Medicare Benefits and Case Management: A Comprehensive Guide, Exams of Nursing

Download Medicare Benefits and Case Management: A Comprehensive Guide and more Exams Nursing in PDF only on Docsity!

CCM exam prep all topics 2023/2024 best

quiz

Case management - answers a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet the client's health and human services needs. Case Management Characteristics - answers characterized by advocacy, communication, and resource management and promotes quality and cost- effective interventions and outcomes. Glagow Coma Scale - answers Client assessment tool that measures level of coma in the acute phase of injury it is an objective way of recording the conscious state of a person. Eye opening, Best verbal, best motor. < 8 coma, 13-15 mild injury. Strengths Based Model - answers assesses clients capacities and potential resources as well as problems and current unmet needs. Eliciting capacities and potential resources as well as problems and current unmet needs. Independent Living Model - answers sees a disability as a construct of society Medicare Prospective Payment System - answers hospitals paid a pre- determined rate for each Medicare admission. Each patient is classified into a DRG. PHQ-9 - answers Client assessment tool for depression Braden Scale - answers Client assessment tool for pressure sore risk Clinical Pathway - answers Structured multidisciplinary CM plan designed to support the implementation of specific clinical guidelines and protocols. They are maps that guide the healthcare team on usual treatment patterns related to common diagnoses, conditions and procedures e.g., CHF SF-36 - answers Client assessment tool to measure physical and mental health. Medicare - answers Established in 1965 under Title XVIII or Social Security Act. Four Parts A-hospital insurance, B-medical insurance (doctors visits), C- Medicare Advantage program in a private plan such as HMO, D-prescription drug benefit Medicare Benefits and Cost Sharing - answers Not covered are: Acupuncture, chiropractor, cosmetic, custodial home care, dental care, DME convenience, hearing aids, eyeglasses, foot care, meals on wheels, personal convenience, prescription drugs, private nurses, routine physical, vision

areas of accountability of case management - answers clinical/outcome financial functional/outcome

satisfaction behavior process *episode or continuum **individual or population Measuring performance: Process - answers The measure of how many pts receive a treatment or service i.e. vaccinations, screenings, ex. diabetic foot exam ALSO practitioner's practice conforming to practice standards. Measuring performance: Functional outcome - answers The measure reflects the health state of a patient as a result of health care ex. increased independency in ADLs, mobility Measuring performance: Clinical outcome - answers The measure reflects the health state of a patient as a result of health care ex. blood pressure goals ex. HgA1c level, wound healing Measuring performance: behavioral 'process' - answers ex. self-monitoring of blood sugar Measuring performance: Financial - answers ex. fewer ED visits, ALOS decreased Women's Health and Cancer Rights Act of 1998 - answers 1. Part of Omnibus Appropriations Bill. 2. required group health plans to provide coverage for mastectomies and provide certain reconstructive related services following mastectomies. Women's health and cancer rights act coverage - answers 1. reconstruction of the breast. 2. surgery and reconstruction of the other breast 3. breast prothesis

4. treatment for physical complications attendant to the mastectomy Women's health and cancer rights act prohibitions - answers Health plans are not allowed to deny anyone coverage for the sole reason of avoiding the requirements of the act AND cannot induce a physician to limit the care that is required under the act by penalizing or limiting reimbursement to the physician. Can states modify HIPAA's portability requirement - answers Yes. HIPAA requirements do not supercede state requirements. Stricter laws prevail. States can 1. shorten the 6 month look back period. 2. shorten 12 month maximum pre-existing condition exclusion period.3. increase the 63 day/significant break in coverage 4. increase 30 day period for newborns, adopted children, children placed in adoption and pregnant women. 5. Expand the prohibitions on conditions and people to whom a pre-existing condition exclusion period may be applied beyond exceptions. 6. reduce additional special enrollment periods. 7. reduce maximum HMO affiliation period to less than 2 months.

Break in coverage - answers 63 days or longer that a subscriber has been without health insurance coverage (not including waiting periods) Waiting period - answers period of time specified by health insurance contract that occurs between signing up for insurance and the beginning of health insurance coverage. Cannot be counted as creditible coverage time. Individuals can use COBRA from their previous employers for health insurance Establishing waiting period - answers HIPAA does not prohibit plans from establishing a waiting period. But the waiting period and the pre-existing conditions exclusions must start at the same time and run concurrently. Creditable Coverage - answers For the purpose of the Health Insurance Portability and Accountability Act, coverage under virtually any type indivual or group health care plan without a break in coverage of 63 days or more. Cannot be taken into account when determining a significant break in coverage. Only coverage after the 63 day break will be counted. Any coverage before the 63 day break will not be considered. COBRA - answers Consolidated Omnibus Budget Reconciliation Act; law to provide terminated employees or those who lose insurance coverage because of reduced work to be able to buy group insurance for themselves and their families for a limited amount of time. Certification of creditable coverage - answers Documentation that is provided automatically by the plan or issuer when the individual loses coverage or becomes entitled to elect COBRA continuation coverage and when an individual's COBRA continuation covearage ceases ; Be provided if requested before loss of coverage or within 24 months of loss of coverage. May be provided through use of model certificate Nondiscrimination requirements - answers Inividuals cannot be excluded from coverage under the terms of the plan based on specified factors related to health status. Health plans cannot establish rules of eligibility based on healht status related factors" such as health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability or disablity. Insurer cannot drop a patient from coverage because it knows that the patient will require a liver transplant next year. Cannot charge more for premiums based on health status. Security of health information and electronic signature standards - answers provides a uniform level of protection of all health information that is housed or transmitted electronically. pertains to the individual. Tax Equity and Fiscal Responsibility ACT of 1982 - answers the purpose of this act is to control the rising cost of providing health care services to medicare beneficiaries and

