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Case Manager Certification Exam
case management - CORRECT ANSWER 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 - CORRECT ANSWER parameters to measure the quality of healthcare clinical guidelines - CORRECT ANSWER statements to help make decisions about health specific circumstances. clinical pathway - CORRECT ANSWER structured multi-disciplined plan of care to support clinical guidelines and protocol to improve continuity and coordination. 4 parts of clinical pathway - CORRECT ANSWER 1. timeline
- categories of care/activities and interventions
- intermediate and long term outcome criteria
- variance tracking are 4 parts of what? decision tree - CORRECT ANSWER used to select the best course of action in decisions where there is no clear decisions. descriptive screening tool - CORRECT ANSWER identifies characteristics about a population to show health prevention. predictive screening tool - CORRECT ANSWER shows what may happen to a specific population. evaluative screening tool - CORRECT ANSWER evaluates the understanding/effectiveness SF-36 - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER health risk assessment: Disease-specific measure of physical, social, and emotional well-being designed as a measure of outcome in arthritis. -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.
- Measurable
- Attainable
- Relevant
- Time oriented Piaget - CORRECT ANSWER Developmental theory for cognitive ability to process/analyze information Assess, plan, implement/intervention, monitor/evaluation - CORRECT ANSWER 4 stages of case management Sensorimotor: object performance and separation anxiety. - CORRECT ANSWER Piaget's age 0-2, Preoperational: pretend, egocentric - CORRECT ANSWER Piaget's stage age 2- Concrete operational: logical, math, conservation - CORRECT ANSWER Piaget's stage 7- Formal operational: abstract, hypothetical - CORRECT ANSWER Piaget's stage 12- adult Trust vs. mistrust - CORRECT ANSWER Erickson 0-1 1/ Autonomy vs. shame - CORRECT ANSWER Erickson 1 1/5- Initiative vs. guilt - CORRECT ANSWER Erickson 3- Industry vs. inferiority - CORRECT ANSWER Erickson 5- Ego id vs. role confusion - CORRECT ANSWER Erickson 12- Intimacy vs. isolation - CORRECT ANSWER Erickson 18- Generative vs. stagnation - CORRECT ANSWER Erickson 40- Integrity vs. despair - CORRECT ANSWER Erickson 65+ Skinner - CORRECT ANSWER Operational conditioning CMAG - CORRECT ANSWER Case management adherence guidelines IM-CAG - CORRECT ANSWER Inter med - complexity assessment grid CMAG - CORRECT ANSWER assessment tool. Comprehensive approach to chronic therapy issues, ex: med adherence, COPD, DVR,DM,HTN, IM-CAG - CORRECT ANSWER Electronic tool that provides risks and vulnerabilities of complex patients with actionable interventions. 4 domains: behavioral, social, health system. evidence based practice - CORRECT ANSWER 1. Question
- ID resources
- Critically appraise resources
- Apply evidence
- Reevaluate application of evidence are 5 steps of what? Integrated CM - CORRECT ANSWER Includes well being, disease management, case management, prevention, triage, utilization management Integrated case management - CORRECT ANSWER 3 functions of ----
- Track patient self management
- Tend/track population management
- Reporting, monitoring quality Patient - CORRECT ANSWER Poor attitude, memory loss, literacy, pride, fear, side effects, can't "see" results, decreased choices, finances are all ----- barriers Patient - CORRECT ANSWER My med list, readiness ruler, Motivational interviewing, modified morisky scale are all tools for ---- barriers Provider - CORRECT ANSWER No knowledge of patient, not familiar with family preferences, lack of accountability are examples of ---- barriers System - CORRECT ANSWER Poor communication, not identified care coordinators are ----- barriers Goal of CM - CORRECT ANSWER 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 - CORRECT ANSWER Maslow's hierarchy of needs Resource management - CORRECT ANSWER Process of identifying, confirming, coordinating, negotiating resources to meet needs Milliman care guidelines - CORRECT ANSWER Soft ware, evidence based guidelines/tool for treating common conditions, chronic care, BH
- conducing, actionable, measurable
- helps cm coordinate care and anticipate needs InterQual - CORRECT ANSWER Clinical decision support tool determines when and how a patient progresses through the continuum.
