Download Case Manager Certification Exam 2026 complete and more Exams Advanced Education in PDF only on Docsity!
Case Manager Certification Exam
2026 complete
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
- categories of care/activities and interventions
- intermediate and long term outcome criteria
- 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),
BASIS-32 - health 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 - health 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 - health 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 - scale 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 - What part of Medicare covers skilled nursing facility?
B - What part of Medicare covers durable medical equipment? Goals - 1. Patient focused
- Measurable
- Attainable
- Relevant
- Time oriented Piaget - Developmental theory for cognitive ability to process/analyze information Assess, plan, implement/intervention, monitor/evaluation - 4 stages of case management Sensorimotor: object performance and separation anxiety. - Piaget's age 0- 2, Preoperational: pretend, egocentric - Piaget's stage age 2- Concrete operational: logical, math, conservation - Piaget's stage 7- Formal operational: abstract, hypothetical - Piaget's stage 12-adult Trust vs. mistrust - Erickson 0-1 1/ Autonomy vs. shame - Erickson 1 1/5- Initiative vs. guilt - Erickson 3- Industry vs. inferiority - Erickson 5-
Integrated CM - Includes well being, disease management, case management, prevention, triage, utilization management Integrated case management - 3 functions of ----
- Track patient self management
- Tend/track population management
- 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
- Provider
- Services
- Setting
- Time
- 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
External review - Handled by an outside Insurance Company when the benefit result is not what was desired. Adverse benefit determination. Needs to be requested Expedited external review - can 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 - Ensure patients receive quality cost-effective, safe, high quality, evidence-based care in the least restrictive setting Acute care - A hospital the largest Healthcare setting in the United States. Case managers need to ensure tests are done in a timely meander results are given to provider and Healthcare team determines the next step. Rehabilitation - Type of care used for CVA spinal cord injuries, TBI can be used outpatient or inpatient. There is a criteria for admission Respite care - Temporary relief for the patient's family or caregiver. This is covered by Medicare waiver or long term insurance and veterans Hospice - Used when someone has less than 6 months to live. Philosophy not a place. Medicare part A covers medical supplies equipment medications nurses doctors dietitians used during this time. Private duty Nursing - One-on-one care when a child or adult is impaired by a catastrophic event or chronic illness. Usually not covered by insurance Sub acute care - When the patient does not meet criteria for inpatient but is unable to go home either
Yes - Is a Skilled Nursing Facility Covered by Medicare part A Custodial long-term care - Not skilled helps with adl's and medication management. The goal is to maximize Independence. No - Is long term care covered by Medicare? Palliative care - a 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 - 1. 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 - Medicare part A covers: 80% - Medicare Part B only covers what percent? Yes - Does Medicare Part B cover oxygen? Physicians Services Outpatient hospital services
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 - state program that assists people with mental or physical impairments that impede them from employment by assisting
quality management - this focusses on customer satisfaction, prevention of errors, management responsibility, continuous improvement quality metrics - parameters or ways of quantitatively measuring quantity variance tracking - deviations from a standard or recommended interventions. Helps ID opportunities for improvement Continuous quality improvement - process to attempt to optimize quality of a system. plan do study act - a cyclic 4 step improvement process that includes gathering data, experimenting, analyzing that data, and adapting improvements. six sigma - data driven quality management process to eliminate defects: define, measure, analyze, improve/design, control/verify balanced budget act - act 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 - tool 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 - health care effectiveness data information set patient centered medical home (PCMH) - a 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 - not 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) - 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
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? Balanced Budget Act - Law enacted in 1977 that created the medicare part C + choice program, also knows as the medicare advantage plan, is a managed care option that allows new types of health plans under private
