A. ACUTE INPATIENT PSYCHIATRIC HOSPITALIZATION
Definition
Inpatient treatment services in a licensed general, psychiatric hospital or a state operated psychiatric hospital offering a full range of diagnostic, educational, and therapeutic services with capability for emergency implementation of life-saving medical and psychiatric interventions. Services are provided in a physically secured setting. Patient admission into this level of care is the result of a serious or dangerous condition that requires rapid stabilization of psychiatric symptoms. This service is generally used when 24-hour medical and nursing supervision are required to provide intensive evaluation, medication titration, symptom stabilization, and intensive brief treatment.
Authorization Process and Time Frame for Service
This level of care requires prior authorization. The first authorization is for up to 3 days. Subsequent authorizations for up to 2 days each can be given if the patient meets continued care criteria. After 7 days the case is reviewed for up to 7 days for continued authorization. Admissions to Riverview Hospital shall be reviewed for medical necessity and will require concurrent reviews on a periodic basis to facilitate discharge planning.
The first 30 days of Court ordered admissions to Riverview Hospital shall be deemed medically necessary and so authorized. Such stays shall be subject to clinical review 21 days post admission to assist with timely discharge planning. Any court ordered stay beyond 30-days shall require prior authorization and be authorized for up to seven days.
( Medical Necessity Criteria ) delete and add Level of Care Guideline*:
A.1.1 Symptoms and functional impairment include all of the following:
A.1.1.1 Diagnosable DSM Axis I or Axis II disorder,
A.1.1.2 Symptoms and impairment must be the result of a psychiatric or substance abuse disorder, excluding V-codes,
A.1.1.3 Functional impairment not solely a result of Pervasive Developmental Disorder or Mental Retardation, and
A.1.1.4 GAF <30
A.1.2 Presentation consistent with at least one of the following Symptom Categories:
A.1.2.1 Current risk of suicide/self-injury: Imminent risk of suicide or self-injury, with an inability to guarantee safety in a less restrictive environment as manifested by:
A.1.2.1.1 Attempt: Recent and serious suicide attempt indicated by degree of lethal intent, impulsiveness of actions and/or concurrent intoxication. Inability to reliably contract for safety; or
A.1.2.1.2 Intent/Plan: Current suicidal ideation with well formulated plan, imminent intent to act and available means that is severe and dangerous with minimal expressed ambivalence or significant barriers to doing so; or
A.1.2.1.3 Self-mutilation: Recent self-mutilation that is severe and dangerous, e.g., deep cuts requiring sutures, 2nd to 3rd degree burns, swallowing objects; or
A.1.2.1.4 Hallucinations and/or Delusions: Recent command/threatening hallucinations or delusions that threaten to override usual impulse control and likely to result in harm to self or others; or
A.1.2.1.5 Extreme recklessness/agitation/impulsivity: Repeated pattern of reckless behavior suggesting an inability or unwillingness to consider potential for risk to self (e.g. extreme scratching, inserting objects, driving while intoxicated, driving without a license, running into traffic; hanging from a moving car; jumping from high places, dangerous use of substances, provocation of others, flagrant exposure to victimization, and other potentially highly self injurious or lethal risk-taking behavior).
A.1.2.2 Current risk of homicide/danger to others: Imminent risk of homicide or harm to others with inability to guarantee safety in a less restrictive environment as manifested by:
A.1.2.2.1 Attempt: Recent and serious homicide attempt indicated by degree of lethal intent, impulsivity and/or concurrent intoxication, severe and dangerous, or inability to reliably contract for safety or a history of serious pat attempts that are not of a chronic, impulsive, or consistent nature; or
A.1.2.2.2 Intent/Plan: Current homicidal ideation with well formulated plan, imminent intent to act and available means that is severe and dangerous with minimal expressed ambivalence or significant barriers to doing so; or
A.1.2.2.3 Severe assault: Recent physically assaultive behavior with a high potential for recurrence and high potential for serious injury to self or others; or
A.1.2.2.4 Hallucinations and/or Delusions: Recent command/threatening hallucinations likely to result in harm to self or others; or
A.1.2.2.5 Extreme recklessness/ /impulsivity: Sustained reckless or impulsive behavior suggesting an inability or unwillingness to consider potential for serious risk to others (e.g. fire setting, sexual abuse, reckless driving, and other risk-taking behavior); or
A.1.2.2.6 Agitation/Aggression: Sustained agitated and uncontrolled behavior including acts of violence against property or persons with high risk of recurrence.
