KAISER PERMANENTE 072523 Shift Care Private Duty Nursing Instructions

KAISER PERMANENTE 072523 Shift Care Private Duty Nursing

Product Information

Specifications

• Product Name: Kaiser Foundation Health Plan – California
• Service: Utilization Management Criteria for Home Health Shift Care/Private Duty Nursing
• Target Users: All Members, except Medi-Cal Members
• Criteria List: NCAL UM Criteria List

Product Usage Instructions

Clinical Review Criteria for Continuous Hourly Care
Continuous hourly care of 8 hours or more is provided for ongoing periods. Authorization for such care requires meeting the following criteria:

1. The patient’s required continuous hourly services at home must be at a skilled level suitable for an unlicensed family member or layperson with proper training and supervision. The family member or layperson must be willing, able, and available.
2. The licensed nurse’s services are necessary on an hourly basis due to specific medical conditions such as tracheostomy with mechanical ventilation, tracheostomy care, dependence on intravenous therapy, peritoneal dialysis treatments, tube feeding, or skilled nursing care.

Clinical Review Criteria for Transitional Period of Time
A transitional period is established to train family members or laypersons to take over 24-hour care responsibilities. Continuous hourly care for a transitional period is essential to facilitate the training process.

FAQ

• Q: What should I do if I am a treating clinician?
  A: If you are in a treatment relationship with a member, your clinical recommendations are not subject to the utilization management criteria. Your recommendations should be based on professional judgment and clinical guidelines.

• Q: Who determines the medical necessity of services?
  A: A qualified physician, different from the treating clinician, reviews service requests against utilization review criteria to determine medical necessity and approve, deny, delay, or modify the request.

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 support utilization review of certain provider-requested health care services. Refer to the NCAL UM Criteria List.
• 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 are 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. A 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 of the following:
   • A tracheostomy with dependence on mechanical ventilation for a minimum of six hours each day
   • 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:
   1. 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
   2. Dependence on peritoneal dialysis treatments requiring at least four exchanges every 24 hours OR
   3. Dependence on tube feeding, nasogastric or gastrostomy tube.
   • 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 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
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 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 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 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
• Elisa l. Avik, MD, Inten/Critical Care Pulmonology,
• Myrza Perez, MD, Medical Director of Pediatrics, Roseville

Approving Bodies

• Home Health Advisory Committee, 10/20/2022
  • 06/05/2020, 07/09/2021
• Resource Management Committee (RMC)
  • 06/02/2020, 08/24/2021, 06/28/22, 0725/2023
• Quality Oversight Committee (QOC)
  • 10/13/2021, 07/13/22

Home Health Shift Care/Private Duty Nursing Services all LOBs UM Criteria 2023.

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