorsal/lumbar

Spinal Cord Injury w. paraparesis/paraplegia; cervical

Amputation, lower extremity

Brain injury (TBI) (update 10-06)

Fracture of Femur/Hip/Arthroplasty

Pediatric Rehabilitation; Levels of care

Rehabilitation Benchmarks

Rehabilitation Benefits

Cardiac Rehabilitation - guideline - refer to Volume II

Notes

Forms

‘Patient Care Plan’ Authorization Form

Request for authorization to provide additional services

Physical Therapy Progress Note/Request for continuation

Referral Authorization, general format

UM form for Home Health, Oxygen and DME -also refer to following coverage guideline

Physical Therapy order forms

Discharge Planning Form (New 2-07)

Notes

Disposable Medical Supplies (DMS)/Durable Medical Equipment (DME)

Disposable medical supplies (DMS)

Diabetic supplies - refer to following Diabetic DMS/DME section under DME Introduction (update 5-05, 7-07)

Incontinence supplies (update 7-07)

Ostomy supplies (new 1-01, update 5-05, 7-07, 7-08)

Porcine Skin and Gradient Pressure Dressings, Medicare NCD (New 05-04) - refer to Plastic/Reconstructive Surgery section in Apollo’s Medical Review Criteria Guidelines for Managing Care Surgical dressings (New 5-05)

Tracheostomy care supplies (New 5-05)

Unna boot (update 5-05, 7-05)

Urological supplies (New 12-04, update 5-05, 2-06, 7-07, 4-08)

DMS Notes

Durable Medical Equipment (DME)

Definitions, Medicare Coverage Criteria for DME (rev 4-00, update 4-04 11-04, 4-05, 7-07)

Anodyne® Infrared (MIRE) Therapy (New 2-05, update 5-05, 10-05)

Apnea monitor - refer to criteria in the Pediatrics chapter Bathroom and Toilet Equipment and Supplies (new 1-01)

Commodes (new 1-01, update 5-05)

Beds/Pressure Reducing Support Surfaces - Introduction (new 06-01, update 5-05, 12-08)

Pressure Reducing Support Surfaces - Group 1 (new 06-01, update 5-05, 9-05)

Pressure Reducing Support Surfaces - Group 2 and 3 (new 06-01, update 5-05, update 9-05)

Air Fluidized Beds - (new 11-00, update 11-04)

Beds, hospital (update 4-05)

Bed Accessories including trapeze bars (new 11-00, 5-05)

Bed and Pillow Covers for Asthmatics (new 01-04)

Bed-wetting Alarm (new 2-01, update 12-04, 10-05)

Breast Pumps (new 2-01, update 6-05)

Cardiac defibrillators, external - refer to the cardiology chapter in Apollo’s Medical Review Criteria for Managing Care

Traction devices,

Cervical (new 1-01, update 9-04, 5-05)

Traction for low back pain (new 12-01, update 5-05, 11-05)

Vertebral decompression/Vertebral axial decompression therapy (New 4-05, update 11-05, 2-07, 11-08)

Chairs, therapeutic, specialized (new 1-01, update 5-05)

Specialized chairs used primarily for children (new 1-01, update 5-05)

Gravity lumbar reduction chairs (New 5-05)

Communication or Speech Generating devices/Voice Prosthesis: Refer to Vol. II. Speech-Language Therapy of Apollo’s Managing Physical/Occupational/Speech Therapy & Rehabilitation Care

Compression garments in the treatment of venous stasis ulcers (‘Jobst’) (new 07-03, update 4-05)

Continuous passive motion device (rev 4-00, update 11-04, 4-05, 9-05)

Cooling devices, external/Cold therapy (New 3-05, update 5-05, 11-05)

Cranial Orthotics - Remodeling Band/Helmet for infants with asymmetrical heads (new 1-01, update 11-04, 4-05, 10-05)

Diabetes mellitus related DMS/DME

Glucose monitors, blood and supplies (updated 1-04, 5-05, 12-07, 10-08)

Continuous Glucose Monitoring, overview - (New 11-01, update 1-04, 12-04, 10-05, 12-06, 7-07)

GlucoWatch® Biographer and other continuous monitoring devices - (New 4-01, update 4-03, 12-04, 10-05, 2-07)

H-wave stimulation for the treatment of diabetic neuropathy - refer to the electrical stimulators section that follows

Insulin Pens (update 6-00, 5-05)

Insulin Syringes (New 5-07)

Jet Injectors for Insulin Administration (update 4-00, 5-05)

Sleep sentry to detect hypoglycemia (update 4-00, 5-05)

Insulin Pumps

Shoes, therapeutic, for diabetics - refer to the Orthotics section that follows

Diathermy (New 7-07)

Electrical Stimulators - Refer to the following wound care DME guidelines and Skeletal-Muscular, Neurology/Neurosurgery, Pulmonary and Urology chapters in Apollo’s Medical Review Criteria for Managing Care for additional electrical stimulation guidelines.

