Private Duty Nursing (PDN) Eligibility Determination Workshop A refresher course for current PIHP Nurses and initial training for new PIHP Nurses
Presenters: Linda Fletcher, RN, MS, CPNP Deb Ziegler, HSW Program Manager 2
Training Session Dates Thursday, August 23 1:00pm- 3:00pm -or- Thursday, August 30 9:30am- 11:30am Register for only one session. The same information will be given at both sessions. Once you ve registered, you ll receive a confirmation email with the link to the webinar and conference line. 3
Goal To assure consistent implementation of the Private Duty Nursing (PDN) state plan policy for waiver enrollees under age 21 and Habilitation Supports Waiver (HSW) policy for HSW enrollees 21 and older. 4
Objectives Review the essential components of the PIHP Nursing Assessment. Review Medical Criteria I, II, and III. Understand the differences between the State Plan policy and HSW policy. Review the PDN Eligibility Determination Worksheet. Identify the importance of integrating the health care plan in to the IPOS/PCP. Train one independent RN for each CMHSP/PIHP to complete the initial PDN eligibility assessment and an annual update to assure the need for continued PDN services. 5
Essential Components of the PIHP Nursing Assessment: Occurs in the person s home prior to the annual IPOS if possible. PIHP assessment is completed by an independent R.N. (not employed by PDN agency) Includes person, parents, case manager or supports coordinator, etc. Medical record review Nursing record review 6
Use of PIHP Nursing Assessment Determine initial eligibility for PDN. Confirm ongoing eligibility by completing an annual update and an update when conditions change. Provide the basis for the narrative documentation for the PDN eligibility determination summary and recommendations. Identify needs that must be addressed on the IPOS 7
Private Duty Nursing For a person under age 21: PDN IS a Medicaid State Plan Service, meaning Medicaid pays Fee-For-Service directly to the nursing agency or independent nurse. PDN under age 21 is not funded by CMH or PIHP and is not reported as encounters. The State Plan policy applies. PDN is not a Children s Waiver (CWP) or HSW Service, but is authorized by the CMHSP/PIHP in the CHAMPS Prior Authorization Section. The CMHSP or PIHP is also responsible for overseeing the IPOS including the nursing care plan & delivery of PDN. 8
Private Duty Nursing For a person age 21 and over : PDN is NOT a Medicaid State Plan Service, meaning Medicaid does not pay Fee-For-Service directly to providers. For HSW enrollees, PDN is reported as encounters. The individual nurse or agency must be enrolled in the provider network and is paid through the PIHP. It is a waiver service through the HSW or MI Choice Waiver Program. Any Medicaid beneficiary age 21 and older who needs PDN in an unlicensed setting must enroll in one of the waivers. If enrolled in HSW, the policy is the HSW Service Description. 9
Private Duty Nursing PDN is for people who require ongoing skilled nursing care on a daily basis to remain at home in the community. The home must be unlicensed (not a group home). PDN must be ordered and provided under the direction of a physician. The person must meet eligibility criteria for PDN as defined in the Medicaid Provider Manual. 10
Private Duty Nursing is NOT: PDN is not intermittent skilled nursing care If intermittent, periodic nursing assessments, judgments, interventions are needed Home Health benefit Health Assessment (as a CMHSP covered service) PDN is not stand-by care in the event someone might need nursing care PDN is not assistance with personal care or activities of daily living If these are the assessed service needs, they can be met by other Medicaid covered services DHS authorized home help services Home Health aide-level services Community Living Services 11
PDN Eligibility Meets medical eligibility criteria Requires continuous skilled nursing assessments and care, on a daily basis, during the time the nurse is authorized to provide care. Meets general eligibility criteria Medicaid eligible in the home setting and PDN can be safely provided in the home PDN is the appropriate service to meet assessed needs in the home setting. Is dependent on medical technologies to sustain life. 12
PDN Process Complete PIHP/CMHSP Nursing Assessment Determine Eligibility for PDN (see Handout PDN Eligibility Determination Worksheet) Determine Intensity of Care State Plan only HSW - can use as a guide Determine Amount of Hours using the Decision Guide (see Handout) & PCP Process Decision Guide is required by State Plan only NOTE: for people 18 and older, cannot require parents to provide 8 hours of care Submit Written Documentation to Case Manager/Supports Coordinator for inclusion in the IPOS through the PCP Process 13
