CASE MANAGER CERTIFICATION EXAM 2023 COMPLETE UPDATE ACTUAL
.pdf
keyboard_arrow_up
School
Grand Canyon University *
*We aren’t endorsed by this school
Course
2023
Subject
Nursing
Date
Nov 24, 2024
Type
Pages
19
Uploaded by carolnje
CASE MANAGER CERTIFICATION EXAM 2023
COMPLETE UPDATE ACTUAL
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 - 1. timeline
2. categories of care/activities and interventions
3. intermediate and long term outcome criteria
4. 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.
BASIS-32 - health risk assessment: 32-item Behavior and Symptom Identification Scale.
behavioral health assessment tool.
- measures the change in self-reported symptom and problem difficulty over the course of
treatment.
- assesses: Relation to Self and Others, Depression and Anxiety, Daily Living and Role
Functioning, Impulsive and Addictive Behavior, Psychosis.
- higher score poorer outcome
mini mental state exam - health risk assessment:
30-point questionnaire measures cognitive impairment to screen for dementia.
- higher the score, less dementia
- 18-23 is mild dementia
- 0-17 is sever dementia
hopkins symptom checklist-25 - health risk assessment: self-reporting questionnaire symptom
inventory which measures symptoms of anxiety and depression.
-The scale for each question includes four categories of response ("Not at all," "A little," "Quite
a bit," "Extremely," rated 1 to 4, respectively). 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 questionnaire - scale of rating pain. It is a self-report questionnaire that allows
individuals to give their doctor a good description 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. After completing the questionnaire, 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 - 1. Patient focused
2. Measurable
3. Attainable
4. Relevant
5. Time oriented
Piaget - Developmental theory for cognitive ability to process/analyze information
Assess, plan, implement/intervention, monitor/evaluation - 4 stages of case management
Sensorimotor: object performance and separation anxiety. - Piaget's age 0-2,
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
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 1/2
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 - 1. Question
2. ID resources
3. Critically appraise resources
4. Apply evidence
5. 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 ----
1. Track patient self management
2. Tend/track population management
3. 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 - Soft ware, evidence based guidelines/tool for treating common
conditions, chronic care, BH
- conducing, actionable, measurable
- helps cm coordinate care and anticipate needs
InterQual - Clinical decision support tool determines when and how a patient progresses
through the continuum.
- organizes resources utilization,
- objective evidence based criteria for assessing appropriate care for patients. Helps
fraud/abuae
Utilization management - Forward looking using evidence based criteria to support decisions.
Utilization review - Backward looking to ensure patient's 5 rights were observed
1. Provider
2. Services
3. Setting
4. Time
5. Cost - 5 rights of utilization review
Utilization Management - CM that identifies patients, their needs, develops individual holistic
care plans addressing barriers
Prior authorization - Before services determines actual need
Denial - Requires: patent and provider notified, clinical rationale, rights to appeal, legally
entitled to due process to appeal
Concurrent review - Process of reviewing if patient meets criteria while services are occurring
Retrospective review - Looks back, ID outliers, provides helpful information for future changes
Cost benefit analysis - Shows what the cost would be if Services were provided and outcomes
occurred verses their current situation. demonstrates ration of dollars spent vs. savings
achieved.
Discharge planning - Assessing care needs to ensure patients are transitioned safely.
Due process - The right to appeal decisions
MD - 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
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
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 - 1. Older than 65
2. People eligible for social security retirement
3. Permanent resident for five continuous years
4. May claim up to 24 months after illness diagnosis or date of injury.
5. If you have received Social Security disability for 24 months
6. 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 - Also known as the Medicare Advantage plan operated by private companies.
Covers medications transportation 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
cost sharing - amount of money paid out of pocket, includes copays, deductible. Does not
include premiums.
tricare prime - for active duty military members to help them be "fit for duty"
tricare standard - fee-for-service insurance option. You can see any tricare authorized provider
inside or outside of network.
tricare extra - insurance option, you don't have to pain an annual fee but you have an annual
deductible. outpatient discounts on cost-sharing.
deductible - amount of money that you must pay before the insurance will pay a claim.
health maintenance organization (HMO) - a health insurance provider for a group of people in a
geographical area that delivers agreed to set of services and products to an enrolled group for a
predetermined periodic payment (usually monthly). Patients have to see in network providers.
