interqual behavioral health decision support tool

InterQual® Behavioral Health Decision Support ToolEvidence that Works for Payor and Provider Organizations

McKesson Health Solutions

McKesson: Your Single Sourcefor Care Management andAnalytic SolutionsMcKesson offers the most comprehensiveportfolio of best-in-class care managementand analytic solutions available to healthcareorganizations today. Our CareEnhance®

products, which include InterQual® clinicaldecision support tools, address every facet of your organization’s efforts to improvehealthcare quality while improving resource management:

• Utilization, case and disease management

• Predictive modeling

• Analysis and reporting

CareEnhance best in class solutions arebased on decades of experience in health-care and information technology servingthousands of client organizations and millions of individuals. Our broad spectrumof products lets you move through the continuum of care — from prospective caseidentification to real-time care managementto retrospective analysis.

We’re delivering on our vision as a singlesource for clinical, analytic and workflowsolutions that bring together all the key elements for managing healthcare delivery.So you can implement tools in whatevercombination you need, at whatever pace youneed them to reduce risk, drive healthcarequality, and continually optimize yourmedical management programs.

These reports reveal a healthcare system that often falls short on translating knowledge into practice. At the same time, funding

decreases and bed reductions coupled with rising demand for services are creatingaccess issues. The call to improve medical and behavioral healthcare and controlunnecessary expenses using clinical evidence has never been greater.

Your organization — whether it is an MBHO, behavioral health managementgroup within a health plan or behavioral health provider — has the power tomake a positive impact on the direction of service delivery. The key to thatpower is applying scientific evidence to care-related decisions consistently,while considering the individual needs of each patient.

For objective, evidence-based criteria that support your level-of-care andcontinued stay decisions, InterQual Behavioral Health Criteria is the premiersolution. This product suite facilitates patients’ movement along the behavioralhealth continuum, so each receives the right care at the right time.

What’s more, InterQual Criteria can boost your organization’s quality initiativesby enabling you to track information about different populations. This tool helps

document the need for additional levels of care, identify process or system delaysthat impact lengths of stay, and detect outlier practice patterns, so you have

information that empowers you to plan resource utilization and health serviceimprovements.

The Challenge: Translating Knowledge into Practice

The Intitute of Medicine’s Crossing the Quality Chasm proclaims that while

medical science and technology have advanced rapidly, the modern healthcare

delivery system has failed to provide consistently high quality care to all Americans.1

Other studies show that although investments have greatly increased the scientific

knowledge base and led to developing numerous effective treatments for mental

illness, many people are not benefiting from these developments.2

1 Institute of Medicine (2001). Crossing the Quality Chasm: A New Health System for the 21st Century.Washington DC: National Academies Press.

2 New Freedom Commission on Mental Health (2003). Achieving the Promise: Transforming Mental HealthCare in America. Executive Summary. DHHS Pub. No. SMA-03-3831. Rockville, Maryland.

InterQual BehavioralHealth CriteriaHealthcare organizations face complexchallenges when it comes to makingdecisions about the intensity andlength of treatment for individualswith behavioral health problems.Confusion may arise when medical,psychiatric, and social work profes-sionals use different vocabularies.And decision-support tools based on diagnosis only or statistics are notsensitive to a patient’s specific situation,leading to potential under-or over-utilization.

These challenges—together withaccreditation requirements, mentalhealth parity regulation, and wide differences in practice patterns—are driving both payor and providerorganizations to seek better tools formanaging the delivery of behavioralhealthcare.

The InterQual Behavioral HealthCriteria suite is a clinically based toolfor making initial and successive level-of-care decisions. Developed with amultidisciplinary panel of psychiatrists,psychologists, psychiatric nurses andsocial workers, the criteria allowreviewers to consider the severity ofillness as well as episode-specificvariables and match the level of care to the patient’s current condition.Standardized decision paths providecase managers, utilization reviewersand providers with a common languagethat enables consistent, objectivedecision-making.

• Guides Patient Placement — Helpsin the selection of an appropriatelevel of care and in demonstratingthe medical necessity of the behav-ioral health services provided.

• Clinically Oriented and Patient-specific — Evaluates every patientbased on his or her clinical characteristics such as behavior,symptoms, functioning, social risk or supports, ensuring the recommended level of care is specific to that patient.

• Reflects Treatment Options — The comprehensive set of level-of-care alternatives supports movementup and down the continuum becausebehavioral health patients requirevarying intensities of treatmentover time.

• Tailored to BehavioralDevelopment — Age-specific content considers the behavioraldevelopment and needs of child,adolescent, adult and geriatricpatients.

