Case Manager Review

Which of the following provides federal protection for individually identifiable healthcare information held by covered facilities and their business associates?

A. The HIPAA Privacy Rule B. Security Rule C. The HIPAA Availability Rule . D. The HIPAA Integrity Rule

Of the following patients, which one would NOT be considered for case management services

15 year old female with a urinary tract infection 88 year old , 100 lbs. female who has suffered a hip fracture. 42 year old man who is one the list for a kidney transplant 22 year old man who was recently diagnosed with schizophrenia.

Which of the following are benefits of working as an independent case manager under the Independent/Private Case Management Model?

A. Stable income and working with all types of patients B. Flexibility and autonomy in decision-making C. Interdisciplinary team assistance with planning D. Help with decision-making

Which of the following affects the case load index?

A.

Comprehensive healthcare reform in the U.S. was not enacted by Congress until:

A. 1993 B. 1995 C. 2005 D. 2010

The severity of illness indicator that represents an illness that occurred within one week is:

A. Acute/sudden onset B. Recent onset C. New onset D. Newly discovered

Which case management model is often use in clinical practices, such as identifying patient with diabetes and encouraging them to attend education classes or when distributing material to women who need Pap smears?

A. Admission Office Case Management Model B. Large Case Management Model C. Disease Management Model D. Insurance Case Management Model

Which item in the Code of Professional Conduct for Case Managers describes the role of the case manager in legal compliance, client identity, electronic recordings, disclosure, storage, disposal, and reporting?

A. Advocacy B. Case manager and patient relationship C. Confidentiality, privacy, and record-keeping D. Research

Qualified handicapped person under the Rehabilitation Act of 1973 is someone who can perform the main functions of the job:

A. All of the time B. With reasonable accommodations C. Without any accommodations C. With considerable assistance and the necessary accommodations

Which of the following profession communication skill is used to facilitate communication with interdisciplinary team members?

A. Asking question that challenge someone's idea B. Providing advice when it needed C. Interpreting the statement of a person to improve idea flow. D. Reacting to facts rather than feelings.

When communication does not resolve an ethical problem or conflict among the concerned parties, the case manager should consult or meet with the:

A. Attending physician B. Ethics committee C. Nursing manager D. Patient's family

3. A 44-year-old man insists that his pain medicine is not working. He calls the nurse case manager and asks her to contact the physician for another medication. Due to patient, the nurse believes the patient is noncompliant and refuses to advocate for him. Which ethical principle is involved in this situation?

A. Autonomy B. Non-maleficence Beneficence C. Beneficence D. Justice

Why do the roles and responsibilities of the care manager vary?

A. Because the setting where care is provided vary B. Because the patient population served varies C. Because all the case mix of patient varies D. All of the above E. None of the above

Which calculation is used to identify variable in various setting that affect caseloads?

A. Case management (CM) outcomes B. Major diagnostic categories (MDCs) C. Caseload matrix D. Case mix index (CMI)

Which value is calculated by multiplying the relative weight and the facility's base rate?

A. Case mix index B. Caseload matrix C. Hospital payment D. None of the above

What is the proper sequence for the stages of the case management process?

A. Case selection, problem identification, case plan development , and coordination, case plan reassessment, case plan implementation, case plan evaluation, case closure B. Case plan development and coordination, problem identification, case plan reassessment and reevaluation, case plan evaluation, case plan implementation, case selection, case closure C. Case selection, problem identification, case plan development and coordination, case plan implementation, case plan evaluation, case plan reassessment and reevaluation, case closure. D. Case selection, problem identification, case plan evaluation, case plan development and coordination, case plan implementation, case plan reassessment and reevaluation, case closure.

Which case management model involve join decision-making among numerous parties where these person have collective responsibilities for outcomes and bring positive outcomes, such as reduced cost with improved quality of care and increased patient and staff satisfaction?

