How often should the LTCCN RN and CM communicate?
At a minimum the LTCCN RN and CM must communicate every six months before the CM authorizes the next six months of service. The best practice is to use the information on the Nursing Service Summary (SDS 0752) as a guide for checking in with the nurse.If the CM wants more information on an event the CM should contact the nurse. Guidelines for communication include:
- Both the case manager and the nurse will contact each other in a timely manner whenever they become aware of a change of condition (see the referral list) or the individual needs more intensive medical supports such as hospitalization, a referral to specialist or a change in physician services.
- Frequent communication by email is encouraged as the case manager can easily add these information to the ACCESS narrative.
- Scheduling of face-to-face meetings must factor in the case manager’s workload, schedule and the fact that nurses do not get paid for travel time.
- Problems or concerns that either the nurse or case manager has regarding communication must be immediately brought to management attention.
Do I need secure email to communicate with
Provider must provide all written, and electronic information regarding individuals
to comply with HIPAA, and must use a secure email system, refer to OAR
What if the LTCCN RN needs an interpreter to
provide nursing services?
nurse needs an interpreter to provide nursing services such as teaching or
delegation for the individual or caregivers, the nurse should contact the CM to
arrange interpreter services; the nurse should not arrange for interpreter
services without contacting the CM.
What if the RN stops communicating with me
or stops providing me with documentation concerning my individual?
If a LTCCN
RN stops communicating with you or stops providing you with documentation at
the visitation frequency identified
on the Nursing Service Plan, contact the RN directly and ask why there
has been no documentation or communication concerning your individual. Long
Term Care RNs are required to submit a completed RN Services Summary to you for
every individual encounter. If you cannot reach the LTCCN RN alert local
How does the RN know if an individual has been moved to
another service location or is no longer eligible?
Nurses always need to check the MMIS web portal
before providing services to verify that the person is eligible. Case managers and LTCCN RNs are expected to
communication to each other if either of them become aware of changes in an
individual’s health conditions that would impact the nursing service plan.
Can the LTCCN RN and Case Manager review service plans
over the phone?
face meetings are optimal for the six month Nursing Service Plan reviews of
nursing service plans especially if either the individual or the nurse is new
to the case manager, however the LTCCN RN and CM may mutually agree to conduct
the review by phone. A face to face
meeting ensures that you and the nurse have a common understanding of the individual’s
needs and how the nurse plans to meet these needs. It is easier to ask the nurse for
clarification or additional information if the meeting is face to face.
Delegation of a
nursing task is a legal procedure overseen by the Board of Nursing (OAR
851-047). Delegation means the nurse provides training and supervision to ensure
that the individual receives safe ongoing provision of a specific nursing task
by a qualified caregiver. ‘Nursing’
tasks are activities that must be delegated if performed by non- family members
without a nursing license. Tasks might
include subcutaneous insulin injection, tracheotomy care and suctioning, and
the administration of nutritional supplements, medications and hydration
through a gastrostomy tube. Nurses have
sole authority whether to perform delegation or not and it must be limited to individuals
with stable health conditions. Each
delegation is performed by a specific nurse and is focused on a specific task,
delivered by a specific caregiver to a specific individual. The delegation
process must be restarted if any of these components changes (the task, the
caregiver, the individual or the nurse). Nurses are expected to use forms of their
choice to document delegation and teaching activities.
What is the difference between teaching and delegation?
Teaching is a much
broader range of activities that can be provided to a group of care givers or
to an individual. Teaching can be
specific to a person or a health condition.
Teaching can be provided to one or a group of caregivers. Teaching can support a range of tasks that individuals
may need to prevent, minimize or manage a health problem. Examples of teaching
tasks include administration of oral medications, capillary blood glucose
(CBGs) levels or transfer techniques. Nurses who provide teaching must be aware
of and uphold the licensing standards of the setting where the individual lives.
Although teaching can be informal and provided whenever a nurse is in an
individual’s home there should also be a goal, strategy and end date so that
the nurse and the case manager can determine if the teaching is effective. If there is no impact on the individual or
caregiver as a result of the teaching and no further strategies can be
identified then the nursing service may need to be discontinued.
