Each Carrier is expected to have identified staff or departments that will be responsible to coordinate communications between the Carrier and the ED for the placement of patients requiring inpatient admissions. Carriers will maintain lists for use by all Massachusetts EDs of these identified staff or departments and the best methods to contact these persons.
When an individual being evaluated within an ED by an Emergency Services Provider ("ESP") or other ED staff member who determines that the individual requires an inpatient psychiatric hospital level of care and the patient is waiting for an inpatient bed more than 24 hours after arrival in the ED, the ESP/ED will notify the relevant Carrier that one of its members is still waiting for an inpatient bed at the 24-hour mark. At this point, the Carrier will cooperate with the ED to determine if there is useful information that can be provided to the ESP/ED in the placement process.
At any time after the decision to admit the individual to a psychiatric hospital level of care has been made, the ESP or ED may contact the Carrier with a Request for Assistance which will provide the Carrier with clinical information about the individual, barriers to admission, evidence of the bed searches to date and what individual psychiatric units said when asked to admit the individual. If this patient continues to be waiting in the ED by the 48-hour mark, then the ED/ESP is required to send a Request for Assistance to the Carrier. An appropriate person from the Carrier will respond to the ED's or ESP's Request for Assistance within a reasonable time- no later than two hours during normal working hours and no later than the next morning outside normal working hours -to identify that the Carrier is meaningfully engaged and to provide the name of the person who is coordinating the Carrier's activity to locate an acceptable hospital bed for the individual.
The purpose of the Request for Assistance is to engage the Carrier's help in determining the hospital(s) most appropriate to meet the needs of the member at that time and finding placement. The more targeted and specific the Request for Assistance is, the more efficient and effective the Carrier's response will be. As an example, the Request for Assistance can include the following information:
- Specific providers who may be willing t take the individual but require additional supports or resources
- A specific provider who does not have an immediate bed but will have one within the next 24 hours
- Authorization issues fr successful placement are required
- Out of network requests
- Notification that the Carrier needs to call specific providers for bed availability
Once a Request for Assistance is sent to a Carrier, the Carrier is expected to provide assistance, working with the ED/ESP to avoid duplication, in the placement of the Carrier's member in the appropriate inpatient bed with appropriate additional supports or resources needed by specific facilities to allow for admission. The Carrier will be expected to use its own internal escalation process in an active and strategic advocacy process, including senior leadership and/or medical directors where appropriate, when engaging with appropriate high-level clinical and administrative leadership within network hospitals. If the specific hospital that is deemed most appropriate for the patient does not have an immediate bed, but will have one within 24-48 hours, the Carrier will seek priority for this bed. If there are not any network hospital beds anticipated to be available within the 24-48 hours after receipt of the Request for Assistance, the Carrier will seek placement in appropriate out-of-network facilities.
Once a Carrier has exhausted its network options and has explored all appropriate out-of-network options, or after another 48 hours has passed and the Carrier's member has not secured a placement in an inpatient psychiatric level of care, the Carrier is required to make an appropriate contact to DMH. The Carrier is also responsible for informing hospitals deemed appropriate to admit the individual that the process is being escalated to DMH.
When a Carrier contacts DMH, the Carrier is to use a standardized template to explain the clinical status of the patient, all the actions that the ED/ESP and then the Carrier have taken to identify an appropriate placement, and any barriers that have prevented the patient from obtaining appropriate placement. The Carrier shall use the standardized template so that DMH has all necessary information to understand the status and be able to consider next steps. The Carrier's medical director or designee should also be available to discuss the patient's status and initiate a clinical conversation as needed. If a payment concern is discovered, a discussion between the Carrier and the Division shall take place in order to allow for resolution to allow for the appropriate placement of the patient.