1. SMI Determination Form Clinical Guide

2. SMI Determination Form
The diagnostic section:
Indicate what, if any, SMI diagnoses
you are proposing
You may circle/check or write
the diagnosis and ICD-10 code on
the paperwork, section 1
You may write a description of the SMI diagnosis/criteria (1a) or attach a document

3. SMI Determination Form
Functional Impairment Section:
2a-2c: Indicate whether you are proposing that there is an area of functional impairment that is due to the qualifying diagnosis, for the duration specified.
If so, check off the appropriate box(es)
The eval and records submitted should reflect that there is functional impairment in those areas, and that they are caused by the proposed SMI diagnosis.
You may write a description of this here, or attach a document

4. Functional Impairment
Risk of Deterioration (3) criteria is only indicated when the other functional criteria are not met, but the person is expected to deteriorate to such a level without treatment
Indicate whether they have a history of decompensation related to their SMI diagnosis, whether they have persistent and chronic risk factors, co- morbidities placing them at high risk, and whether they have barriers to obtaining treatment

5. When Functional Criteria May Not be Met
Ensure that you are only checking off functional impairment boxes when you have clear documentation linking the SMI dx to that functional impairment for the time frame noted
If there are any doubts, leave that portion blank
You may write something like:
“It is possible that the fx impairment is directly caused by the SMI diagnosis, but there may be other causal factors”, such as substance use, medical conditions, criminal record, non-SMI diagnoses, etc.

6. Functional Decision Making: The Psychologist’s Approach
If there is evidence for an SMI qualifying diagnosis, then we examine whether SMI functional criteria are met
There must be at least one area of Functional Impairment that is due to the Qualifying Diagnosis, for the duration specified
Eval/records should demonstrate how the diagnosis is directly linked to the impairment and how the duration criterion is met

7. Functional Decision Making: The Psychologist’s Approach cont.
Additionally: it needs to be clear that the identified Functional Impairment is caused by the qualifying SMI diagnosis and not other conditions or stressors, such as:
Substance Use, Head Injury or TBI, Chronic Pain, Autism, Intellectual Impairment, Eating Disorder, Antisocial Personality Disorder, Conduct Disorder, ADHD, Adjustment Disorder, Incarceration/Legal Issues, etc.

8. Functional Decision Making: The Psychologist’s Approach cont.
If there is a history of substance abuse, we look for evidence of symptoms in periods of sustained sobriety and persistence of Functional Impairment during those periods
EEP may be an option if there is ongoing substance use and criteria are not clearly supported

9. Functional Decision Making Final Thoughts
Clearly document areas of functioning and include details on: housing, ADLs, ILS, DTS/DTO history, employment hx, schooling and parenting duties if applicable, and risk factors.
Indicate how the impairment is linked to an SMI diagnosis, for the required timeframe
Indicate whether other diagnoses or factors may impact areas of functioning

10. Diagnostic Documentation Guide

11. Diagnostic Decision Making: The Psychologist's Approach
We are looking for evidence and documentation to support an SMI qualifying diagnosis
We use DSM-V criteria, as well as clinical expertise and judgment
Clear, objective, thorough, and cohesive documentation is key!

12. Decision Making, cont.
We look for documentation of the individual’s symptoms, to include onset, duration, and frequency of symptoms or episodes.
We look for examples, quotes, and observations, not simply a list of DSM-V criteria.
We review mental status exams and whether that is consistent with the symptoms reported
We look for information across records to help us determine if an SMI diagnosis is supported or if another diagnosis may better explain the person’s symptoms, behaviors, and presentation.

13. Decision Making, cont. We also review:
Treatment history (IP, OP) and medications
Substance abuse history
Family history of mental illness and suicide
Hx of suicide attempts or self-injurious behaviors
Situational Stressors possibly impacting their symptoms
Physical or other health conditions that may be associated with psychiatric sx

14. Documentation We have access to: It’s all about the documentation!
Previous determinations
CRN Crisis Notes (if present)
Records received from ROI
Provider records
It’s all about the documentation!
You are our eyes and ears
We know you understand SMI criteria based on staffings – we just need it reflected in the documentation

15. Summary of Diagnostic Decision Making
Are the proposed diagnoses consistent with the information provided? Why or why not?
There must be at least one SMI qualifying diagnosis in which the symptoms documented are consistent with the diagnostic criteria and information in the assessment and records
Include specific examples of symptoms, behaviors, quotes, and observations. This includes type, onset, frequency, duration, and severity
Include a psychiatric eval and other clinical records to assist in the decision making

16. Incarceration Considerations

17. Incarceration Considerations
Individuals may be assessed while incarcerated, while awaiting sentencing, while under Rule 11, or while awaiting release from jail or prison
Include jail or prison records, Rule 11 evals if applicable, and contact information for clinical jail staff

18. Incarceration Considerations
Documentation:
Include the reason for referral (clinical staff, lawyer, self-referral, etc)
Include date of incarceration, charges, date of hearing or release, and other relevant data related to the incarceration or past arrests
Include treatment details while incarcerated
Medications, suicide watch history, therapy, etc
Include similar information regarding diagnoses and areas of functioning as other evaluations

19. Documentation Continued…
Indicate whether symptoms may be due to situational stressors (such as depressed mood or anxiety due to incarceration), other factors (substance use, antisocial personality, etc) or whether there is clear evidence of an SMI diagnosis
Indicate whether their functional impairment is due to an SMI diagnosis as opposed to other diagnoses or factors (such as difficulty finding housing or employment due to felony history)

20. SMI Determination Form
Follow the same instructions on how to complete the SMI determination form
If you do not have enough documentation to support the diagnostic or functional criteria, indicate this on the form and only check the boxes that you have support for.

21. Questions/Comments? CRN Eligibility and Care Services 1-855-832-2866
Website
Includes Tips, Application, Required Forms,
Submission Instructions, FAQ’s, etc.