Should Utilization Review Be Effective?

However, if the manager of this department sees improvement and would like too, she can recommend this process to other departments throughout the hospital. This could possibly lead to a positive impact on the hospitals overall score in patient

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).

In order to, differentiate between utilization management and case management using the seven case management standards, it is first important to define each individual component. To begin with, a key component of quality and cost effective care is Utilization Management (UM). Utilization management is a way to assure that the appropriate care is medically efficient, a suitable use of health care services, proper procedures, and is applicable with provisions aligned in the health benefits plan. Case Management engages quality services in a timely coordination of patients’ specific needs in an approach that promotes positive outcomes by means that are cost effective. Case management may be developed during a single health care setting that may then transition throughout the care continuum. The seven standards are key components that described to maximize benefits and minimize the opposition.

The utilization review process is a health insurance company's opportunity to review a request for medical treatment. The purpose of the review is to confirm that the plan provides coverage for your medical services. It also helps the company minimize costs and determine if the recommended treatment is appropriate. A utilization review also gives you the opportunity to confirm that your health plan provides adequate coverage for your particular condition. If the company denies coverage as a result of a utilization review, you can always appeal the decision. The three steps in medical necessity and utilization review are: initial clinical review, peer clinical review, and appeals consideration. The UM is often used interchangeably with utilization

Evaluation of a patient’s outcome, to determine the effectiveness of the treatment that they received while under my care, is

A long-term risk is if patients have a negative experience, they won’t access care in the future. They may wait too long

An evaluation which shares on the ways in which concerns about poor practice can be reported is by following the correct procedures that your school may have in place or by law. We need to ensure that those who are reporting findings with in a school are protected and not shamed. The whistle-blower we take this action to protect children and ensure that others know what is going on, it is important for the school to take this information and question it. It is every staffs responsibility to raise concerns if they have any and then it is the schools job to ensure they follow up the concerns, or it may be an outside organisation or service that may need to follow up the concerns. I have come to understand how in some cases whistle-blowing can be put off by fears or getting it wrong, by fear of repercussions or not even being believed. I feel whistle-blowing is important and in some reported cases has be vital in prosecutions because or those in schools doing wrong. Such as a case where recently a list of schools where under investigation by Ofsted which where involved in the Trojan Horse cases. Schools that were not following laws and practices and ways of teaching as they should be. They broke rules and become head line news. Concerns were raised and then came an investigation, if this was not investigated then the schools could have carried on and this would cause damage to children and young poeople education and ways of thinking.

If patients were truly offloaded to NP’s by the triage system it would be cost effective based upon the service rate. But this did not happen. In fact, the percent of patients seen by NPs decreased from 40% to 28%, and the percent patients seen by MDs increased from 41% to 48% (excluding patients that requested a particular provider).

The SCHC addressed meaningful use by recording patient demographics, maintaining an active medication lists and incorporating clinical lab test results into the HER, as apart of their meaningful use objectives. For recording patient demographics, they maintained data for accurate billing and ensured that the practice workflow was adjusted to capture all of the necessary patient data. They addressed active medication lists by following the requirements for e-prescribing. Patients were able to review their active medication list during their visit. Changes to the medication list were reviewed with the nurse and adjusted within the EHR system by the doctor. They communicated information for the care coordination process by making test results efficient and safe to access. Physicians were able to make real time decisions when they receive the test results from LabCorp, Quest, and other health

Methods: This study was a retrospective study that used patient information from 34 maintenance treatment facilities of the CRC Health Group Inc. in the United States from July 1, 2012 to July 1, 2013. 8,442 patients

These programs can be successful when applied but without a physician being required to participate they can be unuseful as it leads to lack of accurate information for public health records. Doctors and pharmacist should both have a legal obligation to check a drug monitoring database and participate further in drug monitoring programs. Doctors and pharmacies should also be investigated for prescribing large quantity of prescription medication resulting in legal action if perhaps they are found guilty of overprescribing. With legislators onboard to curb the misuse of prescription medication this problem can finally be

URAC stands for Utilization Review Accreditation Commission. It is a process or system by which an independent or self-governing organization utilizes trained assessors to examine an organization’s operations and to guarantee that they are delivering healthcare in the appropriate manner in concordance with the national standards. URAC is known to help promote healthcare quality through the accreditation of organizations that are connected to medical

First the use of power can be beneficial when utilized for the right reasons and for the good of your customers. When using your power always remember to think about the use of your power and know when you are going to use your power. This is the task that is the most daunting knowing exactly when to exert your power and plan ahead of time the moment and how your power will be utilized in that moment. The use of power is acceptable when you are benefiting your patients to provide better quality of care and for the care provided to become more efficient. Power can also be used when your organization has come to a standstill about a decision needing to be made and push certain individuals that are stakeholders in the direction of the best decision for the organization. Using power can also save time in instances where a crucial decision is needed in a timely manner. There is always a time and place to exert your power knowing the right moment is crucial in these decisions (Burns and Bradley and Weiner, 2011).

Great post. The advantage of disseminating EBP knowledge, such as the use of chlorhexidine to prevent MRSA & VRE is huge. MRSA & VRE are some of the hospital acquired infection that is of huge cost to the hospitals because insurance companies will not pay for such treatment. In addition, the quality of care given to patients depends on how safe our patients entrusted to our care are (free of hospital acquired infection). I think the need to disseminate EBP knowledge should be encouraged to promote quality of care and reduce cost. In response, to your question about the use of PCAT, I would say that PCAT are overwhelmed because PCAT/patient ratio is higher than RN/patient ratio. Although, 2 hourly rounding may be adopted, I think patients’

After Action reviews, are used to get feedback from a training event or a operation. There are two types of AARs, formal and informal. Both differ in areas of time, resources, planning, location, and who’s conducting it. There are also important people involved in the AAR; such as facilitators, participants, and last observers. Facilitators as I learned today are those people who make the planning and conducting of an AAR a bit easier for those involved. There is also different phases that go with the AAR: Planning, preparing, conducting, and last follow up. These are basic steps that help organize the actual AAR. Total participation is great in AAR it allows more input to the discussion that allows everyone to say their pros and cons. A method