INDICIATM FOR UTILIZATION REVIEW

Build your business case

Created by Milliman Care Guidelines

For hospital decision-making teams

How to Use This Resource

• If your organization is considering Indicia for Utilization Review, you may have other team members who are less familiar with the product

• We have designed this PowerPoint deck so that you may customize it or use any of its assets in presentations to your team

A Word About Content Rights

• We’ve left these slides editable so they can be easily used

• Once you have adapted the deck, however, we can no longer be responsible for the validity or accuracy of its content

• The names Milliman Care Guidelines and Indicia are trademarks of Milliman Care Guidelines and screenshots of our products are the property of Milliman Care Guidelines

Indicia for Utilization Review

• Designed for providers

• Contains the most thoroughly researched, most broadly used care guidelines in the industry

• iPad enabled

• Supports utilization review efforts

• Helps avoid inappropriate admissions

Tackles Practical Needs

• Easy to look up and interpret criteria

• Streamlined user experience for any member of the care team – triage nurse or ED physician alike

• Visual go/no-go indication

• Mobile access for iPad

Admissions Utilization Review

• PDF, save and print capabilities

• Automated admission/discharge indications across various care settings

• Can integrate with existing case management or EMR software

• Internet-like search capabilities

How Indicia would benefit us

• Helps ensure focus on patients’ path to health

• Supports existing workflow

• Helps achieve reimbursement and care management goals

• Facilitates conversations with payors about appropriate care

Our Organization’s UR Challenges

• [What challenges are you experiencing with regard to your existing UR process? Place those here.]

Our Plans for Indicia Include

• [If you have specific goals or business needs that could be addressed by using Indicia for Utilization Review, include those here.]

How It’s Being Used

Example Use Case

Weekend Admissions

What Happens in Our Organization at Night or on a Weekend?• Who is responsible for making judgment calls about

admission?

• Are admissions handled consistently and in accordance with the most up to date, valid criteria used by our payors and CMS?

• Is the patient receiving the appropriate level of care?

• How is that decision documented?

• How is the case manager brought up to speed Monday morning?

• How can we ensure we will be reimbursed for this care?

What Are the Costs Over the Course of One Weekend?

X 5 patients

=

=

X 5 bed days

=

X 5 patients

2.5 hours

2.5 hours

$60,000

[EXAMPLE]

What Are the Costs Over the Course of One Weekend?

X # patients

=

=

X # bed days

=

X # patients

X hours

X hours

$X

[Fill in your own estimates here]

Selection Criteria: How Indicia Stacks Up

Let’s Walk Through a Typical Admission

• A patient presents to the Emergency Department in some respiratory distress

• Given the patient's condition the admitting physician thinks she should admit him

• The triage nurse is responsible for determining the appropriateness of the admission according to the evidence

Easy Guideline Lookup

The Triage Nurse looks up the criteria for hospital admission for a patient with acute exacerbation of Asthma on her iPad.

Clear Indication for Admission

The Triage Nurse documents the symptoms and a yellow bar indicates the patient does not need to be admitted.

Quick Documentation

The Triage Nurse then views indications for Observation Care, determines he’s a good fit, and documents her decision for the Case Manager by saving a copy of the indications to her department’s shared drive.

How will Indicia Benefit Our Organization?

• Promoting evidence-based clinical decisions

• Improving documentation for utilization review

• Improving reimbursement rates by using the same, evidence based best practices used by our health plans

• Reducing staff time by x% and saving up to $x in inappropriate admission costs [insert your own figures here]