Health Care Delivery
Refer to: Goldberg GA, Hein LM, Rosales SM, et al: Criteria and flowsheet for utilization review by level of care (Health Care Delivery). West J Med 126:318-323, Apr 1977
Criteria and Flowsheet for Utilization Review by Level of Care GEORGE A. GOLDBERG, MD; LINDA M. HEIN, RRA, MPH; SUZANNE M. ROSALES, RN, and JOYCE F. ALEXANDER, RN, Los Angeles
THE CONCEPT of level of care,' a well established touchstone for deciding on the appropriate placement of patients in one of a number of available long-term care facilities, has more recently been recognized as a reasonable basis for deciding whether or not a patient, at any given moment, should be located in an acute-care hospital.2 In epitome, the application of level of care to hospital utilization review entails determining whether or not a given patient, at a given moment, requires a level of care that can be furnished only in an acute-care hospital rather than in a facility providing less intensive care. At the University of California, Los Angeles, Hospital and Clinics, we define level of care as "the type, number, and/or intensity of a combination of physician, skilled nursing, and ancillary services."' If, at any selected moment during a patient's stay, the patient requires a level of care that can be provided only in an acutecare hospital, he or she belongs in the hospital; if the services needed could be provided in a less intensive setting, the patient is said not to require an "acute hospital level of care," and is inappropriately placed in our acute-care hos-
pital. Although a number of acute-care hospitals From the Department of Medicine, Division of General Internal Medicine and Health Services Research (Dr. Goldberg) and the Department of Medical Records (Ms. Hein, Rosales and Alexander), UCLA School of Medicine. Supported in part by the National Center for Health Services Research, U.S. Department of Health, Education, and Welfare, under USPES Grant No. HS 01320. Reprint requests to: George A. Goldberg, MD, Department of Medicine, UCLA Center for Health Sciences, Los Angeles, CA 90024.
318
APRIL 1977 * 126 * 4
(many of which employ utilization review coordinators) make use of level-of-care criteria for determining appropriate hospital placement,3 most of the guidelines for determining level of care have been, up to this time, quite vague. The example of level-of-care criteria provided by Goran and co-workers2 gives only the general outline of questions to be addressed by the person determining the patient's needed level of care. A physician or utilization review coordinator using this outline of so-called level-of-care criteria to review an individual patient, could be said to be approaching the problem logically, but not really explicitly. The notion of what is a "hospital-only" physician service, or skilled nursing service, or ancillary service (whether as to type, number or intensity) would still remain in the reviewer's head. The review therefore would be subjective, at a time when greater objectivity of review is desired." 4
Explicit Level-of-Care Criteria To remedy this situation, we developed a set of explicit level-of-care criteria, to be used as guidelines for review of UCLA utilization review coordinators (see Figure 1). We amalgamated, adapted and expanded three provisional sets of level-of-care criteria which had been developed previously by three nonacademic acute-care hospital utilization review (UR) committees in the San Francisco Bay area.5 Our effort in no way constitutes a research project, nor does it purport to be one. It is a considered empirical step to assist our
UTILIZATION REVIEW
UCLA HOSPITALS AN,lD CLINIACS LEVEL OF CARE CRITERIA: Guidelines for Utilization Review 'The Levei of Care Guidelines are representative, not all-inclusive.
iVHAl SERVICES SHOULD A PATIENT BE RECEIVING OR NEED AVAILABLE IN ORDER TO JUSTIFY ACUTE HOSPITAL LEVEL OF CARE ? I. PHYSIChIA SERVICES 1. Specific requirement for daily visits, e. g. , situations requiring physician skills to observe, evaluate, and adjust orders. 2. Examinaltions and orders for treatment during preoperative and other acute care periods of stay. 3. Operative and othe r technical procedures.
