Q&A: Collaborating with utilization management
Q: We are looking for ways to have our CDI and utilization management (UM)/utilization review (UR) teams work more closely and possibly cross-train the team members. Does anyone currently work closely with the utilization management department or have cross-trained employees? Does anyone complete UM and CDI reviews simultaneously? If so, what do the workflows look like for these individuals?
Response #1: We work with UM by attending the UM meeting and reporting several metrics, but our staff do not cross-review. I believe that the two departments have two very different focuses, and you would lose more on the CDI side, since UM issues tend to be more urgent. CDI can assist UM by making sure that the full clinical picture is being captured, which can highlight why the patient needs to be inpatient. I would think that if you expanded your CDI reviews to outpatient observation you might be able to identify and capture documentation gaps that would justify changing their status to inpatient.
Response #2: My chief nursing officer had asked me about the CDI specialists looking at UR as well. Initially, I was very concerned about scope creep. However, I do have two specialists that used to status for case management, so they have the knowledge. I am just not sure how this could work. With the Medicare Advantage plans being instructed to also follow the 2-midnights rule, that alone may be a game changer.
Response #3: We are just starting down this journey. I have recently been assigned to UR along with CDI, coding, and HIM. My plan is to cross train both the CDI team and UR team to have a general understanding of what each of the teams do, so they can collaborate more when they are reviewing medical records. My hopes are with accurate documentation and a general understanding of what both teams do, together we can make recommendations on the documentation requirement thus impacting documentation for medical necessity.
Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council and originally appeared in the CDI Leadership Insider, the monthly newsletter for members of the Leadership Council. For the purposes of this article, all Council member answers have been deidentified.