2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry

Home , Geriatric psychiatry, Partial hospitalization

InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry

Overview Select Level of Care Partial Hospital Program (1, 2) Notes

InterQual® criteria (IQ) is confidential and proprietary information and is being provided to you solely as it pertains to the information requested. IQ may contain advanced clinical knowledge which we recommend you discuss with your physician upon disclosure to you. Use permitted by and subject to license with Change Healthcare LLC and/or one of its subsidiaries. IQ reflects clinical interpretations and analyses and cannot alone either (a) resolve medical ambiguities of particular situations; or (b) provide the sole basis for definitive decisions. IQ is intended solely for use as screening guidelines with respect to medical appropriateness of healthcare services. All ultimate care decisions are strictly and solely the obligation and responsibility of your health care provider. © 2019 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved.

Overview

Informational Notes

The Adult and Geriatric Psychiatry Criteria are for the review of patients who are ages 18 and older.

InterQual® content contains numerous references to gender. Depending on the context, these references may refer to either genotypic or phenotypic gender. At the individual patient level, a variety of factors, including, but not limited to, gender identity and gender reassignment via surgery or hormonal manipulation, may affect the applicability of some InterQual criteria. This is most often the case with genetic testing and procedures that assume the presence of gender−specific anatomy. With these considerations in mind, all references to gender in InterQual have been reviewed and modified when appropriate. InterQual users should carefully consider issues related to patient genotype and anatomy, especially for transgender individuals, when appropriate.

InterQual® criteria are derived from the systematic, continuous review and critical appraisal of the most current evidence−based literature and include input from our independent panel of clinical experts. To generate the most appropriate recommendations, a comprehensive literature review of the clinical evidence was conducted. Sources searched included the Agency for Healthcare Research and Quality (AHRQ) Effective Health Care Program, American Psychiatric Association, American Academy of Child and Adolescent Psychiatry, American Psychological Association, American Society of Addiction Medicine, Centers for Medicare and Medicaid Services, Choosing Wisely, Cochrane Library, National Institute of Alcohol Abuse and Alcoholism, National Institute for Health and Care Excellence, National Institute on Drug Abuse, PubMed, Substance Abuse and Mental Health Services Administration, and other key medical societies. The Association of Ambulatory Behavioral Healthcare, Commission on Accreditation of Rehabilitation Facilities, and the Joint Commission were also searched. Other medical literature databases, medical content providers, data sources, regulatory body websites, and specialty society resources may also have been utilized. Relevant studies were assessed for risk of bias following principles described in the Cochrane Handbook. The resulting evidence was assessed for consistency, directness, precision, effect size, and publication bias. Observational trials were also evaluated for the presence of a dose−response gradient and the likely effect of plausible confounders.

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InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry PARTIAL HOSPITAL PROGRAM, One: (1, 2)  Episode Day 1, All:  Functional impairment, ≥ One: (3)  Eating disorder and discharge from authorized Residential Treatment Center within last 24 hours, Two: − Inconsistent use of learned coping skills − Lack of daytime structure − Minimizing consequences of symptoms − Unable to independently make appropriate food choices  Severe and change in baseline within last month, ≥ One: − Decision making or judgment poor − Does not recognize or acknowledge severe neglect of or dangerous living conditions − Frequent angry or irrational outbursts responsive to de−escalation or prn medication (4)  Job or school performance impaired, ≥ One: − Self−employed and unable to maintain business − Suspended or terminated − Unsafe to care for dependent children or vulnerable adults due to impaired judgement − Medical or psychiatric treatments or medication nonadherence (5) − Not engaging in or abrupt withdrawal from social interactions or activities (6) − Rapid deterioration in functional ability − Repetitive impulsive behavior that places self or other in harm − Resists needed assistance to perform or complete self care tasks  Unacceptable social behaviors, ≥ One: − Intrusiveness causing altercations with others − Restraining or protection order in place and continued stalking − Stable housing available − Support system able to provide required care and supervision during non−program hours (7, 8)  Symptom within last week, ≥ One:  Auditory hallucinations increasing and risk of dangerous behavior if continues, ≥ One: − History of physical harm to self or other attempted or completed within last 6 months (9) − Impaired judgement places patient at risk to harm self or others − Resistant to answering interview questions  Co−occurring substance use disorder and psychiatric symptoms worsening, Both: − Not at risk for severe withdrawal − Unable to refrain from substance use  Eating disorder, Both: (10)  Requires monitoring to prevent further deterioration in condition, ≥ One:  Need for external structure, ≥ One: (11) − Needs part−time external limits to prevent over−exercising (12) − Needs part−time external structure to prevent restricting behaviors and to gain weight − Needs part−time support from others to refrain from purging (13, 14) − Unable to break binge−purge cycle in outpatient or intensive outpatient treatment − Unable to stop use of substances to control or reduce weight while in outpatient or intensive outpatient treatment (15) − Preoccupied with intrusive or repetitive thoughts about eating or weight or body image greater than 3 hours per day (16)  Symptom, ≥ One: − Laxative abuse and diarrhea reported with each bowel movement (17) − Pregnant with weight of fetus less than 10th percentile based on ultrasound evaluation (18) − Purging 3 to 4 times daily (14) − Recent and continuing weight loss and weight greater than 75%(0.75) but less than or equal 85%(0.85) ideal body weight (17, 19) − Recent and continuing weight loss and BMI at least 16 but less than 18 (20) − Restricting or refusing food intake at 2 or more meals daily − Status post acute medical treatment for life−threatening complication of eating disorder  Hypomanic symptom increasing and risk of manic episode, ≥ One: − Decreased sleep and history of rapid cycling (21) − Pregnant

