Health Authority Abu Dhabi

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1 Health Authority Abu Dhabi Document Title: HAAD Standard for Provision of Long-Term Care in healthcare facilities in the Emirate of Abu Dhabi Document Ref. Number: HAAD/LTHC/SD/1.3 Version 1.3 Approval Date: 12/12/2013 Effective Date: 15/12/2013 Last Reviewed: December 2012 Next Review: January 2015 Revision History Document Owner: Applies to: Classification: May 2010 Version 1.0 November 2010 Version 1.1 December 2012 Version 1.2 Health System Financing Division, Government Prices and Product Benefits Section HAAD Licensed Healthcare facilities Public 1. Purpose 1.1. This standard sets out the definitions and parameters for Long-Term Care (LTC) healthcare services to ensure quality, safe and accessible healthcare for patients. To do this, it mandates the: Definition of Long-Term Care and defines patients identified as requiring and eligible for Long-Term Care health services, including adults and children; Treatment and care services, service specifications and patient eligibility criteria; Payment for services under the health insurance scheme and the Services included in Long-Term Care; and Data reporting and records management requirements. 2. Scope 2.1 This standard applies to: All HAAD Licensed Healthcare facilities with inpatient services and healthcare professionals employed by these facilities; All payers and third party administrators; and Patient stay in Intensive care Unit (ICU), Neonatal Intensive Care Unit Page 1 of 11

2 (NICU) and/or Pediatric Intensive Care Unit (PICU), and authorized (when appropriate) acute medical/surgical interventions that require active medical interventions are excluded from the scope of this Standard. 3. Duties for Healthcare Providers Healthcare Professionals 3.1All HAAD licensed healthcare facilities with inpatient facilities and healthcare professionals providing Long-Term Care and provider TPAs must: Provide medical, clinical, nursing and health support interventions in accordance with the specifications of this Standard and consistent with HAAD policies and the federal and Abu Dhabi laws; submit data to HAAD via e-claims and in accordance with the HAAD Reporting of Health Statistics Policy Chapter VI, Health Regulator Policy Manual, Version 1.0 and as set out in the HAAD Data Management Policy Standards and Procedures (available from and comply with the health insurance pre-authorization requirements, where applicable for payment for Long-Term Care in accordance with the patients health insurance product (including Thiqa patients where considered necessary) and the requirements of this Standard; Itemise, code accurately and document the actual services, for each acuity level and for each of the care domains detailed in Appendix 1, supported by the Evaluation and Management Level established in accordance with HAAD Coding Manual; licensed professionals responsible for managing patients must ensure that patients assessment, review and management is documented in a patient tailored care plan that is subject to regular monitoring and evaluation. Patient evaluation for continued LTC eligibility must be undertaken every 30 days by the treating specialist physician; and licensed healthcare provider must comply with HAAD requirements for patient confidentiality, patient records and information technology and data management. 4. Duties for Payers and Payer Third Party Administrators (TPAs) 4.1. All payers and TPAs must: comply with the health insurance pre-authorization requirement (where applicable) for payment for Long-Term Care in accordance with the patients health insurance product and the provisions as detailed in this Standard; and audit medical records of all Long-Term Care patients as per the specifications of the HAAD Standard Provider Contract and consistent with the care domains and acuity levels detailed in Appendix 1 of this Standard. Page 2 of 11

