Section 13: Levels of Care: GI, Routine, Continuous Care, & Respite Reviewed: June 13, 2012 Section Author(s): megging
Section 13: Levels of Care 2 Section 13: Levels of Care Field Guide
Section Contents Continuous Care & GI Comparison Chart... 5 Example CarePlus Notes... 6 Hospice CarePlus Protocol... 7 CarePlus Checklist... 9 Tips for Explaining CarePlus to Patients/Families... 11 Q & A About Medicaid... 13 What is Medicaid?... 13 How Do I Qualify for Assistance?... 13 What if I have more than the Resource Limit?... 13 Is there a Penalty for Transferring Resources?... 13 Is there an Estate Recovery Program?... 14 How Do I Apply?... 14 Is There Any Payment Required?... 15 A Guide to Understanding the Hospice Benefit... 16 Change to Medicare Summary Notice... 17 Field Guide Section 13: Levels of Care 3
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Continuous Care & GI Comparison Chart CarePlus (Continuous Care) Symptoms out of control that can lead to psychosocial/caregiver breakdown General Inpatient (GI) Symptoms out of control Must have skilled need Bill hourly: With many rules Start by 4:00pm if possible (Medicare/Medicaid) Can only bill for RN, LPN, CNA time Must have skilled need Bill per diem: Whole IDT can provide care for billing Charting- hourly Settings: Home or Assisted Living (may occasionally use in nursing home) Daily contact- phone or visit Nursing Home staff must document every shift Settings: Medicare certified Nursing Home, inpatient unit, or hospital Field Guide Section 13: Levels of Care 5
Example CarePlus Notes 6 Section 13: Levels of Care Field Guide
Hospice CarePlus Protocol Field Guide Section 13: Levels of Care 7
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CarePlus Checklist Considering Care Plus Initiating Care Plus Maintaining Care Plus Discontinuing Care Plus Process: Ensure you have a care plus folder with you Face to face assessment of patient o Ensure that interventions have been tried to address patients current condition Contact Clinical manager for approval of continuous care o If pt has commercial insurance as primary an authorization will need to be obtained Process: Email Laura Garcia(AHC if weekend or nights) o Report on pt o Start time o Level of nursing required: RN or LPN. Would C.N.A. be appropriate for a maximum of 11 hours/day for a case Email: IDT & COAs (CNA will be D/C d while pt on CarePlus), status change, AHC (if weekend or nights) Documentation: Paper ** Documents are to remain in burgundy folder in the home while the patient is on continuous care EMR Review Expectations & Responsibilities for Hospice CarePlus and have family sign Complete Instructions for Patient Care Plan Start CarePlus Medication Administration Record Write brief note in CarePlus Notes indicating reason for CarePlus and plan for symptom management and pt/family education (no need to document physical assessment here) Complete Billing Level of Care Update POC o Initiate Place on Care Plus intervention under problem requiring CarePlus o Initiate RN68: Patient Care, Complex r/t Update Medication List When creating block appointment: RN Visit CarePlus as Service and CarePlus as Visit Type Complete TDH NURS Hospice Visit Profile, including why CarePlus is appropriate. Process: Daily RN visits- first thing each am to assess patient Email: IDT, Laura Garcia, AHC (if weekend or nights) Documentation: ** Documents are to remain in burgundy folder in the home while the patient is on continuous care Paper Update Instructions for Patient Care Plan, including section on bottom indicating CarePlus to continue. Update CarePlus Medication Administration Record Write brief note in CarePlus Notes indicating reason for CarePlus and plan for symptom management and pt/family education (no need to document physical assessment here) EMR Update POC based on changes made during visit Update Medication List When creating block appointment: RN Visit Care Plus as Service and Care Plus as Visit Type Complete TDH NURS Hospice Visit Profile, identifying why Care Plus is appropriate. Process: Daily RN visits- first thing each am to assess patient Email: IDT, Laura Garcia, COAs, status change, AHC (if weekend or nights) Documentation: Paper Write brief note in CarePlus Notes indicating reason for CarePlus discontinuing Billing Level of Care **Deliver CarePlus folder to Laura Garcia** EMR Update POC o Discontinue Place on CarePlus intervention under problem requiring CarePlus o Discontinue RN68: Patient Care, Complex r/t Update CarePlus Medication Administration Record When creating block appointment: Choose RN Care Plus as Service and CarePlus as Visit Type Complete TDH NUR Hospice Nurse Visit Profile, identifying why CarePlus is being discontinued.