A. Collaborative Case management Model B. Medical-Social Case Management Model D. Palliative Care Management Model

Which of the following is a true statement concerning major diagnostic categories (MCSs)

A. DRGs are not separated by MDCs. B. The number of DRGs in each MDC ranges from 1 to 10 C. MDS are grouped according to anatomical and pathophysiological sections. D. MDCs are categorized as either acute or chronic

All of the following are component of the utilization management domain of case management EXCEPT:

A. Evaluation of appropriate level of care B. Reporting termination of services to stakeholders C. Managing reimbursement appeals and denials D. Assessing a patient's support network

Within the domain of case management related to case finding and intake, which of the following tasks would you expect to perform?

A. Facilitating and coordinating care activities B. Obtaining informed consent for services C. Reviewing and modifying health care services D. Data collecting, analyzing, and reporting.

Which of the following is NOT an example of a population served under the Community-Base Care Management Model?

A. Homeless Families B. Substance abuse patients C. Mental Health patients D. Geriatric patients E. None of the above

Which of the following is NOT a component of the vocational issues domain of case management?

A. Identification of need for changes in the home environment. B. Elimination of access barriers C. Review of patient conditions for appropriateness of hospitalization D. Arrangement for vocational assessment and services.

Discharge screens indicates:

A. If the patient is clinically ready for discharge B. If the patient is clinically ready for transfer C. All of the above D. None of the above

With InterQual's review process, the admission review is:

A. Initiated before patient admission to the health care facility. B. Usually the initial chart review, done within 24 hours of admission C. Done throughout the hospitalization, typically every three days D. Initiated when the patient is ready for discharge or transfer.

The type of conflict that occurs between the self and another person is:

A. Intrapersonal B. Interpersonal C. Intragroup D. Intergroup

Failure to provide reasonable care based on expertise and appropriate standards is an example of:

A. Negligence B. Malpractice C. Laziness D. Poor Supervision

A case manager is conducting research concerning the gender of a patient population. Male sex is number one (1), and female sex is num ber two (2). What level of measurement and data type is gender?

A. Nominal level of measurement; nonparametric data type B. Ordinal level of measurement; nonparametric data type C. Interval level of measurement; parametric data D. Ratio level of measurement; parametric data

Of the following, which is NOT an indicator of a severity of illness criteria?

A. Oral temperature of 104 Fahrenheit B. Sustained pulse of greater than 100 bpm C. Respiratory rate grater than 22 with pulse oximeter less than 88% on room air. C. Diastolic blood pressure grater than 120 or less than 40 mmhg.

What ethical conflicts are related to individuals of the healthcare facility and pertain to a hospital or facility's behaviors?

A. Organizational ethical conflicts B. Physician ethical conflicts C. Nurse ethical conflicts D. Clinical ethical conflicts

Which of the following is NOT one of the four types of review involved in InterQual's review process?

A. Preadmission B. Admission C. Case closure D. Discharge

The nurse case manager identifies acute care needs and discharge requirements in addition to developing the treatment plan along with members of an interdisciplinary team. Which model does the case manager use? D. Emergency Department Case Management Model

A. Primary Nurse Case Management Model B. Acute Care Case Management Model C. Leveled Practice Model

Coaching and educating health car providers and nurses regarding conflict can be accomplished by/through:

A. Role-playing exercises, staff meeting, educational videos, and effective communication. B. Procedure and processes for identification of potential common conflicts C. Engaging in dialogues that address conflict in order to create a health work environment D. Careful consideration of the objective that led to the conflict.

Which indicator dictates the complexity and types of services provided by a health care facility?

A. Severity of illness B. Prognosis C. Number of patients D. Both A and B

Which of the following is one purpose of case management practice?

A. To minimize efficiency of valuable and available recourses usage. B. To promote informed decision-making by the patient and others by interjecting objectivity and information. C. To work with the insurance company to implement a plan of care that meets the patient's needs. D. To make the health care delivery system more costly.

Regarding the Acute Care Case Management Model, which of the five method is involved when the case manager follows patient from admission to discharge.

