INTERQUAL HOME CARE CRITERIA REVIEW PROCESS

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3 ORGANISATION InterQual Home Care Criteria subsets are organised by services (e.g., Physiotherapy, Skilled Nursing: Wound) and then into Initial and Ongoing Review. The Initial Review criteria are used for reviewing and approving the initial visits or initial authorisation period. The Ongoing Review criteria are used for approving additional visits after the initial visits or period is completed or for subsequent authorisation. The adult subsets limit the ongoing review to less than 60 days. After 60 days, continued request for skilled nursing will be reviewed using the Skilled Nursing: Long-term Care subset. Requests for continued therapy visits after 60 days would be referred for secondary review. AGE PARAMETERS Adult criteria are for review of patients > 17 years of age. Paediatric criteria are for patients 17 years of age. LEVEL OF CARE COMPONENTS Severity of Illness (SI) criteria consist of objective clinical indicators. The SI rule requires All SI criteria to be met. The clinical indicators include: Patient s illness / injury / exacerbation / surgery The need for skilled intervention(s) Reasons that services need to be provided in the home setting Intensity of Service (IS) criteria consist of diagnostic, monitoring, and therapeutic services, singularly or in combination, that can be administered in the home. The IS rule requires that One IS criteria be met. Each IS criterion has an associated number of visits within a given time period. Discharge Screens (DS) are used as a safety net to determine if the patient has reached the level of clinical stability appropriate for safe discharge from home care. The DS rule requires One. INITIAL REVIEW Initial Review Rule To determine the appropriateness of services at the home care level, both the SI rule and the IS rule from the same Initial Review criteria subset must be met. An initial review is conducted when there are requests for any new service(s). Review Type Initial Review Time Before first visit Review Rule Apply Severity of Illness (SI) and Intensity of Service (IS) Initial Review Steps 1. Obtain and review patient specific clinical and psychosocial information (e.g., medical practitioner, therapy, nursing progress notes, medical practitioner orders, laboratory reports, and other information, as needed). 2. Select the most appropriate Initial Review criteria subset based on the requested services (e.g., skilled nursing, PT, OT). RP-3

4 3. Apply SI rule. Select SI criteria based on patient s clinical findings and determine if All criteria are met. Document the SI criteria met. 4. Apply IS rule. Select IS criteria based on skilled services from the same criteria subset used to select SI and determine if One IS criteria is met. Document the IS criteria met. 5. Continue according to the following recommended actions. Initial Review Actions For these Review Findings SI and IS rule met SI or IS rule not met Do this Approve the initial visit(s). Schedule ongoing review, if appropriate. Obtain additional information from the ordering medical practitioner or other health care provider(s). If additional information does not meet the corresponding SI or IS, determine if the patient meets DS criteria. Discuss alternate levels of care with the ordering medical practitioner. Facilitate transfer if the ordering medical practitioner is agreeable to an alternate level of care. Refer for Secondary Review if the ordering medical practitioner does not agree with alternate level of care or alternate level of care not available. (For information about the Secondary Review process, refer to page RP-8.) Practical Tips More than One Service Requested: When more than one service is requested and will be provided by different disciplines (e.g., skilled nursing clinical assessment, paraprofessional services, and physiotherapy), the reviewer needs to review each of these services separately. Finding the Most Appropriate Skilled Nursing Criteria Subset: As there are several skilled nursing criteria subsets, the general descriptors below will assist the reviewer in selecting the correct one. Clinical Assessment is intended for patients whose primary skilled needs are hands-on clinical assessment (e.g., vital signs, lung sounds, oedema), monitoring of medication effectiveness, and teaching / evaluation of prescribed therapies / safety precautions. The criteria include bowel, bladder, diabetes, hospice, psychiatric nursing, and body system specific services (e.g., cardiovascular, respiratory). Also included are criteria for nutrition, medical social services, and psychiatric nurse consults. Disease Management is criteria that focuses on educating the patient or caregiver in selfmanagement of their disease and equipment use. The intent of these criteria is to allow the reviewer to approve visits for preventative care that will result in reduced hospital / A&E / office visits. A time frame is not included. The frequency of the visits or telephonic visits should be determined by the patient or caregiver s ability to learn. High Risk Obstetrics is intended for antepartum women with potential or actual risk for abnormal conditions of pregnancy. RP-4

