Ask Proactive – We have a current patient receiving rehabilitation following a stroke. Her family signed her out for their Thanksgiving holiday meal, but kept her out overnight and didn’t return until the following evening. Her family is already asking how long they can have her out for attending their Christmas celebrations. We’re questioning if she can remain skilled if her family is able to care for her outside our SNF.

We have a current patient receiving rehabilitation following a stroke. Her family signed her out for their Thanksgiving holiday meal, but kept her out overnight and didn’t return until the following evening. Her family is already asking how long they can have her out for attending their Christmas celebrations. We’re questioning if she can remain skilled if her family is able to care for her outside our SNF.

A:

Chapter 8 of the Medicare Benefit Policy Manual addresses SNF patient leaves within Section 30.7.3, Whether the Patient’s Physical Condition Would Permit Utilization of an Available, More Economical Care Alternative. The interdisciplinary team must determine whether the daily skilled care needed by the individual can only be provided in a SNF on an inpatient basis. If the team determines the patient does require ongoing daily skilled care, as a practical matter, the decision must be well documented. For example, would the availability of willing family be ineffective because the patient would have insufficient assistance to safely reside at home with home health care once her children have returned to their home after the holiday? The team must also consider the time requested and whether the leave would increase risks for the patient without receiving daily skilled therapy services. I encourage the interdisciplinary team to read through Medicare guidance as you are reviewing this case to make a determination regarding the need for skilled services.

MBPM Ch 8 Sec 30.7.3:

The “practical matter” criterion should never be interpreted so strictly that it results in the automatic denial of coverage for patients who have been meeting all of the SNF level of care requirements, but who have occasion to be away from the SNF for a brief period of time. While most beneficiaries requiring a SNF level of care find that they are unable to leave the facility, the fact that a patient is granted an outside pass or short leave of absence for the purpose of attending a special religious service, holiday meal, family occasion, going on a car ride, or for a trial visit home, is not, by itself evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care. Where frequent or prolonged periods away from the SNF become possible, the A/B MAC (A) may question whether the patient’s care can, as a practical matter, only be furnished on an inpatient basis in a SNF. Decisions in these cases should be based on information reflecting the care needed and received by the patient while in the SNF and on the arrangements needed for the provision, if any, of this care during any absences.