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Utilization management is "a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision," as defined by the Institute of Medicine [1] Committee on Utilization Management by Third Parties (1989; IOM is now the National ...
A clinical pathway is a multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare).
UM criteria are medical guidelines which may be developed in house, acquired from a vendor, or acquired and adapted to suit local conditions. Two commonly used UM criteria frameworks are the McKesson InterQual criteria [23] and MCG (previously known as the Milliman Care Guidelines). [24]
The generic model used in the United States is the chronic care model, which holds that health care does not only involve change in the patient and that high-quality disease care counts the community, the health system, self-management support, delivery system design, decision support, and clinical information systems as important elements in ...
On February 8, 2023, CMS awarded Battelle Memorial Institute a $53 million contract to procure the services of a consensus-based entity, [11] necessary to support various duties pertaining to health care performance measurement, as required under Section 1890 of the Social Security Act. As a result, the National Quality Forum is no longer the ...
It remains standard of care in that situation," Dr. Michael J. Blaha, director of clinical research for the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease.
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [1]
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