II. SK I LLED N|URS I NG 5SERV I CES 1. Continuous availability of nurses for intermittent observation and delcision-making, including, but not limited to: a. wvhere patient is acutely ill such as with uncontrolled diabetes or hypertensionr.. b. where complex diagnostic or therapeutic procedures are being done requiring frequent or repeated observation. c. wh-ere pre and postsurgical manaQement is provided. d. -,, here potentialiy dangerous drugs or drug combinations are being used. 2. Frecuent skilled nursi ng services inchluding, but not iimited to. a. INP medications and IV therapy. b. inFihalation therapy, pulmonary therapy, and urgent administration of oxygen. c. teaching managemernt of postsurgical appliances, medication regimens, and special diets. d. specialized proced u res, e. g. , suction ing, postu ral drai nage, com presses, f requent d ressing c han ges. e. cardiac resuscitation. f. intensive care nursing, e.g., ICU, CCL, RCU, premature nursery. g. speci a li zed n u rsi ng ca re, e. Q. , re habi itat ion, d ialys s. h obstetrical care: (Ii anienatal complications
121rdelivery 3i postpartu m care and education 11. MEDICAL SERVlCES AVAILABLE ONLY IN ACUTE HOSPITAL 1. Surgery with major anesthesia (general or spinal). 2. Diagnostic tests, therapeutic nrocedures, and medications that are dangerous (or potentially dangerous), e.g., liver biopsy, cardiac catheterization, monitoring equipment, chemotherapeutic drugs, angiography. 3. Tests or procedures requiring scheduling too intense or complexity too great (e. g., equipment and/or personnel and-'or expertise not availablei for performance outside the acute hospital. 4. Patient's condition is too fragile to conduct tests as outpatient, because complications would be likely to occur, or the tests might be unsuccessfully performed. 5. Daily laboratory work on Lunstable conditions. 6. Traction for acute condition or acute exacerbation of chronic problem. 7. Radi2tiorn therapy for unstable patients.
IV. REHABILITATION SERVICES 1. Patient is undergoing intensive rehabilitation program requiring the involvement of various allied health professionals. 2. Intensive therapy or rehabilitation requires multiple sessions daily. 3. Initial rehabilitation efforts where there is rehabilitative potential and improvement is expected in a reasonable period of time. V. PSYCHIATRIC SERVICES 1. Only when there is a concomitant acute medical condition.
VI. ADDITIONAL CONSIDERATIONS 1. The patient's condition requires more complete bedrest than available at home. 2. Condition is terminal, and it is appropriate to keep patient in the acute hospital for at most 14 days for humanitarian reasons. 3. The total number and intensity of skilled nursing services needed ito perform a combination of direct services, observations, and decision-makingi, ate available in this hospital, but not in a Skilled Nursing Facility. 4. The patient is convalescing from an illness, and it is anticipated that his/her stay in a Skilled Nursing Facility would be less than 72 hours.
Figure 1.-The utilization review (UR) reviewer refers to these level-of-care guidelines while following the UR flowsheet (Figure 2). These guidelines provide representative examples of services available only in an acutecare hospital environment.
THE WESTERN JOURNAL OF MEDICINE
319
UTILIZATION REVIEW UCLA HOSPITALS AND CLINICS LEVEL OF CARE: ADMISSION .
.
~~ yes
Does this patient's diagnosis obviously require acute hospital level of care ? (consult list)
if
if no
Document diagnosis and assign first continued- 2 stay review date.
Refer to Level of Care: Continued Stay.
Does this patient require direct nursing services frequently ? Does this patient have a condition that requires the skills of a nurse to detect and evaluate the need for possible modification of treatment or institution of medical procedures ?
3
4 5
whether yes or no Does this patient require ancillary services and/or equipment available only in the acute hospital setting ?
if no I
Does this patient require constant availability of physician's services for direct action (i. e., proceduresl operations) ? Does this patient require constant availability of physician's services for determining and directing care (i.e., therapy)?
8 r
2G 3oH
if yes
Go to 7.
if yes
lGo to R.
9
-i
if no Do the type, number or frequency of the combination of physician, skilled nursing and ancillary services being
received by this patient require acute hospital level of care ? (too intense for SNF)
10
if no r-
Are there any extenuating circumstances not covered by the above categories that mandate acute hospital level of care ?
if no Refer to Utilization and Quality of Medical Care Committee Member.
12
Figure 2.-The utilization review (UR) reviewer follows these flowsheets (for upon-admission review and for continued-stay review) in order to apply the level-of-care guidelines. Starting with box 1, and proceeding in a direction dependent upon yes or no responses, the UR reviewer simultaneously documents the current level of care and reaches one of two decisions: (1) assign next review date or (2) refer questionable case for further consideration and possible disapproval.
320
APRIL 1977 * 126 * 4
UTILIZATION REVIEW Today's date is on or before the 50th percentile review date for diagnosis or the assigned review date. Has this patient's diagnosis changed since admission or previous
1
Is the new diagnosis alone one which requires acute hospital level of care ?
if yes
2
ye
review ?
if
if
if e
3
s
Document diagnosis and assign next review date
4
no
no
FGotoi
Go to #5.
