A review of chapter 23 in your Hamric, et al., Etext can provide you with potential ‘indicators’ you may wish to conduct your ‘search’ with. Feel free to explore any indicator that may be of interest to you or the practice setting you envision you want to practice in when you graduate. When providing the source(s) to support your discussion ensure that you follow APA guidelines for in-text and reference citations.
- What is utilization and case management?
- How is this related to managed care and quality care and control issues?
- How does APNP clinical expertise and patient management skills provide a foundation for utilization and case management?
- Provide an example of how case management improves patient care outcomes. Use an Evidence Base Practice research article to support your case. Provide detailed examples.
Post an initial substantive response of 250. Conform to APA format include in text citation.Include at least 2 peer review journals
Part2:Respond to each classmate post.
- Substantive comments add to the discussion and provide your fellow students with information that will enhance the learning environment.
- The peer postings should be at least one paragraph (approximately 100 words) and include references as indicated by the instructor.
- References and citations should conform to the APA 6th edition.
Utilization and Case Management
Utilization management is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan (Gardner, 2017). Case management nurses coordinate all aspects of the care of individual patients. They ensure proper utilization of services and resources as well. Case managers provide assistance within, between, and outside of facilities. Nurses working in case management facilitate outstanding patient care using fiscally responsible strategies. They are experts at obtaining resources work with patients, families and other professionals. Managed care is a health care delivery system organized to manage cost, utilization, and quality. This can be describing a group of activities that are intended to reduce the cost of providing for profit health care while improving the quality of that care (Medicaid.gov, 2014). Case management uses quality care to obtain desired health outcomes that are consistent with current professional knowledge. By using quality care and managed care, case managers are able to fully understand any issues their facility might be having and use these statistics and newly gathered data to help control any issues the facility might be having.
Providing a Foundation
APNPs are able to bring extensive clinical expertise to their facility by combining clinical expertise in diagnosing and treating health conditions with an added emphasis on disease prevention and patient health management. Their advanced training allows them to bring a comprehensive perspective to their health care facility and provide medical necessity along with appropriate and effective treatments to patients while ensuring proper utilization all health care resources (American Academy of Nurse Practitioners, 2017). Case management is an important strategy and an advanced practice in nursing because they are responsible for coordinating care while also reducing health care costs and ensuring patients’ quality of care. Case management ensures high-quality, patient centered care, and it has been shown to be effective in many aspects of illness care (Joo, & Huber, 2014). For example, a case-management approach using clinical plans was developed to enhance outcomes. Patients with congestive heart failure who were admitted to home care and case managed by nurses specially trained in cardiovascular nursing, case management, and the use of a clinical plan, had improved outcomes with fewer visits than patients with congestive heart failure managed with traditional care practices. Quality management and cost-effectiveness of patient care may be positively affected when using this approach (Huggins, & Phillips, 2008).
American Academy of Nurse Practitioners. (2017). AANP. Retrieved September 23, 2018, from https://www.aanp.org/all-about-nps/what-is-an-np
Gardner, K. (2017). What Is Utilization Management? Retrieved September 23, 2018, from http://www.apta.org
Joo, & Huber. (2014). Evidence-Based Nurse Case Management Practice in Community Health. Professional Case Management, 19(6), 265-273. Retrieved September 23, 2018.
Huggins, & Phillips. (2008, January). Using case management with clinical plans to improve patient outcomes. Retrieved September 23, 2018, from https://www.ncbi.nlm.nih.gov
Medicaid.gov. (2014). Managed Care. Retrieved September 23, 2018, from https://www.medicaid.gov/medicaid/managed-care/index.html
Utilization and Case Management
Utilization review is used to review patient care from the perspectives of quality of care, propriety of decision-making, length of stay, and medical necessity (Silberstein, 2018). Utilization review can be prospective, retrospective, or concurrent (Silberstein, 2018). Utilization is a safeguard against inappropriate or unnesseary medical care (Silberstein, 2018). Utilization management can help to promote best practice, cost efficiency, use of appropriate healthcare resources and improvement in patient care (Ghazisaeedi, Mohammadzadeh, & Safdari, 2014).
Case management is a collaborative process of planning, assessment, care coordination, facilitation, evaluation and advocacy for options and services that meet the individual and family’s medical needs through communication and resource that promote quality cost-effective outcomes. Case managers advocate for patients in care coordination, medication management, self-care support, monitoring and review (Ghazisaeedi et al., 2014). Case managers review utilization, improve the quality of patient care, save costs for clients, and improve patient outcomes (Ghazisaeedi et al., 2014). The case managers in the hospital where I am employed meet with the nurses in case conference, review utilization, and plan services for the patient once they are discharged to keep them out of the hospital.
Companies manage the care of clients and attempt to decrease costs by analyzing health care utilization. In the U.S. there are companies that manage private insurance cases and there are managed care companies that manage Medicaid clients. In a study by Shi & Zhang (2013), the authors found that managed care is generally associated with higher care utilization. According to Trombetta (2017), the provision of healthcare to the Medicaid segment of the population is shifting to a value based venue and empirical evidence of improvement in patient
care is lacking. However, recently development healthcare delivery models show promise in cost containment and quality care improvement (Trombetta, 2017).
APNs deliver insightful care that is based on critical thinking and evidence. APNs collaborate with other professionals to assure quality care. APNs perform assessments, evaluate the care needed for the client, refer when required, and plan the care of the patient. APNs are facilitators of patient centered care. I plan to include the patient in the care being provided by discussing plans and available resourses to promote quality outcomes.
Example of Case Management
In a study by deVet, van Luijtelaar, Brilleslijper, Vanderplasschen, & Beijersbergen (2013), the authors reviewed the literature on case management. They found that homeless persons had better outcomes when case managers were involved. Case management improved housing stability, reduced and removed employment barriers, and reduced substance use and abuse (de Vet et al., 2013).
De Vet, R., Van Luijtelaar, M. J., Brilleslijper, S. N., Vanderplasschen, W. P., & Beijersbergen, M. D. (2013). Effectiveness of case management for homeless persons: A systematic review. American Journal of Public Health, 103(10), 13-26. Retrieved from https://prx-herzing.lirn.net/login?url=https://sea…
Ghazisaeedi, M., Mohammadzadeh, N., & Safdari, R. (2014). Electronic health record (EHR) as a vehicle for successful health care best practice. Medical Archives, 68(6), 419-421. https://doi.org/10.5455/medarh.2014.68.419-421
Shi, P., & Zhang, W. (2013). Managed care and health care utilization: Specification of bivariate models using copulas. North American Actuarial Journal, 17(4), 306-324. https://doi.org/10.1080/10920277.2013.849192
Silberstein, G. S. (2018). Predictions of charges of individual hospital cases and a method for selecting cases for review. Management Accounting Quarterly, 19(2), 18-27. Retrieved from https://prx-herzing.lirn.net/login?url=https://sea…
Trombetta, W. (2017). Managed care Medicaid- How the delivery of healthcare to the most vulnerable healthcare population is changing: A general review. International Journal of Pharmaceutical and Healthcare Marketing, 11(2), 198-210. https://doi.org/10.1108/IJPHM-09-2016-0049