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Case or Care Management, 3rd Edition (2009 Update)
Apollo Managed Care Consultants, Jan 2009, Pages: 175
Plans, policies, procedures and strategies that ‘work’ to improve quality, efficiency of care while controlling unnecessary costs. This report includes specific case management effectiveness data by disease entity and behavioral healthcare conditions. Also included are forms, patient handouts, position descriptions, competency requirements, references and resource materials and websites.
This ‘single topic’ has been developed to provide a representative model. Each policy and procedure must be reviewed by the medical policy committee of the HMO or medical group, modified and adapted as appropriate. It is strongly recommended that any applicable documents that will be used to manage medical care in the organization be sent to affected providers for review and comment prior to implementation. This will always promote an understanding of the guideline, avoid compliance issues, and frequently improve the document by additional input. Cost effective health care is quality driven (true quality, that is; not excessive care) and attention must always be focused on the issues that will result in optimal medical/surgical outcomes in a specific local medical environment.
Once adopted, all policies, procedures, guidelines, protocols, benefit interpretations, review criteria, pathways and the like should be reviewed at least every two years and preferably at annual intervals. In some cases, even more frequently, as clinically significant changes occur due to new technology, medications or practices entering the medical mainstream. The sources of the information in a guideline, whenever possible, should be included as a reference or footnote.
Use clear and unambiguous language in a stated policy or procedure. Avoid any implications of guaranteed clinical results or outcomes as a result of following a particular guideline. All policies, procedures, guidelines and similar criteria should be followed consistently, significant variations noted with justification, and be a written form available for dissemination.
When using this single topic publication, it should be noted that the policies/guidelines may be subject to needed changes that occur periodically based on objective studies in the medical literature, recommendations by national bodies such as the AMA, ACP, HCFA and/or other objective sources of new information.
To assure an organized process for the compilation, approval and distribution of medical policy, procedures, guidelines and related information - all policies or guidelines proposed for use by any physician or medical organization should be submitted to the Medical Director or Vice President, Medical Services for a detailed review, circulation to others in the organization and specific approval by governance prior to implementation.
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