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Case Manager CerƟficaƟon Exam
case management the dynamic and systemaƟc collaboraƟve approach to providing and coordinaƟng health care services to a defined populaƟon.
- parƟcipaƟve process to idenƟfy and facility opƟons and services for meeƟng individual healthcare needs while decreasing fragmentaƟon and duplicaƟon of care and increasing quality and cost effecƟve 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 mulƟ-disciplined plan of care to support clinical guidelines and protocol to improve conƟnuity and coordinaƟon. 4 parts of clinical pathway
- Ɵmeline
- categories of care/acƟviƟes and intervenƟons
- intermediate and long term outcome criteria
- variance tracking are 4 parts of what? decision tree used to select the best course of acƟon in decisions where there is no clear decisions. descripƟve screening tool idenƟfies characterisƟcs about a populaƟon to show health prevenƟon. predicƟve screening tool shows what may happen to a specific populaƟon. evaluaƟve screening tool evaluates the understanding/effecƟveness
SF-
predicƟve screening tool to assess funcƟonal health and well being. Assesses physical and mental health.
- used in health economics, cost-effecƟveness of health tx
- evals individual paƟent health status.
- does not consider sleep -scored 00-100, lower score-> incr. disability paƟent acƟvaƟon measure 13 item predicƟve screening tool to evaluate paƟent's knowledge, skills, confidence in self-care.
- higher the score the beƩer (scored 0-52)
- predicts health care outcomes, medicaƟon adherence and ER visits. health risk assessment predicƟve screening tool: paƟent'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 condiƟon.
- 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 characterisƟcs: (a) the site must include either the sternum (any level) or the leŌ arm and leŌ 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 aƩempt 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 Ɵme when the subject stands sƟll." Possible myocardial infarcƟon1 was defined as, "one or more aƩacks of severe pain across the front of the chest lasƟng for 30 min or longer." seaƩle angina quesƟonnaire 19-item self-administered health risk assessment for angina and funcƟonal artery disease measuring five dimensions of coronary artery disease: 1 physical limitaƟon, 2 anginal stability, 3 anginal frequency, 4 treatment saƟsfacƟon and 5
health risk assessment: self-reporƟng quesƟonnaire symptom inventory which measures symptoms of anxiety and depression.
- The scale for each quesƟon includes four categories of response ("Not at all," "A liƩle," "Quite a bit," "Extremely," rated 1 to 4, respecƟvely). 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 quesƟonnaire scale of raƟng pain. It is a self-report quesƟonnaire that allows individuals to give their doctor a good descripƟon 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. AŌer compleƟng the quesƟonnaire, 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
- PaƟent focused
- Measurable
- AƩainable
- Relevant
- Time oriented Piaget Developmental theory for cogniƟve ability to process/analyze informaƟon Assess, plan, implement/intervenƟon, monitor/evaluaƟon 4 stages of case management Sensorimotor: object performance and separaƟon anxiety. Piaget's age 0-2, PreoperaƟonal: pretend, egocentric Piaget's stage age 2-
Concrete operaƟonal: logical, math, conservaƟon Piaget's stage 7- Formal operaƟonal: abstract, hypotheƟcal Piaget's stage 12-adult Trust vs. mistrust Erickson 0-1 1/ Autonomy vs. shame Erickson 1 1/5- IniƟaƟve vs. guilt Erickson 3- Industry vs. inferiority Erickson 5- Ego id vs. role confusion Erickson 12- InƟmacy vs. isolaƟon Erickson 18- GeneraƟve vs. stagnaƟon Erickson 40- Integrity vs. despair Erickson 65+ Skinner OperaƟonal condiƟoning CMAG Case management adherence guidelines IM-CAG Inter med - complexity assessment grid
System Poor communicaƟon, not idenƟfied care coordinators are ----- barriers Goal of CM To ensure paƟents have the tools and resources to help manage their needs, increase self confidence and control and self management Physiological, safety, love, esteem, self-actualizaƟon Maslow's hierarchy of needs Resource management Process of idenƟfying, confirming, coordinaƟng, negoƟaƟng resources to meet needs Milliman care guidelines SoŌ ware, evidence based guidelines/tool for treaƟng common condiƟons, chronic care, BH
- conducing, acƟonable, measurable
- helps cm coordinate care and anƟcipate needs InterQual Clinical decision support tool determines when and how a paƟent progresses through the conƟnuum.