Introduction/Limitations (New 6-01, update 9-05)

Dorsal Column Stimulators/Spinal Cord Stimulators: Chronic pain, Angina pectoris New 11-00, update 06-01, 5-05, 10-05)

Neuromuscular electrical stimulation (NMES) (update 04-03, 4-05, 5-05, 6-06, revised 5-07)

Electrical Stimulators for Levator Syndrome (New 06-01, update 5-05)

Transcutaneous electrical nerve stimulation (TENS) including TENS Supplies - Form-fitting Conductive Garment for TENS or NMES (updated 06-01, 11-04, 4-05, 9-05, 5-06)

ReliefBand (New 06-01, update 11-04)

‘Sympathetic Therapy’ (New 2-02, update 5-05)

Interferential/Inferential current stimulation/therapy (updated 06-01, update 12-04, 7-05, 5-06)

Pelvic Floor Electrical Stimulation, non-implantable (New 10-01, update 5-05)

Percutaneous electrical nerve stimulation (PENS)/Peripheral Neuromodulation (update 04-04, 9-05)

Peripheral Electrical Nerve Stimulation, Implanted (New 3-01, update 12-04, 5-05, 9-05)

Pulsed electrical stimulation/Pulsed signal therapy (New 11-04, update 9-05, 2-07)

Electrical Stimulation/Electro-magnetic Therapy for the Treatment of Wounds: Chronic Stage III & IV Musculo-Cutaneous Ulcerations (update 5-04, 5-05, 10-05)

Surface electrical muscle stimulation (New 10-01, update 11-04, 6-05)

H-wave stimulation for the treatment of diabetic neuropathy (update 11-04, 9-05)

Electrical Stimulation Notes

Environmental Control Systems (New 1-01, review 6-05)

Vaporizers (New 1-01, update 6-05)

Exercise Equipment (New 1-01, update 6-05)

Hearing aids - Introduction (reviewed 10-05)

Bone-anchored hearing aids/Implantable bone conduction hearing aids (update 12-02, 12-04, 10-05)

Pumps

Infusion pumps, external (update 4-04, 1-05, 4-05)

Infusion pumps, implantable (update 1-01, 11-04, 3-05, 7-05, 9-05)

Home uterine activity monitoring - refer to Ob/Gyn chapter

Intra-oral appliances for the management of headache syndromes, TMJ - refer to the ENT chapter of Apollo’s Medical Review Criteria for Managing Care Pulmonary/Respiratory DMS/DME - refer to Pulmonary chapter for additional guidelines

Airway Clearance/High Frequency Chest Wall Oscillation Devices (New 9-04, update 11-04, 4-05, 9-05)

Mechanical in-exsufflation/in-exsufflator devices (New 9-04, update 12-04)

Intrapulmonary Percussive Ventilator (IPV), Medicare NCD (New 5-04, update 12-04, 5-05)

Nebulizers (update 4-00, 5-05)

Oxygen coverage guidelines, outpatient (update 4-00, 9-04, 4-05, 9-05, 3-06)

Portable oxygen guideline (update 4-00, review 10-05)

o Oxygen for travel (New 5-05)

Peak expiratory flow meters (update 9-05)

Postural drainage boards - refer to ‘Standers, Boards and Tilt Tables’ criteria

Respiratory Assist Devices (New 2-01, update 5-05, 9-05)

Suction pumps (New 5-05)

Vaporizers - refer to preceding Environmental Control Devices section.

