Comprehensive Healthcare Change Proposal

Comprehensive Healthcare Change Proposal

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Proposal

1. Create a proposal by doing the following:
2. A value-based healthcare change that I proposed within the managed care organization (MCO) for which I work is to separate the utilization management (UM) review nurse and discharge planning roles.
3. Select an organizational sponsor in a leadership role and meet with them to authorize your proposed change and complete the attached “Professional Verification Form.”

Note: See the “Professional Verification Form” for details on how to complete the document, and include all required sections. An organizational sponsor is an individual who fulfills a leadership role, such as a supervisor, manager, director, or clinical specialist.

1. During my discussion with my supervisor, I outlined the rationale for separating Utilization Management (UM) and Discharge Planning (DP) responsibilities, emphasizing the potential benefits for the nurse, the member, and the organization. I explained that currently, a single nurse is tasked with both inpatient hospitalization reviews and discharge planning, which creates significant workflow demands. UM duties include applying InterQual criteria, documenting review notes, referring cases to the medical director when necessary, notifying the hospital and member, and generating appropriate correspondence—all within one business day. Each review typically takes 30–45 minutes. In addition, discharge planning involves initiating outreach to the facility within 24 hours of notification, maintaining follow-up with hospital case management every 2–3 days, and coordinating post-discharge needs such as home care and durable medical equipment. I proposed that separating UM and DP roles would improve clinical integrity by allowing UM nurses to focus on medical necessity while dedicated discharge planners manage psychosocial complexities and continuity of care. This division would support more patient-centered planning, reduce discharge delays, lower readmission risks, and enhance interdisciplinary collaboration, ultimately improving both payer compliance and patient outcomes. My supervisor was receptive to these points and acknowledged the challenges of the current model.

1. Explain any changes you had to make to your proposal based on the sponsor’s feedback, or explain why no changes were needed based on your sponsor’s feedback. None
2. Effective discharge planning has been shown to significantly reduce hospital readmission rates, decrease post-discharge complications, enhance patient satisfaction, and support better recovery outcomes. National data consistently highlight that hospitals investing in comprehensive discharge planning not only improve quality of care but also achieve measurable cost savings. These benefits extend to patients, families, and the broader healthcare system. Given that both Utilization Management (UM) and Discharge Planning (DP) are complex and time-intensive processes, expecting one nurse to manage both effectively can compromise the quality and timeliness of care. This underscores the need to separate these roles to ensure optimal performance and better outcomes. (Deepak 2025)
3. Two potential barriers to implementing the proposed change include the current shortage of nursing staff, which makes it challenging to allocate separate personnel for Utilization Management and Discharge Planning roles, and potential resistance from senior management, who may be concerned about the resource implications or may be hesitant to alter established workflows.
4. A potential negative outcome of not implementing the proposed change is non-compliance with required turnaround times, which could result in failed audits, financial penalties for the health plan, and the potential risk of losing accreditation.
5. If there is a lack of support for the proposed change, a potential course of action would be to present a detailed risk-benefit analysis to key stakeholders. This analysis would highlight the advantages of separating Utilization Management and Discharge Planning roles—such as improved compliance, enhanced patient outcomes, reduced readmission rates, and increased staff efficiency—against the potential consequences of maintaining the current structure, including non-compliance with regulatory timelines, increased audit risks, staff burnout, and compromised quality of care. Presenting this data-driven comparison can help facilitate informed decision-making and encourage reconsideration of the proposed change.
6. This proposed change could enhance value-based care in two key ways. First, by reducing nurse burnout through a more manageable workload, the organization may experience lower staff turnover, leading to cost savings associated with recruitment and training. Second, separating Utilization Management and Discharge Planning roles allows each team to focus more effectively on their specific responsibilities, improving attention to detail and overall performance—ultimately resulting in better patient outcomes and more efficient care delivery.
7. Key stakeholders essential to the success of this proposal include the Director of Utilization Management and the Utilization Management Supervisor. The Director of Utilization Management plays a critical leadership role by guiding the organization’s UM strategy, overseeing the implementation of core functions, and providing executive-level oversight to ensure alignment with departmental goals and performance standards. The Utilization Management Supervisor is instrumental in managing the day-to-day operations of care management processes, including utilization review, strategic planning, cost containment efforts, system improvements, and quality outcomes. Their engagement and support are vital for effectively implementing and sustaining the proposed change.

1. To collaborate with key stakeholders, I would schedule initial meetings with the UM Director and Supervisor to present the proposal and gather feedback. Ongoing communication and regular check-ins would ensure alignment, address concerns, and support implementation. I would also involve them in planning staff training, adjusting workflows, and ensuring compliance, fostering shared ownership and a smooth transition.

Implementation Strategy

1. Create an implementation strategy by doing the following:
2. Identify the key resources needed to implement your proposed change.
3. Identify the costs associated with implementing your proposed change.
4. Discuss twobenefits of implementing your proposed change.
5. Provide a timeline for your implementation strategy that includes the following phases:

• planning
• milestones
• implementation
• evaluation

5. Explain how you would use data to support your implementation strategy.
6. Analyze the potential outcomes of your proposed change by doing the following:
7. Discuss a potential financial benefit of the outcome of your proposed change.
8. Discuss twopotential ethical implications of the proposed change.
9. Discuss how you could integrate technology into your implementation strategy, including a relevant example of how the technology would be used.
10. Describe how you would measure your proposed change’s success.

Reflection

1. Write a reflection statement by doing the following:
2. Describe how you were a change agent in creating this proposed change and implementation plan, including a relevant example.
3. Examine your influence over the proposed change by doing the following:
4. Describe the knowledge and skills you obtained and used, including a relevant example.
5.  Analyze how you could expand the proposal beyond the organization or environment in which you envisioned your proposed change would take place.
6.  Incorporate the following components into your task:

•  citations that include the author(s) and date of publication—for example: (author, date)
• references that include all four components, in the order of author, date, title, and location

Deepak. (2025). The role of nurses in discharge planning. Nursing Expert. https://nursingexpert.in/the-role-of-nurses-in-discharge-planning/

1. Demonstrate professional communication in the content and presentation of your submission.