Private Duty Nursing for Case Managers and PIHP Nurses

1. Private Duty Nursingfor Case Managersand PIHP Nurses

2. PDN Nursing • This session is a requirement for any CMHSP case manager, HSW supports coordinator, or PIHP nurse who has not previously attended this session.

3. Presenters • Joan Deschamps • Linda Fletcher

4. Objectives • Define Private Duty Nursing • Identify 95% of the key steps in determining eligibility for PDN • Identify 95% of the essential components of the PIHP nursing assessment • Determine appropriate Intensity of Care based on the PIHP nursing assessment • Describe 95% of the steps necessary to determine the number of hours of PDN to authorize. • Integrate PDN services and the nursing plan of care into the child’s IPOS

5. Private Duty Nursing For a Consumer under age 21: • PDN is a Medicaid State Plan Service. • PDN is not a Children’s Waiver Service.

6. PDN Nursing For a consumer age 21 and over : • PDN is a Medicaid State Plan Service. • It is a waiver service through the Habilitation Supports Waiver or MI Choice Waiver Program.

7. Private Duty Nursing • The consumer requires ongoing nursing care to remain at home in the community. • PDN must be ordered and provided under the direction of a physician. • The consumer must meet Medicaid eligibility criteria for PDN

8. Determining PDN Eligibility • 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. • 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. • Is dependent on medical technologies to sustain life.

9. Determining PDN Eligibility – con’t • 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

10. Essential Components of the PIHP Nursing Assessment • Occurs in the consumer’s home prior to the annual IPOS. • PIHP assessment is completed by an R.N. • Includes consumer, parents, CM, etc. • Medical record review • Nursing record review • Independent complete nursing assessment • Narrative summary

11. PIHP Assessment Used to: • Determine initial eligibility for PDN • Confirm ongoing eligibility for PDN • Provide the basis for the narrative documentation of “Intensity of Care” • Identify needs that must be addressed in the IPOS • Identify changes in child’s care needs over time.

12. Intensity of Care Based on: • The medical condition • Complete clinical assessment • Type and frequency of required skilled nursing care • Impact of delayed nursing interventions • Other related needs • Equipment needs alone don’t determine intensity of care.

13. Intensity Of Care – High, Medium or Low? • Oral suctioning • Trach and trach suctioning • Naso-gastric tube feeding • Gastrostomy-tube feeding • Continuous oxygen adminstration and monitoring • Mechanical ventilation • Total parenteral nutrition

14. How Much PDN Can Be Authorized? • In preparation for the IPOS planning meeting, the CM will want to think about the range of hours that could be authorized given the child’s and family’s needs • The Decision Guide is a tool used to identify the range of hours that can be authorized • Considerations include: • The Intensity-of-Care category

15. How Much PDN Can Be Authorized? – con’t. • Review the PIHP nursing assessment and all other assessments of service needs and other factors that impact the caregiver's availability to provide care, including • Family circumstances and health status • Other resources for daily care • When the child is in school

16. Is child between ages of 6-16? Is the child in school at least 25 hours per week, including school transport time? How does the school provide for child’s needs? Is child’s attendance at school medically contraindicated? Do physician and IEPC support a home-bound school program? The school max. does not apply if the child is out of school for at least 5 consecutive days for planned school breaks or medical reasons SCHOOL!!Note: PDN does not pay for nursing care at school

17. Decision Guide for PDN

18. Integrated IPOS • Each service does not require an individual goal. • Each service must be identified in the plan • The purpose of each service must be clear • PDN goals and objectives are part of the integrated IPOS.

19. Annual Review • Annual PIHP nursing assessment required for all kids receiving PDN services • Original copy of PIHP assessment to CM prior to annual IPOS • Annually the CM sends to DCH the IPOS, PIHP nursing assessment and the nursing care plan (applies to CWP only).

20. Quarterly Review • This applies to the CWP for Intensity of Care High PDN • CM sends DCH quarterly budget and report and two weeks of recent nursing notes.

21. Authorizing PDN • The “old” Oracle Prior Authorization system will no longer be used to generate the prior authorizations for PDN • The “new” CHAMPS PA process is a little more “user friendly”, and should result in fewer errors • PDN still needs to be prior authorized • Your agency has designated someone to do the PAs • A special training has been developed specifically for CMHSPs and PDN prior authorization

22. Other CHAMPS-related PDN Changes • AuthentiCare will no longer be used • PDN providers (agencies and individual nurses) will directly bill Medicaid for PDN services • We recommend you require the PDN provider send you a copy of the PDN service log prior to paying nursing respite claims (if you authorize the same provider for PDN and nursing respite)

23. Conclusion • Define PDN • Key steps to determine PDN eligibility • Essential components of the PIHP nursing assessment • Appropriate Intensity of Care • PDN authorization • Integrated IPOS

24. Resources • http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf • Michigan Medicaid Provider Manual, PDN Policy Section (includes Decision Guide) • PIHP Eligibility Determination Worksheet • Children’s Waiver Technical Manual

25. Resources – con’t. • CHILDREN’S WAIVER Joan Deschamps deschampsj@michigan.gov 517/241-5754 Linda Fletcher fletcherL@michigan.gov 517/241-0268

26. Resources – con’t. • HABILITATION SUPPORTS WAIVER Deb Ziegler zieglerd@michigan.gov 517/241-3044