5 High Technology addresses specialised medical therapies, including infusions, medical gas management (paediatric only), and TPN / PPN. Medical gas management for the adult is located in Skilled Nursing: Clinical Assessment. Postpartum / Newborn addresses the well mother / baby visit(s) as well as problematic areas present within the postpartum period (6 weeks post delivery). Ongoing infant problems after initial certification are covered in the Paediatric criteria subsets. Wound addresses dressing changes, nutrition assessment, drain care, ostomy management, wound specialist needs, and general skin conditions. Initial Authorisation Period: Each IS criterion specifies a timeframe for the delivery of the requested service. While generally, this timeframe is limited to the first 2 weeks, some IS criteria have longer timeframes. In the following example, the reviewer would approve a 4-week initial authorisation period. Example (IS): Bladder, one: Catheter change / irrigation / reinsertion and patient / primary caregiver unable to perform 2 visits 4 wks A week is defined as any 7-day period. You may select as many SI and IS as you wish or as specified by your organisation for documentation purposes, as long as the minimum number of criteria required has been met. Knowing Which Visit Pattern to Approve: The number of visits assigned is based on the criterion with the greatest number of visits. The visits are not cumulative. For example, a patient requires daily dressing changes and clinical assessment for diabetes. The reviewer would approve 14 visits (Wound) versus 6 visits (Clinical Assessment, Diabetes) over 2 weeks. Consults for medical social services, nutrition, and psychiatric nursing criteria are provided to validate the need for these services anytime during the patient s episode of care. These visits are in addition to the approved nursing or therapy visits the patient is receiving and should be used only once during the episode of care. Example: A patient was approved for 6 visits 2 wks for diabetes education. After the first week of home care services a request is made for a medical social service consult for long-term planning. Medical social services consult for inadequate resources / supports interfering with medical progress, 2 visits 2 wks (once per episode), one: Long-term planning / Durable power of attorney / Legal guardian Initial Assessment (1 visit only): When available information does not clearly identify whether home care services are warranted, the criteria provide for a single visit to determine if the patient has a skilled need. If it is determined that a skilled need is present, the reviewer should conduct an Initial Review based on the identified need to approve additional visits. New Clinical Problem(s): If a different service is being requested than originally authorised, then an Initial Review should be conducted to determine if home care services are appropriate. Example: A patient was initially authorised under Skilled Nursing: Wound, but develops a cardiovascular instability during the course of care requiring clinical assessment and medication adjustments. The reviewer should refer to the Initial Review Skilled Nursing: Clinical Assessment criteria subset to validate that visits for this new condition are appropriate. Discharge Screens are provided to validate that the patient can be safely discharged from home care services when the initial time period authorised has ended or when SI and / or IS are not met. This review is optional. RP-5

6 ONGOING REVIEW Ongoing Review Rule To validate the need for ongoing services at the home care level, both the SI rule and the IS rule from the same Ongoing Review criteria subset must be met. Ongoing Review is conducted only for services authorised during an Initial Review. For example, 6 visits over a 2-week period for physiotherapy were authorised at the time of the initial review. Ongoing Review is required as additional physiotherapy visits are being requested. If a different service is being requested than originally authorised (e.g., skilled nursing), then an Initial Review should be conducted. Review Type Ongoing Review Review Time Beyond initial approved visits / After last ongoing review period completed Review Rule Apply Severity of Illness (SI) and Intensity of Service (IS) Ongoing Review Steps 1. Obtain and review patient specific clinical and psychosocial information (e.g., medical practitioner, therapy, nursing progress notes, medical practitioner orders, laboratory reports, and other information, as needed). 2. Select the same Ongoing Review criteria subset as used during the Initial Review or the last Ongoing Review. 3. Apply SI rule. Select SI criteria based on patient s clinical findings and care needs, and determine if All criteria are met. Document the SI criteria met. NOTE: When determining SI, there should be either changes / additions to the plan of care or documented progress in therapies toward self-care since the initial authorisation. 4. Apply IS rule. Select IS criteria based on skilled services from the same criteria subset used to select SI and determine if One IS criteria is met. Document the IS criteria met. 5. Continue according to the following recommended actions. RP-6