has incentives for cost containment. The act:1. established a case based reimbursement system (DRG) payment system determined the cost of care for selected diagnoses while also placing limits on rate increases in hospital venues. 2. Exempted medical rehabilitation from DRGs. Rehabiliation would continue as a cost based reimbursement system with limits. 3. Amended social security act so that group health plans pay before medicare for active employees 65-69 years old and for their spouses in the same age group. 4. revised Age discrimination act by requiring employers to offer health benefits to active employees 65-69 and their spouses in the same age bracket. 5. establish peer review organizations to reduce costs associated with the hospital stays of medicare and medicaid patients. Also established hospice benefit. The Mental Health Parity Act of 1996 - answers A statute that forbids health plans from placing lifetime or annual limits on mental health coverage that are less generous than those placed on medical or surgical benefits. Excluded substance abuse. If a plan does cover mental health, it cannot set a separate dollar limit from medical care. Other limits allowed: limited number of annual outpatient visits; Limited number of annual inpatient days; a per visit fee; Higher deductibles and copayments without parity in medical and surgical benefits. If a parity would require an increase of 1% or more in its health care costs, the plan would be exempt. The Pregnancy discrimination act - answers is an amendment to Title VII stating that employment discrimination based on pregnancy, childbirth, or related medical conditions is prohibited as a form of sex discrimination Newborns and Mother's Health Protection Act of 1996 - answers Health plans may not restrict benefits for any hospital length of stay in connection with child birth for new born or her bother to less than 48 hours following a normal vaginal delivery or less than 96 hours following a delivery by cesarean section. They may not require providers to request for authorization for up to 48/96 hours. May not increase an individuals coinsurance for any later portion of a 48 hour /96 hour hospital stay. 3. they cannot provide monetary payments to encourage a mother to accept less than minimum protections available under NMHPA. They cannot penalizeor other wise reduce or limit the reimbursement of an attending provider because the provider furnished care to a mother or newborn in accordance to NMHPA. They cannot provide monetary or other incentives to an attending provier to induce the provider to furnish care to a mother or new born in a manner inconsistent with the NMHPA. The Mental Health Parity and Addiction Equity Act of 2008 - answers MHPAEA preserves the MHPA protections and adds significant new protections, such as extending the parity requirements to substance use disorders. Although the law requires a general equivalence in the way MH/SUD and medical/surgical benefits are treated with respect to annual and lifetime dollar limits, financial requirements and treatment limitations, MHPAEA does NOT require large group health plans or health insurance issuers to cover MH/SUD benefits. The law's requirements apply only to large

group

health plans and health insurance issuers that choose to include MH/SUD benefits in their benefit packages. However, the Affordable Care Act builds on MHPAEA and requires coverage of mental health and substance use disorder services as one of ten EHB categories Exceptions to MHPAEA 2008 - answers Except as noted below, MHPAEA requirements do not apply to: Non-Federal governmental plans that have 100 or fewer employees; Small private employers that have 50 or fewer employees; Group health plans and health insurance issuers that are exempt from MHPAEA based on their increased cost (except as noted below). Plans and issuers that make changes to comply with MHPAEA and incur an increased cost of at least 2% in the first year that MHPAEA applies to the plan or coverage or at least one percent in any subsequent plan year may claim an exemption from MHPAEA based on their increased cost. If such a cost is incurred, the plan or coverage is exempt from MHPAEA requirements for the plan or policy year following the year the cost was incurred. These exemptions last one year. After that, the plan or coverage is required to comply again; however, if the plan or coverage incurs an increased cost of at least 1% in that plan or policy year, the plan or coverage could claim the exemption for the following plan or policy year; Large, self-funded non-Federal governmental employers that opt-out of the requirements of MHPAEA. hard savings - answers Examples of "hard" savings are directly linked to Case Management. Examples would be reduction in payer denials or decrease in avoidable days. soft savings - answers Examples of "soft" savings are indirectly linked to Case Management such as lower readmission rates or lower post-op complication rates. These can be converted into dollars. 1987 Nursing Home Reform Act - answers The basic objective of the Nursing Home Reform Act is to ensure that residents of nursing homes receive quality care that will result in their achieving or maintaining their "highest practicable" physical, mental, and psychosocial well-being. To secure quality care in nursing homes, the Nursing Home Reform Act requires the provision of certain services to each resident and establishes a Residents' Bill of Rights. CARF - answers Commission on Accreditation of Rehabilitation Facilities Wickline v. The State of California - answers the point of this litigation is that a physician/surgeon is still responsible for negligently discharging a patient even if the financial benefits related to the hospital stay have been exhausted. Wickline also seems to suggest that a physician can be negligent for not acting more aggressively as a patient's advocate with third-party payers

