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Questions and Answers
What is the primary role of Utilization Management in health care organizations?
What is the primary role of Utilization Management in health care organizations?
Which technique is utilized by health care payers to control costs?
Which technique is utilized by health care payers to control costs?
What aspect of patient care is primarily assessed by Utilization Management?
What aspect of patient care is primarily assessed by Utilization Management?
How does Utilization Management impact cost management in health care?
How does Utilization Management impact cost management in health care?
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What type of plans must Utilization Management approve within health care organizations?
What type of plans must Utilization Management approve within health care organizations?
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What is the primary focus of a utilization management plan in a healthcare organization?
What is the primary focus of a utilization management plan in a healthcare organization?
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Which of the following best describes a significant outcome of effective utilization management?
Which of the following best describes a significant outcome of effective utilization management?
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In the context of utilization management, optimizing quality outcomes means focusing on which of the following?
In the context of utilization management, optimizing quality outcomes means focusing on which of the following?
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What is a potential consequence of neglecting utilization management in healthcare settings?
What is a potential consequence of neglecting utilization management in healthcare settings?
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How does financial performance relate to utilization management in healthcare?
How does financial performance relate to utilization management in healthcare?
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What is the primary function of Utilization Management in a healthcare organization?
What is the primary function of Utilization Management in a healthcare organization?
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Which of the following elements is NOT typically approved by Utilization Management?
Which of the following elements is NOT typically approved by Utilization Management?
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In the context of cost management, what aspect does Utilization Management focus on?
In the context of cost management, what aspect does Utilization Management focus on?
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Which statement best describes the approval process by Utilization Management?
Which statement best describes the approval process by Utilization Management?
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What should organizations prioritize in relation to plans that require Utilization Management's approval?
What should organizations prioritize in relation to plans that require Utilization Management's approval?
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What is a key objective of the utilization management plan in healthcare organizations?
What is a key objective of the utilization management plan in healthcare organizations?
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Which statement correctly reflects the relationship between quality outcomes and utilization management?
Which statement correctly reflects the relationship between quality outcomes and utilization management?
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In the context of utilization management, what is primarily meant by 'appropriate level of care'?
In the context of utilization management, what is primarily meant by 'appropriate level of care'?
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What is a potential outcome of not optimizing financial performance through utilization management?
What is a potential outcome of not optimizing financial performance through utilization management?
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What aspect of care does utilization management NOT focus on?
What aspect of care does utilization management NOT focus on?
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What is the primary aim of a utilization management plan within healthcare organizations?
What is the primary aim of a utilization management plan within healthcare organizations?
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Which aspect is NOT typically included in the objectives of a utilization management plan?
Which aspect is NOT typically included in the objectives of a utilization management plan?
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Which of the following best describes the intended outcome of effective utilization management?
Which of the following best describes the intended outcome of effective utilization management?
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What challenge might healthcare organizations face if utilization management is poorly implemented?
What challenge might healthcare organizations face if utilization management is poorly implemented?
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In utilization management, optimizing quality outcomes entails which of the following considerations?
In utilization management, optimizing quality outcomes entails which of the following considerations?
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What primary factor must be analyzed to determine medical necessity in Utilization Management?
What primary factor must be analyzed to determine medical necessity in Utilization Management?
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Which of the following best describes a key responsibility of Utilization Management within healthcare organizations?
Which of the following best describes a key responsibility of Utilization Management within healthcare organizations?
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In terms of cost management, which area is NOT typically evaluated by Utilization Management?
In terms of cost management, which area is NOT typically evaluated by Utilization Management?
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Which statement regarding Utilization Management plans is accurate?
Which statement regarding Utilization Management plans is accurate?
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What is a common misconception about the role of Utilization Management in healthcare cost control?
What is a common misconception about the role of Utilization Management in healthcare cost control?
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Study Notes
Utilization Management
- Utilization management is a technique used by healthcare payers to manage costs.
- It analyzes the medical necessity and appropriateness of care services.
- Appropriateness is considered for: admission, treatment and investigations, length of stay (LOS), and discharge needs.
- The goal is to achieve high quality care while being cost-effective.
- Techniques for managing cost include analysis of medical necessity and appropriateness of care.
- Specific factors analyzed include admission, treatment, length of stay and discharge needs.
Quality, Risk, Utilization, and Patient Safety Plans
- Written plans describe quality management, utilization review, risk management, and patient safety functions and govern operations.
- These plans may be separate or integrated.
- All plans need to align with the organization's vision and strategic goals.
- An organization-wide approach to patient care and services requires approval from the governing body and administration.
Utilization Review
- Inpatient: Considers admission criteria, treatment necessity, length of stay, transition care, discharge criteria, and readmission.
- Outpatient: Considers encounter/visit, treatment necessity, accessibility of service, multiple encounter/revisits, and referral/revisits.
Utilization Problems
- Underutilization: Inefficient use of resources; no order of treatment, no investigation done, no care coordination (lack of consultation), and no follow-up.
- Overutilization: Abuse of hospital resources without necessity; admission without necessity, overuse of antibiotics, increase in length of stay without necessity, and abuse for investigations.
