InterQual® Criteria Overview

InterQual® Criteria Overview
Presented by:

Introduction For Training Purposes Only
The purpose of InterQual training is to teach you the concepts necessary to conduct reviews and to use InterQual® Criteria and CareEnhance® Review Manager software effectively Training materials include case studies, which are provided for demonstration and training purposes only The criteria shown in the training materials might differ from the current version of InterQual Criteria When conducting reviews at your organization, use Review Manager (or other software) or the InterQual Criteria books, as licensed For Training Purposes Only © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Ground Rules: Web Discussion
Your participation is essential; please be open and give freely of your experiences regarding the topic of discussion Please identify yourself when asking a question or making a comment Please avoid putting your phone on “Hold” as there may be music on Hold Please, if possible, place your mobile devices in silent or mute mode If you need to leave the meeting, please inform the instructor prior to signing off Please be prompt when returning from breaks © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Ground Rules: Onsite Discussion
Your participation is essential; please be open and give freely of your experiences regarding the topic of discussion Please, if possible, place your mobile devices in silent or mute mode Please try to refrain from stepping in/out of the room during the discussion Please be prompt when returning from breaks © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Objectives Following this discussion, participants should be able to:
Describe the philosophy and benefits of InterQual Criteria Describe how InterQual Criteria are developed Discuss how InterQual Criteria support reviewers in making clinical care decisions Describe how InterQual Criteria support data aggregation and outcomes reporting Demonstrate an understanding of the criteria composition and application to the review process © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

About InterQual Criteria
The most widely used tool in the industry for providers, health plans, payers, and government entities Evidence-based clinical content for determining medical necessity and appropriate care An objective tool used to support clinical rationale for decision-making 300+ health plans 4,100+ hospitals For over 30 years, InterQual Criteria have been the most widely used tool in the industry for determining medical necessity. Currently, there are over 4,100 provider organizations and over 300 health plans using the criteria. McKesson clinicians continuously research the medical literature and existing best practice standard guidelines to develop clinical statements for determining medical necessity and appropriate level of care and/or medical services and interventions. InterQual Criteria provide objectivity to support decision-making based on clinical—and not financial—rationale. InterQual Criteria do not replace provider judgment; rather, they serve as a tool to promote sound and efficient utilization of resources. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Benefits of Using InterQual Criteria
Evidence-based medicine, incorporating current medical literature Best medical practice / accepted standards of care Clinically based and patient-specific InterQual Criteria are based on the most current evidence-based information in the medical literature and accepted best-practice standards of care. The criteria are clinically rich and allow for specific application to case reviews. Review and testing of the criteria are ongoing and updates are published semi-annually, with the largest release in April of each year. Rule-based application allows for consistent, reproducible—or, in other words—reliable reviews. Continuously reviewed and updated semi-annually Objective, rule-based, and reliable © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Benefits of Using InterQual Criteria
(continued) Triages patient care to a level of clinical appropriateness Screens against over- and under-utilization of clinical resources Facilitates meeting regulatory requirements Additional benefits include support for triaging cases to the most appropriate level of care and preventing over- and under-utilization of clinical resources. The criteria also incorporate regulatory requirements, for example, The Joint Commission standards and NCQA quality measures. Data collected from all reviews can be aggregated and analyzed for patterns and trends with resource utilization. This information can be used in operational decision-making for ongoing analysis, evaluation, education, and process improvement initiatives. The criteria support healthcare providers and payers in managing healthcare resources in relationship to the three pillars of the Healthcare Management Triad. Allows for data aggregation and reporting of review outcomes and enables operational decision-making Encompasses the Healthcare Management Triad © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Healthcare Management Triad
Quality Access The 3 pillars of managing healthcare resources are quality, efficiency, and access. If we manage healthcare in these areas, we manage the resources—and, therefore, the cost—by reducing waste and duplication, as well as inappropriate, fragmented, and even unsafe care. Quality and efficiency of and access to healthcare are equally important for everyone, including healthcare providers and consumers of care. Efficiency and access have a close correlation: the more efficient the care, the greater the access, and vice versa. For example, variance or avoidable days tie up beds and services unnecessarily and then these services are not available for other patients in need. Delay of services, which happens everyday and everywhere, creates waste and inappropriate utilization of services. Common examples include patients waiting for consults, inefficient or untimely procedures, and delayed transitions in care. Efficiency © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

