D.1 - VANHE110 DEPARTMENT OF VETERANS AFFAIRS (VA) COMMUNITY NURSING HOME PROGRAM LEVEL OF CARE - DESCRIPTIONS.docx

D.1 DEPARTMENT OF VETERANS AFFAIRS (VA) COMMUNITY NURSING HOME PROGRAM LEVEL OF CARE - DESCRIPTIONS Level of Care determinations are based on the VA Resource Utilization Groups (RUGS-III) case-mix, the industry standard. See {PATRICK....CFR CITATION. A case-mix system categorizes patients into groups according to their level of care needs. RUGS-III, like other case-mix systems, defines patients for clinical and reimbursement purposes.

Additional information on RUGS III use for VA purposes can be acquired from the Contracting Officer in concert with the appropriate VA community health official.

****CO should apply the rates associated with the following VA levels of care when using comparable local state levels of care. Rates for private care nursing homes should be approved in accordance with M 5, Part II, Chapter 3, paragraph 3.16.

Reduced Physical Functioning Group: RUG Scores. These residents have care needs primarily of activities of daily living and general supervision. ****CO is reminded that rates should be appropriately reduced below the "Clinically Complex" rate. See rate chart on CNH Program Website.

Impaired Cognition Group: RUG Scores: These residents have cognitive impairment in decision-making, recall and short-term memory.

Clinically Complex Group: RUG Scores: These residents receive complex clinical care or have conditions requiring skilled nursing management and interventions for conditions and treatments such as burns, coma, septicemia, pneumonia, foot infections or wounds, internal bleeding, dehydration, tube feeding, oxygen, transfusions, hemiplegia Special Care Group: RUG Scores These residents receive complex clinical care or have serious medical conditions such as multiple sclerosis, quadriplegia, respiratory therapy, ulcers, stage III or IV pressure ulcers, radiation, surgical wounds or open lesions, tube feeding and aphasia, fever with dehydration, pneumonia, vomiting, weight loss or tube feeding.

Extensive Services Group: RUG Scores: These residents receive complex clinical care or have complex clinical needs such as IV feeding or medications, suctioning, tracheostomy care, ventilator/respirator and co-morbidities that make the resident eligible for other RUG categories.

Rehabilitation Group: RUG Scores. These residents receive physical, speech or occupational therapy. Therapy must be ordered by a VA physician for a specific period of time, not to exceed one month. Orders may be recertified. A copy of the therapy notes will be sent to the VA facility each month. ****CO is reminded that rates may not exceed .

Rehabilitation Plus Extensive Services Group: RUG Scores These residents receive physical, speech or occupational therapy AND receive IV feeding or medications, suctioning, tracheostomy care or ventilator/respirator.

Ventilator Dependent Care: Level of care is self explanatory. This level of care is used in cases which cannot be covered by the ventilator care rates outlined above. ****CO should know that, given the high cost of ventilator care, rates for this level of care require approval of the Chief Consultant, Geriatrics and Extended Care Group.

HIV+/AIDS Care: Specialized services for HIV+ and/or AIDS patients. May be specialized program care of an individual patient. ****CO is reminded that rates may not exceed 80 percent of the "basic care" rate without approval of the Chief Consultant, Geriatrics and Extended Care Group. See M 5, Part II, Chapter 3, paragraph 3.13D.