The Utilization Review Plan For Chestatee Regional Hospital

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).

They are able to perform patient care by IV and oral medication administration, cardiac monitoring, airway management, blood transfusion, wound care etc… They are accountable to implement family central patient care.

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

The Affordable Care Act was signed into law March 23, 2010 by President Barack Obama; however, the constitutionality of the law remained in question. In a controversial 5-to-4 ruling, The U.S. Supreme Court upheld the law on June 28, 2012. The ACA is thought by some as the United States health care rescue, and as its downfall by others.

The precise tasks performed by the different PAs are determined by the boundaries of factors like education, experience, state laws, facility policy and the supervising physician’s delegatory decisions. Each factor should be effectively constructed in order to deliver the efficient health care to the patients. State laws and regulations

The Patient Protection and Affordable Care Act of 2010 (PPACA) was designed to decrease health care costs and require health care access to all U.S. citizens. The Act has the potential for reducing the cost of health care in the United States; however, with many risks which could possibly strain the health care system, increase debt, and decrease the quality of care many are concerned.

Administrative staff remains at the top- level of the organizational structure, formulated of individual’s that have ownership (stakeholders) with the functions of operations in the healthcare facility. These important individuals are accountable for the enforcement on policies and regulations, with ensuring the implementation for public

“Running a health care organization is a team sport. It is very important that all members of the team-whether on the medical staff, in management or on the board-understand the role of governance and what constitutes effective governance” (Arnwine, 2002). Running a hospital is a difficult task. Several factors need to be seriously thought of and considered in every decision and undertaking. Unfortunately, all the three important factors in governing a hospital is not always in harmony. As likened to a team sport, if the three major components are not working with each other as a team, there will be tension and a great divide will be experienced. And often times, the patients will be in the middle and will be greatly impacted. This writer believes that there are several factors that contribute to the tension that usually exists among the medical staff, the board and administration. One factor is the disconnect, where each entity is not seeing each other eye to eye and their visions may be different from each other. Another factor may be the lack of communication in order to bridge the gap and to build a respectful and a relationship wherein there is trust for each end every member of the group. Often times, the medical staff is concerned with ensuring that patients are cared for in a manner that their practice is protected as well as the patients are getting the appropriate care. On the other hand, the board of trustees may be focused in ensuring that that

Health care systems across the world are facing a number of challenges, which include changing patterns of diseases, a shortage of health care professionals, inaccessibility of services, and insufficient resources. Given that an increasing population creates a greater demand for healthcare services, the shortage of hospital beds due to high admission rates and increased length of stay are some of the challenges that the healthcare system of Saudi Arabia is struggling to overcome. The Saudi Arabian government funds 244 hospitals that have a capacity of 33,277 beds (Almalki, Fitzgerald, & Clark, 2011). However, there was a forecast of bed capacity shows that, by 2013, the healthcare system in Saudi Arabia will require about 14,700 additional beds to meet the increasing demand for healthcare services (RNCOS, 2011). The shortage of beds implies that the healthcare system needs to formulate ways of increasing hospital bed capacity. The problem being investigated is the Saudi Arabian hospital bed shortage due to increased length of stay in hospitals by patients with chronic illnesses, the elderly, and the disabled. The purposes of the proposed study are to describe the post-acute care needs and also the need for effective discharge planning.

Since the hospital is a community based acute care hospital, there are numerous subunits. Under the president of Hospital AB and Health Center, the total organization is divided into seven major units which are controlled by seven senior vice presidents. Each unit under the senior vice president is further subdivided into sub units according to the services being provided. The hospital has a distinct subunit configuration for the nursing departments. Each unit is under either a vice president or a director. The major subunits are perioperative services, nursing practice and education, behavior health services, heart center, out patient women services and perinatal clinic, inpatient women services and pharmacy. Each of these major subunits is further subdivided based on the services being provided. The senior vice president for all these units also oversees the programs for patient safety, patient satisfaction and joint commission accreditation. The departments of imaging services, rehabilitation services, cancer center, breast center and quality management comes under another senior vice president (unknown author, 2005).

Improving the quality of health care system is the main goal of this organization. In this case study we will be talking about the strategic plans being made by the organization for the next decade to deal with the problems of resource management, network growth, patient satisfaction as well as nurse staffing. The readiness of the organization towards catering the citizens' needs for health care will also be discussed in this case study (Goetsch and Davis, 2010).

Time and again, hospitals are often called upon to improve the quality of its various health care activities in order to better serve patients and immediate communities. A quality improvement plan thus helps in the selection of high priority areas and the utilization of evidence-based practices in conducting the improvement (Berenguer et al., 2010). In view of the healthcare improvement needs of Sunlight Hospital, this paper seeks to classify and justify five measurements of quality of care in a hospital, specify the four main features in a health care organization that can be used in the design of a quality improvement plan, and suggest the salient reasons quality of care would add value and create a competitive advantage

The next layer will be filled by the position of Chief Executive Officer (CEO). CEO will provide a link between the functional departments and the board of directors; he will be responsible for presenting the aims and objectives of the hospital to the board of directors and designing strategies to achieve them. There will be an administrative assistant who would be responsible for assisting the CEO in his work by providing him a detailed action plan and keeping him informed about the progress. The next layer will consist of the functional units of the organization which would include financial executives, health informatics, pathway service providers, community relations and a research centre. There would be many other sub functions but they will all be

Over the years, there have been many projects and programs that have been implemented to address access to health care. However, there are still a significant percentage of people in this country that do not have a health care home. Nurse leaders now, more that ever are in a prime position to create and implement programs that allow access to the much needed health care. The purpose of this paper is to review the concepts of resource utilization and financial management in relation to creating a nursing program proposal to increase access to health care.