Are there additional diagnoses and/or complications ?
5
Are the additional diagnoses and/or complications alone ones which require acute hospital level of care ?
s
if
ye
if
6ys
Document diagnoses and/or complications and assign next review date
7
if no if
no
Go to #8.
Does this patient require direct nursing 8 services frequently ? Does this patient have a condition that requires the skills of a nurse to detect and evaluate the need for possible modification 9 of treatment or institution of medical procedures ?
Does this patient require ancillary services and/or equipment available only in the acute hospital setting ?
if
e if Yes
10
11
Gotoi.[
no
Does this patient require constant availability of physician's services for direct action (i.e., procedures/ operations) ? Does this patient require constant availability of physician's services for determining and directing care (i.e.. therapy) ?
Document need, status, and diagnosis of patient and assign next review date.
12 either
M_j Go to fll.-
13
i
if no r-
Do the type, number, or frequency of the combination of physician, skilled nursing and ancillary services being received by this patient require continued acute hospital level of care ? (too intense for SNF)
14
if yes
Go tof.
if no Are there any extenuating circumstances not covered by the above categories that mandate continued acute hospital level of care ?
I~~~~~~~~~~
X5
if
ys
Gotofil.
If no
Refer to Utilization and Quality of Medical Care Committee Member
16
THE WESTERN JOURNAL OF MEDICINE
321
UTILIZATION REVIEW
UR physicians and UR coordinators in making rational, humane and explicable decisions concerning the appropriateness of location of patients in an acute-care hospital. We believe that our level-of-care criteria can serve as an important, practical model for UR committees throughout the country. UR committees are likely to be attracted to level-of-care criteria, instead of to disease-specific criteria, because level-of-care criteria are inherently logical and are often advantageous for an acute-care hospital patient population. There are a number of specific advantages of level-of-care criteria over disease-specific criteria: (1) the application of disease-specific criteria is unsatisfactory for many patients who have multiple problems and diagnoses, since the disease-specific criteria are formulated for single diagnoses only; (2) level-of-care criteria can be effectively applied to indistinct cases where there exists no clear-cut diagnosis to which disease-specific criteria can be applied; (3) there is no need to develop a large number of disease-specific criteria for UR purposes, an advantage particularly important at a medical center such as UCLA, where there are so many different discharge diagnoses that every discharge diagnosis (with the single exception of that associated with delivery) accounts for fewer than 2 percent of all hospital discharges; (4) physician participation in the UR system is facilitated, because it is not necessary for a reviewing physician to have specific knowledge concerning diseases from specialty areas which are not his or her own, and (5) communication among UR coordinators, and between coordinators and physicians, is enhanced because there is a common basis to discuss the functioning of the review system, rather than multiple opinions concerning a specific disease process. None of these advantages is meant to imply that disease-specific criteria have no place in the review process; however, we believe that the UR function should make use nearly exclusively of level-of-care criteria. Disease-specific criteria remain necessary for review of quality of care (medical care evaluation studies), an area in which use of level of care criteria is inappropriate. We cannot identify any major drawbacks to the level-of-care approach, so long as it is understood that level-of-care criteria are meant to be applied for purposes of review of (1) need for admission and (2) need for continued stay, and that they are not appropriate for review of quality
322
APRIL 1977 *
126 * 4
of care. A barrier to the wider adoption of levelof-care criteria has been the unwillingness of a number of fledgling Professional Standards Review Organizations (PSRO'S) to permit hospitals to make use of level-of-care criteria. We believe that such hesitancy is unwarranted, and is based on a misreading of the wishes of the federal government's guidelines, which have consistently reiterated that use of level-of-care criteria is acceptable.
