What are the best practices for Utilization Management in different settings and populations?

1 Acute care

Acute care refers to the provision of short-term, intensive, and often life-saving medical treatment for patients with serious illnesses or injuries. Utilization management (UM) in acute care settings involves managing the admission, discharge, and transfer of patients, as well as the utilization of resources such as beds, staff, equipment, and medications. To ensure successful UM in acute care, best practices include implementing evidence-based criteria and protocols to guide admission and discharge decisions, coordinating care transitions with multidisciplinary teams, monitoring length of stay and readmission rates, and engaging patients and families in shared decision-making. These practices can help identify opportunities for improvement and benchmarking while providing education about patient conditions, treatment options, and discharge goals.

2 Ambulatory care

Ambulatory care refers to the provision of outpatient services that don't require hospitalization, such as primary care, specialty care, preventive care, and diagnostic tests. Utilization Management (UM) in ambulatory care settings is essential for ensuring the appropriateness, quality, and efficiency of the services delivered. Best practices for UM include developing and implementing clinical pathways and guidelines to reduce variation and overuse, utilizing prior authorization and concurrent review processes to verify medical necessity, eligibility, and coverage of services requested and provided, promoting patient-centered medical homes and integrated care models to foster collaboration among providers, patients, and payers, as well as leveraging health information technology and data analytics to support clinical decision-making.

3 Behavioral health

Behavioral health refers to services that address the mental and emotional well-being of patients, such as counseling, psychotherapy, medication management, and substance abuse treatment. UM in behavioral health settings involves assessing and managing the level of care, intensity of service, and duration of treatment for patients with various behavioral health needs and conditions. To ensure the best care for patients, a biopsychosocial approach should be adopted that considers biological, psychological, and social factors. Recovery-oriented and trauma-informed principles should also be applied that respect the patient's autonomy, strengths, preferences, and goals. It is important to collaborate with behavioral health specialists, primary care providers, and community resources to provide comprehensive and coordinated care and referrals. Additionally, outcome-based and value-based payment models should be implemented that reward quality, effectiveness, and efficiency of care while incentivizing innovation and integration.

4 Chronic care

Chronic care involves providing ongoing services and support for patients with long-term, complex, and often multiple chronic conditions. UM in chronic care settings requires managing the complexity, cost, and coordination of care for these high-risk and high-need patients. The best practices for UM in this setting include identifying and stratifying patients based on their risk profile, disease severity, and care needs using risk assessment tools and predictive modeling. Additionally, individualized care plans should be developed to address the patient's medical, behavioral, social, and functional needs and goals. Care management and care coordination services should be provided to facilitate access to care, medication adherence, self-management education, and follow-up. Lastly, engaging patients and caregivers in chronic disease management programs and interventions can help enhance their knowledge, skills, confidence, and motivation.

5 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?