Transcript Skilled Nursing Facility

Medicare, Medicaid, and
Discharge Planning
J. Marvin McBride, MD, MBA
The University of North Carolina at Chapel Hill
With Support from The Donald W. Reynolds Foundation and The John A.
Hartford Foundation
© The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights
Reserved.
Learning Objectives
• Review a few key elements of Medicare and
Medicaid eligibility and benefits
• Distinguish between Inpatient and
Observation status for Medicare patients
• Be able to clearly state a patient’s discharge
needs
• Know the various discharge options and the
key differences between them
• Apply the criteria for Medicare coverage of
various discharge options
Medicare: Eligibility
• Aged:
» > 65 years old
» US citizen OR
• legal resident for at least 5 years
» Paid “Medicare tax” for at least 10 years OR
• spouse paid for at least 10 years
• Disabled
» Receiving Social Security Disability
Insurance (SSDI) benefits
• ALS: immediately
• ESRD: immediately – 4 months depending on
treatment
• Other disabilities: 24 months
Medicare Part A: Patient Cost*
• Inpatient:
» Deductible: $1132 for first 60 days
» Coinsurance:
• $283/day for days 61-90
• $566/day for days 91-150
• 100% for days > 150**
•
SNF:
http://ofifice.microsoft.com
» Coinsurance
• $141.50/day for days 21-100
• 100% for days > 100
• Per “episode” - reset if > 60 days without
facility-based skilled care***
NC Medicaid: Eligibility for Aged,
Blind or Disabled*
• Income:
» If receiving Supplemental Security Income (SSI),
qualify automatically
» Otherwise, monthly income cannot be >
$973 for 1
$1,311 for 2
• Assets:
» Assets do NOT include: home, a car, home furnishing,
clothing and jewelry**
< $2000 for 1
< $3000 for 2
• If high medical expenses, but income or assets >
limit, may qualify with a “Medicaid deductible” aka
“spend-down”
Case 1: Ms. Mildred
http://office.microsoft.com
© Annie Levy, 2008
• 76 woman trips over her Pomeranian landing
on her buttock with immediate pelvic pain.
Brought to ED and found to have a nondisplaced pubic ramus fracture. No other
injuries.
• PMHx: Mild memory impairment, HTN,
hypothyroidism, osteopenia. Meds:
olmesartan/HCTZ, L-thyroxine.
• Soc Hx: Retired bookkeeper, widowed. Lives
alone in a single story house, 2 steps to
enter. Active in church & bridge club, has
family in area.
Case 1: Ms. Mildred
http://office.microsoft.com
© Annie Levy, 2008
• Baseline functional status: Ambulates with
single point cane, otherwise independent in
caring for herself, does not drive, daughter
helps w/ shopping, finances.
• Exam: Vital signs stable, pelvic tenderness,
otherwise unremarkable. Labs: Unremarkable.
• ED requests admit to general medicine service
Inpatient
or
Observation
?
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Inpatient vs. Observation
• Medicare only pays for inpatient status when
the patient meets “medical necessity” criteria
• Criteria are licensed from McKesson’s
InterQual®, details are involved, proprietary,
and diagnosis-specific, but based on:
» Intensity of Service
» Severity of Illness
Inpatient vs. Observation
• Essentially, if the patient needs services that
can typically only be provided in a hospital,
they will meet inpatient criteria. Examples:
most surgery, BiPAP or mechanical
ventilation, emergency dialysis, parenteral
meds
• If you are watching the patient to make sure
they don’t need intense services or develop
severe illness, they should be on observation
status. Examples: chest pain, abdominal
pain, transient neurological sxs
Is It Inpatient vs. Observation ?
1. Atypical chest pain in low-risk patient: serial
ECGs and cardiac enzymes, telemetry.
2. Typical chest pain in high-risk patient: serial
ECGs and cardiac enzymes, telemetry,
heparin drip.
3. Acute abdominal pain, fever, hypotension,
altered mental status in patient w/ Hep C
cirrhosis, ascites: diagnostic paracentesis,
IV fluids and antibiotics.