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InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry − Medication nonadherence and no history of rapid deterioration to mania (5, 22) − Obsessions about contamination or compulsive washing or cleaning behaviors (23) − Panic attacks multiple times daily or severe agoraphobia (24) − Persecutory delusions require clinical assessment and medication evaluation multiple times per week (25) − Placing self in unsafe situations during flashbacks or dissociative episodes − Psychomotor agitation (26) − Psychotic disorder and paranoia or suspiciousness worsening despite active engagement in intensive outpatient program and on medication (27) − Psychosis or hypomania requiring staff re−direction − Severe depressive symptoms (28) − Somatic delusions with repeated emergency department visits within last week  Suicidal or homicidal ideation and denies plan or intent, ≥ One: − Discharge from acute psychiatric inpatient within last 24 hours and continued hopelessness (29) − Insomnia moderate or severe (30) − Moderate or severe major depressive disorder (28, 31) − Recurrent thoughts of death or wanting to die − Recurrent thoughts of killing another − Weight loss, involuntary and persistent within last month due to psychiatric condition − Transportation available (32)  Treatment not expected to be successful in less intensive level of care, ≥ One: − Less intensive level of care attempted and unsuccessful − Requires intensive structured treatment and medical monitoring to prevent further deterioration in condition − Transfer from inpatient but remains unstable to function in community or has history of at least 3 inpatient admissions within last year (17)  Episode Day 2−15, One:  Symptom improved and discharge expected today, One: (33) − Patient or caregiver demonstrates ability to manage condition and condition does not require daily monitoring (see Outpatient criteria)  High risk of hospitalization or rehospitalization (see Intensive Outpatient Program criteria), Both: − Impairment in daily functioning − Symptoms moderate in severity (28)  Patient with severe and persistent mental illness or autism spectrum disorder or intellectual disability and lack of support (see Intensive Community−Based Treatment criteria), Both: (34) − Able to live in unsupervised residence within community − Unable to perform IADLs independently − In lieu of residential based care or patient homebound and requires skilled nursing care or assessment at least 1 time per week (see Home Care criteria)  Patient with severe and persistent mental illness or autism spectrum disorder or intellectual disability and lack of support (see Day Treatment Program criteria), ≥ One: − Able to live within the community − In need of ADL or IADL or vocational training  Symptom improving or expected to improve and not clinically stable for discharge, All:  Clinical finding within last 5 authorized program days, ≥ One: − Auditory hallucinations and difficulty resisting impulses  Co−occurring substance use disorder, ≥ One: − Moderate withdrawal symptoms requiring medical monitoring or management (35) − Severe cravings and difficulty applying coping skills (36) − Substance use  Depression severe, ≥ One: (28) − Hopelessness − Recurrent thoughts of death − Unable to think clearly or concentrate or make decisions (37)  Eating disorder, ≥ One: − Body image distortion (38) − Cognitive impairment (39) − Intense fear of weight gain or obesity

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InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry − Over−exercising when unsupervised − Preoccupied with intrusive or repetitive thoughts about eating or weight or body image greater than 3 hours per day − Purging behavior when unsupervised (14) − Restricting food − Uncontrolled ritualistic or compulsive eating behavior at some meals (40, 41) − Use of diet pills or stimulants or cocaine or amphetamine to reduce appetite (42) − Weight loss and BMI at least 16 but less than 18

(17,− Weight 19) loss and weight greater than 75%(0.75) but less than or equal to 85%(0.85) ideal body weight − Fire setting history and continued preoccupation − Homicidal ideation without intent (43)  Hypomania and associated symptom, ≥ One: − Distractibility (44) − Excessive involvement in activities with potential for painful consequences (45) − Flight of ideas (46) − Inflated self−esteem or grandiosity (47) − Racing thoughts (48) − Nonsuicidal self−injury (49) − Obsessions or compulsions interfering with attending program or groups on time − Placing self in unsafe situations during flashbacks or dissociative episodes  Poor impulse control, ≥ One: (50) − Brandishing a weapon (51) − Destruction of property − Physical altercation (52) − Psychomotor agitation or retardation (53)  Psychosis and associated symptom, ≥ One: − Delusions (54) − Disorganized behavior (55) − Disorganized thinking or speech (56) − Hallucinations (57) − Negative symptoms (58) − Paranoia (27) − Suicidal ideation without intent (59)  Functioning within last 5 authorized program days, ≥ One: − After−hours crisis intervention within last week (60) − Arrest − Eating disorder and unable to judge amount of food to eat at some meals  Interpersonal conflict, ≥ One: − Easily frustrated and frequent irrational or angry outbursts (4) − Threatening − Verbal hostility or physical altercation (52) − Maintaining hygiene only with frequent reminders or supervision