- organizes resources utilization,
Physician of the same specialty - CORRECT ANSWER An appeal must be reviewed by who? Grievance - CORRECT ANSWER A formal way of lodging a complaint against a provider or organization External review - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER Ensure patients receive quality cost- effective, safe, high quality, evidence-based care in the least restrictive setting Acute care - CORRECT ANSWER 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 - CORRECT ANSWER Type of care used for CVA spinal cord injuries, TBI can be used outpatient or inpatient. There is a criteria for admission Respite care - CORRECT ANSWER Temporary relief for the patient's family or caregiver. This is covered by Medicare waiver or long term insurance and veterans Hospice - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER When the patient does not meet criteria for inpatient but is unable to go home either Yes - CORRECT ANSWER Is a Skilled Nursing Facility Covered by Medicare part A Custodial long-term care - CORRECT ANSWER Not skilled helps with adl's and medication management. The goal is to maximize Independence. No - CORRECT ANSWER Is long term care covered by Medicare? Palliative care - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER Medicare part A covers: 80% - CORRECT ANSWER Medicare Part B only covers what percent? Yes - CORRECT ANSWER Does Medicare Part B cover oxygen? Physicians Services Outpatient hospital services Medical equipment and supplies - CORRECT ANSWER Medicare Part B covers: Medicare Part C - CORRECT ANSWER Also known as the Medicare Advantage plan operated by private companies. Covers medications transportation exxtra Medicaid eligibility - CORRECT ANSWER 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 - CORRECT ANSWER Medicaid covers SCHIP - CORRECT ANSWER State children's health insurance program SCHIP - CORRECT ANSWER administered by the center for Medicare and Medicaid. Government gives money to 2 approved State programs up to the age of 19 subsidy - CORRECT ANSWER financial assistance that you do not have to pay back premium - CORRECT ANSWER amount that you pay monthly for insurance cost sharing - CORRECT ANSWER amount of money paid out of pocket, includes copays, deductible. Does not include premiums. tricare prime - CORRECT ANSWER for active duty military members to help them be "fit for duty"
stop loss or reinsurance - CORRECT ANSWER insurance for an insurance company. When a certain threshold has been met. common for high risk claims ex: worker's comp. clinical risk group - CORRECT ANSWER adjusting payment based on clinical characteristics and resource demands of a patient. claims based classification system. disability insurance - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER state 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 - CORRECT ANSWER federally funded support referral services and crisis management. SNAP for seniors - CORRECT ANSWER food stamps for seniors 80% - CORRECT ANSWER medicare covers what percent? 55 - CORRECT ANSWER Medicare will begin coverage of home oxygen with an arterial blood gas result at or above a partial pressure of ___mm Hg while at rest on room air. 88 - CORRECT ANSWER medicare will cover home oxygen if O2 sat is at or below _____% while at rest on room air, exercising on room air or while asleep or a greater than normal fall in oxygen level during sleep (a decrease in arterial PO 2 more than 10 mm Hg, or decrease in arterial oxygen saturation more than 5%) associated with symptoms or signs reasonably attributable to hypoxemia (e.g., impairment of cognitive processes and nocturnal restlessness or insomnia). Dependent edema - CORRECT ANSWER Medicare covers home oxygen for patients whose arterial PO 2 is 56-59 mm Hg or saturation is 89%, if there is evidence of____ suggesting congestive Heart Failure. pulmonary hypertension or cor pulmonale - CORRECT ANSWER Medicare covers home oxygen for patients whose arterial PO 2 is 56-59 mm Hg or saturation is 89%, if there is evidence of __________, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVFL
Erythrocythemia, 56% - CORRECT ANSWER Medicare covers home oxygen for patients whose arterial PO 2 is 56-59 mm Hg or saturation is 89%, if there is evidence of _________ with a hematocrit greater than ___% quality management - CORRECT ANSWER this focusses on customer satisfaction, prevention of errors, management responsibility, continuous improvement quality metrics - CORRECT ANSWER parameters or ways of quantitatively measuring quantity variance tracking - CORRECT ANSWER deviations from a standard or recommended interventions. Helps ID opportunities for improvement Continuous quality improvement - CORRECT ANSWER process to attempt to optimize quality of a system. plan do study act - CORRECT ANSWER a cyclic 4 step improvement process that includes gathering data, experimenting, analyzing that data, and adapting improvements. six sigma - CORRECT ANSWER data driven quality management process to eliminate defects: define, measure, analyze, improve/design, control/verify balanced budget act - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER health care effectiveness data information set patient centered medical home (PCMH) - CORRECT ANSWER 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 - CORRECT ANSWER 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) - CORRECT ANSWER 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.
patients with specific diagnosis and improved outcomes as a result of target outreach. Used in disease management. pay for performance - CORRECT ANSWER method of payment used by medicare resource management - CORRECT ANSWER process of identifying, confirming, coordinating, negotiating resources utilization management - CORRECT ANSWER forward looking evaluation utilization review - CORRECT ANSWER backward looking evaluation quality management - CORRECT ANSWER looks at prevention of patient problems risk management - CORRECT ANSWER analyses a problem and reduces losses after an error disease management - CORRECT ANSWER population specific aggregate data that encourages self care, triage, improved quality and decreased cost. regulations - CORRECT ANSWER interpretations of law that constitutes or constraints rights and allocates responsibility standards of practice or care - CORRECT ANSWER guidelines of what an RN should or should not due. a benchmark of excellence. scope of practice - CORRECT ANSWER actions permitted by law code of ethics - CORRECT ANSWER succinct statements of ethical obligations and duties, goals, and values. scope of nursing practice - CORRECT ANSWER describes nursing practice dependent on education, experience, role and population standards of professional nursing practice - CORRECT ANSWER authoritative statements of RN duties everyone is expected to fill regardless of role, population or specialty. Health insurance portability and accountability act (HIPAA) - CORRECT ANSWER This does not apply in treatment, billing, required reporting, quality assurance, peer review, business planning, training, emergencies privacy practices - CORRECT ANSWER HIPAA individual right #1 is the right of the individual to receive information on the health care provider's what? request restrictions - CORRECT ANSWER HIPAA individual right #2 is the right of the individual to what? access to health information access, inspect, copy - CORRECT ANSWER HIPAA individual right #3 is the individual's right to their health information to do what? disclosures - CORRECT ANSWER HIPAA individual right #4 is the right to request an accounting of all health information what?
