Difference Between Utilization Management And Case Management

Policy analysis is an assessment of specific healthcare policy to determine its effectiveness in improving patient care outcomes. As an organization continues to grow in complexity; health status indicators provided gauges for process to be assessed and evaluated for restructuring. This provides new opportunities for evaluating policies, guidelines and procedures that enhances patient care to benefit all stakeholders. Transformational leaders are healthcare professionals whose knowledge and experience are required when policies analysis is needed that may require examination, designing, implementation, and evaluation for a practice change. In healthcare systems globally, transformational leaders are task with

Case managers also provide support and information to patients and their families. Next, is utilization review. `Its main objective is to review each case and determine the most appropriate level of services, the most appropriate settings in which the services be delivered, the most cost efficient methods for care delivery and the need for planning of subsequent care. Other methods used for utilization and control are choice restriction and practice profiling' (Douglas, 2003, p.328).

Case management services include coordination of health care services with the primary care physician, specialists, and other health care providers to better monitor and provide for a patient’s health care needs. The case managers help to assimilate information about community resources and Kaiser Permanente programs. They also provide disease management when needed. Case managers can assist the patient and their caregivers to understand the patient’s health coverage for medical equipment and services. They also assist with follow-up treatment plans after discharge. These case management services are delivered while maintaining the patient’s privacy, confidentiality, health,

Key People/Structures Dave Burton, & Brent James - Clinical Management System Design Linda Leckman – CEO Medical Group Nancy Nowak – Chief Nursing Officer Brent Wallace – Chief Medical Officer Guidance Councils – one for each of nine care areas – ensure CPMs are implemented Development Teams - developing of and responsibility for Clinical Process Models (CPM) Bill

Utilization management has taken a key role in the health reform act because it evaluates the need, appropriateness, and the efficiency of the health care services which will be used by the covered individual. Health insurance plans are pressured to find ways to reduce plan costs and improve the quality of care provided to their members. Utilization management efforts have reduced inappropriate services and high medical costs just by taking some time to review pre-authorizations instead of providing clinically inappropriate, out-of-network services which prevents the accurate care for patient and increases cost for plans. Today’s decision-making and support of utilizations for members are performed in real-time. Real-time utilization achieves the decrease of unnecessary expenses and improves member’s health. Use of unnecessary services increases the cost for plans and limits them on the amount of services they can provide to members who are in dire need of them.

Strategic leadership in healthcare is the act of transforming a health care organization so that its daily functioning matches the organization’s vision, core values, the cultures it serves, as well as organization’s culture, organizational climate and structure. In implementing strategic leadership, managers and healthcare executives can gain a greater sense of clarity in the changes that need to be made so that the organization can reach its full potential. Healthcare leaders can also make stronger connections internally and externally, with incorporating strategic leadership, to help the organization grow and expand the organization’s reputation, while contribute to the organization’s well-being.

In some way, Utilization Review (UR) can constitute “practicing medicine” because UR is an evaluated healthcare services based on standards of care, treatment guidelines, and evidence-base medicine (Wolter, Beeman, & Lynch, n.d.). The provider must address UR in the proposed decision. UR is a system designed for monitoring, evaluating and efficiency for services provided. UR should not be limited to only medical professionals licensed to practice medicine. Any provider, licensed or unlicensed, that plays a role in the patients care should be under UR. This will determine where the discrepancies are and if there is a trend in an area.

These are the three models of Case Management that are used The role-based case management, the organization-based case management, the responsibility-based case management. The main reason for the difference of the three is for servicing the clients the best and best taking care of their needs. The role-based case management main goal when working with there clients is make sure their clients is receiving the services in which their client needs. Also another important thing is to make sure each service is doing what’s best for the client. An example of this would be making sure the client therapist, rehabilitation are all working together. The next model is the organization-based case management is for clients who have multiple problems and

Today almost every major health care organization has a case management program managing and directing the use of health care services for their clients. Also, case management by payer organization is recognized as external case management (Jacob & Cherry, 2007). Hospitals recognized the need for the case management model in the mid-1980s to manage the lengths of stay of hospitalized patients and the treatment plans (Jacob & Cherry, 2007).

The Utilization Review Plan for Chestatee Regional Hospital is sufficiently organized and detailed. The first section of the plan identifies the purpose, objectives, and scope of the UR plan. The plan states that the Board, through the Administration, and Medical staff, has established a comprehensive utilization process (Chestatee, 2014). The goal of the UR plan is to appropriate allocation of resources through identification, and elimination of over-utilization, under-utilization, and the inefficient delivery of health care services (Chestatee, 2014). This section of the plan includes several objectives to implement an effective process to achieve the highest quality of care in a cost-effective manner. The objectives include:

Utilization management is described as the implementation of guidelines which reduce unnecessary use of medical resources (Kongstvedt, 2007, p.190). There are a variety of methods used to ensure costs are kept at a minimum without compromising patient care. The use of utilization management (UM) are yielding financial benefits resulting in managed care organizations (MCOs) and facilities investing more into UM programs.

According to McConell (2012), the difference in a leader and a follower determines the success of a person regarding leadership. This chapter helps explain the content of qualities and proficiency for healthcare managers to be effective. Once again, effective management skills or certain qualifications enhance a healthcare organization environment. Healthcare managers and supervisors must have the capacity to handle challenges while the organization objectives and regulations may change over a period of time. Effective healthcare management governs the success of a healthcare organization. There are many different skill sets and leadership styles to be effective as a manager. People are interested in knowing what strategies are effective

Accountability, responsibility, and risk are three key leadership concepts that should be properly understood and applied for successful management of resources. Each of these concepts plays essential roles in the development of sound leadership decisions. Conversely, accurate and prompt decision making significantly contributes to the performance of leaders in different organizational settings. As a result, it is important for leaders to examine the key elements and links existing between the three concepts. This is because different stakeholders look at leadership, which is supposed to apply different success concepts to take care of their interests. This paper discusses the role of the three important concepts for leadership in healthcare industry and how they may be employed by leaders to improve patient outcomes. To begin, it is essential to indicate the definition of the three leadership concepts as done in the following section.

The cost of the health care industry has always been rising since the early 1980s. It has been a growing concern in both the industry and society. Massachusetts General Hospital (MGH) is no exception. Even though the average length of stay (LOS) for the patients in MGH has been declining (Exhibit 10), it is still the highest compared to their competitors (Exhibit 6). Besides the cost, there is no uniformity of process and standardization across different facilities and departments of the hospital. MGH lacks communication and coordination between the facilities.

The Utilization Management Program of the Naval Hospital Guam facility is one which is designed to ensure that high quality, cost efficient health care is delivered to all members of the community. The Utilization Management Division is responsible for implementing a Utilization Management Plan which will monitor the appropriate usage of the health care facilities, services and its resources. These services may include utilization reviews, case management, discharge planning and outcome-based evaluations. The Utilization Management Program is completely planned and put into action by this division. It is also responsible for coordinating and monitoring access to care, developing programs, and evaluating