QUESTION 1: UTILIZATION MANAGEMENT – WHAT IT IS, AND WHAT IT ATTEMPTS TO DO.

QUESTION 1: UTILIZATION MANAGEMENT – WHAT IT IS, AND WHAT IT ATTEMPTS TO DO.

 

 

USING ATTACHED OVERVIEW 9, PAGES 1 – 5; POWERPOINT 12, SLIDES 1 – 8. ANSWER THE FOLLOWING:

 

PART A: What are TWO (2) of the main goals of Utilization Management?

 

PART B: Whose behavior do most Utilization Management approaches try to influence?

 

(For Example: Through Utilization Review, Reducing Hospital Acquired Complications, Improving Care Coordination).

 

PART C: Which kinds of health care organizations implement Utilization Management programs in the 21st Century?

 

 

 

QUESTION 2: TRADITIONAL UTILIZATION REVIEW – BASIC COMPONENTS.

 

 

OVERVIEW 9, PAGES 6 – 7; VIDEO 2.B., SLIDES 2-3, 9-10, 5 – 11.

READING 2; AND READING 3 (FOR EXAMPLES).

 

 

PART A:        Briefly define Utilization Review.  (NOTE: Utilization Review is one of the oldest components of Utilization Management.) 

 

OVERVIEW 9, PAGES 6 – 7; VIDEO 2.B., SLIDES 10 – 11; READING 2.

 

PART B:        Briefly describe what Prospective Review does. READING 2.

 

PART C:        Briefly describe what Concurrent Review does. READING 2.

 

PART D:        Clinical Standards: What is their role in Utilization Review decisions about appropriate use of medical services?  

 

(READING 3, FOR SOME EXAMPLES, AND VIDEO 2.B., SLIDES 5 - 8): 

 

 

 

 

 

QUESTION 3: IDENTIFYING HIGH UTILIZERS OF HEALTH SERVICES AND CHANGING THEIR BEHAVIOR.

 

OVERVIEW 8, PAGE 3; READING 4; READING 5.

 

 

PART A:        Briefly describe what “Hot Spotting” programs are designed to do. READING 4

 

PART B:        Are “Hot Spotting” programs equally focused on the provision of appropriate medical services AND the provision social support services to the high utilizers whom they identify? YES OR NO?               READING 4. (Also, READING 6 may help you.)

 

PART C:        What kinds of high utilizers does the Blue Cross program described in Reading 5 identify? READING 5.        

 

 

 

 

QUESTION 4: IMPROVING CARE BY FOCUSING ON SOCIAL DETERMINANTS OF HEALTH.

 

 

USING ATTACHED READING 6.

 

PART A:        Give TWO (2) examples of Social Determinants of Health.

 

PART B:        Give ONE (1) example of how addressing Social Determinants of Health, in addition to providing the right Medical Treatment, is CRITICAL for ensuring that patients get better, and do not have to keep coming back to the hospital for additional health care goods and services.

 

 

 

 

 

 

 

 

 

 

 

 

QUESTION 5: DISEASE MANAGEMENT.

 

 

USING OVERVIEW 9, PAGE 11; AND READINGS 7.A., 7.B., AND 7.C.   ANSWER THE FOLLOWING:

 

PART A:  Disease Management targets people with which kinds of clinical conditions?

 

READINGS 7.A. AND 7.C.

 

 

 

PART B:  Does Disease Management use a data – based Population Health approach to identify the Insurance Plan Enrollees who may need Disease Management services? YES OR NO?

 

READING 7.A

 

 

PART C:  Briefly describe the Collaborative Model of Care Delivery which is the basis for the services which Disease Management offers to the individuals and families which it identifies.

 

READINGS 7.A. AND 7.C.

 

 

PART D:  How does Disease Management DIFFER from Large Case Management in terms of a focus on?

 

• Single patients, or a whole population of persons with particular clinical conditions?
• People with acute catastrophic conditions, or people with targeted chronic conditions?
• People with seriously acute, or with moderately acute clinical conditions?

 

READING 7.B.