Utilization Review Directs Patients to the Right Level of Care

One of our key goals has been to develop a systematic approach to identify and review utilization patterns, trends and variation in care that impact quality outcomes and costs across VHAN. We started by assessing our current systems, defining data sources and identifying utilization trends.

Next, we developed a utilization review process for high- cost claimants and identified opportunities for clinical care standardization to give network clinicians timely insight into ED utilization. We established performance goals and a method to connect patients to needed resources and the right level of care. To help VHAN practices increase access for their patients while offering secondary options for emergent care needs, we developed the VHAN ER Toolkit, available here.

Ernie Buchanan, MD, of Upper Cumberland Family Physicians in Cookeville, TN, and VHAN Regional Medical Director, used some of the tactics from VHAN’s ER Toolkit to reduce the number of total ED visits, percent impactable (PI) visits, and overall ED paid and PI paid. Through patient education, data sharing on ED visits and updated processes (including having a live person answer the phone), unnecessary ED utilization decreased from 38% in 2019 to 31% in 2021. The percentage of potentially impactable ED costs also dropped from 40% to 26% of the total ED cost for this provider.

Looking for more stories of network impact? Visit vhan.com/impact

Network members can access the VHAN ER Toolkit on VHAN Hub.  

VHAN Hub is available exclusively to network members. You must be a VHAN member and register for the Hub to gain access.

Interested in becoming a VHAN Member and joining a collaborative group of physicians, nurses and allied professionals who are transforming health care? Get started on the contact page

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