Concurrent Review

PhotoConcurrent review nurses and medical directors review and evaluate hospital admissions concurrently using nationally recognized criteria. Initial reviews are conducted within 24 hours or the next business day of admission. Subsequent reviews are conducted regularly at intervals which are dependent on the specific clinical condition being treated.

At each initial and subsequent review, the recipient's clinical information is evaluated to determine:

  • Appropriateness of the level of care
  • Estimated length of stay based on optimal recovery guidelines for the diagnosis
  • Planning needs for transfers to other facilities such as rehabilitation or skilled nursing facilities
  • Discharge planning needs such as:
    • Scheduled follow up visits
    • Home health care
    • Durable Medical Equipment (DME)
    • Rehabilitation therapy
    • Care management
    • Coordination of benefits from any other payers
    • Indications of any potential quality of care or utilization issues
    • The recipient's potential to benefit from Enhanced Care Coordination (ECC) following discharge

PhotoConcurrent reviews entail regular communication between facilities and concurrent review staff; daily delivery of the hospital's Medicaid census to SAMAI is expected either by fax or other means. Concurrent review staff focus subsequent concurrent reviews efforts only on those cases likely to benefit from timely information exchanges. This is done telephonically and gathers only those elements of clinical information necessary to ensure timely transition of care and discharge planning.