Mental Health Hospitalization Criteria

1. 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.

2. 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

3. Continued Stay

   All criteria must be met to meet continued stay:

   • Despite reasonable therapeutic efforts, clinical evidence indicates at least one of the following:
     1. 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).
     2. The emergence of additional symptoms and behaviors that meet the admission criteria (both severity of illness and intensity of service).
     3. 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.
     4. 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.
     5. 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.