(61)− Poor or intrusive boundaries causing altercations with others and requiring frequent staff intervention − Psychiatric medication nonadherence and history of psychotic or bipolar or posttraumatic stress disorder (5, 62)

− Severe social withdrawal (63) − Unable to care for dependent children or vulnerable adults due to impaired judgement (64) − Unable to maintain adequate nutritional intake due to symptoms of psychiatric disorder (65)  Intervention within last 5 authorized program days, One:  Diagnosis other than eating disorder, All: − Clinical assessment at least 1 time per day (66) − Individual or group or family therapy at least 4 hours per day, at least 3 days per week (67) − Individualized treatment plan (68, 69) − Psychiatric or medication evaluation at least 1 time per week − Safety plan (70)  Eating disorder diagnosis, All:

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InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry − Clinical assessment at least 1 time per day (66) − Individual or group or family therapy at least 4 hours per day, at least 3 days per week − Individualized treatment plan and supervised activities (68, 71) − Nutritional assessment at least 1 time per week (72) − Psychiatric or medication evaluation at least 1 time per week − Weight measurement at least 1 time per week  Symptom worsening and more intensive level of care indicated, One: (73) − Acute danger to self or others or gravely disabled and requiring nursing observation and psychiatrist availability 24 hours per day (see Inpatient criteria) (74) − Co−occurring substance use disorder and withdrawal syndrome severe or life threatening (see InterQual® Substance Use Disorders Inpatient Detoxification criteria)  Exacerbation of severe symptoms and agrees to voluntary admission (see Residential Crisis Program criteria), All: − Does not require services of an acute inpatient − Requires 24 hour per day clinical monitoring − Severe and persistent mental illness or autism spectrum disorder or intellectual disability  Eating disorder symptom severe (see Residential Treatment Center criteria), Both: − Requires intensive structure treatment and medical monitoring to prevent further deterioration in condition − Treatment not expected to be successful in less intensive level of care  Patient with severe and persistent mental illness or autism spectrum disorder or intellectual disability and lack of support, One: − Unable to be safely and effectively managed within the community (see Residential Treatment Center criteria) − Unable to live independently and high risk of harm to self or others without intensive supervision within the community (see Supervised Living criteria)  Episode Day 16−X, Extended Stay, One:  Symptom improved and discharge expected today, One: (33) − Patient or caregiver demonstrates ability to manage condition and condition does not require daily monitoring (see Outpatient criteria)  High risk of hospitalization or rehospitalization (see Intensive Outpatient Program criteria), Both: − Impairment in daily functioning − Symptoms moderate in severity (28)  Patient with severe and persistent mental illness or autism spectrum disorder or intellectual disability and lack of support (see Intensive Community−Based Treatment criteria), Both: (34) − Able to live in unsupervised residence within community − Unable to perform IADLs independently − In lieu of residential based care or patient homebound and requires skilled nursing care or assessment at least 1 time per week (see Home Care criteria)  Patient with severe and persistent mental illness or autism spectrum disorder or intellectual disability and lack of support (see Day Treatment Program criteria), ≥ One: − Able to live within the community − In need of ADL or IADL or vocational training  Symptom improving or expected to improve and not clinically stable for discharge, All:  Clinical finding within last 5 authorized program days, ≥ One: − Auditory hallucinations and difficulty resisting impulses  Co−occurring substance use disorder, ≥ One: − Moderate withdrawal symptoms requiring medical monitoring or management (35) − Severe cravings and difficulty applying coping skills (36) − Substance use  Depression severe, ≥ One: (28) − Hopelessness − Recurrent thoughts of death − Unable to think clearly or concentrate or make decisions (37)  Eating disorder, ≥ One: − Body image distortion (38) − Cognitive impairment (39)

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InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry − Intense fear of weight gain or obesity − Over−exercising when unsupervised − Preoccupied with intrusive or repetitive thoughts about eating or weight or body image greater than 3 hours per day − Purging behavior when unsupervised (14) − Restricting food − Uncontrolled ritualistic or compulsive eating behavior at some meals (40, 41) − Use of diet pills or stimulants or cocaine or amphetamine to reduce appetite (42) − Weight loss and BMI at least 16 but less than 18

