BH TRP Attachment 3 EPIA Protocol 3.pdf

The Commonwealth of Massachusetts

Executive Office of Health and Human Services Department of Mental Health – Department of Public Health – Office of

MassHealth and the Executive Office of Housing and Economic Development - Division of Insurance

Expedited Psychiatric Inpatient Admission Protocol 3.0

EPIA 3.0

June 28, 2021

Escalation Protocol for Securing Appropriate Placement for Individuals Boarding in Emergency Departments who require Inpatient Psychiatric Hospital Level of Care

Table of Contents

Boarding of Persons in Emergency Departments (EDs)

Expedited Psychiatric Inpatient Admissions Protocol Principles

Guiding Principles for Bed Search Efforts

Steps of Escalation

1. First 24 hours from a patient’s arrival to an ED

2. If an admission has not been procured by 24 hours from a patient's arrival to an ED 7

3. If a placement has not been identified by 60 hours from a patient’s arrival to an ED

4. Individuals who are uninsured or have a Carrier not regulated by the Commonwealth

(DOI)

5. Active Role of ED Evaluation Team for patients without Insurance Carrier support 10

6. Active Role of the Inpatient Psychiatric Providers licensed by DMH

Summary for Insurance Carriers

Summary for Bed Search

Appendix 1: Standardized Admission Packet (the Packet)

Boarding of Persons in Emergency Departments (EDs)

Each day residents of the Commonwealth in need of inpatient psychiatric hospitalization wait in hospital emergency departments (EDs) for extended periods of time, known as ED boarding. For those waiting for a bed in psychiatric hospitals and units, if there is not a plan in place for them after 24 hours in the ED, there needs to be additional steps to facilitate their admission.

The Executive Office of Health and Human Services (EOHHS), its Department of Mental

Health (DMH), Department of Public Health (DPH) and Office of MassHealth and the

Executive Office of Housing and Economic Development (EOHED) and its Division of

Insurance (DOI), are committed to addressing the ongoing crisis of ED boarding in the

Commonwealth and supports this Protocol that identifies and resolves barriers to psychiatric admission.

This Protocol is the product of an Expedited Admissions Task Force, charged by EOHHS

Secretary Marylou Sudders to establish clear steps and responsibility for escalating cases, where an admission has not been achieved in a reasonable period of time, to senior clinical leadership at Insurance Carriers, Inpatient Psychiatric Providers, and ultimately to DMH. The

Division of Insurance (DOI) issued Bulletin 2018-01: Prevention of Emergency Department

Boarding Patients with Acute Behavioral Health and/or Substance Use Disorders

Emergencies co-signed by DOI, DPH, and DMH. This collaboration continues and members of the Task Force work closely together to decrease the length of time behavioral health patients board in EDs waiting admission to an inpatient psychiatric hospital. This effort relies on early and continuous communication by all parties involved.

https://www.mass.gov/news/bulletin-2018-01-prevention-of-emergency-department-boarding-of-patients-with-acute-behavioral https://www.mass.gov/news/bulletin-2018-01-prevention-of-emergency-department-boarding-of-patients-with-acute-behavioral https://www.mass.gov/news/bulletin-2018-01-prevention-of-emergency-department-boarding-of-patients-with-acute-behavioral

Expedited Psychiatric Inpatient Admissions Protocol Principles

Emergency Departments (EDs) and the ED Clinicians including emergency service providers and mobile crisis intervention providers (hereafter referred to as the “ED

Evaluation Team”), Inpatient Psychiatric Providers, Insurance Carriers (commercial and public payers), and the responsible state oversight agencies (DMH, DPH, MassHealth and DOI), are all partners in, and share responsibility for, assuring that

Commonwealth residents in need of inpatient psychiatric hospitalization have access to services in a timely and geographically reasonable manner

ED Evaluation Teams have primary responsibility for identifying and securing inpatient psychiatric hospitalization for patients in psychiatric crisis who require that level of service, and must continue active and assertive efforts throughout the escalation process, particularly in assuring that clinical information is current and communicated, as described in the Protocol

