2. Medical Classification Care Levels.pdf

Attachment 002: Medical Classification – Care Level RRMB – Healthcare Delivery Services

Care Level I

Concept:

Adults in custody (AIC) are generally healthy but may have limited medical conditions that can be easily managed by clinical evaluations every 6 months. Needed subspecialty care is limited

(not regularly required and completed in < 3 months). AICs with mental health conditions are stable and require chronic care appointments and/or individual psychology or health services contacts no more frequently than every 6 months. If more acute services are required, such as crisis intervention, such episodes are short-lived (i.e., less than 3 months duration, and occur no more frequently than every 2 years) and resolve without the need for hospitalization.

Demographic Criteria:

Age < 70 years

Functional Criteria:

• Independent in ADLs and capable of doing physically demanding work assignments

(AICs can be physically disabled, but access to wheelchair or simple adaptive devices make the AIC independent in ADLs; may need limited assistance from AIC companions).

• No history of severe mental illness, self-mutilation or repeated suicide attempts (If mental health condition is present it does not impair AIC's ability to function socially, cognitively, or occupationally.)

Diagnostic Criteria:

• Hyperlipidemia with less than three cardiac risk factors and no CVD or PVD

• Hypertension easily controlled with simple regimen

• CAD - no diagnostic or clinical evidence of significant CAD that warrants treatment

• Mitral valve prolapse without clinically significant mitral insufficiency

• Asthma - mild, intermittent disease, pm bronchodilators only, never hospitalized for asthma

• Diabetes -controlled by diet, i.e., not requiring medications

• GERD or dyspepsia or peptic ulcer disease or hiatal hernia - easily controlled

• Diverticulosis and irritable bowel syndrome without complications

• Gall bladder disease without complicating factors

• Tuberculin skin test -positive requiring treatment for latent TB infection

• Tuberculosis -history of active TB disease adequately treated

• Hepatitis B or C with persistently normal ALT levels and no other evidence of liver disease

• HIV infection -asymptomatic with CD4+ T-cell count> 500 with undetectable viral load

< 50 cps/mL and not treated with medications

• Benign prostatic hypertrophy or acute or chronic prostatitis

• Kidney stones > 1 year ago

• Chronic headaches, including migraine

• Chronic musculoskeletal pain, such as osteoarthritis - not affecting ADLs

• Cancer - cured - no further monitoring required

• Benign skin lesions or easily resected malignancies resulting in cure, e.g. basal cell CA

• Fibrocystic disease of breast, uterine fibroids (asymptomatic)

• Mild menstrual disorders such as irregular menses, endometriosis, and hx of

Hysterectomy

• Eye problem affecting vision, but AIC can perform ADLs and does not require ongoing care from optometrist/ophthalmologist

• Depression or other mental health condition that is easily controlled by single medication

Care Level II

AICs are stable outpatients that have chronic illnesses that require at least quarterly clinician evaluations and are independent in ADLs. AICs with mental health conditions can be managed through chronic care clinics and/or individual psychology or health services contacts no more frequently than monthly to quarterly. If more acute services are required, such as crisis intervention, such episodes are short-lived (i.e., less than 3 months duration, and occur no more frequently than every 2 years) and resolve without the need for hospitalization.

• Any age

• Independent in ADLs and capable of doing multiple work assignments, however, may not be able to perform certain physically demanding tasks due to chronic illness. (AICs can be physically disabled, but access to wheelchair or simple adaptive devices make the

AIC independent in ADLs; may need regular assistance from AIC companions.)

• Mental health conditions may affect AIC functioning, but any limitations are stable, i.e., non-progressive.

• Hypertension that is controlled or intermittently labile and requires quarterly clinician exams

• Hyperlipidemia with three cardiac risk factors or CVD or PVD

• CAD - asymptomatic with history of angina or MI, or with stable angina (symptomatic only with marked exertion)

• Atrial fibrillation or other nonmalignant cardiac arrhythmia without CHF or angina

• History of heart valve replacement, without chronic anticoagulation, stable and asymptomatic

• Mitral valve prolapse with mitral insufficiency without CHF

• CHF without impairments in ADLs

• Peripheral edema or chronic phlebitis of lower extremities

• Asthma - persistent asthma requiring chronic meds, but controlled without history of status, intubation, or hospitalization

• COPD or other lung disease that is stable, not requiring oxygen and not impairing ADLs

• Sleep apnea without history of serious complications; e.g., arrhythmia, heart failure

• Diabetes requiring medications - non-labile without significant complications

• Renal insufficiency -mild/nonprogressive

• Kidney stones during past year or recurrent symptoms

• Seizure disorder - stable on medications, no more than 1 seizure every 2 years

• Neurodisorders such as s/p CVA, mild Parkinsons - but completely independent in ADLs

• Hepatitis B or C infection that may require antiviral tx

• Liver disease or liver failure is manageable by quarterly clinician exams; MELD < 10

• HIV infection - with (1) CD4+ T-cell count < 500 but > 150 OR (2) > 500 CD4+ T-cells with detectable viral load

• Thyroid disease, gout, or other endocrine condition - requiring medications and quarterly exams

• Pregnancy (uncomplicated)

• Sickle cell anemia (no more than 1 crisis every 2 years)

• Cancer in sustained remission, no treatment required - but further monitoring required

• Chronic pain affecting ADLs but AIC requires no nursing assistance

• Systemic lupus, rheumatoid arthritis, or other connective tissue disease (CTD) requiring medications but without end organ damage or affect on ADLs

• Eye problem affecting vision requiring ongoing care from optometrist/ophthalmologist but AIC can perform ADLs

• Serious mental illness such as major depression or schizophrenia - (patient requires quarterly monitoring, but is functionally well-compensated

Care Level III

AICs are fragile outpatients with conditions that require frequent clinical contacts (daily to monthly). AICs with chronic or recurrent mental illnesses or ongoing cognitive impairments which require frequent (daily to monthly) psychiatric/health services and/or psychology contacts to maintain outpatient status. AICs may require assistance in performing some ADLs, but do not require daily nursing care. Such assistance may include the regular services of AIC companions.