Jobst burn garments (update 4-00, update 4-05)

Lifts: Seat and Patient (New 1-01, update 5-05)

Light Emitting Diode (LED) or Infrared Therapy (New 12-04, update 12-06)

Light therapy/phototherapy for seasonal affective disorder (New 9-05, 4-06)

Lymphedema - refer to the Wound Care section that follows

Wound Care - refer to the preceding electrical stimulation & pressure-reducing support surfaces guidelines, Blood bank, General Surgery, Miscellaneous (Hyperbaric oxygen), and Pharmacy chapters in Apollo’s Medical Review Criteria for Managing Care for additional guidelines

Autologous blood-derived products for non-healing wounds (New 7-07, 4-08)

Electrical Stimulation/Electro-magnetic Therapy for the Treatment of Wounds: Chronic Stage III & IV Musculo-Cutaneous Ulcerations (update 5-04, 5-05, 10-05, 5-06)

Negative pressure wound therapy (NPWT)/Vacuum-assisted closure (New 07-03, update 4-05, 10-05)

Noncontact Normothermic Wound Therapy/Radiant Heat Wound Therapy Systems (New 12-04, update 4-05, 9-05)

1. Pneumatic Compression Therapy/Circulator Boot - End-diastolic for extremity ulcers, lymphedema/ Lymphedema ‘pump’/Manual lymph drainage (new 11-02, update 11-03, 10-05, 12-06, 4-07)

2. Wound care resources (New 12-04, update 10-05, 12-08)

Orthotic (braces) and Prosthetic Devices - review criteria (updated 9-04, 11-04, 2-05, 5-05, 10-05, 3-07, 11-08)

Prosthetics & orthotics ordered in a hospital or home prior to a skilled nursing facility admission - payment issues (New 1-09)

3. Aircast ankle brace (New 4-05)

4. Arm brace, robotic - post-stroke therapy (New 7-07)

5. Breast prosthesis, specialized bras for women post-mastectomy (New 2-05, update 5-05)

6. Canes & Crutches

7. Corset used as hernia support (New 05-04)

8. Dynamic or Progressive Stretch Splinting Devices (New 8-04, update 3-05, 9-05)

9. Elastic garments, non-covered (New 1-09)

10. Facial Prostheses (New 2-05, update 5-05)

11. Foot Orthotics; Shoes, Therapeutic/Footwear (updated 1-01, 11-04, 5-05, 6-05, 10-05, 10-08)

12. Hand Neuroprosthesis (New 10-05)

13. Knee braces (New 3-05, update 10-05, 2-07, 3-08)

Magnetic insoles for plantar heel pain (New 10-03)

14. Magnetic Pelvic Floor Stimulation (MPFS) for Incontinence (New 10-03, update 5-05, 10-05)

15. Myoelectric prosthesis, upper extremity (New 1-01)

16. Lower limb prostheses, above-knee, computerized (New 1-05, update 10-05, 2-07)

17. Prosthetic criteria: Functional levels (New 4-07)

18. Scoliosis Braces (New 6-05)

19. Shoe inserts to relieve back pain in patients with leg length discrepancies (New 11-05)

20. Spinal Orthoses - TLSO, LSO (New 5-05, update 10-05)

Spinal Unloading Devices (New 9-05)

Splints, Strapping & Casting (New 5-06)

Speech Generating Devices (New 4-06) Refer to volume II Speech of Apollo’s Managing Physical/Occupational/Speech Therapy & Rehabilitation Care manual Standers, Boards and Tilt Tables (new 06-01, review 6-05)

Support hose/TEDs (New 7-07)

Therabite® Jaw Motion Rehabilitation System (New 1-01, update 6-05, 7-07)

Vacuum therapy as a treatment for female sexual dysfunction (New 4-05, update 7-07)

Vest (formerly Thairapy vest) airway clearance system for cystic fibrosis - refer to preceding ‘Pulmonary’ DME section criteria Mobility Assistive Equipment (New 5-05)

Canes and crutches (New 5-05, update 10-05, 7-07, 2-08)

Strollers for special needs children (New 7-07)

Walkers/Safety Rollers (New 5-05, 10-05, 5-07)

Wheelchairs, Power-type and Power-operated vehicles (POVs) (New 12-03, update 11-04, 10-05, 7-07)

INDEPENDENCE iBOT 4000 Mobility System (New 5-07)

Wheelchair seats, cushions and back supports (New 9-04, update 4-05)

Anti-tipping device for power wheelchairs (New 9-08)

Whirlpool - refer to following table Wigs - refer to following table (update 11-04) DMS/DME Screening List (table) - Review criteria for 275 items (updated 9-04, 10-05, 12-07)

