Managed Care - October 2008 - (Page 27) It’s Time to Ask More Of Utilization Management Case management, utilization management, and quality improvement staff members can play an important part in promoting improved care for patients mized and exploited. Sharing aggregate utilization data about delays or omissions in care (preferably on a diagnosis- or provider-level basis) or about causes for readmissions can reveal opportunities for improvement and a chance to design a meaningful feedback loop between the utilization management and quality improvement departments in each organization. By Sherrie Dulworth, RN and Tiffanie Lenderman, MBA nsurers can help hospitals improve quality through utilization management, but it would mean reaching out in a unique way. Most payers have employees with counterparts on hospital staffs: Both health plans and hospitals have utilization managers, for instance. They and quality improvement Leapfrog personnel in each organization Information can be used to faroutinely converse with each other. cilitate many related quality initiaHowever, like Rudyard Kipling’s tives by payers, including hospital lament, “Oh, East is East, and West rating/ranking programs, and payis West, and never the twain shall for-performance programs. The meet,” the four departments — two Leapfrog Hospital Rewards Proutilization management offices and Insurers and hospitals both have utigram, for example, is gaining motwo quality improvement offices lization managers and quality improvementum. It measures hospital — exist in thickly walled silos and ment personnel who could and should quality and efficiency performthere is only limited integration of work together, say Sherrie Dulworth, ance for five conditions. Hospitals left, and Tiffanie Lenderman. data. that demonstrate excellence or Health plan utilization managers show improvement in both qualhave less opportunity than hospital staff to directly ity and efficiency are rewarded by payers who are affect the quality of inpatient care because they are in the program. typically more than one step removed from actual Hospitals can become more efficient through patient care. However, this does not imply that various processes. For example, consideration of health plan utilization managers cannot be a pospatient throughput or patient flow typically sugitive influence; they serve as a conduit for inforgests improving the transition time from emermation and help to coordinate patient care. gency department (ED) to floor, thereby reducing Still, opportunities for synergy can be maxiED patient backlog, although it applies to other areas as well, including efficient transfer from the critical-care units to intermediate or floor care. Sherrie Dulworth, CPHRM, RN, is vice president Having dedicated UM/CM staff located in the ED for strategic planning and development at can help facilitate patient flow and the throughput Milliman Care Guidelines. Contact her at process. sherrie.dulworth@milliman.com. Tiffanie A program known as D2B, sponsored by the Lenderman, MBA, MSHA, is manager of strategic American College of Cardiology, helps reduce outreach at Milliman Care Guidelines. Contact her door-to-balloon time — the time from when a at tiffanie.lenderman@milliman.com. I OCTOBER 2008 / MANAGED CARE 27
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