There is an expectation that Inpatient Psychiatric Providers will comply with DMH clinical competencies (as required by 104 CMR 27.03(5)(a) and DMH Bulletin #19-01) and shall make every effort to admit a patient with special needs addressed by these clinical competencies, when there is an open bed

24 hours is the maximum threshold for a patient boarding in an ED to initiate escalation steps to obtain admission

At the 60 hour mark of an ED Boarding episode, DMH will receive escalation referrals and take geographic considerations, family preference, etc. into account but without further delay in procuring a bed

Any necessary authorization (for inpatient hospital level of care, 1:1 staffing or other specific needs associated with medical comorbidity such as high-cost medications and special equipment or resources) is provided and documented as soon as the need is known (See Division of Insurance Bulletin 2018-01 and Special Services

Coding Grid dated 8-02-19). This DOI guidance concerning specialing is expected to be incorporated into contracts between Inpatient Psychiatric Providers and

Insurance Carriers. If an Inpatient Psychiatric Provider identifies a need for such special services and the Insurance Carrier authorizes coverage, the facility is expected to admit the patient

• At the time of verbal authorization, Insurance Carriers should be able to provide written authorization, an authorization number, or other identification of services, so that if any issues occur during claims processing, the Inpatient

Psychiatric Provider is able to reference that specialing was authorized

• Insurance Carrier’s billing and payment policies should be updated to reflect how the Insurance Carrier’s specialing process works, how payment will be https://www.mass.gov/service-details/bulletins-0 https://www.mass.gov/info-details/expedited-psychiatric-inpatient-admission-epia https://www.mass.gov/info-details/expedited-psychiatric-inpatient-admission-epia made to Inpatient Psychiatric Providers and also includes the specialing codes established in the coding grid that are required by the plan

• Insurance Carriers must provide authorization of specialing as soon as the need is identified in order to reduce admissions wait time

Early and continuous communication between the ED Evaluation Team and the

Insurance Carrier throughout this process ensures that the most current information is available and that there is no duplication of effort in the bed search work

• This communication must be reciprocal; Insurance Carriers and ED Evaluation

Teams are expected to communicate as to the status of their efforts to secure admission as needed

• To ensure timely communication needed for the EPIA Protocol’s success, it is expected that ED Evaluation Teams and Insurance Carriers have an identified point person updated daily as well as use electronic means to communicate to avoid excessive delays with telephone or fax machine communication methods

• When the boarding individual is affiliated with a State Agency, the Agency should be contacted as soon as possible for information, care management, treatment plans, or special services to aid in a successful admission

Inpatient Psychiatric Providers, Insurance Carriers, ED Evaluation Teams and DMH

(along with other stakeholders) are expected to use the standardized Bed Search

Protocol that was developed with state agency and stakeholder consensus.

If the constraint to finding a hospital bed is an individual or family preference, this protocol will be activated, and the ED Evaluation Team will continue to work on acceptance at those preferred placements

• The ED Evaluation Team will also try to understand and alleviate any barriers that are limiting the scope of Inpatient Psychiatric Provider possibilities with the family

At any time after the decision is made that an individual requires hospital level of care, the Insurance Carrier should be notified immediately but no later than 24 hours into the boarding episode for assistance

• When it is clear that a placement will not be identified by 60 hours of boarding time, DMH may be consulted by the ED Evaluation Team or Insurance Carrier on a case-by-case basis for acceleration of the Protocol

All Insurance Carriers and ED Evaluation Teams must use Adobe Acrobat Reader DC for submitting a request for help to DMH using secure email on the DMH EPIA Webpage

If the request for inpatient placement is withdrawn or there is a level of care change or the ED Evaluation Team acquires a placement after escalating the case, these Protocols no longer apply and all relevant parties (Insurance Carriers, EDs, Parent/guardian, DMH) are notified about this change https://acrobat.adobe.com/us/en/acrobat/pdf-reader.html https://www.mass.gov/expedited-psychiatric-inpatient-admissions

Guiding Principles for Bed Search Efforts

The hospital where a patient is boarding should make every effort to prioritize and procure a bed within their hospital system’s network

The ACO/MCO for the boarding member should make every effort to prioritize and procure a bed within their hospital system’s network

Patients should be re-hospitalized by the same Inpatient Psychiatric Provider where they were most recently hospitalized to the maximum extent possible for continuity of care