A. Unit-based B. Complete-based C. Practice-based D. Disease-based

With which model does the nurse care manager act as liaison between care level to assist the patient during the convalescent period by assessing hi/her condition and determining appropriate services?

A. rehabilitation Case Management Model B. Community-Base Case Management Model C. Skilled Nursing Facility Case Management Model D. Independent/Private Care Management Model

Measuring the effectiveness of an intervention rather than the monetary saving is:

A: A cost-benefit analysis B: An cost-efficacy study C: A product evaluation D. A product evaluation

Using the average cost of a problem and the cost of intervention to demonstrate saving is:

A: A cost-benefit analysis B: An efficacy study C: A product evaluation D. A cost-effective analysis

A:

A: The Medicare hospice benefit is a federal program for Medicare-eligible patient with an estimated life expectancy of 6 months or less. The cost of all supplies and medication being used in relation to the terminal illness are covered. The Medicare hospice benefit covers inpatient respite. care for up to 5 consecutive days to provide short-term relief to a hospice patient's primary caregiver. Additionally, the Medicare hospice benefits covers routine home care, inpatient care for medical condition or complication related to the terminal illness, and continuous home care for medical complications that would otherwise require inpatient hospitalization.

A:

A: While all of these issues may be considered, the red flag is admission from a sheltered living facility. Other red flag concern include homelessness, poor living conditions, limited financial and insurance resources, and dependency on other for care. While reportable events (child/elder abuse, violent crime, domestic violence) automatically require full case management services, other situation must be considered individually. For example, the inability to drive may not be a problem for someone with a spouse or with access to public transportation, although it may prevent other from accessing care.

What diagnosis category constitutes a condition of a target population that meets patient selection criteria for case management

Acute injury or illness Chronic injury or illness Multiple diagnoses None of the above All of the above

Working for the best interests o the patient despite conflict personal values and assisting patients to have access to appropriate resources may be defined as: A. Moral agency B. Advocacy C. Agency D. Collaboration

B: Advocacy is working for the best interest of the patient despite conflicting personal and assisting patients to have access to appropriate resources. Moral agency is the ability to recognize needs and a willingness take action to influence the wholesome outcomes of a conflict or decision. Agency is a general willingness to act arising from openness and the recognition of involved issues. Collaborating is working together to achieve better results.

B:

B: An adult day-care program designed for Alzheimer's patients is the most cost effective solution. These programs vary, but average about $65 per day, and some are supported by grant to defray costs for those with low income. Adult day healthcare program are health-focused program with RN's and therapist (speech, physical, occupational) available with costs depending on services utilized. Residential care facilities may cost from 2,000 to 8,000 or more monthly. Home health Agencies charge on a hourly basis usually about $25.00 per hour for an aide.

B:

B: Patients who undergo amputations often experience Kubler-Ross's five stages of grief associated with death and other losses as they try to cope with physical disability and changes in their body image. During the stage of denial, patients may believe unrealistically that they need no assistance and can return to their routine lives with no problem. Other stages include anger, bargaining, depression, and acceptance. Patient may not go through all stages or may go through the stages in no particular order.

B:

B: When terminally ill patients lack the mental capacity to make end of life treatment decisions, family member usually become the primary medical decision-maker in the absence of a predetermined health care power of attorney. Family members may have conflicting values and opinions about end of life issues, Convening a family conference with palliative care providers is helpful in cases where there is disagreement among family members regarding the plan of care. Once the family member are updated about the medical status of the patient, a respectful and honest conversation should take place in which each family member's opinion and concern about what the plan of care should be elicited. Members of the palliative care team can encourage family members to consider what they believe the patient would have wanted if he or she were able to decide for him or herself. This may be quite different from what they would choose for themselves in a similar situation.

A 76-year old female with lung cancer was place on hospice care by her physician 6 months earlier (two 90-days periods), but she still alive Her family ask the case manager if the patient will be removed from hospice care. The best response is: A "She will be removed from hospice care until her condition worsen because she has exceed the 6 months period" B. "she has exhausted all of her hospice care benefits and will be removed from hospice care" C. "She can continue with hospice care as long the physician authorizes the care every 60 days" D. "She can continue with hospice care if the patient continues to authorize care every 90 days.

