OASIS Alert

Skilled management and evaluation bridges patient care.

Despite what you may have been told by Centers for Medicare & Medicaid contractors in the past, management and evaluation of a patient’s care plan is a skilled service. And it’s a service that’s vital to keeping your patients with complex disease processes in their homes and out of the hospital. Take a closer look at your patients to see how they can benefit from this service.

Background: Skilled management and evaluation (SM&E) has always been a component of the Medicare Part A Home Health benefit, said Arlene Maxim, RN, of A.D. Maxim Consulting, in Troy, Mich. And a recent ruling in the court case Jimmo vs. Sebelius held this fact up.

But agencies submitting claims for SM&E may draw greater attention from CMS, Maxim cautioned in the recent Eli-sponsored audioconference, Skilled Management and Evaluation of an Unskilled Care Plan and Maintenance Therapy. As a result, there’s an increased need for nurses and therapists to clearly differentiate between the services available under the home health benefit, she said.

To successfully rebuff ADRs and denials, documentation must demonstrate the difference between observation and assessment of the patient and skilled management and evaluation of the complex care plan and the unskilled caregiver, Maxim said.

Who is eligible?

In order to be eligible for SM&E, a patient must meet three basic criteria, Maxim said. The patient must:

·         Be homebound.

·         Have an unskilled caregiver.

·         Have a complex care plan.

Examples of situations where the care plan is complex include patients with multiple diagnoses, multiple medications, or multiple unskilled caregivers, Maxim said.

What does SM&E look like?

It’s easy to understand the skilled need in services like catheter changes or wound care, but understanding the skill involved in SM&E is a little harder to grasp. Think of SM&E as a bridge of care between two acute episodes, Maxim said. The skill in SM&E involves the management of a complex care plan that includes unskilled services, she explained. The RN’s role in providing SM&E as “care team captain” is to provide oversight and avoid complications in a patient’s overall medical plan of care.

Important: Skilled nursing visits for management and evaluation of a patient’s care plan are reasonable and necessary when underlying conditions or complications require that only a registered nurse can ensure that essential non-skilled care is achieving its purpose, Maxim said. When you look at the care plan for a patient you think might be an SM&E candidate, ask yourself whether it will take your skills as an RN to go into the home and make sure that the care plan is followed, or is it possible that a lay person could manage?

For example: Your patient had a recent myocardial infarction, has congestive heart failure, frequent falls and has been in the hospital three times over the past year. He is on eight medications and some need to be titrated. This patient has a complex care plan and it will take the skills of an RN to ensure that the care is being performed properly, Maxim said.

On the other hand: Suppose your patient has unstable angina and has been prescribed low-dose aspirin. She has been in the hospital three times over the past year. This is not a complex patient, Maxim said. She can quickly be taught to take the aspirin and you can teach her signs and symptoms to watch for as an indication that she needs to go to the hospital.

Once you’ve identified a patient who requires SM&E and the care has been ordered, it can serve as a qualifying skilled service for the provision of other home care services including home care aides, medical social services, and supplies, Maxim said.

Bottom line: For skilled nursing care to be reasonable and necessary for SM&E of the beneficiary’s plan of care, the complexity of the necessary unskilled services that are part of the medical treatment must require the involvement of skilled nursing personnel to promote the patient’s recovery and medical safety in view of the beneficiary’s overall condition, Maxim said.

Identify potential SM&E patients.

You need look no farther than your OASIS assessments to help see whether you have patients on service who might benefit from SM&E.

Consider going back through three months worth of discharged patient records, Maxim suggested. Determine how many of these patients were either readmitted to your agency, another home health agency, or an acute care setting. These patients may have been eligible for SM&E.

Dig deeper: The typical patient who might benefit from SM&E is between 75 and 80 years old, Maxim said. You should also look to the following assessment items for indications that a patient might benefit from SM&E, although you shouldn’t limit your search to these items alone:

·         M1700/1710 — Confusion or altered mental status.

·         M1200 — Impaired vision.

·         M1242 — Some level of pain.

·         M1400 — Dyspnea.

·         M1350 — Skin Integrity issues-including edema.

·         M1020 — Multiple co-morbidities.

·         M2000-M2040 — More than five medications that are taken multiple times throughout the day.

The patient with a complex care plan may also have multiple physicians each with different care plans. And this patient may use community resources such as home delivered meals, handicapped transportation, and emergency response systems.

Remember these Documentation Points

Your nursing notes for SM&E patients won’t look like typical progress notes, Maxim said. You must briefly document the complicating factors that result in a high potential for complication, she said. You may also need to document the need to ensure that essential non-skilled services are achieving their purpose to promote the beneficiary’s recovery and safety.

You should also have a specific order for skilled management and evaluation when it is the only skilled nursing service your agency will provide, Maxim said.

Bottom line: Skilled management and evaluation involves finding that recovery and safety cannot be assured unless the total care, skilled or not, is planned and managed by a registered nurse, Maxim said. Make sure that your documentation supports this.

Editor’s note: For a sample SM&E nursing note courtesy of A.D. Maxim Consulting, e-mail the editor at janm@codinginstitite.us.