Currentsierra health and lifePolicy N/A

Transitional Care Admissions (Subacute and SNF)

Defines levels of transitional care (medical/subacute, skilled care/skilled rehabilitation, custodial), admission requirements, and expected physician visit frequency for patients transferred into subacute and SNF settings. Affects providers arranging or accepting admissions to these post-acute facilities in North Carolina.

Policy Summary

Payersierra health and life

PolicyTransitional Care Admissions (Subacute and SNF)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain physician evaluation and complete physician orders and a transfer summary prior to direct admission; ensure chest x-ray or portable x-ray orders are available on admission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

dailyattending physician visits for medical subacute patients

weeklyattending physician visits for SNF/subacute rehabilitation patients

chest x-rayradiology on admission

requiredpre-admission physician evaluation

Coverage Criteria for Post-Acute Admissions

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Medical/Subacute Level of Care Admission Criteria

Patient is appropriate for medical/subacute unit when ALL of the following apply:

Medical/Subacute admission: Patient has a subacute/medical need or short-term rehabilitation need

Intensity of services: Services needed cannot be performed in a less intensive setting (e.g., home health or outpatient)

Home environment failure: Patient may have failed in home environment with alternative, less intensive services

Facility capability: Subacute setting can meet patient's needs

Rehab admissions service and contracted medical rehabilitation center criteria are available through facility resources

Source of admission: Admissions may be transfers from acute or skilled/custodial facility, emergency room, urgent care, or surgery center

Admission services case managers will assist with referral

Pre-admission physician evaluation: Patient must be evaluated by a physician prior to a direct admission

Admission documentation: All admissions require physician orders and a transfer summary completed by the transferring physician; chest x-ray or orders for a portable x-ray must be present on admission

Failure to provide these documents may result in denial or delay of admission

Skilled Care/Skilled Rehabilitation Admission Criteria

Admissions to skilled care or skilled rehabilitation follow Medicare skilled care definitions and require:

Therapy need: Patient requires skilled rehabilitation consisting of at least one therapy a day to increase functioning

Ability to participate: Patient is alert and able to follow instructions and participate in therapy

Medicare skilled criteria: Skilled nursing patients meet Medicare Part A skilled criteria and cannot be managed effectively at home

Admission coordinated through facility admissions service per Medicare definitions

Custodial Level of Care Admission Criteria

Admissions to custodial level (group care/intermediate nursing):

Functional limitations: Patient requires assistance with activities of daily living (ADLs) and/or instrumental ADLs (IADLs) and cannot be maintained at home

Includes patients who cannot provide meals, handle medications or finances

No skilled criteria: Patient does not meet any skilled Medicare criteria (i.e., custodial/intermediate nursing level)

Admission to custodial level may be made by contacting the nursing facility directly

No explicit exclusions are listed in this policy. The document defines admission, continued-stay, and discharge expectations for medical/subacute, skilled care/skilled rehabilitation, and custodial levels of care but does not specify any services, diagnoses, or member cohorts that are categorically excluded from coverage.

Admission Criteria by Level of Care

Medical/Subacute

Medical/Subacute admission: See Medical/Subacute Level of Care Admission Criteria set in coverage module

Patients in medical subacute level of care are to be seen by the attending physician daily

SNF / Skilled Rehabilitation

Skilled Care admission: See Skilled Care/Skilled Rehabilitation Admission Criteria set in coverage module

Patients admitted to a SNF/subacute rehabilitation should be seen by the attending physician no less than weekly

Custodial

Custodial admission: See Custodial Level of Care Admission Criteria set in coverage module

Facility will notify HPN of the admission when contacted

Provider Responsibilities and Admission Coordination

Prior Authorization

Admission authorization and coordination

Admission Authorization and Coordination — The patient must be evaluated by a physician prior to any direct admission to the medical/subacute unit. Admissions may be initiated as transfers from an acute or skilled/custodial facility, an emergency room, urgent care, or a surgery center. Admission coordination and referral assistance are provided by admission services case managers. All admissions require completion of physician orders and a transfer summary by the transferring physician (ER/UC/PCP). Failure to obtain the required physician evaluation or to provide complete physician orders and transfer summary may delay or prevent acceptance of the admission.

