Common use of CONTINUING STAY CRITERIA Clause in Contracts

CONTINUING STAY CRITERIA. After a CONSUMER has been certified for admission to an inpatient psychiatric setting, services must be reviewed at regular intervals to assess the current status of the treatment process and to determine the continued necessity for care in an inpatient setting. Treatment within an inpatient psychiatric setting is directed at stabilization of incapacitating signs or symptoms, amelioration of severely disabling functional impairments, arrestment of potentially life-threatening self/other harm inclinations, management of adverse biologic reactions to treatment and/or regulation of complicated medication situations. The continuing stay recertification process is designed to assess the efficacy of the treatment regime in addressing these concerns, and to determine whether the inpatient setting remains the most appropriate, least restrictive, level of care for treatment of the CONSUMER’s problems and dysfunctions. Continuing treatment in an inpatient setting may be certified when signs, symptoms, behaviors, impairments, harm inclinations or biologic/medication complications, similar to those which justified the CONSUMER's admission certification, remain present, and continue to be of such a nature and severity that inpatient psychiatric treatment is still medically necessary. It is anticipated that in those reviews which fall near the end of an episode of care, these problems and dysfunctions will have stabilized or diminished. The Payor is responsible for monitoring patient progress. To the extent possible, PROVIDER will coordinate care with other entities and individuals involved with the care of the consumer that is being served. Continued stay authorization requests are to be submitted to the PAYOR. The PAYOR will, in turn, provide appropriate continued stay authorizations. The PAYOR is responsible for monitoring patient progress. All PAYORCONSUMERs are referred to the PAYOR for aftercare services prior to and/or upon inpatient hospital discharge. Exceptions to this procedure require approval of the CONSUMER and/or the PAYOR. Other staff of the PAYOR may assist in the discharge process as designated. All discharge planning will begin immediately at admission, continue as part of the ongoing treatment planning and review process and involve the CONSUMER, the CONSUMER’s family, significant others, as indicated, and the PROVIDER’s staff and the PAYOR’S staff. The need for continuing stay or treatment shall be determined collaboratively between the PAYOR’s authorized representative and the PROVIDER’s authorized representative at PAYOR determined intervals. The PROVIDER shall cooperate with the PAYOR’s continuing stay review and discharge planning processes and instructions. The PAYOR’s determination is final. The appropriateness of inpatient admissions and inpatient length of stay shall be monitored on a case-by-case basis through the PROVIDER’s Utilization Review (UR) Program. Findings from that UR process may be reviewed by the PAYOR’s designated Utilization Management staff.

CONTINUING STAY CRITERIA. a. After a CONSUMER has been certified for admission to an inpatient psychiatric setting, services must be reviewed at regular intervals to assess the current status of the treatment process and to determine the continued necessity for care in an inpatient setting. Treatment within an inpatient psychiatric setting is directed at stabilization of incapacitating signs or symptoms, amelioration of severely disabling functional impairments, arrestment of potentially life-threatening self/other harm inclinations, management of adverse biologic reactions to treatment and/or regulation of complicated medication situations. The continuing stay recertification process is designed to assess the efficacy of the treatment regime in addressing these concerns, and to determine whether the inpatient setting remains the most appropriate, least restrictive, level of care for treatment of the CONSUMER’s problems and dysfunctions. . b. Continuing treatment in an inpatient setting may be certified when signs, symptoms, behaviors, impairments, harm inclinations or biologic/medication complications, similar to those which justified the CONSUMER's admission certification, remain present, and continue to be of such a nature and severity that inpatient psychiatric treatment is still medically necessary. It is anticipated that in those reviews which fall near the end of an episode of care, these problems and dysfunctions will have stabilized or diminished. . c. The Payor is responsible for monitoring patient progress. To the extent possible, PROVIDER will coordinate care with other entities and individuals involved with the care of the consumer that is being served. . d. Continued stay authorization requests are to be submitted to the PAYOR. The PAYOR will, in turn, provide appropriate continued stay authorizations. . e. The PAYOR is responsible for monitoring patient progress. All PAYORCONSUMERs are referred to the PAYOR for aftercare services prior to and/or upon inpatient hospital discharge. Exceptions to this procedure require approval of the CONSUMER and/or the PAYOR. Other staff of the PAYOR may assist in the discharge process as designated. . f. All discharge planning will begin immediately at admission, continue as part of the ongoing treatment planning and review process and involve the CONSUMER, the CONSUMER’s family, significant others, as indicated, and the PROVIDER’s staff and the PAYOR’S staff. . g. The need for continuing stay or treatment shall be determined collaboratively between the PAYOR’s authorized representative and the PROVIDER’s authorized representative at PAYOR determined intervals. The PROVIDER shall cooperate with the PAYOR’s continuing stay review and discharge planning processes and instructions. The PAYOR’s determination is final. . h. The appropriateness of inpatient admissions and inpatient length of stay shall be monitored on a case-by-by- case basis through the PROVIDER’s Utilization Review (UR) Program. Findings from that UR process may be reviewed by the PAYOR’s designated Utilization Management staff.