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1a. Use of the Care Guidelines to Support Quality Care
and Avoid Readmission for Major Bowel Surgeries

The basis for this UnitedHealthcare project was the well-reported relationship between hospital length of stay (LOS) and facility-acquired complications risk. Clinical literature states that every hospital day is linked to a 6% risk for complications. Based on these complication risk rates, the selected Major Bowel Surgery APRDRGs demonstrated a baseline avoidable risk for complications of >10% per admission.

A Six Sigma approach was taken to identify variation in clinical outcomes that contributed to avoidable inpatient LOS during admits for major bowel surgeries. Sharing of practice profiles based on this data as well as related EBM guidelines, such as Milliman Care Guidelines, was a key strategy to minimizing variance in peri-operative care and resultant clinical outcomes. These interventions demonstrated a statistically significant improvement in clinical quality, reduced avoidable LOS, and reduced readmission rates related to these procedures.

1b. Getting the Level of Care Right the First Time (Observation vs. Inpatient)

This session will focus on how hospital teams can best assign an appropriate level of care (observation versus inpatient) during real-time reviews, and how to get physician buy-in. Case studies will be used.

1c. Accountable Care Organizations - Back to the Future?

Models of care concepts are re-emerging as the result of Healthcare Reform Healthcare costs and other initiatives may change the relationships amongst payers, providers, and patients. How can effective care-management strategies reduce costs? What can be learned from past risk-sharing efforts when exploring new ACO structures?

1d. Benchmarking Performance Using the Care Guidelines

The Care Guidelines include a variety of information that can be used in benchmarking performance. In this session, we will review these various information sources and show how the structure of the Care Guidelines can be used to create actionable, clinically-focused benchmark comparisons.

2a. Successful Strategies for Implementing CareWebQI in Your Health Plan

This session will cover how the ODS Companies recognized the need, and implemented the Milliman Care Guidelines at their health plan.

2b. Best-practice Use of the Care Guidelines
for Multidisciplinary Hospital Patient Rounds

Case management is challenged with the almost impossible task of balancing patient needs and fiscal resources, with the expected outcome of quality care and decreased length of stay. To be successful in this endeavor, case managers require the collaborative efforts of a multidisciplinary team as they coordinate complex medical needs, identify barriers to discharge, or ensure timely transition to a different level of care. A best-practice approach using the care paths outlined in the Care Guidelines, along with a systematic multidisciplinary process to identify barriers and facilitate options, will decrease fragmentation in care, streamline an evidenced-based patient care plan, decrease length of stay, and improve patient satisfaction.

2c. Your Problem Cases: Prior Authorization

Bring your difficult prior authorization cases and your experience to this interactive session. We will discuss tools and tips for effective guideline-based prior authorization.

2d. Interrater Reliability Tool: Measuring the Consistent Application of the Care Guidelines

We will show how we use the Interrater Reliability Tool to assess consistent application of the Care Guidelines across multiple offices and regions. We will explain how we selected case studies relevant to users’ roles and job functions, how Interrater Reliability reports and results supported regulatory and accreditation needs across the organization, and how we used test report data to set action plans for improvement.

3a. Successful Strategies for Implementing the Care Guidelines in Your Health Plan

We identified four key strategies for successfully implementing the Care Guidelines in the health plan environment. We will share details behind the need for committed senior management support to use standard guidelines for clinical UM decisions, the need for several champions among medical directors and UM supervisors, the advantages of early training for UM staff and medical directors, and the power of constant and regular communication between medical directors and UM nurses on the appropriate use of guidelines.

3b. Your Problem Cases: Inpatient

We will present some common difficult cases and model how to use the Care Guidelines for challenging patients making their way through the continuum of care. We will also ask attendees for examples of troublesome situations to discuss with peers and consultants.

3c. Ambulatory Care: 15th Edition Review and Ask the Editor

During this interactive session, you will learn about enhancements in the 15th Edition of Ambulatory Care. We will present our approach to the rapidly expanding field of genetic medicine and describe our approach to new developments for future editions. Bring your questions and input for the Ambulatory Care editor.

3d. Enhanced Reporting Features in CareWebQI Version 3.0

CareWebQI Version 3.0 includes a number of new standard reports and introduces a simple yet powerful tool for creating and modifying new reports. In this session, we will review these new reporting features and demonstrate the capabilities of the new reporting tool in a variety of real-world scenarios.

4a. Auto Authorization: Streamlining the Authorization Process
(Implementing and Using the Care Guidelines Auto Authorization Product)

We will describe Colorado Foundation for Medical Care’s decision making and implementation process of the Auto Authorization tool. In addition, an overview of the Auto Authorization product will be provided with time for questions and answers.

4b. Healthcare Reform: Follow-up to Keynote Address

The Patient Protection and Affordable Care Act (PPACA) is now a year old, and we are just beginning to understand its depth and breadth. This session will review the key components of the PPACA and explore their implications, especially from the health plan and provider perspectives.

4c. Introduction to the Customer Satisfaction Department

In this session, we will introduce clients to the new Milliman Care Guidelines Customer Satisfaction department and explain what it will offer. We also will review Milliman’s existing services and our plans for the future.

5a. “What Hat Are You Wearing?” Role Clarification and Challenges in Combined Case Management and Utilization Management Work in Behavioral Health

We will present the development and implementation of a standardized process for behavioral health medical necessity-based coverage determinations in a group model HMO. We will identify the challenges of separating health plan (insurance) roles from clinical roles in an otherwise integrated delivery system. We will introduce strategies for mitigating these challenges and the potential for dual agency, including changing management strategies for staff transitioning from predominantly case management to the incorporation of utilization management roles. The larger utility of these concepts in the areas of care and case management by staff with utilization management roles will be emphasized.

