Utilization Review Case MgrCMC - Clear Lake Center

Correctional Managed Care Mission

The mission of Correctional Managed Care is to address the healthcare needs of underserved patient populations within the Texas Department of Criminal Justice (TDCJ) and the Texas Juvenile Justice Department (TJJD).

Supports the physician and interdisciplinary team in the provision of patient care (inpatient, outpatient, emergency and infirmary care) with the goal of enhancing quality clinical outcomes, promoting timely access to medical care, and managing care cost and efficient use of medically appropriate services. Integrates and coordinates utilization management activities, care coordination, discharge planning functions, all aspects of Infirmary Bed Management for (506 beds) in the Eastern Sector of Texas, and facilitation/coordination of hospital-to-hospital transfers for offenders in community hospital emergency rooms and community inpatient hospital beds in the Eastern Sector of Texas, and facilitation/coordination of hospital transfers from UTMB TDCJ Hospital to specialty services hospitals.

Utilization Management

• Demonstrates thorough knowledge of Inter Qual Criteria, CMC Specialty Referral Guidelines and Protocols used to determine status for inpatient admission or observation in Community Hospitals and UTMB-TDCJ Hospital.
• Performs utilization review procedures by prospectively, concurrently, and retrospectively assessing the clinical information utilizing Inter Qual criteria, specialty guidelines, and protocols for admissions, observation, emergency care, surgical procedures and urgent clinic referrals.
• Assigns and monitors lengths of stay for all admissions.
• Maintains a documentation system in the AS 400.
• Demonstrates skill in accurately entering required UM data.
• Monitors and facilitates appropriate utilization of resources and provides alternative options to hospital care. (i.e., infirmary placement, urgent clinic)
• Identifies quality of care issues arising during care coordination processes and report issue/concern to the CMC Quality/Risk Management Department.
• Collaborates with UTMB TDCJ Care Managers, Hospital Community Care Managers, TDCJ Bed Placement, and TDCJ Health Services, and internal and external agencies to facilitate care.
• Supports multi-disciplinary strategies to reduce length of stay, reduce resource consumption, and achieve positive patient outcomes.
• Functions as a resource to physicians and nursing staff regarding approved criteria, specialty practice guidelines, and alternative treatment options.
• Provides 24/7 access to care and care coordination through the telephone call center.

Care Coordination

• Conducts daily discharge planning conference with TDCJ Care Managers for patients requiring infirmary bed placement.
• Participates in multidisciplinary rounds for 15 Infirmaries (506 beds) and facilitates clinical care progression, level of care coordination, permanent and non-permanent status, infirmary transfers and discharge planning.
• Facilitates patient care conferences based on special needs of patient.
• Conducts provider conferences for all hospital to hospital transfers and admissions from the prison facility.
• Conducts nurse to nurse conference calls for all infirmary placements, and hospital to hospital transfers.
• Conducts specialty consult conferences between the unit providers and UTMB physicians as needed for patient care.
• Addresses incomplete or unclear clinical information during admission, infirmary placement, urgent clinic requests, and emergency evaluation or hospital transfers. If unsuccessful, elevates to department leadership and Senior Medical Director.

Discharge Planning

• Demonstrates skill in educating providers, community hospital case managers and TDCJ Care Managers regarding post-acute options and addresses the level of care availability at infirmaries, while ensuring security needs are met as well as clinical needs.
• Demonstrates skill in developing discharge plans for the offender/patient with the receiving unit or infirmary nursing staff, medical staff and transport services.
• Adjusts and manages barriers to discharge plans.
• Collaborates with care managers, providers, nursing and pharmacy to…