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The Transprofessional Model: Blending Intents in Terminal Care of AIDS
Published in David Alex Cherin, G. J. Huba, AIDS Capitation, 2021
David A. Cherin, W. June Simmons, Kristine Hillary
One research effort was conducted in Missouri that examined the AIDS case management program of the Missouri Department of Health for the years 1988-1992. The researchers, Twyman and Libbus (1994), gathered a random sample of complete case records of HIV/AIDS patients who had died during the period 1988-1992. The overall purpose of the study was to compare the use of inpatient hospital services for patients in the last 6 months of life and assess the degree of fragmentation in service provisions for each group of patients. The findings demonstrated no significant differences in hospital utilization by either group and indicated that case management clients did not use fewer patient days than clients without case management. The researchers concluded that case managers who were not adequately trained in case management might, in fact, utilize all available services. Utilization management would be a key part of their performance, including hospitalization without considering cost and other implications.
Managed Care: An Introduction
Published in A.F. Al-Assaf, Managed Care Quality, 2020
The medical director and associates are responsible for quality of care, provider recruiting, provider reimbursement, peer management, utilization management, credentialing and medical policy. care management is critical to the managed care effort. The success or failure of a plan largely depends upon care management function to control medical costs, yet not withhold necessary care. The continuum of care management starts with demand management. Demand management is the portion of the plan which puts the patient into the risk sharing concept. Utilization management involves inpatient critical pathway management, clinical practice guidelines management, case management and individual disease management. These functions are measured in terms of outcome data and practice profiling of physicians. The medical director must monitor and report on expected vs. actual quality of care performance and target improvement areas. This is best achieved through the judicious use of other plan physicians who are cultivated to look at issues and lead or participate in peer activities.
Managed Care Pharmacy
Published in William N. Kelly, Pharmacy, 2018
Utilization management is the process of evaluating the necessity, appropriateness, and efficiency of healthcare services against established guidelines and criteria. Common utilization management programs include prior authorization, step therapy, and quantity limits.
Lean and Six Sigma as continuous quality improvement frameworks in the clinical diagnostic laboratory
Published in Critical Reviews in Clinical Laboratory Sciences, 2023
Vinita Thakur, Olatunji Anthony Akerele, Edward Randell
Overutilization or misuse of laboratory resources can result in over-diagnosis, unwarranted investigations, overtreatment/negative health outcomes, and increased healthcare costs. Several studies have approached utilization management issues by Lean, Six Sigma, and other structured process improvement strategies [116–120]. Some utilization of laboratory test improvement studies has focused on test utilization by specific clinical units such as the surgical intensive care unit [116], brain injury, spinal cord injury, stroke, and amputee rehabilitation units [120], patients undergoing elective hip/knee arthroplasty [119], or broader-based care [118,121]. These studies addressed acute care tests and panels, including arterial blood gas orders, complete blood counts, basic metabolic profiles, coagulation profiles [116,119], C-reactive protein and erythrocyte sedimentation rate [117], thyroid hormones [118,120], and vitamin D [120], and on reducing the need for phlebotomy [116]. In some cases, the interventions resulting in reductions in the use of some tests also produced cost savings [116]. Successful interventions in these studies have typically involved the education of physicians about the appropriate use of tests, and implementation of hospital-wide laboratory or forced-function systems with or without reflexive testing.
Factors affecting hospital services overutilization and reductive strategies in Iran: a qualitative study to explore experts’ views
Published in Hospital Practice, 2022
Leila Doshmangir, Hossein Jabbari, Morteza Arab-Zozani, Mohammad Naghavi-Behzad, Zeinab Abedi, Hakimeh Mostafavi
Educating proper utilization was mentioned by participants as an effective factor in optimal utilization. Participant No. 11 emphasized public awareness about the harms of overutilization. He stated that: To be honest, I always communicate to people in the different places and according to their words I could say that improving public awareness is an important factor for proper use of medical services, so we should tell people that each CT scan has 48 times higher amount of radiation compared with a simple x-ray image. (Medical technology officer)Our graduated physicians should be informed about the economic principles of treatment and utilization management at hospitals. (Faculty member)
Medicaid managed care enrollments and potentially preventable admissions: An analysis of adult Medicaid recipients in Florida
Published in International Journal of Healthcare Management, 2021
It is of interest to many researchers whether enrollees in managed care receive better and more preventive care services than their fee-for-service (FFS) counterparts. Under the FFS system, insurers passively reimburse for the claims after the services are provided [3]. A fee-for-service plan also allows the insured to choose their physicians and medical facilities. Since there is no gatekeeper system to coordinate patient care, indemnity plan enrollees are free to go to any provider. Thus, FFS patients are more likely to see a specialist without a proper referral from primary care doctors. Without proper utilization management programs, health care providers under traditional health insurance have an incentive to incur unnecessary health care such as over-utilization and over-treatment [3]. On the other hand, managed care organizations have strong incentives to keep cost and utilization rates low because they internalize costs. Therefore, managed care plans have organized systems focusing on primary care services to avoid costly specialty visits and hospitalizations.