− Severe social withdrawal (63) − Unable to care for dependent children or vulnerable adults due to impaired judgement (64) − Unable to maintain adequate nutritional intake due to symptoms of psychiatric disorder (65)  Intervention within last 5 authorized program days, One:  Diagnosis other than eating disorder, All: − Clinical assessment at least 1 time per day (66) − Individual or group or family therapy at least 4 hours per day, at least 3 days per week − Individualized treatment plan (68, 69) − Psychiatric or medication evaluation at least 1 time per week − Safety plan (70)

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InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry  Eating disorder diagnosis, All: − Clinical assessment at least 1 time per day (66) − Individual or group or family therapy at least 4 hours per day, at least 3 days per week − Individualized treatment plan and supervised activities (68, 71) − Nutritional assessment at least 1 time per week (72) − Psychiatric or medication evaluation at least 1 time per week − Weight measurement at least 1 time per week  Symptom worsening and more intensive level of care indicated, One: (73) − Acute danger to self or others or gravely disabled and requiring nursing observation and psychiatrist availability 24 hours per day (see Inpatient criteria) (74) − Co−occurring substance use disorder and withdrawal syndrome severe or life threatening (see InterQual® Substance Use Disorders Inpatient Detoxification criteria)  Exacerbation of severe symptoms and agrees to voluntary admission (see Residential Crisis Program criteria), All: − Does not require services of an acute inpatient − Requires 24 hour per day clinical monitoring − Severe and persistent mental illness or autism spectrum disorder or intellectual disability  Eating disorder symptom severe (see Residential Treatment Center criteria), Both: − Requires intensive structure treatment and medical monitoring to prevent further deterioration in condition − Treatment not expected to be successful in less intensive level of care  Patient with severe and persistent mental illness or autism spectrum disorder or intellectual disability and lack of support, One: − Unable to be safely and effectively managed within the community (see Residential Treatment Center criteria) − Unable to live independently and high risk of harm to self or others without intensive supervision within the community (see Supervised Living criteria)

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InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry Notes:

1: Introduction The Partial Hospital Program criteria are used for a patient who has been admitted or is expected to be admitted to a partial hospital program. A Partial Hospital Program (PHP) is a time limited, ambulatory treatment program that is offered in the day or evening hours. PHP is often referred to as acute day hospital. A PHP is a less restrictive alternative to inpatient for individuals presenting with acute symptoms of a severe psychiatric disorder, who cannot be effectively treated in a less restrictive level of care, and would otherwise require inpatient treatment (Association For Ambulatory Behavioral Healthcare, 2015 AABH standards and guidelines: partial hospitalization programs and intensive outpatient programs. 2015). Partial Hospital has been found to be as effective as inpatient for acutely ill psychiatric patients (Madden et al., World J Psychiatry 2015, 5: 147−53; Marshall et al., Cochrane Database Syst Rev 2011; (12): CD004026) and is considered an intermediate behavioral health level of care (Association For Ambulatory Behavioral Healthcare, 2015 AABH standards and guidelines: partial hospitalization programs and intensive outpatient programs. 2015). The goals of a PHP are to prevent or reduce the need for inpatient hospitalization or re−hospitalization following discharge from inpatient treatment and to reduce or stabilize symptoms and functional impairment of a psychiatric or co−occurring substance use disorder. Medically necessary treatment is provided within a structured therapeutic milieu. Evaluation and treatment Programming may differ based upon legislative and geographical variances and is subject to organizational policy; however, at a minimum it should include: • Care coordination with other care providers and social services (American Psychiatric Association, Am J Psychiatry 2007, 164(7 Suppl): 5−53; American Psychiatric Association, Practice guideline for the treatment of patients with eating disorders, third edition, 2006, p. 1097−222) • Clinical assessment at least once per program day • Individual or group or family therapy at least 4 hours per day, at least 3 days per week • Psychosocial assessment within first program day • Medication reconciliation initiated within first program day • Psychiatric or medication evaluation at least once per week • Substance evaluation within first 2 program days • Toxicology screen, self−help, 12−step, education group as needed (may be patient or family education group) For eating disorder patients, it is recommended that a patient attend a minimum of 5 days per week for 8 hours per day to ensure the most effective treatment response (American Psychiatric Association, Practice guideline for the treatment of patients with eating disorders, third edition, 2006, p. 1097−222).

2: Active attendance and participation are necessary for an individual to benefit from treatment (Association For Ambulatory Behavioral Healthcare, 2015 AABH standards and guidelines: partial hospitalization programs and intensive outpatient programs. 2015).

3: Partial hospital is appropriate for an individual with marked functional impairment in multiple areas of daily life (Association For Ambulatory Behavioral Healthcare, 2015 AABH standards and guidelines: partial hospitalization programs and intensive outpatient programs. 2015).

4: Angry outbursts can include, but are not limited to, punching a fist into the wall, throwing or smashing items, or tantrums of yelling and screaming.

