WSR 05-15-148

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed July 19, 2005, 4:20 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 04-07-114.

Title of Rule and Other Identifying Information: Part 3 of 3, new sections WAC 388-551-1800 Pediatric palliative care (PPC) case management/coordination services -- General, 388-551-1810 Pediatric palliative care (PPC) case management/coordination services -- Client eligibility, 388-551-1820 Pediatric palliative care (PPC) contact -- Services included and limitations to coverage, 388-551-1830 How to become a department-approved pediatric palliative care (PPC) case management/coordination services provider, 388-551-1840 Pediatric palliative care (PPC) case management/coordination services -- Provider requirements, and 388-551-1850 Pediatric palliative care (PPC) case management/coordination services -- Rates methodology.

Hearing Location(s): Blake Office Park East, Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane, behind Goodyear Tire. A map or directions are available at http://www1.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6097), on August 23, 2005, at 10:00 a.m.

Date of Intended Adoption: Not earlier than August 24, 2005.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail fernaax@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m., August 23, 2005.

Assistance for Persons with Disabilities: Contact Stephanie Schiller, DSHS Rules Consultant, by August 19, 2005, TTY (360) 664-6178 or (360) 664-6097 or by e-mail at schilse@dshs.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The department is adopting these rules to incorporate into rule language for the pediatric palliative care (PPC) case management/coordination services program.

Reasons Supporting Proposal: See Purpose above.

Statutory Authority for Adoption: RCW 74.08.090 and 74.09.520.

Statute Being Implemented: RCW 74.08.090, 74.09.520, and 42 C.F.R. 418.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Department of Social and Health Services, governmental.

Name of Agency Personnel Responsible for Drafting: Kathy Sayre, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1342; Implementation and Enforcement: Pam Colyar, P.O. Box 45506, Olympia, WA 98504-5506, (360) 725-1582.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rule amendment and concludes that it will impose no new costs on small businesses. The preparation of a comprehensive small business economic impact statement is not required.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Pam Colyar, Health and Recovery Services Administration, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1582, fax (360) 586-1471, e-mail colyaps@dshs.wa.gov.

July 15, 2005

Andy Fernando, Manager

Rules and Policies Assistance Unit

3574.2
NEW SECTION
WAC 388-551-1800   Pediatric palliative care (PPC) case management/coordination services - General.   Through a hospice agency, the department's pediatric palliative care (PPC) case management/coordination services provide the care coordination and skilled care services to clients who have life-limiting medical conditions. Family members and caregivers of clients eligible for pediatric palliative care services may also receive support through care coordination when the services are related to the client's medical needs.

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NEW SECTION
WAC 388-551-1810   Pediatric palliative care (PPC) case management/coordination services - Client eligibility.   To receive pediatric palliative care (PPC) case management/coordination services, a person must:

(1) Be twenty years of age or younger;

(2) Be a current recipient of the:

(a) Categorically needy program (CNP);

(b) Limited casualty program - medically needy program (LCP-MNP);

(c) CNP - Alien emergency medical;

(d) LCP-MNP-Alien emergency medical;

(e) Children's health insurance program (SCHIP); and

(3) Have a life-limiting medical condition that requires case management and coordination of medical services due to at least three of the following circumstances. The client must:

(a) Have immediate medical needs during a time of crisis;

(b) Require coordination with family member(s) and providers in more than one setting (i.e. school, home, and multiple medical offices or clinics);

(c) Have a life-limiting medical condition that impacts cognitive, social, and physical development;

(d) Have a medical condition that the family is unable to cope with;

(e) Have a family member(s) and/or caregiver who lacks knowledge regarding the client's medical needs; and

(f) Have therapeutic goals focused on quality of life, comfort, and family stability.

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NEW SECTION
WAC 388-551-1820   Pediatric palliative care (PPC) contact -Services included and limitations to coverage.   (1) The department's pediatric palliative care (PPC) case management/coordination services cover up to six pediatric palliative care contacts per client, per calendar month, subject to the limitations in this section and other applicable WAC.

(2) One pediatric palliative care contact consists of:

(a) One visit with a registered nurse, social worker, or therapist with the client in the client's residence to address:

(i) Pain and symptom management;

(ii) Psychosocial counseling; or

(iii) Education/training.

(b) Two hours or more per month of case management or coordination services to include any combination of the following:

(i) Psychosocial counseling services (includes grief support provided to the client, client's family member(s), or client's caregiver prior to the client's death);

(ii) Establishing or implementing care conferences;

(iii) Arranging, planning, coordinating, and evaluating community resources to meet the client's needs;

(iv) Visits lasting twenty minutes or less (for example, visits to give injections, drop off supplies, or make appointments for other PPC-related services.); and

(v) Visits not provided in the client's home.

