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Nursing Home: Complex Care Cheat Sheet by

Nursing Home: Complex Care
nursing     care     home     complex     snf     healthcare     sc

Overview

South Carolina Medicaid Complex Care is a program that targets Medica­id-­eli­gible hospital patients who no longer require hospit­ali­zation, but meet the nursing facility level of care. The program is intended to provide financial incentives to enrolled nursing facilities who admit Medicaid benefi­ciaries with complex care needs

Admission Criteria

Be a Medicaid recipient.
All Complex care indivi­duals must meet level of care criteria for long-term care.
Have 2 or more of the following requir­ements
    Wound/Decubitus Ulcer Stage 4 or greater
    Oral Suctioning
    Trach/cannula needing aseptic care and suctioning
    Extended duration of parental (IV) fluids for 2 weeks or more
    HIV positive
    Disruptive behavior 60% of the time 24/7. May be r/t mental health illness, head/brain trauma, other neurol­ogical deficits
     Medicaid only partic­ipant in need of goal directed (Physi­cal­/Oc­cup­ati­on/­Speech) therapies.
    Ventilator dependent
    Total Care with all ADLs
    Dialysis

Recert­ifi­cation

Initial CCP approval is for 180 days or 6 months.
Recertification approval is for 90 days or 3 months.
CCP partic­ipants must be recert­ified by SNF prior to expiration of initial approval.
   SNF completes 185s or CCP assessment forms with all pertinent inform­ation. Send to program area via fax or email. Please allow at least 5 days for response.
   SNF must recertify every 90 days for the duration of partic­ipation time at CCP level of care.

Billing

If partic­ipant is in HMO, prior author­ization is necessary before accepting CCP patient. This is a negotiated rate done between HMO and provider.
CCP can transfer. The certif­ication time transfers as well. New SNF is respon­sible for mainta­ining recert­ifi­cation.
 

Services Provided

Reduce difficulty of placing Medicaid benefi­ciaries
Facilitate access to SNF services and to provide most approp­riate level of care in the most approp­riate settings
Provide cost savings
Provide financial incentives to SNF for admission of Medicaid benefi­ciaries with complex care needs

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