CCM

CASE MANAGEMENT

"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. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes" (CCMC, 2010).

Chronic Care Model

(Model of care) Care for people with chronic conditions in primary care seeings using proactive approach 6 components: health system, delivery system, self mgmt support, decision support, clinical info system, community resources Key component is planned, regular interactions with caregivers

CM Accreditation phase 1

1)application

With Medicare, the benefit period ends after patient has been out of facility for

60 days

Break in coverage

63 consecutive days or more without health insurance

Medicare eligibility

65 or older, disabled(5month waiting period), Railroad retirement (24 +5months), ESRD

Medicare select

A HMO type policy that specifies the hospitals a patient must use, unless an emergency

Administrative law

A branch of public law that deals with the various organizations of federal, state and local government which prescribes in detail the manner of their activities. (ACO- Administrative Services Only) an insurance

CONTRACTOR

A business entity that performs delegated functions on behalf of the organization

Case Management System

A computer program that allows you to to organize information by tracking client information on the computer helping you to run your practice.

ELECTRONIC MEDICAL RECORD

A computerized medical and health record a healthcare organization (e.g., a hospital, rehabilitation facility, physician's office or home care agency) uses as part of a health information system that allows documentation of important information about a client's status and care provision. It also allows storage, retrieval, and modification of records specific to the individual client the organization is caring for. Other terms used to refer to EMIR are electronic patient record (EPR), electronic health record (EHR) and computer-based patient record (CPR).

Medicare

A federal program insurance: 65 or older, disabled, ESRD(dialysis or transplant)

Cultural Intelligence (CQ)

A globally recognized way of assessing and improving effectiveness in culturally diverse situations based in rigorous, academic research. 4 categories: drive knowledge strategy dexterity

CHRONIC ILLNESS

A health condition (disease) that lasts three months or longer.

COLLABORATION

A process where two or more individuals work closely or jointlytogether to achieve a mutual goal or purpose such as resolving a problem or improving a situation. This process requires openess, mutual trust and respect, sharing of knowledge and consensus.

DAYS PER THOUSAND

A standard unit of measurement of utilization. Refers to anannualized use of the hospital or other institutional care. It is the number of hospital days that are used in a year for each thousand covered lives. #days/year/1,000covered lives.

ACCREDITATION

A standardized program for evaluating healthcare organizations to ensure a specified level of quality, as defined by a set of national industry standards. Organizations that meet accreditation standards receive an official authorization or approval of their services. Accreditation entails a voluntary peer-reviewed survey process provided by external organization that assesses the extent of a healthcare organization's compliance with the standards for the purpose of improving the systems and processes of care (performance) and, in so doing, improving client outcomes.

Accessible

A term used to denote building facilities that are barrier-free thus enabling all members of society safe access, including prisons with physical disability

CASE MANAGEMENT PLAN

A timeline of patient care activities and expected outcomes of care that address the plan of care of each discipline involved in the care of a particular patient. It is usually developed prospectively by an interdisciplinary healthcare team in relation to a patient's diagnosis, health problem, or surgical procedure.

Error-free costs

All costs including processes, services, equipment, time, materials, etc needed to provide product/service without error-unrelated to planning

Health Coach

Ally; we'll authority and supportive mentor who assist client to achieve goals

Prosthesis

An artificial device to replace/augment a missing/impaired part or all of missing body part

ENROLLEE

An individual who subscribes for a health benefit plan provided by a public or private healthcare insurance organization.

HEALTH BENEFIT PLAN

Any written health insurance plan that pays for specific healthcare services on behalf of covered enrollees.

Standards of care

Are a rigid set of criteria

Guidelines

Are meant to be flexible

Cost-benefit analysis

Average cost of problem and avg cost of intervention = savings

Residential Care Facilities

Avg $2,000 - $8,000 per month

Managers should take the following 3 things into account when working across cultures

Avoid cultural stereotyping, view cultural differences in neutral terms, enhance cognitive skills

Hard Savings

Avoided costs that can be measured-directly related to case manager's actions, ex: decrease length of stay, price negotiations

BAS

Burden Assessment Scale

self-insured

Business pay employees medical claims with own funds, but can by stop loss insurance to protect from high costs

Interdisciplinary team model

CM decisions made jointly with other team members

Primary Therapist Model of CM

CM has therapeutic relationship with client

Continuous Quality Improvement

CQI, process of ongoing review to improve quality of healthcare services

EXECUTIVE FUNCTION

Capacity of a person's working memory which relies on one's state of cognition, attention, aptitude, intellectual capacity, mental processes, ability to maintain focus, and ability to handle a breadth of ideas and facts (Cowen, Elliott, Scott Saults et al., 2005).

