InterQual Level of Care Subacute & SNF Criteria 2011 Clinical Revisions The Clinical Revisions provide details of changes to InterQual Clinical Criteria. They do not provide information on changes made to CareEnhance Review Manager software. For information on Review Manager software changes, see the Review Manager Release Notes and the What's New topic in CareEnhance Review Manager Help. Review and Incorporation of Recent Medical Literature McKesson Health Solutions is committed to keeping the InterQual product suite current and accurate. Criteria are continually reviewed and updated, with new editions of every product released annually. McKesson Health Solutions staff of physicians, nurses, and other licensed healthcare professionals, and its extensive array of primary care and specialty consultants, participate in ongoing criteria revision as new medical information emerges. Each annual release of the criteria reflects a thorough review of new medical literature, society guidelines, and current practice standards and incorporates consultant and user feedback. MHS Customer Hub The MHS Customer Hub (http://mhscustomerhub.mckesson.com) provides interactive support, answers to commonly asked questions, and links to other resources. For a user ID and password, contact your MHS Customer Hub site administrator or MHScustomerhub@mckesson.com Enhancements Bibliography The Bibliography has gone green! As of March 2011, the Bibliography will be available electronically only. The Bibliography will no longer be available in hardcopy InterQual books i.e., in the Appendix section of the InterQual criteria books. Clients may access Bibliographies from the following locations: MHS Customer Hub. Visit at http://mhscustomerhub.mckesson.com. Help Menu. The bibliography can be found listed in the Help Menu of all InterQual software solutions i.e., Review Manager, InterQual Online, InterQual Online Anonymous Review, and InterQual View. Click Help Menu and then click InterQual Clinical Reference to access documents. Page 1 of 6
New Evidence Classification Designations Comparative Effectiveness Research (CER) is used when an article describes a comparative effectiveness research study. CER studies compare two or more interventions against one another in a real-world setting (as opposed to comparing a single intervention to a placebo, sham procedure, or waiting list) and provide information on the relative strengths and weakness of each. Comparative studies are particularly useful when placebo or waitlist-controlled trials have demonstrated the efficacy of more than one intervention for a particular situation, and can help answer the question, Which of these interventions is better? Not Classified (NC) is used for sources that do not constitute clinical evidence and thus do not fit into the McKesson current evidence classification ratings of I-V. Examples of such references include laws, regulations, and online tools. New Transition Plan Icon The Transition Plan document was added last year as a comprehensive discharge planning guideline. This year, select criteria points have been flagged with a new icon ( ), indicating that patient may be at risk for readmission and could benefit from comprehensive discharge planning. The Transition Plan is available in the criteria books and as a reportable, interactive checklist in CareEnhance Review Manager. Global / General Criteria Changes Revision Changed the terminology for Congestive Heart Failure (CHF) to Heart Failure (HF) All Subsets, Level of Care Notes: Updated the Level of Care notes to further define the Subacute and SNF Levels of care. The notes are structured by Patient Status and Program Requirements. All Subsets (excluding Pediatric Subacute) In the Level of Care notes, the RUGs III groupings were changed to reflect the new RUGs IV groupings that may apply to the subset based on the medical and/or therapy resources defined within each subset. Rationale Reflects current terminology Notes updated to enhance usability of the Subacute/SNF content. The new CMS RUGS IV case-mix classification system increases the current RUG categories from 53-66 groupings for fiscal year 2011. These new categories are reflected in the subset note updates. Page 2 of 6
Revision All Subsets: New criteria were added in the Discharge Screens for the following ALOC options. The ALOC rules changed from Both to All to accommodate the new content. The following examples are provided: Home / OP, All: Complete prior to discharge, All: Follow-up care planned Comprehensive written discharge and teaching instructions reviewed Medication reconciliation Understands when and where to seek help Identify and address transportation needs Home Care, All: Complete prior to discharge, All: Follow-up care planned and home care services arranged Comprehensive written discharge and teaching instructions reviewed Medication reconciliation Understands when and where to seek help Identify and address transportation needs Behavioral Health (OP / IOP / PHP), All: and LTC, All: Medication reconciliation Rationale Based on consultant consensus to ensure successful discharge planing. Criteria-Specific Changes Subset Criteria Component Revision Rationale Level I (SNF) SI Change Under Illness / Injury / Exacerbation 30d / Discharged from inpatient facility, One: removed the criterion "Ostomy, (new)". McKesson consultants agree