Utilization review: behind-the-scenes nursing review rounds out patient care

by Traci Chapman, Staff Writer

The world of a utilization review nurse goes far beyond bedside, or even patient, care – it’s a position combining the best of all worlds, combining traditional nursing, quality and cost efficiency, administrative functions and community outreach.
It’s a job Russell Murray Hospice’s director of utilization review and education, Debbie White, said remains new and challenging every single day.
“It makes me very happy to know I can help teach others while caring for patients and families and that I can ensure we offer as much as we possibly can to them – even beyond the nursing care itself,” White said.
The 59-year-old White began working at Russell Murray Hospice 22 years ago. Back then, the company was solely located in El Reno; its single office was a comfortable fit to the few nurses and administrative staff that primarily served Canadian County and surrounding areas.
Much as White’s career has flourished, so too has Russell Murray’s service areas, its patient numbers and variety of the services it provides. RMH now employs about 25 full-time RNs and LPNs and several per diem PRN nurses across four offices located in El Reno, Oklahoma City, Kingfisher and Weatherford.
“We serve approximately 75-mile radius surrounding each of the four offices,” Russell Murray Executive Director – and one of the firm’s founders – Vicki Myers said. “We generally serve about 100 to 110 patients, up to at times close to 120.”
That kind of volume and a service area comprised of hundreds of square miles means having the right process in place to ensure both care and administrative tasks are performed to the highest standards is paramount – and, it’s one reason why utilization review has become so important.
Russell Murray’s nurses, like those working for other hospice providers, face a somewhat unique dynamic, particularly when considering the intensity that comes along with the nature of that care – and the fact their patients are not going to get better. Throw in ever-complex and constantly changing issues in dealing with Medicaid, Medicare and private health insurance, and it can become beyond overwhelming.
Those requirements mean White and other UR nurses review not only what treatments a patient might need, but also make sure those treatments will be of benefit to that patient without overloading healthcare systems. The idea is fairly new, with utilization review primarily developed in the 1980s, as managed care came to the forefront, according to the National Academies of Sciences, Engineering and Medicine.
“Utilization Review can be invaluable in bridging the gap between patient care, insurance and cost expectations and realities and healthcare professionals working to determine the best treatment options and even whether some treatments are appropriate at all,” The National Academies outlined in a 1989 study.
While utilization review is about numbers and dollars on some levels, for White it is primarily a way to help patients and their families get the best and most appropriate care possible. Hospice has a unique place in healthcare – Russell Murray’s nurses are not providing care that will end in a cure or improved condition, at least in the long term, Myers said.
“This is about making sure the individual has the tools to face end of life,” she said. “We want to work with each patient, and their family, to make sure they are able to do this on their own terms and to offer the care they need in the way they need it.”
That philosophy has worked, evidenced not only by Russell Murray’s growth, but also by how long it has been providing hospice care, Myers said. Now in its 30th year, the company continues to evolve – and utilization review, while behind the scenes, is just one way RMH can make sure it is helping both patients and their families, but also staff, as well, she said.
That staff support is also something in which White is very involved, in her “second” position as RMH education director – ensuring nurses are fully compliant in continuing education to conducting new orientation training.
While White said she always thought she would become a nurse, she approached her then-potential career with the study and care she shows now in her work, those who know her said. She first worked as a nurse’s aid before attending University of Oklahoma College of Nursing; as a BSN and RN, she was a pediatric and mental health nurse; but, it was at Russell Murray the Blanchard woman found her professional home and it was in hospice utilization review and education she found a niche where she could best utilize her skills and gifts.
“Although nursing can be complicated and challenging, I feel it is a very special privilege to help serve others in their time of need,” White said.