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UTILIZATION REVIEW

Programs exist to assess and assure prompt, efficient, outcome oriented services to its’ members. Focus is on improving both under-utilization and over-utilization of the vast amount of health care services and facilities available in our network. For Medical (in and out-patient), Surgical, Psychological and Substance Abuse Care, this service includes:

  • Pre-Admission / Certification
  • Second Surgical Opinion
  • Concurrent Review
  • Large Case Identification
  • Discharge Planning

Concurrent Review occurs to monitor and authorize a specific number of days for admission based on statistical averages in this region of the US for a given diagnosis. With complications, or consideration of the individuals personal health status, the need for additional days of stay are considered by the Care Coordinator, who considers intensity of service and severity of illness as reported by the attending physician. Should the case become more complicated, the Care Coordinator then refers the case for Large Case Management.

Periodic review of utilization statistics occurs to determine patterns of individual provider practices and facilities, as well as trends for specific diagnosis and procedures. Review considers appropriate and cost-effective alternatives, as well as availability and suitability of various levels of care for the individual. The coordination of appropriate alternatives is a “win-win” for all parties, as it allows for a smoother, step-down pace in care and recovery. Personal care is maintained, transitioning is more effectively carried out, patients are happier, and health insurance expenses are controlled. Patients express satisfaction with the level of personal care maintained while being allowed to recover in more comfortable settings that cater more to the needs of their specific stage of recovery.

  • Hospital
  • Skilled Nursing Facility
  • Rehabilitation Facility
  • Physical & Occupational Therapy Facility
  • Physical & Occupational Services (out-patient)
  • Home Health Care Services

CASE and DISEASE MANAGEMENT

At PHC, our goal is to improve health and provide the best quality care for the people and organizations we serve. That's why we offer Medical Management Services, such as Case and Disease Management, to all Preferred Health Care members.

What is Case and Disease Management? Case and Disease Management is a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual's health needs through communication and available resources to promote quality, cost-effective outcomes.

Case and Disease Management focuses coordinated attention, resources and patient education on members with significant health risks or medical concerns to improve health, enhance quality of life, and manage chronic disease, all while making the best use of health care resources.

Whole patient health care from dedicated Case Managers.
Case and Disease Management's primary goal is patient advocacy. Our highly trained registered nurses are Certified Case Managers (CCM) who help identify, implement and monitor the services required by a patient with catastrophic or chronic illness. Our Case and Disease Management Programs help patients, families, physicians, facilities and other health care providers resolve complex issues that might otherwise inhibit a patient's ability to achieve a positive outcome.

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Preferred Health Care
Urban Place • 480 New Holland Ave, Suite #7203 • Lancaster, PA 17602
Phone: 717-560-9290 • Fax: 717-560-2312 • Email: info@phcunity.com