Private Duty Nursing for Case Managers and PIHP Nurses.

1. Private Duty Nursing for Case Managers and PIHP Nurses. September 2010

2. Presenters: • Joan Deschamps • Linda Fletcher

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

4. Goal • To assure consistent implementation of the Private Duty Nursing (PDN) state plan policy and Habilitation Supports Waiver (HSW) policy for enrollees 21 and older.

5. Objectives • Define Private Duty Nursing • Recognize that there have been no changes in the PDN eligibility guidelines. • Identify 95% of the key steps in determining eligibility for PDN • Identify 95% of the essential components of the PIHP nursing assessment • Review Medical Criteria I, II, and III.

6. Objectives, continued • Understand the difference between State Plan Policy and HSW Policy. • Review the PDN eligibility worksheet. • 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. • Understand the importance of integrating PDN services and the nursing plan of care into the child’s IPOS/PCP.

7. Private Duty Nursing For a Consumer under age 21: • PDN IS a Medicaid State Plan Service. • The State Plan Policy applies. • PDN is not a Children’s Waiver (CWP) or HSW Service, but is authorized by the Community Mental Health agency. • Medicaid pays enrolled PDN providers (individual nurses or agencies) directly.

8. Private Duty Nursing For a consumer age 21 and over: • PDN is NOT a Medicaid State Plan Service. • It is a waiver service through the HSW or MI Choice waiver Program. • If enrolled in HSW, the policy is the HSW service description. Note: The individual nurse or agency must be part of the PIHP provider network and is paid by the PIHP or its affiliate.

9. Private Duty Nursing • PDN is for consumers who require ongoing nursing care on a daily basis 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. • The HSW service description applies for the HSW and MI Choice Waiver consumer age 21 and older Note: the HSW service description has been slightly modified in the HSW renewal, which is expected to take effect October 1, 2010.

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. 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 • Should be completed prior to the annual IPOS/PCP meeting.

12. Essential Components of the PIHP Nursing Assessment • Occurs in the consumer’s home prior to the annual IPOS. • PIHP assessment is completed by an independent R.N. • Includes consumer, parents, case manager or supports coordinator, etc. • Medical record review • Nursing record review

13. PDN Process • Complete Assessment • Determine Eligibility for PDN • Determine Intensity of Care • State Plan only • HSW - can use as a guide • Determine Amount of Hours using the Decision Guide & 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 • CMH or PIHP Submits Required Documentation to MDCH for Review

14. 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.

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 definition 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 • Note: The HSW service description has been slightly modified in the HSW renewal, which is expected to take effect October 1, 2010.

17. Medical Criteria I The beneficiary is dependent daily on technology-based medical equipment to sustain life. “Dependent daily on technology-based medical equipment” means: • State Plan policy: Mechanical ventilation four or more hours per day or assisted respiration (Bi-PAP or CPAP); • Interpretation: Rate dependent Mechanical Ventilation four or more hours per day or assisted rate-dependent respiration (e.g., some models of Bi-PAP or CPAP);

18. Medical Criteria I – cont’d. • State Plan policy:Oral 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.

19. Medical Criteria I – cont’d. • State Plan Policy: 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 Policy: total parenteral nutrition delivered via a central line associated with complex medical problems or medical fragility; • OR

20. Medical Criteria I – cont’d. • 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 requiring skilled judgments and interventions by a licensed nurse. • 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.

21. 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.

22. Medical Criteria II – cont’d. • 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.

23. Medical Criteria II – cont’d. • Medical instability" means emergency medical treatment in a hospital emergency room or inpatient hospitalization related to the underlying progressively debilitating physical disorder. • "Substantiated" means documented in the clinical/medical record, including the nursing notes.

24. 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.

25. 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.

26. 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. • "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.

27. 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 • NOTE: The HSW PDN service description will include revisions to the definition of skilled nursing.

28. 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.

29. 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.

30. 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…

31. 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.

32. 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

33. Decision Guide – a tool used to identify the range of hours that can be authorized.

34. Determining Hours for the HSW • Maximum allowance is 16 hours per day • Hours determined through the PCP process – all assessments included in the process • Consider natural supports • IPOS must specify amount, scope and duration of PDN

35. Determining Hours for the CWP • Hours determined through the PCP process – all of the assessments including PDN/PIHP assessment • IPOS must specify amount, scope and duration of PDN • Family circumstances and health status • When is the child in school • Other resources for daily care • Consider natural supports

36. SCHOOL • PDN does not pay for nursing care at school. • 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?

37. School – cont’d. • Is child’s attendance at school medically contraindicated? • Do physician and IEPC support a homebound school program? • The school max does not apply if the child is out of school for at least 5consecutive days for planned school breaks or medical reasons.

38. Example of summary and Narrative Recommendation Narrative for PDN. • Following a review of all available resources including medical records, nursing records, IPOS, IEPC and PT/OT assessments. it is determined that this individual’s needs are appropriate for Private Duty Nursing Intensity of Care Medium based on his need suctioning more than 8 times per 24 hour period via tracheostomy as documented per nursing notes. He requires skilled nursing respiratory assessments and judgments every 3 hours per 24 hours. He has been hospitalized three times during the past year for pneumonia. He receives the majority of his nutrition through a gastrostomy tube. He has speech language therapy for oral stimulation and small sips of thickened fluids.

39. Important Change in PDN Billing Procedure • CHAMPS Prior Authorization Subsystem: Instruction Manual for CMH Users Entering Private Duty Nursing Authorizations

40. CHAMPS • Online tutorial@ http://champstraining.mi.health.org Important for first time users.

41. Summary An Annual PDN Eligibility Determination is completed on every individual receiving PDN services. Required documentation to be submitted to DCH • Completed PDN Eligibility Worksheet. All pages to be completed. • Current Nursing Care Plan. • Two weeks of current Nursing Notes.

42. Questions ?

43. Resources • http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf • CHAMPS Prior Authorization Subsystem: Instruction Manual for CMH Users Entering Private duty Nursing authorizations • Michigan Medicaid Provider Manual, Private Duty Nursing Chapter (includes Decision Guide) • PIHP Eligibility Determination Worksheet • Revised HSW PDN service descriptions will be available in the Medicaid Provider Manual (Mental Health & Substance Abuse Chapter, Section 15, HSW) once CMS approves the application.

44. Contact Information HABILITATION SUPPORTS WAIVER Deb Ziegler Heather Sturtz zieglerd@michigan.gov sturtzh@michigan.gov 517/241-3044 517/335-6489 Mary Rehberg can be reached through Deb or Heather CHILDREN’S WAIVER PROGRAM Linda Fletcher Joan Deschamps fletcherl@michigan.gov deschampsj@michigan.gov 517/241-0268 517/241/5754