Ms. Mildred
http://office.microsoft.com
© Annie Levy, 2008
• Pain adequately controlled w/ p.o. pain meds
• Ortho consult: surgery not indicated. Recs –
weight-bearing as tolerated, pain mgmt
 Observation status
• PT eval: needs assistance with getting out of
bed, standing, walking 4 feet
• Daughter works, can’t take patient home
Discharge
Needs
?
13
(Basic) Activities of Daily Living
• Toileting
• Feeding
• Dressing
• Grooming
• Ambulation
• Bathing
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Instrumental ADLs
• Ability to Use Telephone
• Shopping
• Food Preparation
• Housekeeping
• Laundry
• Mode of Transportation
• Responsibility for Own Medications
• Ability to Handle Finances
15
Discharge Needs: Category
• Custodial - food, clothing, shelter,
personal hygiene, supervision
Think healthy newborn baby
vs.
http://office.microsoft.com
• Skilled - services of a licensed health care
worker
» Nursing – RN, LPN, LVN
• Not CNA, Med Tech
» Rehab – PT, OT, ST
• Not rehab aide, CNA, transporter
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Skilled Nursing Services
Examples:
• Injectable medication administration
• Tube feedings (for new G-tube)
• Nasopharyngeal and tracheostomy aspiration
• Catheter changes
• Wound care (wound vac, Stage II+ press. ulcer)
• Ostomy care (for new stoma)
• Monitoring/adjusting medical gases
• Psychiatric evaluation, therapy, and teaching
• Teaching and training pt and caregivers
• Skilled observation and assessment
• Mgmt and evaluation of a patient care plan
Skilled Rehabilitation Services
• Illness or injury has resulted in significant
loss of function
• Significant improvement in function is
expected as the result of rehabilitation
services that would not be expected to
occur spontaneously
• Services are required that can only be
provided by a licensed therapist
Jimmo vs. Sebelius settlement (1/24/13) clarified
that reaching “plateau” does not automatically
mean further rehab services are not covered*
Skilled Needs: Intensity
• Acute: 3 hrs/d, 5 days/wk
• Daily: 1 hr/d, 5 days/wk
• Intermittent: at least once/60 days
typically < 3d/wk,
(though can be daily for short periods)
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Ms. Mildred
http://office.microsoft.com
© Annie Levy, 2008
• Status: observation
• Needs: custodial (“non-skilled”) only
• Discharge options:
» Home
• Independent (no services)
• Personal care services
• Home health services
» Assisted Living Facility (Adult Care Home)
» Long-Term Care Facility (Nursing Home)
» Skilled nursing facility (SNF)
Personal Care Services
• Feeding
• Bathing
• Dressing
• Personal hygiene
• Assistance w/ transfers, positioning
• Supervision
• Medication administration
• Light housecleaning
• Cooking/shopping for food
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Personal Care Services
Provided by:
»
»
Family, friends, volunteers
Paid caregivers
•
•
Agencies
Free-lance
Covered (paid for) by:
»
»
»
Patient/family
LTC Insurance
Medicaid
Generally NOT covered by Medicare*
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Home Health Services
• Skilled nursing
» General med/surg nursing
» Wound care
» Psych nursing
• Skilled rehab
»
»
»
»
Initial evaluation (PT, SLP)
Continuing OT
Therapeutic exercises
Periodic re-eval
• “Home” can be private residence or ALF
26
Home Health Services
• Provided by:
» Medicare-certified, state-licensed Home
Health Agencies
» Not all provide all services, may sub-contract
• Covered (paid for) by:
» Medicare if:
• Medicare beneficiary
• Home-bound
• Intermittent skilled need
» Medicaid if:
• Medicaid beneficiary
• No other coverage
27
CMS Definition of "Homebound"
• There exists a normal inability to leave home
and, consequently, leaving home would
require a considerable and taxing effort
• Generally speaking, a patient is considered
homebound if they have a condition or
illness that restricts their ability to leave their
residence w/o assistive devices (cane,
crutches, w/c, walker); special transportation;
or the assistance of another person, or if
leaving home is medically contraindicated.
