How can you use utilization management to reduce readmissions?

1 What is UM and why is it important?

UM is a set of activities that involve reviewing, evaluating, and managing the use of healthcare services, facilities, and resources. UM can be performed by different stakeholders, such as payers, providers, or third-party organizations. The main goals of UM are to improve patient outcomes, enhance quality of care, reduce waste and variation, and control costs. UM is important because it can help you align your clinical and financial objectives, comply with regulatory and accreditation standards, and meet the expectations of your customers and partners.

2 How does UM relate to readmissions?

Readmissions are defined as the return of a patient to a hospital or other facility within a specified time period after being discharged. Readmissions can be planned or unplanned, and they can be influenced by various factors, such as patient characteristics, clinical conditions, discharge planning, follow-up care, and coordination of care. UM can help you reduce readmissions by ensuring that your patients receive the right care at the right time and at the right place. UM can also help you identify and address the root causes of readmissions, such as gaps in care transitions, medication errors, or lack of patient education.

3 What are some UM strategies to reduce readmissions?

Implementing UM strategies can help reduce readmissions in your healthcare organization. For example, pre-admission screening can assess the medical necessity, appropriateness, and eligibility of a patient's admission, while concurrent review can monitor and evaluate ongoing care. Discharge planning is also important, as it helps ensure that patients have a clear and comprehensive plan of care and access to necessary follow-up services and support. Finally, case management provides ongoing guidance and support to patients and their families throughout the continuum of care.

4 How can you measure and improve your UM performance?

To measure and improve your UM performance, you need to establish and track metrics and indicators that reflect your UM objectives and outcomes. These include the readmission rate, readmission cost, readmission reason, and patient satisfaction. The readmission rate can be calculated by dividing the number of readmitted patients by the number of discharged patients, and it can be compared to national or regional benchmarks. The readmission cost can be calculated by multiplying the number of readmitted patients by the average cost per readmission; it can also be compared to potential savings from reducing readmissions. The readmission reason can be analyzed using clinical classification software (CCS) or other coding systems, while patient satisfaction can be measured using surveys, interviews, or other feedback tools. By measuring and analyzing these metrics and indicators, you can evaluate your UM performance, identify strengths and weaknesses, and implement improvement actions. Quality improvement methods such as the Plan-Do-Study-Act (PDSA) cycle can guide the improvement process.

5 What are some best practices and tips for UM to reduce readmissions?

Successfully using UM to reduce readmissions requires following best practices and tips, such as engaging leadership and staff, involving patients and families, partnering with payers and providers, and utilizing evidence-based and data-driven tools and techniques. A strong and committed leadership team that supports UM as a core value is necessary, as well as a dedicated staff that performs UM functions effectively. It is also essential to have a patient-centered approach that respects the needs of patients and their families. Additionally, a collaborative relationship with payers and providers should be established in order to align incentives, expectations, and standards. Lastly, a reliable system for collecting, analyzing, and reporting data on UM activities and outcomes should be used in combination with comprehensive policies, procedures, and protocols based on best available evidence.

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?