A.1.2.3 Gravely Disabled: Acute and serious deterioration from baseline in mental status and level of functioning resulting in high risk of harm to self or others. Severe impairment of activities of daily living skills and not secondary to abuse or neglect as evidenced by one or more of the following:
A.1.2.3.1 Evidence of severe neglect of personal hygiene (i.e. highly malodorous, parasitic infestation, poor/no oral hygiene, grossly soiled clothing, inability to manage toileting tasks appropriately) despite appropriate and repeated attempts by caretakers to alter behaviors; or
A.1.2.3.2 Malnutrition of life-threatening severity and/or highly compromised nutrition or eating patterns (i.e. eating only food packaged in cellophane, eating only peas counted out one by one) which may be related to paranoid, delusional, or severe eating-disordered beliefs or rituals; or
A.1.2.3.3 Immobility with potential to compromise physical status; or
A.1.2.3.4 Unable to communicate basic needs, not related to mental retardation, autism, or language disorders or barriers; or
A.1.2.3.5 Catatonia; or
A.1.2.3.6 Severe psychomotor agitation (inability to sit still not related to ADHD or medication side effects; several nights without sleeping due to emotional agitation and/or delusions or paranoia; emotional lability with persistent pacing, with or without property damage, unresponsive to support or limits from others); or
A.1.2.3.7 Response to command/threatening hallucinations which could result in harm to self/others; or
A.1.2.3.8 Response to delusions, excessive preoccupations, or developmentally inappropriate inability to sort out fantasy from reality, which interfere with functioning and places child or others at risk (i.e., paranoid ideas that inspire retaliation; delusions of invincibility that lead child to place self in harm's way (e.g., slicing arm open to fix wires like "The Terminator"); or
A.1.2.3.9 Disorientation to person, place and time; or
A.1.2.3.10 Delirium; or
A.1.2.3.11 Dissociative events, which could result in harm to self/others.
A.1.2.4 Acute Medical Risk: Imminent risk for acute medical status deterioration due to the presence and/or treatment of an active psychiatric symptom(s) manifested by:
A.1.2.4.1 Signs, symptoms, and behaviors that interfere with diagnosis or treatment of a serious medical illness requiring inpatient medical services (e.g., endocrine disorders such as diabetes and thyroid disease; cardiac conditions; etc.); or
A.1.2.4.2 A need for acute psychiatric interventions (i.e., drug, ECT, restraint) that have a high probability of resulting in serious and acute deterioration of physical and/or medical health; or
A.1.2.4.3 Not eating and/or excessive exercise to the point that further weight loss is medically threatening.
Medication Adjustment
Patient has met any of the above symptoms within the past 12 months and requires a medication taper and re-evaluation in an inpatient hospital setting. Previous attempts to taper medication have resulted in behavioral escalations that meet admission criteria for inpatient hospitalization.
