Part 1: Understanding Utilization Management and Its Implications for PACE

By: Laura Ferrara, Chief Population Health Officer at IntusCare

Utilization Management (UM) applies to all healthcare services provided to a PACE participant, but in the world of PACE, it most often addresses utilization of services such as hospitalization, emergency department (ED) visit, or skilled nursing admission.

ED visits and hospitalizations are the costliest and not just monetarily. They also have a huge impact on the older adults, rarely leaving a hospital stay in an equal level of function, wellness, or quality of life. Most PACE participants already have chronic conditions and other challenges. Throw in a hospital stay with prolonged immobility, alarms, IV lines, catheters, and the constant noise of a hospital – plus isolation from their friends, family, and community – the participant more often comes out in a deterred state of health, despite all of the care they were given.

It can be challenging for some participants to recover from a hospitalization and get back to their baseline. One visit can have a long-term impact on the participants’ quality of life in addition to the price tag. It is a complicated, compounding issue. UM attempts to get the organization’s arm around the problem – yes, reducing costs, but also, yes, improving the health and quality of life for participants.

This is why utilization management at Intus Care focuses on combining strategies to ensure appropriate access to care, high-quality services, and efficient management of service authorization and payment processes. This multifaceted approach helps manage costs while prioritizing the health and well-being of our participants.

In Part 2 of this blog series, we will look at ways Intus Care works with our partners on proactive and reactive strategies to improve UM and how we can partner with your organization.