- organizes resources uƟlizaƟon,
- objecƟve evidence based criteria for assessing appropriate care for paƟents. Helps fraud/abuae UƟlizaƟon management Forward looking using evidence based criteria to support decisions. UƟlizaƟon review Backward looking to ensure paƟent's 5 rights were observed
- Provider
- Services
- Seƫng
- Time
- Cost 5 rights of uƟlizaƟon review
UƟlizaƟon Management CM that idenƟfies paƟents, their needs, develops individual holisƟc care plans addressing barriers Prior authorizaƟon Before services determines actual need Denial Requires: patent and provider noƟfied, clinical raƟonale, rights to appeal, legally enƟtled to due process to appeal Concurrent review Process of reviewing if paƟent meets criteria while services are occurring RetrospecƟve review Looks back, ID outliers, provides helpful informaƟon for future changes Cost benefit analysis Shows what the cost would be if Services were provided and outcomes occurred verses their current situaƟon. demonstrates raƟon of dollars spent vs. savings achieved. Discharge planning Assessing care needs to ensure paƟents are transiƟoned safely. Due process The right to appeal decisions MD The only people who can deny services Medical director If a paƟent does not meet the criteria it goes to who? UƟlisaƟon management RN These people do not have the authority to deny claims Appeal A formal way of lodging a disagreement with a claim payment or benefit denial
Used when someone has less than 6 months to live. Philosophy not a place. Medicare part A covers medical supplies equipment medicaƟons nurses doctors dieƟƟans used during this Ɵme. 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 paƟent does not meet criteria for inpaƟent 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 medicaƟon management. The goal is to maximize Independence. No Is long term care covered by Medicare? PalliaƟve 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 Ɵme limit. May be covered under Medicare Part B Medicare eligibility
- Older than 65
- People eligible for social security reƟrement
- Permanent resident for five conƟnuous years
- May claim up to 24 months aŌer 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 faciliƟes 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 OutpaƟent 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 medicaƟons transportaƟon 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
capitaƟon type of payment to a provider for a group of people assigned to them where there is a fixed cost per person, per Ɵme period , not dependent on how oŌen that person uƟlizes the resources. The provider is contracted under a HMO. per member, per month prospecƟve pay type of payment that changed medicare reimbursement from a fee for service to a fixed payment based on DRGs. diagnosƟc related group pricing formula used by medicare that reimburses a fixed amount based on a diagnosis. UƟlizaƟon review department case managers evaluate if a diagnosƟc test is medically necessary. all paƟent refined diagnosis related groups (APDRG) type of payment with 2 subclasses based on 1. severity of illness (organ system failure or loss of funƟon and 2. risk of mortality subrogaƟon legal right of an insurance company to get repaid from another insurance enƟty 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 adjusƟng payment based on clinical characterisƟcs and resource demands of a paƟent. claims based classificaƟon system. disability insurance insurance that replaces income lost when the insured person cannot work due to illness or injury based on their own occupaƟon or any occupaƟon. case managers help paƟents 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 disabiliƟes regardless if the worker is at fault. vocaƟonal rehab state program that assists people with mental or physical impairments that impede them from employment by assisƟng with training, higher educaƟon, rehab, financial support. Eligible if between the ages of 16 and 70. 211 federally funded support referral services and crisis management. SNAP for seniors food stamps for seniors 80% medicare covers what percent? 55 Medicare will begin coverage of home oxygen with an arterial blood gas result at or above a parƟal pressure of ___mm Hg while at rest on room air. 88 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 saturaƟon more than 5%) associated with symptoms or signs reasonably aƩributable to hypoxemia (e.g., impairment of cogniƟve processes and nocturnal restlessness or insomnia). Dependent edema Medicare covers home oxygen for paƟents whose arterial PO 2 is 56-59 mm Hg or saturaƟon is 89%, if there is evidence of____ suggesƟng congesƟve Heart Failure. pulmonary hypertension or cor pulmonale Medicare covers home oxygen for paƟents whose arterial PO 2 is 56-59 mm Hg or saturaƟon 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