5: Medication nonadherence refers to an unwillingness or inability of the patient, or their parents or guardians, to accurately or consistently follow a psychiatric medication regimen.

6: Increased social withdrawal refers to an observed significant decrease in a patient's interactions with others or to a patient's subjective feeling of not "fitting in" despite apparent social engagement with friends, family, and activities.

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InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry

7: The supervision and care required is dependent on the patient's symptom and the established symptom−specific treatment plan. Examples include, but are not limited to: • Eating disorder symptoms − supervising during and after meals, assisting in monitoring food intake • Psychotic disorders − pouring and administering medication

8: The availability of an adequate support system is a prerequisite for partial hospital services (Association For Ambulatory Behavioral Healthcare, 2015 AABH standards and guidelines: partial hospitalization programs and intensive outpatient programs. 2015; Centers for Medicare & Medicaid Services (CMS), In: Medicare benefit policy manual. 2014).

9: A history of violence is among risk factors for predicting future violence (Lysell et al., J Clin Psychiatry 2014, 75: 127−32; Sturup and Lindqvist, Crim Behav Ment Health 2014, 24: 5−17; National Institute for Health and Care Excellence (NICE), Antisocial personality disorder. Clinical guideline addendum 77. 2013; Malphurs and Cohen, Am J Geriatr Psychiatry 2005; 13(3): 211−217; Campbell et al., Am J Public Health 2003; 93(7): 1089−1097). Apart from a psychiatric disorder diagnosis, contributing factors reported include a past history of criminal behavior, substance use and prior victimization (Witt et al., PLoS One 2013, 8: e55942; Amore et al., Psychiatry Clin Neurosci 2008, 62: 247−55).

10: A partial hospital program may be as effective as inpatient treatment and at a decrease in cost (Herpertz−Dahlmann et al., Lancet 2014, 383: 1222−9).

11: A Partial Hospital Program is recommended for eating disorder patients who require: • External limits to prevent over−exercising • External structure to prevent restricting behaviors and to gain weight • Support from others to refrain from purging Reference (American Psychiatric Association, Practice guideline for the treatment of patients with eating disorders, third edition, 2006, p. 1097−222).

12: External limits consist of interventions and limitations placed on physical activity or exercise by program staff

13: Support from others consists of supportive discussions with and/or interventions by program staff and/or peers at times when the patient is experiencing urges to purge or is demonstrating behavior that suggests urges to purge, e. g. heading to a bathroom immediately after a meal.

14: Purging refers to the methods patients with eating disorders use to rid themselves of food that has been ingested. Such methods include, but are not limited to, use of diuretics, laxatives, and enemas or self−induced vomiting.

15: Substances that individuals with eating disorders may use to control or reduce their weight include, but are not limited to, amphetamines, cocaine, diet pills, diuretics, herbal supplements, stimulants, and laxatives.

16: The American Psychiatric Association guidelines for the treatment of eating disorders indicate that preoccupation with repetitive thoughts about eating, weight, or body image for 4 to 6 hours daily or more is an indication for residential treatment (American Psychiatric Association, Practice guideline for the treatment of patients with eating disorders, third edition, 2006, p. 1097−222).

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InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry

17: Evidence in the medical literature to support the effectiveness of this intervention or service is mixed or unclear. The criteria point reflects current best evidence and practice. It is the product of a peer review process involving multiple clinicians with diverse expertise in varied practice and geographic settings.

18: Fetal weight less than 10th percentile based on ultrasound evaluation may be referred to as intrauterine growth restriction with fetal growth concern.

19: Ideal body weight (IBW) is a weight that is believed to be the maximum healthy weight for a person. It is based primarily on height, but can be modified by factors such as gender, age, body build, and degree of muscular development. No single formula for calculating IBW is universally employed. Multiple calculators of IBW can be found online which calculate IBW based on just height, or based on height, age, and gender. Utilizing the same calculation for all cases will ensure consistent application of the criteria. Organizational policy determines which calculation should be used to determine IBW.

20: Body mass index (BMI) is a measure of body mass and is calculated with the formula (weight [in Kg] / height [in meters]2). The Centers for Disease Control and Prevention (CDC) provides an online BMI calculator at www.cdc. gov/nccdphp/dnpa/healthyweight/assessing/bmi/index.htm (National Center for Chronic Disease Prevention and Health Promotion, Body mass index. 2015.). Individuals with body mass indexes of less than 18.5 are considered to be underweight (National Center for Chronic Disease Prevention and Health Promotion, Body mass index. 2015.).

21: Rapid cycling is defined as having four or more mood disturbances within a year (American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder, second edition. 2006; p. 851−944.)

22: For patients with a history of rapid deterioration to mania refer to the Residential Crisis Program level of care.

