Guidelines To Guidelines


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Guidelines on how to use clinical guidelines for utilization review.

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Guidelines To Guidelines

  1. 1. Guidelines to the Guidelines Oct 2, 2009 Kalleen Kreps, RN CCM Care Manager
  2. 2. Objectives: <ul><li>Participant will understand the purpose of medical guidelines </li></ul><ul><li>Participant will understand importance of evidence based medicine in relation to medical guidelines </li></ul><ul><li>Participant will be able to use Interqual guidelines as designed </li></ul><ul><li>Participant will be able to utilize Interqual guidelines in their every day practice of case management </li></ul>
  3. 3. Clinical Guidelines <ul><li>Clinical guidelines are defined as: Medical interventions based on medical practice that has been proven to be best practice. It is commonly termed “evidence based medicine”. </li></ul>
  4. 4. Guidelines <ul><li>There are two distinct companies that produce medical/acute guidelines </li></ul><ul><ul><li>Milliman </li></ul></ul><ul><ul><ul><li>Focus is on how the patient presents. They focus on symptom rather than treatment </li></ul></ul></ul><ul><ul><ul><li>For example, if a patient comes in with pneumonia, they will focus on the patients respiratory status versus what treatment is being given. </li></ul></ul></ul>
  5. 5. Interqual <ul><li>- Interqual guidelines </li></ul><ul><li>Interqual’s focus is on the intensity of which the patient is being treated. </li></ul><ul><li>If we take the same patient with pneumonia, they will focus on what treatment is being done, such as antibiotics, respiratory treatments etc. </li></ul>
  6. 6. Interqual <ul><li>Interqual breaks down the information in two ways </li></ul><ul><ul><li>1. Level of care guidelines. These guidelines are to make sure that the patient is in the correct level of care. </li></ul></ul><ul><ul><li>2. Body systems. The guidelines are then broken down by systems such as GI and ID </li></ul></ul>
  7. 7. Further Breakdown <ul><li>Interqual breaks it down further into two additional subsets </li></ul><ul><li>Severity of Illness or SI </li></ul><ul><li>This is used on admission/preadmission only. Patient must meet severity of illness before you can review for intensity of service. This is done upon admission. </li></ul><ul><li>Intensity of service </li></ul><ul><li>These are basically physician orders. What is being done for the patient. It must be met initially and with continued stay </li></ul>
  8. 8. Severity Of Illness <ul><li>This criteria consist of objective, clinicals indicators of illness which focus on the patient’s clinical presentation and/or diagnosis </li></ul><ul><li>Time requirements vary based on the level of care </li></ul><ul><li>Grouped by reason for admission and alphabetized </li></ul>
  9. 9. Continued <ul><li>Most Severity of Illness or SI are organized into subsets </li></ul><ul><ul><li>Clinical Findings </li></ul></ul><ul><ul><li>Imaging Findings </li></ul></ul><ul><ul><li>ECG findings </li></ul></ul><ul><ul><li>Laboratory findings </li></ul></ul>
  10. 10. Intensity of Service <ul><li>This criteria consists of monitoring and therapeutic services, either by themselves or together, that can only be administered at a specific level of care. </li></ul><ul><li>Intensity of service criteria is broken down again into two sections </li></ul><ul><ul><li>One IS This means you only need to meet one of these clinical to meet criteria </li></ul></ul><ul><ul><li>Three IS This mean the patient has to have at least three of these interventions to meet criteria </li></ul></ul><ul><ul><li>IS EXCLUDES PO MEDICATION UNLESS INDICATED </li></ul></ul>
  11. 11. Interqual basics <ul><li>Interqual contains the five basic review types </li></ul><ul><ul><li>Preadmission review. This is for planned admission for a procedure </li></ul></ul><ul><ul><li>Admission review. This is done upon the patient’s admission to the hospital. It includes Observation and Inpatient admissions </li></ul></ul>
  12. 12. Types of review continued <ul><ul><li>Discharge review. This is to determine the safety of discharge or transfer from one level of care to another </li></ul></ul><ul><ul><li>Continued Stay review. This is performed to determine if the level of care is still appropriate. Only intensity of service criteria is used. </li></ul></ul><ul><ul><li>Secondary review. This review occurs when the primary reviewer does not find that patient meets criteria. It is up to the individual originations to determine who does those reviews </li></ul></ul>
  13. 13. Admission Review Process <ul><li>This is done when the patient is admitted to a level of care to determine if that level of care is appropriate. If the patient is transferred from a lower level of care to a higher level of care, an admission review is also required. Both the Severity of Illness (SI) and the Intensity of service (IS) rules from the same criteria subset must be met. </li></ul>
  14. 14. Steps <ul><li>Identify the level of care based on the patients current level </li></ul><ul><li>Select the most appropriate criteria subset based on the patient’s predominant clinical findings </li></ul><ul><li>Review specific clinical information derived at the time of admission. ER data can be utilized. </li></ul><ul><li>Apply the SI rule – pt must meet severity of illness criteria </li></ul><ul><li>Apply the IS rule – pt must meet intensity of service criteria </li></ul>