Utilization Review Flowsheet In order to assure the orderly application of these level-of-care guidelines, we borrowed the concept of "criteria mapping," that has been developed for purposes of quality-of-care review by Greenfield and co-workers,6 and developed a flowsheet so that a UR reviewer, whether physician or UR coordinator, would be certain of asking all the right questions in the right order (see Figure 2). The UR reviewer starts with the first question, and renders a judgment, based on the furnished guidelines. If the answer is yes, the reviewer proceeds to the next question (or required action) horizontally to the right. If the answer is no, the reviewer proceeds to the next question (or required action) vertically below. If there is only one action to follow, the reviewer automatically proceeds vertically below, to the next question (or action). This pattern persists until one of the two actions has taken place: the patient has been approved as requiring further acute-care hospital level of care (and, therefore, stay), or the patient's case must be presented to another reviewer because the initial reviewer has reached the conclusion (based on the guidelines) that an acutecare hospital level of care is not required. In either instance, medical judgment has been brought to bear in a channeled and guided manner. The reader will note that we also developed a list of automatic diagnoses to justify admission to an acute-care hospital. We have not included a particular list, because most hospitals are well aware of this concept, and make use of such lists. It is useful to think of these conditions as conditions whose very presence implies a need for an acute-care hospital level of care, at least in the initial stages of treatment of the condition, whether new or a flare-up. At UCLA this group of conditions was purposely kept small. It will be enlarged only very slowly, as UR committee mem-
UTILIZATION REVIEW
bers document to their satisfaction that there are additional conditions that, in actual practice at our particular hospital, always require an acutecare hospital level of care at the time of admission. Also noteworthy is the fact that the level-ofcare concept is relevant for both upon-admission review, and continued stay review. Separate, similar flowsheets were constructed for the two types of utilization review.
Utilization Review Function Our level-of-care guidelines, list of automatic approval-upon-admission conditions and UR flowsheets for application of the guidelines have all been approved by the UCLA Hospital Utilization Review and Quality of Care Committee. They are being used routinely by our UR coordinators and by the UR physicians when our coordinators bring questionable cases to their attention. Therefore, our basis for judgment is explicit, and our criteria can be easily reviewed by outside inspecting agencies. Therefore, our decisions can be welldocumented and well-defined when challenged either from within, or from outside our hospital. We have also found these guidelines to be useful in orienting and training new UR coordinators and new physician members of the UR committee. The principles are easily grasped, and it is appreciated that the same principles can be applied no matter what the disease or problem and no matter if the question concerns the necessity for a new admission or the necessity for continued stay. Our coordinators and physicians view the level-of-care determination as being a logical way of deciding if the acute-care hospital environment is needed or not, and they do not find themselves deflected from an understanding of UR by personal reservations about particular items in a disease-specific group of criteria. Similarly, the use of level-of-care criteria appears to have been a success vis-a-vis outside agencies. The local PSRO has accepted the UCLA level-of-care UR system as fulfilling its require-
ments, and considers level-of-care criteria to be the preferred method for carrying out the UR function. Third-party intermediaries, including Medi-Cal, have not increased their "questions" or "denials." And, although the application of these criteria would not necessarily be expected to have an effect (increase or decrease) on length of stay, it is gratifying to note that there has been no increase in length of stay. It is obvious that no hospital can adopt, unchanged, the level-of-care criteria used by any other hospital. A hospital must adapt level-ofcare criteria to its special internal and external circumstances. For example, level-of-care criteria will depend upon which services are offered and not offered by the particular hospital. Also, the level of care that can be provided only in an acute-care hospital depends upon what services are available in the less intensive facilities of the local community. To give an example, for a patient who requires rehabilitation and intravenously given medication, one community may have an unusual skilled nursing facility that can provide both, in which case the patient would not require the acute-care hospital level of care. Another community may have no skilled nursing facility capable of providing both; therefore, the same patient would indeed require an acute-care hospital level of care. Although the level-of-care criteria will require adaptation, the flowsheet for applying the hospital's adapted level-of-care criteria can usually find use, unchanged. REFERENCES 1. Goldberg GA, Holloway DC: Emphasizing "level of care" over "length of stay" in hospital utilization review. Med Care 13:
