Private Duty Nursing As A Component of the Person Centered Plan

1. Private Duty Nursing As A Component of the Person Centered Plan For Case Managers and Support Coordinators.

2. Annual Home and Community Based Waiver Conference • Kellogg Center, East Lansing, Michigan • November 7, 2011 • 1- 2:30 PM

3. Presenters • Mary Rehberg, BSN, RN, MA, LPC • Linda Fletcher, RN, MS, CPNP

4. Goal • To assure consistent implementation of Private Duty Nursing (PDN) State Plan for enrollees under age 21 and Habilitation Supports Waiver (HSW) policy for enrollees 21 and older.

5. Objectives • Identify Case Manager (CSM) responsibility for integrating Private Duty Nursing Services into the Individualized Plan of Service (IPOS). • Identify the differences between the Private Duty Nursing State Plan Policy and HSW Private Duty Nursing Policy

6. Objectives, continued • Identify Medical Criteria I,II, and III which determine the eligibility for Private Duty Nursing Services • Identify the importance of integrating the health care plan and Private Duty Nursing Services into the IPOS

7. Components of the IPOS as it relates to Private Duty Nursing • Guides all services provided to the beneficiary by the PDN provider • Family members and the beneficiary, etc., participate in the development of the IPOS • The IPOS must identify the number of hours of Private Duty Nursing to be provided.

8. Components, continued • If the Private Duty Nursing Services are provided by a LPN (Licensed Practical Nurse), the IPOS must identify the frequency of the supervising visits by a Registered Nurse (RN).

9. PIHP PDN Nursing Assessment • Each CMHSP/PIHP must assign an independent RN to complete the initial PDN eligibility assessment and an annual update to assure the need for continued PDN services • PIHP nurse must complete an annual review for PDN eligibility prior to the annual IPOS review • PIHP nurse will provide the CSM with the PDN Eligibility Determination Worksheet.

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

11. Purpose of the 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 • Ideally, should be completed prior to the annual IPOS/PCP meeting.

12. Skilled Nursing Is: • Skilled nursing means assessments. judgments, interventions, and evaluation of interventions requiring the education, training, and experience of a licensed nurse.

13. Private Duty Nursing • PDN is for people who require ongoing skilled 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 person must meet Medicaid eligibility criteria for PDN.

14. 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

15. Equipment Needs Alone • Equipment needs alone do not create the need for skilled nursing services

16. 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.

17. 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 and the individual nurse or agency is paid through the PIHP network. • 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 either the HSW or the MI Choice Waiver Program. • If enrolled in HSW, the policy is the HSW Service Description. • The individual nurse or agency must be part of the PIHP provider network.

18. 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.

19. PDN Process • Complete PIHP/CMHSP Nursing 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

20. Documentation to submit to MDCH • Initial Eligibility and Annually thereafter: • PDN Eligibility 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 • NOTE: This is a new requirement so a desk audit can be completed of PDN eligibility and waiver program eligibility • REMEMBER: Children enrolled in CWP must receive active treatment and people enrolled in the HSW must receive habilitation services in addition to PDN.

21. 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

22. Medical Criteria I The beneficiary is dependent daily on technology-based 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

23. 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 rate-dependent respiration (e.g., some models of Bi-PAP); • 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);

24. 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

25. Bullet # 3 and # 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;

26. 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 requiring skilled judgments and interventions by a licensed nurse.

27. Bullet # 5, continued • 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 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.

28. Bullet # 5, continued • 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.

29. 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 medicalcondition directly related to the developmental disability.

30. 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.

31. Intensity of Care/Decision Guide forState 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.

32. 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…

33. 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.

34. State Plan Decision Guide

35. 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

36. Summary • Identify the importance of integrating the health care plan into the IPOS/PCP • Identify Case Manager (CSM) responsibility for integrating Private Duty Nursing Services into the Individualized Plan of Service (IPOS). • Review Medical Criteria I, II, and III. • Understand the differences between the State Plan policy and HSW policy.

37. Questions?

38. Resources • http://www.mdch.state.mi.us/dch-medicaid/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

39. 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 517/241-0268 517/241-5757

40. Thank you for your attention