3 5. Enforcement and Sanctions 5.1. Healthcare providers, payers and third party administrators must comply with the terms and requirements of this Standard, the HAAD Standard Contract and the HAAD Data Standards and Procedures. HAAD may impose sanctions in relation to any breach of requirements under this standard in accordance with Chapter IX HAAD Policy Complaints, Investigations, Regulatory Action and Sanctions, The Healthcare Regulator Policy Manual Version Standard 1: Definitions The following definitions and requirements apply in the interpretation and enforcement of this Standard Long-Term Care is defined as the non-acute treatment, care and support delivered over long-term in an inpatient facility and provided at one of the four levels of treatment and care, as determined and endorsed by the treating physician in accordance with Appendix Treatment and care level must be determined by the assessing/treating licensed physician with input from the multidisciplinary team in accordance with their job duties and privileges assigned in the facility, and in accordance with the criteria provided in Appendix Long-Term Care is a period that can commence at any time in the inpatient hospital/healthcare facility stay, or at admission to inpatient hospital/healthcare facility, as determined by the treating physician and according to the treatment and care levels defined in section 6.1 and the criteria provided in Appendix In order to continue with acute treatment all patients must be assessed against the eligibility criteria at the 30 day point in their stay. If authorization to continue as an acute stay patient is not granted, and the treating specialist physician determines that the patient requires Long Term Care in an inpatient facility then the period of Long-Term Care will commence with referral and recommendation for LTC by the treating specialist physician. The treating specialist physician must document the evidence in support of the referral for LTC Patients who do not require acute care or long term care in an inpatient facility may be considered for healthcare services in the home in accordance with the HAAD Standard for home care. 7. Standard 2: Long Term Care Service Specifications 7.1. Healthcare Facilities providing Long-Term Care must be licensed by HAAD as a hospital (all subtypes), post-acute hospital, rehabilitation facility or nursing home facility. Information on the HAAD Licensure rules can be obtained from the HAAD website: Healthcare professionals - The licensed Healthcare facility must ensure that: All healthcare professionals are licensed by HAAD; They comply with the HAAD Standard for Clinical Privileging framework, including limiting their practice to their job duties, and to their skills and Page 3 of 11

4 competencies and the privileges granted to them within the particular facility with which they are associated; ensure they are operating within their competence at all times the multi-disciplinary team comprises of the necessary personnel and staff including physicians, nursing and allied health professionals with the requisite mix of qualifications, skills and experience to provide Long-Term Care services including but not limited to: Occupational Therapist; Physiotherapist; Speech and Language Therapist; Respiratory Therapist; Nurses; and Pharmacists the responsible treating physician ensures that patients have a care management plan that is tailored to the specific needs of each patient and that is subject to regular review and evaluation; 7.3. Patient rights - The licensed healthcare provider will comply with the HAAD Patient Rights and Responsibilities Policy and Charter, Patient Consent Policy, General Confidentiality Policy, Medical Record Retention and disposal policy and Policy on Cultural Sensitivity and Awareness Standards. In addition, the Provider will provide appropriate information and education to their patients Quality Management and Training - The licensed healthcare provider must follow internationally recognised best practices and review and document the quality and safety of patient care regularly, adjusting their policies and procedures as necessary. 8. Standard 3: Payment for Long-Term Care Services 8.1. Patient eligibility for Long-Term Care shall follow the definition established in Section 6 of this standard; and the patients insurance product Billing and reimbursement of the Long-Term Care shall be in accordance with Standard Provider Contract, HAAD Mandatory Tariff and associated Claims and Adjudication Rules, and the Claims and Adjudication Standard; all documents are available from the HAAD website: Billing and reimbursement of the Long-Term Care shall commence using, Per diem Service Codes as defined in HAAD Claims and Adjudication Rules and Mandatory Tariff in effect; and The selection of the Service Codes (Payment Levels) must be commensurate with the level of intensity of treatment and care determined by the treating physician and in accordance with Appendix 1 of this Standard; Page 4 of 11

5 Appendix 1: Determination of the level of Treatment and Care required using Care Domains and Intensity Criteria 1. This section describes the care domains and level of acuity of care and support in order to assist the treating physician to: Assess the level of care required for patients admitted for LTC; and Determine the re-imbursement rate for LTC patients (per diem service code); 2. Determination of intensity of care for inpatients qualified for LTC will require accurate completion and submission of Table1. All submissions (including step up and step down care) must be accompanied with supporting documentation. Table 1. Scoring mechanism to determine intensity of care Domain of Care Level of Care Pharmaceutical Nutrition Mobility Continence Skin Breathing Cognition Communication ASC Simple Intermediate Intensive N.A N.A Severe 10 3 N.A N.A N.A N.A Total Score Score Intensity of Care Simple Intermediate Intensive Severe Total Score >= Reimbursement of the Long-Term Care will commence using Per Diem Service Codes as defined in HAAD Claims and Adjudication rules and Mandatory Tariff in effect. The selection of the Service Codes (payment levels) must commensurate with the level of intensity of treatment and care determined by the treating physician and in accordance with Table 2. Page 5 of 11

