ParaRegs-Medi-Cal-Level-of-Care

Code

Effective

ParaReg Text

550-1



In order to qualify for Skilled Nursing Facility services, a patient shall have a medical condition which needs visits by a physician at least every 60 days and constantly available Skilled Nursing services.

 

The following criteria, together with the provisions of §51124, are used in determining appropriate placement.  This section provides that the following criteria are used:

 

(1)        Need for patient observation, evaluation of treatment plans, and updating of medical orders by the responsible physician.

 

(2)        Need for constantly available Skilled Nursing services.  A patient may qualify for nursing home services if the patient has one or more of the following conditions:

 

(A)       A condition which needs therapeutic procedures.  A condition such as the following may weigh in favor of nursing home placement:

 

1.         Dressing of postsurgical wounds, decubiti, leg ulcers, etc.  The severity of the lesions and the frequency of dressing will be determining factors in evaluating whether they require nursing home care.

 

2.         Tracheostomy care, nasal catheter maintenance.

 

3.         Indwelling catheter in conjunction with other conditions.  Its presence without a requirement for other Skilled Nursing care is not a sufficient criterion for nursing home placement.

 

4.         Gastrostomy feeding or other tube feeding.

 

5.         Colostomy care for initial or debilitated patients.  Facilities shall be required to instruct in self-care, where such is feasible for the patient.  Colostomy care alone should not be a reason for continuing nursing home placement.

 

6.         Bladder and bowel training for incontinent patients.

 

(B)       A condition which needs patient Skilled Nursing observation.  Patients whose medical condition requires continuous Skilled Nursing observation of the following may be in a nursing home dependent on the severity of the condition.  Observation must, however, be needed at frequent intervals throughout the 24 hours to warrant care in a nursing home:

 

1.         Regular observation of blood pressure, pulse, and respiration is indicated by the diagnosis or medication and ordered by the attending physician.

 

2.         Regular observation of skin for conditions such as decubiti, edema, color, and turgor.

 

3.         Careful measurement of intake and output as indicated by the diagnosis or medication and ordered by the attending physician.

 

(C)       The patient needs medications which cannot be self-administered and requires Skilled Nursing services for administration of the medications.  Nursing home placement may be necessary for reasons such as the following:

 

1.         Injections administered during more than one nursing shift.  If this is the only reason for nursing home placement, consideration should be given to other therapeutic approaches, or the possibility of teaching the patient or a family member to give the injections.

 

2.         Medications prescribed on an as needed basis.  This will depend on the nature of the drug and the condition being treated and frequency of need as documented.  Many medications are now self-administered on a PRN basis in Residential Care Facilities.

 

3.         Use of restricted or dangerous drugs, if required more than during the daytime, requiring close nursing supervision.

 

4.         Use of new medications requiring close observation during initial stabilization for selected patients.  Depending upon the circumstances, such patients may also be candidates for intermediate care facilities.

 

(D)       A physical or mental functional limitation.

 

1.         Physical limitations.  The physical functional incapacity of certain patients may exceed the patient care capability of intermediate care facilities.

 

a.         Bedfast patients.

 

b.         Quadriplegics, or other severe paralysis cases.  Severe quadriplegics may require demanding attention (skin care, personal assistance, respiratory embarrassment) as to justify placement in nursing homes.

 

c.         Patients who are unable to feed themselves.

 

2.         Mental limitations.  Persons with a primary diagnosis of mental illness (including mental retardation) when such patients are severely incapacitated by the condition. The following criteria are used when considering the type of facility most suitable for the mentally ill and mentally retarded person where care is related to his mental condition:

 

a.         The severity or unpredictability of the patient's behavior or emotional state.

 

b.         The intensity of the care, treatment. services, or skilled observation his condition requires.

 

c.         The physical environment of the facility, its equipment, and the qualification of its staff.

 

d.         The impact of the particular patient on other patients under care in the facility.

 

(§51335(j))

550-3



The Skilled Nursing Facility level of care is the level of care needed by Medi-Cal beneficiaries who do not require the full range of health care services provided in a hospital acute care or hospital extended care facility, but who require the continuous availability of Skilled Nursing care provided by licensed, registered or vocational nurses, or the equivalent thereof. (§51124(b))

550-4



In order to qualify for intermediate care services, a patient shall have a medical condition which needs an out-of-home protective living arrangement with 24-hour supervision and Skilled Nursing care or observation on an ongoing intermittent basis to abate health deterioration.

 

Intermediate care services emphasize care aimed at preventing or delaying acute episodes of physical or mental illness and encouragement of individual patient independence to the extent of his/her ability.  As a guide in determining the need for intermediate care services, the following factors may assist in determining appropriate placement:

 

(1)        The complexity of the patient's medical problems is such that the patient requires Skilled Nursing care or observation on an ongoing intermittent basis and 24-hour supervision to meet his/her health needs.

 

(2)        Medications may be mainly supportive or stabilizing but still require professional nurse observation for response and effect on an intermittent basis.  Patients on daily injectable medications or regular doses of PRN narcotics may not qualify.

 

(3)        Diet may be of a special type, but the patient needs little or no assistance in feeding himself/herself.

 

(4)        The patient may require minor assistance or supervision in personal care, such as in bathing or dressing.

 

(5)        The patient may need encouragement in restorative measures for increasing and strengthening his/her functional capacity to work toward greater independence.

 

(6)        The patient may have some degree of vision, hearing or sensory loss.

 

(7)        The patient may have some limitation in movement, but must be ambulatory with or without an assistive device such as a cane, walker, crutches, prosthesis, wheelchair, etc.

 

(8)        The patient may need some supervision or assistance in transferring to a wheelchair, but must be able to ambulate the chair independently.

 

(9)        The patient may be occasionally incontinent of urine; however, a patient who is incontinent of bowels or urine may qualify for intermediate care service when the patient can care for himself/herself.

 

(10)      The patient may exhibit some mild confusion or depression; however, his behavior must be stabilized to such an extent that it poses no threat to the patient or others.

 

(§51334(l))

550-5



Intermediate care services are services provided in hospitals, Skilled Nursing Facilities or intermediate care facilities to patients who: require protective supportive care, because of mental or physical conditions or both, above the level of board and care; do not require continuous supervision of care by a licensed, registered or vocational nurse except for brief spells of illness; do not have an illness, injury, or disability for which hospital or Skilled Nursing Facility services are required. (§51120(a))

550-6



"Nonmedical out- of-home care" is protective living arrangement outside the individual's own home where, as a minimum, he/she receives board, room, and personal nonmedical care and supervision related to his/her individual needs. (Manual of Policies and Procedures §46-140.1)