- Misutilization: Wrongly using hospital resources; wrong treatment.
How to Prevent Utilization Problems
- Pre-authorization process in managed care organizations.
- Assessment of data or cases by physician advisors or medical directors, followed by discussions with primary care practitioners.
- Quality improvement (QI) team activities to improve systems and processes related to inefficient delivery of care.
Managed Care Organization
- Responsible for the delivery and financing of healthcare services.
- Establishes links among providers, patients, and payers.
- Both patients and providers have agreements with MCOs regarding services and fees.
Effective Utilization Management
- Top-level commitment.
- Recognition of utilization management as part of overall quality management.
- Knowledge of current laws and effective UM( utilization management) plan.
- Coordination with all care levels and care management.
- Effective communication and education.
- Computerized databases for tracking UM(utilization management) data with comprehensive reporting.
Care Coordination
- A function to ensure patients' needs for health services are met and information is shared across people, functions, and sites.
- Maximizes service value by facilitating beneficial, safe, and high-quality services, and improves health outcomes.
- Involves management of wellness and chronic disease care to both individual clients and selected populations.
- Assumes a patient care management system exists that links patient needs to available services.
How Does Care Coordinator Work?
- Proactive care plan and follow-up.
- Available and shared information.
- Easily accessible information systems for practitioners.
- Transition/hand-off between staff.
SBAR
- A structured communication tool used to convey information accurately between healthcare workers.
- This tool helps with conveying information effectively in different situations like handovers, referrals, and seeking advice.
- SBAR improves patient safety and outcomes, especially during emergencies.
Case Management
- Clinical and administrative coordination of all care phases within a defined time frame.
- The case management process involves intake and assessment, care plan development, case coordination, discharge planning, and quality management.
- A comprehensive care plan is developed after the initial assessment.
- Treatment plans are established by healthcare practitioners.
Role of Case Manager
- Ensures medically appropriate care for patients.
- Maintains an overview of the case and supports the primary care provider in maintaining an objective ongoing assessment of patient needs.
- Responsible for ensuring continuity of care from hospital to home, from home to hospital, or from hospital to hospital.
Community of Case Management
- A model developed by healthcare providers to manage patients with chronic conditions, aiming to prevent emergency visits or hospitalizations.
- Includes home visits by nurses and practitioners, communication with primary care physicians, and a team approach involving hospital social services and case management based on patient needs.
- Patients are candidates if they meet one or more criteria.
Population Management
- Case management focuses on individual patients, while population management focuses on groups of patients with similar conditions.
- Programs for managing high-risk, high-cost, and high-volume populations of patients with chronic conditions are created.
Component of Full Service Disease Management Program
- Population identification (selection criteria).
- Clinical practice guidelines (CPGs).
- Plan of care (potential and proactive).
- Risk assessment.
- Patient and family education/behavior change.
- Outcome measurement and evaluation.
Demand Management
- A system to influence patient decisions regarding accessing medical services, including when, where, and how to access services.
- Incorporates tele-service technologies and triage.
- The managed care organization utilizes 24-hour nurse-staffed hotlines and self-management education options.
Risk Management
- Identifying, assessing, and controlling threats to an organization's capital and earnings.
- The threats may arise from financial uncertainty, legal liabilities, strategic management errors, accidents, and natural disasters.
- Includes controlling the increasing incidence of medical issues, legal issues, and controlling financial and emotional costs.
Role of Risk Manager
- Identifies and manages risk.
- Prevents and minimizes risk to patients, visitors, and healthcare workers.
- Identifies improvement opportunities.
- Reduces (not eliminates) financial liabilities.
- Emphasis on harm prevention for patients, visitors, and staff.
Day-to-Day Responsibilities of the Risk Manager
- Dealing with incident reports and investigations.
- Handling patient complaints.
- Addressing adverse patient events and outcomes.
- Conducting root cause analysis.
- Proactively assessing risk.
Traditional and Enterprise Risk Management
- Traditional risk management is retrospective, focusing on hazards within specific segments and using a one-dimensional assessment.
- Enterprise risk management is proactive and focused on potential hazards, with a holistic, multidimensional assessment, and including non-insurable risks.
Risk Management Program Components
- Loss prevention and reduction (clinical and administrative).
- Claims management.
- Safety and security programs.
- Patient relations programs.
- Contract and insurance premium review.
- Employee programs/worker's compensation.
- Resources and support system review.
- Linkage with quality, patient safety, and utilization.
Enterprise Risk Management
- The process of identifying, assessing, and controlling the threats to an organization's capital.
- Risk domains can be Operational, Clinical, Strategic, Financial, Human Capital, Legal/Regulatory, Technological, and Environmental.
Component of ERM: Steps
- Identifying potential risks.
- Analyzing potential risks.
- Evaluating risk significance.
- Treating potential risks.
- Monitoring potential risks.
Risk Identification
- The first step in preventing loss is identifying risks within an organization.
- Clinical or non-clinical/administrative risks are included.
- Processes for identifying potential risks and implementing steps to avoid, reduce, or prevent risk occurrences are contained within the risk management program.
