Utilization Management Programs

Contracted out or managed within, our Utilization Management programs ensure patients have appropriate care.  The components of our programs include  Concurrent Reviews,  Retrospective Reviews,  Disease Management and Complex Case Management Reviews. 

Concurrent Reviews:

Our Concurrent Reviews identify opportunities for alternate levels of care from admission to discharge.  We assess how physicians orders are being carried out and identify inefficiencies and/or quality issues related to the orders based on evidence-based clinical pathways.   

 

A key component of our include enaging and training the hospital team in the use of clinical screening tools, such as Interqual, to ensure that standards are in place, that the standards are understood, and that they are applied consistently across the hospital network.

 

Questionable cases are reviewed ensuring quality issues are quickly addressed.This process enables Discharge Planning to begin before the patient is admitted to hospital and ensures better, more consistent clinical outcomes.

Retrospective Reviews:

We analyze actual patient data in the Retrospective Review process and establish clinical guidelines to look at patterns of use.  New pathways and patterns are developed to improve clinical outcomes.

Complex Case Management:

Complex Cases require different practices.  We identify complex cases and implement specific practices and technologies to ensure appropriate, right time, right place, care is provided to this group based on best practice.  This ensures cost savings and improved outcomes for complex cases.