What type of documentation should I expect
from a RN after I authorize Long Term Care RN services?
There are two
required forms that the nurse completes: The APD Long Term Care Community Nursing
Service Plan (SDS 0754) and the
APD Long Term Care Community Nursing Services Summary (SDS 0752). The purpose of these forms is to ensure that
the RN communicates information to you.
The documentation entered on each form
is required to be legible and easily understood. The RN is not to use medical
abbreviations, medical terminology or jargon. If you find that the RN is not
willing to document in a manner that helps you understand their services,
immediately let your manager or the LTCCN Program Coordinator know of the
communication problems. The nurse must
also complete SDS 4102 as part of
the authorization process.
expect to receive a current Nursing Service Plan each and every time a RN
makes updates to the Service Plan and when there is a request for Prior
The APD Long Term
Care Community Nursing Service Plan (SDS 0754) is a required form
and is intended to communicate the individual’s health issue, the desired
outcomes for that issue and the specific activities that the nurse will be
providing for your individual to help the individual get to these outcomes, and
needs to be individualized to the individual’s needs. The LTCCN RN also uses the nursing service
plan (SDS 0754) to communicate to the CM:
delegation is needed, and the estimated service units for delegation.
frequency of monitoring visits
The APD Long Term
Care Community Nursing Services Summary (SDS 0752) is a required form
and is to be completed by the RN for all individual encounters; i.e., a
professional services visit to your individual's home, attendance at individual
care team or individual support plan meetings, for any telephone consultation
with the individual, the CM or another care team member concerning the individual. The summary should address:
current health status
summary of the services provided to your individual on that date of service
proposed actions that the RN and/or you should take as a result of the services
provided that day
of reassessment and updated service plan if these activities were performed.
What documentation does the nurse leave at
the foster home and ‘in home’ settings?
must leave any instructions regarding teaching, delegation and reporting
expectations that are needed to assure the individual’s health and safety. Nurses must leave an entry in individual’s
AFH care plan or whatever log system is set up in an individual’s ‘in-home’
setting so that it’s clear to persons working in the home when they were there
and what services they provided. Nurses
who do not feel they can leave documentation at the individual’s home must
communicate their concerns with the case manager and together develop an
What other documentation should a RN be
independent licensed contractors, the Long Term Care RNs have to meet
documentation standards in the State Board of Nursing rules governing their
nursing license; this is called ‘nursing practice’. APD does not have the authority to define
these practices. Our forms are designed only to help the nurses summarize ‘nursing
practice’ for the case managers and to provide documentation that can support
their Medicaid claims. Nurses may
create additional documentation to meet their business and licensure
obligations. A RN's documentation of nursing practice is
what the RN generates to meet nursing professional nursing standards and to
promote the safe support of the individual in the home environment. You always
have the authority to request all of the nurse’s documentation of nursing
practice for your individual in the areas of individual assessment, nursing
care plan, medication reviews, monitoring, care coordination, teaching and
delegation. If the RN declines to comply
with your request, contact the LTCCN Program Coordinator.
How long do I keep the documentation that is
given to me by the Long Term Care Community RN?
office must retain LTCCN RN documentation for seven years. Contractors should
refer to 411-048-0200 (1) (6) and their contract for requirements of
Can I ask a contractor to type the required forms for
LTC Community Nursing?
contractor is not required to type the required forms, however, regardless if
the forms are typed or handwritten, all of the forms and notes provided to the
CM must be legible and must not contain medical or nursing, technical terms or
abbreviations. If the CM doesn’t understand the RN notes, they need to contact
the RN to get clarification. If that doesn’t resolve the problem the CM
should notify their manager and the manager can contact the LTCCN Program
Coordinator and the coordinator will go over the program expectations with the
Can contractors use electronic signatures for the
LTCCN required forms?
