Chap 7: Utilization Mngmt Flashcards
What is the difference between the PRO, peer review organization from 1982, and the quality improvement organization, QIO, which is what the PRO was renamed in 2002?
The QIO is aimed more towards quality oversight. The PRO had a utilization focus.
What are some critical components of utilization management systems?
- Easily compare data between providers, patients etc.
- Stay up to date with new developments
- Utilize up-to-date technology
- Follow HIPAA
- Utilize evidence-based medicine
- use reliable and consistent determinations to follow the policy of the UM program.
7: utilization management must occur without delaying care.
Is preauthorization a component of utilization management?
Yes, preauthorization before, concurrent review during the stay, and retrospective review following discharge or all components of the utilization management process.
What are the nine tasks key to effective utilization management?
- Determine priority areas.
- Identify needed info & critical stakeholders. Need accurate, reliable, timely data and buy-in
- Establish appropriate benchmarks
- Design, data collection and data management procedures.
- Implement data collection and management procedures.
- Evaluate the data and present the results.
- Develop guidelines, policies and procedures
- Implement guidelines, policies & procedures.
- Continuously review the task list
What is disease management defined as?
A coordinated system of healthcare interventions and communications for conditions in which patient self-care efforts can significantly improve outcomes.
Disease management programs emphasize collaboration between physician and support service providers, patient self-management education, routine reporting feedback and evidence-based practice guidelines.
What is the difference between utilization management, disease management, and case management?
Case management is defined centralizing the planning come arranging and follow-up of specific health services in order to manage utilization, effectiveness and cost. case management works at the individual pt level.
Disease management works with groups of pts with specific conditions, in which pt self management has an impact on outcome.
What is a care plan?
The care plan maybe use for disease management or case management. The disease management care plan is usually a general plan that is applicable to a large population with one disease. The care plan for case management is individualized to the patient who may need specific referrals or follow up.
What is demand management?
Designed to improve the appropriateness of a members’ use of healthcare resources.
Ongoing process on top of case management and disease management to stop over utilization by certain patients. May do this by supporting caregivers, improving medication compliance or it may increase the cost of care by helping the patient improve their use of healthcare interventions.
Demand management is utilized for all of the population in a benefit plan, as it also encompasses preventive care, as opposed to case management which is utilized for certain individuals.
What components are contained within the chronic care model?
Self-management support, health system, clear delivery system design easily understood by the patient, evidence-based decision support, clinical information systems with timely reminders, and mobilization of community resources.
How does the evidence-based medicine and evidence-based management model differ from the chronic care model?
Similar in many regards including self-management, feedback, reminder systems, disease registries etc. BUT, also adds knowledge from human factors engineering, high reliability organizations, development of pipe performing teams, and continuous improvement.
What is the patient-centered medical home model P-CMH?
Emphasizes the personal physician who leads the care team. Whole person orientation for all stages in life with culturally and linguistically appropriate communication. Hallmarks quality and safety. Enhanced access with open scheduling, expanded hours, with increased payment based on the cost of instituting such a program.
What is the difference between utilization management and utilization review?
Utilization management is to make sure healthcare is delivered in the most efficient and effective manner possible.
Utilization review is an older concept performed to evaluate the cost of care.