23: In a descriptive study of patients with severe OCD, the only symptoms consistently associated with severe impairment were obsessions about contamination and compulsive washing or cleaning (Jacoby et al., Compr Psychiatry 2014, 55: 1195−202). Although hoarding behavior can present health and safety risks, the use of intense, highly structured levels of care has not demonstrated success in treating this condition (Brennan et al., J Psychiatr Res 2014, 56: 98−105).

24: Partial hospitalization may be indicated for an individual with severe agoraphobia (American Psychiatric Association, Practice guideline for the treatment of patients with panic disorder, second edition. 2009).

25: Persecutory delusions may increase the risk of violence in an adult population (Keers et al., Am J Psychiatry 2014, 171: 332−9; Swanson et al., Archives of general psychiatry 2006, 63: 490−9).

26: Psychomotor agitation is excessive motor activity in association with an inner feeling of tension. The activity is usually repetitive and nonproductive (e.g., pacing, fidgeting, wringing of hands, inability to sit still).

27: Paranoia refers to extreme suspiciousness or the false belief that one is being harassed, harmed, persecuted, or unfairly treated. Paranoid individuals may interpret the environment as being hostile when it is not. Examples of

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InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry paranoia are fear of poisoning, concerns that one is being followed by or investigated by the police, and concerns that staff members may be agents of the devil. If these thoughts evolve into beliefs that are fixed and the patient does not respond to rational explanations, these thoughts qualify as delusions.

28: Symptom severity refers to the DSM−5 level of severity rating (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, fifth edition. 2013).

29: Hopelessness is a key risk factor for attempted and completed suicide (Hawton et al., J Affect Disord 2013, 147: 17−28; The Assessment and Management of Risk for Suicide Working Group, VA/DoD clinical practice guideline for assessment and management of patients at risk of suicide. 2013; Hayashi et al., BMC Psychiatry 2012, 12: 186; Links et al., Gen Hosp Psychiatry 2012, 34: 88−97; Lejoyeux et al., Arch Suicide Res 2008, 12: 30−8; American Psychiatric Association. Practice guideline for the treatment of patients with schizophrenia, second edition. 2006; p. 565−762.; Kapur et al., J Clin Psychiatry 2006, 67: 1599−1609; Hawton et al., Br J Psychiatry 2005; 187: 9−20; Hawton et al., J Clin Psychiatry 2005, 66: 693−704; Maser et al., Suicide Life Threat Behav 2002; 32(1): 10−32; Malone et al., Am J Psychiatry 2000; 157(7): 1084−1088; Beck et al., Am J Psychiatry 1990; 147(2): 190−5; Fawcett et al., Am J Psychiatry 1990; 147(9): 1189−1194; Ross et al., Prev Med 1990; 19(3): 323−334).

30: Sleep disturbances, particularly insomnia, are independent risk factors for suicide (Kodaka et al., Sleep Med 2014, 15: 430−5; Winsper and Tang, Int Rev Psychiatry 2014, 26: 189−204; Malik et al., Syst Rev 2014, 3: 18; Nadorff et al., J Gerontol B Psychol Sci Soc Sci 2013, 68: 145−52; Pawlak et al., Gen Hosp Psychiatry 2013, 35: 427−32; The Assessment and Management of Risk for Suicide Working Group, VA/DoD clinical practice guideline for assessment and management of patients at risk of suicide. 2013; Pigeon et al., J Clin Psychiatry 2012, 73: e1160−7; Bolton et al., J Clin Psychiatry 2008, 69: 1139−49; Schneider et al., Eur Psychiatry 2001; 16(5): 283−288; Turvey et al., Am J Geriatr Psychiatry 2002; 10(4): 398−406; Rey Gex et al., Acta Psychiatr Scand 1998; 98(1): 28−33; Fawcett et al., Am J Psychiatry 1990; 147(9): 1189−1194; Pokorny, Arch Gen Psychiatry 1983; 40(3): 249−257).

31: Depression is a major risk for self−harm and suicide, particularly in the elderly (Draper, Maturitas 2014, 79: 179−83; Hawton et al., J Affect Disord 2013, 151: 821−30; Wiktorsson et al., J Affect Disord 2011, 134: 333−40).

32: Available transportation includes either the patient's ability to drive, walk, or access public transportation to come to treatment or the ability of family, friends, or the treatment facility to transport the patient.

33: Selection of this criteria point indicates that the patient is responding to treatment and is clinically stable for discharge to an alternate level of care. To determine the most appropriate level of care go to the recommended level of care.

34: The term "severe and persistent mental illness," also called "serious and persistent mental illness," refers to a mental illness that is characterized by severe symptoms of prolonged duration that require long−term treatment. The illness causes impaired functioning that interferes significantly with primary activities of daily living and results in an inability to maintain independent functioning without treatment, support, and rehabilitation for a prolonged or indefinite period of time. Examples include, but are not limited to, schizophrenia and other psychotic disorders, bipolar disorder, and severe cases of major depression. Substance use disorders without a co−occurring mental illness is not included (Administration, Federal Register − Notices. 1993).