5b. Bringing Best Practice to the Bedside
With the Care Guidelines and CareWebQI

Sound Physicians developed the High Impact Diagnoses Initiative (HIDI) to optimally manage acute diseases in the hospital by bringing process, technology, and informatics to the hospitalist team at the bedside. To attain our goal of improving quality of patient care, we recognized the value of best-practice guidelines, which led to our use of the Care Guidelines and CareWebQI. We will tell how we implemented unique workflows and modified the Care Guidelines to improve quality of care, patient safety, efficiencies, and documentation at our partner hospitals.

5c. Inpatient and Surgical Care, General Recovery Guidelines,
and Patient Information Package: 15th Edition Review and Ask the Editor

In this session, we will present new changes and enhancements to the 15th Edition products. We will cover extensive wording changes, definitions, and features that point out additional helpful content that have been added to make the user experience more effective and efficient. You will also preview the expanded Patient Information Package, a collection of patient-facing handouts ideal for patient education during their various stages of the healthcare continuum.

5d. Chronic Care Guidelines: 15th Edition Review and Ask the Editor,
and Introduction to the Interactive Chronic Care Guidelines Under Development

During this interactive session, you will learn about enhancements in the 15th Edition of Chronic Care Guidelines. We also will update you on the plans and timeline for introduction of our fully interactive version of the Chronic Care Guidelines product. Bring your questions and input for the editor and product manager.

6a. How to Use the Care Guidelines in a Risk-based Medicaid DRG Population

We will describe how MHS Indiana uses the Care Guidelines to monitor, review, and gauge a patient’s care course in planning care and estimating clinical days for appropriate anticipated length of stay. We also will tell how MHS utilization nurses use the Care Guidelines to plan appropriate care following discharges and to assure effective use of case management services and patient education tools.

6b. Use of the Care Guidelines in a Rural Hospital Setting

Wenatchee Valley Hospital’s performance improvement initiative for 2009 was “Elimination of Inappropriate Hospital Admission Status.” Our project goals were to reduce rates of inappropriate admission status in compliance with Medicare-approved guidelines at a rate consistent with other Washington State Hospitals, reduce risk of repayment post Medicare RAC (Recovery Audit Contractors) audit, and create efficient admission processes from the new Emergency Department to ensure minimal impact on elective surgical admission and to minimize patient backup in both of these departments. Implementing CareWebQI interactive software was instrumental in providing real-time guidance to determine appropriate admission status. We also found that CareWebQI provided current best-practice guidelines and documentation capabilities that improved participation from both physicians and nursing personnel.

6c. Recovery Facility Care and Home Care: 15th Edition Review and Ask the Editor

We will demonstrate enhancements to the 15th edition of the Recovery Facility Care and Home Care products, including new features such as the Recovery Facility Care extended stay content and the Home Care expanded data information. Bring your questions and input for the editor.

6d. CareWebQI Open Forum - Ask the Product Development Team

You will learn about enhancements included in CareWebQI Version 3.0 and changes planned for later versions. Bring your questions, ideas, and input for the CareWebQI product manager and developers.

7a. Use of the Care Guidelines Throughout the Continuum of Care

During this session, Johanna Deffenderfer from Group Health Cooperative of South Central Wisconsin (GHC-SCW) will discuss how this staff model HMO has structured its utilization management. She will also identify how the use of the Care Guidelines across the continuum of care has allowed the organization to expand its complex care management program into the clinic settings.

7b. Successful Strategies for Implementing the Care Guidelines in Your Hospital

Do you continue to struggle with getting the correct level of care for your patients? Does it seem that everyone is going in different directions even though you’re all supposed to be working toward the same goal? This session will provide a high-level overview of a value-stream analysis conducted for service type changes at a community hospital, and will give examples of best-practice standard work using the Milliman Care Guidelines and LEAN/Six Sigma principles.

7c. Enhanced Reporting Features in CareWebQI Version 3.0

CareWebQI Version 3.0 includes a number of new standard reports and introduces a simple yet powerful tool for creating and modifying new reports. In this session, we will review these new reporting features and demonstrate the capabilities of the new reporting tool in a variety of real-world scenarios.

7d. Preparing for the User Certification Exam

Milliman Care Guidelines User Certification provides confirmation that a user can accurately apply Inpatient and Surgical Care and General Recovery Guidelines. Open to attendees who are planning to sit for the User Certification Exam, this interactive session will help prepare you for the exam. We will review practice exam questions and key clinical content and formatting content.

PF1. Advanced Inpatient and Surgical Care
and General Recovery Guidelines End-user Training Workshop

Clinical trainers will present interactive training on how to interpret and apply advanced Care Guidelines content. We will use complex case studies to practice applying Extended Stay, Common Complications and Conditions, and General Recovery Guidelines resources.

PF2. User Certification Exam

Milliman Care Guidelines User Certification confirms that a user can accurately apply Inpatient and Surgical Care and General Recovery Guidelines. The 90-minute online exam consists of 50 multiple-choice (single and multi-select), true or false, and yes or no questions. Many questions require review of a clinical case scenario and the Care Guidelines. Key topics include questions related to definitions, descriptions, and accurate application of guideline content. For additional information, go to contact us and submit an inquiry; choose "Training" as the Reason for Inquiry.