CUSTODIAL CARE

Care provided primarily to assist a client in personal home care to meet the activities of daily living but not require skilled nursing or licensed care.

CMAG

Case Management Adherence Guidelines

CMBOK

Case Management Body of Knowledge

CMS

Centers for Medicare & Medicaid Services: Formerly known as the Health Care Financing Administration (HCFA).

Axis I

Clinical disorders (depression, anxiety), anything other than personality disorder or mental retardation.

CM management outcomes

Clinical outcomes measured in groups or individuals Ex: percent of patients readmitted to the hospital within 30 days

CCMC

Commission for Case Manager Certification

CARF

Commission on Accreditation of Rehabilitation Facilities. A private, non-profit organization that establishes standards of quality for services to people with disabilities and offers voluntary accreditation for rehabilitation facilities based on a set of nationally recognized standards.

Medicare Part B

DME, 80% covered if prescribing physician and supplier are Medicare enrollees

HIPAA does not cover...

Disability, auto, liability, or workers compensation insurance; state laws take precedence over HIPAA

Cost-benefit analysis report

Economic model that uses a systematic approach to estimating the strengths and weaknesses of alternatives used to determine options which provide the best approach to achieving benefits while preserving savings. Includes alternative treatments plans and helps in finding the best level of care for the client which ultimately affects the return on investment.

EPR

Electronic patient record

EMTALA

Emergency Medical Treatment and Active Labor Act- federal law that requires emergency department to stabilize and treat regardless of ability to pay- "anti-dumping"law

General subacute

Est stay 10-40 days 3-5 hours nursing services/day

HEARSAY

Evidence not proceeding from the personal knowledge of thewitness, but from the mere repetition of what has been heard from others.

EBP

Evidence-Based Practice

functional capacity evaluation

Examination of a worker's physical ability to perform a required task-tests manual materiel handling capabilities, aerobic capacity, posture, and mobility tolerance done is a structured setting, not the workplace, it is performed by independent MD, PT, OT and not a treating clinician.

EDSS

Expanded Disability Status Scale- A method of quantifying a disability and monitoring changes in the level of disability over time- based on an exam by a neurologist.

BARRIERS

Factors in a person's environment that, if absent or present, limit one's functioning and create disability. Examples are a physical environment that is inaccessible, lack of relevant assistive technology, and negative attitudes of people toward disability. Barriers also include services, systems, and policies that are either nonexistent or that hinder the involvement of people with a health condition in any area of life.

Justice

Fairness- being fair or just, balance of what is best for one patient vs. what is best for larger society

FMLA

Family and Medical Leave Act is not a source of income, but it protects a employee's job

FECA

Federal Employees Compensation Act.

Work adjustment

Focus is on attitude, behavioral and social skills for clients with behavior health issues. Goal is to improve problems preventing employment

Axis III

General medical conditions present that might impact the patient's mental disorder or its management.

Agency

General willingness to act

Risk Sharing

HMO &PROVIDER share financial risk/rewards of caring for plan members

Network model HMO

HMO contract directly with IPA, medical groups & independent Physicians forming a provider Network, organized referrals

Critical Pathways

Healthcare provider management plans that detail the main elements of day to day care activities necessary for a typical patient with a specific diagnosis. It specifies goals and the sequence and timing for that patient to accomplish optimum outcomes.

Cultural Screens

How language prefigures your perception, "filling the blanks" of what others mean 4 screens: 1. language and linguistic structure (formal/informal, native/non-native) 2. selective perception (focus on immediate demands, sensing/missing non-verbal messages) 3. cognitive evaluation (attaching meanings to messages, norm of authenticity, grouping of people) 4. cultural logic (assuming other think & act the same)

prevention quality indicators (PQI)

Identify conditions where good outpatient care can prevent hospitalization Ex: hypertension, diabetes

IM

Important Message from Medicare

Failure to thrive

Indicates insufficient weight gain or inappropriate weight loss in pediatric patients.

CLIENT

Individual who is the recipient of case management services.This individual can be a patient,beneficiary, injured worker, claimant, enrollee, member, college student, resident, or health care consumerof any age group. In addition, when client is used, it may alsoinfer the inclusion of the client's support.

