Utilization Management and Healthcare Models

Utilization management is essential for optimizing scarce resources. The healthcare management team must work hard to improve the safety and quality of limited resources. Getting an excellent return on investment is essential since healthcare organizations seek to “make sure that health care is delivered most efficiently and effectively for the patient and the population, where such activities directly impact the quality of outcomes" (Pelberg in Varkey, p. 145).”

Comparative Analysis of the Models

Chronic Care Model (CCM) fulfills the needs of people that will consistently engage with the healthcare delivery system. Because people with chronic conditions will need attention from the healthcare system on how to individually manage their conditions (Pelberg in Varkey, p. 162) the CCM is well suited for patients with adverse health outcomes. CCM is a universal fit for all chronic diseases of client care (Pelberg in Varkey, p. 162). According to Varkey (2010), “Research by the MacColl Institute for Healthcare Innovation has shown that the model’s outcome is linked to healthier patients, more satisfied providers, and cost savings.”

Vakey (2010) defines the Patient-Centered Medical Home Model (P-CMH) as an approach to providing comprehensive primary care for children, youth, and adults. Although, there is some similarity between CCM and P-CMH, there are also some differences. The similarity between the two models is related to providing an improvement in quality and safety of health of the patient. Both models hinge on trust in the healthcare delivery systems and interaction with providers. The CCM and P-CMH utilize evidenced-based medicine (Pelberg in Varkey, 2010).

Self-management forms the core of CCM. The P-CMH model is patient-oriented and requires a team effort between the physician and the patient. Consequently, patients’ inputs are factored in throughout all of the diagnosis and treatments process (Pelberg in Varkey, 2010).

Elements in Models for Quality and Safety

The element of P-CMH models that may be most significant for achieving quality and safety goals is the evidenced-based practices that look at patient illness as a whole by considering the synergic role all the organ systems play in health. By looking at disease with the whole body perspective, patient’s healthcare need is taken care of by considering all phases of life (Pelberg in Varkey, 2010). Comprehensive planning with this models makes it so that quality and safety elements can successfully be implemented.

One of the critical elements of the health systems of CCM is to facilitate the quality and safety culture that rewards measures that promotes structured error resolutions to encourage improvement in patient care (Pelberg in Varkey, 2010).

Model Structure and Best Medical Outcome

In order to achieve the best medical outcomes for individual patients at the lowest cost to society, the models should be structured to incorporate health information technology. Health information technology may help reduce community cost while at the same time maintaining high quality and safety standards. They can also be structured to optimize utilization

and the meaningful use of evidenced-based practices to facilitate effectiveness and efficiency in healthcare delivery.

References

Varkey, P. (2010). Medical quality management: Theory and practice. Sudbury, MA: Jones & Bartlett.

Institute for Healthcare Improvement. (n.d.). Chronic care model. Retrieved fromhttp://www.ihi.org/knowledge/Pages/Changes/ChangestoImproveChronicCare.aspx

The Commonwealth Fund. (2009). Can patient-centered medical homes transform healthcare delivery? Retrieved from

http://www.commonwealthfund.org/From-the-President/2009/Can-Patient-Centered-Medical- Homes-Transform-Health-Care-Delivery.aspx