ADA reasonable accommodations - answers -Making existing facilities used by employees readily accessible to and usable by persons with disabilities. -Job restructuring, modifying work schedules, reassignment to a vacant position; -Acquiring or modifying equipment or devices, adjusting or modifying examinations, training materials, or policies, and providing qualified readers or interpreters. The Individuals with Disabilities Education Act (IDEA) - answers Public Law 94-142 - a law ensuring services to children with disabilities throughout the nation. IDEA governs how states and public agencies provide early intervention, special education and related services to more than 6.5 million eligible infants, toddlers, children and youth with disabilities. Abandonment - answers termination of a professional relationship without reasonable notice to the patient and without an opportunity for the patient to acquire alternative care or services thereby resulting in injury to the patient. Agency - answers relationship between two or more persons by which one consents that the other (the agent) shall act on his or her behalf. Legal obligations to: 1. use care and skill 2. act in good faith 3. staying within the limits of authority 4. obeying the principal and carrying out all reasonable instructions 5. advancing the interests of the principals 6. acting solely on the principal's benefit. Implies a conflict of interest between the case manager and the employer and the professional duties to the patient. Apparent authority - answers (ostensible agency): When a principal has taken such actions that would indicate to third parties that someone is his or her agent, the principal is held to have given "apparent authority" to the agent. The principal is held responsible for the agent's action Bad Faith - answers attempt to mislead or decieve another or neglect refusal to fulfill some duty or some contractual obligation. Implies a conscious of wrong doing. Example: denying claim to save money. Three Components of bad faith claims denials - answers 1. absence of a reasonable basis for denial of benefits.

2. the insurers or agent's knowledge or reckless disregard of the lack of reasonable basis for denying a claim.
3. misfeasance or maladministration in processing of claims for benefits. Bill of particulars - answers Amplification of a legal complaint that supplies more information and detail, thereby giving the defendant a more specific picture of the claims against him.

Breach of confidentiality - answers failure of fiduciary duty. Refusal to hold secret a priviledged communication entrusted by one party to another. Claim - answers request for payment from an insurance company. Or a report by the insured provider of care to the insurance company based on notification from the patient or the patient's attorney of an event out of which malpractice has been alleged. Comparative negligence - answers A method of measuring negiligence among participants in a suit (defense and plaintiff) in terms of percentages of culpability. Damages are then diminished in proportion to the amount of negligence attributable to the complaining party. Complaint - answers document by which the plaintiff gives the court and the defendant notice of the transactions, occurrences, or series of transactions or occurences intended to be proved and the material elements of each cause of action or defense. Corporate negligence - answers legal ground of a managed care liability based on the corporate activity of the managed care organization itself rather than on the care related activities of participating healthcare professionals. Examples: Negligent credentialing and negligent supervision. Corporate practice of medicine - answers Legal doctrine that prohibits corporations from engaging in the practice of medicine. Corporates who recognize this doctrine cannot employ physicians. Damages - answers Monetary compensation awarded for acts of tort for both tangible (medical expenses, loss wages) and intangible (pain and suffering) Discovery - answers Ascertainment of what is not previously known. All evidence that is material and necessary in the prosecution or defense of action is produced and exchanged by the parties or as ordered by the court. Event (incident) - answers a situation that is reported by the insured provider to his or her insurance company which may lead to a formal claim or malpractice suit. Examination before trial - answers obtaining information by sworn oral testimony False Claims Act - answers Federal penalties for those who knowingly present false claim or against the government. It is illegal to present a false or fraudulent claim upon or against the US. HOld harmless provision - answers Contract between insurer and provider of services that specifies that the providers assumes liability for covered services even if the managed care organization becomes insolvent.