CMS Definition of "Homebound"
If the patient does in fact leave the home,
absences are infrequent or for periods of
relatively short duration, or are attributable to
the need to receive health care treatment, such
as:
• Attendance at adult day centers to receive
medical care
• Dialysis
• Chemotherapy or radiation therapy
Assisted Living Facility
Services:
• Room & board
• Supervision
• Medication Administration
• Limited personal care services
» Laundry
» Housekeeping
» Vital signs
• Local scheduled transportation
Exact services provided and costs vary
30
Assisted Living Facility*
• Residential, not nursing/medical facilities
• Main staff are “Med Techs” – can administer
meds and take vital signs, cannot take
verbal orders or use discretion re: prn meds
• May or may not have a nurse on staff**
• May have a “Special Care Unit” – secure
area w/ additional personal care services –
aka “Memory Care” or “Dementia Unit”
• Rarely have physicians that come to facility
• Patients must have a primary care
physician, but the facility does not have to
get approval for orders from other providers
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Assisted Living Facility
Covered (paid for) by:
• Patient/family
• LTC Insurance
• Medicaid if:
» Medicaid beneficiary
» Meets state criteria for NH placement
(needs assistance w/ 2 or more ADLs)
» State has a waiver for ALF in lieu of NH & pt
qualifies for waiver
Facility fees are NOT covered by Medicare
(physician & HH services, DME are covered)
Hospice can provide services to ALF residents 32
Long-Term Care Facility
• Synonyms: Nursing Home1, Extended Care,
Intermediate Care, Custodial Care
• Licensed by state, most certified by Medicaid
• Every patient has an attending physician, who
must see the patient at least q 60 days –
typically on-site
• Main staff are Certified Nursing Assistants
(CNAs)
• At least one licensed nurse/shift
• Lab available, X-ray may be*
• Nurses can take verbal orders
33
Long-Term Care Facility
Services:
• Room & board
• Supervision
• Medication administration
• Assistance w/ feeding
• Assistance w/ personal hygiene
• Transfers/positioning
• Vital signs
• Transportation to medically necessary
physician visits/tests
34
Long-Term Care Facility
Covered (paid for) by:
• Patient/family
• LTC Insurance
• Medicaid if:
» Medicaid beneficiary
» Meets state criteria for NH placement
(requires assistance w/ 2 or more ADLs)
Facility fees NOT covered by Medicare
(physician & HH services, DME are covered*)
Hospice can provide services to LTC residents
35
Skilled Nursing Facility
Services:
• Room & board
• Supervision
• Personal care services
• Skilled nursing
• Skilled rehab therapy
• Meds (including IVs)
• Transportation to medically necessary
physician visits/tests
36
Skilled Nursing Facility
• Licensed by state, most certified by Medicare,
many certified by Medicaid
• Main staff are CNAs
• At least one licensed nurse/shift
• PT/OT/ST on site
• Labs available, mobile x-ray may be
• Attending physician must see the patient w/i
30 days, then every 30 days for 1st 90 days*
• Paid a daily rate by CMS – must provide all
covered services out of that – may not be
willing to take a patient they expect to cost
more than they are paid (expensive meds,
dialysis, Clinitron bed)
37
Skilled Nursing Facility
Covered (paid for) by:
- Medicare if:
» Medicare beneficiary
» 3 day qualifying stay (inpatient for at least 3
midnights w/i 30 days of SNF admission*
» Dx for SNF admission is the same/related to
dx for acute inpt stay
» Skilled nursing or rehab need
- Medicaid if
» Medicaid beneficiary
» No other coverage
- Other insurance - varies
- Self-pay – theoretically**
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SNF: Medicare Details
• Observation days DO NOT COUNT towards
the 3 day qualifying stay
• Patient financial responsibility:
» No copay for 1st 20 days
» $148/d for days 21-100
• Coverage limit of 100 days per “benefit
period”
• Benefit period reset if > 60 days w/o facilitybased (hospital or SNF) care
• Hospice and SNF generally not compatible1
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Ms. Mildred
http://office.microsoft.com
© Annie Levy, 2008
• Status: observation
• Needs:
» Mainly custodial
» Intermittent skilled nursing (is home-bound)
• Discharge options:
» Medicare won’t cover SNF (no qualifying stay)
» Doesn’t have Medicaid
» Home w/
• Home Health (Medicare)
• 24/7 care by family/friends and paid caregivers
(self-pay)
» ALF (self-pay) w/
• Home Health (Medicare)
Case 2: Ms. Nellie
http://office.microsoft.com
http://www.imagingpathways.health.wa.gov.au
Julie Turkewitz, 2012
• 76 woman trips over her Pomeranian landing
on her buttock with immediate groin pain.