474-485, 1975 2. Goran MJ, Roberts JS, Kellogg M, et al: The PSRO hospital review system. Med Care 13:1-33, 1975 (Supplement to number 5) 3. Holloway DC: Personal communication 4. US Department of Health, Education, and Welfare, Office of Professional Standards Review: PSRO Program Manual. Washington, DC, US Government Printing Office, Mar 1974 5. Holloway DC, Holton JP, Goldberg GA, et al: Development of Hospital Levels of Care Criteria. Health Care Management Review 1:61-72, 1976 6. Greenfield S, Lewis CE, Morner S, et al: Peer review by criteria mapping: Criteria for diabetes mellitus. Ann Intem Med 83:761-770, 1975
THE WESTERN JOURNAL OF MEDICINE
323
Refer to: Goldberg GA, Hein LM, Rosales SM, et al: Criteria and flowsheet for utilization review by level of care (Health Care Delivery). West J Med 126:318-323, Apr 1977
Criteria and Flowsheet for Utilization Review by Level of Care GEORGE A. GOLDBERG, MD; LINDA M. HEIN, RRA, MPH; SUZANNE M. ROSALES, RN, and JOYCE F. ALEXANDER, RN, Los Angeles
THE CONCEPT of level of care,' a well established touchstone for deciding on the appropriate placement of patients in one of a number of available long-term care facilities, has more recently been recognized as a reasonable basis for deciding whether or not a patient, at any given moment, should be located in an acute-care hospital.2 In epitome, the application of level of care to hospital utilization review entails determining whether or not a given patient, at a given moment, requires a level of care that can be furnished only in an acute-care hospital rather than in a facility providing less intensive care. At the University of California, Los Angeles, Hospital and Clinics, we define level of care as "the type, number, and/or intensity of a combination of physician, skilled nursing, and ancillary services."' If, at any selected moment during a patient's stay, the patient requires a level of care that can be provided only in an acutecare hospital, he or she belongs in the hospital; if the services needed could be provided in a less intensive setting, the patient is said not to require an "acute hospital level of care," and is inappropriately placed in our acute-care hos-
pital. Although a number of acute-care hospitals From the Department of Medicine, Division of General Internal Medicine and Health Services Research (Dr. Goldberg) and the Department of Medical Records (Ms. Hein, Rosales and Alexander), UCLA School of Medicine. Supported in part by the National Center for Health Services Research, U.S. Department of Health, Education, and Welfare, under USPES Grant No. HS 01320. Reprint requests to: George A. Goldberg, MD, Department of Medicine, UCLA Center for Health Sciences, Los Angeles, CA 90024.
318
APRIL 1977 * 126 * 4
(many of which employ utilization review coordinators) make use of level-of-care criteria for determining appropriate hospital placement,3 most of the guidelines for determining level of care have been, up to this time, quite vague. The example of level-of-care criteria provided by Goran and co-workers2 gives only the general outline of questions to be addressed by the person determining the patient's needed level of care. A physician or utilization review coordinator using this outline of so-called level-of-care criteria to review an individual patient, could be said to be approaching the problem logically, but not really explicitly. The notion of what is a "hospital-only" physician service, or skilled nursing service, or ancillary service (whether as to type, number or intensity) would still remain in the reviewer's head. The review therefore would be subjective, at a time when greater objectivity of review is desired." 4
Explicit Level-of-Care Criteria To remedy this situation, we developed a set of explicit level-of-care criteria, to be used as guidelines for review of UCLA utilization review coordinators (see Figure 1). We amalgamated, adapted and expanded three provisional sets of level-of-care criteria which had been developed previously by three nonacademic acute-care hospital utilization review (UR) committees in the San Francisco Bay area.5 Our effort in no way constitutes a research project, nor does it purport to be one. It is a considered empirical step to assist our
UTILIZATION REVIEW
UCLA HOSPITALS AN,lD CLINIACS LEVEL OF CARE CRITERIA: Guidelines for Utilization Review 'The Levei of Care Guidelines are representative, not all-inclusive.
iVHAl SERVICES SHOULD A PATIENT BE RECEIVING OR NEED AVAILABLE IN ORDER TO JUSTIFY ACUTE HOSPITAL LEVEL OF CARE ? I. PHYSIChIA SERVICES 1. Specific requirement for daily visits, e. g. , situations requiring physician skills to observe, evaluate, and adjust orders. 2. Examinaltions and orders for treatment during preoperative and other acute care periods of stay. 3. Operative and othe r technical procedures.