that new ostomy treatment and/or education would not be the primary reason for admission to this level of care. For patients who have complications, such as the need for wound care or skilled therapy, a review of these criteria would be in order to determine admission appropriateness. Level I (SNF) SI Change Under "Cardio / Peripheral vascular / Respiratory condition, One:" removed the criterion "DVT". McKesson consultants agree that patients would not be admitted for DVT treatment at this level of care. Level I (SNF) SI Change Under Musculoskeletal condition, combined the following two criteria points, "Inflammatory joint disease" and "Rheumatoid arthritis / Osteoarthritis". The criteria now appear as: Inflammatory joint disease, (eg, rheumatoid arthritis / osteoarthritis). McKesson consultants agree with combining the criteria, since inflammatory joint disease is inclusive of either rheumatoid arthritis or osteoarthritis. Page 3 of 6
Subset Criteria Component Revision Rationale Level I (SNF) IS Change "Anti-infective (single) 1-2x/24h" changed to "Anti-infective (single) 2x/24h". McKesson consultants agree that the change in time frame from 1-2x/24h to 2x/24h more appropriately defines the intensity of service that would warrant admission and continued stay. Level I (SNF) IS Change Removed "Clinical assessment, 1x/24h, One:", and Adjustments / Tapering 1 medication (PO) 2x/wk" and the criteria for "PO medications (new regimen)" with associated subcriteria. McKesson consultants agree that adjustment or initiation of PO medications can be provided at a less intensive setting. Level I (SNF) IS Change Under the header MEDICAL, removed "DVT treatment (SC) 5d". McKesson consultants agree that DVT management with SQ medication can be managed in a less intensive level of care. Level I (SNF) IS Change To the criterion, "Requiring adjustment of feeding schedule / Education for self-management" added "(excludes bolus feedings)". Level I (SNF) IS Change "IV / IM medication 1x/24h" changed to "IV / IM medication 2x/24h". Change made based on consultant consensus that once patients are receiving bolus feedings, they would be appropriate for discharge to a less intensive level of care. McKesson consultants agree that the time frame change from 1x/24h to 2x/24h more appropriately defines the intensity of service that would warrant admission and continued stay. Level I (SNF) IS Change Removed the criterion, "Ostomy (new) management / education 7d". Criterion removed based on removal of 'Ostomy, new" in the Severity of Illness criteria. New ostomy treatment and/or education can be provided at a less intensive level of care. For Tracheostomy care and/or interventions, see the Respiratory interventions criteria in this subset. Level I (SNF) IS Change Changed the time frame for tracheostomy decannulation from 1wk" to 5d. The criterion appears as: "Tracheostomy decannulation 5d. McKesson consultants agree with the time frame change as being sufficient for tracheostomy decannulation at this level of care. Level I (SNF) DS Change Removed DVT resolving / stable, One: and associated subcriteria. Change made based on removal of DVT criterion point in the Severity of Illness criteria. Page 4 of 6
Subset Criteria Component Revision Rationale Level I (SNF) DS Change Removed Ostomy manageable Change made based on removal of the Ostomy, new criterion point in the Severity of Illness. Level II (SAC) SI Change Under Musculoskeletal condition One:, removed the following criteria: Inability to ambulate household distances / Unable to maintain weight bearing precautions, One: Compression fracture Inflammatory joint disease (eg, rheumatoid arthritis / osteoarthritis) Severe sprain / strain of the spine McKesson consultants agree that these conditions would require a maximum of 1-2 hours of rehab therapy. These criteria can be found in the Level I subset. Level II (SAC) IS Change Under Medical, changed "IV therapy" to "IV therapy / medications". Enhances usability Level II (SAC) IS Change Under Medical, changed Medications 2x/24h" to "Medications 3x/24" and eliminated the medication listings. Level III (Complex Care) SI Change Under Musculoskeletal condition, One:, removed the following criteria: Inability to ambulate household distances / Unable to maintain weight bearing precautions, One: Compression fracture Inflammatory joint disease (eg, rheumatoid arthritis / osteoarthritis) Severe sprain / strain of the spine McKesson consultants agree that the time frame change from 2x/24h to 3x/24h more appropriately defines the intensity of service that would warrant subacute services. McKesson consultants agree that these conditions would require a maximum of 1-2 hours of rehab therapy. These criteria can be found in the Level I subset. Level III (Complex Care) IS Change Under Medical, changed "IV therapy" to "IV therapy / medications" Enhances usability Level III (Complex Care) IS Change Under Medical, changed Medications 2x/24h" to "Medications 3x/24" and eliminated the medication listings. McKesson consultants agree that the time frame change from 2x/24h to 3x/24h more appropriately defines the intensity of service that would warrant subacute services. Page 5 of 6
Subset Criteria Component Revision Rationale Pediatric Subacute IS Change Under "Medical" and "IV Therapy, removed "Cardiac glycosides" Based on consultant consensus Page 6 of 6