How InterQual Tools Can Help Improve Quality

Safety Risk Assessment

Patient-specific Behaviorsand Symptoms

InterQual BehavioralHealth Algorithm

Cornerstones

Level of Functioning

Immediate

Potential

Care Across the Continuum

Severe

Moderate

Mild

Level of Care Options

InterQual Criteria applies rules and timeparameters to patient-specific behaviors and symptoms, and provides three levels of filters to help you make clinically appropriate decisions.

InterQual Behavioral Health Criteria

Adult Psychiatry(Ages 17 to 65 years)

· Anxiety· Depressed Mood· Mania/Hypomania· Reckless/Impulsive· Psychosis· Eating Disorder· ECT Acute/Short-term· ECT Continuation/Maintenance· Psychiatric Testing· Neuropsychiatric Testing

· Inpatient/Observation· Partial Hospital· Intensive Outpatient· Outpatient· Residential (Eating Disorders Only)

Adolescent Psychiatry(Ages 13 to 17 years)

· Anxiety· Depressed Mood· Mania/Hypomania· Disruptive Behavior· Psychosis· Eating Disorder· ECT Acute/Short-term· Psychiatric Testing· Neuropsychiatric Testing

· Inpatient/Observation· Partial Hospital· Intensive Outpatient· Outpatient· Residential (Eating Disorders Only)

Child Psychiatry(Ages 6 to 12 years)

· Anxiety· Depressed/Irritable Mood· Mania/Hypomania· Disruptive Behavior· Suspected/Identified Psychosis· Psychiatric Testing· Neuropsychiatric Testing

· Inpatient/Observation· Partial Hospital· Intensive Outpatient· Outpatient

· Anxiety· Mood Disturbance· Behavior Disturbance· Psychosis· ECT Acute/Short-term· ECT Continuation/Maintenance· Psychiatric Testing· Neuropsychiatric Testing

· Inpatient/Observation· Partial Hospital· Home Care· Intensive Outpatient· Outpatient

Chemical Dependency & Dual Diagnosis(Adult/Adolescent)

· Intoxication/Withdrawal· No Withdrawal· Dual Diagnosis

· Inpatient: Psychiatric, Detoxification, Rehabilitation· Observation· Partial Hospital· Ambulatory Detoxification· Intensive Outpatient· Outpatient

Residential(Psychiatry)

Adult

Adolescent and Child

· Psychiatric Residential Crisis Program· Psychiatric Residential Treatment Center· Psychiatric Supervised Living· Psychiatric Assisted Living

· Psychiatric Sub-acute Care· Psychiatric Residential Treatment Center· Psychiatric Therapeutic Group Home

Criteria Subset Levels of Care

Facilitate and improve patient care.Reduce practice pattern variation andsupport appropriate care decisionsleading to better outcomes, improvedsafety and enhanced quality of care.

Help manage resources. Assist inidentifying overutilization and under-utilization of services.

Enhancing Behavioral HealthManagement ProgramsInterQual clinical decision supporttools delivered via CareEnhanceReview Manager Enterprise softwareoffer benefits that can improve theability of your organization to meet itsbehavioral care management goals.

Client: Large Blue Cross and Blue Shield plan

Results over 18 months:

• 1.5 day reduction in ALOS

• Reduced days/1000

• Identified network improvement opportunities:

– created “in-network” provider arrangement substituting two weeks ofintensive outpatient therapy for same cost as one inpatient day

– established eating disorders center of excellence

– developed medically monitored detox service

• Supported more flexible use of the behavioral health benefit for members

• Significant factor in achieving “Excellent” status from NCQA

Client: Medicaid managed care organization in a parity environment

Results over 18 months:

• 5.4 day reduction in ALOS

• Reduced admits/1000 from 24 to 18

Driving Value with InterQual Behavioral Health Criteria

Promote inter-rater reliability.Facilitate consistent and evidence-based decision-making across yourcare management team.

Demonstrate quality. Allow organiza-tions to measure behavioral healthmanagement consistency, supportingreviews by such bodies as URAC, NCQAand JCAHO and helping to identify the need for quality improvementprocesses for multiple stakeholders.

Manage care proactively. Aid in theproactive management of all aspects of care across the behavioral healthcontinuum to guide efficient use of resources.

Improve clinical decision-making.Support care managers in applyingInterQual Criteria for individual patientswith a range of helpful reference tools.

Foster collaborative relationshipsamong payors, provider organizationsand practitioners. Give behavioralhealthcare constituents a commonlanguage for consistent, objectivedecision-making.

Generate confidence. Used by thousands of payor and providerorganizations to support behavioralhealth and medical care management,InterQual Criteria sets are widelyaccepted by reviewers, case managers,physicians and oversight entities.

Support managerial decision-making.Allow managers to collect informationto aid in planning resources.

Supplement with local norms.Enable your organization’s policies tobe entered alongside the criteria, soreviewers can view them and InterQualCriteria simultaneously to make reviewdecisions based on both.

Increase productivity. Eliminatecumbersome paper-based communi-cations in your care managementreview process for greater efficiencies.