(3) The department does not pay for a pediatric palliative care contact described in subsection (2) of this section when a client is receiving services from any of the following:

(a) Home health program;

(b) Hospice program;

(c) Private duty nursing (private duty nursing can subcontract with PPC to provide services)/medical intensive care;

(d) Disease case management program; or

(e) Any other department program that provides similar services.

(4) The department does not pay for a pediatric palliative care contact that includes providing counseling services to a client's family member or the client's caregiver for grief or bereavement for dates of service after a client's death.

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NEW SECTION
WAC 388-551-1830   How to become a department-approved pediatric palliative care (PPC) case management/coordination services provider.   This section applies to department-enrolled providers who currently do not provide pediatric palliative care (PPC) services to medical assistance clients.

(1) To apply to become a department-approved provider of PPC services, a provider must:

(a) Be a department-approved hospice agency (see WAC 388-551-1300 and 388-551-1305); and

(b) Submit a letter to the department's hospice/PPC program manager requesting to become a department-approved provider of PPC and include a copy of the provider's policies and position descriptions with minimum qualifications specific to pediatric palliative care.

(2) A hospice agency qualifies to provide PPC services when:

(a) All the requirements in this section are met; and

(b) The department provides the hospice agency with written notification.

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NEW SECTION
WAC 388-551-1840   Pediatric palliative care (PPC) case management/coordination services - Provider requirements.   (1) An eligible provider of pediatric palliative care (PPC) case management/coordination services must do all of the following:

(a) Meet the conditions in WAC 388-551-1300;

(b) Confirm that a client meets the eligibility criteria in WAC 388-551-1810 prior to providing the pediatric palliative care services;

(c) Place in the client's medical record a written order for PPC from the client's physician;

(d) Determine and document in the client's medical record the medical necessity for the initial and ongoing care coordination of pediatric palliative care services;

(e) Prescribe and document in the client's medical record:

(i) A palliative plan of care (POC) (a written document based on assessment of a client's individual needs that identifies services to meet those needs).

(ii) The medical necessity for those services to be provided in the client's residence; and

(iii) Discharge planning.

(f) Provide medically necessary skilled interventions and psychosocial counseling services by qualified interdisciplinary hospice team members;

(g) Assign and make available a PPC case manager (nurse, social worker or therapist) to implement care coordination with community-based providers to assure clarity, effectiveness, and safety of the client's POC;

(h) Complete and fax the Pediatric Palliative Care (PPC) Referral and 5-Day Notification form (DSHS 13-752) to the department's PPC program manager within five working days from date of occurrence of the client's:

(i) Date of enrollment in PPC.

(ii) Discharge from the hospice agency or PPC program when the client:

(A) No longer meets PPC criteria;

(B) Is able to receive all care in the community;

(C) Does not require any services for sixty days; or

(D) Discharges from the PPC program and enrolls in the department's hospice program.

(iii) Transfer to another hospice agency.

(iv) Death.

(i) Maintain the client's file which includes the POC, visit notes, and all of the following:

(i) The client's start of care date and dates of service;

(ii) Discipline and services provided (in-home or place of service);

(iii) Case management activity and documentation of hours of work; and

(iv) Specific documentation of the client's response to the palliative care and the client's and/or client's family's response to the effectiveness of the palliative care (e.g. would the client have required acute care or hospital emergency room visits without the pediatric palliative care services).

(j) Provide when requested by the department's PPC program manager, a copy of the client's POC, visit notes, and any other documents listing the information identified in subsection (1)(i) of this section.

(2) If the department determines the POC, visit notes, and/or other required information do not meet the criteria for a client's PPC eligibility or does not justify the billed amount, any payment to the provider is subject to recoupment by the department.

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NEW SECTION
WAC 388-551-1850   Pediatric palliative care (PPC) case management/coordination services - Rates methodology.   (1) The department determines the reimbursement rate for a pediatric palliative care (PPC) contact described in WAC 388-551-1820 using the average of statewide Metropolitan Statistical Area (MSA) home health care rates for skilled nursing, physical therapy, speech-language therapy and occupational therapy.

(2) The department makes adjustments to the reimbursement rate for PPC contacts when the legislature grants a vender rate change. New rates become effective as directed by the legislature and are effective until the next rate change.

(3) The reimbursement rate for authorized out-of-state PPC services is the same as the in-state non-MSA rate.

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Washington State Code Reviser's Office