35: Moderate withdrawal symptoms are those symptoms which are not life threatening but present extreme discomfort to a patient. Examples that may require medical monitoring or management include, but are not limited to, intermittent nausea and dry heaves; moderate tremors; moderate anxiety or paranoia; and fluctuating vital signs.

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36: An individual who has decreased or difficulty applying adequate coping skills may be unable to apply skills including, but not limited to, distraction, relaxation, self−assertion, imagery, avoidance, good problem−solving or refusal skills, use of support systems, conflict resolution, and anger management.

37: Unable to think clearly or concentrate refers to the patient's inability to focus attention or to be goal−directed.

38: Many patients with eating disorders become preoccupied with a distorted perception of their body weight and shape, often considering themselves overweight or "fat" when in fact they are emaciated. Other patients may realize they are thin but experience a distorted perception of particular body areas such as the abdomen, buttocks, or thighs. This distorted body image can reach delusional status in patients with severe eating disorders.

39: Studies of patients with eating disorders have shown neuropsychological effects that impair attention and concentration, visual associative learning, visuospatial abilities, problem−solving, and attentional−perceptual motor functions. In addition, such effects are evidenced by psychomotor slowing, poor planning, and lack of insight (American Psychiatric Association, Practice guideline for the treatment of patients with eating disorders, third edition, 2006, p. 1097−222).

40: Symptoms are considered to be uncontrolled when they persist despite therapeutic and/or pharmacologic interventions.

41: Rituals formed around food and eating are common in individuals with eating disorders and examples include, but are not limited to, excessive chewing but refusal to swallow food, cutting food into excessively small pieces, hoarding of food, excessive food preparation for others, and food ingestion in a particular manner or pattern.

42: This behavior may be observed during program hours, may be observed during non−program hours and reported by family or support system, or may occur during non−program hours and be self−reported.

43: Homicidality requires careful assessment, which may lead to a duty to protect or warn potential victims and/or a need to involve law enforcement.

44: Distractibility refers to the inability to sustain attention. The patient's attention shifts quickly, with little apparent reason, from one topic to another, or the patient is attracted to irrelevant and trivial stimuli in the environment.

45: Patients who are manic or hypomanic may exhibit an inability to control their pursuit of, or involvement in, activities despite the potential for significant negative consequences. Behaviors often include excessive overspending (e.g., shopping sprees or large purchases), stealing, random sexual liaisons or extended sexual encounters with single or multiple partners, or exercising to the point of total exhaustion.

46: Flight of ideas refers to racing thoughts punctuated by abrupt changes from topic to topic. Frequently, speech becomes disorganized and incoherent.

47:

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InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry Grandiosity refers to the inflated sense of one's own value, power, knowledge, abilities, identity, or importance.

48: Racing thoughts can be described as thoughts that are "sped up" in one's head, or thoughts that are moving so fast that the person cannot hold on to them long enough to report the content.

49: Nonsuicidal self−injury is the intentional damaging of any part of one's body (e.g., cutting or burning the skin) without suicidal intent.

50: Poor impulse control refers to the inability of an individual to resist an urge or an impulse to engage in behavior that may be excessive or potentially dangerous to themselves or others (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, fifth edition. 2013).

51: Brandishing a weapon is to be distinguished from attempting to assault someone. Brandishing may include carrying or showing a weapon to intimidate others or to increase the perception of one's importance and power.

52: A physical altercation is an attack on another individual that may result in bodily harm.

53: Psychomotor agitation refers to excessive motor activity in association with an inner feeling of tension. The activity is usually repetitive and non−productive (e.g., pacing, fidgeting, wringing of hands, and the inability to sit still). Psychomotor retardation refers to a generalized and excessive slowing of movement and speech.

54: Delusions are false beliefs that do not conform to reality and are not affected by clear evidence to the contrary.

55: Disorganized behavior refers to non−goal−directed or purposeless behavior including, but not limited to, aimlessness, inability to start or complete a task, or sequencing problems.

56: Disorganized thinking is evident when the listener cannot understand how or why the patient has moved from one topic to the next. There is little or no meaningful relationship between ideas, topics, or themes. This can range from being "derailed" or "off−track" to tangential or incoherent speech. Speech is not only evaluated for coherence but for rate, volume, and pressure.