Is there a form for the RN Assessment?
nursing assessment is part of the practice of nursing that is dictated by the
State Board of Nursing we do not provide the nurses with a required form. The Board of Nursing has detailed standards
regarding what is covered and what must be documented. RN’s can use tools of their choice to comply
with this basic nursing practice but must attach for the case manager the
that the document is a RN Assessment
of to whom the Assessment was distributed and date of distribution
of the individual (Name, address, I.D. number, etc)
statements in layperson language of the findings regarding the four issues
of the Long Term Care Community RN and In-Home/HH Agency if applicable
of the evaluation
information is attached to the Nursing Service Plan. If the nurse determines that based on the
assessment that the individual does not need RN services the nurse must be paid
for the time spent making this determination and the Assessment documentation
can be attached to the original referral since there will be no Nursing Service
How do I know if a person is eligible to receive Long
Term Care Community Nursing services?
Individuals must be eligible for either an APD
or DD waiver and receive services in the following settings or programs:
In-Home Services; Comprehensive
In-Home Support for Adults with
Developmental Disabilities; Adult
Foster Homes for Person with Developmental Disabilities; Foster Homes for
Children with Developmental Disabilities, Adult Foster Homes for Aging or
Persons with Physical Disabilities, Independent Choices, or State Plan Personal
Care Services. Settings such as
ventilator homes where persons receive nursing as part of a contracted or
enhanced rate would not be eligible.
Is an individual who receives State Plan Personal Care
(SPPC) services eligible for LTCCN RN services?
Yes, SPPC participants are eligible to receive
LTCCN services, if they meet the other eligibility requirements in OAR
When should I make a referral?
following section identifies reasons why a referral may be made to a
nurse. Services are expected to be
provided in a person centered manner including the individual with a focus on promoting
self-management of the health condition(s) whenever possible. Items marked with
an * indicate situations where the physician should be informed by the nurse,
foster home provider or case manager of the change in health status.
- Need for consumer, family member or care provider
- Delegation is needed for a nursing care task. Nursing care tasks are defined as tasks that
are taught in Schools of Nursing and not performed by the general population.
After an assessment, the nurse would be expected to either ‘teach’ family
members or the individual to perform the nursing task or ‘delegate’ the task to
a paid care provider. The nurse will need to follow this case as long as the
delegation is in effect.
- Medication safety issues or
- *Unexpected increased use of emergency care,
physician visits or hospitalizations. RNs can help the caregivers and case
manager evaluate the placement and ensure that the caregivers have the skills
they need to meet the individual’s needs.
When this situation occurs with an individual who already has a nurse, the
nurse may need to do a Reassessment and provide an updated Nurse Service
- *Changes in behavior or cognition. A RN can
help the caregivers or individual communicate in a manner to ensure the primary
care physician receives relevant information, PRN parameters are clearly
understood and that medications are not used as chemical restraints or for
caregiver convenience. The nurse can assist the caregivers in developing a
positive behavior support plan if the person does not have a Behavior
Consultant or a mental health provider. Individuals who are assessed as a full
assist in cognition may need this type of referral.
- *Nutrition, weight, or dehydration issues.
RNs can help the caregivers or individual communicate effectively to ensure
that physicians and registered dieticians receive relevant information. . The nurse can assist the caregiver and individual
with identification of strategies to help promote adherence to a therapeutic
lifestyle and dietary orders.
- *Pain Issues. The RN can help the caregivers or individual communicate effectively to ensure the primary care provider has all
relevant information related to the underlying potential causes of the
pain. The RN can provide teaching on the
of pain management, including administration of pain medications, use of PRN
medications, safe management of narcotics, assessment of interventions, use of
pain severity scales and how to report pain related issues/concerns.
- *History of recent, frequent
RN would be expected to examine the
reason for the falls, provide a safety assessment of the home, educate
the individual and/or caregivers about mobility safety, fall prevention, when
to access medical care and when to access 911 services. The RN can help the caregivers or individual communicate effectively to
ensure the primary care provider has all relevant information related to the
- *Potential for skin breakdown
or recently resolved skin breakdown. LTCCN RNs would not be used to manage complex
wound care or deteriorating skin conditions, such as advanced pressure
ulcers. A LTCCN referral may be done if
the caregivers or individual need help with ongoing interventions designed to
prevent future problems or maintain a stabilized skin condition.