Inherent risk - answers a complication that is commonly associated with a treatment and is not due to negiligence of the provider of the treatment. Invasion of privacy - answers wrongful intrusion into one's private activities which would cause harm to the patient Liability - answers debt, responsibility, obligation Liability, joint - answers Obligation as a group or as a whole and all its individual members. A party that has been harmed can sue the group as a whole or by its individuals but the suer cannot get more compensation by suing individually than by suing as a whole. Liability limits - answers Restriction or upper boundary on the amount of money on insurance company will pay in order to satisfy a claim against an insured. A calim for a sum beond this limit is not protected bt teh insurance policy and is that the responsibility of the defendant Liable - answers bound by law or fairness responsible and accountable Malpractice - answers Act of negligence, 1. negligence: a deviation from the approved and accepted standards of care. 2. injury which damage is to the patient as result of the negligence. Most favored nation Clause - answers provider is obligated to render products or services to the purchaser at the same rate as his most favored customer Negligence - answers Failure to use the degree of care. Ommision and commission. Negligent credentialing - answers When a organization does not exercise care when investigating a provider's credentials. Example when an organization selects a provider who negligently injures a patient, has a history of doing so or is found not to have the appropriate training , experience, skill or licensure to care for the patient. Negligent Referral - answers Referring a patient to a provider who does not posses the right credentials, skills, licensure or who has been known to be negligent in the past. Ombudsman - answers a person who investigates customer complaints against their employer. Ostensible agency - answers A principal gives a third party reason to believe another person is his/her agent; other person is unaware of the appointment. In these cases the

"principal" is responsible for the acts of the agent. Principal gives apparent authority to the agent and will be liable for his acts Out of Court setllement - answers Agreement or transaction between two litigants to settle the matter privately and not in court Privileged communications - answers Information that is disclosed by a patient to a provider that remains confidential unless patient waives his privilege. Disclosure of such information may constitute as an invasion of privacy which is an actionable tort Res ipsa loquitor - answers (things speak for itself). Mere proof that an occurence took place is sufficient. Injury was case by the defendants exclusive control and that the accident was one that ordinarily doesn't happen in the absense of negiligence. Example: when a patient is found to hav an surgical instrument left in his abdomen. Respondeat Superior - answers Let the master answer: master is liable for acts of his servant. Statutue of limitations - answers period of time which a plaintiff can bring a lawsuit after an incident has occurred. Subpoena - answers A judicial process requiring a witness to give relevant information or testimony "under penalty" of comtempt for disobedience Summons - answers A document issued by the plaintiff's attorney, which, when properly delivered, commensces a legal action. Tort - answers Implies injury: damage or injury or wrongful act done willngly, negligently or in circumstances involving strict liability, a legal wrong doing commited upon the person or property independant of contract. Examples of tort: - answers a direct invasion of some legal right of the individual.2. the infraction of some public duty by which special damage accrues to the individual. 3. the violation of some private obligation by which like damage accrues to the indiviual vicarious liability - answers the legal liability that a pperson may have for the action of someone else. , Legal doctrine under which a party can be held liable for the wrongful actions of another party. HHRG - answers Home health resource group Medicare A case-mix classification in which Pt characteristics and health status information are obtained from an OASIS assessment in conjunction with projected therapy use during a 60-day episode are used to determine Medicare reimbursement. -Eighty HHRGs

-The Outcome & Assessment Information Set (OASIS) determines the HHRG and is completed for each 60-period -A predetermined base payment for each 60-day episode of care is adjusted according to patient's HHRG -No limit to number of 60-day episodes -Payment is adjusted if patient's condition significantly changes DRG - answers Diagnosis-related group Managed care A unit of classifying Pts by diagnosis, average length of hospital stay, and therapy received; the result is used to determine how much money health care providers will be given to cover future procedures and services, primarily for inpatient care. -Primary diagnosis determines assignment to one of 535 DRGs -The DRG payment rate is adjusted based on age, sex, secondary diagnosis and major procedures performed. DRG payment is per stay. -Additional payment (outlier) made only if length of stay far exceeds the norm RUG - answers -Fifty-eight groups -Each beneficiary assigned a per diem payment based on Minimum Data Set (MDS) comprehensive assessment -A specified minimum number of minutes per week is established for each rehabilitation RUG based on MDS score and rehabilitation team estimates SNF - answers A facility that provides 24-hour medical care provided by registered nurses, licensed vocational nurses as well as nurses aides. Licensed Physical Therapists, Occupational Therapists, and Speech Therapists are also available. Typically for patients who require services that can only be given by a licensed provider such as IVABX, IV pain management, wound care, g-tube feeding or physical rehabilitation needed 1-3 hours a day on a daily basis. An M.D. will usually evaluate pt. within the first 72 hours and then monthly thereafter. In order for Medicare to cover (and Medicare only) pt. must have a three-day qualifying stay in the acute setting (think midnights). As long as pt. has a skilled need and a qualifying stay Medicare will cover the first 20 days at 100 percent, day 21-100 is $119.00 a day which the pt. or the pt's secondary insurance is responsible for. Most SNFs also have a custodial side for pts. whose needs can no longer be met at home or at a lower level of care. Other than MediCal, Medicare and most private insurances, (with the exception of long