Documentation to Submit to MDCH CWP ONLY Initial Eligibility and Annually thereafter: PDN Eligibility Determination Worksheet Health Care Plan Copy of Physician s Order for PDN specifying the skilled nursing assessments, interventions, judgments, etc., e.g., how deeply the person must be suctioned. A prescription for skilled nursing is insufficient documentation. Two weeks of recent nursing notes Copy of the IPOS REMEMBER: Children enrolled in CWP must receive active treatment. People enrolled in the HSW must receive habilitation services in addition to PDN. 14
Change in Documentation Requirements HSW ONLY The PIHP no longer submits documentation to MDCH for review and concurrence. Documentation should still be completed & kept on file. If the PIHP nurse needs technical assistance or has questions, MDCH staff is available. 15
PDN Eligibility For initial decision Meets Medical Criteria I and III or Medical Criteria II and III (Reference PDN policy) For annual decision Meets Medical Criteria I and III or Medical Criteria III, if initial decision was based on Medical Criteria II and III 16
Medical Criteria There are two policies with which you must be familiar State Plan PDN policy applies for any assessments you will do for CWP or HSW enrollees who are under age 21 HSW PDN service description applies for enrollees in HSW age 21 and older Both policies are located in the Medicaid Provider Manual 17
Medical Criteria I The beneficiary is dependent daily on technologybased medical equipment to sustain life. State Plan policy and HSW policy both have 5 bullets to describe what it means to be dependent daily on technology-based medical equipment ; HOWEVER, there are differences between the State Plan policy and HSW policy in some of those bullet points 18
Medical Criteria I (Bullet #1) State Plan Policy: Mechanical ventilation four or more hours per day or assisted respiration (Bi-PAP or CPAP); HSW Policy: Mechanical rate-dependent ventilation (four or more hours per day) or assisted ratedependent respiration (e.g., some models of Bi-PAP); Interpretation: Rate dependent Mechanical Ventilation four or more hours per day or assisted ratedependent respiration (e.g., some models of Bi-PAP or CPAP); or 19
Medical Criteria I (Bullet #2) State Plan Policy: Oral or tracheostomy suctioning 8 or more times in a 24-hour period; HSW Policy: Deep oral (past the tonsils) or tracheostomy suctioning 8 or more times in a 24-hour period Interpretation: Deep oral (past the tonsils) or tracheostomy suctioning 8 or more times in a 24-hour period. or 20
Medical Criteria I (Bullet #3 & #4) State Plan and HSW Policies: Nasogastric tube feedings or medications when removal and insertion of the nasogastric tube is required, associated with complex medical problems or medical fragility; or State Plan and HSW Policies: Total parenteral nutrition delivered via a central line associated with complex medical problems or medical fragility; or 21
Medical Criteria I (Bullet #5) State Plan Policy: Continuous oxygen administration, in combination with a pulse oximeter and a documented need for observations and adjustments in the rate of oxygen administration. HSW Policy: Continuous oxygen administration (8 or more hours per day), in combination with a pulse oximeter and a documented need for skilled nursing assessment, judgment, and intervention in the rate of oxygen administration. This would not be met if oxygen adjustment is done only according to a written protocol with no skilled assessment, judgment or intervention required. Continuous use oxygen therapy is a covered Medicaid benefit for beneficiaries age 21 and older when tested at rest while breathing room air and the oxygen saturation rate is 88% or below, or the PO2 level is 55 mm HG or below. Interpretation: This would not be met if oxygen adjustment is done only according to a written protocol with no skilled assessment, judgment or intervention required. Per Medicaid policy, continuous use oxygen therapy is a covered benefit: For children, the oxygen saturation rate is 94% or below. For adults, the oxygen saturation rate is 88% or below. 22
Medical Criteria II State Plan Policy: Frequent episodes of medical instability within the past three to six months, requiring skilled nursing assessments, judgments or interventions as described in III and due to a substantiated progressively debilitating physical disorder. HSW Policy: Frequent episodes of medical instability within the past three to six months, requiring skilled nursing assessments, judgments or interventions (as described in III below) due to a substantiated medical condition directly related to the developmental disability. 23
Medical Criteria II cont d. State Plan and HSW Policies: "Frequent" means at least 12 episodes of medical instability related to the progressively debilitating physical disorder within the past six months, or at least six episodes of medical instability related to the progressively debilitating physical disorder within the past three months. 24
Medical Criteria II cont d. State Plan and HSW Policies: "Medical instability" means emergency medical treatment in a hospital emergency room or inpatient hospitalization related to the underlying progressively debilitating physical disorder. State Plan and HSW Policies: "Substantiated" means documented in the clinical/medical record, including the nursing notes. 25