C: Initially, the physician must certify that a patient who is eligible under Medicare A is terminal with a life expectancy <6 month (two 90-days periods). However, if the patient remains alive, the physician can extend coverage by authorizing continued hospice care every 60 days. The goal is to maintain the patient in the home environment with home health aides, homemaker, durable goods, pain management, case management, counseling, and social worker assistance. Routine intermittent home care must comprise 80% of the total care, with in-home continuous care and in-patient hospice care available for short augmenting period only.

C:

C: Interdisciplinary palliative care teams ensure that providers from multiple specialties (e.g., physician, social worker, nurse, chaplain) can collaborate with the patient and family to craft a care plan that meets the needs and goals of the patient. Care is directed primary by the patient. Ideally, the team provides information and elicits patient values, preferences, and goal as they pertain to end of life care. Once this is completed, specific challenges can be identified and possible solutions planned. Intervention are then provided to the patient and family in accordance with the formulated plan. Reassessment and changes in the care plan are made as illness progresses or preference or goal change.

A 32 year old single mother of a 4 y/o child is being discharge after a hysterectomy for cervical cancer. She states she is very depressed because she has lost her job, cannot feed her family, and will son be homeless, Which referral is most appropriate. A. Food bank. B. Homeless Shelter C. Homeless Shelter D. Mental Health Clinic

C: Referring the single mother to a social worker is the most appropriate, as social worker have the expertise required to assist a patient to apply for social services, including program such as Temporary Assistance for Needy Family (TANF) and food stamps. The social worker may be able to help the patient avoid homelessness by assisting to a mental health clinic, this will not solve the immediate underlying problem of food and shelter.

The most common surgical site of infection is: A. Deep incision infection B. Organ infection C. Superficial incision infection D. Fascia infection

C: Surgical site infection (SSIs) are most commonly found in the superficial incision; however, infections can appear anywhere (eg., deep incision infection, organ infection, fascia infection). they are most commonly caused by bacteria on the patient's skin. Risk factor include obesity, smoking history, underlying medical condition (eg. diabetes), malnutrition, and a long surgical procedure. Prophylactic broad-spectrum antibiotics therapy before and after a surgical procedure can reduce the incidence of SSIs by 40-80%.

All of the pathogenic organisms listed below are commonly associated with surgical site infection EXCEPT: A: Staphylococcus Aureus B. Enterococcus spp. C. Streptococcus pneumoniae D. Staphylococcus epidermidis

C: Surgical site infections (SSIs) are most commonly caused by Staphylococcus aureus, Enterococcus ssp., and S. epidermidis. Streptococcus pneumonia is a common cause of pneumonia.

A 67 y/o terminally ill patient wishes to receive comfort care measures in his home. The patient's physician recommends placement in a hospice facility so that Medicare will cover the cost of the hospice care. Which of the following statements most accurately describes the Medicare hospice benefit? A. The Medicare hospice applies to patient who have a life expectancy of 12 month or less B. The Medicare hospice benefits does not cover the cost of medication use to treat symptoms of terminal illness C. The Medicare hospice benefit covers the cost of hospice service in multiple settings including the patient's home. D. Services provided under the Medicare hospice benefit vary from state to state.

C: The Medicare hospice benefit is a federal program for Medicare-eligible patient with an estimated life expectancy of 6 months or less. Because Medicare is a federally funded program, eligibility requirement and benefits do not vary from state to state. The cost of all supplies and medication being used in relation to the terminal illness are covered under the Medicare hospital benefit. Hospice care may be provided in multiple setting, including home, outpatient, and inpatient settings. A patient needs not have a Do Not Resuscitate order to qualify for the Medicare hospice benefit. Patient who have activated the Medicare hospice benefit may opt to return to "regular" Medicare (ie. Medicare Part A) at any time.