Brought to ED and found to have a nondisplaced right femoral neck fracture. No
other injuries.
• PMHx: Mild memory impairment, HTN,
hypothyroidism, osteopenia. Meds:
olmesartan/HCTZ, L-thyroxine.
• Soc Hx: Retired retail clerk, widowed. Lives
alone in a single story house, 2 steps to
enter. Active in church & garden club, has
family in area.
Case 2: Ms. Nellie
http://office.microsoft.com
Julie Turkewitz, 2012
• Baseline functional status: Ambulates with
single point cane, otherwise independent in
caring for herself, does not drive, daughterin-law helps w/ shopping, finances.
• Exam: Vital signs stable, externally rotated
right leg, otherwise unremarkable. Labs:
unremarkable.
• Ortho consult: ORIF planned tomorrow am
• Inpatient or observation status?
Ms. Nellie
http://office.microsoft.com
Julie Turkewitz, 2012
• Inpatient status
• Internal fixation with screw of her hip fracture
next day
• PT eval post-op: needs assistance with
getting out of bed, standing, walking 4 feet
• Hgb drops to 9.4, then stable
• PCA opiods for 1st 24 hrs post-op, p. o. pain
meds adequate after that
• A little confused after pain meds
• Daughter-in-law works, can’t take her home
Needs?
Ms. Nellie
http://office.microsoft.com
Julie Turkewitz, 2012
Needs:
• Personal care services
• Skilled nursing
(monitor delirium, pain meds)
• Skilled rehab services
(has lost function as a result of injury, is
expected to improve significantly w/
PT/OT)
Discharge Options?
44
Ms. Nellie
http://office.microsoft.com
Julie Turkewitz, 2012
• Meets Medicare criteria for SNF coverage
»
»
»
»
Has Medicare
Has qualifying stay
Has skilled need
Dx for SNF is the same as for inpt stay
• However, pt/family don’t like the idea of her
going to a “nursing home”, prefer to go to the
Rehab Hospital where her husband went
after his hip replacement 10 years ago.
45
Inpatient Rehabilitation Facility
• Synonyms:
Acute Inpatient Rehab (AIR)
Rehab Hospital
• These may be housed w/i the same brick
and mortar as a general med/surg hospital,
or may be a stand-alone building, but are
considered separate entities
•
Services:
» Attending physician is required to see the
patient at least 3d/wk
» Nursing (usually won’t take IVs)
» Rehabilitation therapy
» Labs, x-ray, etc.
46
Inpatient Rehabilitation Facility
a.k.a. Acute Inpatient Rehab
• “The complexity of the patient’s nursing,
medical management, and rehabilitation
needs requires an inpatient stay and an
interdisciplinary team approach to care.”
• Must be able to participate in 3 hours of
therapy a day in at least 2 disciplines:
PT/OT/ST
• Inpatient care must be medically necessary
AIR / IRF
• Patient financial responsibility (Medicare):
» Part A deductible (once per benefit period)
» 20% of Part B charges
• @ UNC: “OK if no insurance – just needs
firm dispo”
• Private insurance requires preauthorization
• Central-Eastern NC:
» Chapel Hill, Durham, Raleigh, Greensboro,
Fayetteville, Greenville, Cape Fear1
• Not compatible w/ hospice
Ms. Nellie
http://office.microsoft.com
Julie Turkewitz, 2012
• Meets Medicare criteria for SNF coverage
»
»
»
»
Has Medicare
Has qualifying stay
Has skilled need
Dx for SNF is the same as for inpt stay
• Doesn’t meet Medicare criteria for medical
necessity of AIR – may or may not be able to
complete 3 hours therapy per day (probably
not), but doesn’t have complex medical and
rehab needs, and would be expected to have
similar outcomes whether sent to SNF or
AIR.