term care insurance) will NOT cover custodial care in a SNF. Subacute Care Unit - answers For patients who no longer require the intensive procedures of an acute care Hospital, but do require the diagnostic or invasive procedures of an inpatient healthcare facility. Patients who are transferred to a sub acute facility may have a trach and require frequent suctioning. Individuals may also need to be weaned from a ventilator. Patients residing in this environment generally need between four and seven hours of skilled nursing/respiratory care each day. Medicare does not recognize the sub acute level of care and will only reimburse on a SNF level, so the determination of acceptance is usually made on a case by case basis by the individual facility. MediCal does recognize the Sub acute level, however, the pt. must have a trach AND another needs i.e. feeding tube, wound care or TPN. Only a few sub cutes have dialysis available on site. LTAC - answers Structured and programmed for medically complex and often catastrophically ill patients. Patients are admitted for acute care, with lengths of stay that average 25-30 days; typical of medically complex patients. The intensity of service will normally exceed the care needs that can be met by a sub-acute or skilled nursing facility. An LTAC will generally be able to provide such services as vent weaning and respiratory care, complicated wound care, TPN; Surgeries such as Tracheotomies, wound debridment, skin flaps, PEG/GT placement, and Central line placement. An LTAC will also have an ICU as well as telemetry units. Pts. will be seen on a daily basis by an M.D. and will be treated by P.T., O.T., and Speech. The patient must have specific and realistic discharge goals from the LTAC. Mainly for Medicare recipients, MediCal does not recognize this level of care, and private insurance is on a case-by-case basis. Acute Rehab Unit - answers Typically for neuro related diagnosis (but not always, this too is decided on a case by case basis

dependant on insurance and accepting facility), the pt. must actively participate, tolerate, and benefit from a MINIMUM of three hours of therapy daily (P.T., O.T., and Speech Therapy). The pt. must have a discharge goal of home or an assisted living facility, pt will NOT be accepted if the goal is SNF. Accessible - answers A term used to denote building facilities that are barrier-free thus enabling all members of society safe access, including persons with physical disabilities. Barrier - Free - answers A physical, manmade environment or arrangement of structures that is safe and accessible to persons with disabilities. Activity Limitations - answers Difficulties an individual may have in executing activities. An activity limitation may range from a slight to a severe deviation in terms of quality or quantity in executing the activity in a manner or to the extent that is expected of people without the health condition. Developmental Disability - answers Any mental and/or physical disability that has an onset before age 22 and may continue indefinitely. It can limit major life activities. Individuals with mental retardation, cerebral palsy, autism, epilepsy (and other seizure disorders), sensory impairments, congenital disabilities, traumatic brain injury or conditions caused by disease (e.g. polio and muscular dystrophy) may be considered developmentally disabled. Disability - answers A physical or neurological deviation in an individual makeup. It may refer to a physical, mental or sensory condition. A disability may or may not be a handicap to an individual, depending on one's adjustment to it. Disability - answers Diminished function, based on the anatomic, physiological or mental impairment that has reduced the individual's activity or presumed ability to engage in any substantial gainful activity. Disability - answers Inability or limitation in performing tasks, activities, and roles int he manner or within the range considered normal for a person of the same age, gender, culture and education. Can also refer to any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being. Disability Case Mangemtn - answers A process of managing occupational and no- occupational diseases with the aim of returning the disabled employee to a productive work schedule and employment.

Disability Income Insurance - answers A form of health insurance that provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury or disease Handicap - answers The functional disadvantage and limitation of potentials based on a physical or mental impairment or disability that substantially limits or prevents the fulfillment of one or more major life actives, otherwise considered normal for that individual based on age, sex and social/cultural factors, such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, working, etc. Handicap is a classification of role reduction resulting from circumstances that place an impaired or disabled person at a disadvantage compared to other persons. Handicapped - answers Refers to the disadvantage of an individual with a physical or mental impairment resulting in a handicap. Learning Disability - answers A lack of achievement or ability in a specific learning area(s) within the range of achievement of individuals with comparable mental ability. Most definitions emphasize a basic disorder in psychological processes involved in understanding and using language, spoken, or written SSDI - answers Social Security Disability Income: Federal benefit program sponsored by the Social Security Administration. Primary factor: disability and/or benefits received from deceased or disabled parent. Benefit depends upon money contributed to the Social Security program either by the individual involved and/or the parent involved. Total Disability - answers An illness or injury that prevents an insured person from continuously performing every duty pertaining to his/her occupation or engaging in any other type of work Case Management - answers A collaborative process, which assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual's health needs, using communication and available resources to promote quality, cost-effective outcomes. Key elements to Case Management (9) (a p cs ds l a me er po) - answers • Assessment • Planning

• Coordinate Services • Deliver Services
• Linkage • Advocate
• Monitoring & Evaluating • Efficient use of Resources
• Promote Positive Outcome Assessment - answers Getting the background info