And meets at least one of the following criteria:
A.1.3 Intensity of Service Need
A.1.3.1 Individual requires inpatient psychiatric care with 24-hour medical management. The above symptoms cannot be contained, attenuated, evaluated and treated in a psychiatric residential treatment facility or lower level of care as evidenced by:
A.1.3.1.1 Psychiatric treatment (e.g., medication, ECT) presents a significant risk of serious medical compromise (e.g., ECT for a child with a cardiac condition, restraint or seclusion of a child with a cardiac condition, initiation of or change in neuroleptic medication for a child with history of neuroleptic malignancy syndrome, or administration of depakote to a child with a history of neutropenia); or
A.1.3.1.2 Patient requires or is likely to have diagnostic or evaluative procedures readily available in a hospital setting (e.g., MRI, 24-hour EEG, neurological examination, or specialized lab work, etc.); or
A.1.3.1.3 Intrusive route of medication administration requires medical management (e.g., intramuscular administration of PRN medication or administration by means of an NG tube); or.
A.1.3.1.4 Patient has had frequent (e.g., once every other day) restraints or seclusions or has recently had mechanical restraint; or
A.1.3.1.5 The administration of restraints or seclusions has required the involvement of three or more persons or presented high risk of serious injury to self or others; or
A.1.3.1.6 Patient requires 1:1 supervision or frequent checks for safety (e.g., every 15 minutes or less ); or
A.1.3.1.7 Efforts to manage medical risk symptom or behavior (see III.A.1.b.(4)) in a lower level of care are ineffective or result in an acute escalation of behavior with risk of harm to self or others; or
A.1.3.1.8 Requires close medical monitoring or skilled care to adjust dosage of psychotropic medications and such medical monitoring and dosage adjustment could not safely be conducted in a psychiatric residential treatment facility, residential treatment center, or ambulatory setting.
A.2.1 Patient has met admission criteria within the past 48 hours or has been prevented from engaging in qualifying behavior due to use of 1:1 supervision, frequent checks (q5), physical/mechanical restraint, or locked seclusion; or
A.2.2 Evidence of active treatment and care management as evidenced by:
A.2.2.1 Patient and family participation in treatment consistent with care plan, or active efforts to engage the patient and/or family are in process. Type, frequency, and intensity of services are consistent with the treatment plan, and
A.2.2.2 A care plan with evaluation and treatment objectives appropriate for this level of care has been established. Treatment objectives are related to readiness for discharge and progress toward objectives is being monitored daily, and
A.2.2.3 Vigorous efforts are being made to affect a timely discharge (e.g., meeting with caseworker, convening aftercare planning meetings with aftercare providers, identifying and referring for aftercare or local systems of care or local DCF Managed Service System, scheduling initial aftercare appointments).
A.2.3 If the patient does not meet criterion A.2.1, continued stay may still be authorized under any of the following exceptional circumstances:
A.2.3.1 Patient has clear behaviorally defined treatment objectives that can reasonably be achieved within 30 days and are determined necessary in order for the discharge plan to be successful, and there is no other suitable environment in which the objectives can be safely accomplished; or
A.2.3.2 Patient can achieve certain treatment objectives in the current level of care and achievement of those objectives will enable the patient to be discharged directly to the community rather than to another institutional setting; or
A.2.3.3 Patient is expected to transfer to another institutional treatment setting within 30 days of discharge and continued stay at this level of care, rather than an interim placement, can avoid disrupting care and compromising patient stability. Continued stays for this purpose may be as long as 30 days; or
A.2.3.4 Patient is scheduled for discharge, but the patient's community-based aftercare plan is missing critical components. These components have been vigorously pursued but are not available (including but not limited to such resources as placement options, psychiatrist or therapist appointments, day treatment or partial hospital programs, etc.). Authorization may be extended for up to 30 days. In such cases, if it is reasonably determined that critical component of the discharge plan will not be available within 30 days, the patient should be discharged to a less restrictive level of care.
B7 All requests for services not satisfying these criteria must be individually reviewed and may not be denied unless the request does not meet the Department's definition of medical necessity and medical appropriateness and, for the anyone under 21, does not meet the EPSDT criteria.
Additional notes:
A recommendation has been made to add discharge criteria to this level of care.
Do these criteria apply to adults and children? If they do, this should be stated.