The Insurance Carrier and/or EPIA establish a working partnership with the ED

Evaluation Team who referred a boarding patient to this escalation process as soon as possible

A standardized admission packet will be used for bed searches by all Inpatient

Psychiatric Providers – please refer to Appendix 1

Utilizing secure electronic transfer of clinical information is preferred

Inpatient Psychiatric Providers have 2 hours at maximum after they receive the complete admission packet to respond to an ED Evaluation Team, Insurance Carrier, or EPIA with their decision whether to admit a boarding patient

EPIA Protocol Escalation Steps

1. First 24 hours after ED arrival

a. Any time after a patient is admitted to the ED, the ED Evaluation Team may notify the appropriate person at the Insurance Carrier that one of their members is in the ED waiting for a psychiatric hospital admission

b. The Insurance Carrier will use its internal care management processes to determine if there is useful information for the ED Evaluation Team to assist with finding a bed

c. At any time after the decision is made to admit the individual to an Inpatient

Psychiatric Provider and no later than 24 hours from arrival to the ED, the ED

Evaluation Team notifies the Insurance Carrier with a Request for Assistance

2. If an admission bed has not been procured by 24 hours from a patient’s arrival to an ED

a. The ED Evaluation Team must make a formal Request for Assistance to the Insurance

Carrier if this has not already been done

b. Within two hours of the submission of a Request for Assistance by an ED Evaluation

Team during normal business hours, an employee of the Insurance Carrier will act on the request and initiate a process to facilitate the admission of the individual into an appropriate hospital

i. When a Request for Assistance is made outside of normal business hours (e.g.

after hours and on weekends or holidays), the Insurance Carrier shall acknowledge receipt of the Request no later than the morning of the next calendar day after the request is made, and shall proactively provide assistance

c. The Request for Assistance must provide the Insurance Carrier with clinical information about the individual, updated clinical information, barriers to admission, evidence of the bed searches to date, and a summary of responses from hospitals who have denied admission to the individual

d. The Insurance Carrier must work closely with the ED Evaluation Team point person to avoid redundancy in bed searches and to determine which hospital(s) is most appropriate to meet the needs of their member. Insurance Carriers must engage senior clinical and administrative officials at potential Inpatient Psychiatric Providers continuously until an admission bed is identified and agreed upon

i. The Insurance Carrier in discussion with Inpatient Psychiatric Providers proactively offers, determines and authorizes payment for required supports or resources (i.e., single room, extra staffing, high-cost medications for complex comorbid medical conditions etc.) when such supports or resources are determined to be needed by the Inpatient Psychiatric Provider who also has the capability to provide such specialized resources to allow for admission. All authorizations are documented and provided to the ED Evaluation Team and to the Inpatient Psychiatric Provider. A clear mechanism of how payment will be provided by the Insurance Carrier is included when making these specialing arrangements. When an Insurance Carrier authorizes these resources, the

Inpatient Psychiatric Provider is expected to accept the patient

ii. The Insurance Carrier must mitigate any authorization issues that are presenting barriers to a successful admission acceptance and shall provide documentation of such authorization to the Inpatient Psychiatric Provider in a timely manner

iii. If a specific Inpatient Psychiatric Provider considered most appropriate by the

Insurance Carrier to serve the individual does not have an immediate bed but will have one within the next 24-48 hours, the Insurance Carrier should seek to have the Inpatient Psychiatric Provider agree to prioritize the admission of the individual against the next discharge. However, the bed search continues and if another

Inpatient Psychiatric Provider is found to have a bed prior to the preferred Inpatient

Psychiatric Provider’s availability, that readily available bed should be secured for the patient should all parties agree

iv. If an in-network bed is unavailable, the Insurance Carrier should seek placement in appropriate out-of-network facilities (considering services required by the individual, geography, etc.)

v. The Insurance Carrier actively seeks to obtain admission of the individual until an inpatient bed has been secured. This includes a review of the updated clinical referral packets and ongoing discussion with senior leaders of the Inpatient

