Inpatient psychiatric care

These criteria pertain to geriatric (over age 65), adult, adolescent, and child patients.

A. Medical necessity

Criteria 1, 2 and either 3, 4 or 5 must be met to satisfy the criteria for admission.

1. The patient has a diagnosed or suspected mental illness. Mental illness is defined as a psychiatric disorder that, by accepted medical standards, can be expected to improve significantly through medically necessary and appropriate therapy. Presence of the illness must be documented through the assignment of appropriate DSM-IV codes on all applicable axes (I-V).
2. The patient requires an individual plan of active psychiatric treatment that includes 24-hour access to the full spectrum of psychiatric staffing. This psychiatric staffing must provide 24-hour services in a controlled environment, including, but not limited to, medication monitoring and administration, other therapeutic interventions, quiet room, seclusion, intermittent restraints, and suicidal/homicidal observation and precautions.
3. The patient demonstrates a clear and reasonable inference of imminent serious harm to self. This is evidenced by having any one of the following:
• A current plan or intent to harm self with an available and lethal means
• Recent severe self-harm behavior or suicide attempt, with continued imminent risk as demonstrated by poor impulse control or an inability to plan reliably for their safety
• Imminently dangerous inability to care adequately for his/her own physical needs or to participate in such care due to disordered, disorganized or bizarre behavior
• Other similarly clear and reasonable evidence of imminent serious harm to self
4. The patient demonstrates a clear and reasonable inference of imminent serious harm to others. This is evidenced by having any one of the following:
• A current plan or intent to harm others with an available and lethal means
• A recent, severe attempt to harm others, with continued imminent risk as demonstrated by poor impulse control and an inability to plan reliably for their safety
• Violent unpredictable or uncontrolled behavior that represents an imminent risk of serious harm to the body or property of others, or other similarly clear and reasonable evidence of imminent serious harm to others
5. The patient's condition requires an acute psychiatric assessment technique or intervention that, unless managed in an inpatient setting, would have a high probability of leading to serious, imminent and dangerous deterioration of the patient's general medical or mental health.

B. Admission criteria

All are required to consider for admission.

1. The patient must be medically evaluated and cleared of co-morbid medical conditions that may be contributing to the psychiatric condition prior to an acute inpatient psychiatric admission.
2. The evaluation and assignment of the mental illness diagnosis must take place in a face-to-face evaluation of the patient performed by an attending psychiatrist within 24 hours following the admission. There must be the availability of an appropriate initial medical assessment and ongoing medical management to evaluate and manage co-morbid medical conditions. Caretakers/guardians/family members should be included in the evaluation process, unless there are specific contraindications to their involvement.
3. This care must provide an individual plan of active psychiatric treatment that includes 24-hour access to the full spectrum of psychiatric staffing. This psychiatric staffing must provide 24-hour services in a controlled environment, including, but not limited to, medication monitoring and administration, other therapeutic interventions, quiet room, seclusion, intermittent restraints, and suicidal/homicidal observation and precautions.
4. A discharge plan is initially formulated that is directly linked to the behaviors and/or symptoms that resulted in admission and begins to identify appropriate post-hospitalization treatment resources.

C. Continuing care criteria

All criteria are required to consider for admission.

1. Despite reasonable therapeutic efforts, clinical evidence indicates at least one of the following:
• The persistence of problems that caused the admission to a degree that continues to meet the admission criteria (both severity of need and intensity of service needs)
• The emergence of additional problems that meet the admission criteria (both severity of need and intensity of service needs)
• 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 psychiatrist
2. The current treatment plan includes documentation of diagnosis (DSM-IV axes I-V), individualized goals of treatment, treatment modalities needed and provided on a 24-hour basis, discharge planning, and ongoing contact with the family, facility of residence, personal caretakers and medical caretakers (unless there is an identified valid reason why such contact is not clinically appropriate or feasible). 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.
3. The current or revised treatment plan can be reasonably expected to bring about significant improvement in the problems meeting criterion C1. This evolving clinical status is documented by daily progress notes, one of which evidences a daily examination by the psychiatrist.
4. Additional criterion for child/adolescent continuing care: Documented evidence of significant family involvement at least 3 times weekly or clearly documented evidence that such is medically or clinically contraindicated.