CASE MANAGER CERTIFICATION EXAM WITH 100% VERIFIED ANSWERS, Exams of Health sciences

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CASE MANAGER CERTIFICATION EXAM WITH 100% VERIFIED ANSWERS case management the dynamic and systematic collaborative approach to providing and coordinating health care services to a defined population. - participative process to identify and facility options and services for meeting individual healthcare needs while decreasing fragmentation and duplication of care and increasing quality and cost effective clinical outcomes. standards of care parameters to measure the quality of healthcare clinical guidelines statements to help make decisions about health specific circumstances. clinical pathway structured multi-disciplined plan of care to support clinical guidelines and protocol to improve continuity and coordination. 4 parts of clinical pathway 1. timeline 2. categories of care/activities and interventions 3. intermediate and long term outcome criteria 4. variance tracking are 4 parts of what? decision tree used to select the best course of action in decisions where there is no clear decisions. descriptive screening tool identifies characteristics about a population to show health prevention. predictive screening tool shows what may happen to a specific population. evaluative screening tool evaluates the understanding/effectiveness SF-36 predictive screening tool to assess functional health and well being. Assesses physical and mental health. - used in health economics, cost-effectiveness of health tx -evals individual patient health status. - does not consider sleep -scored 00-100, lower score-> incr. disability patient activation measure 13 item predictive screening tool to evaluate patient's knowledge, skills, confidence in self-care. - higher the score the better (scored 0-52) -predicts health care outcomes, medication adherence and ER visits. health risk assessment predictive screening tool: patient's self assessment of their health and how likely they will seek care. - predicts future health costs - predicts likely-hood of progression of their illness to a worse condition. - examples: PHQ-9, etc. rose Q health risk assessment for angina, MI, coronary heart disease. defined angina pectoris as, "a chest pain or discomfort with these characteristics: (a) the site must include either the sternum (any level) or the left arm and left anterior chest (defined as the anterior chest wall between the levels of clavicle and lower end of sternum), (b) it must be provoked by either hurrying or walking uphill (or by walking on the level, for those who never attempt more), (c) when it occurs on walking it must make the subject either stop or slacken pace, unless nitroglycerin is taken, (d) it must disappear on a majority of occasions in 10 min or less from the time when the subject stands still." Possible myocardial infarction1 was defined as, "one or more attacks of severe pain across the front of the chest lasting for 30 min or longer." seattle angina questionnaire 19-item self-administered health risk assessment for angina and functional artery disease measuring five dimensions of coronary artery disease: 1 physical limitation, 2 anginal stability, 3 anginal frequency, 4 treatment satisfaction and 5 disease perception. -score of 0 to 100, where higher scores indicate better function (eg, less physical limitation, less angina, and better quality of life). arthritis impact measurement scales Erickson 3-5 Industry vs. inferiority Erickson 5-12 Ego id vs. role confusion Erickson 12-18 Intimacy vs. isolation Erickson 18-40 Generative vs. stagnation Erickson 40-65 Integrity vs. despair Erickson 65+ Skinner Operational conditioning CMAG Case management adherence guidelines IM-CAG Inter med - complexity assessment grid CMAG assessment tool. Comprehensive approach to chronic therapy issues, ex: med adherence, COPD, DVR,DM,HTN, IM-CAG Electronic tool that provides risks and vulnerabilities of complex patients with actionable interventions. 4 domains: behavioral, social, health system. evidence based practice 1. Question 2. ID resources 3. Critically appraise resources 4. Apply evidence 5. Reevaluate application of evidence are 5 steps of what? Integrated CM Includes well being, disease management, case management, prevention, triage, utilization management Integrated case management 3 functions of ---- 1. Track patient self management 2. Tend/track population management 3. Reporting, monitoring quality Patient Poor attitude, memory loss, literacy, pride, fear, side effects, can't "see" results, decreased choices, finances are all ----- barriers Patient My med list, readiness ruler, Motivational interviewing, modified morisky scale are all tools for ---- barriers Provider No knowledge of patient, not familiar with family preferences, lack of accountability are examples of ---- barriers System Poor communication, not identified care coordinators are ----- barriers Goal of CM To ensure patients have the tools and resources to help manage their needs, increase self confidence and control and self management Physiological, safety, love, esteem, self-actualization Maslow's hierarchy of needs Resource management Process of