Interqual or similar resource for Hospital Case Managers

[EllbellRN]

I'm a new Hospital Case Manager and my facility does not use Interqual or Millman as a guide when determining Inpatient Vs Outpatient status. It's all "clinical judgement" at this point, and being new to this position, I'm struggling in this area. I know if your hospital subscribes to Interqual, you can obtain a manual. Since mine does not, does anyone know where I can obtain a manual or a similar resource to assist with the criteria? Thanks so much for any suggestions.

[SummerGarden, BSN, MSN, RN]

i'm confused, how does your hospital receive reimbursement/payment from insurers and contractors without using a standard criteria? is it possible that your hospital uses a standard criteria but does not use a duel role for its

cms? in other words, you may perform discharge planning but there may be other nurses who perform utilization management and unfortunately are not communicating well with you or the other cms that perform discharge planning. in any case, resources you can use to help your practice are listed on the ccmc suggested reading list: ccmc suggested reference list - reference books

[EllbellRN]

Thanks for the suggestion. I just started this month and was told they are planning to get Interqual sometime this year. The CMs do both UR and discharge planning. So far I find the most challenging thing the Inpatient vs Observation status review since there is no guidelines. We just look in the chart/computer for consults and document data and then participate in rounds with the MDs for updates. They mentioned interqual in my Interview, but another CM said it will take up to a year to get it. I will certainly check out the references you mentioned.

[SummerGarden, BSN, MSN, RN]

I received training and information through my employers. However, since you may need to wait, you also may want to contact McKesson to receive training on your own (this costs $$ but you can receive CEUs) or maybe you can purchase a book with discharge planning criteria as it relates to Observation vs. Inpatient, such as the one used for Interqual?: http://www.mckesson.com/en_us/McKesson.com/For%2BPayers/Private%2BSector/InterQual%2BDecision%2BSupport/InterQual%2BCriteria%2BProducts/InterQual%2BCriteria%2BProducts.html.