Real-world Success Stories

25

20

15

10

5

0

Inpatient Acute Mental Health Utilization Reduced by5.4 days/1000

Q4Year 1 Year 2 Year 3

Q1 Q2 Q3 Q4 Q1 Q2

• Patient-driven. Helps evaluateappropriateness based on eachpatient’s unique presentation —including co-morbidities.

• Updated annually. Published every year, delivering the most current, clinically valid referenceon the market.

• Flexible. Can be used prospectively,concurrently and retrospectively tomatch your organization’s approachto care management.

• Easy to understand and apply.User-friendly, nested decision treeformat follows clinical logic.

Clinical reviewers can accessInterQual Criteria any time, anywherevia McKesson’s CareEnhance ReviewManager Enterprise software—all that’sneeded is a computer with InternetExplorer. And because the InterQualsoftware solution resides on a commonWeb application server, it’s easy toinstall and maintain — saving your ITdepartment resources.

Improve security. Customize yourorganization’s care management workflow and help it comply withHIPAA privacy regulations by allowingmanagers to control staff access to review and reporting functions.

Extend continuity of review process.Allow reviewers to enter comments atspecific criteria points, so subsequentreviewers can follow their logic andbuild on it.

Support appeals process. Enable your organization to support appealsbased on medical necessity throughobjective criteria.

Superior Clinical Content viaBrowser-based TechnologyThe clinical core of InterQual Criteriais recognized across the healthcareindustry for its excellence. McKessondevelops content using our provenmethodology: A seasoned team ofMcKesson physicians, nurses andother healthcare professionals managea process that incorporates the latestevidence-based medical literaturewith consensus-building among consultants drawn from a pool of more than 800 specialists and subspecialists. By combining well-researched scientific knowledge andreal-world experience, McKessonbuilds criteria that are based on best practices.

What’s more, the clinical content ofInterQual products is:

• Unparalleled in scope. Covers the medical and behavioral healthcontinuums in both inpatient andoutpatient settings, so the criteriaare relevant for all types of clinicalsituations.

InterQual Behavioral Health Criteriaallows a non-physician reviewer toefficiently identify the majority ofcases for which a clinical interventionis warranted, or to support a level of care decision in inpatient and outpatient settings.

During a typical initial review, a clinical reviewer applies the criteria toinformation obtained from the patient’srecord or care providers to determinewhether an intervention or designatedlevel of care is appropriate. If the criteria requirements are not met, or ifthe reviewer is uncertain about aspectsof the review, a supervisor, specialistor physician reviewer — depending onyour organization’s process — performsa secondary review.

InterQual Criteria tools can also beused as an aid in appeal determinations.

InterQual Tools:Addressing Your Care Management Needs

Using InterQual Criteria

InterQual pioneered the developmentof educational tools and clinical crite-ria for hospitals to develop utilizationreview and quality assurance programsalmost 30 years ago. With evidence-based and clinically validated contentas their hallmark, InterQual productshave expanded and evolved with thechanging healthcare landscape. TodayMcKesson’s InterQual tools remainthe industry standard: They are used by more than 3,500 managed careorganizations, hospitals and govern-ment agencies to assist in decisionsthat touch over 100 million lives internationally.

Since the launch of InterQual BehavioralHealth Criteria in 2000, over 300payor and provider organizations havecome to rely on it, including managedcare organizations, managed behavioralhealth organizations, hospital systems,general hospitals and free-standingpsychiatric centers — many of whichdeploy the criteria at multiple treatmentand case management sites.

CareEnhance Review ManagerEnterprise — the software delivery system for InterQual Criteria — has been URAC certified in UtilizationManagement since 2003.

Leaders in Clinical Decision Support

Enhanced Productivity and EfficiencyCareEnhance Review ManagerEnterprise software facilitates InterQualreviews, documentation and reportingto increase the efficiency of your caremanagement review workflow. Nesteddecisions trees allow reviewers andcase managers to quickly evaluate apatient’s situation without the need toread long passages of text. Extensivemedical references, glossaries, discus-sions of patient management, andsafety warnings combined with theability to enter your organization’smedical management policies providea comprehensive source of informa-tion for conducting reviews.

Additional features include:

• Role assignment. Managers canauthorize access to review functionsbased on a staff member’s need forspecific InterQual Criteria sets,location and responsibilities, providing the flexibility to matchyour organization’s review processand helping to meet HIPAA privacyguidelines.

• Review assignment. Administrativestaff can enter preliminary infor-mation and assign reviews to anappropriate reviewer, reducing theburden on clinical reviewers. Thesame feature allows managers to re-adjust workloads as needs shift.

• Work list. The initial page listsnewly assigned and ongoing reviews,helping reviewers to focus on the tasks required today, preparefor future assignments and prioritize cases.