identifying, confirming, coordinating, negotiating resources to meet needs Milliman care guidelines Soft ware, evidence based guidelines/tool for treating common conditions, chronic care, BH - conducing, actionable, measurable - helps cm coordinate care and anticipate needs InterQual Clinical decision support tool determines when and how a patient progresses through the continuum. - organizes resources utilization, - objective evidence based criteria for assessing appropriate care for patients. Helps fraud/abuae Utilization management Forward looking using evidence based criteria to support decisions. Utilization review Backward looking to ensure patient's 5 rights were observed 1. Provider 2. Services 3. Setting 4. Time 5. Cost 5 rights of utilization review Utilization Management CM that identifies patients, their needs, develops individual holistic care plans addressing barriers Prior authorization Before services determines actual need Denial Requires: patent and provider notified, clinical rationale, rights to appeal, legally entitled to due process to appeal Concurrent review Process of reviewing if patient meets criteria while services are occurring Retrospective review Looks back, ID outliers, provides helpful information for future changes Cost benefit analysis Shows what the cost would be if Services were provided and outcomes occurred verses their current situation. demonstrates ration of dollars spent vs. savings achieved. Discharge planning Assessing care needs to ensure patients are transitioned safely. Due process Hospital Skilled nursing facilities Hospice Approved Home Health Medicare part A covers: 80% Medicare Part B only covers what percent? Yes Does Medicare Part B cover oxygen? Physicians Services Outpatient hospital services Medical equipment and supplies Medicare Part B covers: Medicare Part C Also known as the Medicare Advantage plan operated by private companies. Covers medications transportation exxtra Medicaid eligibility Based on income and financial resources. If you've already been receiving government Social Security If a child less than 21 years old and has a disability severe enough to meet disability standards under Social Security disability. Parental income is disregarded Skilled home health care and long-term care Medicaid covers SCHIP State children's health insurance program SCHIP administered by the center for Medicare and Medicaid. Government gives money to 2 approved State programs up to the age of 19 subsidy financial assistance that you do not have to pay back premium amount that you pay monthly for insurance cost sharing amount of money paid out of pocket, includes copays, deductible. Does not include premiums. tricare prime for active duty military members to help them be "fit for duty" tricare standard fee-for-service insurance option. You can see any tricare authorized provider inside or outside of network. tricare extra insurance option, you don't have to pain an annual fee but you have an annual deductible. outpatient discounts on cost-sharing. deductible amount of money that you must pay before the insurance will pay a claim. health maintenance organization (HMO) a health insurance provider for a group of people in a geographical area that delivers agreed to set of services and products to an enrolled group for a predetermined periodic payment (usually monthly). Patients have to see in network providers. Your PCP has to give you a referral for outside specialists except: internists, OB/GYN and pediatrics. Requires preauthorization for outside providers. preferred provider organization (PPO) pooled group of providers who are able to pool their resources. Have a stronger negotiating power with health maintenance organizations. point of service providers (POS) insurance benefit for HMOs or PPOs to see any provider in or out of network for an additional premium. gate keeper = requires a PCP referral. self insured large companies use this. They need a third party administer to handle claims. Case managers report to the third party administer. fee for service type of payment where providers are paid for each service. capitation type of payment to a provider for a group of people assigned to them where there is a fixed cost per person, per time period , not dependent on how often that person utilizes the resources. The provider is contracted under a HMO. per member, per month prospective pay type of payment that changed medicare reimbursement from a fee for service to a fixed payment based on DRGs. diagnostic related group pricing formula used by medicare that reimburses a fixed amount based on a diagnosis. Utilization review department case managers evaluate if a diagnostic test is medically necessary. all patient refined diagnosis related groups (APDRG) type of payment with 2 subclasses based on 1. severity of illness (organ system failure or loss of funtion and 2. risk of mortality subrogation legal right of an insurance company to get repaid from another insurance entity if they are found responsible for the medical care or wage-loss. Example your insurance company gets repaid by another driver's insurance company. stop loss or reinsurance insurance for an insurance company. When a certain threshold has been met. common for high