Region 1 SouthRegion 1 SouthCrisis Care System Crisis Care System Concurrent ReviewConcurrent 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)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)

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

www.illinoismentalhealthcollaborative.com(888) 359-7953