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Case Manager Certification Exam.
case management - ANSWERthe 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 - ANSWERparameters to measure the quality of healthcare clinical guidelines - ANSWERstatements to help make decisions about health specific circumstances. clinical pathway - ANSWERstructured multi-disciplined plan of care to support clinical guidelines and protocol to improve continuity and coordination. 4 parts of clinical pathway - ANSWER1. timeline
- categories of care/activities and interventions
- intermediate and long term outcome criteria
- variance tracking are 4 parts of what? decision tree - ANSWERused to select the best course of action in decisions where there is no clear decisions.
descriptive screening tool - ANSWERidentifies characteristics about a population to show health prevention. predictive screening tool - ANSWERshows what may happen to a specific population. evaluative screening tool - ANSWERevaluates the understanding/effectiveness SF- 36 - ANSWERpredictive 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 - ANSWER13 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 - ANSWERpredictive 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.
- scales: mobility, physical activity (walking, bending, lifting), dexterity, household activity (managing money and medications, housekeeping), social activities, activities of daily living, pain, depression, and anxiety. Score range: Range is 0-10 for each section. Total health score 0-60. --> Zero represents good health status, 10 and 60 represent poor health status. functional living index-cancer - ANSWERhealth risk assessment: Cancer- specific, functionally-oriented quality of life instrument.
- 22 items assessing 5 domains: Physical well-being and ability, emotional state, sociability, family situation, nausea
- Higher score indicates better quality of life. BASIS- 32 - ANSWERhealth risk assessment: 32-item Behavior and Symptom Identification Scale. behavioral health assessment tool.
- measures the change in self-reported symptom and problem difficulty over the course of treatment.
- assesses: Relation to Self and Others, Depression and Anxiety, Daily Living and Role Functioning, Impulsive and Addictive Behavior, Psychosis.
- higher score poorer outcome mini mental state exam - ANSWERhealth risk assessment: 30 - point questionnaire measures cognitive impairment to screen for dementia.
- higher the score, less dementia
- 18 - 23 is mild dementia
- 0 - 17 is sever dementia hopkins symptom checklist- 25 - ANSWERhealth risk assessment: self- reporting questionnaire symptom inventory which measures symptoms of anxiety and depression.
- The scale for each question includes four categories of response ("Not at all," "A little," "Quite a bit," "Extremely," rated 1 to 4, respectively). Two scores are calculated: the total score is the average of all 25 items, while the depression score is the average of the 15 depression items mcgill pain questionnaire - ANSWERscale of rating pain. It is a self-report questionnaire that allows individuals to give their doctor a good description of the quality and intensity of pain that they are experiencing. Users first select a single word from each group that best reflects their pain. Users then review the list and select the three words from groups 1-10 that best describe their pain, two words from groups 11-15, a single word from group 16, and then one word from groups 17-20. After completing the questionnaire, users will have selected seven words that best describe their pain. A - ANSWERWhat part of Medicare covers skilled nursing facility? B - ANSWERWhat part of Medicare covers durable medical equipment? Goals - ANSWER1. Patient focused
- Measurable
- Attainable
- Relevant
- Time oriented
Intimacy vs. isolation - ANSWERErickson 18- 40 Generative vs. stagnation - ANSWERErickson 40- 65 Integrity vs. despair - ANSWERErickson 65+ Skinner - ANSWEROperational conditioning CMAG - ANSWERCase management adherence guidelines IM-CAG - ANSWERInter med - complexity assessment grid CMAG - ANSWERassessment tool. Comprehensive approach to chronic therapy issues, ex: med adherence, COPD, DVR,DM,HTN, IM-CAG - ANSWERElectronic tool that provides risks and vulnerabilities of complex patients with actionable interventions. 4 domains: behavioral, social, health system. evidence based practice - ANSWER1. Question
- ID resources
- Critically appraise resources
- Apply evidence
- Reevaluate application of evidence
are 5 steps of what? Integrated CM - ANSWERIncludes well being, disease management, case management, prevention, triage, utilization management Integrated case management - ANSWER3 functions of ----
- Track patient self management
- Tend/track population management
- Reporting, monitoring quality Patient - ANSWERPoor attitude, memory loss, literacy, pride, fear, side effects, can't "see" results, decreased choices, finances are all ----- barriers Patient - ANSWERMy med list, readiness ruler, Motivational interviewing, modified morisky scale are all tools for ---- barriers Provider - ANSWERNo knowledge of patient, not familiar with family preferences, lack of accountability are examples of ---- barriers System - ANSWERPoor communication, not identified care coordinators are -- --- barriers Goal of CM - ANSWERTo ensure patients have the tools and resources to help manage their needs, increase self confidence and control and self management
- Cost - ANSWER5 rights of utilization review Utilization Management - ANSWERCM that identifies patients, their needs, develops individual holistic care plans addressing barriers Prior authorization - ANSWERBefore services determines actual need Denial - ANSWERRequires: patent and provider notified, clinical rationale, rights to appeal, legally entitled to due process to appeal Concurrent review - ANSWERProcess of reviewing if patient meets criteria while services are occurring Retrospective review - ANSWERLooks back, ID outliers, provides helpful information for future changes Cost benefit analysis - ANSWERShows 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 - ANSWERAssessing care needs to ensure patients are transitioned safely. Due process - ANSWERThe right to appeal decisions MD - ANSWERThe only people who can deny services
Medical director - ANSWERIf a patient does not meet the criteria it goes to who? Utilisation management RN - ANSWERThese people do not have the authority to deny claims Appeal - ANSWERA formal way of lodging a disagreement with a claim payment or benefit denial Fair hearing - ANSWERIf denied an appeal you have the right to a Physician of the same specialty - ANSWERAn appeal must be reviewed by who? Grievance - ANSWERA formal way of lodging a complaint against a provider or organization External review - ANSWERHandled by an outside Insurance Company when the benefit result is not what was desired. Adverse benefit determination. Needs to be requested Expedited external review - ANSWERcan be requested if the patient's health status would be jeopardized due to the time frame. also possible if it concerns admission availability of care, continue to stay or a healthcare item but the patient has not been discharged from the facility Case management - ANSWEREnsure patients receive quality cost-effective, safe, high quality, evidence-based care in the least restrictive setting
No - ANSWERIs long term care covered by Medicare? Palliative care - ANSWERa type of care for someone with a serious illness and needs help with symptom management they do not have to be terminally ill and there is no time limit. May be covered under Medicare Part B Medicare eligibility - ANSWER1. Older than 65
- People eligible for social security retirement
- Permanent resident for five continuous years
- May claim up to 24 months after illness diagnosis or date of injury.
