Northwest Region Crisis Care System Authorization Training

Illinois Mental Health Collaborative, for Access and Choice

Presenters:

  • Lee Ann Reinert, LCSW, Clinical Policy Specialist, DHS/DMH
  • Callie R. Lacy, LCPC, Clinical Supervisor, Collaborative
  • Author:  Patricia E. Hill, CSS

Summary:  This document will review the procedures regarding the authorization and functions of the Northwest Region Crisis Care System

Glossary of Terms

  • CMHC-Community Mental Health Center
  • LOC-Level of Care
  • SMI-Serious Mental Illness
  • LOCUS-Level of Care Utilization System
  • USARF-Uniform Screening and Referral Form
  • MNC-Medical Necessity Criteria
  • CCM-Clinical Care Manager

What Is It?

  • A Utilization Management Service implemented by the State of IL in conjunction with DHS/DMH where the Collaborative will handle:
    • Authorization for Northwest Crisis Care System, including inpatient, residential and acute community care

Who Is Eligible for the Levels of Care?

  • Consumers that are Unfunded
  • Consumers that would previously have been admitted to Singer Hospital
  • Consumers with SMI that need immediate evaluation and care during a crisis situation

Type of Service

  • The Assessor will assess in two categories:
    • Mental Health
    • Financial Eligibility

The Process.... 

  • Once the Consumer has met the criteria, the Evaluator will contact the Collaborative at (866)359-7953 and select option "#4" to obtain authorization
  • The Collaborative will review the clinical information to verify that the Consumer meets the Medical Necessity Criteria (MNC) for the LOC being requested
  • Once the Consumer has been approved, the Collaborative will assist with locating a bed if needed
  • The Collaborative will issue an Initial Review Authorization according to the LOC determined by the Evaluator

The Collaborative Call

Demographics

  • Consumer Information
    • First and Last Name
    • RIN
    • Date of Birth
    • Social Security Number
    • Address (last known address or current location if homeless)
    • Gender
    • Ethnicity
    • Provider Information
  • Financial Information 
    • Funding Source (verify non-funded status)
  • Level of Service
  • Level of Care Requested
    • Inpatient
    • Mental Health Crisis Residential
    • Acute Community Care


Assessment

  • Diagnosis
    • Axis 1
    • Axis 2
    • Axis 3
    • Axis 4
    • Axis 5
      • Current
      • Past 
  • Current Risks
    • Mental Status
    • Risk to Self
    • Risk to Others
  • Current Impairment
    • Mood Disturbance(s)
    • Anxiety
    • Psychosis
    • Eating Disorder
    • Chemical Dependence
    • Under 19 or Over 65
  • LOCUS Score
    • Dimension 1: Risk of Harm
    • Dimension 2: Functional Status
    • Dimension 3: Medical, Addictive & Psychiatric Co-Morbidity
    • Dimension 4a: Recovery Environment-Level of Stress
    • Dimension 4b: Recovery Environment-Level of Support
    • Dimension 5: Treatment & Recovery History
    • Dimension 6: Engagement
    • Composite Score
    • LOCUS Recommended Level of Care
    • Evaluator Recommended Level of Care
    • Reason for Deviation (if any) 


Consumer History

  • Treatment History 
    • Psychiatric Treatment in the past 12 months
      • Outpatient
      • Intensive Outpatient
      • Hospitalization
    • Substance Abuse in the past 12 months
      • Outpatient
      • Intensive Outpatient
      • Hospitalization
    • Medical Treatment in the past 12 months
      • Routine Medical Treatment
      • Significant Medical Treatment


Medication History 

  • Psychotropic Medications 
    • Medicine
    • Dosage
    • Frequency
    • Side Effects
    • Compliance
    • Effectiveness
    • Prescriber
  • Additional Medications
    • Medicine
    • Dosage
    • Frequency
    • Side Effects
    • Compliance
    • Effectiveness
    • Prescriber

Substance Abuse History 

  • Substance Used
    • Total years of use
    • Length of current use
    • Amount of current use
    • Frequency of current use
    • Date last used
  • Withdrawal Symptoms

Decisions

  • If the CCM proposes an alternative level of service due to either clinical factors or lack of capacity
    • The Evaluator will discuss the alternative with the ED physician (if involved), the individual and appropriate parties
    • If agreement on the proposed alternative level of service is reached, then authorization will be provided
    • If the Evaluator cannot accept the proposed alternative level of service, then the CCM will call Elgin or McFarland MHC to initiate an appeal
    • Elgin/McFarland's decision will be final


What's Next? 

FOR INPATIENT CARE:

  • Once the Collaborative has determined the Consumer meets MNC, the Collaborative will:
    • If in a hospital that has a CHIPS contract, verify if a bed is available
    • If there is an available bed, an authorization will be given and the initial
    • authorization process will be complete
    • If there are no beds available, the Collaborative will assist with locating a bed via the approved facility listing
    • Once a bed is located for the Consumer, the initial authorization process will be complete

And...

FOR MENTAL HEALTH CRISIS RESIDENTIAL LOC:

  • Once the Collaborative has determined the Consumer meets MNC, the Collaborative will:
    • Assist with locating a bed via the approved facility listing
    • Provide the Evaluator with the contact information for the approved facility and an authorization number

Also... 

FOR ACUTE COMMUNITY CARE:

  • Once the Collaborative has determined the Consumer meets MNC, the Collaborative will:
    • Assist with determining the appropriate provider via the geographic provider listing (this will generally be the same provider as the EDA provider)
    • Provide the Evaluator with an authorization number and the contact information for the provider (if necessary)

More Time

Continued Stay Request...

  • If the Consumer is still hospitalized when the Initial Authorization timeframe is up, they will need a concurrent review for continued stay
  • 24 hours before the expiration date (or on the preceding Friday if a weekend), the attending physician and/or designee will contact the Collaborative at (866)359-7953 and select option "#4" to request an authorization for continued stay
    • Concurrent authorizations must be done during regular business hours (Monday - Friday, 8 am - 5 pm)
    • The Collaborative will review the clinical information to verify that the Consumer meets the Medical Necessity Criteria (MNC) for Continued Stay
    • Once the Consumer has been approved, the Collaborative will issue a Concurrent Review Authorization
    • If longer term services are needed, the hospital should make arrangements for a more appropriate care setting (i.e. state hospital, nursing home, etc.)


Decisions

  • A PA Review is conducted if there is a difference of opinion concerning a request for extended length of stay for the consumer
  • If the PA Review agrees, services will be authorized
  • If the PA Review does not agree with the extension, a Second Level Reconsideration Review will be conducted with another VO MD
  • If the PA Second Level Reconsideration Review agrees, services will be authorized
  • If the Second Level Reconsideration Review remains unresolved then DMH will make the final determination

Questions and Answers???

Thanks for your Participation

Illinois Mental Health Collaborative, for Access and Choice

www.illinoismentalhealthcollaborative.com

(888)359-7953