II. SK I LLED N|URS I NG 5SERV I CES 1. Continuous availability of nurses for intermittent observation and delcision-making, including, but not limited to: a. wvhere patient is acutely ill such as with uncontrolled diabetes or hypertensionr.. b. where complex diagnostic or therapeutic procedures are being done requiring frequent or repeated observation. c. wh-ere pre and postsurgical manaQement is provided. d. -,, here potentialiy dangerous drugs or drug combinations are being used. 2. Frecuent skilled nursi ng services inchluding, but not iimited to. a. INP medications and IV therapy. b. inFihalation therapy, pulmonary therapy, and urgent administration of oxygen. c. teaching managemernt of postsurgical appliances, medication regimens, and special diets. d. specialized proced u res, e. g. , suction ing, postu ral drai nage, com presses, f requent d ressing c han ges. e. cardiac resuscitation. f. intensive care nursing, e.g., ICU, CCL, RCU, premature nursery. g. speci a li zed n u rsi ng ca re, e. Q. , re habi itat ion, d ialys s. h obstetrical care: (Ii anienatal complications
121rdelivery 3i postpartu m care and education 11. MEDICAL SERVlCES AVAILABLE ONLY IN ACUTE HOSPITAL 1. Surgery with major anesthesia (general or spinal). 2. Diagnostic tests, therapeutic nrocedures, and medications that are dangerous (or potentially dangerous), e.g., liver biopsy, cardiac catheterization, monitoring equipment, chemotherapeutic drugs, angiography. 3. Tests or procedures requiring scheduling too intense or complexity too great (e. g., equipment and/or personnel and-'or expertise not availablei for performance outside the acute hospital. 4. Patient's condition is too fragile to conduct tests as outpatient, because complications would be likely to occur, or the tests might be unsuccessfully performed. 5. Daily laboratory work on Lunstable conditions. 6. Traction for acute condition or acute exacerbation of chronic problem. 7. Radi2tiorn therapy for unstable patients.
IV. REHABILITATION SERVICES 1. Patient is undergoing intensive rehabilitation program requiring the involvement of various allied health professionals. 2. Intensive therapy or rehabilitation requires multiple sessions daily. 3. Initial rehabilitation efforts where there is rehabilitative potential and improvement is expected in a reasonable period of time. V. PSYCHIATRIC SERVICES 1. Only when there is a concomitant acute medical condition.
VI. ADDITIONAL CONSIDERATIONS 1. The patient's condition requires more complete bedrest than available at home. 2. Condition is terminal, and it is appropriate to keep patient in the acute hospital for at most 14 days for humanitarian reasons. 3. The total number and intensity of skilled nursing services needed ito perform a combination of direct services, observations, and decision-makingi, ate available in this hospital, but not in a Skilled Nursing Facility. 4. The patient is convalescing from an illness, and it is anticipated that his/her stay in a Skilled Nursing Facility would be less than 72 hours.
Figure 1.-The utilization review (UR) reviewer refers to these level-of-care guidelines while following the UR flowsheet (Figure 2). These guidelines provide representative examples of services available only in an acutecare hospital environment.
THE WESTERN JOURNAL OF MEDICINE
319
UTILIZATION REVIEW UCLA HOSPITALS AND CLINICS LEVEL OF CARE: ADMISSION .
.
~~ yes
Does this patient's diagnosis obviously require acute hospital level of care ? (consult list)
if
if no
Document diagnosis and assign first continued- 2 stay review date.
Refer to Level of Care: Continued Stay.
Does this patient require direct nursing services frequently ? Does this patient have a condition that requires the skills of a nurse to detect and evaluate the need for possible modification of treatment or institution of medical procedures ?
3
4 5
whether yes or no Does this patient require ancillary services and/or equipment available only in the acute hospital setting ?
if no I
Does this patient require constant availability of physician's services for direct action (i. e., proceduresl operations) ? Does this patient require constant availability of physician's services for determining and directing care (i.e., therapy)?
8 r
2G 3oH
if yes
Go to 7.
if yes
lGo to R.
9
-i
if no Do the type, number or frequency of the combination of physician, skilled nursing and ancillary services being
received by this patient require acute hospital level of care ? (too intense for SNF)
10
if no r-
Are there any extenuating circumstances not covered by the above categories that mandate acute hospital level of care ?
if no Refer to Utilization and Quality of Medical Care Committee Member.
12
Figure 2.-The utilization review (UR) reviewer follows these flowsheets (for upon-admission review and for continued-stay review) in order to apply the level-of-care guidelines. Starting with box 1, and proceeding in a direction dependent upon yes or no responses, the UR reviewer simultaneously documents the current level of care and reaches one of two decisions: (1) assign next review date or (2) refer questionable case for further consideration and possible disapproval.
320
APRIL 1977 * 126 * 4
UTILIZATION REVIEW Today's date is on or before the 50th percentile review date for diagnosis or the assigned review date. Has this patient's diagnosis changed since admission or previous
1
Is the new diagnosis alone one which requires acute hospital level of care ?
if yes
2
ye
review ?
if
if
if e
3
s
Document diagnosis and assign next review date
4
no
no
FGotoi
Go to #5.
