PUMA Step-downs and Discharges QRG
Therapeutic Group Home (TGH) Admission template/requirements:
Scenario: Completing a pre-authorization review for the TGH LOC.
Effective Date: 12/01/2015
• Name/phone number of the requestor
| |
• Name/phone number of the legal guardian
| |
• Anticipated d/c plan with residence
| |
• Anticipated family involvement (willingness to participate)
| |
• History of inpatient stays/days/dates
| |
• History of outpatient treatment? Was it helpful? Why not?
| |
• Diagnosis (to include psych, SA, DD, medical)
| |
• Current medications
| |
• Medical History/special needs (who is the PCP)
| |
• Full scale IQ
| |
• History of OCDD involvement/status of referral (if applicable)
| |
• Risk factors (family history of MI, substance use, trauma, SI/HI, psychosis
| |
• Legal History and current legal issues
| |
• Compliance related issues
| |
• Current mental status with most recent psych eval (within the last 30 days)
| |
• Behaviorally measurable goals/expected outcomes from the TGH stay
| |
• Has a room & board provider been identified:
For additional days requested:
• Specific and measurable goals
| |
• Progress
| |
• D/C plan
| |
• Why is lower LOC not appropriate
| |
• Support system involvement
| |
• Coordination of care
| |
-----------------------
1
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.