risk claims ex: worker's comp. clinical risk group adjusting payment based on clinical characteristics and resource demands of a patient. claims based classification system. disability insurance insurance that replaces income lost when the insured person cannot work due to illness or injury based on their own occupation or any occupation. case managers help patients return to work. worker's comp state governed insurance company that requires your employer to provide wage replacement and medical benefits for temporary and permanent disabilities regardless if the worker is at fault. vocational rehab national committee for quality assurance (NCQA) private not for profit organization that accredits certain organizations if they meet standards to improve health care quality. includes a quality compass to score health plans. utilization review accreditation commission (URAC) An independent nonprofit organization that offers quality benchmark programs to improve quality and accountability of health care organizations. Joint Commission not for profit organization that set performance standards and accredit hospitals, nursing homes, and ambulatory care clinics for safe and effective care with site visits every 3 years. Quality Seal. Magnet accreditation developed by ANCC demonstrating quality nursing leadership and excellence. It focuses on: Quality, identifying excellence in nursing, and disseminating best practice. International Organization for Standardization (ISO) not for profit organizations that identifies and develops standards for everything. Peer Review Quality Improvement Organization (QIO) private not for profit organization contracted by the center for medicare and medicaid services consisting of health care professionals who review complaints about care and implement changes for medicare patients. They ensure the patient right care for the right person at the right time is safe, patient centered, timely, and equitable. Part of the US department of health and human services. quality management prevention of client care problems risk management analyzes problems and minimizes losses after an error occurs. evaluates options, cost, feasibility, social and selects and implements measures to decrease risk risk assessment evaluates hazards, cost, feasibility, dose-response model. risk communication an important step in risk management that involves stakeholders from the start aggregate data data that has a common variable. An example would be diabetes. root cause analysis process of identifying the cause and factors contributing to variation in performance outcomes. histogram bar graph used to display numerical data. It can show a trend such as a bell shaped. return on investiment the measure of a company's ability to use a profit and then generate addition value for patients and providers benchmarking ongoing system of measuring things against another. Helpful for providers to increase competitors. predictive modeling a way of using data to predict what will occur in the future for health care or behavior. it confirms correlation between patients with specific diagnosis and improved outcomes as a result of target outreach. Used in disease management. pay for performance method of payment used by medicare resource management process of identifying, confirming, coordinating, negotiating resources utilization management forward looking evaluation utilization review backward looking evaluation quality management looks at prevention of patient problems risk management analyses a problem and reduces losses after an error disease management population specific aggregate data that encourages self care, triage, improved quality and decreased cost. regulations interpretations of law that constitutes or constraints rights and allocates responsibility standards of practice or care guidelines of what an RN should or should not due. a benchmark of excellence. scope of practice actions permitted by law code of ethics succinct statements of ethical obligations and duties, goals, and values. scope of nursing practice describes nursing practice dependent on education, experience, role and population standards of professional nursing practice authoritative statements of RN duties everyone is expected to fill regardless of role, population or specialty. Health insurance portability and accountability act (HIPAA) This does not apply in treatment, billing, required reporting, quality assurance, peer review, business planning, training, emergencies privacy practices HIPAA individual right #1 is the right of the individual to receive information on the health care provider's what? request restrictions HIPAA individual right #2 is the right of the individual to what? access to health information access, inspect, copy HIPAA individual right #3 is the individual's right to their health information to do what? disclosures HIPAA individual right #4 is the right to request an accounting of all health information what? corrected HIPAA individual right #5 is the right to request health information to be HIPAA health care providers are required to: provide security of paper and electronic health records, institute a complaint process to investigate compliance, and train staff on which law? a