KAISER PERMANENTE Foundation Health Plan California Instructions

KAISER PERMANENTE Foundation Health Plan California Instructions

Kaiser Foundation Health Plan – California

2023 Utilization Management (UM) Criteria for Home Health Shift Care /
Private Duty Nursing for All Members, except Medi-Cal members for
whom EPSDT criteria should be considered

Utilization Management Criteria Statement

This document includes criteria that supports utilization review of certain provider requested health care services.

Utilization review occurs when a qualified physician other than the treating clinician reviews the treating clinician’s request against utilization review criteria. The qualified physician is in the position to approve, deny, delay, or modify the service request based on a determination of medical necessity. These criteria are consistent with professional standards of practice and provided for your reference.

If you are in a treatment relationship with a member your clinical recommendations are not subject to these criteria. Your treatment recommendations are guided by your professional judgment and influenced, where applicable, by clinical practice guidelines and clinical support tools found in the Library under “Guidelines”.

Clinical Review

Criteria for Continuous Hourly Care – 8 hours or greater of medically necessary licensed care for an ongoing period

For authorization of continuous hourly care for an ongoing period, both criteria below must be met:

1. The continuous hourly services the patient requires in the home setting are at a skilled level that could be safely and effectively performed by an unlicensed family member or other layperson with appropriate training and supervision. Family member or layperson is willing, able, and available.
2. The services of the licensed nurse are required on a continuous hourly basis based on any the following:
   a. A tracheostomy with dependence on mechanical ventilation for a minimum of six hours each day
   b. Dependence on tracheostomy care requiring suctioning at least every six hours, and room air mist or oxygen as needed, and dependence on one of the three treatment procedures listed in (i) through (iii) below:
   i. Dependence on continuous intravenous therapy including administration of therapeutic agents necessary for hydration or intravenous pharmaceuticals; or intravenous pharmaceutical administration of more than one agent, via a peripheral or central line, without continuous infusion OR
   ii. Dependence on peritoneal dialysis treatments requiring at least four exchanges every 24 hours OR
   iii. Dependence on tube feeding, nasogastric or gastrostomy tube.
   c. Dependence on skilled nursing care in the administration of all three of the treatment procedures listed in (b) (i) through (iii) above

For Medi-Cal members under the age of 21 years old and who do not meet the clinical review criteria in this document, the EPSDT PDN Shift Care criteria must also be considered.

Criteria for Continuous Hourly Care – 8 hours or greater for a transitional period of time

The purpose of a transitional period is to assist family member(s) or other layperson caregiver(s) with the completion of training to assume 24-hour responsibility for the patient’s care in the home setting. Continuous Hourly Care is required for a transitional period of time to accomplish the training noted above.

For authorization of continuous hourly care for a transitional period, all 3 criteria below must be met:

1. There is evidence that the family member(s) or other layperson caregiver(s) require further teaching, observation, and/or monitoring to perform the services the patient requires to safely and effectively remain in the home setting.:
2. Continuous Hourly Care is required for a defined temporary period of time that has a specified start and end date
3. A transition plan must be developed that specifies a continuous and gradual reduction in hours over a defined period of time to less than 8 hours per day.

Contributors/Clinical Experts

Colleen Keller, NCAL Regional Director, Home Health/Hospice Marla Foreman, NCAL Regional Service Director, Home Health Hospice Vance Purcell, Site Director, Sacramento, Home Health/Hospice Richard Rabens, MD, Regional Medical Director for Pediatrics Theodore Fong, MD, Regional Adult Pulmonologist Myrza Perez, MD, Medical Director of Pediatrics, Roseville Southern California Home Health Care Services Regional Leaders for Clinical and Quality:

Menyea Baker, RN
Southern California Home Health Care Services

Approving Bodies

Home Health Shift Care / Private Duty Nursing Services for Non-Medi-Cal members
UM Criteria 2023

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