Are there additional diagnoses and/or complications ?
5
Are the additional diagnoses and/or complications alone ones which require acute hospital level of care ?
s
if
ye
if
6ys
Document diagnoses and/or complications and assign next review date
7
if no if
no
Go to #8.
Does this patient require direct nursing 8 services frequently ? Does this patient have a condition that requires the skills of a nurse to detect and evaluate the need for possible modification 9 of treatment or institution of medical procedures ?
Does this patient require ancillary services and/or equipment available only in the acute hospital setting ?
if
e if Yes
10
11
Gotoi.[
no
Does this patient require constant availability of physician's services for direct action (i.e., procedures/ operations) ? Does this patient require constant availability of physician's services for determining and directing care (i.e.. therapy) ?
Document need, status, and diagnosis of patient and assign next review date.
12 either
M_j Go to fll.-
13
i
if no r-
Do the type, number, or frequency of the combination of physician, skilled nursing and ancillary services being received by this patient require continued acute hospital level of care ? (too intense for SNF)
14
if yes
Go tof.
if no Are there any extenuating circumstances not covered by the above categories that mandate continued acute hospital level of care ?
I~~~~~~~~~~
X5
if
ys
Gotofil.
If no
Refer to Utilization and Quality of Medical Care Committee Member
16
THE WESTERN JOURNAL OF MEDICINE
321
UTILIZATION REVIEW
UR physicians and UR coordinators in making rational, humane and explicable decisions concerning the appropriateness of location of patients in an acute-care hospital. We believe that our level-of-care criteria can serve as an important, practical model for UR committees throughout the country. UR committees are likely to be attracted to level-of-care criteria, instead of to disease-specific criteria, because level-of-care criteria are inherently logical and are often advantageous for an acute-care hospital patient population. There are a number of specific advantages of level-of-care criteria over disease-specific criteria: (1) the application of disease-specific criteria is unsatisfactory for many patients who have multiple problems and diagnoses, since the disease-specific criteria are formulated for single diagnoses only; (2) level-of-care criteria can be effectively applied to indistinct cases where there exists no clear-cut diagnosis to which disease-specific criteria can be applied; (3) there is no need to develop a large number of disease-specific criteria for UR purposes, an advantage particularly important at a medical center such as UCLA, where there are so many different discharge diagnoses that every discharge diagnosis (with the single exception of that associated with delivery) accounts for fewer than 2 percent of all hospital discharges; (4) physician participation in the UR system is facilitated, because it is not necessary for a reviewing physician to have specific knowledge concerning diseases from specialty areas which are not his or her own, and (5) communication among UR coordinators, and between coordinators and physicians, is enhanced because there is a common basis to discuss the functioning of the review system, rather than multiple opinions concerning a specific disease process. None of these advantages is meant to imply that disease-specific criteria have no place in the review process; however, we believe that the UR function should make use nearly exclusively of level-of-care criteria. Disease-specific criteria remain necessary for review of quality of care (medical care evaluation studies), an area in which use of level of care criteria is inappropriate. We cannot identify any major drawbacks to the level-of-care approach, so long as it is understood that level-of-care criteria are meant to be applied for purposes of review of (1) need for admission and (2) need for continued stay, and that they are not appropriate for review of quality
322
APRIL 1977 *
126 * 4
of care. A barrier to the wider adoption of levelof-care criteria has been the unwillingness of a number of fledgling Professional Standards Review Organizations (PSRO'S) to permit hospitals to make use of level-of-care criteria. We believe that such hesitancy is unwarranted, and is based on a misreading of the wishes of the federal government's guidelines, which have consistently reiterated that use of level-of-care criteria is acceptable.
