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Certified Case Manager
Principles of Case Management Practice - focus on pt and family, negotiating, procuring and coordinating services and resources, use of clinical reasoning, development of various relationships, episode or continuum based Target Populations - diagnosis, high utilizers, age & health status, procedure, LOS, psychological factors, vocational, functional impairments, disability Case finding and intake - ID member, obtain consent, communicating member needs to others, ID members who need alternate levels of care Provision of services - facilitate and coordinate, communicate with other healthcare providers, monitor progress, review and modify healthcare services, collaborate with stakeholders on CM plan, advocate for pt and family, assure adherence to various standards Evaluation and Case closure - collect, analyze and report data, evaluate quality of services, ensure access to services, apply evidence based practices, close relationship when appropriate, report termination to stakeholders, education pt re illness prevention Utilization Management - evaluate appropriate level of care, communicate with payers and healthcare providers, allocate resources, manage appeals and denials, review pt condition for appropriateness of hospitalization, ID cases that are at risk for complications Psychosocial & economic issues - review pt social & financial resources, assess support network, consider culture, evaluate ability of caregiver outside hospital setting, determine eligibility for insurance coverage or charity services Vocational issues - ID need for changes in home environment, eliminate access barriers, determine need for specialized services, arrange vocational assessment and services, coordinate job analysis to implement modifications, manage return to work activities Clinical Patient Care Role - Discuss preventive services, direct patient care, asses coping skills, social supports, financial/insurance status, intervene when problems ID'd, facilitate progress through healthcare system, arrange for consultations with specialists, ensure transfer to appropriate levels of care, collaborate with team Managerial Leadership Role -
Evaluate quality of care, conduct chart reviews for UM, guide care and interventions, facilitate communication among team, serve as preceptor for CM's in training Financial Business Role - Assess variances, ensure continuity, integration and coordinator to avoid duplication or fragmentation, access information on case mix indexes, practice patterns, and consumption of resources, ensure use of necessary treatments & completed procedures with reimbursable time frames Information Management-Communication Role - Data collection & analysis of variances, quality assurance, outcomes management, communication and dissemination of information, generation of reports, presentation of information, development and revision of policies and procedures, obtain authorization for services from managed care organizations, reports findings of UM activities Professional Development-Career Advancement Role - Conduct research and utilize findings, promote evidence based practices, advocate for pt and families, share into at public forums, train novice CM's, participate in continuing ed, remain up to date with latest practices Purpose of CM - maximize use of resources, promote informed decision making, implement a plan of care to meet pts needs, make healthcare deliver more effective, assisted in meeting outcomes, promote, safe, cost- effective, accessible & quality care, assist pts in managing resources Goals of CM - promote wellness, achieve optimum level of functioning, direct self care, cost effectiveness, maintain highest level of independence, provide comprehensive and coordinated response to needs, improve safety, satisfaction, productivity, and quality of life, Acute care model - unit based, complete based, disease based, practice based, primary based. Primary Nurse CM model - services & caseloads are designated for specific patients Leveled practice model - focuses on management and coordination of patient case needs Emergency Department CM model - provide gate keeping oversight to emergency department Admission Office CM model - evaluates patients prior to admission Large CM model - case selection includes patients who are at risk for high healthcare costs (AIDS, Premie's) Disease management model -
Problem Identification Assessment - Patient history, demographics, current medical status, nutritional assessment, medication assessment, financial assessment, functional, psycho-social, cultural and religious assessment Medication Assessment - allergies, poly-pharmacy, non-compliance, no transportation, financial, insurance, lab monitoring, ineffective route, dosing, containers, education deficits Functional assessment - stairs, telephone, toilet, tub, shower, utilities, sanitation, equipment, ADL's, transportation, communication Psycho-social assessment - stressors, people in home, exhaustion & burn out, hobbies & recreation, supports, cognitive & mental status Cultural & Religious Assessment - gestures, language barriers, cultural traditions & taboos, religious & spiritual beliefs, cultural & religious conflicts Case Plan Development & Coordination - Establishing goals, Prioritizing needs & goals, Service planning & resource allocation Changes that require monitoring - changes in medical status, social stability, quality of care, functional capability, educational needs, pain management, patient/family satisfaction Case closure - request for termination, patient no longer eligible, change in medical condition, goals met, death of patient, program discontinued or company closed, CM retires Communication with Interdisciplinary Team - react and respond to facts Communication with patient - be aware of non-verbal as well as verbal Interview Techniques - know purpose, information needed, active listening, review of info discussed Negotiation techniques - to control costs & gain benefits for patient Emotional Intelligence - Mayer-Salovey Model - perceive, use, understand, and manage emotions Data Interpretation & Reporting - Thought, Data, Information, Knowledge, Wisdom
