Scope of Work.pdf

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Navajo Area Indian Health Service

SCOPE OF WORK

Interqual or equivalent certification and evidence-based practice.

Objectives

• Provides well-informed clinical decisions using Interqual or equivalent care guidelines to stay abreast of new methods, technology and treatments.

• Provides fast access to evidence-based best practices and care-planning tools across the continuum of care.

• Supports the providers and the Utilization Review nurse to properly place the patient in observation status, full admission or transitioned to the next level of care.

• Interqual or equivalent assists in managing length of stay by analyzing and evaluating avoidable variations from optimal care against national benchmarks.

• Enables the Utilization Review nurse to quickly review and make note of care decisions as they are made with the guidelines, so reimbursements are safeguarded.

• Reinforce provider and nursing documentation by giving them confidence in identifying and applying the guidelines consistently in their documentation.

• Interqual or equivalent shall support the staff in clinical decision making and documentation to maintain job performance and staff satisfaction, which shall create less retrospective charting to support the clinical decisions.

• Interqual or equivalent helps ensure proper utilization of resources and centered on the patient.

• Enables NAIHS to reduce denials from private payers and Center of Medicare/Medicaid services by using evidence-based guidelines to support the decision-making.

Goals of contract with Interqual or equivalent:

• Evidence-based, not consensus-based, guidance – thoroughly reviewed clinical evidence in the medical industry. Interqual or equivalent develops the care guidelines in strict accordance with the principles of evidence-based medicine.

• Review supporting evidence – Give case managers and physicians guidelines that expose them to the evidence and clinical rationale supporting care decisions

• Protect revenue – Mitigate commercial payor and CMS contractor denials and reduce dependence on physician advisory services by using the best available evidence

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• Optimize length of stay – Reduce length of stay by identifying and addressing patterns of avoidable variances from optimal care pathways outlined in each guideline

• Reduce readmissions – Effectively manage care transitions and reduce preventable readmissions using discharge planning, patient education, and readmission risk assessment tools

• Drive quality and efficiency – Measure performance against ER and observation care utilization, level of care, length of stay, and other benchmarking data.

Methods of Analysis The Utilization Review Nurse at each Service Unit will utilize the Interqual or equivalent program on a daily basis.

All patient notes will be compared to the Interqual or equivalent care guidelines. Suggestions will be made to the providers or other nurses.

The use of the Interqual or equivalent evidence-based care guidelines will be documented in the yearly UR action plan or for the life of certification.

Service Unit Business Offices will report less denials from private payers and CMS.

Agenda & Action Plan --- To be developed by the Utilization Review Nurse with the support of the UR committee members upon contract execution.

Period of Performance ---

Period Period of Performance Base Period: October 1, 2022 – September 30, 2023 Option Period 1: October 1, 2023 – September 30, 2024 Option Period 2: October 1, 2024 – September 30, 2025 Option Period 3: October 1, 2025 – September 30, 2026 Option Period 4: October 1, 2026 – September 30, 2027

Virtual Training Dates --- To be determined upon contract execution.