How does utilization review differ from case management?  In either case, nurses assess patient needs and find solutions to various health care-related issues.  While the focus of utilization review is on discharge planning, the focus of a case manager may include more complex problem solving and finding healthcare resources to meet the patient’s continuing needs in the community or other setting.  Utilization review nurses assess patients and if needed, refer cases for review to physicians.  Along the way, they also provide explanation of length of stay requirements; establish criteria necessary for the level of care, and other information.  Both utilization review nurses and case managers attend multi-disciplinary meetings, and coordinate patient care and treatment with the hospital staff.

Nurses experienced in utilization review who may be seeking a job change can view our  nurse job bulletin, which offers a variety of employment opportunities across the country.  If you are interested in utilization review as a career choice, some requirements include the ability to work with minimal supervision, work independently, ability to use sound judgement and be familiar with medical terminologies, medical conditions, and medications.   Knowledge of insurance policy language, alternate resources, and knowledge of criteria for decision-making is a must, in order to assist in finding cost-saving ways without compromising quality of patient health care resources.

Physical status is evaluated against the criteria and a determination made as to whether or not a patient requires care at a particular level of service, i.e. hospital, in-patient rehabilitation, etc. The criteria used are usually developed by physicians, a review of current evidence and national guidelines published by specialty organizations.

There are levels in the utilization review process. The first level is the initial screening and review of health status and requested service by a licensed healthcare professional, usually a registered nurse or license social worker (outpatient therapy).  If there is any question regarding the need for services, the review is passed on to a physician, who holds active state licensure. That physician will review all available information, i.e. progress notes, admission history, lab data, x-rays, etc., and assess the appropriateness of the care.  If the physician determines that the care needs do not require the health services being received, he or she will sometimes discuss the care with the attending physician and determine an agreed upon treatment plan.  In some cases, there is not agreement between the attending physician and the reviewing physician and a “non-certification” notice is recommended.  With the non-certification notice, instruction is provided as to the opportunity for continued dialogue with your attending physician or how you can appeal the non-certification recommendation.

If the patient or the attending physician disagrees with the non-certification recommendation, there is a right to appeal, either telephonically or by letter to the insurance company making the recommendation.  An appeal can be “expedited”, requested immediately, or requested within a specific time period from the time of the notification.  On appeal, a specialty physician who is board-certified in the same area of practice as the attending physician will review all information, and make a recommendation to uphold or overturn the original recommendation.  In the event the appeal is not overturned, either on an expedited review or later, and the patient is still not satisfied, there may be additional appeal rights, depending on the state.

A nurse in utilization review assesses information, provides clinical information to others involved as needed and refers cases for review to physician peers in the event of any questions regarding medical necessity.

Health Literacy is the ability to “obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

The webinar will be offered on:

• Thursday, December 3 from 3:30 pm – 4:30 pm EST; and,
• Wednesday, December 9 from 12:00 pm – 1:00 pm EST.

By attending and completing an evaluation form, nurse case managers and social workers will earn one CCM CEU. Cost per person is $45.00.

Key issues to be discussed include:

• Definition of Health Literacy;
• Considerations of Health Literacy and the impact to: an individual’s access to health care, patient safety, individual’s ability to participate in self efficacy and in the healthcare delivery system;
• Information and tools to assist the learner in identifying appropriateness of healthcare information; and,
• Regulatory requirements in regards to health literacy. Additionally, resources will be provided to assist the learner in preparing materials to meet the needs of patients.

To learn more and/or register, please visit http://www.psninc.net/webinar-topics.html.

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PSN is a woman and nurse-owned healthcare accreditation company that serves as an industry leader in URAC, NCQA, CARF, and Joint Commission accreditation preparation and consultation.  PSN is excited about its health literacy webinar as health literacy is a topic weaved in to each of the accreditation standards.

In addition to the nursing webinars, PSN offers many customizable training solutions. To learn more about our various services or schedule a presentation that works for your organization, please contact us.

1. Provide adequate resources: The NCQA standards not only address quality improvement, but they also address a number of other areas, too. Areas such as utilization management, provider relations, marketing, informatics, member services and support must be involved. These areas must be supported by senior management and must be given the training and time to devote to the survey preparation effort.
2. You can never start too early: Many NCQA standards require an organization to demonstrate compliance over a number of years. It is advisable for an organization to start preparation activities three years prior to a survey. This will afford the organization with time to make sure that structure and processes are in place and that required measurements and improvements can be documented.
3. Engage expert help: Preparation for an NCQA survey requires expertise in NCQA subject matter and complex project management skills. Often times the day-to-day working operations within an organization are all encompassing and do not afford individuals with the time to devote to the NCQA process. If permanent staff devoted to NCQA oversight and preparation is not possible, consider investing in a NCQA consultant. A NCQA consultant can establish project plans, interpret the intent of the standards, assess compliance, participate in and coordinate preparation activities, and track time lines and milestones. If considering the use of a NCQA consultant, make sure that the consultant is an NCQA surveyor. Only an NCQA surveyor will truly understand the NCQA process, the intent of the standards, the philosophy behind NCQA accreditation and certification.

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Written by: Ellen Pauley, RN, MSB. Ellen, one of PSN’s NCQA consultants, has been an active NCQA surveyor since 1991 and helped to develop many of the NCQA Accreditation and Certification products.