Nominal - numerical naming where numbers do not represent a degree or quantity, non-parametric - Ethnicity Ordinal - Rank-ordered numbers, non-parametric - patient acuity Interval - equal differences between numbers represent equal differences in the variable, parametric - length of stay Ratio - number represent equal amounts to form an absolute zero, parametric - Fahrenheit temperature scale Categories of healthcare date - historical, encountered patient data, sub-group data, work-flow management date, knowledge databases Data Warehouse - population based management - contains financial & clinical data Data Repository - focus is on clinical and operational data available in real time Statistical Approach - Uses statistical techniques to analyze and graph data Information Processing Approach - Involves automating data analysis in an attempt to discover date in large databases. known as knowledge discovery databases (KDD) Continuous Quality Improvement Approach - data is reported by idea generation, portrayal of beliefs, display, and analysis Steps of implementing CM model - Define Target population Define target areas determine design structure form collaborative practice groups choose benchmarks collect pre-implementation data provide advanced skills & knowledge implement the model evaluate the model End outcomes of the Healthcare CM System - high quality care appropriate or decreased costs improved health status
Performance Improvment - involved the 4 step process of design, improvement, measurement & control Quality Assurance - maintenance of a desired level of quality Risk Management - Identifying potential risk areas & interventions that will improve patient safety while preventing adverse events and unfortunate incidents, falls assessment program, injury reduction program, pressure ulcer prevention programs, infection control surveillance, failure mode analysis, prevention of deep vein thrombosis, daily review of patient flow activities 4 key functions of a case manager - assessment, planning, facilitation, & advocacy Outcomes - are the consequences of received care of of omitted care Outcome indicators - cost, utilization, transitional planning, clinical, satisfaction, variance Categories of Quality of Life (QOL)Indicators - Physical, psychological, social, functioning, economic resources, general well being Strategies for conflict resolution - focus on goals, meets the needs of both parties, build consensus, engage in dialogue, coach & education healthcare providers and nurses, identify potential conflicts Things that affect acuity - Severity of illness, intensity of service, discharge screens Severity of illness criteria - acute/sudden onset, recent onset (1 week), new onset (> 1 week), newly discovered Discharge screens - are parameters that are objective, functional, & indicate readiness and stability for discharge or transfer to another level of care InterQual's Intensity of Service Criteria - 4 types of review - pre-admission, admission, subsequent, and discharge reviews Major Diagnostic Catergories (MDC) - formed by dividing all possible principal diagnoses from ICD-9 into 25 exclusive diagnosis areas Case Mix Index (CMI) - patients are classified into groups by conditions or illness Factors that affect Case Mix Index -
severity of illness, need for intervention, treatment difficulty, presense of complications and/or co- morbidities Caseload Matrix - used in caseload calculation to identify variable in different settings that could affect caseload Elements that can affect caseload - business environment & market segment, regulatory & legal requirements, clinical practice setting, environmental factors, psycho social factors, CM outcomes, long term outcomes Commission on Accreditation of Rehabilitation Facilities (CARF) - addresses who is responsible for directing medical rehabilitation case management Utilization Review Accreditation Commission (URAC) - Core standards include, organization structure, policies and procedures, information management, interdepartmental coordination, clinical oversight, regulatory compliance, communications, quality management, patient & family satisfaction Accreditation Process - Address caseload size, case management qualifications, evaluation in the case management program, collection & analysis of data for cost, access, & confidentiality, outcome studies Ethical Principals of Case Management - Autonomy, non-maleficence (do no harm), beneficence (do as much good as you can), justice Ethical Behavior Strategies - Form ethics committees & groups, understand types of ethical conflicts that can arise, be able to to justify an ethical act, be familiar with code of conduct for case managers, work within the CM scope of practice 6 standards of professional conduct - Advocacy, professional responsibility, case manager & patient relationship, confidentiality, privacy, & record keeping, professional relationships, research Social Health Maintenance Organization (SHMO) - is a national managed care demonstration program that provides & finances long term care for the elderly Employee Retirement Income Security Act (ERISA) - involves the regulation of pension plans Federal Workforce Flexibility Act of 2004 - Strategic capital management to ensure all human resource activity directly contributes to achieving results Family & Medical Leave Act (FMLA) - entitles eligible employees of covered employers to take unpaid, job-protected leave for specified medical and family reason with continuation of group health insurance coverage
Crime - is a public wrong Intentional torts - assault, battery, trespass & false imprisonment Professional Negligence & Malpractice - 4 elements include duty, breach, cause, & harm Liability exposure for case managers - Case managers who provide services to an HMO can be held liable for various acts & actions, called join liability Health Security Act - initiated in 1993, comprehensive healthcare reform Adverse Patient Outcomes (APO) - any adverse patient occurrence that should not happen under natural circumstances with the patient's disease process or as the end result of medical procedure Level One Adverse Patient Outcome - an identified quality problem with minimal potential for adverse effects on the patient Level 2 Adverse Patient Outcome - an identified quality problem with significant potential for adverse effects on the patient Level 3 Adverse Patient Outcome - an Identified quality problem with significant deviation from acceptable levels of care & it results in injury or harm to the patient Root Cause Analysis - process of identifying, investigating, reporting and accreting adverse patient outcomes Incident - an error, accident, or the discovery of a hazardous condition that is not consistent with quality standards of care or practice CMS Core Measures - core Measures set by the Centers for Medicare & Medicaid Services (CMS) 8 related to myocardial infarction care 4 related to heart failure care 7 related to pneumonia care 5 related to surgical infection prevention 3 related to asthma care for children
