Mental Health Hospitalization Criteria
Reviewed: 2/11, 3/14, 1/15, 1/16, 1/17
Revised: 3/10, 1/12, 1/13, 3/14, 1/15, 1/16, 1/17
Severity of illness:
All criteria must be met to meet medical necessity for inpatient mental health:
- The patient has a diagnosed or suspected mental illness.
- The diagnosis is listed in the DSM-V manual.
- The patient requires an individual plan of active psychiatric treatment that includes 24 hour access to the full spectrum of psychiatric staffing.
- The patient demonstrates an actual or potential danger to self or others, or inability to care for self.
- The patient’s condition requires an intervention that at a less restrictive treatment program is not appropriate.
Intensity of Service
All criteria must be met to meet intensity of service:
- The evaluation and assignment of the diagnosis by a board certified psychiatrist must take place with the 24 hours following admission.
- Need for specialty testing or consultation not available on a outpatient basis in a timely manner.
- There must be the availability of an appropriate initial medical assessment and ongoing medical management to evaluate and manage co-morbid medical conditions.
- Care must provide an individual plan of active psychiatric treatment that includes 24 hour access to the full spectrum of psychiatric staffing; this must include but is not limited to medication monitoring and administration, seclusion, restraints, and suicidal/homicidal observation precautions.
- A discharge plan is initially formulated that is directly linked to behaviors and/or symptoms that resulted in admissions.
Criteria for Continued Stay
All criteria must be met to meet continued stay:
- Despite reasonable therapeutic efforts, clinical evidence indicates at least one of the following:
- The persistence of symptoms and behaviors that caused the admission to a degree that continues to meet the admission criteria (both severity of illness and intensity of service).
- The emergence of additional symptoms and behaviors that meet the admission criteria (both severity of illness and intensity of service).
- That discharge planning, increase in hospital privileges and/or attempts at less restrictive level of care have resulted in, or would result in, exacerbation of the psychiatric illness to the degree that would necessitate continued hospitalization.
- A severe reaction to medication or need for further monitoring and adjustment of dosage in an inpatient setting, documented in daily progress notes by a physician.
- Emergence of medical complications or co-morbidities that effect the response to the psychiatric care and treatment.
- The treatment plan includes documentation of diagnosis, individualized goals of treatment, treatment modalities needed and provided on a 24 hour basis, discharge planning, and ongoing contact with the patient’s family and/or other support systems. This plan receives regular review and revision that includes ongoing plans for timely access to treatment resources that will meet the patient’s post-hospitalization needs.
- The current or revised treatment plan can be reasonably expected to bring about significant improvement. This evolving clinical status is documented by daily progress notes, one of which evidences a daily examination by the psychiatrist.