Utilization Review (UR)

The process of determining whether the medical care provided to a specific patient is necessary according to reestablished objective screening criteria at time frames specified in the organizations utilization management plan.

Community Needs Assessment

One of the performance tools utilized to help HMOs address their specific members' needs. A team that is composed of community members, HMO members and community leaders.

Case management

The principal process by which healthcare organizations optimize the continuum of care for their patients. It reviews the condition of patients to identify each patients care needs and to integrate patient data with the patients cause of treatment.

Critical Pathway

The case manager in many organizations matches the patients course with a predetermined optimal course. Multidisciplinary outline of anticipated care within an appropriate time frame to aid a patient in moving progressively through a clinical experience t

Indicator

(criterion) is a performance measure that enables healthcare organizations to monitor a process to determine whether it is meeting requirements. This criteria may be established and implemented internally, externally, or generically.

Intensity of service

Refers to the type of services or care the patient requires.

Severity of illness

refers to how sick the patient is or what level of care the patient requires, such as intensive care or general medical care.

Ratio

is used ad a tool for monitoring care and service.

Gantt chart

is a project management tool used to schedule important activities. They divide a horizontal scale into days, weeks, or months and a vertical scale into project activities or tasks. They are used in clinical process improvement to depict clinical guidelin

Core Processes

assessing patient needs; planning care, treatment, and services; providing the care, treatment, and services that the patients needs; and coordinating care, treatment, and services.

Clinical Laboratory Improvement Amendments (CLIA)

federal regulations outlining the quality assurance activities required of laboratories that provide clinical services.

transfusion reaction

Signs, symptoms, or conditions suffered by a patient as the result of the administration of an incompatible transfusion

standards of care

a set of clinical decisions and actions taken by clinicians and other representatives of healthcare organizations in accordance with state and federal laws, regulations, and guidelines.

Clinical Practice Standards

this model defines practice based on diagnosis. The flow of treatment interventions and the patients progress are evaluated on the basis of nationally accepted standards of care for the diagnosis.

Clinical guidelines

The descriptions of medical interventions for specific diagnoses in which treatment regimens and the patients' progress are evaluated on the basis of nationally accepted standards of care for each diagnosis

evidence-based medicine

attempts to identify the care processes or interventions that achieve the best outcomes in different types of medical practice. Researches preform large population based studies.

patient-centered care

providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions

Minimum Data Set (MDS) for Long Term Care

A federally mandated standard assessment form that Medicare- and Medicaid-certified nursing facilities must use to collect demographic and clinical data on nursing home residents; includes screening, clinical, and functional status elements

Facility quality indicator profile

A report based on the data gathered during the Minimum Data Set for Long-Term Care that indicates what proportion of the facility's residents have deficits in each area of assessment during the reporting period and, specifically, which residents have whi

State the reasons for the shift in healthcare to paying for value

In an attempt to balance healthcare and spending, utilization review was implemented. The UR actives were put into place to assure that care is delivered in the right setting, meets medical necessity, and reduces or eliminates duplication of services.

Quality Family Healthcare HMO sent a survey out to their members about what services they would like added to their pediatric and adolescent healthcare sector. The idea for the enhancement of these services for pediatric and adolescent healthcare came fro

Community needs assessment.

Upon receiving a call from Kathy's physician to schedule a hysterectomy, the case manager contacts Kathy's insurance company to get their approval for the procedure. This is an example of which step in the case management process?

Preadmission care planning.

Dorothy was admitted to the hospital after she fell and fractured her right hip. She will need rehabilitation services after she leaves the hospital. Dorothy is assisted by the case manager in the hospital with her placement at Sunnyville Rehab Center. Wh

Discharge Planning.

Write a valid indicator to monitor the accuracy of fulfilling release of information requests in the mont of July.

# of accurately fulfilled ROI requests in July./ # of ROI requested received in July X 100 = the accuracy rate indicator for ROI requests.

For a large PI project, Joe would like to diagram all of the required important steps in the process, their dependency, interaction, and schedule requirements. What would you recommend Joe use to do this?

A Gantt chart is a project management tool used to schedule important activities.

The core care process that determines the patients appropriateness for admission to the facility and the level of care and service to be rendered is called.

Assessing the patients needs.

Betsy was admitted to the hospital through the emergency department with congestive heart failure. After her initial assessment was completed it was determined that Betsy met the criteria for inpatient admission to treat her condition. Her nurse is writin

Care pathway

Jim was admitted for hip replacement surgery, and during his procedure he was administered blood products. Postoperatively, Jim developed a rash and a fever. The presence of these symptoms will be investigated by the hospital as a possible:

Transfusion reaction.

An established set of clinical decisions and actions taken by clinicians and other representatives of healthcare organizations in accordance with state and federal laws, regulations, and guidelines is called standards of care. Defend this practice and why

These standards of care are based on evidence-based practice and research to provide the optimal results for patient safety and quality of care.

Illustrate the potential benefits of Telehealth technologies to healthcare providers and patients in remote locations as a method to improve access to and outcomes of healthcare.

Telehealth removes the barriers of distance in the provision of care by using readily accessible technology to provide treatment and medical guidance. It allows for convenient care to occur.

Diane has bilateral painful bunions. She has decided that her right foot is so painful that she cannot walk. Diane consults her physician to seek removal of the bunion from her right foot. She does not want to have surgery on both feet at the same time as

The universal protocol for surgery includes three steps: conduct a pre-procedure verification process, mark the procedure site, and perform a time-out.

The descriptions of medical interventions for specific diagnoses in which treatment regimens and the patient's progress are evaluated based on nationally accepted standards of care for each diagnosis is called

Clinical Guidelines

A graphic tool used to communicate established standards of patient care for specific diagnoses is called

Clinical Care Pathways

What organization was formed in the late 1980s to address the lack of uniform standards for utilization review services by promoting quality and accountability of healthcare organizations through accreditation, education, and measuremenT programs?

URAC

If a patient comes into the emergency room with left-sided hemiparesis that started within the last three hours, which admission criterion would be used to justify admitting this patient as an inpatient?

severity of illness

Ann's physician suspects that she has cholecystitis and has ordered a gallbladder ultrasound to be performed. The staff at the physician office contacts Caitlin's third-party payer to determine benefits and coverage for this procedure prior to scheduling

Preauthorization