AADL Authorizer Training Primary Module A Medical Surgical Benefits

Transcription

1 AADL Authorizer Training Primary Module A Medical Surgical Benefits Presented by Lori Harmon, RN Med/Surg Manager Agenda Benefit eligibility criteria (ostomy, catheters, diapers/liners) Exclusions Authorizer qualifications/competency Forms and processes Expiry dates- including extending authorizations Advanced quantity requests Resources Authorizer Qualifications for medical/surgical benefits Knowledge of AADL policy, including benefit specific eligibility criteria, product quantity maximums, time frame of authorizations, vendors, etc. The following files can be found at Manual M: Medical-Surgical Policy and Procedures Manual M: Medical-Surgical Approved Product List Manual M: Incontinence Supplies List 1

2 (Continued) Competency to assess, apply interventions and strategies. Consult with others for complex cases, etc. (problem solving, assistance with product combinations). Consultation/referral to Nurse Continence Advisor (NCA) or Enterostomal Therapy (ET) Registered Nurse as required Note: Ostomy, catheters (and their supplies), diapers, pads and liners are part of the primary product range for nurses. OT s and PT s must apply for these product ranges. Eligibility for Ostomy supplies The clients ostomy (colostomy, ileostomy, urostomy) is considered chronic (the client will have the ostomy at a minimum of six months). Fistula management (not wound fistulas), cecostomies and esophagectomies. Exclusions for ostomy products: Wound care Enteral feedings Collecting drainage from tubing or wounds Enemas Temporary stomas ( less than six months) 2

3 Authorizer competency: ostomy Competency in ostomy care. This includes the skill set to assess the stoma, address client concerns, and basic product knowledge. Consult with an ET where applicable. Note: Clients may require products that need an authorization from an ET: pediatric clients, clients with an esophagostomy, cecostomy, or a fistula. Also note some products require and authorization by an ET (e.g., ostomy hernia belt, powder and flange extenders). Approved Product List ( ostomy) 3

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5 Eligibility for catheters, diapers and liners Chronic, involuntary daily urinary incontinence related to bladder or urethral dysfunction (moderate to severe). Catheters for stoma diversion - permanent stoma for urinary continent diversion which can only be managed by catheterization. Note: AADL does not fund nephrostomy tubes or their supplies. Exclusions Clients who chose not to follow medical advice to address their incontinence Menses or pregnancy induced incontinence Night time enuresis Post surgical conditions less than six months post event. Authorizer competency: catheters, diapers and liners: Interventions and strategies to address, reduce and eliminate (if applicable) include but are not limited to the following: Physician/specialist assessment - clients should have an incontinence condition not amenable to improvement by surgery or application of any device, or be unfit for such a procedure. They should have been assessed and certified as such by a specialist continence practitioner (e.g. urologist, gynecologist, geriatrician, gastroenterologist, proctologist, pediatrician, registered nurse or nurse practitioner). 5

6 (continued) Lifestyle modification and conservative strategies should have been tried for a minimum of three months, such as bladder training, pelvic muscle exercises (with or without biofeedback), diet and exercise, weight loss, ensuring appropriate and timely fluid intake. Where appropriate, medications for urinary incontinence should also have been tried, and have failed to significantly improve symptoms. Note: Clients who chose not to follow medical advice to address their incontinence will not be eligible for funding through AADL Note: Children who are projected to achieve continence past age four are required to meet criteria in the first point under intervention and strategies prior to submission of an AADL authorization. (continued) Note: Individuals with a diagnosed congenital anomaly, or physiological abnormalities, including lack of bladder innervation that prevents the ability to achieve continence are exempt from the requirements outlined in the first point under intervention and strategies. Note: Adults with diagnosed Dementia or any other cognitive impairment for whom it has been determined by the appropriate medical professional, that interventions and strategies would be ineffective or inappropriate are exempt from the requirements outlined in the first point under intervention and strategies. Clients with a end-of-life diagnosis (life expectancy of no longer than six months) will be authorized for a period of six months are exempt from the requirements outlined in the first point under intervention and strategies. (continued) Ensure all interventions and strategies have been completed where applicable prior to sending the clients authorization to AADL. Note: The AADL Incontinence Assessment Summary must be attached to every new authorization and when applicable, every Correction and Change form or Reauthorization for Medical Surgical supplies letter. 6

