Note: Additional savings through management and clerical staff transition to model not included above.
Health System State of Hospital Case Management
Over-Allocating to UR
The majority of clinical hospital-based Case Management (CM) time spent on administrative Utilization Review (UR) functions.
Lagging Admission Reviews
Challenges with Admission Reviews being performed within 24 hours.
Lack of Transparency
No visibility into UR workflow or productivity; technology difficult for management and staff to navigate; worklists inaccurate.
CM not supporting physicians or nursing; poor coordination with social work and transition of care team.
Suboptimal Continued Stay Reviews
Challenges with Continued Stay Reviews performed within 24 hours and appropriate use of criteria.
Lack of Patient Interaction
No interaction with patient and no rapid rounds to set discharge expectation with care team.
Poor Review Quality
Poor quality and inconsistent application of criteria and utilization of escalation protocols.
Recruiting & Attrition Challenges
Relatively high turnover and difficulty recruiting experienced CM nurses with right attitude, attention to detail, and capability.
Case Management RNs spend an estimated 81% of time on utilization review work.
Across the 204 hospital case management FTEs in the system, this equates to 164 FTEs worth of time spent on UR work