Adult subacute care is a level of care that is defined as a level of care needed by a patient who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility.

Pediatric subacute care is a level of care needed by a person less than 21 years of age who uses a medical technology that compensates for the loss of a vital bodily function.

Subacute patients require special medical equipment, supplies and treatments such as ventilators, tracheostomies, total parenteral nutrition, tube feeding and complex wound management care.

The primary care physician (PCP) continues to provide care during the transition to subacute care, and coordinates with the Subacute attending physician to ensure continuity of care. This includes forwarding all pertinent records to the new PCP when identified and available to consult.

Medi-Cal members who reside in a Subacute Care Facility for long-term care beyond the month of admission plus one month, are deemed permanently institutionalized. These members are reassigned from their participating physician groups (PPGs) to Health Net for utilization management upon Health Net's evaluation that the member is deemed permanently institutionalized and qualifies for reassignment. PPGs are responsible for subacute members until they are no longer listed on their monthly eligibility reports.

Health Net must authorize subacute long-term care services when a member has a medical condition that requires subacute level of care. Subacute care includes both skilled nursing care and non-skilled care, specific to out-of-home protective living arrangements with 24-hour supervised or observation care on an ongoing intermittent basis to abate deterioration.

Members in need of Subacute care services are placed in facilities providing the level of care commensurate with their medical needs.

Adult subacute level of care refers to very intensive, licensed, skilled nursing care provided to members who have a fragile medical condition. To qualify for the adult subacute program, the member must require at least four hours of direct skilled nursing care per day and at least one of the following:

• Tracheostomy care with continuous mechanical ventilation for at least 50 percent of the day
• Tracheostomy care with suctioning and room air mist or oxygen as needed, and one of the six treatment procedures listed below; or
• Administration of any three of the six following treatment procedures:
  • total parenteral nutrition
  • inpatient physical, occupational or speech therapy at least two hours per day, five days per week
  • tube feeding (nasogastric or gastrostomy)
  • inhalation therapy treatments every shift and a minimum of four times per 24-hour period
  • intravenous (IV) therapy involving one of the following:
    • continuous administration of a therapeutic agent
    • hydration
    • frequent intermittent IV medication administration via a peripheral or central line (heparin lock)
  • wound debridement, packing and medicated irrigation with or without whirlpool treatment

One of the criteria Health Net uses to determine medical necessity is the Department of Health Care Services (DHCS) Manual of Criteria for Medi-Cal Authorization (PDF).

To qualify for the pediatric subacute care program, the member must be under age 21 and need one of the following:

• Tracheostomy care with dependence on mechanical ventilation for a minimum of six hours each day
• Tracheostomy care requiring suctioning at least every six hours, room air mist or oxygen as needed, and dependence on one of the four (2-5) treatment procedures listed below
• Total parenteral nutrition or other intravenous nutritional support and one of the five treatment procedures listed below
• Skilled nursing care in the administration of any three of the five treatment procedures listed below

Treatment Criteria for Pediatric Subacute Care

1. Intermittent suctioning at least every eight hours and room air mist or oxygen as needed.
2. Continuous intravenous therapy, including administration of therapeutic agents necessary for hydration or of intravenous pharmaceuticals, or intravenous pharmaceutical administration of more than one agent via a peripheral or central line without continuous infusion.
3. Peritoneal dialysis treatment requiring at least four exchanges every 24 hours.
4. Tube feeding via nasogastric or gastrostomy tube.
5. Other medical technologies required continuously, which, in the opinion of the attending physician and Medi-Cal consultant, require the services of a professional nurse.

• The intensity of medical/skilled nursing care required by the member is such that the continuous availability of a registered nurse in the pediatric subacute unit is medically necessary to meet the member's health care needs and not be any less than the nursing staff ratios required.
• The member's medical condition must have stabilized so that the immediate services of an acute care hospital, including daily physician visits, are not medically necessary.
• The intensity of medical/skilled nursing care required by the member is such that, in the absence of a facility providing pediatric subacute care services, the only other medically necessary inpatient care appropriate to meet the member's health care needs under the Medi-Cal program is in an acute care licensed hospital bed.

One of the criteria Health Net uses to determine medical necessity is the Department of Health Care Services (DHCS) Manual of Criteria for Medi-Cal Authorization (PDF).