law that requires employers (50 or more employees) to provide up to 12 weeks of unpaid job- protected leave in a 12 month period for employees who have worked for at least 1 year for a certain family or medical reason.They may also work fewer hours a week or work day if medical condition warrants. This must be granted for births, adoption, foster care, family is sick, to attend to a serious health condition. Doesn't protect your particular job. Longshore and Harbor Worker's Compensation act the statutory workers' compensation scheme, first enacted in 1927, that covers certain maritime workers, including most dock workers. provides medical and financial benefits while unable to work due to job modifications and retraining. occupational safety and health act (OSHA) regulatory system for health place safety which requires organizations to maintain injury records and provide employees with information regarding hazards in the workplace. OBRA amended social security act requires medicare to be the secondary payer behind an employer group plan. requires the employer to assume cost of occupational disability, death, disease without regard to fault and wage replacement. affordable care act this law in 2010 created the innovation center with in the center for medicare and medicaid services which assists with research regarding quality. transitions program the affordable care act title 3 section 3026 established community based care what? This program provides funding to hospitals and community based organizations to furnish evidence based ____ services to medicare patients at risk of readmission. reduction program the affordable care act title 3 section 3025 created the hospital readmission what? This adjusted payments for potentially preventable medicare readmits. medical home the affordable care act title 3 section 3502 focusses on establishing community health teams to support the patient-centered what? chronic diseases and public health The affordable care act title 4 increases data collection, analysis, and sharing to improve care coordination and transitions of care for the prevention of what? pilot program on payment bundling The affordable care act title 3 section 3020 directed the secretary to develop a national 5 year program to encouraged increased patient care and increased savings for medicare through a national what? heart failure, MI, and pneumonia the national pilot program on payment bundling under the affordable care act adjusted payments for hospitals for preventable medicare readmissions for what medical conditions? hospitalization The affordable care act title 2 section 2704 created a demo project to evaluate integrated care around what? exchanges The affordable care act title 2 created state health insurance what? This offered choices to individuals and small business. chronic conditions The affordable care act title 2 section 2703 provided a State option to provide health homes to medicaid enrollees with what? research institute The affordable care act title 6 section 6307 created the patient centered outcomes what? This is a nonprofit to assist with informed decisions and identify priorities felony an act punishable by death or imprisonment for over one year. (murder, child abuse, patient abuse, neglect) abandonment willful neglect of responsibility of another person by a person who is assigned to care for that patient or by a person in a caregiving position. accountable care organizations groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.They decrease fragmentation and improve collaboration. Created from the affordable care act. "medical neighborhood" informed consent before CM services you must have capacity, voluntariness, and understandable information in order to have what? patient bill of rights This requires patient to know diagnosis, proposed treatment, possibility of success, risks and benefits, treatment alternatives, risks and benefits of alternatives. The patient is also allowed to withdraw at any time. guardianship legal relationship appointed by court to control all legal and financial decisions. The incapacitated individual has the right to participate as fully as possible, be safe, have the least restrictive environment. ad litem guardianship appointed to represent a child when the parents conflict or in situations such as abuse. intentional tort an act in which the outcome was planned, although the person may not have expected the outcome to harm anyone. assult an intentional tort/act of threatening or attempting to touch without consent. battery an intentional tort/act of touching without consent false imprisonment an intentional tort or act of using unwarranted restraints Quasi intentional tort A wrongful act based on speech committed by a person or entity against another person or entity that causes economic harm or damage to reputation invasion of privacy a quasi intentional tort that is a breach of confidentiality defamation of character a quasi intentional tort that includes slander, disclosing information or telling stories about a coworker unintentional act an act in which the outcome was not intended negligence an unintentional act of not acting as a reasonable and prudent person would have acted. malpractice