Pediatric Utilization Management through a Leadership Lens

Maryanne Bourque, director of utilization management, nurse case management and complex scheduling at Nemours, brings a strong foundation in nursing, pediatrics and healthcare management. Her early NICU, Transport and ED experience shaped her focus on care quality and system efficiency. Leadership roles sharpened her strategic skills, while crossdisciplinary collaboration at Nemours fuels her commitment to innovation and improved outcomes.

Patient-Centered Utilization Management and Tech-Driven Improvements

Although utilization management is designed to be an objective review of medical necessity and progression of care, I’ve always approached this discipline with a strong patient advocacy focus. As patients, especially pediatric patients, are not always in a position to advocate for themselves, I’ve always considered a key part of my role to be looking for barriers to care and timely access to care, as well as how disparities affect the way patients receive care. I’ve always established performance metrics and worked with teams to clearly understand not just expectations but how to meet those expectations. I’ve also worked to incorporate continuous improvement processes to ensure the best outcomes. Nemours’ philosophy of child- and family-centered care aligns strongly with my own beliefs: when you prioritize what’s best for patients and families, best practices and excellent care naturally follow.

Some of the advancements are technological and some are low-tech but highly impactful:

• Referrals to complex scheduling previously came into the team in a variety of ways, through referrals, emails and even faxes. We worked with our EMR team to develop a work queue that provided transparency in work, along with the ability to prioritize based on patient need and afforded us the ability to track outcomes of processes so that children receive access to the care they need when they need it.

• For the UM team, we worked with some of our payers to allow access of the payer UM team to our EMR, allowing them to extract needed information to perform utilization reviews. The UM team, through process improvement and collaborative efforts with our EMR team, also found work queues to be a streamlined approach to prioritizing reviews.

• The UM team also works closely with their case management counterparts to obtain needed clinical information that may not yet be found in the chart but does provide crucial support for requested patient days.

Nursing Leadership’s Role in Pediatric Strategy

Pediatrics requires adaptability and innovation to address the diverse and evolving needs of children and the changing landscape of healthcare and financial models of reimbursement. My experience in pediatrics has certainly equipped me with the ability to adapt to changing circumstances and implement innovative solutions.

Storytelling to Support Policy and Engagement

By sharing real-life stories of patients and healthcare providers, I can bring statistics and data to life. These narratives help readers connect emotionally with the issues at hand, making the need for policy changes or improved patient engagement more compelling.

Sometimes, other business leaders within the health system do not fully understand the complexity of pediatric illnesses and how this can impact the utilization of health resources. Storytelling allows me to break down these complexities into relatable and understandable narratives, making it easier for readers to grasp the importance of the issues.

Pandemic Lessons in Pediatric Health Leadership

I think the biggest challenge of the past 7 years would have to be the COVID-19 pandemic and its effects on pediatrics. Unlike adult hospitals that were overwhelmed immediately with COVID-19 patients, pediatric hospitals were not as severely affected during the early months of the pandemic. Rather, the issue was trying to get children all that they needed that affects long-term care: immunizations, access to learning and the ability to address social and psychiatric problems early in the course. Once vaccinations were made readily available, we did see a large upswing in volume. Having to pivot quickly and adeptly and being prepared for the next shift were all skills I developed during this period. I think this time brought senior leaders closer to the frontline staff, helping them to more fully understand how they worked to ensure the highest quality of care to patients during professionally and personally challenging times.

Lifelong Learning Advice for Future Leaders

I would advise any leader to listen and develop a lifelong learning mindset. This is especially true in pediatrics— lessons can be heartwarming, poignant, painful or joyous, but there are plenty of lessons to be learned.