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Case management: two regulations with coexisting functions (utilization review + discharge planning = case
1Professional Services for Curaspan, Inc/e Discharge. jbirmingham@curaspan.com
Professional Case Management
|March 28, 2007
Summary
Hospitals often struggle to balance utilization review and discharge planning in case management. This study examines trends causing this imbalance and offers recommendations for rebalancing these essential functions.
Area of Science:
- Healthcare Administration
- Case Management
- Health Services Research
Background:
- Hospitals perform two mandated functions: utilization review and discharge planning.
- These functions directly impact case management operations.
- A trend exists where utilization review (financially driven) is prioritized over discharge planning (needs-based).
Purpose of the Study:
- To examine trends in case management that have led to an imbalance between utilization review and discharge planning.
- To provide recommendations for rebalancing these coexisting functions within healthcare settings.
Main Methods:
- Analysis of trends in case management practices.
- Review of hospital operational models.
- Synthesis of existing literature on utilization review and discharge planning.
Main Results:
- An observed shift in focus towards fiscally driven utilization review.
- A potential detriment to needs-based discharge planning due to this imbalance.
- Identification of factors contributing to the prioritization of one function over the other.
Conclusions:
- Rebalancing utilization review and discharge planning is crucial for effective case management.
- Recommendations are proposed to restore equilibrium between these functions.
- Optimizing both functions can lead to improved patient care and hospital efficiency.
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