FMEA and RCA
- FMEA is a pre-problem solving methodology that anticipates issues and takes preventive actions.
- Root Cause Analysis (RCA) analyzes problems after they occur, aiming to prevent recurrence.
How to Identify Risk
- Continuously monitoring incidents, using incident reports as an early warning system.
- Reviewing external data (e.g., patient satisfaction, physician referrals).
- Reviewing litigation cases and medical records.
- Analyzing key exposure areas.
- Identifying professional malpractice, general liability, and director liability risks.
Example of Negligence
- Lack of proper care.
- Malpractice based on a defined standard.
- Reasonableness of care.
Organization-Wide Early Warning Systems
- Concurrently screen all patients in hospitalizations, ambulatory services, and home care.
- Review the process of adverse event reporting and notifications.
- Include the collection of patient safety data through screens (e.g., NAHQ survey).
Risk Assessment
- Analyzing potential risks once they are identified, and determining their significance.
- Root Cause Analysis (RCA) is used in determining the significance of an adverse event.
- Failure Mode Effectiveness Analysis (FMEA) may be used to identify the risk and eliminate it before an adverse event occurs.
Risk Evaluation (Time)
- Prioritization of potential risks is determined by evaluating their severity, likelihood, and detection potential, using the Risk Priority Number (RPN).
Risk Treatment
- Selecting and implementing strategies to modify risks, manage them, or treat them.
- Ways of treating or managing risks include: acceptance, reduction, transfer or avoidance.
Risk Transfer
- A risk is transferred via a contract to an external party that assumes the risk on behalf of the organization.
Risk Monitoring
- Tracking and evaluating the level of residual risk after implementing an action plan.
- Assessing the power of frontline understanding of processes.
Role of Governing Body in ERM
- Supporting implementation of risk management programs.
- Establishing policies to minimize risks.
- Enforcing compliance with laws and regulations.
- Overseeing the process for public reporting of adverse events.
- Supporting the proper obtaining of informed consent for medical care.
- Tracking and monitoring organizational risks (using FMEA) and results.
Infection Prevention and Control
- Infection preventionists must be aware of and prepared for global outbreaks.
- Their concern centers on patient/employee safety, reducing pathogen-related morbidity and mortality, and lowering institutional costs.
Goal of Infection Control
- Reduce hospital-acquired infections (HAIs).
- Active surveillance plays a central role in the infection control program.
- Surveillance types include total (infection rate) and targeted surveillance like CAUTI (catheter-associated urinary tract infection) and CLABSI (central-line associated bloodstream infection).
The Centers for Disease Control and Prevention (CDC)
- The CDC is the national public health institute focused on protecting public health and safety through disease control and prevention.
The National Healthcare Safety Network
- A system used by the CDC to identify and track infection control issues.
- Complies with reporting mandates to encourage national efforts in reducing healthcare-acquired infections.
- Organizations like acute care hospitals, psychiatric facilities, rehabilitation hospitals, outpatient centers, and dialysis centers are included.
- Includes components such as patient safety, long-term, and health personnel safety.
Environmental Safety Program
- The Environment of Care Committee (EOC), also known as the safety committee, is a multidisciplinary group that monitors environmental safety.
- The committee is responsible for the environment and facilities and includes different staff members, senior leadership, quality improvement staff, and infection prevention and the risk manager.
- Includes seven monitored areas within the organization (e.g., safety, security, fire safety, and emergency management).
Financial Management
- Financial management involves studying and controlling the use of money to meet organizational goals.
- There is a linking to the annual budget with daily operations and it is one of the objective forms of performance measurement.
- Financial plan (budget), monitoring financial activity, analysis and variance reporting are important factors for financial management.
Cost Analysis/Return on Investment (ROI)
- Cost analysis is about evaluating costs and benefits quantitatively for services or programs in financial terms.
- ROI is used to calculate how much an investor gains compared to investment.
Role of Quality/Utilization/Risk Professionals
- Securing approval for quality, utilization, and risk management strategies.
- Establishing support mechanisms, including involvement from governing bodies, administrative leaders, medical staff, medical directors, nursing leaders, and support-staff leaders.
- Fostering a proactive passion for Q/R/U management in all organizational departments.
- Leaders in Q/R/U management must possess skills for encouraging and guiding employees.
Additional Information:
- Utilization Management: Includes proactive measures to optimize quality and efficiency.
- Risk Management: An overarching strategy that proactively identifies and controls threats to protect resources and capital.
- Care Coordination: Includes ongoing communication and support for patients dealing with chronic conditions.
- SBAR: Enhanced communication tool that streamlines information flow during critical situations and improve patient safety.
- Case Management: An important component of an integrated patient care framework that involves multidisciplinary teamwork across healthcare systems.
- Infection Control: A critical function to prevent the spread of infections and ensure patient safety.
- Financial Management: Crucial to efficient resource allocation and performance measurement.
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Description
This quiz explores the critical role of Utilization Management (UM) in healthcare settings. It covers the primary focus of UM, techniques for cost control, and the impact on patient care quality. Test your knowledge on how UM contributes to effective healthcare delivery and financial performance.
