LEARNING FORUM TEAM FIRST PRINCIPLES TERMS OF USE HELP DESK
   
  Monday Memo  
 

Weekly update from...
Athena Forum logo

 
Monday, March 11, 2013
  Clinical Accuracy Spoken Here  

UM: Managing for Value

The goal of utilization management (UM) is to decrease the patient's length of stay (LOS) while simultaneously providing optimum quality patient care. UM brings patient-level and system-level concerns together which creates a win-win situation.

The hospital case manager (HCM) is charged with "managing for value." This means delivering high-quality care, service and outcomes cost efficiently.

[Reference: UM, Module B, Payers, Contracting and UM]
www.athenaforum.com


  Excellence in Case Mgmt  

UM Determines Needed Actions

The UR process practiced in most hospitals is a compulsory obligation under the terms of insurance contracts. It is also compulsory under CMS through the Conditions of Participation (CoP) for patients covered under Medicare and Medicaid. A clear distinction is drawn between the UR mandated by the payors and the UR as expressed by regulatory agencies.

Each type of review utilizes specific criteria to determine the need for further:

  • Action
  • Decision
  • Intervention

[Reference: UM, Module A, Standards and Requirements]
www.athenaforum.com


  Improving Patient Care...  

UM Influences Quality

The HCM tracks the activities of the team and advocates for the patient in an effort to promote appropriate, efficient, quality, cost-effective care

At the same time the HCM monitors for over-utilization/under-utilization of resources (duplication of tests, timely results).

By being informed of patient progress toward goals the team members can make timely decisions pertaining to the appropriateness of care and change interventions and treatments to more effective ones based on the clinical status of the patient supported by objective data (results of tests and procedures).

[Reference: UM, Module C, Quality of Care and UM]
www.athenaforum.com


 

Tom RasmussenTom Rasmussen
Publisher
Athena Forum
Tom.Rasmussen@AthenaForum.com

 
 

NEW courses in Development

» Professional Identity
» Ethics in Case Management
» Depression Care
» Breast Cancer Care
» Improving Outcomes in ESRD

 

 

Cathy WrightCathy Wright, BSN, RN
Clinical Editor
Athena Forum

Cathy.Wright@AthenaForum.com

 

 

Online CE for RN, CCM & LSW
4,000 pages of clinical excellence.

Clinical Excellence® Series
» Asthma
» Behavioral Health
» Colorectal Cancer
» COPD
» CV Risk: Stroke & MI
» Diabetes
» EOL & Palliative Care
» GI Disorders
» Heart Failure
» Multiple Sclerosis
» Obesity Management
» Pain Management
» Rheumatoid Arthritis
» Sepsis Care
» Women's Health
» Wound Care & Payments

CM Excellence® Series

» Discharge Planning
» Hospital Revenue Cycle
» Patient Advocacy
» Population Health
» Principles of Hospital CM
» Utilization Management

 

 
 

Athena Forum Help Desk
Mon-Fri 9am-5pm ET
301-279-2160

Recommend to a friend
Tom Rasmussen, Publisher
Tom@AthenaForum.com

Enrollment & passwords
Janice Graham, Registrar
JaniceG@AthenaForum.com

  Monday Memo Archives
Did you miss an issue? Need to look up a reference in a past Monday Memo? All past issues are archived for your use. Click here.
 


Social Workers Month

Athena Forum Applauds Social Work Excellence!

Happy Social Work Month!

horizontal line

To Weave Resilience & Advocacy for so very
many patients takes unique expertise.

Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRP
Director of Social Work Education, Athena Forum

Athena Forum, LLC awards CE for ANCC - NASW - CCMC

Athena Forum is a world wide service mark in nursing education
by the U.S. Office of Trademarks and Patents.

Copyright 2012 All rights reserved | Headquarters in Boca Raton, FL | 800-583-2506 | www.athenaforum.com