PSN is an industry-leader in NCQA accreditation services.  Each of PSN’s NCQA consultants have worked as NCQA surveyors, have over 30 years of combined NCQA surveyor experience, and total more than 50 years of NCQA consulting experience.  Feel free to contact us to learn more about our NCQA accreditation services.

Bottom line: Will patients be able to understand and act upon the instructions that you or your organization provide?  The National Academy on Aging Society estimates that “the inability to understand medical direction costs more than $73 billion in healthcare costs per year.”

Last month, PSN held a webinar entitled, “Health Literacy: Why It’s a Concern.” Our presenter, Connie Sunderhaus, RN-BC, CCM delivered valuable substance and insight, with a vibrant presentation.

A quick analysis of the program evaluations show the attendees thought it was a hit! Scores of 4.7/5.0 were given for the following measures: program met objective of defining the importance of health literacy, program met objectives of how to address health literacy requirements, presenter provided information in a clear and understandable manner, and information obtained can be applied to my practice.

Connie presents three tools to measure health literacy. Why is this important? Unlike most other webinars, this one goes beyond the “what” and the “why”. Three methods are presented to give the practitioner additional tols in their resource tool belt.

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PSN is very busy putting together the next webinar! If you have any ideas or have a program that you would be interested in attending, please let us know! Please visit our webinar page t learn about the exciting programs ahead! Should you wish to be emailed when a course is announced, please feel free to contact us.

In addition to the nursing webinars, PSN offers many customizable training programs either via webinar or on-site. Please contact us to discuss and/or arrange customized training for your organization.

For us, it was only a website…

Everything from color scheme and navigation to new pages and content was worked on. Overall, the website user experience was improved allowing users to learn more about our staffing or consulting services, any of our individual accreditation services, and even a few featured job openings and blog posts – all from the homepage.

Enough telling you about the redesign, I invite you to share the experience and browse around. Enjoy!

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Professional Services Network, Inc. is a woman/nurse-owned healthcare company located in Silver Spring, MD. Special thanks to Reef Light Interactive, for working hard to achieve a beautiful new home for PSN. To receive more information about PSN or any of our services, feel free to contact us or email us at nurseworks@psninc.net.

As a helpful resource, PSN helps you sort through the application documents, supported documentation, and the plethora of instructions that need to be followed to ensure a successful submission of your URAC application. Here are some helpful hints that may make the transition a little easier for you and your organization.

1. Once you receive your username and password from URAC, watch the tutorial and read the instruction manual thoroughly to familiarize yourself with the process.
2. Be aware that documentation will be needed to support both standards and substandards. In some cases only a portion of a document will apply.
3. As you familiarize yourself with each standard, look at your policies and procedures and keep a record of which documents (or portions of documents) support which standard/substandard by writing down which section of text supports which part of the standard or by electronically highlighting and labeling each section.
4. A helpful hint for highlighting documents… Using the “Comment” feature on Microsoft Word can make your job a lot easier. First, make sure you are in “Print Layout” mode. You won’t see the commenting if you’re in “Normal” mode. Then, just select the portion of text that supports the standard, go to the Insert menu (Word 2003) and click on “Comment.” A comment bubble will appear, and you simply type in the name of the standard/substandard it refers to. If you have a sentence in the middle of an already highlighted portion that applies to a different standard, create a new comment. When you select that comment, it will highlight just the portion that applies to the other standard.
5. Wise idea: Do not start loading documents onto AccreditNet until they are absolutely final. At this time, if a document needs to be replaced, it must be removed from each standard it supports before it can be deleted from the library. Then, when the edited document gets uploaded, it needs to be reattached to each standard. This can be time-consuming.
6. AccreditNet only allows nine (9) support documents to support each standard (including the substandards). Sometimes, more than nine documents are necessary to support a standard. For example, you might have 20 documents that support a standard which has four substandards.

a.    To submit all 20 documents, the best way is to create four folders, identifying each by standard/substandard number/letter (e.g., 3a), and copy supporting files into each folder. Make sure that citations are highlighted within each document file of each folder.
b.    When uploading each zip file, enter a name such as “Support Documents for Core Standard 3c” in the Document Title box. You can have as many documents in each zip file as are needed to support the standard, because it will only register as four (in this case) zip file documents.

These are only a few ways to help expedite the process, but if you have additional questions, URAC is very helpful. They can be reached at (202) 216-9010 or accreditnet@urac.org.

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Professional Services Network is an industry-leader in URAC Accreditation services. All of our URAC consultants have worked as URAC surveyors and have many years of URAC consulting experience. Feel free to contact us or learn more about our URAC Accreditation services.

As PSN seeks new ways to communicate in this internet world, we hope you will find our topics posted to be of interest to you! As you are interested in accreditation – related information, news in the staffing and job world, or continuing education information in areas of case management, quality or utilization review, we hope we can add to your ability to benefit from the available knowledge at your fingertips, taking only seconds to read, while yet offering up-to-date information in your field of interest!

Drop us a line at any time, and let us know of your information interests! If we can find the answers, and write a couple of paragraphs to provide you with quick hands on information regarding topics you would find helpful, to stay informed, we will be glad to help out!

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Professional Services Network, Inc. is a woman/nurse-owned specialized nurse staffing and health care accreditation consulting company with a solid 19-year history. To receive more information about PSN or any of our services, feel free to contact us or email us at nurseworks@psninc.net.