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Using case vignettes to train clinicians and utilization reviewers to make level-of-care decisions
P B Rosenquist1, C C Colenda, J Briggs
1Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1087, USA. rosenqui@wfubmc.edu
Psychiatric Services (Washington, D.C.)
|November 1, 2000
Summary
Academic health systems can improve care decisions by internalizing utilization review. This approach addresses provider challenges and drives best practices through data-driven insights.
Area of Science:
- Health Services Research
- Healthcare Management
- Behavioral Health Services
Background:
- Managed behavioral health organizations (MBHOs) traditionally provide utilization review (UR) and case management.
- Academic health systems often experience challenges with external UR processes.
- Internalizing UR functions offers a potential solution for providers.
Purpose of the Study:
- To describe the process of an academic health maintenance organization (HMO) internalizing its utilization review function.
- To explore how this internalization facilitates data-driven improvements in clinical decision-making.
- To present a model for achieving best practices in healthcare delivery.
Main Methods:
- Collaborative training between an academic HMO and an external MBHO on level-of-care decision-making.
- Transition of UR responsibilities from the external MBHO to the academic department.
- Internal data collection and analysis for quality improvement.
Main Results:
- Successful internalization of the UR function within the academic department.
- Development of a process to leverage internal data for enhanced clinical decision-making.
- Establishment of a pathway toward evidence-based best practices.
Conclusions:
- Internalizing utilization review can empower academic health systems to better manage care.
- This model offers a solution to mitigate negative impacts of external UR on providers.
- Data-driven internal UR processes are crucial for achieving and refining best practices in healthcare.