InterQual Evidence-Based Development
Unmatched Rigor and Integrity InterQual Clinical Development Team identifies content for development and updating Clinical Development Team critically appraises the clinical evidence Independent Clinical Review Panel, drawn from 750+ experts, provides authoritative peer review New set of Independent Physician Experts validates content Clinical Development Team conducts final quality assurance check and releases content 1. InterQual Clinical Development Team identifies content for development and updating • Teams of physicians, registered nurses, and allied health professionals • Monitors latest evidence, market trends, and client needs to identify, assess, and case-test potential new offerings and changes to existing content • Evaluates industry and regulatory trends in practice, coverage, and reimbursement 2. InterQual Clinical Development Team critically appraises the clinical evidence • Comprehensively reviews medical literature (including behavioral health) and other respected sources • Evaluates validity using extensive training and experience in evidence-based medicine • Incorporates new evidence • Classifies and cites sources used 3. Independent Clinical Review Panel, drawn from 750+ experts, provides authoritative peer review • All physician panel members are board-certified in the specialties they review; licensed, credentialed, or both in their areas of practice, actively practicing, and screened for conflicts of interest • Multiple reviewers from across the country evaluate each proposed new criteria and criteria change for correct interpretation of the literature • Provide expert guidance on standards of care for areas not conducive to clinical trials 4. New set of Independent Physician Experts validates content • Provides additional round of expert review to validate clinical accuracy • Confirms that the content reflects current standards of care for areas not conducive to clinical trials 5. InterQual Clinical Development Team conducts final quality assurance check and releases content • Reviews for clinical consistency and completeness across products • Prepares approved content for distribution © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Conducting Reviews with InterQual Criteria
The purpose is to determine medical necessity—and not to make the case meet criteria Not every case will meet criteria; when a case doesn’t meet criteria, further review is required to determine medical necessity and appropriateness This secondary review process will be discussed in your training session The purpose of conducting a review with InterQual Criteria is to determine and/or demonstrate medical necessity—and not to make the case meet criteria. Not every case will meet criteria; when a case doesn’t meet criteria, further review is required to determine medical necessity and appropriateness. This secondary review process will be discussed in your training session. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Product Support When there are questions regarding InterQual Criteria and/or CareEnhance® Review Manager, contact Product Support: Web MHS Customer Hub Phone CRITERIA or © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

2016 InterQual® Acute Level of Care Criteria
Presented by:

What You’ll Learn Upon completion of this course, you should be able to: Explain key concepts of InterQual Criteria and the process of conducting a review to determine medical necessity. Discuss how InterQual Criteria support the reviewer to manage patient care. Consistently and correctly apply InterQual Criteria when conducting reviews. Explain the process and purpose of conducting a primary and secondary review. Demonstrate the application of InterQual Criteria and the review process utilizing case studies to support clinical care decisions. Navigate the format of InterQual Criteria used by your organization. Refer to the Review Process document and support resources when conducting criteria reviews. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

About this Course Getting Started Criteria Concepts Case Studies
Understanding Data Aggregation © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

