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COMMON <br />Utilization Management Key Interactive Components <br />We control oasts by perforuing the fallowing types of revlew: <br />1. PROSPECTIVER €VIEW - Occursprlor to delivery of <br />Outcomes May Include <br />care and establishes medical necessity, ensuring <br />appropriate and cost- effective care within the <br />correct tirneframe. The following services are <br />V Request for additional <br />reviewed for all requests: <br />information for proper <br />• Hospitalizations -- scheduled inpatient and <br />determination <br />observation <br />V Nurse or physician review <br />• Outpatient surgical or non- surgical <br />✓ Nurse or physician approval <br />procedures <br />v' Alternate plan of care <br />• Specialty office visits and procedures <br />• Diagnostics,' durable medical equipment and <br />prosthetics <br />• Course of outpatient#reatment—physical therapy, <br />dialysis, chemo, radiation <br />NapfiCare's site Medical Director, designated site staff, Chief Medical officer or designee, and a <br />dedicated utillaatfan nurse review and discuss proposed non -emergent Services to determine <br />the most appropriate and medically sound approach to care. Resulting outcomes and planned <br />courses of action are shared with the site Medical Director or designee and progress notes are <br />documented In TechCcre' ". <br />Prospective review can produce multiple outcomes, all of which are tracked by TechCrxren; In <br />our approach to correctional UR, we do not Use the germ "denial," but rather, discuss the case <br />physician -to- physician and develop alternate plans of care. Our UR process takes less than 24 <br />hours on routine cases when all necessary clinical information is provided. Requestsfor care <br />within 14 days are reviewed and processed the same business day. <br />High Acuity Notifications, NaphCare's Utilization and Case Management team closelyrnonitprs <br />Inmates diagnosed with chronic and complex illness, TechCarev' aids staff In this process by <br />tracking the number of off•slte visits byway of a watch list. Inmate acuity level Is based on the <br />severity of illness and subsequent off-site treatments. when our nurse anticipates that an <br />Inmate's, care will require a wide range of resources, multiple off -site trips, at extended <br />hospitalizations and treatments, a high acuity notification is sent to the Captain and appropriate <br />jail personnel, hlaphCare ensures that high acuity Inmates are closely monitored, which reduces <br />readmission, prolonged length of stay, and repeat surgery, as well as other medical expenses. <br />Pre.Procedure Instructions to, Inmates^ With <br />the goal of educating inmates on scheduled <br />procedures, NaphCare's clinical support staff <br />provides Inmates with medical instructions and <br />information prior to these procedures,Thraugli <br />this process, inmates receive evidence - based <br />answers to clinical questions at the point of <br />care. Informed of their procedures, Inmates are <br />prepared to ask questions and engage in convey <br />Inmate modlcal Services <br />Citytrf Santa 'Ana <br />25H -74 <br />fly following ourpvficfes we orc able to <br />shorten the length of stray, preserve <br />quality of core, and enhance d{schorge <br />pionninq for return to the f'cactlfty. <br />satlnns with clinical staff regarding course of <br />RFP Na, 14� 34 <br />70 <br />