Reuse Information (notice 07-02)

Notes

Potpourri

Assessment of falls (New 5-05)

Common medical management issues

Claims review for extended care services

Preventive physical activity regimens

Resistance training for older individuals

Post-Work Injury Evaluation and Hardening

Handicapped Access Guidelines

SNF/Home Health Educational Brochure, example

Legal issues - elder abuse (New 3-05)

Legal Notes

Quality Assurance and Improvement

Quality Improvement guidelines/outcome studies

Hospital/SNF/Rehab QA Screens

Rehab Care; QI Indicators

Measuring satisfaction: post-acute facility care

Medical Record Review Tool; ECS

Site Survey Review Tool

Provider alerts to QA Committee representatives (New 1-06)

Urgent Complaint Resolution Policy for ECS

Quality Notes

Home Health Care - refer to additional home healthcare guidelines throughout the manual (section update 4-05, 7-06)

Introduction to Home Health/Hospice Services

Maternity and Newborn Care Services (update 11-04)

JCAHO Emergency Preparedness for Home Care (updated 4-04)

Utilization Management of Home Health Care (update 3-07)

Home Health/Hospice - Case Management - P & P

Homebound coverage criteria (updated 11-03)

Home health visits to a blind diabetic (New 5-07)

Home health nursing visits to patients requiring heparin injections (New 5-07)

Common reasons for failure of home health case management

Skilled Home Nursing Care/Private duty (added 07-01, update 7-05)

Home Nursing for Ventilator or C-PAP Patients (added 07-01)

‘Homebound’ program - Physician-directed

Homecare physician visits (updated 4-05)

Social Work Services, Home (New 8-04, update 7-05)

Home Care Plan Oversight (new 07-02)

Home Health Teaching Coverage (new 8-04, 1-07)

Home Healthcare referrals - processing

Termination of home healthcare services

Home health aides/assistants

Caregivers

Home health infusion services

Home ventilator management

Oxygen guidelines, home

National patient safety goals, home care and checklist

Hospice

Karnofsky Performance Scale

Patient choice and disclosure for selection of home health agency

Care plan oversight

Home healthcare for psychiatric services

Personal assistance services for ADL (New 10-08)

ND Home Health Quality Initiative -s

Home healthcare web sites - links

Home Care/Hospice Notes

Education - Clinical/Review Guidelines (section added 11-05)

Educational materials, introduction (update 10-04)

Home Health Care for Psychiatric Services - Medicare (added 10-01)

OBRA regulations (updated 10-01)

Home Ventilator Management (New 8-06)

Minimum Data Set for Patient Transfers (New 8-06)

Catheter Care and Feeding Tube Care Coverage (new 8-04)

Complex medication regimen supervision (new 8-04)

Wound care (new 8-04) - also refer to the DME chapter

Home Health Referrals - Processing (update 7-06)

Diabetes Self-management Training, Medicare coverage (added 07-01, update 6-04)

Pressure ulcers - prevention and care (new 5-05)

JCAHO National Patient Safety Goals (added 1-04, update 4-04)

Hospice; Hospice eligibility requirements/coverage (updated 3-07)

Hospice Care in the SNF (updated 1-02)

Hospice resource links (Update 3-07)

Caregivers (added 1-02, updated 08-02, 5-07, 1-08)

Home Health Aides/Assistants (rev 4-00)

Termination of Home Health Care Services

Home Health Infusion Services

Oxygen - Home risk management (refer to the DME chapter for oxygen criteria) (update 10-06)

Patient Education Materials - Development, Approval and Review P & P

Notes

References/resources - healthcare education programs

Institutional and Home Care Patient Education Programs, Medicare NCD (New 5-04)

“Self-care” or “Self-management” Educational Programs (New 5-07)

Diabetes Outpatient self-management training programs (New 5-07)

Education as a utilization strategy

Notes

Resources

LTC DRGs - Medicare Geometric Average Length of Stay

OBRA regulations

CMS SNF Manual, Chapter II, Coverage of Services

ECS Acronyms and Abbreviations

Types of facilities, definitions

Reference and Resource Lists

Resources

Web links: Geriatric, Medicaid, Medicare, Palliative care, Post-acute Care, Caregiver resources (update 3-07, 1-09)

Apollo Publication List

Abstract

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