About Level of Care Criteria
Provide support for determining appropriateness of a patient’s admission to, continued stay at, or discharge from a level of care Acute Acute Adult (≥18 years) Acute Pediatric (<18 years) Post Acute Inpatient Long-Term Acute Care Rehabilitation (Adult and Pediatric) Subacute & SNF (Adult and Pediatric) Post Acute Outpatient Home Care (Adult and Pediatric) Outpatient Rehabilitation (Adult, Adolescent, and Pediatric) & Chiropractic (Adult and Adolescent) Available in software (all products) and printed books (all products, except Home Care) LOC content delivery Software CareEnhance® Review Manager (standalone or in an integrated environment) InterQual® View InterQual® Online Printed Books Each InterQual Level of Care product (except Home Care) is delivered as a separate book. Adult criteria are for the review of patients ≥ 18 years of age. Pediatric criteria are for the review of patients < 18 years of age. The criteria are intended solely for use as screening guidelines with respect to the medical appropriateness of healthcare services. Criteria are not intended to decide final clinical or payment actions concerning the type or level of medical care provided (or proposed to be provided) to a patient. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Questions Answered by InterQual Level of Care Criteria
Is the patient's illness severe enough to require the current or proposed level of care? Are the provided services (for example, prescribed therapies, monitoring, and interventions) appropriate for the patient's current or proposed level of care? Is the patient clinically stable, and if so, can the patient's care needs be met at an alternate level of care? © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Review Process Document
Guideline for using criteria, found in the InterQual Clinical Reference and in books Specific to each criteria product Overview of criteria concepts and components Review steps Information on supporting materials Practical tips Instructor: Be sure to clarify that, in this context, “Review Process” refers to a document and not a methodology! © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Review Stages Primary review Secondary review Appeal
The stages of the review process are described below. Primary review—The first, or initial, review a healthcare organization conducts to determine if a medical intervention is (or was) appropriate for a patient. Secondary review—Any review that is conducted after a primary review. A supervisor, specialist (therapist, nurse, etc.), or physician may conduct a secondary review. Each organization determines the qualifications of the reviewers, as well as the extent to which a secondary review is conducted in order to render a review outcome. Multiple secondary reviews are allowed. Any secondary reviewer may refer a review to another secondary reviewer. Appeal—At the request of the patient, provider, physician, or facility, a review determination may be reconsidered. An appeal is a formal request that a decision be reviewed and reconsidered for a change in the decision outcome. This review process is consistent with most accrediting agencies and regulatory bodies. Reviewers must be aware of—and follow—their organization's policies and procedures. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Primary Review Primary reviews:
The first, or initial, review a healthcare organization conducts to determine if a medical intervention is (or was) appropriate for a patient Conducted by a clinical (non-physician) reviewer The primary reviewer may: If criteria are met, approve If criteria are not met, obtain additional information If criteria are still not met, refer for secondary review © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Secondary Review Secondary Review:
Any review performed after the primary review Occurs when criteria are not met Performed by: Supervisor/Manager/Director (based on organizational policy) Physician Advisor/Medical Director May review medical record May discuss with attending provider Makes determination for medical appropriateness Review Process: “Secondary review determines the appropriateness of the current or proposed level of care. A supervisor, specialist (e.g., therapist, wound or ostomy nurse), or medical practitioner conducts the secondary review. Organizational policy should dictate the extent to which secondary review is performed in order to render a review outcome. The secondary reviewer determines medical necessity based on review of the medical record; discussions with nursing staff, the discharge planner, and the attending medical practitioner; and clinical knowledge.” If group tells you they do not have secondary reviewer or secondary review process in place, explain the purpose and goal of secondary review and discuss the value of collecting data. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Referring for Secondary Review
Criteria not met Service delays Case Management / Discharge Planning / Social Services delay ALOC bed not available Patient has comorbid condition(s) Patient choice and preference Other (organization-specific) © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Criteria Notes Explanations of criteria
Definitions of medical terminology Information about a clinical condition Specific instructions on how to apply criteria Format Subset-level notes Notes associated with criteria points Software Click note icon or subset name Click note icon Books First page of subset Superscripted number refers to Notes/Glossary section Instructor: Emphasize the following: As you conduct a review, read all notes. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Supporting Materials Available in the InterQual Clinical Reference, software, and/or criteria books Abbreviations & Symbols Drug List Bibliography Clinical Revisions Inpatient List Index Transition Plan Quality Indicator Checklist © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Knowledge Check What questions are answered by Level of Care Criteria?
In what resource can you find an overview of criteria concepts and the steps for conducting reviews? Answer: Refer to the list of questions on a previous slide. Answer: The Review Process ? © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Criteria Composition Products Categories Criteria subsets Episode days
Levels of care Responder-type criteria Criteria points Rules Time requirements Notes © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Products Acute Post Acute Inpatient Post Acute Outpatient
Acute Adult (≥18 years) Acute Pediatric (<18 years) Post Acute Inpatient Long-Term Acute Care Rehabilitation (Adult and Pediatric) Subacute & SNF (Adult and Pediatric) Post Acute Outpatient Home Care (Adult and Pediatric) Outpatient Rehabilitation (Adult, Adolescent, and Pediatric) & Chiropractic (Adult and Adolescent) © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Categories Acute Adult and Pediatric Criteria Medical Surgical
© Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Criteria Subsets Acute Adult and Pediatric Criteria Medical category
Condition-specific General Medical General Trauma Nursery Extended Stay Surgical category General Surgery General Transplant Criteria subsets vary by product Condition-specific and General criteria subsets: Organized by episode/operative day Comprise multiple levels of care Integrate relevant complications, comorbidities, and guideline standard treatments The General Surgical subset includes Pre-op Day, Operative Day, and Post-op day 1, Post-op day 2, etc. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Criteria Subsets (continued) Criteria Subsets Description Use when
Condition-specific Address one or more conditions A patient’s primary condition or diagnosis corresponds to a condition-specific subset General Include General Medical, General Trauma, and Nursery A patient’s primary condition, symptom, or finding does not correspond to a condition-specific subset Extended Stay Address the conditions, diagnoses, and symptoms that necessitate an extended stay The episode days within a condition-specific subset or end-points within a general subset are exhausted and a patient requires continued stay, refer to one the extended stay subsets. Surgical Address one or more surgical procedures A patient requires an inpatient surgical procedure or management of complications related to an ambulatory procedure Condition-specific Subsets Condition-specific subsets address one or more conditions, for example, Acute Coronary Syndrome (ACS) addresses ACS, while Anemia/Bleeding addresses anemia (hemolytic anemia or anemia of unknown etiology) or bleeding (GI bleeding, hematuria, hemoptysis, epistaxis, or vaginal bleeding). According to the Acute Criteria Review Process, if a patient’s primary condition or diagnosis corresponds to one of the condition-specific subsets, then you conduct a review using the appropriate condition-specific subset. General Subsets General subsets include: General Medical and General Trauma—Comprise an unlimited number of episode days (designated as Episode Day 3-X) and a variety of diagnoses and symptoms Nursery—Comprises an unlimited number of episode days (designated as Episode Day 2-X) and a variety of findings and interventions According to the Acute Criteria Review Process, if a patient’s primary condition, symptom, or finding does not correspond to one of the condition-specific subsets, then you conduct a review using the appropriate general subset. Extended Stay Subsets The Extended Stay subsets—one each for Acute Adult and Acute Pediatric Criteria—address the conditions, diagnoses, and symptoms that necessitate an extended stay. For example, the Extended Stay (Acute Adult) subset includes “Cardiovascular or peripheral vascular,” “Gastrointestinal,” and “Infection” criteria. Unlike condition-specific and general subsets, the Extended Stay subset does not include specific episode days. You can use this subset until the designated endpoints are fulfilled; the patient’s condition or symptom resolves and Responder criteria are met; or until a condition-specific or general subset would be more appropriate. If criteria are not met within the Extended Stay subset, refer for secondary review. The Extended Stay subset cannot be used on admission. Surgical Subsets Surgical subsets include the General Surgical and General Transplant subsets and address one or more surgical procedures. According to the Acute Criteria Review Process, you conduct a review using a surgical subset when a patient requires an inpatient surgical procedure (including solid organ, bone marrow, or stem cell transplant) or management of complications related to an ambulatory procedure. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Episode Days Acute Adult and Pediatric Criteria Episode Day 1