Lions Club International

Initiatives for vision screening, prevention of blindness and disabilities including diabetes and prevention

Maximum Medical Improvement (MMI)

Injured worker has recovered to max level. Does not mean worker is back to baseline

Medicare Part A

Inpatient Acute care, critical care, inpatient rehab, skilled nursing, hospice, some home health care

ICT

Interdisciplinary care team

ICD 10

International Classification of Diseases, Tenth Edition, used for coding MR for reimbursement

essential job functions

Job duties and responsibilities that are the reasons for the job's existence (aka basic fundamental duties)

Tort Law

Law that deals with harm to a person or a person's property.

Indemnity payments

Monies paid as wage replacement for injured worker medically unfit to work .

To qualify for inpatient rehab after knee/hip replacement

Must have BMI >50 (extreme obesity) Bilateral knee/hip surgery or Age >85

Case Management Process Phases

Nine phases through which case managers provide care: Screening, Assessing, Stratifying Risk, Planning, Implementing Follow up, Transition, Post Transition, and Evaluate (identify patients, assess problems, develop, Implement, evaluate, & terminate POC)

Medicare Part B

Outpatient care. Extends Medicare to supplemental treatments, and physicians

Health Insurance

Provides money to pay for health care for illness, injury, or in some cases preventive care.

Clinical Pathway

Provides outcome-focused care within a certain timeline. Developed from evidence based guidelines CM plan. a timeline of patient care activities and expected outcomes of care.

Work accommodation

Reasonable accommodation is to provide a medical examination for individual with a disability so the employer will know what environmental changes are needed

HIPAA Title V

Revenue offsets governing tax deductions for employers

Prospective review

Reviewing possible hospitalization before admission to determine necessity and LOS

CARVE OUT

Services excluded from one care provider contract that may be covered through arrangements with other providers. Providers are not financially responsible for services carved out of their contract.

Under the 60 percent rule 13 conditions qualify. Conditions that require additional criteria to qualify include:

Severe Osteoartritis systemic vasculitides Other arthritis conditions

SF 36

Short-Form Health Survey that measures adult patient care outcomes

Quality improve

Systematic, data driven effort to measure and improve client services

DEMAND MANAGEMENT

Telephone triage and online health advice services to reduce members' avoidable visits to health providers. This helps reduce unnecessary costs and contributes to better outcomes by helping members become more involved in their own care.

TANF

Temporary Assistance for Needy Families

Respite Care

Temporary care that relieves caregivers of their responsibilities for a short period of time.

CASE CLOSURE

Terminating the provision of case management services to aclient/support system. The process of communicating the decision to terminate services to clients/support systems, payor representative, and other healthcare professional involved.

CONTRACTUAL ETHICS

Terms and conditions in a contract that are ethical in context and must be adhered to by the involved parties. Sometimes these terms are not explicit and impose moral rather than legal obligations, for example, undue influence and informed consent.

GROUP MODEL HMO

The HMO contracts with a group of physicians for a set fee per client to provide many different health services in a central location. The group of physicians determines the compensation of each individual physician, often sharing profits.

Access to Care

The ability and ease of clients to obtain healthcare when they need it

APPROVED CHARGE

The amount Medicare pays a physician based on the Medicare fee schedule. Physicians may bill the beneficiaries for an additional amount, subject to the limiting charge allowed.

CARRIER

The insurance company or the one who agrees to pay the losses. A carrier may be organized as a company, either stock, mutual, or reciprocal, or as an Association or Underwriters.

HEALTHCARE TRILOGY

The quality, cost, and outcomes aspects of healthcare delivery. This term is attributed to the works of Donabedian.

a

The questioning of a witness during a trial or deposition by the party opposing those who originally asked him/her to testify

shame culture

Type of culture (Ruth Benedict): collectivism, loss of face, fear of abandonment, incompetence

guilt culture

Type of culture (Ruth Benedict): individualism, sin, fear of punishment, transgression of norms

Medigap

Type of health care insurance that covers out of pocket costs for Medicare covered services

Bereavement Counseling

Type of psychotherapy that helps a person deal with grief after a loss

APPROPRIATENESS OF SETTING

Used to determine if the level of care needed is being delivered in the most appropriate and cost-effective setting possible.

DELAY IN SERVICE

Used to identify delays in the delivery of needed services and to facilitate and expedite such services when necessary.