C:

C: The best response t a patient who believes that staff is lying is to state, "I'll try to answer all of your question and explain you need for transfer." The CCM should avoid agreeing or disagreeing as this suggest the CCM is in the position to pass judgment. The CCM should not attempt to defend the doctor or the system because this may make the patient feel the CCM is taking sides. The CCM should calmly allow the patient to vent and answer questions and provide information.

A legal document that specifically designates someone to make decisions regarding medical and end of life if a patient is mentally incompetent is an A. Advance directive B. Do not Resuscitate Order C. Durable Power of Attorney for Health Care D. General Power of Attorney

C: The legal document that designate someone to make decision regarding medical and end-of-life a patient is mentally incompetent is Durable Power of Attorney for care. This is one type of Advance Directive, which can also include a living will a heath medical power of attorney, and other specific request of the patient regarding his or her health care. A Do-Not-Resuscitate Order is a physician generate document that is completed when a patient does not want resuscitative treatment in an end of life situation. A General Power of Attorney allows a designated person to make decisions for a person over broader areas, including financial concerns.

Which concept is systems-oriented and involves the management of various benefits of health insurance plans?

Case Management Managed care Care Management Care Coordinator

Cost-Effective Analysis

Cost-Effective Analysis measures the effectiveness of an intervention rather than monetary savings. For example, annually 2 million nosocomial infections result in 90,000 deaths and an estimated $6.7 billion in additional health costs. From that perspective decreasing infections should reduce costs, but there are human savings in suffering as well, and it can be difficult to place a dollar value on that. If each infection adds about 12 days to hospitalization, then a reduction of 5 infections (5x12=60) would result in a cost-effective saving of 60 fewer patient infection days

Cost-benefit analysis

Cost-benefit analysis uses average cost of a problem (such as wound in infections) and the average cost of intervention to demonstrate savings. For example, if a surgical unit averaged 10 surgical site infections annually at an addition average cost of 27,000 each, the total annual cost would be 270,000. If the total cost for intervention, (new staff person, benefits, education, and software) totals 92,000, and the goal is to reduce infection by 50% (05.x 270,000 for a total projected savings of 135,000), cost benefit is demonstrated by subtracting the proposed saving from the intervention cost (135,000 - 92,000) for a saving of 43,43,000 annually

A patient with end-stage bone cancer has elected hospice and palliative care. The patient is experiencing severe bone pain from a tumor, and the physician orders radiotherapy to reduce the tumor's size and to reduce pain. Is this treatment acceptable under hospice care criteria. A. No, the patient elected to forego curative treatment, so Medicare will not pay for the radiotherapy. B. No, The patient needs to be removed from hospice care first. C. Yes. hospice recommends only palliative care but curative treatment is acceptable D. Yes, if the purpose of the treatment is to relieve pain, it is essentially palliative.

D: Palliative care provides comfort rather than curative treatments, although curative treatments my also relieve pain or symptoms. Thus, there is no clear line between the two. Palliative care is meant to improve the quality of life and to relieve suffering, but it does not include treatment solely intended to prolong life or hasten death. The goal of palliative care are to provide adequate pain management and relief of symptoms (such as nausea or shortness of breath), to provide support for both the patient and the caregiver or family, and to ensure that patients and family receive psychosocial, spiritual and bereavement support

D:

D: Rotary International focuses on six areas for grant, including two that focus on health: disease prevention and treatment (which provides grants to combat the spread of HIV/AIDS) and meternal and child health. Kiwanis provides funding for many charitable endeavors, including a focus on the need of people with physical/developmental disabilities and support of the Special Olympics. Lions Club International contributes to many causes and focuses on initiatives for vision screening, preventing of blindness, and disabilities, including diabetes prevention and treatments.

Which of the following is NOT one of the principle of case management practice?

Focus on patient and family Negotiating, procuring, and coordinating services and resources Use of the clinical reasoning process Insurance-based