First day in episode of care for the patient, for that condition Includes all appropriate levels of care for the condition Episode Day 2, Episode Day 3, etc. Second day in episode of care, third day, and so on Include criteria only for levels of care that are clinically appropriate for the condition on that day Extended Stay subsets do not include specific episode days You evaluate criteria for the appropriate episode day. The number of episode days varies, based on: Condition Comorbidities Complicating factors Acute Adult and Pediatric Criteria subsets (except the Extended Stay subsets) are organized by episode day: Episode Day 1, Episode Day 2, and so on. The General Surgical subset includes Pre-op Day, Operative Day, and Post-op day 1, Post-op day 2, etc. Episode Day 1 Episode Day 1 represents the first day in the episode of care for the patient, for that condition. The criteria include all of the appropriate levels of care for the condition, organized from least to most intensive. Episode Day 2, Episode Day 3, etc. Episode Day 2 represents the second day in the episode of care; Episode Day 3 represents the third day, etc. The number of episode days varies based on the condition and includes common comorbidities and complicating factors associated with the primary condition. For example, the average clinical course for heart failure is 3-4 days; the Heart Failure subset includes criteria through Episode Day 6. You evaluate criteria for the appropriate episode day. The frequency of reviews is determined by organizational policy; reviews are not required to be conducted on every episode day. Although the subset includes criteria for each episode day, you do not need to change your organization’s policies or processes. Each episode day includes criteria only for the levels of care that are clinically appropriate for the condition on that day. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Levels of Care Acute Adult and Pediatric Criteria Observation Acute
Intermediate Critical Nursery (Acute Pediatric only) Neonatal Intensive Care Level IV Neonatal Intensive Care Level III Special Care Level II Newborn Level I Transitional Care Each episode day includes the appropriate levels of care. Extended Stay subsets comprise only levels of care (no episode days). Show the levels of care in Review Manager or InterQual View. For book users, have participants open their books to the Acute Adult LOC list. The name of the place where the patient is located might not represent the level of care the patient is receiving. For example, a patient might be in a critical care unit while receiving an intermediate level of care. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Responder-type Criteria
Indicates … Responder Patient is clinically stable (in the last hours) Discharge is expected on that day Partial responder For this condition and episode day, the patient is clinically appropriate for continued stay at this level of care Non-responder Patient requires continued stay Episode days or level of care within the current subset have been exhausted Show examples of responder types in the criteria. Software Users In the navigation pane, a small, red “R” icon indicates that a specific episode day is the first day on which Responder criteria for the Acute or Intermediate level of care are available—and the first day on which discharge might be appropriate. (This icon displays only in subsets that focus on a single condition, like Heart Failure or Asthma and not, for example, Anemia/Bleeding or Infection: CNS.) © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Criteria Points Clinical statements that refer to:
Test results Medications Symptoms Findings Monitoring Medical management Functional status Prescribed therapies Criteria points might stand alone or be organized in a decision tree Criteria points validate admission to, continued stay at, or discharge from an inpatient level of care Show examples of standalone criteria points and criteria points in a decision tree in the criteria. Review Manager In Review Manager, the decision tree is initially collapsed. To expand the decision tree, you click the plus sign to display the underlying criteria points. To collapse the decision tree, you click the minus sign. Review Manager enables you to select criteria points. A check mark indicates a selected criteria point. InterQual View does not enable such interaction. Criteria Books Criteria books display all criteria points; the decision tree is fully expanded. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Rules Specify how many of the next-level criteria are required
Examples: One ≥ One Both All Show examples of rules in the criteria. Rules (for example, One, Both, and All) specify how many of the next-level criteria are required. To meet criteria and determine that admission to, continued stay at, or discharge from a level of care is appropriate, the reviewer must select criteria points as the rules specify. Applying the rules ensures consistent and reliable criteria application. For the rule of ≥ One, only one criteria point needs to be selected to meet the rule. The reviewer might, however, want to document all applicable criteria points. Software Users For the rule of One, the software allows you to select only one underlying criteria point. If you select a second criteria point, an error message displays. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Time Requirements Timeframe within which the symptoms or findings must be present and clinically significant Criteria point time requirements Show examples of time requirements in the criteria. Be sure participants grasp how the component-level time requirements and criteria-point time requirements work. Acute Adult and Pediatric Criteria include a time requirement, “Symptom or finding within 24 hours,” that must be met or adhered to when determining the presence of symptoms, delivery of services, or patient stability. The symptoms or findings must be present and clinically significant within that time frame. They do not have to have first occurred or reoccurred within that timeframe. Criteria point time requirements address the frequency of services or an endpoint for the criteria point. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Knowledge Check Identify Time Requirements
Component time requirement: Symptom or finding within 24h Criteria point time requirement: IV ≥ 2x/24h Criteria endpoint: Post Critical care ≤ 24h Note: The Review Process refers to time requirements as time “rules.” © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Extended Stay criteria
Knowledge Check Identify Criteria Composition Criteria that indicate the patient is clinically stable (last 12h–24h); patient may be clinically ready for discharge Refer to test results, medications, symptoms, findings, monitoring, or medical management When the episode days within a condition-specific subset are exhausted and a patient requires continued stay, refer to this Tell how many of the next-level criteria are required Must be met initially when determining the presence or onset of symptoms or delivery of services Time requirement A Criteria points B Responder criteria C Direct participants to match each definition on the left with a term on the right. C B E D A Goal: Assess recall. Criteria rules D E Extended Stay criteria © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Benchmark Length of Stay (LOS) Data
Available for select conditions Provide guidance around a typical length of stay for the condition Facilitate management of the patient to that LOS target © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Benchmark Length of Stay (LOS) Data
(continued) Available in the software on the left navigation pane © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Care Management Information
Available for select subsets (i.e., conditions) Outlines the expected clinical progress of each condition and provides suggestions for managing a patient if there are barriers to clinical progression Includes care facilitation to the next appropriate level of care © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

