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Region 1 South Crisis Care System Concurrent Review

Region 1 South Crisis Care System Concurrent Review. Region 1 South Crisis Care System. Presenters: Lee Ann Reinert, LCSW Clinical Policy Specialist, DHS/DMH Patricia Palmer, LCSW, CADC Clinical Director, Collaborative Author: Patricia E. Hill, CSS

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Region 1 South Crisis Care System Concurrent Review

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  1. Region 1 SouthCrisis Care System Concurrent Review

  2. Region 1 South Crisis Care System 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

  3. Continued Stay Request • 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)359-7953 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)

  4. 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

  5. Medical Needs Criteria • 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

  6. 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

  7. Continued Stay Request • 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

  8. 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.)

  9. Decisions • 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

  10. Q & A

  11. Thanks for your Participation www.illinoismentalhealthcollaborative.com (888) 359-7953

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