Utilization management, case management, and care coordination

Abstract

Previously, the responsibilities of utilization management (UM) professionals were seen as distinct, but the value of connecting UM with quality and safety management is becoming clear and is now driven by a shift from fee for service reimbursement to the more outcome-oriented value-based models. The underlying reason to integrate the frameworks of utilization management, case management (CM), and care coordination (CC) is to make sure that health care is delivered to the patient and the population efficiently and effectively where such activities directly impact the quality of outcomes. This contrasts with the older concept of utilization review as a sole means to control resources and the cost of care. Intrinsic to UM, CM, and CC are structured programs and methodologies that incorporate indicators, monitors, and benchmarks that track and note trends in the processes and outcomes of care as planned and delivered. This chapter describes the UM, CM, and CC processes and discusses how aligning these overlapping processes is essential to high-quality, cost-effective care delivery models such as the chronic care model and the patient- and family-centered medical home.