Utilization Review Flowsheet In order to assure the orderly application of these level-of-care guidelines, we borrowed the concept of "criteria mapping," that has been developed for purposes of quality-of-care review by Greenfield and co-workers,6 and developed a flowsheet so that a UR reviewer, whether physician or UR coordinator, would be certain of asking all the right questions in the right order (see Figure 2). The UR reviewer starts with the first question, and renders a judgment, based on the furnished guidelines. If the answer is yes, the reviewer proceeds to the next question (or required action) horizontally to the right. If the answer is no, the reviewer proceeds to the next question (or required action) vertically below. If there is only one action to follow, the reviewer automatically proceeds vertically below, to the next question (or action). This pattern persists until one of the two actions has taken place: the patient has been approved as requiring further acute-care hospital level of care (and, therefore, stay), or the patient's case must be presented to another reviewer because the initial reviewer has reached the conclusion (based on the guidelines) that an acutecare hospital level of care is not required. In either instance, medical judgment has been brought to bear in a channeled and guided manner. The reader will note that we also developed a list of automatic diagnoses to justify admission to an acute-care hospital. We have not included a particular list, because most hospitals are well aware of this concept, and make use of such lists. It is useful to think of these conditions as conditions whose very presence implies a need for an acute-care hospital level of care, at least in the initial stages of treatment of the condition, whether new or a flare-up. At UCLA this group of conditions was purposely kept small. It will be enlarged only very slowly, as UR committee mem-
UTILIZATION REVIEW
bers document to their satisfaction that there are additional conditions that, in actual practice at our particular hospital, always require an acutecare hospital level of care at the time of admission. Also noteworthy is the fact that the level-ofcare concept is relevant for both upon-admission review, and continued stay review. Separate, similar flowsheets were constructed for the two types of utilization review.
Utilization Review Function Our level-of-care guidelines, list of automatic approval-upon-admission conditions and UR flowsheets for application of the guidelines have all been approved by the UCLA Hospital Utilization Review and Quality of Care Committee. They are being used routinely by our UR coordinators and by the UR physicians when our coordinators bring questionable cases to their attention. Therefore, our basis for judgment is explicit, and our criteria can be easily reviewed by outside inspecting agencies. Therefore, our decisions can be welldocumented and well-defined when challenged either from within, or from outside our hospital. We have also found these guidelines to be useful in orienting and training new UR coordinators and new physician members of the UR committee. The principles are easily grasped, and it is appreciated that the same principles can be applied no matter what the disease or problem and no matter if the question concerns the necessity for a new admission or the necessity for continued stay. Our coordinators and physicians view the level-of-care determination as being a logical way of deciding if the acute-care hospital environment is needed or not, and they do not find themselves deflected from an understanding of UR by personal reservations about particular items in a disease-specific group of criteria. Similarly, the use of level-of-care criteria appears to have been a success vis-a-vis outside agencies. The local PSRO has accepted the UCLA level-of-care UR system as fulfilling its require-
ments, and considers level-of-care criteria to be the preferred method for carrying out the UR function. Third-party intermediaries, including Medi-Cal, have not increased their "questions" or "denials." And, although the application of these criteria would not necessarily be expected to have an effect (increase or decrease) on length of stay, it is gratifying to note that there has been no increase in length of stay. It is obvious that no hospital can adopt, unchanged, the level-of-care criteria used by any other hospital. A hospital must adapt level-ofcare criteria to its special internal and external circumstances. For example, level-of-care criteria will depend upon which services are offered and not offered by the particular hospital. Also, the level of care that can be provided only in an acute-care hospital depends upon what services are available in the less intensive facilities of the local community. To give an example, for a patient who requires rehabilitation and intravenously given medication, one community may have an unusual skilled nursing facility that can provide both, in which case the patient would not require the acute-care hospital level of care. Another community may have no skilled nursing facility capable of providing both; therefore, the same patient would indeed require an acute-care hospital level of care. Although the level-of-care criteria will require adaptation, the flowsheet for applying the hospital's adapted level-of-care criteria can usually find use, unchanged. REFERENCES 1. Goldberg GA, Holloway DC: Emphasizing "level of care" over "length of stay" in hospital utilization review. Med Care 13:
474-485, 1975 2. Goran MJ, Roberts JS, Kellogg M, et al: The PSRO hospital review system. Med Care 13:1-33, 1975 (Supplement to number 5) 3. Holloway DC: Personal communication 4. US Department of Health, Education, and Welfare, Office of Professional Standards Review: PSRO Program Manual. Washington, DC, US Government Printing Office, Mar 1974 5. Holloway DC, Holton JP, Goldberg GA, et al: Development of Hospital Levels of Care Criteria. Health Care Management Review 1:61-72, 1976 6. Greenfield S, Lewis CE, Morner S, et al: Peer review by criteria mapping: Criteria for diabetes mellitus. Ann Intem Med 83:761-770, 1975
THE WESTERN JOURNAL OF MEDICINE
323