• Follow-up review trigger. Userscan schedule the next review for apatient at the appropriate interval,and a review request appears on thework list on the selected date.

• Monitoring capability. Managerscan monitor the completion timefor reviews by department or facility,or discover the types of review thatare resulting in delays and addressthem before they are overdue.

• Review locator. Users can look upthe status of a review by searchingon criteria, date range, reviewer,outcome or review number.

• Outcome reasons tracking.Organizations can customize reviewoutcome reasons to track resource,quality and network issues requiringmedical management interventionsand use this information as a basisfor defining quality initiatives.

• Book view. Users can quickly access the criteria without openinga review, facilitating discussionswith members of the clinical team.

• Flexible and customizable reporting. Standard report formatswith multiple filtering, groupingand sorting options enable you toquickly view summary level infor-mation in a way that best suits yourorganization’s needs. You can assessefficiency with reports that monitorcases remaining open and report on turnaround times. And you can

evaluate your program’s effectivenessby generating outcomes reports that show the number of reviewsapproved, withdrawn or referredfor secondary review, and variancereports that indicate the number ofdays a patient could have receivedless intensive and less costly care.

Evidence-drivenDevelopment ProcessInterQual Criteria sets are developedin annual cycles with five stages.

1 Select new topics and content forrevisions. McKesson’s clinical teamselects new areas to develop andareas to revise based on systematic,continuous review of the most current medical and behavioralhealth literature and feedback fromclients and clinical consultants overthe course of the year.

2 Research evidence-based literature.Our clinical team performs a comprehensive review of evidence-based and general medical andbehavioral health literature, thenincorporates input from our externalconsultants to create initial drafts.There are more than 10,000 citationswithin the InterQual clinical decisionsupport tools.

3 Review and revise. Clinical consultants review the criteria andsuggest revisions to the McKessonteam, which synthesizes them andthen sends the criteria back to theconsultants for further reviews inan iterative, consensus-buildingprocess. In areas where no agreementis reached, the McKesson teamincludes a rationale for the clinicalstance chosen with supportingnotes and literature references inthe criteria.

4 Validate. Consultants who have notbeen part of the process up to thispoint assess and validate the criteriasets for clinical accuracy.

5 Format and review for qualityassurance. Criteria sets are preparedfor software and book versions andreviewed for clinical consistencyand completeness across productsby McKesson’s clinical staff beforedistribution to our clients.

When we introduce new clinicalcontent products and make signifi-cant content or workflow changes to current ones, another step isadded to this cycle: Criteria sets are field tested in client settings to ensure they work for real peoplein real working environments.Similarly, our software applicationsare beta tested to assure you receivereliable products.

InterQual Annual Development Cycle

Researchevidence-based

literatureMcKesson clinical

development team anddiverse panel of 800+

clinical consultants

Flexible Delivery OptionsInterQual Behavioral Health Criteriacan be delivered in a variety of ways to meet your organization’s needsincluding:

• CareEnhance Review Manager, abrowser-based software application

• CareEnhance Care Manager,McKesson’s care managementworkflow application

• a range of interfaces and integratedoptions

• book format (criteria only)

Expert Customer SupportMcKesson’s primary goal is to assistour clients in successfully achievingtheir healthcare management goals.That’s why we offer expert support andservices for InterQual care managementdecision support tools. Our client

services professionals have in-depthclinical and technical knowledgegrounded by an expansive under-standing of real-world medicalenvironments, so they can addressyour business challenges effectively.

For your clinical and technical questions, McKesson has telephoneand online support dedicated to clientswho use InterQual products.

And whether you are new to an InterQualproduct, an experienced user seekingto refresh your knowledge, or imple-menting an update to an InterQualapplication, we have a training option.Our offerings include training on-site,in select cities, and via the Web. Wealso offer certified instructor training,so you can leverage your in-housestaff. Plus, we can design and deliverother types of training and consultingcustomized to your situation.

CareEnhance and InterQual are registered trademarks of McKesson Health Solutions LLC. © 2005 McKesson Health Solutions LLC. All rights reserved. IQBH/12-05 Mac

Start on the Path toImproved Clinical Decision-makingFor more information about howInterQual Behavioral Health Criteriacan help you meet your behavioralhealth management goals, please contact McKesson Health Solutions at800.522.6780 or [email protected].

About McKessonFounded in 1833, today McKessonCorporation ranks among the 20 largestcompanies in the United States and is theleading provider of supply, information andcare management products and servicesdesigned to reduce costs and improve quality across the healthcare industry. TheMcKesson Health Solutions business unitoffers integrated technologies and servicesfor payor and provider organizations.

McKesson Health Solutions

McKesson Health SolutionsCareEnhance Products 275 Grove StreetNewton, MA 02466-2273HealthSolutions.McKesson.com

[email protected]

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