Medical Criteria II - cont d. State Plan Policy: "Progressively debilitating physical disorder" means an illness, diagnosis, or syndrome that results in increasing loss of function due to a physical disease process, and that has progressed to the point that continuous skilled nursing care (as defined in III below) is required. HSW Policy: "Directly related to the developmental disability" means an illness, diagnosis, or syndrome occurred during the developmental period prior to age 22, is likely to continue indefinitely, and results in significant functional limitations in 3 or more areas of life activity. Illnesses or disability acquired after the developmental period, such as stroke or heart conditions, would not be considered directly related to the developmental disability. 26
Medical Criteria II - cont d. For beneficiaries described in II, the requirement for frequent episodes of medical instability is applicable only to the initial determination of medical necessity for PDN. Determination of continuing eligibility for PDN for beneficiaries defined in II is based on the original need for skilled nursing assessments, judgments, or interventions as described in III below. 27
Medical Criteria III The beneficiary requires continuous skilled nursing care on a daily basis during the time when a licensed nurse is paid to provide services. State Plan and HSW Policies: "Continuous" means at least once every three hours throughout a 24-hour period, and/or when delayed interventions may result in further deterioration of health status, in loss of function or death, in acceleration of the chronic condition, or in a preventable acute episode. 28
Medical Criteria III cont d. "Skilled nursing" means assessments, judgments, interventions, and evaluations of interventions requiring the education, training, and experience of a licensed nurse. State Plan Policy: Skilled nursing care includes, but is not limited to, performing assessments to determine the basis for acting or a need for action; monitoring fluid and electrolyte balance; suctioning of the airway; injections; indwelling central venous catheter care; managing mechanical ventilation; oxygen administration and evaluation; and tracheostomy care. HSW Policy: Following slides outline the 8 bullets that define skilled nursing. For HSW enrollees, the nurse must apply the HSW definition of skilled nursing. 29
Medical Criteria III HSW Skilled Nursing Requirements "Skilled nursing" means assessments, judgments, interventions, and evaluations of interventions requiring the education, training, and experience of a licensed nurse. Skilled nursing care includes, but is not limited to: performing assessments to determine the basis for acting or a need for action, and documentation to support the frequency and scope of those decisions or actions; managing mechanical rate-dependent ventilation or assisted ratedependent respiration (e.g., some models of Bi-PAP) that is required by the beneficiary four or more hours per day; deep oral (past the tonsils) or tracheostomy suctioning; injections when there is a regular or predicted schedule, or prn injections that are required at least once per month (insulin administration is not considered a skilled nursing intervention); nasogastric tube feedings or medications when removal and insertion of the nasogastric tube is required, associated with complex medical problems or medical fragility; 30
Medical Criteria III HSW Skilled Nursing Requirements (cont d) total parenteral nutrition delivered via a central line and care of the central line; continuous oxygen administration (eight or more hours per day), in combination with a pulse oximeter, and a documented need for adjustments in the rate of oxygen administration requiring skilled nursing assessments, judgments and interventions. This would not be met if oxygen adjustment is done only according to a written protocol with no skilled assessment, judgment or intervention required. Continuous use of oxygen therapy is a covered Medicaid benefit for beneficiaries age 21 and older when tested at rest while breathing room air and the oxygen saturation rate is 88 percent or below, or the PO2 level is 55 mm HG or below; monitoring fluid and electrolyte balances where imbalances may occur rapidly due to complex medical problems or medical fragility. Monitoring by a skilled nurse would include maintaining strict intake and output, monitoring skin for edema or dehydration, and watching for cardiac and respiratory signs and symptoms. Taking routine blood pressure and pulse once per shift that does not require any skilled assessment, judgment or intervention at least once every three hours during a 24-hour period, as documented in the nursing notes, would not be considered skilled nursing. 31