Psychiatric Providers to break down barriers to admission

vi. Once the Insurance Carrier has exhausted its network and appropriate out-of-network options, and when 60 hours of boarding time has elapsed and the individual still has not been accepted by an Inpatient Psychiatric Provider, the Insurance Carrier must escalate to DMH for assistance

vii. If at any time after the decision is made that an individual with co-occurring complexity requires psychiatric hospital level of care and it is clear that a placement will not be identified within 60 hours, Insurance Carrier (or, in the absence of an engaged Insurance Carrier, the ED Evaluation Team), may consult with DMH on a case-by-case basis for acceleration of the Protocol

viii. The Insurance Carrier is responsible for informing Inpatient Psychiatric

Providers considered appropriate to admit the individual that the process is being escalated to DMH

3. If an admission bed has not been identified by 60 hours from a patient’s arrival to an ED

a. The Insurance Carrier (or, in the absence of an engaged Insurance Carrier, the ED

Evaluation Team) MUST request assistance from DMH at 60 hours

b. The Insurance Carrier (or, in the absence of an engaged Insurance Carrier, the ED

Evaluation Team) MUST contact DMH by submitting an online referral using Adobe

Acrobat Reader DC, as directed by DMH

i. The Deputy Commissioner of Clinical & Professional Services or designee oversees the DMH team that ensures placement

ii. The Insurance Carrier or ED Evaluation Team designates a senior clinical administrator to communicate with DMH

iii. The internal DMH EPIA team will work with Insurance Carriers, ED Evaluation

Teams and Inpatient Psychiatric Providers to determine next steps to ensure that psychiatric admission for the individual is accomplished

c. DMH works with ED Evaluation Teams, Insurance Carriers and Inpatient Psychiatric

Providers to ensure up to-date information and clinical assessment is provided in a timely and effective manner until a bed becomes available

d. All parties involved agree to use the Standard Bed Search Protocol developed by the

EPIA Multi-Stakeholder Implementation Workgroup (attached)

e. DMH engages senior clinicians and administrators of Inpatient Psychiatric Providers, Insurance Carriers and ED Evaluation Teams, as indicated, to understand and resolve any barriers to admission

f. If State Agencies’ involvement is required to resolve barriers to admission, DMH will convene a conference call with the appropriate State Agency representatives, Inpatient Psychiatric Providers, Insurance Carriers and others as needed to resolve such barriers

g. When network adequacy and payment issues create barriers to admission, DMH facilitates a discussion with the Insurance Carrier, MassHealth and DOI as appropriate

h. Data collected from this process is reviewed on a regular basis by DMH

Licensing for use during regulated surveys for continuing licensure and as indicated

4. Individuals who are uninsured or have a Carrier not regulated by the Commonwealth

(DOI)

No individual boarding in an ED waiting placement by an Inpatient Psychiatric Provider will wait more than 60 hours before DMH has been notified, including those who are uninsured or who have coverage not regulated by DOI. This includes but is not limited to those who are:

a) Not insured and not eligible for MassHealth benefits

b) Not insured and eligible for MassHealth benefits

c) Insured by unmanaged Medicaid

d) Insured by unmanaged Medicare/Medicaid

e) Insured by a self-funded ERISA Plan

f) Insured solely by Medicare or

g) Insured through an out-of-state insurance carrier (commercial or Medicaid)

The ED Evaluation Team will continue its efforts to locate an appropriate placement and to engage the identified payer (if there is one) for assistance as outlined above. If these efforts are unsuccessful, the ED Evaluation Team MUST submit a Request for Assistance to DMH at 60 hours. If at any time, it becomes clear that an inpatient bed will not be identified within 60 hours, the ED Evaluation Team may consult with DMH on a case-by-case basis for acceleration of the Protocol.