Your PCP has to give you a referral for outside specialists except: internists, OB/GYN and
pediatrics. Requires preauthorization for outside providers.
preferred provider organization (PPO) - 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.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
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 - parameters or ways of quantitatively measuring quantity
variance tracking - deviations from a standard or recommended interventions. Helps ID
opportunities for improvement
Continuous quality improvement - process to attempt to optimize quality of a system.
plan do study act - a cyclic 4 step improvement process that includes gathering data,
experimenting, analyzing that data, and adapting improvements.
six sigma - data driven quality management process to eliminate defects: define, measure,
analyze, improve/design, control/verify
balanced budget act - act that gives medicare and medicaid services authority to establish and
oversee a program that allows private, national accredited organizations to "deem" weather or
not a medicare advantage organization is compliant with medicare requirements. example:
JCAHO and NCQA
HEDIS - tool managed by NCQA used by more than 90 percent of America's health plans to
measure performance on important dimensions of care and service. 80 measures and 5
domains including: effectiveness, access, experience, UR, descriptive info
HEDIS - health care effectiveness data information set
patient centered medical home (PCMH) - a care delivery model whereby patient treatment is
coordinated through their primary care physician to ensure they receive the necessary care
when and where they need it, in a manner they can understand.
national quality forum - not for profit membership organization to develop and implement a
national strategy for standardizing health care quality measures and reporting. This
organization was charged by the affordable care act to create the national priorities partnership
and nursing sensitive care standards ( death of surgery patients, pressure ulcers, falls,
restraints, UTIs urinary catheters), ventilator associated pneumonia, smoking cessation)
national committee for quality assurance (NCQA) - private not for profit organization that
accredits certain organizations if they meet standards to improve health care quality. includes a
quality compass to score health plans.
utilization review accreditation commission (URAC) - An independent nonprofit organization
that offers quality benchmark programs to improve quality and accountability of health care
organizations.
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
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
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
privacy practices - HIPAA individual right #1 is the right of the individual to receive information
on the health care provider's what?
request restrictions - HIPAA individual right #2 is the right of the individual to what? access to
health information
access, inspect, copy - HIPAA individual right #3 is the individual's right to their health
information to do what?
disclosures - HIPAA individual right #4 is the right to request an accounting of all health
information what?
corrected - HIPAA individual right #5 is the right to request health information to be
HIPAA - health care providers are required to: provide security of paper and electronic health
records, institute a complaint process to investigate compliance, and train staff on which law?
Balanced Budget Act - Law enacted in 1977 that created the medicare part C + choice program,
also knows as the medicare advantage plan, is a managed care option that allows new types of
health plans under private companies to cover medicare benefits at a capitated (per enrollee)
amount to include hospital and medical, parts A and B.
medicare prescription drug improvement and modernization act - law enacted in 2003 signed
by George Bush that allowed seniors and people with disabilities to have prescription drug
coverage
mental health parity act - a law enacted in 1996 that prevented a group health plan from
putting a lifetime or annual financial cap on mental health that was less than medical health.
emergency medical treatment and active labor act (EMTALA) - a law in 1986 that requires
hospital receiving medicare and have an ER to asses, provide treatment and stabilize a patient
before determining their ability to pay. An amendment in 1989 requires hospitals to accept
transfer of a patient requiring special treatment regardless of ability to pay.
