What is Skilled Nursing?

A Home Health Agency in the State of Wisconsin is defined as “an organization that primarily
provides both skilled nursing and other therapeutic services to patients in their homes,” according to
Wisconsin Administrative Code, HFS 133.02.

Important Background Information Regarding “Skilled Level” Patients:
There are certain conditions that must be met for a patient to qualify for skilled home health services
under Medicare, Medicaid, and some insurance companies; they are:

• Be confined to the home (homebound);
• Be under the care of a physician;
• Receive services under a plan of care established and periodically reviewed by a physician;
• Be in need of skilled nursing care on an intermittent basis or need physical therapy or speech
• Have a continuing need for occupational therapy
Clarification of Homebound:
This does not mean the patient must never leave their home. In general terms, a patient is considered
“home bound” if they:
• Have a medical condition or an injury that restricts their ability to leave their home unless
they use an assistive device (crutches, cane, wheelchair, walker);
• Require the use of special transportation;
• Require the assistance of another person;
• Or, leaving their home is not medically advised
Patients may leave their homes occasionally; for church services, hairdressing, attending a family
functions while being driven in a vehicle by another person. Absences from the home to receive
medical treatments are also allowed, such as:
• attending adult day centers (licensed by the State of Wisconsin) to receive medical care;
• kidney dialysis;
• chemo/radiation therapy;
• and outpatient physical therapy, including whirlpool therapy
Obtaining a Home Health Agency License:
During the time an agency holds a Wisconsin provisional license, they are required to serve at least
10 skilled level patients requiring skilled nursing or other skilled services (physical, occupational, or
speech therapy). Out of these 10 skilled level patients, at least 7 must require skilled nursing

Clarification of Skilled Nursing Duties:
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.”

Some examples of patients who would 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.
If the patient’s nursing goals are met (considered to be stable), or teaching can be completed in one
visit, the patient is no longer considered “skilled” and no longer considered “qualified” for skilled

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.

Medicare Benefit Manual http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf

1 comment:

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