Does the patient leave home fequently for non-medical purposes?
- NO (any character) causes a
transition to the Requires Assistance
state.
- YES leads to the
Not Eligible
Does the patient require assistance when leaving home?
- NO (any character) is
allowed.
- YES (any character) causes a
transition to the Considerable Effort
state.
Does the patient require considerable and taxing effort when leaving home?
- NO (any character) is
allowed.
- YES (any character) causes a
transition to the Skilled Nursing
state.
Does the patient have a skilled need for nursing?
- NO (any character) is
allowed.
- YES (any character) causes a
transition to the Assess Skilled
state.
Continue to assess for PT or ST skilled need
- NO (any character) is
allowed.
- YES (any character) causes a
transition to the Assess Skilled
state.
Make a referral for skilled nursing care
Make a referral for therapy services
Not Eligible for Referral
Not Eligible for Referral
Not Eligible for Referral
Not Eligible for Referral
A need for Skilled Nursing Services may occur due to one or more of the following:
* Hospitalization
* Recent, New, or Exacerbated DX
* Change in Medications in the last 60 days
* New Medication in the last 30 Days
* Change in Primary Caregiver with a knowledge deficiency
Skilled Nursing Care related to a treatment of an illness or injury that must be performed by a nurse:
* Medication Administration (other than oral)
* Parenteral/Enteral Nutritional Support
* Urinary Catheter Care
* Diabetic Care
* Wound Care
* IV Therapy
Does the patient require PT or ST due to the following:
* Recent marked decline in functional status
* E.g. speech, ambulation, strength, endurance
* Recent falls, fractures, stroke
* Need for Home Maintenance Program to maintain current level of function