6 Table 2. Care Domain and Level of Acuity and Corresponding Payment Levels Care Domain Level of Acuity and Corresponding Payment Levels Simple (Service Code 17-13) Intermediate (Service Code 17-14) Intensive (Service Code 17-15) Severe (Service Code 17-16) Pharmaceutical Therapies Has a drug regime prescribed by licensed physician; that includes oral pharmaceutical therapy, that: Requires supervision/administration of medication or have Cognitive impairment requiring support to take medication, but is compliant with medication regime. Has a drug regime prescribed by licensed physician; that includes regular IM, IV or SC pharmaceutical therapy, such as insulin; (Statutory dose IM, IV or SC not included.) Pharmaceutical management, which requires daily adjustment of oral medication. Has a drug regime prescribed by Has a drug regime prescribed by licensed physician; that requires licensed physician; that requires: administration and 1. monitoring of medication regime 2. Continuous bedside medical by a registered nurse, because monitoring and management by there are risks associated certified clinicians (physicians or with the potential fluctuation of registered nurses) the medical condition or mental state, or risks regarding the effectiveness of the medication or the potential nature or severity of side-effects. Administration of drugs regime that exceed AED 500 in cumulative cost per day. Administration of drugs or supply (excluding durable medical equipment) regime that exceed AED 2000 in cumulative cost per day. Page 6 of 11

7 Nutrition Needs supervision, prompting with meals, or may need feeding and/or a special diet. Able to take food and drink by mouth but requires additional/supplementary feeding. Needs feeding to ensure adequate intake of food and takes a long time (half an hour or more), including liquidized feed. Unable to take any food and drink by mouth, requires feeding devices (such as PEG) and daily skilled assessment, intervention and review Nutritional status at risk and requiring intravenous fluids management. Completely dependent on Total Parenteral Nutrition (TPN) that requires ongoing, skilled professional intervention and monitoring over a 24hour period to ensure nutrition/hydration Dysphagia requiring skilled intervention to ensure adequate nutrition/hydration and minimize the risk of aspiration. Page 7 of 11

8 Mobility Able to weight-bear but needs some assistance and/or requires mobility equipment for daily living Unable to full weight-bear consistently, requiring skilled intervention for safe gait/mobility management and or pain management. Is able to assist and Cooperate with care givers for transfer and positioning Completely immobile with gross muscle power score 0/5 (absolute absence of any voluntary movement) passive movement, positioning or transfer carries: High risk of serious physical harm, including involuntary spasms or contractures Overwhelming pain on movement needs careful positioning and is unable to cooperate with care givers Continence Continence care is routine but requires monitoring to minimize risks, for example those associated with urinary catheters, double incontinence, chronic urinary tract infections and/or the management of constipation. Continence care is problematic and requires timely and skilled intervention beyond routine care. Problematic could include for example frequent bladder washouts, complex Ostomy care catheter care and manual evacuation of bowel. (for all the elements), requires assessment/re-assessment and current treatment plan from a HAAD licensed Physiotherapist Page 8 of 11

