Houston Methodist’s Utilization Management Program
Houston Methodist embraces various models and health terminologies in order to remain a leader in healthcare delivery. Comprised of six different hospitals, the institution focuses on the best health practices in an attempt to deliver quality care to more citizens in Houston. The hospital has implemented a powerful utilization management program to address the needs of more patients and deliver quality care to them (Houston Methodist, 2016). The institution utilization management (UM) program is implemented as a powerful initiative capable of supporting the needs of every patient.
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The UM program is characterized by a number of functions (Plebani, Zaninotto, & Faggian, 2014). The first function is known as preadmission review and management. During this function, different physicians analyze and understand the health needs of every new patient. Admissions for inpatients are done depending on their needs and the availability of resources. Such resources are used to ensure the targeted individuals receive quality medical support. The admission process is managed by competent healthcare professionals in order to present the most desirable proposals (Houston Methodist, 2016).
The second function of the program is “the admission, continued to stay, and readmission review” (Houston Methodist, 2016, para. 3). This function treats healthcare delivery as a continuum especially for patients who have been admitted to different hospitals. During this stage, patients are monitored in order to ensure they receive quality medical support. The relevant decisions and medications are considered during this phase. The ultimate goal is to ensure the admitted patients get exemplary health support. The UM team embraces the most appropriate practices to prevent never events and support the diverse needs of different patients.
The next stage is “the management of observation status of patients” (Houston Methodist, 2016, para. 5). The hospital has hired utilization specialists and case managers (CMs) to manage the experiences of newly-admitted patients. These professionals monitor the health conditions and outcomes of the targeted patients. The status of every patient is analyzed in order to ensure the available resources are used to address his or her needs. Whenever necessary, referrals are made thus ensuring the best health services are available to the targeted patients.
Precertification of managed care for patients is another critical aspect of the UM program (Houston Methodist, 2016). This practice is aimed at analyzing the quality of care provided to different patients. Recertification is done to minimize delays or inadequacies of care. Any form of delay is addressed by the relevant professionals. The hospital’s UM program supports more physicians embrace evidence-based practices that can benefit different patients. The program has been observed to reconcile patient-specific needs with the services available at the hospital.
Another “unique function of the UM is the medical necessity denial management” (Houston Methodist, 2016, para. 8). The purpose of this function is to monitor when services might not be able to meet the needs of the patients. Denials are appealed in a timely manner in order to ensure the patients receive quality care. Every identified issue throughout the healthcare delivery process is identified and addressed (Plebani et al., 2014).
This program, therefore, continued to support the institution’s goals. A pre-billing review is done for Medicare cases. This practice is aimed at assuring that medical necessity, level of care, and documentation meet the provided federal regulations.
Comparing and Critiquing Houston Methodist’s UM Program to that of Johns Hopkins Hospital
Houston Methodist is one of the best healthcare institutions in the United States. This is the case because the institution uses powerful procedures to deliver quality and evidence-based care to its patients. However, the hospital’s UM program can be compared with that of a model facility such as Johns Hopkins Hospital (The Johns Hopkins Hospital, 2016). The latest rankings show clearly that Johns Hopkins Hospital outperforms Houston Methodist in terms of health service delivery. A comparison of these institutions’ UM programs can present meaningful insights that have the potential to make Houston Methodist successful.
Johns Hopkins Hospital’s program has four unique phases. These include referral management, preauthorization, concurrent review, and the retrospective review. On the other hand, Houston Methodist’s UM program does not have distinct steps or phases. The referral management phase is aimed at minimizing unnecessary admissions. Cases that do not meet the existing criteria are denied or allowed to get appropriate care elsewhere.
The second phase embraced by Johns Hopkins Hospital is executed to ensure the best decisions are made throughout the healthcare delivery process. Preauthorization is done to ensure the patients are allocated to the most desirable healthcare settings. The “concurrent review phase minimizes denials while at the same time ensuring every patient is placed at the best point of care” (The Johns Hopkins Hospital, 2016, para. 7). The process is also used to coordinate care and plan for discharge. The final stage monitors the quality of care available to different patients in the hospital.
After comparing the UM programs used by the two hospitals, it is notable that Johns Hopkins Hospital adheres to the recognized standard for utilization management. This is the case because unnecessary admissions are avoided during the first stage. At Houston Methodist, the UM program is not properly defined (The Johns Hopkins Hospital, 2016). What stands out is that the hospital’s program is guided by its mission of delivering exemplary services to more patients.
From an analytical perspective, it is notable that Johns Hopkins Hospital’s UM program embraces the power of utilization review to ensure the needs of more patients are supported. This is the case because the program monitors the existing gaps throughout the healthcare delivery process and presents powerful recommendations that can support the needs of the targeted patients. The utilization review is executed to analyze the quality of patient care and decision-making processes (The Johns Hopkins Hospital, 2016).
Delays and never events are prevented through the use of an effective utilization review. The gathered information is used to make new improvements capable of delivering quality and timely care to every patient.
Similarly, the utilization review process has continued to play a positive role at Houston Methodist. This is the case because it leads to new ideas and practices that can result in improved patient care. The existing gaps in care delivery are identified during the review process. Positive decisions and quality improvements are made based on the information obtained during the utilization review process. The hospital acquires new resources and human capital in order to improve the quality of care available to more clients (Houston Methodist, 2016). This approach explains why Houston Methodist is a revered healthcare institution.
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Areas for Improvement and Recommendations to Improve Patient Care
Houston Methodist’s utilization management (UM) program has been effective in delivering quality care to more clients. However, the program does not have distinct phases or functions. This issue has caused confusion thus affecting the performance of different healthcare providers. The institution should therefore borrow a lot from Johns Hopkins Hospital. The approach will ensure the UM program is capable of supporting the needs of more patients (The Johns Hopkins Hospital, 2016).
The institution should also ensure the utilization review process is supported by feedback from different stakeholders. Such reviews can be used to implement the most desirable improvements (Plebani et al., 2014. This evidence-based practice will eventually make the facility’s healthcare delivery model sustainable.
The main recommendation that can make a difference for Houston Methodist is the inclusion of lean-based principles. These principles will ensure the UM program is evidence-based and guided by the unique needs of the targeted clients. The use of the principles will make it easier for the hospital to minimize wastes and deliver evidence-based services guided by the changing needs of the targeted customers (Lawal et al., 2014). The lean concept has been applied in healthcare to improve the processes used to deliver care to different patients. This approach will play a critical role in improving the quality of patient care.
The second recommendation is summarizing the UM program so that it captures four distinct phases. These phases will improve the level of coordination and monitoring. Different issues such as billings and placement of patients will be executed in a timely manner. The approach will make it easier for the hospital to strike a balance between the existing resources and the needs of its patients (Lawal et al., 2014). Different healthcare professionals and workers should be empowered to support the needs of more patients. These recommendations will make Houston Methodist one of the leading providers of culturally-competent, timely, and evidence-based health support.
Houston Methodist. (2016). Web.
Lawal, A., Rotter, T., Kinsman, L., Sari, N., Harrison, L., Jeffrey, C.,…Flynn, R. (2014). Lean management in health care: definition, concepts, methodology and effects reported (systematic review protocol). Systematic Review, 3(1), 103-123.
Plebani, M., Zaninotto, M., & Faggian, D. (2014). Utilization management: a European perspective. Clinica Chimica Acta, 427(1), 137-141.
The Johns Hopkins Hospital. (2016). Web.