skilled nursing

Skilled nursing care is an extended-care option to meet the needs of patients who are in a transition phase of illness and recovery. It is a bridge from the hospital before going home or to a long-term-care facility. It includes rehabilitation therapies and can be used to help patients recover from surgery, illness or an accident.

Some of the skilled nursing services include specialized nursing care, physical therapy and occupational therapy. A skilled nursing patient is one who requires the skills of a Registered Nurse.

The registered nurse is responsible for:

Making the initial evaluation visit to the patient,
Reevaluating their needs regularly,
Initiating and revising the nursing plan of care,
Providing the services that require more specialized nursing care,
Planning for preventative and rehabilitative care,
Preparing clinical notes and informing physicians and others participating in the patient’s care

of changes as they occur.

According to the Medicare Benefit Manual, 30.4, (Medicare reimbursement) “skilled nursing care must be reasonable and necessary, needed on an intermittent basis, and not be solely needed for venipunctures for the purposes of obtaining blood samples.”

Examples of patients who DO QUALIFY for skilled nursing care:

• Patients who require intravenous and intramuscular injections

• Patients needing Foley catheter insertions

• Patients with pre-existing peripheral vascular or circulatory disease (needing observation for complications, pain management, teaching related to skin care, preservation of skin integrity, and prevention of skin breakdown)

• A patient who requires teaching related to illness or injury until they can demonstrate independence in their care.

• Patients in need of medication management which also requires a nursing assessment (such as blood pressures, pulses, respiratory assessment, blood sugars, oxygen saturations), monitoring of medication changes or physician consults.

In home health care, it is anticipated that the patient and/or caregiver(s) will be taught how to perform self-cares by the registered nurse. Typically this teaching is done over several days/weeks, depending on the complexity of the task and the patient’s condition. For this reason, agencies can expect to see patients frequently upon admission, and then begin to reduce the number of registered nurse visits when competency in the task is demonstrated and documented.

Examples of patients who DO NOT QUALIFY for skilled care:

• Skilled nurse admits a patient to agency for bathing, and completes the teaching of medication administration and safety in the home, at the admission visit.

• Patient is not compliant with taking medications, and needs reminders to take them on time.

• Patient has a wound, which the caregiver manages competently, and patient is driving their own vehicle.

• Medication set-up when the medications taken do not require ongoing nursing assessments, monitoring or physician consults.

Venipunctures alone do not qualify a patient for home care.

The documentation must support the rationale behind the venipunctures, for example:

• A patient is taking coumadin (blood thinner) and requires protimes to monitor it effectiveness. Documentation reflects no changes in the coumadin therapy for 6 weeks. This patient would not qualify for skilled care based on this alone.

• A physician requests a chemistry panel and CBC drawn on his patient prior to the patient’s 6 month check up. This patient would not qualify for skilled care based on this alone.

• A patient newly diagnosed with Atrial Fibrillation, and new to coumadin therapy, needs protimes to monitor for therapeutic effects. This patient would qualify for skilled care.