1.9 Utilization Management Principles Flashcards
Ensures that services provided are medically necessary and provided at the appropriate and least costly level of care.
Utilization Management
These reviews are done prior to the elective admission or procedure to ensure the requested service is necessary, meets criteria for coverage, and is at the appropriate level of care.
Prospective/precertification
These reviews include continued stay reviews and are conducted as the care is occuring.
Concurrent
This review is done after care has already occurred.
Retrospective
The diagnosis is only one factor in evaluating the ___ level of the patient.
acuity
Other factors taken into account to evaluate acuity level:
there are 8
co-morbid conditions intensity of intervention needed complex medical needs family/social support poly pharmacy psychological/cognitive status complex treatment plan number of providers involved.
this care is the most intense level of care, during which a patient is treated for a brief but severe episode of illness, for conditions that are the result of disease or trauma, and/or during recovery from surgery
Acute
____, or_____ and _____ focus on patients who stay more than 25 days on average.
Long term Acute Care Hospital (LTAC), Long Term Care Hospitals (LTCH) and Transitional Hospitals
services provided in this setting typically include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.
Long term acute care hospital (LTAC)
Care provided in this setting are for patients who are stable and do not require hospital acute care, but who require more intensive skilled nursing care, therapy, and physician services than are provided to the majority of patients in a skilled nursing facility.
Sub acute/transitional
this provides intense, multidisciplinary therapy to patients with a functional loss. TO qualify for the level of care, patients must be able to tolerate a minimum of __ hours of therapy per day, __ to __ days per week, and be medically stable.
Inpatient Rehabilitation, 3, 5, 7
This facility offers 24-hour skilled nursing and personal care (e.g. bathing, eating, toileting). They also provide rehabilitation services, such as PT, OT, and speech therapy.
Skilled Nursing Facility (SNF)
This facility provides housing and support with ADLs and IADLs to residents.
Assisted Living
This facility houses and provides therapy for patients with drug and alcohol addictions, emotional or behavioral problems, and/or mental illness.
Residential Treatment Facilities