(continued) Expected Progress Defines changes in the patient condition that indicate improvement within a time frame appropriate for the condition Barriers to progression Identifies barriers that are preventing the patient from meeting expected progress targets Provides suggested interventions Care Facilitation Identifies when a plateau has been reached Directs the user to look at ALOC © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Quality Indicator Checklist
Track National Quality Forum (NQF) inpatient quality measures Criteria points marked with a Q icon have an associated note that prompts the reviewer to complete a Quality Indicator Checklist Patient-specific Episode-centric (only one QI checklist per episode of care) Not a required part of the Review Process Members of the National Quality Forum (NQF) including The Joint Commission, Centers for Medicare Services (CMS), hospitals, private sector purchasers, and consumers, have worked together to define a national standard set of hospital quality measures. These measures focus on common data elements for the purpose of measuring the quality of hospital care and the goal of improving the healthcare delivery process. Some InterQual Criteria have been identified as quality indicators so that organizations can participate in working toward the same goals. The quality indicator checklist, provided in both software and book formats, enables reviewers to track and record data measures. Quality Indicator notes indicate those conditions for which there is a quality indicator. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Transition Plan Identifies patients who are at high risk of readmission Provides a framework for identifying discharge needs Outlines interventions necessary to ensure continuity of quality care Not a required part of the Review Process The transition plan provides guidelines for planning a patient’s safe transition to the most appropriate post-acute level of care. This tool helps reviewers to identify patients who are at high risk of readmission and provides a framework for identifying discharge needs. The National Quality Forum Consensus Standards Maintenance Committee has identified hospital discharge as a critical area for improvement. Reviewers are encouraged to begin using transition plan criteria at the time of admission. Serving as an adjunct to the review process, the transition plan describes interventions that are necessary to ensure continuity of quality care. Like the quality indicator checklist, Transition Plan notes are found in both software and book formats. See the Review Process for more information. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Transition Plan (continued)