Planning - answers Looking ahead Coordinate Service - answers Holistic view of the client, many services must be coordinated Deliver Service - answers CMs often deliver services themselves Linkage - answers Relates to service coordination. Makes sure the client is connected to resources out there Advocacy - answers CM have the responsibility for being the voice of the client Monitoring and evaluating - answers • If providing management, you must assess and assure the delivery of the services are on target

• What's the impact of the services
  • Evaluating (more formal) Efficient use of resources - answers Try to do more with less Positive outcome - answers Trying to bring about a benefit for the client Managed care: - answers • a system of health care (HMO, PPO) that controls costs by placing limits on physicians' fees and by restricting the patient's choice of physicians.
• Strong motive for the insurance co. to make profits, managed care optimizing access
• Iron Triangle - Access, Cost, Quality
• We want to optimize access, minimize cost, and maximize outcome) Three-way dilemma in US - answers • Customer have high need
• Health care system has high capacity and horsepower
• No one really wants to pay for services Iron Triangle - answers (a term coined to describe the relationship between access, cost, and outcome)
• optimizing access
• minimizing cost
• maximize outcome Role of Case Manager - answers • "Big brother"
  • CM usually has the big picture on the client
  • Broad scope of care and management of the client
• Balance "Hands off" vs. "hands on" roles
• Driven by organizational/agency context
• Significant variation in roles across settings

• Bridge among PwDs, services, and payers History of Case Managers (5 key milestones) Part 1 - answers 1. 20s & 30s - Polio treatment centers, first coordinated systems of care

2. 30s & 40s - Antibiotics developed
3. Post WWII, 1946 - physiatry was born & rehab nurses functioned as CMs
4. 54 - Rehab act of 54, established funds for universities to train VR counselors with CM as key curriculum component History of Case Managers (5 key milestones) part 2 - answers 5. 70s & 80s: (a) Workers Comp provided rehab services (b)rehab facilities became more persuasive (more government money) (c) public mental health deinstitutionalization (d)passage of Rehab Act of 73, beginning of private rehab Physiatry - answers A branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities (AKA: rehabilitation medicine) Key Case Manager competencies (Part 1) - answers • Relationship building and counseling

• Assessment/monitoring/evaluating
• Planning
• Decision making Key Case Manager competencies (Part 2) - answers
• Advocacy
• Conflict resolution
• Payment sources (how, rules and regs, code usage)
• Caseload management
• Community resources (making connections, who provides) Case Manager Credentials - answers • Certification
  • CCM (Certified Case Manager)
  • CDMS (Certified Disability Management Specialist)
  • LCP (Life Care Planning)
• Certification require a base in one's own field first
• Adds to credibility Rehab Counselor vs. Social Worker - answers Better understanding of a disability, or VC rehab

Rehab Counselor vs. Nursing - answers Nurses better on medical knowledge Case Managers vs. Counseling - answers Counselors more specific service provided ; a CM is more general orientated Case Managers Setting (a wide variety) 10 total (Part 1) - answers • Secondary school (help client move on to higher ed)

• University (DRS office for post-secondary)
• Corporate (work stations in order, WC claims, health benefits)
• Public VR (return client to work quickly)
• Private VR (return client to work, take your time) Case Managers Setting (a wide variety) 10 total (Part 2) - answers • Community (MH, substance abuse, VR)
• Public Health (HIV resources)
• Hospital (community support post release)
• Insurance (Utilization & physician work review)
• Forensic (Testifying) Mental Health Case Manager (Part 1) 5 total - answers • Residential
• Pre-discharge planning (post release needs reapply)
• Day support
• Medication management Mental Health Case Manager (Part2) 5 total - answers • Intensive Case Manager
  • (serve most needy people ; take the team to the client rather than the client coming to the community because they could not do so)
• Homelessness Case Manager
  • Search for mentally ill homeless people
  • Blend in & build relationships w/ the homeless Future of Case Managers - answers • Increasing recognition
• Increasing professionalization and credentialing
• Decreasing the proverbial "CM burden"
  • Second class citizen compared to the clinician or other providers CM Outcomes in Practice Settings: Acute Care - answers ALOS; readmissions;satisfaction;CMS & JCAHO quality 'core' measures; d/c planning; no denial days; clinical resource management; progression of care 'throughput'. DRG

