Utilization & Care Management

Utilization & Care Management

Objectives. Participants will learn how to:

  1. Coordinate with hospital staff on discharge planning and receive notifications when assigned members are admitted and discharged
  2. Develop and support case management programs for high-risk and highly-acute members
  3. Develop and manage chronic disease management priorities and programs that are supported with care teams, registries, protocols, alerts, analysis and reporting
  4. Develop and manage care plans
  5. Develop standards and policies for overseeing and managing appropriate care guidelines and utilization standards
  6. Create processes for reviewing member care based on medical necessity, quality and appropriateness

Note: Some of the objectives and topics may be supported by CCI curriculum and should be developed in coordination with CCI activities

 Curriculum Description

  1. Care coordination and care transitions:
    1. Coordinating care with continuum partners including primary care, specialists hospitals, post-acute care (PAC), palliative care, pharmacy, lab and other services
    2. Creating mechanisms and processes for receiving and responding to notification when member are admitted to hospitals, EDs and PAC facilities
    3. Staffing requirements to manage access and support same day visits
    4. Conducting outreach to patients
    5. Understanding the impact of ACA Section 2703 (PCMH)
    6. Partnering with plans to identify high-risk patients and to support predictive analytics
  2. Case management:
    1. Coordinating with health plan case managers
    2. Embedding case managers at sites of care
    3. Understanding and establishing necessary qualifications and training requirements for case managers
  3. Chronic disease management and prevention:
    1. Developing care plans
    2. Creating and utilizing registries and EHR health maintenance modules (See also: Reporting & Analysis section)
    3. Utilizing appropriate alternative touches
  4. Overview of utilization management (UM) and utilization review (UR)
    1. Coordinating UM and UR processes with health plans and MSOs

Suggested team member participants:  C Suite (CMO, COO), Care Management and Coordination, IT

If you have any dietary restrictions, please email Charlotte Reische, atcreische@cpca.org.

7/20/2017 9:00 AM - 4:30 PM
QLN Conference Center 1938 Avenida Del Oro Oceanside, CA 92056 UNITED STATES

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