405 IAC 1-3-3 Examples illustrating criteria for level of care; differentiation between skilled and intermediate care

Sec. 3. The following examples illustrate some of the considerations involved in the differentiation between Skilled and Intermediate care. SKILLED CARE INTERMEDIATE CARE Anemia Rapid breakdown of red blood cells which may produce a hemolytic crisis. Treatment – intravenous solutions or transfusions. Frequently present in the elderly. Oral medication or infrequent injections usually sufficient for routine treatment. Arteriosclerosic Heart Disease Severe vascular heart disease requiring powerful antihypertensive drugs. There may be symptoms of heart failure requiring accurate digitalization and diuretics. Minimal or moderate amounts of medication without adjustment to medications. Arthritis Drugs used in large doses and over a prolonged period of time that may produce metabolic or toxic symptoms. Long history of chronic arthritis. Routine medication and physical therapy. Brain Syndromes (Psychoses) Must receive active treatment. (1) Treatment developed by a physician in conjunction with staff members. (2) Services are expected to improve the patient's condition and level of functioning. (3) Services are supervised and evaluated by a physician and documented in the medical record. Therapy not planned for the particular patient. Activities are diversional in nature, i.e., to provide social or recreational outlet for the patient. Non-energetic treatment with medications. Bronchitis (chronic) and Bronchiectasis Limited pulmonary reserve with changes in oxygen requirements. Intractable congestive heart failure. Standard oral medication. Patient has been taught to manage own inhalation equipment. Cataract Skilled care required for 14 days because of very recent surgery or complications. Usually cataract extractions are followed by a normal uncomplicated convalescence in the hospital and discharge to the patient's home. Cancer Recent major surgery. Current treatment with radium, radioactive isotopes, X-ray, and anti-neoplastic agents. Active treatment for serious complications such as severe pain, acute infections, decubiti, fractures, special training while patient learns to handle appliances or surgical wounds, including colostomy. No specific treatment. Considered arrested. If metastasis, the cancer is not being actively treated. Cerebrovascular Accident Hemiplegia and/or speech disturbance. Less than six months since cerebrovascular accident. Active speech or physical therapy. Small cerebral vessel involved with minor paralysis (Ischemia Attacks). Patient can ambulate. More than six months since C.V.A. Cirrhosis of Liver Persistent ascites being treated by diuretics, by paracentesis or both. Bed rest and diet. Moderate use of diuretic drugs. Congestive Heart Failure Patient requires vigorous and comprehensive treatment. Severe shortness of breath, requiring tourniquets on limbs, phlebotomy, or oxygen therapy. Incipient or mild failure with exertional shortness of breath, fatigue, and perhaps edema of the ankles, which usually subside readily with diuretic and digitalis therapy. Convulsions Frequent attacks due to serious brain diseases, such as tumors, cerebral edema, and cerebrovascular accidents. Difficult to control. Infrequent attacks that can be controlled or alleviated by medication. Frequency of once a month will be considered skilled care. Decubitus Ulcer Energetic treatment by debridement of necrotic tissue, medications, and bandages. Tissue necrosis and infection must be actively treated. Minor healing decubiti or skin care to prevent decubiti. Diabetes Mellitus Severe or "brittle" diabetes. Variations in insulin requirements. Also for the juvenile diabetic. Diabetes easily controlled by diet and oral medication or insulin. Emotional Disturbances To control severe agitation or depression for short period of time, large doses of tranquilizers or anti-depressives are required. Close supervision is required (when IM medications are being given daily). Anxiety and depression are not severe. Mental condition does not require close continuous supervision. Emphysema "Respiratory cripple" may show symptoms of respiratory infection, severe bronchial secretion, carbon dioxide retention, and cardiac failure. These symptoms require energetic medical treatment. Symptoms of wheezing, chronic cough, and mild dyspnea which do not require special treatment by skilled personnel. Patient may require IPPB treatment for a period. Fractures Many factors are involved in the amount of skilled care patient requires. Care depends upon the location of the fracture, the degree of healing, the type of treatment, and the severity of any complications. The healing process is almost complete. Restorative physical therapy may be necessary. Hypertensive Heart Disease Vigorous and diligent treatment for patient showing cerebral signs (encephalopathy) strokes, transient hemiparesis, cardiac insufficiency, coronary ischemia, and severe headaches not controlled by routine analgesics. Patient has been on long-term antihypertensive therapy or alarming symptoms are absent and the patient is not under vigorous treatment. Malnutrition Condition is so serious that patient requires frequent visits by his physician. I.V. or tube feedings generally required. Patient's poor eating habits are corrected by special diets. Myocardial Infarction Recent infarction. Relative rest for the injured heart. Possible congestive heart failure. Attack over 2 – 3 months ago. Routine prophylaxis (anti-coagulants) against thromboembolic complications. Heart compensating. Nephritis, Nephrosclerosis, Nephroses Acute phase of these conditions requires active therapy. In the chronic state they may require special treatment for heart failure, electrolyte abnormalities, acidosis and uremia. Many elderly patients suffer from renal diseases. Treatment often is a dietary regimen and diuretic drugs. Osteoporosis Collapse and wedging of the atrophic vertebral bones may appear under minimal stress. Skilled care will be required to treat the fracture or alleviate the pain. This condition is found in many elderly people. Oral medications may be administered.