Stabilization of the AIC's medical or mental health condition may periodically require hospitalization.

• No age restrictions

• AIC is limited in ability to perform ADLs (including disabled AICs); however, daily nursing care or skilled nursing care is not required. May work if medically cleared.

• CAD with angina on minimal exertion; affects ADLs

• Atrial fibrillation or other nonmalignant cardiac arrhythmia with CHF or angina but does not require oxygen or daily nursing care

• History of malignant arrhythmia, cardiac arrest, pacemaker, or implantable defibrillator, but no arrhythmia during past year (stable)

• History of heart valve replacement with chronic anticoagulation or with symptomatic insufficiency of the prosthetic valve

• Mitral insufficiency with CHF (NYHA > II)

• Aortic stenosis without angina or syncope, but which will likely require surgery during incarceration

• CHF from any cause significantly limits ADLs (NYHA class III), but does not require oxygen or daily nursing care

• Asthma - poorly controlled on a chronic basis with a history of status asthmaticus, intubation, or recurrent hospitalization

• COPD or other lung disease that significantly limits ADLs, but does not require oxygen or daily nursing

• Sleep apnea with history of complications; e.g., arrhythmias, heart failure

• Diabetes that is markedly labile despite at least twice daily fingerstick glucose monitoring, or complicated by significant cardiac disease, renal disease, or retinopathy, or glycated hemoglobin > 10 despite 12 months of appropriate tx in a compliant patient

• Chronic pancreatitis

• Inflammatory bowel disease, Crohn’s or ulcerative colitis (active/uncontrol1ed on meds)

• Renal insufficiency - progressive (GFR < 20)

• Liver disease (MELD 15 -30) and/or recurrent ascites, GI bleeding or intermittent encephalopathy, AND not requiring skilled nursing care

• HIV infection with CD4+ T-cell count < 150 but otherwise stable; on or off meds

• Sickle cell anemia (crisis yearly or more frequently)

• Hematopoietic disorder with stable blood counts: e.g., polycythemia vera, myelofibrosis

• Chronic anticoagulation from any indication

• Seizures poorly controlled on medications - seizures every three months or more frequently

• Neurologic disorders such as dementia, Parkinson’s disease, s/p CVA, paralysis, and multiple sclerosis that limit ADLs but can be managed in outpatient setting without daily nursing care

• Systemic lupus, RA, or other connective tissue disease requiring medications and causing end organ damage or significantly affecting ADLs but not requiring daily nursing care.

• Cancer in recent remission (< 1 year) or at risk of relapse requiring close monitoring

• Organ transplant recipients (> 1 year) that are stable without evidence of organ rejection

• Chronic mentally ill requiring the structured outpatient treatment of a STEPDOWN

UNIT.

Care Level IV

AIC requires services available at a MRC and may require daily nursing care. Mental health conditions are acute or chronic and have resulted in severe impairment of functioning. Current symptomology or treatments require 24-hour skilled nursing care or nursing assistance.

• No age criteria

• AIC is limited in ability to perform ADLs and requires 24 hour skilled nursing care or nursing assistance (Disabled AICs are not independent in ADLs and require ongoing nursing assistance or have unstable medical or mental health conditions.) May work if medically cleared.

• CAD with unstable angina

• Atrial fibrillation or other nonmalignant cardiac arrhythmia with CHF or angina requiring oxygen and/or daily nursing care

• History of malignant arrhythmia, cardiac arrest, pacemaker, or implantable defibrillator with ongoing arrhythmias or unstable cardiac status

• Aortic stenosis with any symptoms of CHF, syncope, or angina

• CHF from any cause affecting ADLs and requiring oxygen or daily nursing care

• COPD or other lung disease that requires oxygen or daily nursing care

• AICs requiring chronic mechanical ventilation

• Renal failure - requiring dialysis now or in the near future

• Liver disease (MELD> 30) or requiring skilled nursing care

• HIV infection with CD4+ T-cell count < 50 or refractory to treatment

• Pregnancy (complicated)

• Hematopoietic disorder with unstable blood counts: e.g., polycythemia vera, myelofibrosis

• Sickle cell anemia with end organ damage

• Cancer requiring treatment: chemotherapy, radiation therapy, or palliative care

• Organ transplant recipients (< 1 year) or any evidence of rejection/complications

• Neurodisorders such as dementia, Parkinson’s disease, s/p CVA, paralysis, and multiple sclerosis that requires daily nursing care or skilled inpatient nursing care

• Chronic pain requiring invasive/special procedures or pain-specialist management

• Systemic lupus, RA, or other CTD markedly affecting ADLs and requiring daily nursing care

• Eye problem affecting vision and ADLs. AIC requires daily nursing assistance.

• Candidate for surgical intervention or rehabilitation provided at the MRC or more cost effectively at the MRC

• AICs requiring subacute or long-term medical inpatient care

• AICs with major mental illness requiring inpatient care, ECT, or intensive monitoring.