Case Management Guidelines and Scenarios

As good practice, and because over utilization of COPES Skilled Nursing Services for one client can result in lack of resources for others who need them, case managers need to be certain no other resources to provide for the service is available, and that the scope and duration of service authorization meets the client need. The scenarios below are intended to serve as guidelines in that direction. Case managers need to include the conditions of discharge from this service as a part of the service plan. As with any other case, Case Managers also need to schedule an appropriate level of contact to monitor for changing conditions.

Examples of clients that may meet these criteria are:

• A client with a diagnosis of quadriplegia has an indwelling foley catheter secondary to loss of bladder control. The client is unable to self-direct the catheter change and will require a catheter change and associated nursing interventions monthly for an indefinite period of time. The client is not eligible for home health care funded under Medical Assistance Administration (MAA) as the client’s condition is stable and not acute, and MAA is presently not serving them as an exception to policy. The client is also unable to go to the doctor’s office for this procedure related to the transfer restrictions onto an exam table. A referral to a contracted COPES skilled nursing provider would be appropriate for monthly catheter changes and approval of two “as needed” visits every month for replacement of incidental dislodging of the catheter.

• A client with a diagnosis of Multiple Sclerosis is to receive weekly injections of a medication to reduce the exacerbations of his/her relapsing- remitting disease process. The client is unable to self-direct this care and unable to access a physician office or clinic for the weekly injections secondary to immobility and fatigue. This client is not eligible for home health care funded under MAA as their condition is stable, the treatment plan is long-term, and MAA is not presently serving them as an exception to policy. A referral to a COPES skilled nursing provider would be appropriate for the weekly injection to allow the client access to medically necessary care and to remain in the least restrictive setting.

• A client with a diagnosis of insulin dependent diabetes had been seen by a home health agency for six months after an exacerbation of diabetes with irregular blood sugar, and the initiation of sliding scale coverage for insulin. The client has stabilized on the sliding scale with no changes in insulin dose in the last two months. The home health agency is discharging, as the client is no longer in an acute stage of his/her illness. Due to the clients low vision and concern for long-term compliance and stability, COPES skilled nursing is referred for weekly visits for an additional 90 days to assess blood sugar readings, signs and symptoms of hypo and hyperglycemia, and report to the physician any patterns of varying blood sugar or symptoms of hypo/hyperglycemia requiring adjustment of the insulin dosage.

• A client with a diagnosis of multiple areas of stasis ulcerations on his bilateral lower extremities requires weekly wound care and skin observation. The client lives in a rural area of the state and has limited access to health care and provider options. The client is receiving care from an agency worker and is unable to self-direct the wound care. The client is no longer eligible for skilled nursing services under MAA, as the client has had chronic edema and stasis ulcers for one year with no change in the physician ordered treatment plan for six months. The physician has ordered weekly changes of a compression dressing to both legs, ankle to knee weekly. The client has severe swelling in both legs as well as shortness of breath at rest and with exertion. The nurse must allow the client frequent rest periods during care due to the shortness of breath. This treatment requires a two to three hour nursing visit to unwrap the legs, wash, observe, and measure the ulcerations, and apply the compression dressing. Due to the client’s discomfort secondary to shortness of breath, the extent of the treatment, and the rural location of the client, SSPS code 5290 for Skilled Nursing Special Circumstance was authorized.

• A client is currently receiving two times daily wound care from a home health agency being paid under MAA. The physician has ordered the wound care to be performed three times a day. Under the billing instructions for home health care the maximum allowable visits are two times a day. COPES skilled nursing for one time day visit can be authorized to supplement the two times daily provided under MAA.