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Tips for Explaining CarePlus to Patients/Families When you feel CAREPLUS is an option for your patient, if the patient does not have Medicare or Kaiser, be sure to check with your clinical manager to be sure the hours will be covered. When initiating CAREPLUS with patient/families, be sure they are aware that this is for a limited time period: 24 hours, 48 hours, we don t know. Once symptoms are controlled, CAREPLUS needs to end. While explaining CAREPLUS, you can also go over other options once CAREPLUS is completed: returning to routine home care as they were before, The Denver Hospice inpatient hospice, nursing home placement, private pay home care. Be sure that they know that whatever their choice is, The Denver Hospice will still be involved and helping them. Tips for Explaining CarePlus to Patients/Families Revised: 03/28/11 Reviewed by: megging Field Guide Section 13: Levels of Care 11
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Q & A About Medicaid What is Medicaid? Medicaid is a state and federally funded program that can provide help in a variety of ways: Long Term Care (room & board in a nursing home, assisted living costs, personal care provider help at home), medical care, burial or financial assistance. This document primarily addresses the financial requirements for Long Term Care, however the documentation required for submission applies to most programs. How Do I Qualify for Assistance? Medicaid considers your primary residence, automobile, household goods and irrevocable burial plan not counted as part of your assets in determining your eligibility for Medicaid. 1) The total resource value of your countable assets (bank accounts, stocks, bonds, CD s, annuities, retirement funds, cash surrender value of life insurance with a face value greater than $1500.00, vehicle(s) if more than one vehicle is owned, and property other than primary residence) will need to be less than $2000.00. 2) If the applicant is married, spousal resource limit is $109,560.00. 3) If married and both need assistance at home or both are in a nursing home, the resource limit is $3000.00 4) Applicant s monthly gross income must be below $2022.00. If the monthly income is over this amount, then an Income Trust will need to be completed. An income trust packet is available through the county social services office or from your Social Worker. What if I have more than the Resource Limit? If you do not meet the above criteria, you must spend down your resources until the value is below the amount allowed. Medicaid will not begin until the applicant and his/her spouse are BELOW the resource limit. The following are some ways the applicant may spend down: Room and board expenses at a nursing home, assisted living Payment of outstanding medical bills Purchase of an irrevocable funeral/burial plan Payment of repairs/maintenance on home Payment of other outstanding bills Is there a Penalty for Transferring Resources? Yes. Transferring assets will disqualify the applicant for a period of time, depending on the amount of the gift. All gifts and transfers must be disclosed to Medicaid. Failure to disclose such gifts and transfer is fraud. Medicaid will look back 5 years to review all gifts and transfers made by applicant and spouse. Field Guide Section 13: Levels of Care 13
Is there an Estate Recovery Program? Yes, there are several factors used to make this determination. The following information is from Colorado Medicaid Recovery at www.comedicaidrecovery.com/co/cofaqs.htm or call 303-837-8293. The State may recover the costs of medical assistance from an estate only when medical services were delivered to a person of any age living in a nursing facility or to a person over the age of 55 in any living situation and the Medicaid recipient is not survived by a spouse, child under 21 or blind or disabled dependent. o The State will not recover medical assistance costs from the sale f recipient s home if there is a brother or sister who lived in the home for at least one year before the recipients went into a nursing facility, and who has lived there continuously since the date of entry into the facility OR there is a son or daughter who lived in the home for at least two years before the recipients entered a nursing facility whose care allowed the recipients to delay nursing facility placement and who has lived in the home continuously since the date of nursing facility entry. How Do I Apply? The Denver Hospice will provide you with an application or you can get one from your county social services office or at http://www.chcpf.state.co.us click on Medicaid. The application is submitted to the Department of Human Services in the county where the person is living. Copies of the following items must be provided by the applicant plus * items must be provided by the spouse. a. * Picture ID b. Original citizenship and identity documents (such as: birth certificate or passport) are required if applicant DOES NOT receive Medicare, Social Security, Social Security Disability or Social Security Supplemental Income. These must be submitted in person with application before it can be processed. c. Veteran s serial number (if applicable) d. * Social security card e. * Medicare card (if applicable) f. * Proof of all gross monthly income i.e. social security and pension income g. Document of proof of purchase of an irrevocable burial/funeral plan h. Life insurance (face value amount and cash surrender amount). i. * Documents to verify savings and checking accounts, certificates of deposit, IRA statements (minimum of 6 months of recent records) j. * Car registration and documentation of insurance costs on the vehicle(s) 14 Section 13: Levels of Care Field Guide
k. * Tax assessments for any property owned l. * Proof of one month of current living expenses: rent/house payment, utilities including phone m. * Medical bills: monthly insurance or monthly prescriptions The County Technician may request other financial information based on your application. Is There Any Payment Required? Yes, if a person lives in a nursing home facility or assisted living facility Medicaid requires a monthly payment, which will be about the same as the applicant s gross monthly income less a monthly personal needs allowance. There is consideration for the amount of the patient pay if applicant is married. The patient pay portion is paid directly to the facility. Failure to pay this portion may result in the Medicaid being discontinued. The county has a minimum of 45 days to finalize and make a decision on approval of the application. If applicant does not receive Social Security Benefits, the minimum is 90 days to process the application. During this time you may be required to pay the facility a month up front for room and board. You must make payment arrangements directly with the facility. There are other programs available, in addition to Long Term Care Medicaid. For more information about other programs and assistance in completing the Medicaid application, please ask your Social Worker or call Patient Benefit Advisor, at 303-398-6220. Medicaid Q & A 2010 Medical Records Field Guide Section 13: Levels of Care 15
A Guide to Understanding the Hospice Benefit 16 Section 13: Levels of Care Field Guide
Change to Medicare Summary Notice From: Melinda Egging To: Group Clinical Managers & Group Education Team Sent: Wed 6/13/2012 10:24 AM Medicare will change the format of the Medicare Summary Notice (MSN) effective July 1, 2012. The MSN is mailed to Medicare beneficiaries every 3 months and shows all services billed during the period what Medicare paid and what may be owed to the provider. This notice has caused great confusion and sometimes angst among our patients when they see the charges which would trigger conversations with the staff, clinical managers, billing and myself to provide an explanation of the charges. The changes are to no longer show all of the visit charges, indent and make the visits more clear to read, associate visits to the level of care, and will now include this statement: Payment for this hospice service is included in the payment for the hospice daily level of care; therefore, you should not be billed for this service. Here is an example: You may wish to share this information and the example with your staff so that they are aware of this change should they have patients/families that ask questions about this notice. Thanks, Melinda Egging Director of Quality and Compliance The Denver Hospice & Optio Health Services megging@care4denver.org Field Guide Section 13: Levels of Care 17
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