Medical Criteria III cont d. Equipment needs alone do not create the need for skilled nursing services. Interpretation of skilled nursing: Regular insulin injections do not require skilled nursing. If oxygen adjustment is done only according to a written protocol with no skilled assessment, judgment or intervention required, it is not skilled nursing. Oral suctioning requiring skilled nursing would be deep oral suctioning beyond the tonsils. 32
Intensity of Care/ Decision Guide for State Plan PDN Based on: The medical condition Complete clinical assessment Type and frequency of required skilled nursing care Impact of delayed nursing interventions Equipment needs alone don t determine intensity of care Other aspects of care (e.g., administering medications) are important when developing a plan for meeting the overall needs of the beneficiary, but do not determine the number of hours of nursing for which the beneficiary is eligible. 33
Intensity of Care for State Plan PDN High: at least one time each hour throughout a 24-hour period Medium: at least one time every three hours throughout a 24-hour period, or at least 1 time each hour for at least 12 hours per day Low: at least one time every three hours for at least 12 hours per day 34
PDN Determination Decision Guide for State Plan PDN The amount of PDN (number of hours) that can be authorized is based on several factors: beneficiary s care needs which establish medical necessity for PDN the beneficiary s and family s circumstances Other resources for daily care (private insurance) Only those factors that influence the maximum number of hours that can be authorized are included on the decision matrix. Other factors (e.g., additional dependent children, additional children with special needs, and required nighttime interventions) that impact the caregiver's availability to provide care should be identified during an assessment of service needs. These factors have implications for service planning and should be considered when determining the actual number of hours (within the range) to authorize. 35
Decision Guide for State Plan PDN See Handout Factor I Availability of Care Giver(s) Living in the Home Factor II Health Status of Caregiver(s) Factor III School 36
Decision Guide FAMILY SITUATION/RESOURCE CONSIDERATION Factor I Availability of Care Givers Living in the Home Factor II Health Status of Care Giver(s) Factor III School * 2 or more caregiver; both work or are in school F/T or P/T 2 or more caregivers; 1 works or is in school F/T or P/T 2 or more caregivers; neither works or is in school at least P/T 1 caregiver; works or is in school F/T or P/T 1 caregiver; does not work or is not a student Significant Health issues Some health issues Beneficiary attends school 35 or more hours per week, on average INTENSITY OF CARE Average Number of Hours Per Day LOW MEDIUM HIGH 4-8 6-12 10-16 4-6 4-10 10-14 1-4 4-8 6-12 4-8 6-12 10-16 1-4 6-10 8-14 Add 2 hours if Factor I <=8 Add 1hour if Factor I <= 7 Maximum of 6 hours per day Add 2 hours if Factor I <= 12 Add 1 hours if Factor I <= 9 Maximum of 8 hours per day Add 2 hours if Factor I <= 14 Add 1 hour if Factor I <= 13 Maximum of 12 hours per day * Factor III limits the maximum number of hours which can be authorized for a beneficiary: Of any age in a center-based school program for more than 25 hours per week; or Age six and older for whom there is no medical justification for a homebound school program. In both cases, the lesser of the maximum allowable for Factors I and II, or the maximum specified for Factor III applies 37
Determining Hours for HSW Maximum allowance is 16 hours per day Hours determined through the PCP process Consider natural supports IPOS must specify amount, scope and duration of PDN 38
Summary Review the essential components of the PIHP Nursing Assessment. Review Medical Criteria I, II, and III. Understand the differences between the State Plan policy and HSW policy. Review the PDN Eligibility Determination Worksheet. Identify the importance of integrating the health care plan in to the IPOS/PCP. Train one independent RN for each CMHSP/PIHP to complete the initial PDN eligibility assessment and an annual update to assure the need for continued PDN services. 39
Summary An Annual PDN Eligibility Determination is completed on every individual receiving PDN services. Required documentation to be submitted to MDCH for CWP ONLY: 1. Completed PDN Eligibility Worksheet 2. Current Health Care Plan 3. Copy of Physician s Order for PDN specifying the skilled nursing interventions, judgments, etc., e.g., how deeply the person must be suctioned. 4. Two weeks of current Nursing Notes. 5. Copy of the IPOS 40
Questions? 41
Resources http://www.mdch.state.mi.us/dchmedicaid/manuals/medicaidprovidermanual.pdf Michigan Medicaid Provider Manual State Plan Policy: Private Duty Nursing Chapter (includes Decision Guide) HSW Policy: Mental Health & Substance Abuse Chapter, Section 15.1, HSW Supports and Services PIHP PDN Eligibility Determination Worksheet 42
Contact Information HABILITATION SUPPORTS WAIVER Deb Ziegler zieglerd@michigan.gov 517/241-3044 CHILDREN S WAIVER PROGRAM Linda Fletcher Audrey Craft fletcherl@michigan.gov crafta@michigan.gov 517/241-5071 517/241-5757 43