Region 1 South Crisis Care System Concurrent Review

Presenters: Lee Ann Reinert, LCSW Clinical Policy Specialist, DHS/DMH Patricia Palmer, LCSW, CADC Clinical Director, Collaborative Author: Patricia E. Hill, CSS Summary: This document will review the procedures regarding concurrent review for inpatient care in a CHIPS hospital Region 1 South Crisis Care System

 If the Consumer is still hospitalized when the Initial Authorization timeframe is up, they will need a concurrent review for continued stay  24 hours before the expiration date (or on the preceding Friday if a weekend), the attending physician and/or designee will contact the Collaborative at (866) and select option “#4” to request an authorization for continued stay  Concurrent authorizations must be done during regular business hours (Monday – Friday, 8 am – 5 pm) Continued Stay Request

 The Collaborative will review the clinical information to verify that the Consumer meets the Medical Needs Criteria (MNC) for Continued Stay  Medical Needs Criteria includes both Severity of Illness and Intensity of Services criteria Continued Stay Request

 Severity of Illness Criteria  Individual requires continuous skilled psychiatric observation, planned psycho-therapeutic services, and/or psychotropic drug management  Individual exhibits an inability to care for self due to an interaction of mental and their physical disorders creating incapacitating symptoms or behaviors  Individual poses significant suicide risk  Individual has a history of assaultive or self-mutilating behavior or reported evidence of being a danger to self or others  Individual exhibits homicidal behavior accompanied by a psychiatric disorder  Individual exhibits impaired reality testing accompanied by disordered behavior Medical Needs Criteria

 Intensity of Services Criteria  Complex treatment is necessary due to co-existing conditions requiring concurrent treatment  There is a need for a controlled environment in order to protect self and others  Specialized treatment modalities are only available in the hospital due to need for special environment, equipment or ancillary services  There is a high potential for readmission within 30 days; medical record MUST reflect efforts taken to address these issues Medical Needs Criteria

 Areas addressed during the review call include  Who has evaluated them and the results of all evaluations  Current mental status including risk to self or others  Current impairments  Are they on meds; if so, what  Has family treatment occurred and when  What is their baseline functioning  What is the treatment plan  What is the discharge/transition plan and estimated length of stay  Diagnoses on all 5 axes Continued Stay Request

 After reviewing the clinical information presented, the Collaborative will verify that the Consumer does or does not meet the Medical Needs Criteria (MNC) for Continued Stay  Once the Consumer has been approved, the Collaborative will issue a Concurrent Review Authorization  If longer term services are indicated, the hospital should make arrangements for a more appropriate care setting (i.e. state hospital, nursing home, etc.) Continued Stay Request

 A PA Review is conducted if there is a difference of opinion concerning a request for extended length of stay for the consumer  If the PA Review agrees, services will be authorized  If the PA Review does not agree with the extension, a Second Level Reconsideration Review will be conducted with another VO MD  If the PA Second Level Reconsideration Review agrees, services will be authorized  If the Second Level Reconsideration Review remains unresolved then DMH will make the final determination Decisions

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