57: A hallucination is a sensory perception that occurs without external stimulation of the sensory organ (e.g., vision, hearing, touch, taste, smell). Patients may or may not be able to distinguish between the hallucination and reality. Types of hallucinations are: • Auditory: a false perception of sound, typically voices that are experienced as coming from either inside or outside of one's head and are different from one's own thoughts. Command hallucinations consist of a false perception of a voice telling the patient to do something, typically destructive to oneself or others • Gustatory: a false perception of taste, usually unpleasant • Olfactory: a false perception of smell, usually unpleasant • Somatic: a false perception of a physical experience within the body • Tactile: a false perception of being touched or of something on or under the skin (e.g., bugs crawling) • Visual: falsely perceived images, either formed (e.g., people) or unformed (e.g., flashes of light)

58:

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InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry Negative symptoms may include: • Alogia, or lack of thoughts or words (often referred to as poverty of speech) • Anhedonia, a lack of enjoyment in activities previously found pleasurable • Apathy, which refers to a lack of motivation, restricted emotional and cognitive engagement, and diminished purposeful behavior • Asociality, which refers to a lack of interest in social interactions • Avolition, which refers to the inability to initiate or sustain goal−directed activity • Decreased range and intensity of emotional expression

59: Suicidal ideation includes not only active ideation that entails serious thoughts and/or plans to commit suicide but also passive ideation without an active plan, intent, or means. Passive ideation can present as a recurrent wish to die, or thoughts of dying in one's sleep.

60: After−hours crisis intervention may include, but is not limited to, contact with a primary behavioral health clinician, a police intervention, an emergency department visit, a mobile crisis intervention or frequent contact with on−call program staff.

61: A patient who displays poor or intrusive boundaries has difficulty maintaining personal physical space, frequently interrupts and asks inappropriate questions, or exhibits interactions or behaviors that are inappropriate for the situation. These patients frequently require staff redirection and reminders regarding appropriate interactions.

62: Individuals diagnosed with schizophrenia who do not adhere to recommended medication regimens appear to have an increased risk of relapse, hospitalization, readmission or suicide attempts (Novick et al., Psychiatry Res 2010, 176: 109−13; Janssen et al., Psychopharmacology (Berl) 2006; 187(2): 229−36; Gilmer et al., Am J Psychiatry 2004; 161 (4): 692−699).

63: Social withdrawal is evident when the patient stops interacting with family, friends, fellow employees, acquaintances, or even strangers because of symptoms of their disorder. Examples of a patient with severe social withdrawal include, but are not limited to, the patient not responding to questions, locking himself/herself in a room, or covering room windows so others can't look inside.

64: A patient may be deemed neglectful or unable to meet the needs of dependent children or vulnerable adults when such a dependent is placed in an unsafe situation. Unsafe situations involve exposure to health and environmental risks and include lack of food or medical care, living in squalor, and exposure to the use of illegal substances. The patient is unable to perform the responsibilities of caregiver due to the psychiatric or substance use disorder.

65: Impaired nutritional status may be the result of the patient's inability to tolerate food or the refusal to eat due to the severity of psychiatric symptoms (e.g., depression, hallucinations, delusions, mania, or anxiety).

66: Clinical assessment by a multidisciplinary team is an essential part of stabilizing a patient in a partial hospital program. A clinical assessment by the primary therapist or nursing staff should be performed each program day the patient is in attendance. Additional clinicians such as substance use disorder counselors, occupational therapists, movement therapists, and art therapists are frequently involved in the treatment planning.

67: Cognitive behavioral therapy (CBT) was found to not be effective in the treatment of clozapine−resistant schizophrenia (Morrison et al., Lancet Psychiatry 2018:) and CBT did not improve the long−term relapse rates of

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InterQual® 2019, Rev. 1 BH:Adult and Geriatric Psychiatry Adult and Geriatric Psychiatry schizophrenics receiving standard care which included but was not limited to the treatment of schizophrenia with the use of antipsychotic medication (Jones et al., Cochrane Database Syst Rev 2018, 12: CD007964).

68: Each patient should have an individualized goal−directed treatment plan. The plan should clearly articulate the primary problems for which the patient presents and interventions specific to the reduction or resolution of those problems.

69: The individualized treatment plan should include specific symptoms, functional impairment, medication, or safety concerns that require clinical monitoring on each program day.

70: A safety plan includes a list of coping strategies and available resources the patient can use during a crisis.

71: Activities that may need to be supervised include: • Bathroom use • Exercise • Meal planning and selection • Meals and snacks Supervision may be necessary to intervene with or prevent restricting at meals or with snacks, to prevent self−induced vomiting after meals or snacks (including preventing bathroom or shower access for a period of time after meals or snacks if necessary), or to intervene with or prevent excessive or compulsive exercising.

72: The nutritional assessment should be done by a dietician or nutritionist.

73: Selection of this criteria point indicates that the patient's symptom is worsening and may require a more intensive level of care. To determine the most appropriate level of care go to the recommended level of care.

74: Gravely disabled is a term that generally refers to an individual who, as a result of a psychiatric or substance use disorder, is in acute danger of serious physical harm due to an inability or failure to provide the essential human needs of food, clothing, shelter, and essential medical care. The individual lacks the capacity to make an informed decision concerning his/her need for treatment and lacks the support to provide needed care. Gravely disabled is a term most often used for the emergency involuntary commitment of an individual to an inpatient unit and the definition of gravely disabled may differ based on legislative and geographical variances.

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