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Creating a Nurse Utilization Management Program

Introduction

Many healthcare organizations experience either overutilization or underutilization of their resources. These challenges create further problems with costs. In this particular scenario, the organization under consideration is experiencing underutilization of its resources hence the organization incurs high costs. The paper proposes a new service called Managed Care. The focus of Managed Care is to manage patients in the Veterans Affairs (VA) while utilizing care within VA hospitals rather than using community hospitals where the cost is significantly higher than VA hospitals. This paper addresses how to control costs using a change model to move patients back into the VA system. The change model is in the form of a nurse utilization program.

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The Need for the Proposed Change

The change being proposed in the organization is a result of the need to optimize the resources in the organization. At the moment, the organizational resources are underutilized because many patients use the community hospitals instead of the VA healthcare system.

Organizational Barriers to the Proposed Change

Disagreement on the need for transparency

Many clinical and administrative leaders are unsure of the need for scrutiny of the use of resources. Clinical leaders believe that this is their purview and that their autonomy should not be disturbed. They are unconvinced of the value of reviewing the use of resources during clinical transactions. However, administrative clinical and managerial leaders understand the potential benefits of the retrospective, concurrent and prospective examination of resource use (American College of Medical Quality, 2005).

Fear of creeping bureaucracy

Many clinical professionals, as opposed to administrative leaders, are certain that utilization review is an expansion of the administrative bureaucracy. Regardless of the potential clinical benefits, clinicians believe that they and their staff will waste clinical hours in nonproductive administrative bookkeeping and data manipulation (American College of Medical Quality, 2005).

Unfocused attention

Administrative and clinical leaders attempt to evaluate every aspect of clinical operations. Although this evaluation is a desirable goal, successful utilization management programs must focus their efforts on specific targets of opportunity: those procedures or service units that seem to be highly variable in their use of resources and are considered high-volume or high-risk services provided by the organization.

Inadequate resources

Some utilization management programs develop as pilot experiments. Such programs are often structured on a lean resource base and therefore are inadequately funded. Together with ambitious leadership that intends to review all services, this shortage of resources hampers the efforts of utilization management employees. Without sufficient resources, staff will be unable to document contributions to the organization and to the management of patient care within the expected period of time (American College of Medical Quality, 2005).

Poor team membership

Utilization management programs have been managed by physicians and nurses. Early efforts did not recognize that strong utilization management programs were interdisciplinary in nature and required a mix of medical service disciplines and administrative department representatives. Although the design of the team members appears to be a simple task, the participation of various stakeholders becomes a challenge in terms of team characteristics. A balanced group should be composed of junior and senior leaders who possess organizational advocacy and authority.

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Individual Barriers to the Proposed Change

Job security

The creation and implementation of a utilization management program creation of a specific department within the organization to oversee the process. This may require the organization to move the personnel from other departments to the newly created department. This may create anxiety within the affected employees and more so if they will assume new job titles roles and responsibilities. As a result, some of the employees may be resistant to the proposed change (Rossi, 2003).

Communication barriers

The creation and implementation of a utilization management program require successful communication between the utilization management committee and the various stakeholders, both internal and external. Specifically, the committee needs to communicate with the stakeholders about the resource utilization progress, and the impact of the program on the employees and management. Communication should also be done to recognize and reward group and individual efforts (Rossi, 2003).

Factors Influencing the Proposed Change

There are several factors that will affect the implementation of the proposed plan. These factors include third-party payer review and coordination, discharge planning monitoring, overutilization and underutilization surveillance, identification of quality of care and liability problems, financial issues, and physician and staff education. Third-party payer review and coordination involve a review of the medical record during a patient’s hospitalization to facilitate appropriate reimbursement. Coordination may also include facilitating referrals, for instance, to home health, rehabilitation, or long-term care for aftercare with the selected agencies of the third party.

The discharge planning and monitoring component facilitates appropriate, timely, and effective discharge planning. Discharge planning may actually be performed by nurses, social workers, case managers, or discharge planners (American College of Medical Quality, 2005).

Utilization management professionals review cases for appropriate use of resources using criteria sets, clinical pathways, or practice guidelines. Surveillance facilitates the identification or underutilization or overutilization of resources. During the course of the review, quality of care and risk/liability issues can be identified. Reporting of these issues to quality and risk management allows for timely corrective action. It is an integral part of an effective utilization program to obtain concurrent financial as well as clinical data on all cases. These data can educate providers about the cost of treating patients as well as provide the administration with information regarding case mix, cost, length of stay, complications, and mortality. A goal of every effective UM program is the education of physicians and staff in managing resources (Rossi, 2003).

Factors Influencing Organizational Readiness for the Proposed Change

Availability of resources

The organization can only be ready for the proposed change if it has adequate resources both human and physical resources to support the process. Without the resources, the organization will find it difficult to implement the utilization management program (Spector, 2010).

Education of the organization’s personnel

The organization can also only be ready for the creation and implementation of the utilization management program if the employees are educated and trained on the proposed change. Education and training create awareness among the employees

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The Theoretical Model that Relates to the Proposed Change

The theoretical model that relates to the utilization management program is quality improvement. Quality improvement is a process that entails changing the manner in which things are run in an organization so as to improve the quality of the services offered while minimizing the costs at the same time. Utilization management will ensure the achievement of these two goals by minimizing the wastage of resources while ensuring that the patients receive adequate care.

Internal Resources Available to Support the Change Initiative

Human resource

The organization requires a committed human resource to support the utilization management program. The employees need to work collaboratively towards the accomplishment and success of the program (Borkowski, 2005).

Financial resources

The organization needs substantial financial resources to oversee the creation and implementation of the utilization management program. The financial resources will be used in the purchase of material resources and the reimbursement of the human personnel.

Information technology

The creation and implementation of the utilization management requires huge data of the clients as well as providers. This huge database can only be effectively and successfully managed through advanced information technology systems.

External Resources Available to Support the Change Initiative

Consultants

The organization will require external resources in the form of experts or consultants. The consultants will provide the organization with the knowledge and skills required to create and implement the utilization management program effectively. The consultants will come in handy in situations where the organization lacks certain skills and knowledge.

Conclusion

The paper proposes a change initiative in the form of a nurse utilization management program. The program aims at increasing the utilization of the organization’s resources and avoiding wastage. Nevertheless, various factors determine the success of the program’s creation and implementation. It is thus the management’s responsibility to ensure that these factors are dealt with to ensure the smooth running of the change process.

References

American College of Medical Quality. (2005). Core curriculum for medical quality management. Sudbury, MA: Jones & Bartlett.

Borkowski, N. (2005). Organizational behavior in health care. Sudbury, MA: Jones and Bartlett Publishers.

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Rossi, P. (2003). Case management in healthcare. New York: Elsevier Health Sciences.

Spector, B. (2010). Implementing Organizational Change: Theory into Practice (2nd ed.). Upper Saddle River: NJ: Pearson Prentice Hall.

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StudyCorgi. 2022. "Creating a Nurse Utilization Management Program." May 4, 2022. https://studycorgi.com/creating-a-nurse-utilization-management-program/.

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