Utilization And Case Management At A Hospital

Utilization And Case Management At A Hospital Sierra View District Hospitals (SVDH) utilization review (UR) process originates in the Case Management (CM) department. They are responsible for the case review and obtaining social services for those patients in need of services. This paper will describe how this process works and how SVDH compares to another facilitys UR structure. There will also be a discussion about the weaknesses of the SVDH program. Utilization Management at SVDH The CM department is responsible for the UR process at SVDH. This department, which has 13 employees, is staffed as follows: four Case Managers; two licensed clinical social workers; four social services worker; a Department Analyst; and a Wound Care Specialist. An Administrative Director oversees the department. The CM department follows a Utilization Review Plan (Appendix A) which establishes how the CM department will review cases and address potential discrepancies from established best practice guidelines like McKessons InterQual Criteria (McKesson, 2010). The four Case Managers are to conduct concurrent reviews on all Medicare admissions. They evaluate the patient chart and documentation to ensure the correct medical care status of Inpatient or Observation Services is assigned to the patient. If the patient is assigned the correct status then the Case Manager will flag the case for review in three to four days to ensure the status of the patient has not changed to such a degree that either a higher or lower service level is required. If that is the case, the manager will contact the primary care physician and seek an order changing the service level. If the physician does not agree, and the documentation in the case ceases to support the current level of care, the case manager will forw ard the case to the physician advisor for review. If the physician advisor agrees that a new level of care is called for then he/she will contact the physician to seek further clarification as to why the patient needs continued services at the current level. Depending on this conversation, there are four possible outcomes for the patient status. One, the patient status will remain at the current level of care because the initial physician has informed the physician advisor of extenuating circumstances regarding the case. Two, the physician will agree to the conversion of the patient status to either a higher or lower level of care. Three, the physician will not agree with the physician advisor, and the advisor will refer the case for the UR committee for a panel decision, which can overrule the original physician; or Four, the patient can be discharged from the hospital. While Case Managers are working the UR of a patient, the Social Workers are concerned about any after-care the patient may require. The Case Managers and Social Workers work together to come up with a discharge plan beginning on the first day of admission. The Social Workers make sure the patients have all the contact information they may need once discharged, and the Case Managers work to ensure placement of the patient in an extended recovery care facility if needed. SVDHs UR Program Compared to Other Hospitals SVDHs UR program is comparable to that of Jewish Hospital (St. Louis). Prior to 1985, the Center for Medicare and Medicaid Services (CMS) reimbursed hospitals for services rendered. Due to increasing costs to the Medicare Trust Fund, the Diagnostic Related Group (DRG) system was developed to reimburse hospitals based on what the average cost of a particular surgery. UR programs at both hospitals began to change to meet the new challenges instituted by CMS. Utilization Review became Case Management at SVDH, while Jewish Hospital named their program Case Coordination. The staff members at both facilities became more involved in complete patient care, from admission to post-discharge. SVDH experienced the same growing pains that Jewish Hospital did when Observation Services became a new cost savings service line instituted by CMS. The next challenge arose in 1990, when quality initiatives arose. These initiatives have only increased since that time, with the establishment of Quality Initiative Organizations (QIO). The QIOs review hospital data and report results back to CMS. The goal of these organizations is to locate services that do not meet their (CMS) standards. When found the QIO will deny payment for the services. While Jewish Hospital attempts to complete a 100% review for quality indicators on all cases, either concurrent or retrospective, SVDH chose to focus 100% on Core Measure cases only. While Jewish Hospital might be ensuring that all cases have a minimum standard of quality, SVDH complies with Joint Commission standards by only reviewing the Core Measure cases. Weakness of the Program There is a major weakness in the SVDH Case Management program, and it has been a weakness for some time. SVDH CM is not a 24/7/365 program. The Case Managers work Monday through Friday from eight to five. One Case Manager works from eight until noon on Saturday in the emergency room, but there is no coverage on Sunday. This means that the one Case Manager only reviews the cases that were admitted from Friday at 5:00 PM until 8:00 AM Saturday morning. If she has time she will also pick up any additional cases she can prior to leaving at noon, but there is no guarantee of that happening. The entire CM staff will review any cases not previously reviewed on Monday, if the patient is still in-house, or the case will undergo a retrospective review. This can cause continuing care problems for patients. An example of one of these problems recently occurred when a patient was not reviewed due to no CM personnel on staff on Friday evenings. The patient presented to the Emergency Room on Friday, and was subsequently placed in Observation Services at the hospital, This case was not reviewed by the weekend case manager. On Monday morning, the CM personnel started reviewing the Medicare admissions and saw this patient on the CM list. In reviewing the chart, the patient plainly met Inpatient criteria. The attending physician could not be contacted so the case was referred to the physician advisor, who agreed the patient should have been classified as Inpatient. The status was changed as of Monday morning. CMS guidelines state that a status can only be changed upon the presentation of an order, and at no point can an Observation Services case be converted to an Inpatient status retroactively. The patient needed additional therapeutic services that would be provided in a long term care facil ity, but CMS guidelines state that Medicare will only pay for those services if the patient has had a qualifying Inpatient stay in a hospital for a minimum of three calendar days (Centers for Medicare Medicaid Services, 2009). Since this patients status converted to Inpatient on Monday morning, the time spent in the hospital from Friday until conversion on Monday did not count towards the qualifying stay. The quandary then is to either discharge the patient to the care facility without a qualifying stay, thereby making the patient responsible for the entire cost of the care, or keeping the patient in the hospital for an additional two days in order to meet the qualifying stay requirements. The obvious answer is to keep the patient in order for them to obtain the necessary time to earn the qualifying stay. This, however, places a bed out of circulation that could have been used by another patient, and might incur costs that do not meet reimbursement criteria for the hospital. Had a CM staff member been on duty Friday night, the case could have been caught earlier, and the qualifying stay could have begun on Friday instead of Monday. The major obstacle to hiring more Case Managers is, frankly, the cost of salaries. Any additional overhead costs are scrutinized closely in these times of shrinking reimbursements. Prior to bringing on new staff, in any area, the return on the investment is reviewed for a profitability margin. If a profit margin cannot be realized then the likelihood of incurring that additional expense is small. Other projects that bring a greater profitability margin have taken priority over additional staff in the CM department. Conclusion The CM Department administers SVDHs UR program. The CM Department encompasses several different services, all dedicated to providing total care to the patient while in the hospital and post-discharge. SVDHs program mirrors common practices within the industry. Like Jewish Hospital (St. Louis), CM at SVDH has evolved and changed over the years to meet the new demands placed on it by regulatory agencies. The CM Department constantly works with physicians to ensure patients receive the appropriate level of care based on physician documentation and InterQual guidelines. The major weakness in the CM program at SVDH is that it is not a 24/7/365 department. This flaw sometimes places the continuum of care for the patient at odds with the regulatory guidelines, and SVDH has to forego reimbursement for services in exchange for better overall patient care and patient financial security.

