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Case Manager Certification Exam
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 -
- 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), (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 - 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. --> Zero represents good health status, 10 and 60 represent poor health status. functional living index-cancer - health 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.
Sensorimotor: object performance and separation anxiety. - Piaget's age 0-2, Preoperational: pretend, egocentric - Piaget's stage age 2- 6 Concrete operational: logical, math, conservation - Piaget's stage 7- 12 Formal operational: abstract, hypothetical - Piaget's stage 12-adult Trust vs. mistrust - Erickson 0-1 1/ Autonomy vs. shame - Erickson 1 1/5- 3 Initiative vs. guilt - 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 -
- Question
- ID resources
- Critically appraise resources
- Apply evidence
- 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 ----
- 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 -
The only people who can deny services Medical director - If a patient does not meet the criteria it goes to who? Utilisation 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 Fair hearing - If denied an appeal you have the right to a Physician of the same specialty - An appeal must be reviewed by who? Grievance - A formal way of lodging a complaint against a provider or organization 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 -
- 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 Medical equipment and supplies - Medicare Part B covers: Medicare Part C -
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 with training, higher education, 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 partial 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 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 - 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 - 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% - 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 - this focusses on customer satisfaction, prevention of errors, management responsibility, continuous improvement quality metrics -
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
advanced directive - 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 - 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 - 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 gifts act - this law improved the system for allocating organs to transplant recipients. Smith Hughes Act - act in 1917 that created funding for vocational rehab programs. in 1920 it provided funding for civilian vocational rehab programs. Social Security Act - this law in 1935 established vocational rehab as a permanent federal program. Rehab Act - This act of 1973 prohibits discrimination on the basis of disability in programs run by federal agencies Americans with disabilities act - this act established in 1990 has 5 titles. companies cannot discriminate and must make reasonable accommodations if they have 15 or more employees, must have access to public transportation, have access to telecommunication devices, and seek restitution for damage caused by inaccessibility of services. education for all handicapped children act - law in 1975 that required equal access for disabled children in public education SSDI - in 1956 this law provides disability insurance to replace portions of earnings lost. consolidated omnibus budget reconciliation act (COBRA) - this law established in 1986 requires employers and their health insurance group plans to provide temporary expansion of benefits to an employee, spouse and dependent children after an employee leaves the job for up to 18 months, 36 months if due to death, divorce, emplyee's eligible for medicare workers compensation act - this law in 1911 established a no-fault system determined by individual states to protect injured workers from on the job injuries.
Employment retirement and income security act - law in 1974 that set minimum standards for pension plans fair labor standards act - enforced by the department of labor family medical leave act (FMLA) - 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 -
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 - an unintentional tort of a failure of a professional to care as a reasonable and prudent member would in similar circumstances which leads to harm. malpractice - duty, breach of duty, causation, and damages are all required for what? beneficence - do good , well being, prevent or remove from harm autonomy - respecting the individual's right to make their own decisions
nonmaleficence - to do no harm, reporting positive and negative outcomes, care transitions justice - fairly, appropriate allocation of resources and trust fidelity - followthrough, keeping promises, informed consent. 25 - the dollar amount the gifts are limited to to avoid conflict of interest patient bill of rights - information disclosure, choice of providers and plans, access to emergency services, participation in treatment decisions, respect, confidentiality, complaits and appeals are all part of the self management - the ultimate goal of case management education outcomes - empowerment, effective and efficient care coordination and adherence to the plan of care are 3 key case management what? adults - These learners are autonomous, goal and relevancy oriented, have experience, care about what is practical and need respect. learning - motivation, reinforcement, retention, and transference are 4 elements of what? behavior change - The trans-theoretical model of what includes these 6 steps? pre-contemplation, contemplation, preparation, action, maintenace, termination learner readiness - this is achieved when patients:
- perceive themselves at risk of developing a specific condition
- the condition is perceived to be serious with negative consequences.
- Risks will be decreased with specific behavioral changes
- barriers can be overcome or managed. learning styles - 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 -