corrected - CORRECT ANSWER HIPAA individual right #5 is the right to request health information to be HIPAA - CORRECT ANSWER 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 - CORRECT ANSWER 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 companies to cover medicare benefits at a capitated (per enrollee) amount to include hospital and medical, parts A and B. medicare prescription drug improvement and modernization act - CORRECT ANSWER law enacted in 2003 signed by George Bush that allowed seniors and people with disabilities to have prescription drug coverage mental health parity act - CORRECT ANSWER a law enacted in 1996 that prevented a group health plan from putting a lifetime or annual financial cap on mental health that was less than medical health. emergency medical treatment and active labor act (EMTALA) - CORRECT ANSWER a law in 1986 that requires hospital receiving medicare and have an ER to asses, provide treatment and stabilize a patient before determining their ability to pay. An amendment in 1989 requires hospitals to accept transfer of a patient requiring special treatment regardless of ability to pay. Omnibus Budget Reconciliation Act - CORRECT ANSWER a law in 1989-1990 that required all states to have medicaid coverage for pregnant women and their children up to age 6 if the family is homeless or below 133% of the federal poverty level. patient self determination act - CORRECT ANSWER a law that requires health care providers to inform patients of their right to refuse or accept treatment. They must provide written information on their state law regarding advanced directives. They must also document if they have an advanced directive, ensure state compliance, create policies, educate staff. advanced directive - CORRECT ANSWER written statement of medical wishes in the future in the event they are unable to make decisions for themselves. It includes a living will or a durable power of attorney. living will - CORRECT ANSWER a written statement describing individual desires for life-prolonging treatment in the event they are terminally ill or permanently unconscious and unable to communicate decisions about continued care. This is about What the decisions are. durable power of attorney - CORRECT ANSWER designates who will make their medical treatment decisions in the event they are unable to make their own decisions. aka healthcare proxy. this is about who will make decisions. Applies during temporary disability.
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) - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER the affordable care act title 3 section 3025 created the hospital readmission what? This adjusted payments for potentially preventable medicare readmits. medical home - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER The affordable care act title 2 section 2704 created a demo project to evaluate integrated care around what? exchanges - CORRECT ANSWER The affordable care act title 2 created state health insurance what? This offered choices to individuals and small business. chronic conditions - CORRECT ANSWER The affordable care act title 2 section 2703 provided a State option to provide health homes to medicaid enrollees with what?
research institute - CORRECT ANSWER 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 - CORRECT ANSWER an act punishable by death or imprisonment for over one year. (murder, child abuse, patient abuse, neglect) abandonment - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER before CM services you must have capacity, voluntariness, and understandable information in order to have what? patient bill of rights - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER guardianship appointed to represent a child when the parents conflict or in situations such as abuse. intentional tort - CORRECT ANSWER an act in which the outcome was planned, although the person may not have expected the outcome to harm anyone. assult - CORRECT ANSWER an intentional tort/act of threatening or attempting to touch without consent. battery - CORRECT ANSWER an intentional tort/act of touching without consent false imprisonment - CORRECT ANSWER an intentional tort or act of using unwarranted restraints Quasi intentional tort - CORRECT ANSWER 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 - CORRECT ANSWER a quasi intentional tort that is a breach of confidentiality defamation of character - CORRECT ANSWER a quasi intentional tort that includes slander, disclosing information or telling stories about a coworker
- Risks will be decreased with specific behavioral changes
- barriers can be overcome or managed. learning styles - CORRECT ANSWER perpetual modality (visual/audio/touch), information processing (way we sense/think), and personality paterns (attention, emotion, values) are all types of what? HIPAA Omnibus Rule - CORRECT ANSWER final rule mandated by HITEC to increase patient privacy, allows patients to ask for a copy of medical records in electronic form., if a patient pays out of pocket for a service, they can instruct the provider not to share information with the insurance company. HITEC - CORRECT ANSWER increases privacy and security under HIPPA and increases enforcement motivational interviewing - CORRECT ANSWER a form of guiding to elicit or strengthen motivation for change. The steps include:
- express empathy
- avoid arguments
- develop discrepancy
- role with resistance
- support self efficacy change - CORRECT ANSWER likilihood of change increases with the patient's belief in the ability to what? management - CORRECT ANSWER collaborative process of assessing, planning, collaborating, implementing, monitoring and evaluating patient needs and using services to meet needs through communication and available resources to improve quality cost effective outcomes is CMSA's definition of case what? process - CORRECT ANSWER 1. identify the client and obtain consent,
- assessing problems,
- planing goals, prioritizing needs, identifying resources
- implementation
- evaluation and follow up
- discharged from case management. are all components of the case management catastrophic and chronic - CORRECT ANSWER case management services are needed for patients with what type of injuries or chronic illnesses?
