How do you apply Utilization Management skills to different types of healthcare settings and populations?

The interesting thing about acute care settings is that UM/CM skills needed in this setting include all of the continuum of care, levels of care and SDoH skills. The UM team in the acute care setting needs to be well versed in community services, care giver support, medical necessity, clinical appropriateness, payer requirements, bio-psychosocial issues, health team collaboration, family negotiation, and the list goes on. It is important for the UM team to approach each patient as an individual, include their support team in the discussion whenever possible, and co-develop transition and health improvement plans together to achieve timely, effective, and safe discharges.

Another acute care setting is the acute rehabilitation hospital. UM skills are needed to assess patient readiness for this level of treatment in order to receive optimum outcomes. In addition, UM teams can work with the patient and their family to ensure the discharge plan has the best chance of success.

A person with both behavioral health conditions and chronic physical health conditions must be supported holistically to achieve optimum health and well being. In addition to the above noted skills, UM teams can ensure the patient has a comprehensive care plan in place post discharge from either a behavioral health setting or an acute hospital encounter.

Os serviços de saúde nos últimos 20 anos passaram a compreender a importância das métricas e do gerenciamento de dados para a melhoria e escalada da performance com vistas a melhor entrega de resultados, assistência e maturidade da gestão. Aliado ao dinamismo das pesquisas científicas e metodologia de investigação os indicadores passam a ser essenciais para a elaboração e construção de metas mais assertivas, com informações mais precisas e aceno de cenários e Tendências baseados em séries históricas com visão mais global, integrada e alinhada as disposições e definições estratégica das organizações.

Analyzing UM data is helpful in identifying patients who are readmitted to the inpatient setting within 30 days for the same condition and for those individuals who use the emergency room frequently. In these scenarios, the patient may benefit from case management to address underlying causes of readmissions and to provide support to provide alternatives while working collaboratively to improve overall health and well being.

When making decisions, UM healthcare professionals need to take into consideration the needs and characteristics of the population to which each patient and plan member belongs. Inappropriate or suboptimal UM decisions can occur when the population health context isn't considered during UM reviews.

involve identifying and stratifying population health risks and needs, designing and delivering population health programs and interventions, and evaluating and demonstrating population health impact and value

Significant progress has been made across the health care industry to refine UM techniques using a suite of technologies such as robotics, predictive models, and defined algorithms to reduce the administrative burden of UM on healthcare systems. The evolution of these technologies will facilitate real or near real time approvals and will facilitate the use of "gold carding" for some healthcare providers while continuing to use advanced analytics to detect waste, fraud, and abuse.