5. Active Role of the ED Evaluation Team for those without Insurance Carrier Support

It is expected that the ED Evaluation Team’s clinical and administrative leadership play an active role during the daily (or more frequent) bed searches in the 60 hour period prior to submitting a request for DMH assistance.

a. The ED Evaluation Teams must have an Internal Escalation Protocol in place for any long-stay ED Boarding individual that involves ED Evaluation Team clinical and administrative leaders who will then escalate their search efforts to clinical and administrative leaders at the Inpatient Psychiatric Providers that have an available bed

b. This Internal Escalation Protocol is activated after the first 24 hours boarding in the ED

c. Protocols must be developed to assure active efforts to apply for MassHealth coverage for boarding individuals who may be eligible, including use of protocols for Hospital

Presumptive Eligibility if applicable

d. Use of the Standardized Bed Search Protocol is expected

e. Full escalation prior to DMH involvement at 60 hours includes but is not limited to involvement of the Hospital’s senior clinical and administrative officials (including the

ED Attending of record) where the individual is boarding

f. The Boarding Hospital’s senior administrators are expected to seek placement within their hospital system’s network to optimize these relationships on behalf of the boarding individual

g. The Boarding Hospital’s senior administrators will contact similar senior leadership at

Inpatient Psychiatric Providers with available psychiatric beds to advocate for their boarding patient’s admission

h. Escalation efforts will be documented and reported to DMH when escalated to DMH

i. ED Evaluation Teams must submit referral requests to DMH using Adobe Acrobat

Reader DC

j. This Internal Escalation Protocol applies to all individuals without an Insurance Carrier advocate

6. Active Role of the Inpatient Psychiatric Providers licensed by DMH

a. It is expected that all licensed Inpatient Psychiatric Providers maintain Admission Denial

Logs signed by Medical Directors or designee serving as the medical director who are consulted on all admission denials when there is a bed available

b. All inpatient units and facilities are expected to maintain a daily Unit Conditions log for review by DMH Licensing teams during scheduled and unannounced survey visits

c. The daily emails from EPIA listing those currently expedited to DMH must be reviewed and taken into account when considering admissions for the day as well as planning against next discharges

d. There should be an Inpatient Psychiatric Provider point person who is readily available to engage in timely discussions with ED Evaluation Teams, Insurance Carriers and the EPIA team concerning expedited ED Boarders

e. Adherence to the Bed Search Protocol developed by the EPIA Multistakeholder Implementation Workgroup is expected

Use of the standardized admission packet

Decision whether to admit or not within 1-2 hours of receiving a complete admission packet

Assurance that all denials were reviewed by the Medical Director or designee serving as the medical director prior to the decision to deny

Work to admit those patients deemed appropriate by the Inpatient Psychiatric Provider against next discharge

f. Regular admission of long waiting (14+ days) ED Boarding patients from the EPIA list should be prioritized and planned for by hospital leadership

g. Electronic communication of clinical information from ED Evaluation Teams, Carriers and EPIA is expected

Summary for Insurance Carriers

Member Insurance Proposed Process

MassHealth Involved

MassHealth managed care ED Evaluation Team Request for Assistance to Insurance Carrier by 24 hours

Senior administrative & clinical leaders are actively involved with bed finding

Insurance Carrier outreaches to DMH by 60 hours MassHealth non-managed care (FFS, HSN, duals)

ED Evaluation Team activates their Internal Escalation Protocol by 24 hours

ED Evaluation Team leaders outreach to DMH by 60 hours

Commercial Coverage

Insurance Carrier regulated by DOI ED Evaluation Team notification and Request for Assistance to Insurance Carrier before or by 24 hours

Senior administrative & clinical leaders are actively involved with bed finding

Insurance Carrier outreaches to DMH at 60 hours if individual is still boarding

Administrator for self-funded ERISA Plans not regulated by DOI

ED Evaluation Team Request for Assistance to appropriate Plan Administrator or Insurance Carrier by 24 hours

If Insurance Carrier will not engage in this protocol, the ED Evaluation Team continues to search for a bed and activates their Internal Escalation Protocol and

Escalates to DMH at 60 hours if the individual is still boarding

Out of state insurance carrier

Other Medicare Only The ED Evaluation Team makes active efforts to assist patients with application for MassHealth coverage starting at 24 hours; and/or, Continues to search for a bed and activates their Internal Escalation Protocol;

Requests help from DMH at 60 hours if still unplaced

Uninsured

Insurance in BOLD represents those in the standard protocol outlined.

