Subacute Care Facilities
Provider Type
- Physicians and Practitioners
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Members in need of adult or pediatric subacute care services must be placed in a health care facility that is licensed for subacute care with the California Department of Public Health and providing the level of care commensurate with their medical needs.
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.
Coordination of 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 (attending in subacute facility) when identified and available to consult.
Long-Term Care for Permanently Institutionalized
Medi-Cal members residing in a Subacute Care Facility with institutional status, as indicated by long-term aid codes, are considered permanently institutionalized if their inpatient stay continues beyond the initial month of admission and the expected subsequent month. PPGs remain responsible for Subacute members until those members are removed from 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.
Members in need of Subacute care services are placed in facilities providing the level of care commensurate with their medical needs.
Criteria for Adult Subacute Care Program
Adult subacute level of care refers refers to the level of care required by a patient who does not require hospital acute care, but who requires a more intensive level of licensed skilled nursing care than is typically provided to the majority of patients in a skilled nursing facility. To qualify for Subacute level of Care, the member must require twenty four (24) hour access to nursing care by registered nurse for services available in a general acute care hospital including but not limited to the following:
Topic | Description |
|---|---|
Tracheostomy/Mechanical Ventilation | Tracheostomy care with continuous mechanical ventilation for at least 50 percent of the day; OR Tracheostomy care with suctioning and room air mist or oxygen as needed, and one of the six treatment procedures listed below. |
Treatment Procedures (Administration of any three of the six treatment procedures listed) | Administration of any three of the following treatment procedures:
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The criteria Health Net uses to determine medical necessity for Subacute services is Title 22 Chapter 7 of theDepartment of Health Care Services (DHCS) Manual of Criteria for Medi-Cal Authorization (PDF). California Code of Regulations (CCR), Title 22, Section 51124.5.
Criteria for Pediatric Subacute Care Program
To qualify for the pediatric subacute care program, the member must be under 21 years of age and require services consistent with the criteria outlined below. For complete criteria, refer to California Code of Regulations (CCR), Title 22, Section 51124.6.
Topic | Description |
|---|---|
Mechanical Ventilation | Tracheostomy care with dependence on mechanical ventilation for a minimum of six hours each day. |
Tracheostomy with Suctioning | Tracheostomy care requiring suctioning at least every six hours, room air mist or oxygen as needed, and dependence on one of the treatment procedures listed in items 2 through 5 below. |
Total Parenteral Nutrition (TPN) | Total parenteral nutrition or other intravenous nutritional support and dependence on one of the treatment procedures listed in items 1 through 5 below. |
Skilled Nursing with Multiple Treatments | Skilled nursing care in the administration of any three of the treatment procedures listed in items 1 through 5 below. |
Treatment Procedures (Items 1–5) | Dependence on the following:
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The criteria Health Net uses to determine medical necessity for Subacute services is Title 22 Chapter 7 of theDepartment of Health Care Services (DHCS) Manual of Criteria for Medi-Cal Authorization (PDF). California Code of Regulations (CCR), Title 22, Section 51124.6