Chapter 8 Part 2 Flashcards
The process of determining whether medical care provided to a specific patient is necessary according to pre-established objective screening criteria at timeframes specified in the organization’s utilization management plan
Utilization Review (UR)
In the 1980’s the PPS system added ____ codes which assist with UR functions and provide parameters that can be used by organizations for efficient UR programs.
DRG
What metric is used to monitor the Hospital Readmission Reduction Program?
Excess Readmission Rate (ERR)
Review the condition of patients to identify each patient’s care needs. Integrate patient data with the patient’s course of treatment.
Case management
Reviews for medical necessity and appropriateness. Improves patient outcomes and decreases healthcare spending.
Utilization management
A performance measure that enables the healthcare organization to monitor a process to determine if it is meeting process requirements
The criteria may be established and implemented internally, externally, or generically
Indicators
How are Gantt charts beneficial in project management?
Schedule important activities.
How are Gantt charts beneficial in clinical process improvement?
Depict clinical guidelines or critical paths in the treatment of common medical conditions.
Program lowers payments to IP PPS hospitals with too many readmissions
Designed to improve coordination of care and post-discharge planning
Hospital Readmission Reduction Program Goal
Hospital Hospital outpatient Physician practice Ambulatory surgery center Other Medicare VBP - End-stage renal disease - Inpatient psychiatric - PPS exempt cancer hospital - Skilled nursing facility - Home health
Value-Based Purchasing Programs
__________ seeks to improve patient safety and experience by basing Medicare payments on the quality of care provided, rather than on the quantity of services performed.
Value Based Purchasing Goal