  15. 15. Admission review findings <ul><li>When the SI and IS rules are met. </li></ul><ul><li>1. Approve stay and schedule a continued stay review </li></ul><ul><li>SI and IS rules not met. </li></ul><ul><li>1. Obtain additional information from admitting MD or other caregivers </li></ul><ul><li>2. If additional information does not meet SI or IS, discuss alternate levels of care with attending md. </li></ul><ul><li>3. Facilitate transfer if the attending physician is agreeable </li></ul>
  16. 16. Continued Stay Review <ul><li>Continued stay review is performed to determine the appropriateness of continued stay at a level of care. </li></ul><ul><li>Apply the intensity of service criteria (one IS/*three IS) </li></ul><ul><li>The patient has to meet criteria on a daily basis </li></ul>
  17. 17. Steps <ul><li>Begin at the same criteria subset used during the Admission review unless </li></ul><ul><ul><li>Pt has been transferred to a lower level of care </li></ul></ul><ul><ul><li>Pt has been transferred to a higher level of care – then it would be an admission review </li></ul></ul><ul><ul><li>Pt remains at the same level of care but their medical condition has changed. You do not need to meet severity of illness. </li></ul></ul>
  18. 18. Steps continued <ul><li>Review patient specific clinical information </li></ul><ul><li>Apply IS by selecting the IS criteria based on treatments, medication or interventions making sure they meet all the rules for duration, time frames and number of criteria </li></ul>
  19. 19. Continued stay review actions <ul><li>If IS is met, approve level of care for that day and schedule a continued stay review </li></ul><ul><li>Three *IS met, approve level of care for that day. Review the discharge screens and document the discharge plan. Schedule a continued stay review. </li></ul><ul><li>IS or three*IS not met or IS and discharge review criteria are selected, obtain additional information from the attending MD or other caregivers. If IS is not met, perform discharge review. </li></ul>
  20. 20. Discharge Review <ul><li>Discharge reviews are done when criteria for continued stay are not met, an IS criteria is selected that states “and discharge review”, or to assist in determining the next appropriate level of care within the facility or transfer to another facility. </li></ul>
  21. 21. Steps <ul><li>Select the same criteria subset used for the admission or continued stay review and apply the DS rule the appropriate level of care </li></ul><ul><ul><li>One IS that states “ and discharge review ” </li></ul></ul>
  22. 22. Discharge Review Actions <ul><li>If the discharge screen is NOT met, approve the day and schedule the next review within 24 hours. </li></ul><ul><li>On the next review, if DS is still not met, it should go to secondary review. </li></ul>
  23. 23. Discharge review actions continued <ul><li>If the discharge screen is met and discharge is scheduled, no action required </li></ul><ul><li>If discharge not scheduled, contact the attending physician to discuss the d/c plan and ALOC options </li></ul><ul><li>Facilitate discharge or transfer if the attending physician agrees </li></ul>
  24. 24. Secondary Review <ul><li>This review is completed by a supervisor, specialist or a physician may conduct a secondary review. </li></ul><ul><li>Organizational policy should determine the qualifications of the reviewer as well as the extent to which the reviewer has oversight </li></ul><ul><li>The secondary reviewer determines the medical necessity of admission or continued stay based on review of the medical record, discussions with nursing, discharge planner and attending physician and by applying clinicals experience. </li></ul>
  25. 25. Interqual Tips <ul><li>Don’t be afraid to use the reference materials </li></ul><ul><ul><li>The index can assist in identifying the appropriate criteria subset </li></ul></ul><ul><ul><li>Inpatient list identifies procedures that are appropriate for the inpatient setting </li></ul></ul><ul><ul><li>Abbreviation and symbols list </li></ul></ul><ul><ul><li>Drug list </li></ul></ul>
  26. 26. Process Tips <ul><li>Review all notes attached to criteria. They are in parentheses and are numbered. </li></ul><ul><li>PRN medication can be used to meet the IS criteria during an admission review but only if the required frequency is met </li></ul><ul><li>Oxygen saturation is based on room air measurements unless otherwise noted. </li></ul><ul><li>Treatments or services that are only given once while in the ED cannot be used for IS criteria </li></ul>
  27. 27. Process Tips continued <ul><li>If there is no IS on an admission review, this does not meet criteria. You can use the discharge screen to determine an alternate level of care </li></ul><ul><li>A 24 hour grace period can be given, one time only, when DS are not met and the IS rule (one IS/*three IS) is not met. For example: </li></ul><ul><ul><li>A therapeutic pause of medication is needed. </li></ul></ul>
  28. 28. Tips <ul><li>It is acceptable for a patient to be in observation even if they meet acute criteria. This can occur when the expected length of stay is less than 24 hours </li></ul><ul><li>Don’t confuse patient status issues with billing issues. Some payers contract with facilities to provide observation level of care when it could be either inpatient or outpatient </li></ul>
  29. 29. Questions?