Utilization Management Paper

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

The second part of The Model for Improvement is the PDSA cycle. This is the testing phase of the model. The acronym PDSA stands for Plan, Do, Study, and Act. This is a four step process which is a simple way to test and make changes to the process. If The Model for Improvement is applied to Mr. B’s scenario, the aim of the improvement plan would be to make sure that patients coming into the emergency room receive the appropriate dose of medications, that the patients are monitored correctly, and that the staff is educated about proper medication administration. The measures part, How will we know a change is an improvement, could be answered by compiling data with the number of patients receiving hydromorphone in the emergency room, what type of monitoring was used

The graded unit is a mandatory project that will allow me to demonstrate the skills and knowledge I have gained during my HNC studies. In order, to achieve my HNC Care Administration Practice it is essential that I successfully complete and pass the graded unit. The graded unit consists of three stages: planning, development and evaluation of an activity I will be undertaken with a patient that I have been building a therapeutic relationship with within my current placement. My timescale for completion of this activity will be: planning by 20th of March, development by 24th of April and evaluation by 15th of May 2017.

Explain when and why inquiries and serious case reviews are required and how the sharing of the findings informs practice?

UHDDS is specific to hospitals that provide medical services for those covered by Medicaid and Medicare. As the federal government was becoming increasingly involved in healthcare, analysts realized the importance of creating a standardized system of medical coding that would be allowed for an easier comparison between hospitals. This data could also be used to compare the reimbursement rates of different hospitals for similar medical procedures, and thereby work towards a standardized system of reimbursement for the federal government nationwide. Standardization in reimbursement rates also helped hospitals move towards standardization in quality of

9. The review of systems (ROS) is documented for patient care purposes and also factors into the ________________ for the patient 's visit.

Regular reviews, target setting and referring to the initial assessments target setting is vital in ensuring a

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).

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.

Ashton, C., Kuykendall, David H., Johnson, Michael M. (1999). An Empirical Assessment of the Validity of Explicit and Implicit Process-of-Care Criteria for Quality Assessment. 27(8). 798-808.

For the appropriate care to be planned for a patient it should be looked at in a holistic manner (NMC

“A thorough understanding of how information is currently collected, and processed is the starting point in performing a needs assessment” (Hebda & Czar, 2013, p. 155). There are four stages of conducting a needs assessment, these include: gap analysis, identify barriers, identify priorities, and summarize results (Young, 2008). The gap analysis can determine what the difference is between the current state and the desired state. Some of these areas that need to be considered are staff computer skill level, patient volume, time, resources, and the repetitive tasks. “ The goal is to determine what information is used, who will be using it and how it is used. All the data items used in the current system should be analyzed” (Hebda & Czar, 2013, p. 155). Important decisions need to be made regarding what types of information should be kept, what is redundant and what is necessary. To determine this, an evaluation of the strengths and weaknesses of the current process needs to be made, either manual or automated, to see what the organization needs. Systems should have a streamline data collection and it should be presented as information that can enable clinicians to coordinate care with ease and efficiently (Hebda & Czar, 2013). The data that is involved in the gap phase is collected through methods like observations, surveys,

• Resource: Applying the Results and Conclusion of the Research Process to Problems in Health Care Grading Criteria.