CM Outcomes in Practice Settings: Home Care - answers # visits; level of care; accurate OASIS assessments; outcome measures in clinical, functional and readmission domains. HHRG CM Outcomes in Practice Settings: Skilled Nursing (SNF) - answers LOS; level of care;accurate assessments of clinical & functional measures. RUG CM Outcomes in Practice Settings: Health Plan - answers level of care; clinical measures for chronic disease; satisfaction; NCQA & URAC CM standards if accredited; cost avoidance; adherence to guidelines ALOS: avg length of stay - answers affects ratings and ability to negotiate new contracts with medicare, hmo's or commercial plans DRG/HHRG/RUG - answers Identify severity of illnes for payment AND used for data collection on clinical outcomes. Critical pathways/Clinical pathways/Care Maps - answers multidisciplinary, evidence- based foundation for care delivery. Facilitates longitudinal care. Variances from pathways - answers can be operational, health care provider, patient/family, clinical McGill Pain Questionaire - answers The 3 major measures are: (1) the pain rating index, based on two types of numerical values that can be assigned to each word descriptor, (2) the number of words chosen; and (3) the present pain intensity based on a 1-5 intensity scale. Visual Analog Scale - answers faces for description PHQ-9 tool - answers measures depression: Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression morisky medication adherence questionaire - answers Do you sometimes forget to take your medicine? People sometimes miss taking their medicines for reasons other than forgetting. Thinking over the past 2 weeks, were there any days when you did not take your medicine?

Have you ever cut back or stopped taking your medicine without telling your doctor because you felt worse when you took it? When you travel or leave home, do you sometimes forget to bring along your medicine? Did you take all your medicines yesterday? When you feel like your symptoms are under control, do you sometimes stop taking your medicine? Taking medicine every day is a real inconvenience for some people. Do you ever feel hassled about sticking to your treatment plan? How often do you have difficulty remembering to take all your medicine? A. Never/rarely B. Once in a while C. Sometimes D. Usually E. All the time Tools for child development assessment - answers HELP, Bayley and Denver Tools for brain injury - answers Glasgow Coma Scale Rancho Los Amigos Braden scale - answers pressure sore risk MDS for SNF - answers Categories of MDS (Minimum Data Set)

1. Cognitive patterns
2. Communication and hearing patterns
3. Vision patterns
4. Physical functioning and structural problems
5. Continence
6. Psychosocial well-being
7. Mood and behavior patterns 8)Activity pursuit patterns
8. Disease diagnoses 10)Other health conditions 11)Oral/nutritional status 12)Oral/dental status 13)Skin condition 14)Medication use 15)Treatments and procedures Short form-36 - answers Quality of life perception tool

The RAND 36-Item Health Survey (Version 1.0) laps eight concepts: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, emotional well-being, social functioning, energy/fatigue, and general health perceptions. It also includes a single item that provides an indication of perceived change in health. Subacute - answers a broad range of medical and rehabilitative services and settings that provide care to post-acute patients Acute Care - answers Acute care is a care setting where a patient is treated for a brief but severe episode of illness. The term is generally associated with care rendered in an emergency department, ambulatory care clinic, or other short-term stay facility. The most common acute care setting is a traditional hospital, which typically offers both inpatient and outpatient care in specialty areas including but not limited to emergency care, intensive care, coronary care, cardiology, surgical services, psychiatric care and childbirth and pediatric care. The function and goal of acute medical care is to diagnose and treat the presenting condition or illness and return the person to his/her state of health prior to the episode. Acute care settings often have full-time physicians and hospital staff who are available 24 hours a day. They may offer higher nurse-to-patient ratios, including licensed nursing staff especially trained in acute care. Acute care hospitals often also have social workers, dieticians, physician specialists, pharmacists and rehabilitation staff on-site. long-term acute care hospital - answers A long-term acute care hospital is an acute care hospital that specializes in the treatment and rehabilitation of medically complex patients who require an extended stay in a hospital setting. LTACs are focused on patients with serious medical problems that require intense, special treatment for a long time (usually about 20-30 days). These patients often transfer from intensive care units in traditional hospitals. It would not be unusual for a LTAC patient to need ventilator or other life support medical assistance. The typical LTAC patient is older with three to six concurrent active diagnoses, or someone who has suffered an acute episode on top of several chronic illnesses. Long term care - answers Long-term care is a concept that encompasses a full continuum of care provided in a wide variety of settings. It includes everything from long term acute care to nursing home care to assisted living and even hospice care. Such care can be provided in almost every conceivable setting, from an individual's home to a retirement community or even a long-term acute care hospital. Long-term care settings provide a variety of services and supports to meet health or personal care needs over an extended period of time. Most long-term care is non-skilled personal care assistance, such as help performing everyday activities of daily living (ADLs), which are: bathing