International Language Essay

Across 294 countries in the world, there are about 6,500 languages are commonly using in the daily life. The domination of English has been proved as an international language all across with the coming of globalization in future, English is the language of diplomacy and international communications for the use of business, tourism, education, science, computer technology, media, Internet and etc. Without language, all the things couldn’t happen and stay in place like today. People nowadays who stand in the marketplace ordinarily using English as an international language for the purpose of fulfilling communicative needs, a common language to facilitate trade and communication seems unavoidable. Some people think that globalization will become a big threat to the national, cultural and even religious identities as using only a single language and ultimatum to the development of a country. Posses single language may lead to cultural corrosion, a loss of local linguistic knowledge, and mainly will cause to losing of own language which is the carrier of all their cultural values identity is the first thought of conservative minded while they firstly expose to the word of globalization. However, in my opinion, it is possible to use an official international language and still retain theirs own languages with their own cultures values identity. I presented to support that having a single language as an international official language not only provides the opportunities for social mobility and modernity but also removes the probability of losing the national language the carrier of identity by helping people to be identified to the whole world as they are given voices. It is getting involved in international interactions and communications is required. Therefore, to be an active participant in globalized relations, it is necessary to adopt the international language. Using an international language provides opportunities for people to make contributions to the formation and development of that language to lead to scientific and cultural independence. Language is only the instrument of communication for people around the world. Many countries had been adapted to the cultural with an official language or languages. In any country where there are innumerable languages spoken, there is a need for official languages to ensure the flow of communication between different sections of the population and the different states. Above all, international language is important as a common language for people, without language, there will be absence of interaction between people, while there will be a link occurred to no communication to no trading and etc. It’s also important in every aspect for the world. Nowadays, English is considered the universal language for business, international communications, entertainment, tourism, trade and technology. The majority of all resources on the internet are all in English, affecting people to learn English to take full advantage of it. More important, learning English is significant for human to being able for information exchange and connecting to others. In the prevalent globalization there is no doubt that an international language is unavoidability. While trading a business, language is playing an important role of people, if human found difficult in the activation of a common in language spoken, they cannot trade in business. In this sense, not only is an international language inevitable, but also a necessary for trading, commerce and economic expansion by the turn of the century. The criticism to opposing the using of an international official language contends that it would lead to cultural corrosion and a loss of cultural values identity. However, the use of an international official language does not mean that their local languages will disappear. If English already functions as a kind of unofficial international language but this doesn’t mean that people only converse in using English or they ignore their own languages. English is used in specific contexts such as trade, business, etc. and native languages are used for everyday instruction.