Summary for Bed Search

Proposed Process

Bed searches are initiated with a phone call by ED Evaluation Team clinicians or their designee

General search for bed availability

- Meaningful Waitlist for Child/Adolescent and specialty units by Inpatient Psychiatric Providers is encouraged

Patient specific bed search

- Get DCF/DMH/DDS involvement as soon as possible if applicable

- Insurance Carriers advocate at senior administrative/clinical levels and work to decrease any perceived barrier to admission by Inpatient Psychiatric Providers

- Prioritize hospital network/system where the patient is boarding and/or the system where the patient receives their outpatient care (ACO/MCO)

- For boarding individuals with lapsed Medicaid, or are uninsured and applying for

MassHealth, ED Evaluation Teams are expected to work with MassHealth to expedite this re-insurance process

- If there is a family preference, only the packet and updated one page worksheets are sent to the preferred Inpatient Psychiatric Providers while continuing to work with family to enlarge the number of preferred Inpatient Psychiatric Providers

Begin Calling Inpatient Psychiatric Providers – outcome of calls:

Yes, there is a Bed Available

- Send complete Admission Packet for review (secure email or eFAX, if possible)

- Once a complete Admission Packet is received, the Inpatient Provider reviews and provides a clear Yes/No within one hour

- If Inpatient Psychiatric Provider determines that the case is complicated and requires internal escalation, a final determination about admission is made within an additional hour

- If the initial clinical presentation and/or unit conditions do not permit admission, provide a clear ‘No” and document in the Medical Director Log (per DMH regulations)

Maybe, Bed Available or opening up later in the day

- Identify the clinical barrier, acuity, or staffing issues that need addressed by the

Inpatient Psychiatric Provider to overcome hesitancy to accept

- May require communication with the ED Evaluation Team or others involved in the escalation (Insurance Carrier and/or EPIA) and the necessary transparency to resolve barriers

- Decision from the Inpatient Psychiatric Provider is received by COB; if patient presented after 3pm, by COB the next day

No, Bed Not Available, however:

- Based on initial clinical presentation, would this Inpatient Psychiatric Provider consider accepting the patient pending a discharge?

Yes – put on waitlist (only for C/A or Geriatric units) and provide more clinical information No – Provide a clear “No” from Inpatient Psychiatric Provider to ED Evaluation Team

Transmission of the Admission Packet only when requested by the Inpatient Psychiatric Provider based on phone call above

- Exceptions: any EPIA involved youth is expected to have their Admission Packet sent to all the child and adolescent Inpatient Psychiatric Providers and the daily one-page update until admission bed is procured

Acceptance for transfer to the Inpatient Psychiatric Provider

- Any Insurance Authorization needed, including authorization for any special services that are required to facilitate admission are completed prior to transfer

- Planned arrival time agreed upon with appropriate doctor to doctor and nurse to nurse communication before transfer

- Availability of parent or guardian to sign the Conditional Voluntary Admission legal status within 24 hours for youth under 18 years of age

- Notification of other participating stakeholders, as applicable

- Close the loop with all stakeholder advocates involved

Appendix 1: Standardized Admission Packet (the Packet)

The following demographics and clinical information do not need to be presented on the initial cold call but should be collected and provided to the Insurance Carrier and Inpatient Psychiatric

Providers (and to DMH if requested) pursuant to the escalation process:

1. Administrative Face Sheet (minimally includes full name, date of birth, insurance numbers and guardianship)

2. Comprehensive Evaluation (3-5 Pages)

a. Initial Evaluation

i. Diagnosis/Presenting Problems

ii. Clinical assessment and need for inpatient level of care

b. Medical Clearance

c. Current updated clinical information

i. Summary ED Course & any treatment provided

ii. Medications administered in the ED

iii. Behavioral response to medication administered

iv. High risk behaviors (substance use, etc)

v. Court involvement

vi. Family or other therapeutic interventions in ED

vii. Patient’s baseline

d. Current assessment and mental status exam (same day as bed search)

i. Requirement of any special services including but not limited to single room, 1:1, medical accommodation

ii. Disposition expected at the end of acute hospitalization (if applicable)

iii. Parent/guardian preferences (if applicable)

iv. Guardianship/Rogers (if applicable)

v. Agency involvement (if applicable)

vi. Collateral contacts (if applicable)

3. 24 Hour ED Course Summary/Update for each day in the ED since arrival (one page per day)