CCM Exam Prep Course 56 Questions with Verified Answers
Case management definition - CORRECT ANSWER "A collaborative process that assesses, plans,
... [Show More] implements, coordinates, monitors and evaluates the options and services
required to meet the client's health and human services needs. It is characterized by advocacy, communication, and resource
management and promotes quality and cost-effective interventions and outcomes" (CCMC, 2010).
Goals of case management - CORRECT ANSWER Wellness, self-determination, resource value
The Case Management Process - CORRECT ANSWER 1) Selection and engagement
2) Comprehensive assessment to identify barriers to outcomes
3) Planning
4) Implementation/Coordination
5) Ongoing monitoring of the plan
6) Evaluation- goals reached?
Philosophy of case management - CORRECT ANSWER Practice is based on trust and relationship-building
Client-centered process!
The Role of the Case Manager - CORRECT ANSWER ADVOCATE
Assessor
Planner
Coordinator
Facilitator
Educator (re: choices, options, concerns)
Broker- help them make informed decisions, negotiating for buy-in
Case Management Assessments- sources of info - CORRECT ANSWER Client
Provider
Medical Records
Family
Employer
Three point assessment in worker's comp - CORRECT ANSWER Client
Providers
Employer
Reasons for case closure - CORRECT ANSWER -Goals met OR unable to be achieved through CM
-Not enough benefit from CM to continue
-Client refuses CM
What should CM do when closing case - CORRECT ANSWER -Communicate closure with client and others as indicated (and where to go to address further needs)
-Document reason for closure
-Ensure that client has knowledge of resources and/or strategies for continuing needs
Clinical case management - CORRECT ANSWER Focus on clinical needs, provides both clinical and CM services (ex: home care or ambulatory care CM)
Broker case management - CORRECT ANSWER Focus on securing and coordinating services (ex: human service CM)
Strengths based case management - CORRECT ANSWER Focus is on client's strengths; ex: mental health counselor
Assertive/intensive community treatment model - CORRECT ANSWER Team provides CM
Field CM - CORRECT ANSWER Works in the community- face to face with clients and providers
Onsite CM - CORRECT ANSWER Works face to face, but may not travel
External CM - CORRECT ANSWER CM in a payer/insurance setting
IADLs - CORRECT ANSWER Support an independent lifestyle, people can still live independently even though they need help with some IADLs
-Cooking
-Driving
-Using a telephone or computer
-Shopping
-Keeping track of finances
-Managing medication
Caseload capacity calculator - CORRECT ANSWER Management strategy- uses survey statistics and user inputs to calculate possible caseloads and capacity based on numerous factors
Skill Set for CM - CORRECT ANSWER -Assessment
-Communication
-Relationship building and collaboration
-Critical thinking
-Resolve conflict and promote change
-Plan/organize
-Promote Autonomy
Knowledge Set for CM - CORRECT ANSWER -Case management principles
-Clinical protocols and expected outcomes
-Healthcare system
-Human behavior
-Health financing and benefit structures
-Outcome/Quality measurement
Care Coordination - CORRECT ANSWER "the deliberate organization of patient care activities between 2 or more participants to facilitate the appropriate delivery of health care services" (AHRQ.gov)
"ensure that the patient's needs and preferences for health services and information sharing across people, functions, and sites that are met over time" (NQF)
Shared decision making - CORRECT ANSWER -Seek client's participation
-Help client explore and compare tx options
-Assess client's values and preferences -> reach a decision with the client
-Evaluate the client's decision
Independent Living Model - CORRECT ANSWER *Moving away from medical model in which the physician tells the client what to do*
-Client has control
-Self-determination is a goal
-More focus on care than goal
-Residing in the least restrictive setting
-Conversion from the Medical Model (a transition from "top down" to "bottom up" support
Stages for Readiness to Change Behavior - CORRECT ANSWER **Gear intervention at the level that the client is at**
*Also referred to as transtheoretical model of change*
-Precontemplation- individual does not intend to take action in the foreseeable future
-Contemplation- individual desires and intends to make a behavioral change in the near future but has not made a commitment to do so
-Preparation- the individual intends to take action within the next 30 days and has taken some small step toward it
-Action- the individual has successfully made the behavioral change and has sustained it for less than 6 months
-Maintenance- the individual has sustained a positive behavioral change for more than 6 months
Cost benefit analysis - CORRECT ANSWER -Follows needs assessment
-Identifies options to meet needs
