-3 References: U. S. Department of Health, Education, and Welfare, Social Security Administration, Conditions of Participation; Extended Care Facilities. HIR-11, February, 1968. American Medical Association, The Extended Care Facility: A Handbook for the Medical Society. 1967. Case prepared by: Mr. Nicholas Griffin Committee on Aging American Medical Association Chicago, Illinois CASE STUDY CASE C THE MEDICAL SOCIETY ESTABLISHES A COMMUNITY-WIDE UTILIZATION REVIEW PLAN Background Information: Tiller County has six nursing homes with a total of 250 beds available for long term care, with two other facilities proposed, which would add another 190 beds. The problem of establishing a plan for utilization review has been urgent for those facilities trying to meet conditions of participation in the health insurance program for the aged (Medicare). The need for liaison and strengthened relationships between the extended care facilities, the hospitals, other types of medical care facilities, the available community agency programs, and the practicing physicians and other professionals has been brought sharply to the fore in qualifying with the statutory requirements for participation in this program. The nursing homes feel that since the physician is the central figure in determining what and when health care facilities are to be used in meeting any needs of his patients, the Medical Society should have primary responsibility for planning and implementing a utilization review program. The Tiller County Medical Society has been active in attempting to promote coordination of community health problems through its committees and participation in regional "Medical Needs Committee" meetings attended by representatives of hospitals, public health agencies, medical schools, and voluntary health associations. The Society has a Committee for the Aging, which has issued a guide to special services for older patients in the area, and has sponsored some lectures on patient care for nursing home personnel. However, no specific activities have been undertaken thus far, other than educational, in connection with Titles XVIII and XIX of Public Law 89-97 (Medicare and Medicaid). Problem: The Tiller County Medical Society has been approached by a committee from the Tiller County Nursing Home Association for help in setting up a community-wide utilization review program. Since the extended care facilities in the area vary widely in size, staff, and resources, they propose that a community-based, central utilization review committee established by the Medical Society would produce maximum results with a minimum expenditure of time on the part of busy physicians and nursing home staff. They suggest also that such a plan of utilization review would be the most effective method for objective appraisal of quality of medical care in the community, and would encompass the best means of evaluation and appropriate utilization of all services and facilities. -2 Questions: 1. 2. 3. 4. 5. Assuming that the Medical Society agrees to establish a Utilization Review Committee as proposed by the Nursing Home Association, what are the statutory requirements under the health insurance program? What should be the Medical Society's approach to the organization of such a committee, and what should the organization plan include? What would be a suggested procedure after establishment of the committee on utilization review in order to coordinate the committee's activities with the facilities? What procedure might be established for review of cases? What relationship might a utilization review committee established in this manner have to other concerns of the extended care facilities such as the Policy Committee and Patient Care Policies, Transfer Agreements, and relationships with other professional personnel? CASE STUDY CASE C THE MEDICAL SOCIETY ESTABLISHES A COMMUNITY-WIDE UTILIZATION REVIEW PLAN Possible Solutions to Problems and Discussion: 1. 2. Assuming that the Medical Society agrees to establish a Utilization Review Committee as proposed by the Nursing Home Association, what are the statutory requirements for participation in the health insurance program? a. b. A written description of the utilization review plan must be 1) 2) 3) 4) 5) 6) 7) 8) The organization and composition of the committee. Frequency of meetings. The type of records to be kept. The method to be used in selecting cases on a sample or The definition of what constitutes the period or periods of extended duration. The relationship of the utilization review plan to the fiscal intermediary. Arrangements for committee reports and their dissemination. Responsibilities of the facility's administrative staff in Where a committee outside the extended care facility is established, any plan for utilization review must have the approval of the facility's medical staff and the facility's governing body. What should be the Medical Society's approach to the organization of such a committee, and what should the organization plan include? ~2 The Medical Society Committee appointed to study the proposal should Any proposed plan should then be discussed with the administrators of the facilities to be included and with their advisory physicians. A suggested organization statement for a Utilization Review 3. What would be a suggested procedure after establishment of the Utilization Review Committee by the Medical Society by which to coordinate the committee's activities with the facilities? 4. a. Two copies of the Utilization Review Committee structure as agreed upon should be signed by both the chairman of the committee and the administrator of the facility. Each organization would retain a copy in its files. b. c. Representatives of the committee and the participating facilities 1) To determine procedures for presentation of cases for review. 2) To establish the schedule of reimbursement for committee members and the procedure for payment. Each participating facility should be asked to furnish the committee in writing information on size, staffing patterns, services available, and any other information the committee feels necessary for the proper performance of its function. d. Each participating facility should keep the committee informed of What procedure might be established for review of cases? a. C. A Utilization Review form (such as the sample appended hereto) should be adopted. (In the following procedure it is assumed that it will be completed in triplicate.) Person responsible for medical records in the facility pulls Nursing supervisor completes second section of the form, using |