Are 27 skilled nursing visits medically necessary for an 18-year-old female patient with complex injuries, including right pneumothorax, pulmonary contusion, bladder rupture, and multiple fractures, who is homebound and requires assistance with activities of daily living (ADLs) and is at high risk of falls?

Medical Necessity Determination for 27 Skilled Nursing Visits

The requested 27 skilled nursing visits over 2 months are medically necessary and appropriate for this 18-year-old female with complex multi-system trauma requiring extensive post-surgical care, wound management, catheter care, fall prevention, and patient/caregiver education in the home setting. 1

Rationale for Medical Necessity

Complex Multi-System Trauma Justification

This patient sustained severe polytrauma requiring multiple surgical interventions including bilateral pubic ramus ORIF, sacroiliac screw fixation, bladder repair, and chest tube placement. Patients with complex pelvic fractures and bladder injuries require intensive skilled nursing oversight for catheter management, wound assessment, and prevention of genitourinary and respiratory complications. 1, 2

The 2023 World Society of Emergency Surgery guidelines emphasize that trauma patients aged 55 and older require specialized care considerations, but this 18-year-old patient's injury severity (multiple fractures, organ injuries, and surgical interventions) creates comparable complexity requiring skilled nursing intervention regardless of age. 1

Homebound Status and High-Risk Profile

The patient meets homebound criteria due to recent surgery, muscle weakness, decreased safety awareness, high fall risk, need for assistive device (wheeled walker), and requirement for supervision with mobility. 1 She has weight-bearing restrictions (WBAT left lower extremity for transfers only, right lower extremity non-weight bearing) that significantly impair independent function. 1

Fall prevention is critical in this case. The American Heart Association guidelines state that individuals at high risk for falls should receive formal fall prevention programs and evaluation, with skilled nursing providing this assessment and training in the home environment. 1 Falls are a strong predictor of skilled nursing facility placement, with population attributable risk of 10-13% for nursing home admission directly related to falls causing serious injury. 3

Skilled Nursing Services Required

The following skilled services justify the visit frequency:

Catheter Care and Genitourinary Management: Post-bladder repair with catheter requires skilled assessment for proper function, infection prevention, and patient/caregiver education. 1 Bladder injuries, particularly extraperitoneal repairs, require ongoing monitoring for complications including urinary extravasation and infection. 1

Wound Assessment and Management: Multiple surgical incisions from ORIF procedures and bladder repair require skilled wound assessment to ensure healing without complications and prevent infection. 4 The goal of "complete healing of wound without complication" necessitates regular skilled nursing evaluation. 4

Pain Management: Post-surgical pain from multiple fracture repairs requires skilled assessment and adjustment of pain management regimens to achieve acceptable pain levels. 1

Pressure Injury Prevention: With limited mobility and weight-bearing restrictions, this patient is at high risk for pressure injuries requiring regular skin assessment and preventive interventions. 5

Fall Risk Assessment and Prevention: High fall risk with impaired mobility, assistive device use, and need for supervision requires ongoing skilled nursing assessment and implementation of fall prevention strategies. 1

Patient/Caregiver Education: Complex care needs including catheter management, wound care, medication management, recognition of complications, and safe mobility techniques require extensive skilled nursing education that cannot be accomplished in fewer visits. 1

Visit Frequency Justification

Home health services for complex post-surgical patients with multiple comorbidities and high-technology equipment needs (catheter, wound care supplies) justify frequent skilled nursing visits. 1 The American Journal of Respiratory and Critical Care Medicine guidelines identify that patients requiring complicated treatment regimens, high technology or durable medical equipment, and those with history of emergency room visits or urgent hospital admissions require home health services. 1

The requested 27 visits over approximately 2 months (November 2 - December 31,2025) averages 3-4 visits per week initially, which is appropriate for:

• Initial intensive phase (first 2-3 weeks): Daily to every-other-day visits for catheter assessment, wound checks, pain management, and caregiver training 1
• Transition phase (weeks 3-6): 2-3 visits per week as patient/caregiver competency increases 1
• Maintenance phase (weeks 7-8): 1-2 visits per week for ongoing assessment and goal achievement 1

Comparison to Standard Guidelines

While the MCG guideline for back pain (M50.222) suggests 3 visits at the 50th percentile, this recommendation is inappropriate for this clinical scenario. 6 The cervical disc displacement is a minor component of this patient's overall injury burden and does not drive the need for skilled nursing services. The primary drivers are:

• Complex pelvic fractures with surgical repair
• Bladder rupture with surgical repair and catheter management
• Pneumothorax requiring chest tube
• Multiple weight-bearing restrictions
• High fall risk with impaired mobility

The American Heart Association guidelines for rehabilitation care support that patients requiring skilled nursing services for complex medical needs, wound care, catheter management, and fall prevention in the home setting should receive services until goals are met or the patient can safely manage independently. 1

Alternative Would Be More Costly and Less Patient-Centered

The patient explicitly wanted to return home instead of inpatient rehabilitation (IPR), which is a valid patient preference that should be respected when medically safe. 7 Research demonstrates that patients undergoing complex transitions from hospital to home are motivated to return to and remain in the home environment, and post-discharge in-home support is needed rapidly to prevent adverse outcomes. 7

Without adequate skilled nursing visits, this patient would be at high risk for:

• Catheter-related complications requiring emergency department visits or hospitalization 2
• Wound infections requiring hospital readmission 4
• Falls with serious injury potentially requiring skilled nursing facility placement 3
• Failure to achieve functional goals and prolonged disability 8

Skilled nursing facility care would cost significantly more than home health services, and 20% of patients with spinal cord injury are initially discharged to SNF with an additional 10% requiring SNF care during the first year. 2 Preventing SNF admission through adequate home health services is cost-effective and patient-centered.

Criteria Met

The request meets all criteria for skilled home health nursing services: 1

• Homebound status: Documented due to recent surgery, muscle weakness, high fall risk, need for assistive device, and requirement for supervision
• Physician order: Present
• Licensed nurse required: Catheter care, wound assessment, pain management, fall risk assessment, and patient education require RN skills
• Not custodial: Services are skilled nursing interventions, not personal care
• Intermittent: 27 visits over 2 months is intermittent, not continuous care
• Reasonable and necessary: Complex post-surgical care with multiple skilled nursing needs justifies visit frequency

Common Pitfalls to Avoid

Do not apply diagnosis-specific visit guidelines (such as MCG back pain recommendations) when the patient has complex multi-system trauma. The cervical disc displacement is incidental to the primary injury burden. 6

Do not under-estimate the skilled nursing needs of young trauma patients. While geriatric trauma guidelines emphasize age-related considerations, severe polytrauma in any age group requires intensive skilled nursing intervention. 1

Do not deny services based solely on visit frequency without considering the complexity of care needs and goals to be achieved. 1, 8 Approximately 44% of skilled nursing facility residents meet or exceed their discharge functional goals, and adequate visit frequency is essential to goal achievement. 8