- Not following medical advice. If an individual refuses
medications or therapies , all parties (nurse, caregiver, foster home provider,
case manager and primary care provider) need to closely coordinate and ensure
the individual understands the risks. A
LTCCN referral may be helpful in these situations, as a nurse may help the individual
identify and communicate what is preventing him or her from following through
with the needed interventions. Through
teaching, the nurse can help identify solutions to provide the individual with
more acceptable interventions. Nurses may refuse to accept or continue with the
case unless there is a strong team approach and it’s clear that the individual can
provide informed consent.
Can individuals receive LTCCN services if they have no
Individuals may receive teaching and nursing
supports if they are in any of the eligible benefit programs. Most persons who are in these programs
require supports from family members, friends or paid caregivers, however an
eligible individual without caregivers may receive LTC Community Nursing services.
Can individuals receive LTCCN services while they are
in a hospital or nursing home?
It depends on whether the case manager has ended
their Home and Community Based Care (HCBC) benefit. If a person the nurse has been seeing has to
go to another care setting, the nurse should check with the case manager to see
if they should continue to provide Care Coordination, transition/discharge
planning etc while the individual is in the hospital. If the HCBC benefit has been closed, the
LTCCN RN cannot be paid for services, so in most cases this will not be
Can an individual decline RN services?
An individual with the ability to make an
informed decision has the right to decline RN services. If the case manager
feels that the individual's decision to decline LTCCN RN services jeopardizes
their health and safety then you must communicate these concerns to their
manager. In some situations this
decision may create the need for a new placement if the absence of nursing
supports will create licensing problems for the foster home provider or a
significant deterioration in the individual’s health status.
Can an individual receive Home Health or Hospice
nursing and LTC Community Nursing?
When an individual’s condition deteriorates to an unstable, fluctuating or
unpredictable status and will require nursing from home health, hospice or an
In-Home agency the case manager should be informed. An assigned LTCCN RN might
continue to provide the supports in the individual’s LTCCN nursing service plan
during a period of deterioration while the person is also receiving different
short term nursing services for the acute condition. In these situations the
two RNs are expected to coordinate the services they provide to ensure there is
no duplication of nursing services.
Coordination might include sharing their service plans and establishing
points of communication such as notification when the short term nursing
What if my individual who has RN services
goes on Hospice?
When an individual
who is receiving RN services goes on Hospice, you as a case manager must
determine if the Hospice program will be providing all nursing services
for the individual including any teaching or delegation that the individual or
his/her caregivers will need. If the
Hospice program is providing an ongoing nurse to the individual’s case then the
APD funded RN services must end. Hospice
is funded to provide a full range of nursing supports; including assessment and
planning, directions for seeking medical care, delegation and training for care
providers, coordination for equipment needs, review of medications and other
orders, pain management and comfort measures, anxiety management and direct
services. If an individual stabilizes and Hospice services are stopped, then
you may need to restart the RN service.
Contact your local manager if you have an unusual situation where you
think both nursing services may be needed.
Can an In-Home individual who receives
services from a contracted In-Home Agency also receive LTC Nursing Services?
LTCCN RNs can be assigned to in-home individuals
only if the individual has a Home Care Worker(s)(HCW) providing services in
addition to the employees of the In Home
Agency and the HCW has to perform a delegated task. The LTCCN RN would not provide
delegation to employees of the In Home Agency, and would only provide
delegation to the HCW(s). In these
situations the LTCCN RN would be expected to use Care Coordination time to
coordinate teaching, delegation instructions and nursing service plans with the
nursing services the Agency is providing, and document that coordination. If an In Home Agency refuses to provide
nursing services including delegation for their employees for any individuals
they have accepted for In Home agency services then the person’s case manager and
the In-Home Agency Program Coordinator need to be notified.