dressing using the toilet transferring (to or from bed or chair) caring for incontinence eating. The goal of long-term care services is to help you maximize your independence and functioning at a time when you are unable to be fully independent. SNFs - answers Nursing homes, also called skilled nursing facilities (SNF) or convalescent care facilities, provide a wide range of services, including nursing care, 24-hour supervision, assistance with activities of daily living, and rehabilitation services such as physical, occupational, and speech therapy. Some people need nursing home services for a short period of time for recovery or rehabilitation after a serious illness or operation, while others need longer stays because of chronic physical, health, or cognitive conditions that require constant care or supervision Acute inpatient rehabilitation - answers A special type of rehab care often required when an individual's medical status requires more intense services that can't reasonably be provided in an alternative setting. Such care settings might be in a hospital or skilled nursing facility or a free-standing facility and are licensed and certified and primarily promote special rehabilitative health care services rather than general medical and surgical services. Examples of conditions requiring acute inpatient rehabilitation include, but are not limited to, individuals with significant functional disabilities associated with stroke, spinal cord injuries, acquired brain injuries, major trauma and burns. The goal is the restoration of a disabled person to self-sufficiency or maximal possible functional independence. An inpatient rehabilitation program utilizes an inter-disciplinary coordinated team approach that typically involves a minimum of three (3) hours of rehabilitation services daily. These services may include physical therapy, occupational therapy, speech therapy, cognitive therapy, respiratory therapy, psychology services, prosthetic/orthotic services, or a combination thereof. FIM (Functional Independence Measure) - answers is the most widely accepted functional assessment measure in use in the rehabilitation community. The FIM(TM) is an 18-item ordinal scale, used with all diagnoses within a rehabilitation population. It is viewed as most useful for assessment of progress during inpatient rehabilitation. What is Case management - answers it is a cross-disciplinary and interdependent specialty practice. Case management is - answers a means for improving clients' health and promoting wellness and autonomy through advocacy, communication, education, identification of service resources, and facilitation of service. Case management is guided by the principles of autonomy, beneficence,

nonmaleficence, and justice

primary function of case managers - answers to advocate for clients/support systems Case managers' first duty - answers coordinating care that is safe, timely, effective, efficient, equitable, and client-centered. Case Management Process - answers Screening, Assessing, Stratifying Risk, Planning, Implementing (Care Coordination), Following-Up, Transitioning (Transitional Care), Communicating Post Transition, and Evaluating Case Management Plan of Care - answers Describes: The client's problems, needs, and desires, as determined from the findings of the client's assessment. The strategies, such as treatments and interventions, to be instituted to address the client's problems and needs. The measurable goals - including specific outcomes - to be achieved to demonstrate resolution of the client's problems and needs, the time frame(s) for achieving them, the resources available and to be used to realize the outcomes, and the desires/motivation of the client that may have an impact on the plan Level of Care - answers The intensity and effort of health and human services and care activities required to diagnose, treat, preserve, or maintain clients' health. Level of care may vary from least to most complex, least to most intense, or prevention and wellness to acute care and services The High Level Case Management Process - answers Case managers navigate the phases of the process with careful consideration of the client's cultural beliefs, interests, wishes, needs, and values. By following the steps, they help clients/support systems to: Evaluate and understand the care options available to them Determine what is best to meet their needs Institute action to achieve their goals and meet their interests/expectations At the same time, case managers apply: Relevant state and federal laws. Ethical principles and standards such as the CCMC's Code of Professional Conduct for Case Managers with Standards, Rules, Procedures, and Penalties (CCMC, 2009), which applies to persons holding the CCM® credential. Accreditation and regulatory standards. Standards of care and practice such as the CMSA Standards of Practice for Case Management (CMSA, 2010) Evidence-based practice guidelines.

And at every phase of the Case Management Process, case managers provide vital documentation. Case Management Process:Screening - answers The Screening phase focuses on the review of key information related to an individual's health situation in order to identify the need for health and human services (case management services). The case manager's objective in screening is to determine if a client would benefit from such services. Screening promotes early intervention and the achievement of desired outcomes. Key information gathered during screening may include - to the extent available - risk stratification category or class, claims data, health services utilization, past and current health condition, socioeconomic and financial status, health insurance coverage, home environment, prior services, physical/emotional/cognitive functioning, psychosocial network and support system, and self-care ability. Case Management Process: Assesssing - answers The Assessing phase involves the collection of information about a client's situation similar to those reviewed during screening, however to greater depth. This information may include past and current health conditions, service utilization, socioeconomic and financial status, insurance coverage, home condition and safety, availability of prior services, physical/emotional/cognitive functioning, psychosocial network system, self-care knowledge and ability, and readiness for change. The case manager has two primary objectives while assessing: Identifying the client's key problems to be addressed, as well as individual needs and interests. Developing a comprehensive case management plan of care that addresses these problems and needs. Additionally, the case manager seeks to confirm or update the client's risk category based on the information gathered. Using standardized assessment tools and checklists, the case manager gathers information telephonically or through face-to-face contact with the client, the client's support system, and the clinicians involved in the client's care. The case manager also collects necessary information through a review of current and past medical records, personal health records Case Management Process: Stratifying Risk (1) - answers The Stratifying Risk phase involves the classification of a client into one of three risk categories - low, moderate, and high - in order to determine the appropriate level of intervention based on the client's situation and interests. This classification allows the implementation of targeted risk category-based interventions and treatments that enhance the client's outcomes