- If you have received Social Security disability for 24 months
- Less than 65 with kidney disease that appears to be irreversible or permanent requiring regular dialysis or kidney transplant to maintain life. Kidney transplant Hospital Skilled nursing facilities Hospice Approved Home Health - ANSWERMedicare part A covers: 80% - ANSWERMedicare Part B only covers what percent? Yes - ANSWERDoes Medicare Part B cover oxygen? Physicians Services Outpatient hospital services
Medical equipment and supplies - ANSWERMedicare Part B covers: Medicare Part C - ANSWERAlso known as the Medicare Advantage plan operated by private companies. Covers medications transportation exxtra Medicaid eligibility - ANSWERBased 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 - ANSWERMedicaid covers SCHIP - ANSWERState children's health insurance program SCHIP - ANSWERadministered by the center for Medicare and Medicaid. Government gives money to 2 approved State programs up to the age of 19 subsidy - ANSWERfinancial assistance that you do not have to pay back premium - ANSWERamount that you pay monthly for insurance cost sharing - ANSWERamount of money paid out of pocket, includes copays, deductible. Does not include premiums.
self insured - ANSWERlarge companies use this. They need a third party administer to handle claims. Case managers report to the third party administer. fee for service - ANSWERtype of payment where providers are paid for each service. capitation - ANSWERtype 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 - ANSWERtype of payment that changed medicare reimbursement from a fee for service to a fixed payment based on DRGs. diagnostic related group - ANSWERpricing 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) - ANSWERtype of payment with 2 subclasses based on 1. severity of illness (organ system failure or loss of funtion and 2. risk of mortality subrogation - ANSWERlegal 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 - ANSWERinsurance for an insurance company. When a certain threshold has been met. common for high risk claims ex: worker's comp. clinical risk group - ANSWERadjusting payment based on clinical characteristics and resource demands of a patient. claims based classification system. disability insurance - ANSWERinsurance 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 - ANSWERstate 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 - ANSWERstate program that assists people with mental or physical impairments that impede them from employment by assisting with training, higher education, rehab, financial support. Eligible if between the ages of 16 and 70. 211 - ANSWERfederally funded support referral services and crisis management. SNAP for seniors - ANSWERfood stamps for seniors
quality metrics - ANSWERparameters or ways of quantitatively measuring quantity variance tracking - ANSWERdeviations from a standard or recommended interventions. Helps ID opportunities for improvement Continuous quality improvement - ANSWERprocess to attempt to optimize quality of a system. plan do study act - ANSWERa cyclic 4 step improvement process that includes gathering data, experimenting, analyzing that data, and adapting improvements. six sigma - ANSWERdata driven quality management process to eliminate defects: define, measure, analyze, improve/design, control/verify balanced budget act - ANSWERact that gives medicare and medicaid services authority to establish and oversee a program that allows private, national accredited organizations to "deem" weather or not a medicare advantage organization is compliant with medicare requirements. example: JCAHO and NCQA HEDIS - ANSWERtool managed by NCQA used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. 80 measures and 5 domains including: effectiveness, access, experience, UR, descriptive info HEDIS - ANSWERhealth care effectiveness data information set
patient centered medical home (PCMH) - ANSWERa care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand. national quality forum - ANSWERnot for profit membership organization to develop and implement a national strategy for standardizing health care quality measures and reporting. This organization was charged by the affordable care act to create the national priorities partnership and nursing sensitive care standards ( death of surgery patients, pressure ulcers, falls, restraints, UTIs urinary catheters), ventilator associated pneumonia, smoking cessation) national committee for quality assurance (NCQA) - ANSWERprivate 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) - ANSWERAn independent nonprofit organization that offers quality benchmark programs to improve quality and accountability of health care organizations. Joint Commission - ANSWERnot 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 - ANSWERaccreditation developed by ANCC demonstrating quality nursing leadership and excellence. It focuses on: Quality, identifying excellence in nursing, and disseminating best practice.
