Transformational Impact: Revolutionizing Utilization Review and Care Management Processes for Optimal Outcomes

Seeking A Comprehensive Solution to Address Operational Challenges

Hoa Cooper, Vice President of OSF Care Management, set out to find an artificial intelligence (AI)-driven utilization management (UM) platform that could significantly enhance OSF HealthCare’s operations. Their goal was to mitigate clinical denials, improve patient status determinations, streamline length of stay management, and automate the case management process. According to Hoa, “We were in search of a UM platform that could address all these needs comprehensively, and Xsolis emerged as the most promising solution in the market. With Xsolis’ advanced technology, we can now efficiently monitor our collective performance to drive superior outcomes.”

OSF HealthCare faced the dual challenge of navigating staffing shortages and the strain caused by COVID on the healthcare system. Additionally, their UM and Care Management teams were facing numerous challenges. These included fragmented information across disparate systems, inconsistent processes for medical necessity reviews, and limited collaboration across internal teams and health plan partners throughout the continuum of care. Disparate systems, manual processes, and fragmented data led to inefficiencies, redundant resources, strained relationships between OSF HealthCare and their health plan partners, and siloed information. Recognizing the urgent need for a transformative solution, Hoa turned to Xsolis to help them address these challenges and drive operational efficiencies. In August 2023, OSF HealthCare implemented the Xsolis platform to optimize their UM workflows.

 

Leveraging AI and Machine Learning to Streamline Processes and Optimize Resources

OSF HealthCare sought an AI platform capable of supporting their virtual centralized UM staff, enabling them to work seamlessly across multiple locations. Following the implementation of the Xsolis platform, the UM team at OSF HealthCare swiftly optimized their workflows, enhancing transparency across internal departments and health plan partners. Hoa Cooper, Vice President of Care Management at OSF HealthCare, emphasizes that, “Xsolis has equipped our staff, whether working from our facility or remotely, with streamlined workflows and standardized processes for consistency.”

Furthermore, the OSF HealthCare UM Team can now efficiently prioritize patients using the Xsolis Care Level Score (CLS). The CLS utilizes real-time predictive analytics and machine learning to assess patient data and determine the likelihood of appropriate patient status. Dr. Matthew Gorman, Medical Director of Care Management at OSF HealthCare, highlights that “Xsolis’ CLS provides invaluable insights, allowing us to allocate resources efficiently and optimize processes and staff performance organization wide.”

Fostering Collaborative Health Plan Partnerships for Enhanced Outcomes

The success achieved with the Xsolis platform has also positively impacted OSF HealthCare’s health plan partners. To facilitate seamless collaboration and communication, OSF HealthCare is now connected via Dragonfly with two of their primary health plan partners. This shared platform enables the health system and their health plans to align their processes, fostering effective communication without the need for cumbersome phone calls and faxes.

Additionally, OSF HealthCare implemented Precision UM with a major national health plan partner, further enhancing their collaborative efforts and ability to deliver optimal outcomes for patients and members. Precision UM automates inpatient determinations that are mutually agreed upon by both parties (OSF HealthCare and the health plan). According to Hoa, “It’s really about doing the right thing together. Previously, our processes were riddled with friction. Now, the Care Level Score (CLS) has been established with our health plan partners, resulting in improved data sharing, heightened transparency, and ultimately, trust, which we lacked before.”

“Xsolis emerged as the most promising solution in the market.”

– Hoa Cooper
Vice President, OSF Care Management

 

Achieving Results and Continuing to Drive Operational Improvements

From September 2023 to December 2023, OSF HealthCare’s initial collaboration with Xsolis has yielded significant results, including a 1.7x return on investment equivalent to over $595k, a notable 6% reduction in observation rates, and an impressive 8.1% enhancement in review efficiency (percentage of reviews completed within 24 hours). These operational efficiencies have enabled the health system to reevaluate their staffing requirements. Given the challenges in hiring UR nurses, OSF HealthCare has refrained from backfilling positions when UR staff resign, thanks to the workflow enhancements facilitated by the Xsolis platform.

Looking forward to 2024 and beyond, in collaboration with Xsolis, OSF HealthCare is concentrating on identifying potential inpatient conversion opportunities to ensure accurate patient status determination from the outset, thereby maximizing revenue potential. Additionally, they plan to leverage CM Analytics to bolster length of stay initiatives and refine discharge planning processes. Other key initiatives for 2024 include optimizing health plan connections, promoting collaboration across teams and with health plan partners, and streamlining the 2nd level review process.

To discover how you can empower your organization to optimize UM workflows and enhance your team’s efficiency to achieve optimal outcomes, contact Xsolis today.  

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¹Legal Disclaimer: ROI projections are estimates based on similar system information and averages over the first 2 years of utilization. Such ROI projections do not guarantee future results. Actual ROI will vary based on various conditions and factors for each customer, including, but not limited to, client baseline information, best practice utilization of the products, etc.