paƟent centered medical home (PCMH) a care delivery model whereby paƟent 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. naƟonal quality forum not for profit membership organizaƟon to develop and implement a naƟonal strategy for standardizing health care quality measures and reporƟng. This organizaƟon was charged by the affordable care act to create the naƟonal prioriƟes partnership and nursing sensiƟve care standards ( death of surgery paƟents, pressure ulcers, falls, restraints, UTIs urinary catheters), venƟlator associated pneumonia, smoking cessaƟon) naƟonal commiƩee for quality assurance (NCQA) private not for profit organizaƟon that accredits certain organizaƟons if they meet standards to improve health care quality. includes a quality compass to score health plans. uƟlizaƟon review accreditaƟon commission (URAC) An independent nonprofit organizaƟon that offers quality benchmark programs to improve quality and accountability of health care organizaƟons. Joint Commission not for profit organizaƟon that set performance standards and accredit hospitals, nursing homes, and ambulatory care clinics for safe and effecƟve care with site visits every 3 years. Quality Seal. Magnet accreditaƟon developed by ANCC demonstraƟng quality nursing leadership and excellence. It focuses on: Quality, idenƟfying excellence in nursing, and disseminaƟng best pracƟce. InternaƟonal OrganizaƟon for StandardizaƟon (ISO) not for profit organizaƟons that idenƟfies and develops standards for everything. Peer Review Quality Improvement OrganizaƟon (QIO) private not for profit organizaƟon contracted by the center for medicare and medicaid services consisƟng of health care professionals who review complaints about care and implement changes for medicare paƟents. They ensure the paƟent right care for the right person at the right Ɵme is safe, paƟent centered, Ɵmely, and equitable. Part of the US department of health and human services.
quality management prevenƟon of client care problems risk management analyzes problems and minimizes losses aŌer an error occurs. evaluates opƟons, cost, feasibility, social and selects and implements measures to decrease risk risk assessment evaluates hazards, cost, feasibility, dose-response model. risk communicaƟon 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 idenƟfying the cause and factors contribuƟng to variaƟon in performance outcomes. histogram bar graph used to display numerical data. It can show a trend such as a bell shaped. return on invesƟment the measure of a company's ability to use a profit and then generate addiƟon value for paƟents and providers benchmarking ongoing system of measuring things against another. Helpful for providers to increase compeƟtors. predicƟve modeling a way of using data to predict what will occur in the future for health care or behavior. it confirms correlaƟon between paƟents 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
This does not apply in treatment, billing, required reporƟng, quality assurance, peer review, business planning, training, emergencies privacy pracƟces HIPAA individual right #1 is the right of the individual to receive informaƟon on the health care provider's what? request restricƟons HIPAA individual right #2 is the right of the individual to what? access to health informaƟon access, inspect, copy HIPAA individual right #3 is the individual's right to their health informaƟon to do what? disclosures HIPAA individual right #4 is the right to request an accounƟng of all health informaƟon what? corrected HIPAA individual right #5 is the right to request health informaƟon to be HIPAA health care providers are required to: provide security of paper and electronic health records, insƟtute a complaint process to invesƟgate 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 opƟon 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 prescripƟon drug improvement and modernizaƟon act law enacted in 2003 signed by George Bush that allowed seniors and people with disabiliƟes to have prescripƟon drug coverage mental health parity act a law enacted in 1996 that prevented a group health plan from puƫng a lifeƟme or annual financial cap on mental health that was less than medical health. emergency medical treatment and acƟve labor act (EMTALA)
a law in 1986 that requires hospital receiving medicare and have an ER to asses, provide treatment and stabilize a paƟent before determining their ability to pay. An amendment in 1989 requires hospitals to accept transfer of a paƟent requiring special treatment regardless of ability to pay. Omnibus Budget ReconciliaƟon Act 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. paƟent self determinaƟon act a law that requires health care providers to inform paƟents of their right to refuse or accept treatment. They must provide wriƩen informaƟon on their state law regarding advanced direcƟves. They must also document if they have an advanced direcƟve, ensure state compliance, create policies, educate staff. advanced direcƟve wriƩen 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 aƩorney. living will a wriƩen statement describing individual desires for life-prolonging treatment in the event they are terminally ill or permanently unconscious and unable to communicate decisions about conƟnued care. This is about What the decisions are. durable power of aƩorney 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. uniform anatomical giŌs act this law improved the system for allocaƟng organs to transplant recipients. Smith Hughes Act act in 1917 that created funding for vocaƟonal rehab programs. in 1920 it provided funding for civilian vocaƟonal rehab programs. Social Security Act this law in 1935 established vocaƟonal rehab as a permanent federal program.
