A DAY IN THE LIFE
Whole Health Index 3
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devices , procedures , medications , genetic tests , etc .). These reviews also offer an opportunity to connect with my peers who are caring for patients on the front line to see how we can partner with them to better support the patient from the insurance end — this means making sure they get “ medically necessary ” care , but also going the extra mile to make sure patients with extra needs are connected to other services .
On the commercial side of insurance , our services can vary depending on the employer and plan selected , but typically include case management , including specialized case management ( for example , cancer care navigation ) and chronic disease management ( for example , specialized support for those with diabetes , COPD or inflammatory bowel disease ).
An essential side note about UM : I learned pretty quickly that the utilization management ( UM ) language and activities are major components missing from our medical education . I knew and understood prior authorizations , peer-to-peers and appeals from my experience as a primary care provider , but they always seemed like a complete enigma to me . What did these denial letters actually mean ? What on earth is an MCG Guideline ? How can I possibly understand all of the 50 different formularies for the thousands of medicines that my patients take ? Having now experienced things from the other side , I would encourage physicians to reach out to a physician colleague who has done UM to learn more ! Some of the barriers and frustrations I faced in my practice could have been more easily averted in many cases if I ’ d had a deeper UM foundation during my training .
Case Management ( CM )
I work with our multidisciplinary case management teams in order to directly assist patients with complex needs . Our case management spans both inpatient and outpatient realms . These CM teams , include behavioral health experts , social workers , pharmacists , dieticians and nurses , similar to the multidisciplinary rounding team you might have on an inpatient service . We might help patients to find an alternative treatment option to the emergency room or make sure that they have timely follow up after hospital discharge . We might be smoothing the way for a successful transition from inpatient care to home by assisting with home health arrangements , reaching out to the pharmacy to ensure discharge medications are available for pick up or delivery , and assuring that durable medical equipment has been obtained . Next time you have a complex patient , especially one that might need extra support , reach out to their insurance provider for help from case management or encourage the patient to do so — the CM team can provide more resources to both you and your patient !
Population Health
( Chi WC , et al . 2023 )
Population health is defined as “ the health outcomes of a group of individuals , including the distribution of such outcomes within the group .” 1 This definition is similar to that of community health , which aims to improve the health outcomes of a group of people through interventions in a community . 2 The definition for both includes figuring out what makes up your “ population ” or “ community ”— it might be a geographic region , a certain demographic or it might be a group of people that work for a certain employer . For the purpose of my current role , I am serving various smaller populations — those who are employed by certain companies . We look at health outcomes for those groups and determine which interventions may be most helpful to improve health outcomes , quality of care and to reduce the cost of that care for those groups .
10 LOUISVILLE MEDICINE