For clinical leaders, accurate data and strong relationships with staff members are foundational for utilization management, this new CMO says.
The new CMO of AdventHealth New Smyrna Beach says having more than 15 years of experience in emergency medicine has provided him with valuable insights about utilization management.
Jose Rosado, MD, became CMO of the AdventHealth hospital on Jan. 19. His prior leadership experience includes serving as chief of staff at the hospital.
Succeeding in utilization management is lot like working effectively as an emergency medicine physician in a busy ER, according to Rosado.
"It comes down to good data, good instincts, and good relationships," Rosado says.
Gathering accurate data is essential in utilization management, Rosado explains.
"At AdventHealth, we have several dashboards that allow clinical leaders to look at data, assess metrics, and look at trends that show us opportunities for improvement," Rosado says. "In utilization management, important data points include length of stay and reducing unnecessary days in the hospital."
Utilization management often leads to changes, which makes strong relationships between clinical leaders and staff members important, according to Rosado.
"People have a natural tendency to be resistant to change even if change leads to a situation that is better for them," Rosado says. "With strong relationships, staff members can understand your perspective on utilization management, and you can understand their perspective."
Communication can play a pivotal role in utilization management, Rosado explains.
"When physicians understand why certain criteria are necessary, they stop seeing utilization management as people saying 'no' as opposed to care teams giving the right care at the right time," Rosado says.
Jose Rosado, MD, is CMO of AdventHealth New Smyrna Beach. Photo courtesy of AdventHealth.
Quality Improvement Initiatives
Two of the essential elements of successful quality improvement initiatives are actionable data and engagement of the staff members who are doing the work, according to Rosado.
Rosado helped lead an initiative to improve sepsis care, which included focusing on key data points such as how long it was taking care teams to administer antibiotics and IV fluids.
Part of staff engagement for the initiative was making sure care teams understood the 'why' behind the quality improvement effort, Rosado explains.
"We made sure staff members understood that we were not making arbitrary changes," Rosado says. "We let them know that we were following data and making changes rooted in evidence-based practice. We communicated the ultimate goal, which was providing the best care for our patients and community."
One of the changes that was made as part of the sepsis care initiative was the creation of a sepsis alert. Whenever there was a patient with a high shock index or a patient who was hypotensive with a high fever, the sepsis alert would be activated to make care team members aware that there was a patient who needed special attention and timely care.
The sepsis alert was coordinated with multiple departments, according to Rosado.
"There would be a response from an ICU physician, the hospitalist team, and a nursing supervisor," Rosado says. "So, when a patient was admitted to the hospital, there was coordinated care and an inpatient bed was available."
The sepsis care improvement initiative generated significant results, including a reduction of sepsis mortality from 19% to about 10%.
Telemedicine Best Practices for Physicians
In telemedicine, there are several best practices for physicians, according to Rosado, who worked as a telemedicine physician for Amwell from 2020 to 2023.
Clear communication with telemedicine patients is pivotal, Rosado explains.
"When I conducted telemedicine visits, I spoke at a slow pace and checked for understanding with the patient more frequently than I would during an in-person visit," Rosado says.
Physicians should be aware of privacy concerns during telemedicine visits such as knowing whether there are other people in the home with a patient, Rosado says.
Physicians must be aware of the limitations of virtual visits, according to Rosado. For example, patients can help a telemedicine physician conduct physical exams during virtual visits, but the physician needs to understand the limitations of a virtual exam and when an in-person visit is required.
Sometimes, patients seek care through virtual visits, but there are clear indications when a telemedicine physician should encourage patients to get in-person care, Rosado explains.
"I had several elderly patients with multiple risk factors who would present for a telemedicine visit with chest pain and a history of cardiac disease," Rosado says. "At a bare minimum, those kinds of patients require an EKG, which cannot be provided through telemedicine."
Patients who may be having a stroke are another example when in-person care is needed rather than a telemedicine visit.
"If a patient has slurred speech and there is a risk of stroke, they should receive care in an emergency department rather than a telemedicine visit," Rosado says.
Christopher Cheney is the CMO editor at HealthLeaders.
KEY TAKEAWAYS
Communication such as ensuring that physicians understand why certain criteria are necessary can play a pivotal role in utilization management.
Two essential elements of successful quality improvement initiatives are actionable data and engagement of the staff members who are doing the work.
For telemedicine physicians, best practices include speaking slowly during telehealth visits and checking for understanding with patients more frequently than during in-person visits.