Provides healthcare organizations with the ability to prospectively, concurrently, and retrospectively assess clinical appropriateness.
Robust clinical detail allows organizations to evaluate severity of illness, comorbidities, and complications, as well as the intensity of services being delivered, to determine the most suitable and safest level of care.
The criteria also assist in discharge planning and care transitioning across the continuum.
The Acute Adult module helps clinicians evaluate the appropriateness of admission, continued stay, and discharge of acute care patients age 18 and older. Criteria are organized by primary condition presented in a single view that incorporates relevant complications, comorbidities, guideline standard treatments, proactive care management guidance, and length-of-stay benchmarks. By addressing the complete needs of each patient, the criteria facilitate movement of patients through the care continuum based on their condition and response to treatment. This integrated, holistic approach provides a powerful mechanism for decreasing inappropriate admissions, avoidable days, and readmissions.
The Acute Pediatric module helps clinicians determine the appropriateness of admission, continued stay, and discharge at acute care facilities for patients under 18 years of age. The module features the same condition-specific format as the adult criteria and also includes comorbidities and lengthof-stay benchmarks.
The Long-Term Acute Care module helps clinicians determine the appropriateness of admission, continued stay, and discharge for long-term acute care patients. This module includes responder and partial responder criteria to help clinicians adjust patient care time frames and interventions based on outcomes. It also offers guidance around discharge and transition planning for patients who no longer require skilled care or whose care can be safely managed in an outpatient setting or at a lower level of care.
The Inpatient Rehabilitation module helps clinicians determine appropriateness of admission, continued stay, and discharge at inpatient rehabilitation facilities for adult and pediatric populations. The module includes methods for addressing complications and setbacks associated with the onset of medical instability in a timely and medically appropriate way.
The Subacute and Skilled Nursing module helps clinicians identify medical necessity and the most suitable level and complexity of care based on clinical need and stability. Guidance also is provided for discharge and transition planning. Clinical evidence supports the appropriateness of skilled treatments and services to ensure optimal care and to help organizations withstand audit scrutiny.
The Home Care module streamlines care management for patients who require services in the home setting. The criteria help determine the appropriateness of the initial review and ongoing service needs, visit recommendations, and discharge. The criteria address both adult and pediatric patients and include intermittent skilled home care services, private duty nursing, hospice, and palliative care needs.
The Outpatient Rehabilitation and Chiropractic module illuminates the most suitable level and complexity of rehabilitation and chiropractic care. The criteria help clinicians screen for the initial authorization and ongoing care needs and also provide guidance around discharge and transition planning to help avoid costly readmissions. Coordination in the outpatient rehab and chiropractic setting can help improve outcomes, minimize costs, and ensure timely transitions to appropriate levels of care.
Guide to the InterQual® Criteria comprehensive decision support portfolio
InterQual® Level of Care fact sheet outlining support for appropriate acute care for pediatric patients
Behavioral health services guide outlining how to drive appropriate utilization to streamline authorizations and reduce denials
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