9 Skin integrity High risk of skin breakdown (as per documented risk assessment) requiring skilled assessment and intervention more than once per day, in order to prevent skin damage. Evidence of pressure damage and/or pressure ulcer(s) (Grade 1/4)either with discolouration of intact skin or a minor wound. Requires monitoring or reassessment daily and that is responding to treatment meets at least the below criteria: Size: Length x width is <16sq. cm Depth: partial thickness skin loss involving epidermis and/or dermis Necrotic tissue type: white/grey non-viable tissue &/or non-adherent yellow slough Necrotic tissue amount: <25% of wound bed covered Pressure damage or open wound(s), pressure ulcer(s) (Grade 2/4) which is responding to treatment and requires more than one daily treatment, monitoring/reassessment to ensure that it is responding to treatment. meets at least the below criteria: Size: Length x width is 16.1sq. cm to < 36sq. cm Depth: full thickness skin loss involving damage or necrosis of subcutaneous tissue; may extend down to but not through underlying fascia; &/or mixed partial & full thickness &/or tissue layers obscured by granulation tissue Necrotic tissue type: loosely adherent yellow slough Necrotic tissue amount: 25% to 50% of wound covered Pressure damage or open wound(s), pressure ulcer(s) (Grade 3/4)which is responding to treatment and requires more than one daily treatment, monitoring/reassessment to ensure that it is responding to treatment. Pressure damage or open wound(s), pressure ulcer(s) (Grade 2/4)which is not responding to treatment and requires monitoring or reassessment daily All three of the above must meet at least the following additional criteria: Size: Length x width is 36.1sq. cm to <80sq. cm Depth: obscured by necrosis Necrotic tissue type: adherent soft, black eschar Necrotic tissue amount: 50% to <75% of wound covered Large open wound(s)*, pressure ulcer(s) (exclusive: Grade 3/4 or 4/4) that requires extensive wound care (frequent/ complex/specialist dressing changes and/or wound drain with daily medical monitoring /reassessment) under the supervision of professional and skilled personnel such as physicians or registered nurses (*e.g. large draining wounds, lower extremity non-healing wounds due to severe ischemia, necrotic wounds, post skin flaps/grafts, etc.) meets at least the below criteria: Size: Length x width is >80sq. cm Depth: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures Necrotic tissue type: firmly adherent hard, black eschar Necrotic tissue amount: 75% to 100% of wound covered Page 9 of 11

10 Breathing Cognition Episodes of Shortness of breath that requires medical management/supervision Shortness of breath, which may require the use of inhalers or a nebuliser and limit some daily living activities Requires low level oxygen therapy (24%); room air ventilators via a facial or nasal mask; or other therapeutic appliances to maintain airflow Patient diagnosed with simple Patient diagnosed with Cognitive impairment (example, intermediate Cognitive difficulties in retrieving shortterm memory which requires limited supervision, prompting and /or assistance with activities of daily living, but awareness of basic risks that affect their safety. impairment that requires frequent supervision, prompting and assistance with daily living activities. The individual has limited ability even with supervision, prompting or assistance to make decisions about some aspects of their lives, (impaired ability to selfdetermine) which consequently puts them at some risk of harm, neglect or health deterioration. Is able to breathe independently and requires minimum of 8h of Intermittent mechanical ventilation CPAP (Continuous Positive Airways Pressure) Patient diagnosed with extensive cognitive impairment and complete disorientation to time, place and person that requires supervision, prompting and assistance with daily living activities Requires continuous monitoring (not necessarily bedside); and Assessment, regular review and management by a HAAD licensed specialist/consultant neurologist/ geriatrician or psychiatrist. Completely dependent on continuous (24h/day) invasive mechanical ventilator (Non-invasive mechanical ventilation is excluded) Intermittent invasive mechanical ventilation (less than24h and more than 8h /day) as part of a weaning/ventilator liberation protocol. Patient diagnosed with severe cognition impairment conditions associated with serious threats to health or personal safety or behaviors placing patient at high risk of harm to self or others. Patient Glasgow Coma (GCS) < 8 with a severe reduction in consciousness rendering patient unlikely to be able to maintain their airway spontaneously 1. Requires continuous bedside monitoring; and Page 10 of 11

11 2. Assessment and management by a HAAD licensed specialist/consultant neurologist/geriatrician or psychiatrist Communication Altered State of Consciousness (ASC) Needs assistance to communicate their needs. Special effort may be needed to Communication about needs is difficult to understand or Interpret even when assisted. ensure accurate interpretation of needs or additional support may be needed either visually, Must have at least monthly through touch or with hearing assessment/re-assessment and current treatment plan from a HAAD Licensed Speech and Language therapist Occasional episodes of ASC that Frequent episodes of ASC that require the supervision of a require the supervision of skilled skilled care giver to minimise the care giver. risk of harm. Registered Nurse to minimise the risk of harm Occasional ASCs that require skilled intervention to reduce the risk of harm Unable to reliably communicate their needs at any time and in any way, even when all practicable Steps to do so have been taken. Must have at least assessment/reassessment and current treatment plan from a HAAD licensed Speech and Language therapist. Page 11 of 11