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Case 3: Ms. Beatrice
http://office.microsoft.com
Annie Levy 2010
• 76 woman is walking her Pomeranian which
chases a chipmunk, pulling her into the
street where she is struck by a passing car.
In ED found to have a subdural hematoma,
multiple rib and long-bone fractures, and a
ruptured spleen.
• PMHx: HTN, hypothyroidism, osteopenia.
Meds: olmesartan/HCTZ, L-thyroxine.
• Soc Hx: Retired school teacher, divorced.
Lives alone in a single story condo, 2 steps
to enter. Active in politics and women’s
issues, has family in state, but not locally.
Case 3: Ms. Beatrice
http://office.microsoft.com
Annie Levy 2010
• Baseline functional status: Ambulates with
single point cane, otherwise independent,
including driving.
• Emergent cranial decompression and
splenectomy, admitted to SICU on
ventilator support with multiple long bone
splints.
• 2 weeks into the hospital course, she is
conscious and medically stable, but unable
to be weaned from ventilator, and
cognitively impaired (though improving).
May need orthopedic surgery later.
Ms. Beatrice: options
1. Meets criteria for SNF, but SNF unable to
provide intensity of care that she needs
2. Not appropriate for Acute Rehab – AIR
unable to provide intensity of care that she
needs, and pt not yet able to participate in
intense rehab
3. Continued stay in current location
4. Long-term acute care hospital
55
Long Term Acute Care Hospital
• Specialty hospitals that specialize in patients
that need prolonged acute care.
• Medically complex, multi-trauma, multiple
complication patients.
• Intensive medical mgt, vent weaning,
dialysis, IV abx, wound care, basic
rehabilitation
• Physician visits 3x/wk min
• Up to 1 hour of PT/OT per day
LTACH
• Patient financial responsibility:
» Part A deductible (once per benefit period)
» 20% of Part B charges
• Medicare or Private insurance only
Self pay or Medicaid need not apply
• Central/Eastern NC*:
»
»
»
»
»
Select Specialty Hospital, Durham
Select Specialty Hospital, Winston-Salem
Kindred Hospital, Greensboro
Lifecare, Rocky Mount
Highsmith Raney, Fayetteville
Post-Acute Care and
Rehabilitation
Inpatient Rehab
Long Term Acute
Care Hospital
Acute
Home
(incl. ALF)
w/ HHA or
Outpt Tx
SNF
LTC
Hospice
D/C Planning for Medicare Pts
1. Does pt have skilled needs?
A. Nursing
B. Rehab
2. What is the intensity of the need?
A. Acute
B. Subacute
C. Intermittent
3. Did pt have a 3-day inpatient stay?
4. Will pt be home-bound upon d/c?
63
Questions?
References
•
Medicare and You 2014. Center for Medicare and Medicaid Services.
•
“Medicaid in NC” – NCMJ Special Supplement, Vol 74, March 2013
http://www.ncmedicaljournal.com/wp-content/uploads/2013/03/NCMJ_74-supplement.pdf
•
NC Medicaid ABD eligibility criteria: http://www.ncdhhs.gov/dma/medicaid/abd.htm
•
InterQual: http://www.mckesson.com/about-mckesson/our-company/businesses/mckessonhealth-solutions/interqual-decision-support/
•
Lawson MP, Brody EM. Assessment of older people: self-maintaining and instrumental
activities of daily living. Gerontologist 1969, 9: 179-186
•
CMS: Medicare Policy Benefit Manual: http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.html
•
CMS: State Operations Manual, Chapter 7 – Survey and Enforcement Process for Skilled
Nursing Facilities and Nursing Facilities: http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS1201984.html
•
“ 65%, 13 Conditions” : Code of Federal Regulations, Title 42, Section 412.23 (b)(2)(ii)
65
Acknowledgements and Disclaimer
This project was supported by funds from The Donald
W. Reynolds Foundation. This information or content
and conclusions are those of the author and should not
be construed as the official position or policy of, nor
should any endorsements be inferred by The Donald
W. Reynolds Foundation.
The UNC Center for Aging and Health, the UNC
Division of Geriatric Medicine and the Department of
Family Medicine also provided support for this activity.
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©2014 The University of North Carolina at
Chapel Hill, Center for Aging and Health.
All Rights Reserved.
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