Utilization and Case Management
Utilization management refers to a process where physicians, healthcare providers, and payers use an evidence-based approach to determine the efficiency, appropriateness, and necessity of a particular health program on a patient. Utilization management can be conducted retrospectively, prospectively, or concurrently. Similarly, case management is the coordination of patient needs on time to enhance positive health outcomes that are not only efficient but also cost-effective (Harris and Popejoy, 2018). Utilization management focuses on ensuring that patients receive the right care at the most appropriate time. On the other hand, case management refers to all interventions undertaken to improve the quality of care on a patient, as well as reduced the cost of such services. Case management applies commonly to patients with complex health conditions such as chronic co-morbid, psychological needs, among others (Wickizer and Lessler, 2002). It aims to find the most effective, convenient, and least costly manner to offer care to a patient.
APNP clinical expertise acts as a foundation for utilization and case management since APNs have the requisite knowledge needed to implement case management scenarios (Case Management Society of America, 2015). They can analyze client health conditions, and prescribe the best case management scenario that is cost-effective. Research by Lee et al. (2017) revealed that involvement of APNs in case management and utilization among critical care patients led to improved treatment and patient satisfaction, as well as reduced costs and mortality rates.
An example of case management and how it improves patient care is illustrated below. John, who has muscular dystrophy and frequently breathes with the help of a ventilator, attends the clinic weekly to see a physician. The whole idea is costly and time-consuming. To address the challenge, a case manager and the insurer to inquire whether he and the hospital could find an arrangement to make the process cheaper. After visiting his home, the physicians recommend that John can be attended from home, a physician who lives in the neighborhood. Such a plan reduces the cost of healthcare and offers John constant care from an APNP hence improving his overall health. Such is an example of utilization and case management that helps improve patient care.
References
Case Management Society of America. (2015). “What is A Case Manager?” (Links to an external site.)
Harris, R.C, and Popejoy, L.L (2018). “Case management: An evolving role.” Western Journal of Nursing Research. https://journals.sagepub.com/doi/10.1177/0193945918797601
Lee, J. X. Woo, B.F, and Tam, W.S. (2017). “The impact of the advanced practice nursing role on quality care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: a systemic review.” Human Resources for Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5594520/
Wickizer, T. M, and Lessler, D. (2002). “Utilization management: Issues, effects, and future prospects.” (Links to an external site.) Annual Review of Public Health.