InterQual® Criteria

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The InterQual Criteria portfolio offers comprehensive clinical decision support designed to strengthen patient outcomes and reinforce appropriate utilization by providing access to evidence-based clinical criteria. Detailed decision support is delivered across the continuum of care through specialized modules organized into four content suites. The clinical criteria populating each module are updated at least once annually and are produced through a rigorous process grounded in the principles of evidence-based medicine. Criteria development is conducted by a clinical team that includes physicians, registered nurses, and allied health professionals. The team relies on systematic, critical appraisal of the medical literature using elements of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Draft criteria are subjected to systematic scrutiny by our InterQual Clinical Review Panel of more than 1,000 independent, multidisciplinary experts.

Assess

Provides healthcare organizations with the ability to prospectively, concurrently, and retrospectively assess clinical appropriateness.

Evaluate

Robust clinical detail allows organizations to evaluate severity of illness, comorbidities, and complications, as well as the intensity of services being delivered, to determine the most suitable and safest level of care.

Assist

The criteria also assist in discharge planning and care transitioning across the continuum.

Included Modules

InterQual® Acute Adult Criteria

The Acute Adult module helps clinicians evaluate the appropriateness of admission, continued stay, and discharge of acute care patients age 18 and older. Criteria are organized by primary condition presented in a single view that incorporates relevant complications, comorbidities, guideline standard treatments, proactive care management guidance, and length-of-stay benchmarks. By addressing the complete needs of each patient, the criteria facilitate movement of patients through the care continuum based on their condition and response to treatment. This integrated, holistic approach provides a powerful mechanism for decreasing inappropriate admissions, avoidable days, and readmissions.
InterQual® Acute Pediatric

The Acute Pediatric module helps clinicians determine the appropriateness of admission, continued stay, and discharge at acute care facilities for patients under 18 years of age. The module features the same condition-specific format as the adult criteria and also includes comorbidities and lengthof-stay benchmarks.
InterQual® Long-Term Acute Care

The Long-Term Acute Care module helps clinicians determine the appropriateness of admission, continued stay, and discharge for long-term acute care patients. This module includes responder and partial responder criteria to help clinicians adjust patient care time frames and interventions based on outcomes. It also offers guidance around discharge and transition planning for patients who no longer require skilled care or whose care can be safely managed in an outpatient setting or at a lower level of care.
InterQual® Inpatient Rehabilitation

The Inpatient Rehabilitation module helps clinicians determine appropriateness of admission, continued stay, and discharge at inpatient rehabilitation facilities for adult and pediatric populations. The module includes methods for addressing complications and setbacks associated with the onset of medical instability in a timely and medically appropriate way.
InterQual® Subacute and Skilled Nursing

The Subacute and Skilled Nursing module helps clinicians identify medical necessity and the most suitable level and complexity of care based on clinical need and stability. Guidance also is provided for discharge and transition planning. Clinical evidence supports the appropriateness of skilled treatments and services to ensure optimal care and to help organizations withstand audit scrutiny.
InterQual® Home Care

The Home Care module streamlines care management for patients who require services in the home setting. The criteria help determine the appropriateness of the initial review and ongoing service needs, visit recommendations, and discharge. The criteria address both adult and pediatric patients and include intermittent skilled home care services, private duty nursing, hospice, and palliative care needs.
InterQual® Rehabilitation and Chiropractic

The Outpatient Rehabilitation and Chiropractic module illuminates the most suitable level and complexity of rehabilitation and chiropractic care. The criteria help clinicians screen for the initial authorization and ongoing care needs and also provide guidance around discharge and transition planning to help avoid costly readmissions. Coordination in the outpatient rehab and chiropractic setting can help improve outcomes, minimize costs, and ensure timely transitions to appropriate levels of care.