7 Approved Product List ( briefs, diapers and liners). 7

8 Assessment Summary for Incontinence Products /documents/aadl- Incontinence-Product- Assess.pdf Authorizer competency: catheter supplies Ensure competency in catheter knowledge/client care: 1) Selecting the proper catheter (material, size, straight, coude, intermittent, Foley). 2) Addressing client specific areas: adequate hydration* (note potential fluid restrictions) and is avoiding fluids that could irritate the bladder (coffee, tea, alcohol, carbonated drinks); proper catheterization technique by client if appropriate; and catheterizing frequently enough to maintain a bladder capacity of 500 ml (children- age +2x 30) on fluid intake and output monitoring adequately during the day (total bladder capacity voided volume plus residual volumes). (continued) proper peri care (wiping from front to back); and cleans/dries/stores catheters adequately if applicable review of potential irritation causative factors including: feminine hygiene products (deodorants, sprays, powders, and douches as these may irritate the urethra), birth control such as diaphragms or spermicides). 8

9 Approved Product List ( catheters and catheter supplies) Continued AADL Authorization Forms and Process 1. Authorization Form 2. Authorization Correction and Change Form 3. Client Reassessment Letter 4. Vendor Change Form 9

10 Authorization Forms and Process: Authorization Form Confirm eligibility Obtain prior approval and any supporting documents required prior to submitting the authorization form Complete separate form per type of benefit dressings, ostomy, incontinence. Residence codes AADL provides Medical Surgical Benefits to residents in all settings except Long Term Care (Code 04) Notify AADL once a client has been transferred to Long Term Care Diagnostic codes E.g. incontinence The primary diagnosis for incontinence supplies is chronic urinary/bowel incontinence Provide the underlying diagnosis causing or contributing to the incontinence under other on the authorization form 10

11 Completing the form Residence Primary Diagnosis Other additional diagnosis Age (briefs, diaper/liner) Palliative Eligibility Criteria: Benefit Specific Authorization Form Choice of Vendor Authorization Forms and Process Authorization Form Clients are provided choice of vendor List of vendors on website Take note of vendor number 11

12 Authorization Correction, Change or Extension Form Adjust/ change products. Reassessment to extend an authorization ( must be sent a maximum of three months before authorization expires or up to six months after expiration). The Authorization Correction, Change or Extension form can be found at under General forms Approved Product List (APL) Cat.no and Description of Benefits indicate the type of product. Additional details- may indicate size, specific features.(anything in bolded print must be included on the 1250). Two month pattern as follows: January/February March/April May/June July/August September/October November/December Clients pick up only what they need (up to the maximum authorized for). Benchmark pricing applies-clients are responsible for any upgrade charges. Manual M Approved Product list is available under Eligibility Criteria: Benefit Specific Quantity and Frequency Limits Consider totals when combining products such as diapers and liners Two month periods are consistent no matter when the authorization started 12

13 Authorization Forms & Process Authorization Form Benefit Codes Manual M Approved Product list is available under Authorization Forms & Process Authorization Form Indicate the quantity needed Quantity limits for each benefit. Approved Product List (APL) Order quantity according to clinical assessment results Reassessment letter Note: effective September 1, 2018, AADL no longer sends the Reassessment of Medical Surgical Supplies letter. 13

14 Authorization Forms & Process Change of Vendor Form Clients are allowed vendor choice and may want to change vendors Clients complete vendor change forms Changes take effect at the start of the next two month period. Note: if a client moves, AADL can change clients vendor before the next scheduled vendor change. Vendor change forms are on line at: aadl/aadl-change-vendor-form.pdf Authorization Expiry Dates Expiry Dates AADL 1250 authorizations are for a minimal period of two years and a maximum of four years. Note the following exceptions: Palliative 6 months Note: If the expiry date is not indicated on the 1250, change form or reassessment letter, the authorization will be entered with two year expiry date, where applicable. Advance Quantity Requests Catheter, or ostomy supplies For clients traveling out of the province. Full month amounts only. Requests must be submitted at least one month prior to departure. accepted from July 1 May 31st, not accepted during the month of June. Clients must pick up the advance quantity prior to leaving the province. Vendor must not deliver benefits to an out of province address. Clients may request a maximum seven months advance for out of province travel and must maintain their Alberta Health Care for the entire period. 14

15 Resources available on AADL website Behavior Modification Strategies Fluid Management in Children Bladder Irritants Urinary Incontinence Pediatric Incontinence Toilet training strategies The teaching tools are available in on AADL s website at Questions? 15