Physician evaluation required prior to direct admission
Admissions may originate from acute hospital, skilled facility, ER, urgent care, or surgery center
Admission services case managers assist with referral and coordination
Transferring physician must complete physician orders and a transfer summary

Documentation Required

Radiology requirement

Radiology Requirement — A chest x-ray or orders for a portable x-ray must be provided on admission. If a chest x-ray or orders for a portable x-ray are not available at the time of admission, the facility may be unable to accept the patient.

Chest x-ray or orders for a portable x-ray required on admission
Lack of chest x-ray/orders may affect facility acceptance

Definitions of Patient Types and Levels of Care

Subacute patient — key attributes

DefinitionMedically complex patient who qualifies for acute hospitalization but does not require the high-technology care of an acute hospital; requires coordinated interdisciplinary services from physicians, nurses, and other disciplines.

Admission triggersSubacute/medical need or short-term rehabilitation need; services cannot be provided in a less intensive setting (e.g., home health or outpatient).

Home environment considerationPatient may have failed in the home environment despite alternative, less intensive services.

Documentation & assessmentPatient must be evaluated by a physician prior to direct admission; all admissions require physician orders and a transfer summary completed by the transferring physician; chest x-ray or orders for a portable x-ray on admission.

Attending physician follow-upPatients in medical subacute level of care are to be seen by the attending physician daily.

Acute rehabilitation patient — key attributes

DefinitionPatient who requires the care of an interdisciplinary team, has good rehabilitation potential, and can tolerate at least three hours of therapy a day.

Setting coordinationAcute rehabilitation admissions are managed through the rehab admissions service; contracted medical rehabilitation centers listed in online directories.

Intensity of therapyTolerates a high-intensity therapy schedule (approximately three hours per day).

Interdisciplinary careRequires coordinated care from physicians, nurses, and other rehabilitation professionals.

Admission requirementSubject to the same physician evaluation and admission documentation requirements as other subacute admissions (physician evaluation prior to direct admission; physician orders and transfer summary; chest x-ray or portable x-ray orders).

Skilled rehabilitation patient — key attributes

DefinitionPatient who requires at least one therapy a day to increase functioning and is alert and able to follow instructions.

Therapy requirementRequires at least one therapy session per day (skilled rehabilitation level).

Participation abilityPatient must be alert and able to follow instructions to participate in therapy.

CoordinationAdmission coordinated through the facility admissions service in accordance with Medicare definitions of skilled care and skilled rehabilitation.

Follow-upPatients admitted to SNF/subacute rehabilitation should be seen by the attending physician no less than weekly.

Skilled nursing patient — Medicare Part A skilled criteria & attributes

Medicare Part A skilled criteriaA skilled nursing patient is one who, regardless of age, meets Medicare Part A skilled criteria and cannot be managed effectively at home.

SettingAdmission to skilled care or skilled rehabilitation is coordinated through the facility admissions service and follows Medicare definitions of skilled care.

Physician follow-upPatients admitted to a SNF/subacute rehabilitation should be seen by the attending physician no less than weekly.

Management considerationPatient cannot be managed effectively at home due to the need for skilled care services.

Custodial (group care/intermediate nursing) patient — key attributes

Definition (group care)Independently mobile patient who cannot remain at home due to inability to provide meals or handle medications or finances.

Definition (intermediate nursing)Patient unable to be maintained at home; requires assistance with ADLs (bathing, dressing, transferring, ambulating) and IADLs (shopping, homemaking) and does not meet any skilled Medicare criteria.

Admission processAdmission to custodial level can be made by contacting the nursing facility directly; the facility will notify HPN of the admission.

Skilled criteria exclusionCustodial patients do not meet skilled Medicare criteria and therefore require non-skilled assistance with ADLs/IADLs.

OpenPayer

Transitional Care Admissions (Subacute and SNF)

Coverage Criteria for Post-Acute Admissions

Admission Criteria by Level of Care

Criteria for Continued Stay

Provider Responsibilities and Admission Coordination

Definitions of Patient Types and Levels of Care

Background and Context

Discharge Criteria