Utilization Management and Models of Care

Health care providers and other interested parties must continuously look for ways to manage limited resources while improving quality and promoting patient safety. Utilization management is intended to “make sure that health care is delivered in the most efficient and effective manner for the patient and the population, where such activities directly impact the quality of outcomes” (Pelberg in Varkey, p. 145). The utilization management process bridges clinical, financial, and administrative functions.

Within traditional health care settings, utilization management can have a significant impact on the delivery of services. In addition, various models of care are emerging that may help transform health care delivery to achieve the aims of utilization management and quality improvement.

To prepare for this Application:

  • Review the information on utilization management in Chapter 7 of Medical Quality Management. Also conduct additional research using the Walden library and credible Web sites (some of which are listed under Optional Resources).
  • Analyze the Chronic Care Model and the Patient-Centered Medical Home Model. How might these models be beneficial for providing care to patients, especially those with multiple medical conditions?
  • Identify the elements of each of these models, and evaluate which may be most significant for achieving quality and safety goals. Consider each of the six dimensions of quality identified by the Institute of Medicine.
  • Reflect on how these models should be structured in order to achieve the best medical outcomes for individual patients at the lowest cost to society.

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