Can a contracted
In-Home Agency provide delegation or teaching for CEP/HCW providers if the
In-Home individual they are serving has both agency staff and CEP/HCW
this time, an In Home agency that provides In Home agency services to individuals
cannot provide LTCCN RN services for any individuals they serve, even if
those same individuals have CEPs/HCWs.
What is the geographic area that an In-Home Care
agency or Home Health agency can provide LTC Nursing Services?
The Long Term Care (LTC) Community Nursing has contracted with several In-Home Care Agency (IHCA) and Home Health (HH) agencies to provide LTC Community Nursing Services subject to the standards in OAR 411-048-0210.
IHCA and HH agencies are licensed by OHA, Public Health, Health Care Regulation and Quality Improvement (HCRQI), and licensing standards do not allow IHCA or HH agencies to provide nursing services more than 60 miles from the agency’s “parent” agency office.
It is the responsibility of the IHCA/HH agency to screen a client referral and
ensure the location of the referral meets their licensing requirements.
If a IHCA/HH agency contracted to provide LTC Community Nursing Services
is interested in a possible mileage waiver, the agency should be referred to APD’s
LTC Community Nursing Program Coordinator, to coordinate with the OHA, Health Care Regulation and Quality Improvement Program
Can a Home Health
agency providing LTCCN services to a client provide Home Health nursing for
that same client?
Yes. The Home Health
RN and the RN providing LTC Community Nursing Services must coordinate and
clearly document the services they are providing to ensure there is no
duplication of nursing services.
What kinds of nursing services are provided by a LTC
services provided under this program focus on teaching and supporting the
person or the person’s caregivers to
ensure that the person’s health needs are supported. These nurses do not duplicate or replace the
nursing services provided through home health, hospice, hospital or other
clinical settings. While the LTCCN RN
may be teaching or delegating caregivers to provide direct hands on nursing
tasks LTCCN RNs cannot provide these tasks themselves. The nursing
services they provide include:
- Review of referrals from case managers.
- An assessment of an individual's
ongoing health support needs.
- Based on this assessment the nurse
creates a nursing service plan which describes the activities they
will provide to address these needs. All plans must include a medication
- This plan must include an estimate of
the hours of specific services they will need the case manager to prior
- Provide the referring case manager with
ongoing nursing service summaries documenting the monitoring, teaching
and/or delegation, and care coordination activities they have
What services cannot be provided by a LTC
The RN cannot provide the following services:
to support unscheduled/emergency placements. This is not a crisis service.
of medically unstable or fluctuating conditions that are unpredictable or which
require frequent or ongoing nurse assessment or judgment
or health care services in lieu of those that should be provided by a medical
provider or other licensed or certified practitioner.
hands-on nursing care or an ongoing nursing task cannot be performed except in
isolated situations that are prior authorized by management at both the
local and state levels.
individuals in their cars.
activities such as corrective action, licensing, protective services
investigations, individual welfare checks, nursing facility pre-admission
screenings, eligibility determinations,
rate setting or case management services.
audit, review or to "check up" on the services provided by another
RN. However, nurses may be assigned and paid as mentors for newly contracted
nurses with authorization by central office.
manager assessments. However nurses who
have completed an initial assessment and nursing service plan on an individual
may be asked by the case manager to participate in interdisciplinary planning
or to consult on development of a placement plan.
medical appointments or coordination of medical services unless prior
authorized by a case manager. If the
nurse is going to provide this type of medical support services the case
manager must provide clear documentation why either the foster home provider,
paid caregiver or Oregon Health Plan provider cannot provide these
supports. These coordination activities
should be listed on the Nursing Service Plan.
What should a RN Nursing Assessment tell me?
The nursing assessment is the nursing
process used to collect information about your individual and their living
environment. At a minimum the nursing assessment should review:
individual's health support needs related to both the reason and other known
environmental concerns that prevent challenges to health or safety
individual's key health beliefs and health behaviors including behaviors that
create potential and current risk to the individual.
teaching or delegation needs that need to be addressed.