Part I: Service or Severity of Illness Criteria
Read the definitions below for Intensity of Service and Severity of Illness, noting the differences between the two. Review the list of criteria in #1 through #10 which includes both Intensity of Service and Severity of Illness criteria, based on the definitions; identify which type each one is. Then, within this table, list the policy criteria in the appropriate column based upon whether they are Intensity of Service or Severity of Illness criteria.
IS Criteria: Intensity of Service
Measures the level of intensity of treatment needed or resources used – “How much care do they need?”
SI Criteria: Severity of Illness
A measure of how serious is the patient’s illness or condition – “How sick are they?”
The following criteria indicate medical necessity and continued hospital stay:
- IV pain medications 3 or more times daily
- White blood count >15,000/cu.mm.
- Special neurological monitoring every 2 hours or more
- Oral temperature > or equal to 101 degrees
- Uncontrolled active bleeding at present time
- Sudden onset of unconsciousness
- Blood culture positive for pathogens
- Respiratory assistance required
- Surgery performed
- Acute onset of chest pain/pressure
Part II: Utilization Review for 3 Patients
Perform a Utilization Review on 3 patients. Below are notes from 3 patients who are currently inpatients at the hospital. Based on the notes provided, complete the Utilization Review Form that follows. Be sure to indicate if the documentation in the notes supports continued stay or if you believe the patient should be discharged.
0200 Sleeping in bed, breathing easily.
0115 SVN with albuterol 0.5 cc given.
0130 Breathing easy, good air exchange. Lungs fields with only minor crackles. No c/o at
0640 Feels better after treatment. Improving air flow in all lung fields. Foley catheter removed.
0700 Up to BR, voids well.
0800 Dr. Wainwright visits. Patient resting well. Blood sugar 130, vital signs stable. Ext. no edema. VS stable. Patient alert & oriented.
Continue present treatment.
IV Percocet every 4 hours
IV Percocet every 6 hours
7-3pm Tylenol #3 given for incisional pain.
Has been ambulating well in hallway without assistance.
Up to bathroom ad lib.
Staples removed, Steri-Strips applied.
Taking diet well.
Continues to complain of abdominal pain, possible gas.
Temp 101.9 degrees.
Patient feeling dizzy on ambulation.
Utilization Review Form
Complete this Utilization Review Form, indicating if continued stay or discharge is appropriate based on the documentation in the notes.
Be sure to state, on the review form, the specific Intensity of Service or Severity of Illness criteria from the previous list, if you feel the patient should continue their stay. If a patient does not meet any of those criteria than a decision for discharge should be made.
For Part 3 of this assignment, consider the patient who has diabetes and has begun the process of monitoring, medications, lab work and dietary counseling involved with that condition. Perform an online search using your favorite search engine by using terms such as, “diabetes case management.”
Write 2-3 paragraphs below summarizing specific, potential benefits for diabetic patients who have been provided with case management services. Include a description of services the case management could include, and specific health benefits that research has demonstrated can result from diabetes case management. Be sure to cite all your sources appropriately using APA format.