How can you ensure cost-effective care delivery?

1 Understand the criteria

Utilization management and review (UMR) is the process of evaluating the appropriateness, necessity, and efficiency of health care services, procedures, and facilities. UMR can be done prospectively, concurrently, or retrospectively, depending on the purpose and scope of the review. To ensure cost-effective care delivery, you need to understand the criteria and guidelines that are used to assess the level of care, the length of stay, the discharge plan, and the follow-up services for your clients. These criteria may vary depending on the payer, the provider, the diagnosis, and the evidence-based practices.

2 Communicate effectively

Communication is essential for successful UMR, as you need to coordinate with multiple stakeholders, such as clients, families, providers, payers, and regulators. You need to communicate clearly, timely, accurately, and respectfully, using the appropriate channels and methods. You also need to document your communication and decisions in a comprehensive and consistent manner, following the standards and policies of your organization and profession. Effective communication can help you avoid delays, denials, disputes, and errors that may affect the cost and quality of care delivery.

3 Advocate for your clients

As a case manager, you have a dual role of being an advocate for your clients and a steward of resources. You need to balance these roles by ensuring that your clients receive the care that meets their needs and preferences, while also respecting the limitations and requirements of the health care system. You need to educate your clients and families about their rights and responsibilities, their options and alternatives, and their benefits and costs. You also need to negotiate with payers and providers to obtain the best possible outcomes for your clients, while also complying with the UMR criteria and processes.

4 Monitor and evaluate

UMR is not a one-time event, but a continuous cycle of monitoring and evaluating the care delivery process and outcomes. You need to track and measure the indicators and metrics that reflect the cost-effectiveness of your interventions, such as the utilization rate, the readmission rate, the satisfaction rate, and the quality of life. You also need to collect and analyze feedback from your clients, families, providers, payers, and colleagues to identify the strengths and weaknesses of your UMR practices. You need to use this data and information to improve your performance, adjust your plans, and report your results.

5 Learn and update

UMR is a dynamic and complex field that requires constant learning and updating of your knowledge and skills. You need to stay informed of the latest trends, developments, and innovations in health care delivery, such as new technologies, models, and standards. You need to update your UMR criteria and guidelines according to the best available evidence and practice. You also need to participate in ongoing education, training, and certification programs to enhance your competence and credibility as a case manager.

6 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?