7 Ongoing Review Actions For these review findings SI and IS rule met SI or IS rule not met Do this Approve continued home care services. Schedule next review if appropriate. Review DS to determine if an alternate level of care is appropriate. Contact the ordering medical practitioner or other healthcare provider to discuss the treatment, discharge plans, and alternate level of care options, if appropriate. Facilitate transfer / discharge if the ordering medical practitioner agrees with an alternate level of care / discharge. Refer for Secondary Review if ordering medical practitioner does not agree with the alternate level of care / discharge recommendation or the alternate level of care is unavailable. (For information about the Secondary Review process, refer to page RP-8.) Practical Tips Multiple Services: When more than one service is requested and will be provided by different disciplines (e.g., skilled nursing clinical assessment, Home Health Care Assistant, and physiotherapy), you need to review each of these services separately. Knowing Which Visit Pattern to Approve: The number of visits assigned is based on the criterion with the greatest number of visits. The visits are not cumulative. For example, a patient requires daily dressing changes and clinical assessment for diabetes. The reviewer would approve 14 visits (Wound) versus 6 visits (Clinical Assessment, Diabetes) over 2 weeks. Some criterion points have subcriterion that may have a different number of visits assigned. If the subcriterion is used, use the visit numbers assigned to that subcriterion. Week: A week is defined as any 7-day period. New Clinical Problem(s) / Skilled Need: If a different service is being requested during the Ongoing Review period than originally authorised, an Initial Review should be conducted to determine if home care services are appropriate. Example: A patient was initially authorised under Skilled Nursing: Wound, but develops a cardiovascular instability during the course of care requiring clinical assessment and medication adjustments. The reviewer should refer to the Initial Review Skilled Nursing: Clinical Assessment criteria subset to validate that visits for this "new" condition are appropriate. Documentation of SI: You may select as many SI criteria as you wish or as specified by your organisation for documentation purposes, as long as the minimum number of criteria required has been met. Ongoing Review Criteria are limited to weeks 3 through 8 (adult only). After 8 weeks of home care service, the reviewer would use the Skilled Nursing: Long-term Care subset for additional nursing visits. Skilled Nursing: Long-term Care (Adult Only) criteria are used to address the needs of the patient that requires skilled nursing after 60 days (one episode of care). Discharge Screens (DS) are provided to validate that the patient can be safely discharged from home care services when SI or IS are not met. RP-7

8 SECONDARY REVIEW When a case does not meet criteria, it is referred for a Secondary Review. A supervisor, a specialist (e.g., therapist, wound ostomy nurse) or a medical practitioner may conduct secondary review. Organisational policy should determine the qualifications of the reviewers as well as the extent to which secondary review(s) is performed in order to render a review outcome. 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 ordering medical practitioner, and by applying clinical experience. When is a Secondary Review Appropriate? Review rules are not met. You have questions about the quality of care. What Questions Does a Secondary Review Address? Does the patient require this level of care? What are the treatment options? Is there a quality of care question? Should a specialist evaluate this case? Secondary Review Process The Secondary Review process determines the appropriateness of the current or alternate level of care. Follow these steps when you conduct a Secondary Review: If the secondary reviewer agrees with the existing level of care, approve the level of care and schedule the next review. If the secondary reviewer does not agree with the existing level of care, he or she discusses the alternate level of care options for this patient with the ordering medical practitioner. If the ordering medical practitioner agrees with the secondary reviewer, facilitate the transfer to the alternate level of care, if available. If the ordering medical practitioner does not agree with the secondary reviewer, initiate action as determined by organisational policy. If the alternate level of care is unavailable, finalise the Variance Code. Document the review outcome. IMPORTANT: The Criteria reflect clinical interpretations and analyses and cannot alone either resolve medical ambiguities of particular situations or provide the sole basis for definitive decisions. The Criteria are intended solely for use as screening guidelines with respect to the medical appropriateness of healthcare services and not for final clinical or payment determinations concerning the type or level of medical care provided, or proposed to be provided, to a patient. RP-8