In many an agency, hospital and insurance company, the Utilization Management or Utilization Review teams are seen as the antithesis of clinical services.
Tasked with reducing expenses for the organization, determining the right level of care for a patient, and helping move the patient through the continuum of care from highest and most expensive to lowest and least expensive, the UM/UR departments are the bean counters of clinical organizations. Clinicians often see them as getting in the way, as being stingy with the services that are available. They are the “No” team. No, this patient cannot stay longer, no this patient cannot be admitted to this facility or that after care program.
But is this true? Is there any good that comes from these accountant types? Do they even understand what the clinicians are trying to do out here?
The Readmission Problem
It may help to understand how the utilization teams are measured. What is success for them? One of the main measurements is how often a patient is readmitted to the hospital within 30 days of discharge.
According to Heslin & Weiss (2015), the average cost per readmission for the same psychiatric or substance use diagnosis as the first admission is between $6,500 and $13,600. The average percentage of readmissions for the same psychiatric or substance use diagnosis is between 3.8 and 15.7% with schizophrenia being the diagnosis with the highest readmission rate, followed by mood disorders as the next highest diagnosis with readmissions.
The goal of most hospitals and agencies is to reduce the readmission rate to somewhere between 6 and 15 percent.
Clinicians are looking at what is in front of them. Especially in an inpatient setting, clinicians are very focused on the here and now. This person feels this way right now, and we need to get them to feel another way. They are using substances, they are feeling suicidal, they are feeling depressed, they are feeling or acting out of control. We need to get them past this place and get them ready to discharge. There are only so many interventions that can happen in the hospital. The era of deinstitutionalization from the 70’s rightfully limits how long people should remain in the hospital so long term hospitalizations are a thing of the past, except in very rare instances. The goal is stability and then releasing the patient back to the community.
So in an inpatient setting the focus is on creating safety; psychiatric intervention to assess and often medicate the patient; groups to bring awareness to the patient’s current situation and to adjust future thinking; and discharge planning to figure out the next steps. Community based outpatient treatment is where the magic happens!
Inpatient and outpatient teams should be coming together to develop a solid discharge plan so that the magic is ready to happen when the patient leaves the hospital. Coordination between those two teams, the patient, and the family is crucial. What needs will the patient have? How and where will they get their medications filled and continued? Where will they go? Do they have a safe and appropriate place to live? How can what they have learned in the hospital be reinforced in the community? What resources can be contacted? What support does the patient need in order to connect to those resources? Do they need transportation to those resources? Do they have the skills and knowledge necessary to get there and to truly connect and engage?
Inpatient Utilization Review
The inpatient Utilization Review team is the key to making sure there is a solid discharge plan in place when the patient leaves the hospital. They pitch the inpatient timeline to the payer source and then they hold the inpatient team accountable for getting the work done during that timeline in preparation for the discharge. This timeline includes getting the patient, family, and outpatient team as well as other collateral resources lined up to support this member upon discharge. If the plan is not solid when the authorization ends, the UR team will have to pitch for more time and they will have to look closely at the reasons why the plan is not in place. Is it because of the patient? Or is it because the professionals involved have not coordinated in a timely enough manner to be ready for what we all knew was coming? There are a lot of moving parts to a proper discharge plan and it is the UR department’s job to make sure they all come together to coincide with the patient’s wellness and the payer’s authorization. If the authorization ends before the patient is ready to discharge with a solid discharge plan, then the readmission will happen.
Outpatient Utilization Management
The outpatient Utilization Management/Review team is tasked with holding their outpatient team accountable for creating and executing the discharge plan. The best laid plans can be put on paper during the hospitalization, but if nothing happens when the patient leaves, then it has no value. The readmission will happen if the patient believes that something in particular will happen when they leave and it does not happen. From their perspective, promises have been broken and the hard work that they have put into their recovery is inconsequential when the support they were promised disintegrates when they walk out the door of the hospital.
The outpatient UR/UM team reviews the discharge plan, they follow up to be assured that the plan is being executed by the outpatient team. If the patient readmits, they review the prior plan and determine what went wrong. Was the plan unrealistic? Did agency staff fail to fulfil their responsibilities? Did the patient fail to engage? Why? How can that be different next time?
Utilization Review is not the Enemy
Coordination of care between all of these parties in support of one struggling patient is tricky. There are many players, all with their own agendas, pressures, caseloads and goals. The underlying goal of everyone though is to provide the services that will best support the patient. UR/UM does this by creating the process and the accountability for that process whereby the patient will be supported during what will likely be some of the darkest days of their year. By examining the historical and current admissions for the patient, and planning to avoid the need for the next one, UR/UM provides and supports good clinical services every step of the way.
Heslin KC (AHRQ), Weiss AJ (Truven Health Analytics). Hospital Readmissions Involving Psychiatric Disorders, 2012. HCUP Statistical Brief #189. May 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb189-Hospital-Readmissions-PsychiatricDisorders-2012.pdf.
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