Case Management at the Saint Francis Physician Hospital Organization (PHO) is focused on monitoring the efficiency and quality of care provided to patients treated by PHO Members in both the inpatient and outpatient settings.

Inpatient -  The PHO has earned recognition amongst area health plans and provider organizations for its Inpatient Utilization Management Program. The State of Connecticut has licensed the PHO as a utilization review company since 1998.  In partnership with the Saint Francis Hospital and Medical Center (SFH&MC) Case Management Department and health plan utilization management personnel, three PHO Medical Directors serve as inpatient physician reviewers performing medical necessity review activities to facilitate appropriate utilization of services across the continuum.

The PHO and Hospital Case Managers have implemented a formalized systematic review of utilization and financial data in order to assess performance and facilitate resolution of identified issues.  The Inpatient Case Management process includes:

• SFH&MC case manager, payor nurse reviewer and attending physician collaboration with regard to continued stay and discharge planning
• PHO Medical Director involvement in the event of disagreements among interdisciplinary team members with regard to medical necessity decisions
• PHO Medical Director review of patient medical record including validation of appropriate level of care and identification of optimum medical management strategies

Outpatient - Refer to "Multidisciplinary Disease Management" bullet at top of "Medical Management" page.

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