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Nursing home and assisted living plans - Chapter 9, 2021 UnitedHealthcare Administrative Guide

UnitedHealthcare nursing home plans and assisted living plans are Medicare Advantage Institutional Special Needs Plans. These protocols are only applicable to primary care providers (PCPs), nurse practitioners (NP), and physician assistants (PA) who participate in the network for the nursing home plan and/or the assisted living plan care team, which includes both an onsite advance practice clinician (ARNP/PA) and a registered nurse (RN) who cooperate with and are bound by these additional protocols.

If these protocols conflict with other protocols in connection with any matter pertaining to UnitedHealthcare Nursing Home Plan or Assisted Living Plan members, these protocols apply, unless statutes and regulations dictate otherwise.

As the PCP, you cooperate with and are bound by these additional protocols:

  1. Attend PCP orientation session and annual PCP meetings.
  2. Conduct face-to-face initial and ongoing assessments of the medical needs of our members, including those mandated by regulatory requirements.
  3. Deliver health care to our members at their residence with the primary care team.
  4. Participate in family care conferences with responsible parties, family and/or legal guardian to discuss the member’s condition, care needs, overall plan of care and goals of care, including advance care planning.
  5. Collaborate with other members of the primary care team designated by us and other treating professionals to provide and arrange for the provision of covered services to our nursing home plan members. This includes making joint visits with other primary care team members and participating in formal and informal conferences with primary care team members and/or other treating professionals following a scheduled member reassessment, significant change in plan of care and/or condition.
  6. Collaborate with us when a change in the primary care team is necessary.
  7. Give us at least 45 calendar days prior notice when stopping services at a facility where our members live.
  8. When admitting our member to a hospital, immediately notify the PCP and UnitedHealthcare nursing home plan or payer of the admission and reasons for the admission.

The nursing home plan NP, PA, and/or assisted living plan care team member (i.e., RN or ARNP/PA), must follow these additional protocols:

  1. Attend training and orientation meetings as scheduled by the plan.
  2. Deliver health care to our members at their place of residence in collaboration with a PCP.
  3. Communicate with the member’s responsible parties, family and/or legal guardian on a regular basis. Participate in conferences with responsible parties to discuss the member’s condition, care needs, overall plan of care and goals of care.
  4. Making joint visits with others on the primary care team to our members
    • Participating in conferences with primary care team members and/or other treating professionals following a scheduled member reassessment, significant change in plan of care and/or condition
    • Collaborate with other members of the primary care team and other care providers to provide and arrange for the provision of covered services for our members. This includes:
  5. Collaborate and communicate with the Director of Clinical Operations to coordinate all inpatient, outpatient and facility care for our members. Forward copies of the required documentation to our office. Work with the director to develop a network of care providers who are aware of the special needs of the frail elderly.
  6. Conduct a complete initial assessment for all of our nursing home plan members within 30 calendar days of enrollment (90 days for assisted living plan members), that includes:
    • History and physical examination, including mini-mental status and functional assessment
    • Review previous medical records
    • Prepare problem list
    • Review medications and treatments
    • Review lab and x-ray results
    • Review current therapies (physical therapy, occupational therapy, and speech therapy)
    • Update treatment plan
    • Review advance directive documentation including Do Not Resuscitate: Do Not Intervene (DNR/DNI) and use of other life-sustaining techniques
    • Contact the family/responsible party within 30 calendar days of enrollment to:
      • Schedule a meeting at the facility, if possible
      • Obtain further history
      • Agree on type and frequency of future contacts
      • Discuss advance directives
    • Perform clinical and quality initiative documentation as directed
  7. Provide care management services to coordinate all the covered services outlined in our member’s benefit plan. Examples include:
    • All medically necessary and appropriate facility services
    • Outpatient procedures and consultations
    • Inpatient care management
    • Podiatry, audiology, vision care and mental health care provided in the facility
      • When a member is admitted, notify the PCP and UnitedHealthcare or payer immediately if it is for an emergency or observation.
      • If contact information is not available, call the local office or coordinate communication through the nursing facility clinical staff.
  8. Give us at least 45 calendar days’ notice when discontinuing services at any facility where our members live.