Understanding Data Aggregation

Variance Decisions When the designated level of care is not available or Continued Stay criteria are not met and an ALOC is appropriate but unavailable, a variance in the treatment plan has occurred Many organizations maintain a list of alternate level of care options within their area Review Manager The number of variance days and the alternate level of care display on the Review Results pane. The reason for the variance displays on the Primary or Secondary Outcome pane. You can create Variance Days and Variance Days with Reasons reports. © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Variance Decisions (continued)
When a variance occurs, the reviewer identifies and documents the appropriate ALOC and variance AKA “Avoidable Day” or “Avoidable Delay” Reviewer documents: Appropriate level of care Number of days the variance occurred Variance/outcome reason (e.g., bed not available) © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Variance Decisions (continued)
Examples of variance/outcome reasons include: Alternate Level of Care bed unavailable Alternate Level of Care service unavailable Delay in care, treatments, services Delay in discharge plan © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

Data Aggregation Aggregated data is data that is analyzed as a whole
Aggregated case decisions help identify trends to maximize resources and reduce variation © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland. 55

Data Aggregation (continued)
Total Care Days = Total Variance Days = 1016 SNF 280 (28%) Critical Care 12 (1%) LTAC 142 (14%) Home Care 316 (31%) Residence 24 (2%) Acute Care 188 (19%) SurgiCenter 32 (3%) Preadmission Testing Center 22 (2%) © Copyright 2016 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Produced in Cork, Ireland.

InterQual® Criteria Overview

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