Managed Care - October 2008 - (Page 32) Double vision Perceptual ambiguity may keep us from seeing the role of utilization management as one that can significantly contribute to quality improvement. This is akin to the “My wife and my mother-in-law” — familiar visual and psychological Intervene which do you see? Proper utilization illustrations such as the 1890 deHowever, it is more likely that in management will allow health care the course of a routine surgical stakeholders to help both the individual piction of “My Wife and My Mother-in-Law.” The viewer, vacpost-op case review, a utilization patient and the medical system. illating, may eventually see each manager would, or at least could, one with its unique representation; however, it is identify and intervene in the failure of the patient to receive anticoagulant therapy within 24 hours virtually impossible to see both figures simultanepost-operatively to prevent a deep vein thromboously, although both are present. It is possible that sis — especially for elective surgeries. For this measby creating a frame that includes utilization manure, the top reporting hospitals in the United States agement and quality improvement, and in which rank at 95 percent while the average is only 75 perthere is freely flowing information, both the indicent. vidual patient and the entire health care system And yet, many utilization managers do not rewould ultimately benefit. MC view cases with an eye toward looking for care delays as long as the inpatient stay meets medical neReprints Available cessity criteria; nor do they intervene to correct Major articles are reviewed by appropriate memthis type of omission in care during concurrent rebers of MANAGED CARE’s editorial advisory board view of a case. This failure to recognize or intervene and/or other qualified experts. Reprints of these should not be categorized as one of not knowing or articles may be a useful tool for your company. not caring, but as an organizational deficit — in To obtain information concerning the purchase that it is not a structured, incorporated, encourof professionally printed reprints, please contact: aged, or rewarded part of the utilization manager’s Lisa Gardineer job expectations, tools, or mindset. Phone: 267-685-2789 Common duties for utilization management E-mail: lgardineer@medimedia.com staff include discussing expected length of stay MANAGED upon admission and identifying the discharge readiness and the discharge destination of the patient — often facilitating an appropriate length of stay and the transition to the next level of care The CMS hospital process-of-care measures serve as examples of how the roles and responsibilities of utilization management and quality management personnel might sometimes intersect. For example, heart attack patients present to the hospital ED on an unscheduled basis, at all hours of the day and night, and it may be more than 24 hours after their arrival when the UM nurse first reviews the chart. Therefore, many utilization managers are unable to identify when aspirin hasn’t been given to a particular heart attack patient. For this reporting measure, the top hospitals in the United States already rank at 100 percent compared to the average of 93 percent. while communicating with a variety of parties. But consider that for heart failure, a diagnosis prone to frequent readmissions, the average percentage of patients provided with discharge instructions at the time of hospital discharge was 66 percent for all U.S. reporting hospitals. Would it be wise for hospitals to invest the resources that would allow utilization management nurses to expand their attention and activities from approvals and focus on higher-impact aspects such as improving quality? Care 32 MANAGED CARE / OCTOBER 2008
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