Skilled Care vs. Custodial Care
According to the American College of Medical Quality:
Skilled care is the provision of services and supplies that can be given only by or under the supervision of skilled or licensed medical personnel. Skilled care is medically necessary when provided to improve the quality of health care of patients or to maintain or slow the decompensation of a patient’s condition, including palliative treatment. Skilled care is prescribed for settings that have the capability to deliver such services safely and effectively.
Custodial care is the provision of services and supplies that can be given safely and reasonably by individuals who are neither skilled nor licensed medical personnel. The medical necessity and desired results of skilled care must be clearly documented by a written treatment plan approved by a physician. A patient may have skilled and custodial needs at the same time. In these circumstances, only those services and supplies provided in connection with the skilled care are to be considered as such. The treatment plan must include:
- the applied therapies;
- the frequency of the treatment which is consistent with the therapeutic goals;
- the potential for a patient’s restoration within a predictable period of time, if applicable;
- the time frame in which the prescribing physician will review the case for the purpose of evaluating a patient’s status and before reassessing the medical necessity of ongoing treatment; or
- the maintenance, palliative relief, or the slowing of decompensation in a patient’s status, if applicable.
Determinations of the medical necessity of skilled care must be based on the applicable standard of care.
Hughes v. Blue Cross of Northern California, 215 Cal App 3d 832; 263 Cal Rptr 850 (1985).
Wickline v. State of California, 12 Cal App 3d 1630, 239 Cal Rptr 810 (1986).
Compendium of AAFP Positions of Selected Health Issues, Kansas City: American Academy of Family Physicians], 1994-1995:72-74.
Medical Necessity of Physical and Occupational Therapy in Skilled Nursing Facilities, Office of the Inspector General, 1998.
Adopted by the Board of Trustees, 9/14/00
Amendments adopted by the Board of Trustees, 4/30/04