For those of you that have heard me speak about Medicare, Therapy, Case Mix, MDS, PPS or simply my four daughters, there probably has never been a session that I do not utter my favorite words that “Nurses Rule the World!” Being intimately familiar with the day-to-day tasks (or should I say night-to-night tasks, as well) of patient care, medication administration, documentation, physician interactions, family discussions, caregiver communication, and so on, only one in the healthcare field sees the heart, sweat and tears this profession renders to their patient caseload. Too often, the value of the nursing profession is taken for granted, especially when they do their job well. Frequently, the field underestimates the complexity and finesse required to successfully care for the geriatric patient.
In a Skilled Nursing Facility, the care complexities are compounded by multiple insurance payers resulting in multiple insurance rules in which the nurse needs to be well versed. In particular, Medicare Part A has specific criterion that is “must learn” for every nurse caring for this population. A knowledge deficit directly impacts patient care and patient outcomes. Simply speaking, patient care lies in the hands of nursing. On average, 50% of patients discharged from their SNF Medicare Part A Benefit are discharged home. These discharges are critical because safety is paramount while hospital readmissions are an ongoing concern within the industry.
The following requirements are helpful to any provider of SNF Medicare Part A patients:
1. Remember, that skilled coverage occurs when the patient is skilled for a condition which was treated during a qualified stay…or… which arose while in a SNF for a treatment of condition for which the beneficiary previously was treated in a hospital.
- For Example: A Fractured hip patient who develops pneumonia secondary to immobility.
2. The patient requires Skilled Nursing Services or Skilled Rehabilitation Services (i.e., services that must be performed by or under the supervision of professional or technical personnel) (See §214.1 – 214.3). Although therapy can skill the Medicare Part A patient sans nursing, these scenarios are rare. It is the nurse that observes and assesses the patient 24 hours per day. It is the nurse that needs to anchor the skilled coverage and define what constitutes skilled coverage. It is the medical complexities that nursing must manage, which in turn support why the provision of skilled rehabilitation services can only be provided at the SNF (versus home).
3. The patient requires these skilled services on a daily basis (see §214.5).
4. As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in an SNF (see §214.6). In other words, home care, outpatient or another setting would not afford the patient proper care.
Other Requirements Include:
- Requires the skills of qualified technical or professional health personnel such as RN, LPN, PT, OT or SLP.
- Must be provided directly by or under the general supervision of a licensed nurse or skilled rehab personnel to assure the safety of the resident and to achieve the medically desired result.
- “General supervision” requires initial direction and periodic inspection of activity.
- Ordered by a physician.
- Services are needed and provided on a daily basis.
- The need for skilled care must be justified and documented in the medical record!
- Conditions may have prompted the initial hospitalization, but also include the conditions that arose during recovery in the SNF.
Details of Nursing Skills:
- Direct Skilled Nursing Services: Harmony (HHI) classifies these services as skilled “inherent complexities”. Meaning that they are not ambiguous. Such as IV feeding, IM or IV medication administration, tracheal or nasopharyngeal suctioning, tracheotomy care, ventilator support, daily care of extensive pressure ulcers or widespread skin disorders, tube feedings, respiratory therapy, unstable clinically with diabetes and injections, colostomy care, early post-operative care to assess for complications, along with irrigation, replacement or insertion of suprapubic catheters.
- Management and Evaluation of a Care Plan: This criterion applies to daily nursing oversight to ensure medical safety and to promote recovery.
- Observation and Assessment: When the daily oversight is needed for a nurse to identify signs and symptom related to an exacerbation of the skilled diagnoses, this criterion applies.
- Teaching and Training: Activities which require skilled nursing or skilled rehabilitation personnel to teach a patient and/or family member how to manage the patient’s treatment regimen.
In conclusion, be sure to pass this on to all of the nurses that may need a refresher in the complexities of Medicare reimbursement. Although the rules change frequently, the above mentioned requirements have been the foundation of the program since the late 1960’s.
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Do your medical records support skilled care?