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Nursing Home: Complex Care Cheat Sheet (DRAFT) by [deleted]

Nursing Home: Complex Care

This is a draft cheat sheet. It is a work in progress and is not finished yet.


South Carolina Medicaid Complex Care is a program that targets Medica­id-­eli­gible hospital patients who no longer require hospit­ali­zation, but meet the nursing facility level of care. The program is intended to provide financial incentives to enrolled nursing facilities who admit Medicaid benefi­ciaries with complex care needs

Admission Criteria

Be a Medicaid recipient.
All Complex care indivi­duals must meet level of care criteria for long-term care.
Have 2 or more of the following requir­ements
 ­ ­ ­ Wound/­Dec­ubitus Ulcer Stage 4 or greater
 ­ ­ ­ Oral Suctioning
 ­ ­ ­ Trach/­cannula needing aseptic care and suctioning
 ­ ­ ­ Extended duration of parental (IV) fluids for 2 weeks or more
 ­ ­ ­ HIV positive
 ­ ­ ­ Disruptive behavior 60% of the time 24/7. May be r/t mental health illness, head/brain trauma, other neurol­ogical deficits
 ­ ­ ­  Medicaid only partic­ipant in need of goal directed (Physi­cal­/Oc­cup­ati­on/­Speech) therapies.
 ­ ­ ­ Ventilator dependent
 ­ ­ ­ Total Care with all ADLs
 ­ ­ ­ Dialysis


Initial CCP approval is for 180 days or 6 months.
Recert­ifi­cation approval is for 90 days or 3 months.
CCP partic­ipants must be recert­ified by SNF prior to expiration of initial approval.
 ­ ­ SNF completes 185s or CCP assessment forms with all pertinent inform­ation. Send to program area via fax or email. Please allow at least 5 days for response.
 ­ ­ SNF must recertify every 90 days for the duration of partic­ipation time at CCP level of care.


If partic­ipant is in HMO, prior author­ization is necessary before accepting CCP patient. This is a negotiated rate done between HMO and provider.
CCP can transfer. The certif­ication time transfers as well. New SNF is respon­sible for mainta­ining recert­ifi­cation.

Services Provided

Reduce difficulty of placing Medicaid benefi­ciaries
Facilitate access to SNF services and to provide most approp­riate level of care in the most approp­riate settings
Provide cost savings
Provide financial incentives to SNF for admission of Medicaid benefi­ciaries with complex care needs