What are the current trends and challenges in utilization management in different settings and populations?

1 Acute care UM

Acute care UM focuses on managing the admission, discharge, and transition of patients who need hospitalization or emergency services. The goal of acute care UM is to reduce unnecessary hospitalizations, avoid readmissions, improve care coordination, and optimize resource utilization. To achieve this, evidence-based criteria and guidelines must be implemented to support clinical decision making and standardize care delivery. Additionally, data analytics and technology should be leveraged to monitor and improve performance, quality, and outcomes. Collaboration between multidisciplinary teams and external stakeholders is also essential for timely and appropriate referrals, transfers, and follow-ups. Moreover, social determinants of health and patient preferences must be addressed to enhance patient satisfaction and engagement. Lastly, acute care UM must remain adaptable to changing regulations, reimbursement models, and accreditation standards that affect UM processes and policies.

2 Behavioral health UM

Behavioral health UM is the management of access, delivery, and coordination of mental health and substance use disorder services. Its purpose is to ensure that patients receive the most suitable, efficient, and effective care for their goals and needs. Integrating behavioral health and physical health services, expanding the availability and utilization of telehealth, digital health, and other innovative modalities, promoting recovery-oriented and trauma-informed care practices that empower patients, addressing the stigma, discrimination, and disparities in behavioral health care quality and access, as well as aligning with evolving regulatory, ethical, and legal frameworks are some of the current trends and challenges in behavioral health UM.

3 Chronic care UM

Chronic care UM is the management of patients with one or more chronic conditions that require ongoing monitoring and management. Its goals include preventing or delaying the progression of chronic diseases, reducing complications and hospitalizations, improving quality of life, and lowering costs. Current trends and challenges in chronic care UM include implementing programs that provide comprehensive, coordinated, and patient-centered care; engaging patients and caregivers in self-management education and support; utilizing remote patient monitoring, wearable devices, and mobile apps to collect and analyze real-time data and feedback; developing predictive models and risk stratification tools to identify high-risk/high-cost patients; as well as collaborating with community-based organizations and resources to address social needs and barriers to care.

4 Population health UM

Population health UM is a method of managing the health outcomes and costs of a specific group of people, such as a geographic area, an employer group, or a health plan. It strives to improve the health status and well-being of the population by addressing the determinants of health, reducing health disparities, and promoting health equity. Currently, population health UM involves adopting value-based payment models that incentivize quality and efficiency, establishing and participating in accountable care organizations and other collaborative networks that share data, implementing population health management strategies that target prevention and chronic disease management, applying population health analytics to measure performance, outcomes, and value, and engaging patients and communities in health promotion.

5 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?