Shortcuts to Ap English Lianguage and Composition Argument Essay Samples That Only the Pros Know

Shortcuts to Ap English Lianguage and Composition Argument Essay Samples That Only the Pros Know In writing a composition or an essay, it's crucial to know your examiners won't only take a look at your content but in addition look at important things like your grammar, punctuation, and your style of writing. So far as the students are involved, writing a research paper is among the toughest and frustrating endeavor in their opinion. Therefore, many students and employees decide to acquire cheap essay rather than writing it themselves. If you would like to track your scores, you can earn a totally free account with Varsity Tutors, but it's not essential in order to access the quizzes. Students lead busy lives and frequently forget about an approaching deadline. It is also necessary for students as soon as it comes to English Language examinations. Likewise don't forget that every student differs and creative approaches may also be highly beneficial. 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Instead, you would like to analyze the essay and make certain your claim is supported. When you compose the essay, you have to choose one particular side to concentrate on. When you're writing an English essay, you have zero opportunity to verify your paper by another individual. A thesis is the principal argument of your essay. In English Language, compositions or essays actually are one of the most significant facets of the subject. An argumentative essay is a kind of essay that asks you to have a stand on a specific issue or idea, usually expressed in the shape of a quotation. You may be asked to compose English AP essay, History AP essay, Biology AP essay etc, regardless of what the topic is, you merely have to adhere to the provided tips. Facts, Fiction and Ap English Lianguage and Composition Argument Essay Samples Our life was not traditional though. A house without brick and mortar won't fall, but nevertheless, it won't be quite a good home to inhabit. 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The Clash of Civilizations Free Essay Example, 1750 words

Another controversial observation of Huntington (1998, pp. 66) is that the population of Muslims is increasing significantly and their proportion in the world population would ensure their domination of the world. The major clash that Huntington (1998, pp. 185) has foreseen is between the Eastern world led by China and the Muslim world for dominating the world. Further Islam is equated with orthodoxy and authoritarianism by Huntington (1998, pp. 126). The conclusions made by Huntington (1998) have invited both criticism and rave reviews. But his arguments have neglected the class equations and also the gender and sub-racial divides that exist within a race or a civilization. Overall his arguments can be called nothing but too deductive and one-sided. The making of a society or a civilization is a historical process and a complex interplay of multitudes of factors. The racial or religious aspect can counted as only one among the many. In particular, the notions of Huntington regarding the Muslim people have been reflective of a racial prejudice. The world’s Muslim population has never been a monolithic block as envisaged by Huntington (Gelvin, 2008, pp. 3). We will write a custom essay sample on The Clash of Civilizations or any topic specifically for you Only $17.96 $11.86/pageorder now It has been aptly observed that â€Å"in the case of the Islamic civilization, †¦interests tied to particular states have repeatedly triumphed over Islamic or pan-Arabs segments† (as cited by Lubjuhn, 2010, pp. 7). And when Huntington says that â€Å"Islam has bloody borders†, what he means is that Muslims, as a civilization has been inherently violent in their nature because of certain characteristics of their religion. While making this comment, he is forgetting the blood that has been shed and lives been lost in the crusades, in the Vietnam war, in Hiroshima and recently in the war against terrorism by the West. Compared to that, the blood shed by Islam has been far more less (Little and Wickham-Jones, 2000, pp. 56). Huntington (1998, pp. 20) has used the terminology, â€Å"fault line conflicts†, to describe the so called inter-civilizational clashes happening between adjacent states belonging to two different civilizations and also inside states where populations from two different civilizations co-exist. He has termed these fault line conflicts as the most dangerous of all kinds of conflicts and has predicted that these fault lines would become â€Å"the central lines of conflict in global politics† (Huntington, 1998, pp. 125). The major fault line in the world as drawn by Huntington is between Islam and the West but this approach has been described as erratic by scholars like Milton-Edwards (2004, pp. 99).