Utilization Management

The principal objective of utilization management is the reduction of practice variations by establishing parameters for cost-effective use of health care resources. There are four main techniques or tools used in utilization management: demand management, utilization review, case management, and disease management. Utilization management helps MCOs control costs and improve quality.

Refer to the readings of this week and the Internet on the above information, answer the following questions:

What are the challenges faced by MCOs regarding practice variations? What do you think can be done to meet these challenges?
Differentiate between the three main processes of institutional utilization management.
Determine the main purposes of each process of institutional utilization management? Which process do you think is the most important, and why?
Research the role of the utilization management nurse.
Explain the functions of the utilization management nurse, and compare and contrast the information from that organization.
Explain your understanding of disease management and case management. What in your opinion are one major similarity and one major difference between the two types of management?
Now, access information on disease and case management by searching the Internet by using the following keywords:

Care Continuum Alliance
Commission of Case Manager Certification
Based on your research, answer the following questions:

What is the purpose or mission of these professional organizations?
What standards do these organizations set for certification or membership?
How do these organizations define disease or case management and do they differ from the text definitions?

Case Study

A 46-year-old, 230lb woman with a family history of breast cancer. She is up to date on yearly mammograms. She has a history of HTN. She complains of hot flushing, night sweats, and genitourinary symptoms. She had felt well until 1 month ago and she presented to her gynecologist for her annual gyn examination and to discuss her symptoms. She has a history of ASCUS about 5 years ago on her pap, other than that, Pap smears have been normal. Home medications are Norvasc 10mg qd and HCTZ 25mg qd. Her BP today is 150/90. She has regular monthly menstrual cycles. Her LMP was 1 month ago.

 

Post a brief description of your patient’s health needs from the patient case study you assigned. Be specific. Then, explain the type of treatment regimen you would recommend for treating your patient, including the choice of pharmacotherapeutics you would recommend, and explain why. Be sure to justify your response. Explain a patient education strategy you might recommend for assisting your patient with the management of their health needs. Be specific and provide examples.

Quantitative methods in nursing practice

Discuss why the quantitative method is the best method based on your project questions and data. Choose three potential designs that you could use for your project. Based on the three potential designs, determine potential analyses methods and why?

Clinical/PICOT Questions:
Do elderly patients in long-term care (P) that have a urinary Foley catheter that is placed on a Prevention Strategy Urinary Catheter Protocol (I) experience reduced chances of acquiring catheter-associated urinary infections (O) compared to those without (C) within 4 weeks of implementation?

The quality improvement will be based on a perspective that will be carried out on elderly patients in medical/surgical/telemetry. The setting for the study is West Covina, CA 76-bed hospital. The hospital provides care for patients in West Covina and the surrounding communities. The quality improvement project will also be supported by the hospital’s management at all levels. The quality improvement will involve of patients 65 years and older.

How do the ten commandments of data collection relate to public health professionals?
How to use and explain the charts for each variable. For the most part, I am having a difficult time trying to determine which graph best suits the variable.

A baccalaureate nurse understands, relates, and values the fundamental elements of research, process, and designs as a foundation for evidence-based practice (AACN, 2008; QSEN, 2018).

Purpose:

This assignment provides a learning activity for students to demonstrate understanding of quantitative and qualitative research, the purpose and importance of designs, and how research is critical for creating a credible evidence-based nursing practice.

Course Outcomes:

This assignment enables the student to meet the following Course Outcomes.

CO 1: Examine the sources of evidence that contribute to professional nursing practice. (PO 7)

CO 2: Apply research principles to the interpretation of the content of published research studies. (PO 4 & 8)

CO 5: Recognize the role of research findings in evidence-based practice. (PO 7 & 8)