Omnibus Budget Reconciliation Act - a law in 1989-1990 that required all states to have
medicaid coverage for pregnant women and their children up to age 6 if the family is homeless
or below 133% of the federal poverty level.
patient self determination act - a law that requires health care providers to inform patients of
their right to refuse or accept treatment. They must provide written information on their state
law regarding advanced directives. They must also document if they have an advanced
directive, ensure state compliance, create policies, educate staff.
advanced directive - 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.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
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 - The affordable care act title 3 section 3020 directed the
secretary to develop a national 5 year program to encouraged increased patient care and
increased savings for medicare through a national what?
heart failure, MI, and pneumonia - the national pilot program on payment bundling under the
affordable care act adjusted payments for hospitals for preventable medicare readmissions for
what medical conditions?
hospitalization - The affordable care act title 2 section 2704 created a demo project to evaluate
integrated care around what?
exchanges - The affordable care act title 2 created state health insurance what? This offered
choices to individuals and small business.
chronic conditions - The affordable care act title 2 section 2703 provided a State option to
provide health homes to medicaid enrollees with what?
research institute - The affordable care act title 6 section 6307 created the patient centered
outcomes what? This is a nonprofit to assist with informed decisions and identify priorities
felony - an act punishable by death or imprisonment for over one year. (murder, child abuse,
patient abuse, neglect)
abandonment - willful neglect of responsibility of another person by a person who is assigned
to care for that patient or by a person in a caregiving position.
accountable care organizations - groups of doctors, hospitals, and other health care providers,
who come together voluntarily to give coordinated high quality care to their Medicare
patients.They decrease fragmentation and improve collaboration. Created from the affordable
care act. "medical neighborhood"
informed consent - before CM services you must have capacity, voluntariness, and
understandable information in order to have what?
patient bill of rights - This requires patient to know diagnosis, proposed treatment, possibility of
success, risks and benefits, treatment alternatives, risks and benefits of alternatives. The
patient is also allowed to withdraw at any time.
guardianship - 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:
1. perceive themselves at risk of developing a specific condition
2. the condition is perceived to be serious with negative consequences.
3. Risks will be decreased with specific behavioral changes
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
4. 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 - final rule mandated by HITEC to increase patient privacy, allows patients
to ask for a copy of medical records in electronic form., if a patient pays out of pocket for a
service, they can instruct the provider not to share information with the insurance company.
HITEC - increases privacy and security under HIPPA and increases enforcement
motivational interviewing - a form of guiding to elicit or strengthen motivation for change. The
steps include:
1. express empathy
2. avoid arguments
3. develop discrepancy
4. role with resistance
5. support self efficacy
change - likilihood of change increases with the patient's belief in the ability to what?
management - collaborative process of assessing, planning, collaborating, implementing,
monitoring and evaluating patient needs and using services to meet needs through
communication and available resources to improve quality cost effective outcomes is CMSA's
definition of case what?
process - 1. identify the client and obtain consent,
2. assessing problems,
3. planing goals, prioritizing needs, identifying resources
4. implementation
5. evaluation and follow up
6. discharged from case management.
are all components of the case management
catastrophic and chronic - case management services are needed for patients with what type of
injuries or chronic illnesses?
Recommended textbooks for you
Comprehensive Medical Assisting: Administrative a...
Nursing
ISBN:9781305964792
Author:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa
Publisher:Cengage Learning
Case Studies In Health Information Management
Biology
ISBN:9781337676908
Author:SCHNERING
Publisher:Cengage
Understanding Health Insurance: A Guide to Billin...
Health & Nutrition
ISBN:9781337679480
Author:GREEN
Publisher:Cengage
Recommended textbooks for you
- Comprehensive Medical Assisting: Administrative a...NursingISBN:9781305964792Author:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy CorreaPublisher:Cengage LearningCase Studies In Health Information ManagementBiologyISBN:9781337676908Author:SCHNERINGPublisher:Cengage
- Understanding Health Insurance: A Guide to Billin...Health & NutritionISBN:9781337679480Author:GREENPublisher:Cengage
Comprehensive Medical Assisting: Administrative a...
Nursing
ISBN:9781305964792
Author:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa
Publisher:Cengage Learning
Case Studies In Health Information Management
Biology
ISBN:9781337676908
Author:SCHNERING
Publisher:Cengage
Understanding Health Insurance: A Guide to Billin...
Health & Nutrition
ISBN:9781337679480
Author:GREEN
Publisher:Cengage