This applies to all states
When planning for a Medicare or Medicare Advantage patient to discharge to home, it is important to consider what services the patient does and does not need. Sending a one size fits all order to your home health partners is not doing them any favors. When determining the patient’s needs, establish if they meet the basic Medicare criteria for home health: Beneficiary is ‘Homebound’ and ‘Beneficiary has a ‘Skilled Need’. Homebound does not mean bedbound but rather leaving their home would require considerable and taxing effort. If they are able to drive or go to the store as a daily activity, for example, they may not qualify as homebound.
Ordering a ‘laundry list’ of services such as Medical Social Worker, RN nursing, PT, OT and home health aide requires the agency to evaluate for the services to remain compliant with the orders or seek to do a change order. Be specific about the services needed; if it is determined that additional services are needed, the Home Health Agency can make the request to the physician following the patient in the home setting.
For Medicare Advantage plans, the process for engaging home health can vary. Ask the plan’s concurrent review nurse for direction or reach out to your MCCFL Liaison for assistance.
VA Community Care Network
This applies to all except Texas
The VA Community Care Network (CCN) is the VA’s link with your community providers to ensure Veterans receive the highest quality care. CCN is comprised of six regional networks covering all of the United States and territories. Optum, part of the United Health Group, has partnered with the Department of Veteran Affairs through the VA’s new Community Care Network. Optum has been named as the TPA for the CCN network as of December 2018 for Regions 1,2 and 3. CCN is rolling their programs out through each of these regions. While facilities may hold the CCN contract, their particular county may not have the CCN in place. Working with your areas VA Case Manager and your MCCFL Liaison will be the fastest and easiest way to expedite current information and potential admissions. Once the VA Community Care Network is fully implemented, it will be the preferred national network the VA uses to assist Veterans with their continual needs in their community.