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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