-Comparison of cost/expected outcome of options
-Often used to facilitate funding and service decisions
-Can also be a method of measuring outcomes
Measuring Performance- Measures and Examples - CORRECT ANSWER Process- diabetic foot exam; medication reconciliation
Functional- increased independence in ADLs, mobility
Behavior- self-monitoring of blood sugar
Clinical- wound healing, A1c level
Financial- less ED visits/hospitals, average length of stay, cost per case, denial rate
Satisfaction- would recommend program
Evidence-based care standards - CORRECT ANSWER Insurers are paying for evidence-based standards
More credible, less variability, more easily measured
Why measure CM outcomes? - CORRECT ANSWER ID for opportunities for improvement
Measurement for CM performance
Documentation for CM value
National Care Coordination Measures - CORRECT ANSWER **Agency for Healthcare Quality and Research (AHRQ)**
**National Quality Forum (NQF)**
National Transitions of Care Coalition (NTOCC)
CMSA's Council for CM Accountability (CCMA)
Types of Quality Improvement Processes - CORRECT ANSWER Root Cause Analysis & PDSA Analysis
Root cause analysis - CORRECT ANSWER -Obtain baseline data
-Determine intervention for improvement
-Evaluate the results
PDSA Analysis - CORRECT ANSWER Plan
Do
Study
Act
*Developed by the Institute for Healthcare Improvement*
Clinical Pathways - CORRECT ANSWER *Blueprint for care*
Provides a collaborative, multidisciplinary foundation for care delivery
AKA critical paths and care maps
Often lead to standardized orders
Facilitate delivery of longitudinal care driven by evidence based care
Reasons for variance from clinical pathways - CORRECT ANSWER Operational (computer down)
Healthcare provider (delayed/refused order)
Pt/family (unable to be contacted for d/c decision or refused care)
Clinical (oxygen saturation level not reached)
System-related (service unavailable)
Inpatient Rehab Facility- 3 hour rule - CORRECT ANSWER A client must benefit from and participate in at least three hours of skilled rehab services per day. This will open the door for Medicare for hume healthcare (PT, nursing, speech therapy)
Nurse Practice Act - CORRECT ANSWER A nurse can only practice case management where they're licensed
Nurse Licensure Compact - CORRECT ANSWER If a nurse is licensed in one state, they're also licensed in 25 states
Two prerequisites of informed consent - CORRECT ANSWER Capacity and voluntary
Wickline v. State of CA - CORRECT ANSWER Hospital didn't think client needed to be discharged, insurance said she did. The physician didn't protest and she ultimately needed a below the knee amputation
EMTALA - CORRECT ANSWER ED care mandate; "anti-dumping" law- anyone who presents to the ED must be assessed and cannot be discharged unless they are stable
Nursing Home Reform Act - CORRECT ANSWER Significant rights for residents in long-term care facilities- residents have a right to a team meeting every 3 months
Health Centers Consolidation Act - CORRECT ANSWER Requires CM in federally qualified health centers
Comprehensive Long Term Care Act - CORRECT ANSWER Requires CM within Medicare HMOs
CHIP - CORRECT ANSWER Federally mandated health insurance for low income children in all states (above Medicaid eligibility but below FPL)
Health Insurance Portability and Accountability Act - CORRECT ANSWER Health insurance eligibility is portable from one coverage to another- can't exclude due to pre-existing conditions
CMSA's Ethical Principles - CORRECT ANSWER Autonomy (voluntary, informed decisions)
Beneficence (promote wellness)
Nomaleficence (do no harm)
Justice (be fair to all)
Veracity (to tell the truth)
Fidelity (follow through, keep promises)
Example of an ethical challenge in CM practice - CORRECT ANSWER Dual masters- serving both the client and the employer (client ALWAYS comes first)
Reinsurance - CORRECT ANSWER Insurance policy for insurer to protect against high utilizers
Health insurance policy eligibility for children: Birthday rul - CORRECT ANSWER If the child has two policies, the birthday of the parent determines who's first or second (month, not year)
Employment Retirement Income Security Act (ERISA) - CORRECT ANSWER Allows for employers to self-insure their health plans
Consolidated Omnibus Budget Reconciliation Act (COBRA) - CORRECT ANSWER Same insurance but person has left the company
Utilization management - CORRECT ANSWER The evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities
UM guidelines - CORRECT ANSWER Based on the intensity of service and severity of illness
Disease management: Secondary prevention - CORRECT ANSWER How to be healthier with the disease
Viatical settlements - CORRECT ANSWER Cashing in life insurance before you die (only certain types of life insurance- whole life)
Medicare - CORRECT ANSWER Age 65, or SSDI x 2 years, or End Stage Renal Disease, or ALS [Show Less]