Integrated Delivery System

Variety of providers and organizations who come together to provide coordinated continuum of services to defined population

EARLY RETURN-TO-WORK

When a worker who had suffered a job-related injury or illness resumes work before complete recovery and while still suffering some sort of a partial disability. Usually the early return of the worker may involve the same job but with modified responsibilities or another job altogether.

Dual Diagnosis

When an individual is diagnosed with both a psychiatric disorder and a substance use disorder

Unbundling

When bundling agreement is dissolved and separate costs are paid

Quality metrics of facilities

When determine the quality of a rehab facility and it's programs, assess accreditation, scope of services, proximity, flexibility, outcomes measurement systems

Bundling

When insurance plan negotiates specific fee for procedure

Viatical Settlements

ability to sell own insurance policy

POMA

assesses mobility, gait, balance

COB

coordination of benefits

Primary consideration for medication management for patient with kidney disease

drug clearance

Staff Model HMO

group of physicians who work and are paid by the HMO and see only HMO patients

Managed care

is an approach that has developed in response to rising health care costs

Email communication

non-verbal communication

a

prevents Providers from discussing uncovered(plan) treatment options with the patient

Pre-Authorization/Pre-Certification

process of obtaining & documenting approval for health plan befor delivery of Medical Services

Root Cause Analysis (RCA)

process to identify underlying factors that contribute to variation in outcomes in sentinel event

HRA components

questionnaire, risk calculation, and feedback

Veracity

truthfulness

understanding

what comes first: translation or understanding?

Two Physicians can serve as surrogate

when no legal guardian, sibling/friend/or significant other can make decisions

Skilled workers

workers specialized at a specific task, credentials

HEALTHCARE DELIVERY SYSTEM

"A comprehensive model or structure used in the delivery of healthcare services to individuals--for example, integrated delivery system (IDS)." Also includes HMOs, PPOs, POSs, and EPOs. (Powell & Tahan, 2008, pp. 20, 29-31)

HEALTHCARE CONTINUUM

"Care settings that vary across a continuum based on levels of care that are also charactierized by complexity and intensity of resources and services" (Powell & Tahan, 2008, p. 43). See also health and human services continuum.

globalization

"The inexorable integration of markets, capital, nation states, and technologies in ways that allow individuals, groups, corporations, and countries to reach around the world farther, faster and more deeply, and more cheaply than ever before" Cochrane & Pain, globalization is: stretching of social relations, increased density of interaction, interpretation of social and economic practices, facilitated by a transnational infrastructure

Special Needs Plan (SNP)

(Model of care) Available to people with Medicare A &B Limits membership to people with specific diseases

Health Homes

(Model of care) Medicaid . Coordinated care to people with multiple chronic conditions including mental health and substance use Or people with 2 chronic conditions

Health Plan Employer Data and Information Set (HEDIS)

(Part of NCQA) Collection of standardized performance measures Info from HEDIS helps employers and purchasers evaluate health plan operations

Six stigma approach DMAIC

(Quality improvement tech) Define: goal is identified Measure: collect data to develop baseline Analyze: find root cause of inefficiencies and make solutions Improve: develop and implement methods and address deficiencies (test runs) Control: metrics are developed to assess success; cycle continues if need to make adjustments

lean approach

(Quality improvement tech) Reducing waste to increase value Consumers say what is valuable

Plan-Do-Study-Act

(Quality improvement technique) Plan:identify a process that yielded non ideal outcome Do: measure key performance attributes Study: make a new approach Act: integrate new approach

communicative discourse

(collaborative bargaining): relationship between parties is mutual trust coordination is achieved against shared traditions legitimacy of agreement based on voluntary consent based on reasoned arguments language is primarily a vehicle of dialogue

strategic discourse

(competitive bargaining): relationship between parties is like between strategic adversaries coordination of actions is based on money effectiveness of influence is based on empirical knowledge, no need for consent of the other party language is an instrument to exercise power (manipulative

Under Inpatient Rehabilitation Facility Prospective payment System (IRF PPS) patients are classified by

- Impairment categories - Then into Case-Mix Groups (CMGs) - similar motor functioning, age and cognitive ability - CMGs further grouped into 4 tiers, depending on comorbidities - determines reimbursement

Medicare Advantage Plan (MAP)

- approved by Medicare but administered by private insurance companies -Medicare pays fixed $ per month to insurance company for people enrolled - MAP is a form of managed care - Less flexible - must choose from network - treatment requires pre-approval

Change theory (Kurt Lewin)

1 precontemplation, 2 contemplation, 3 preparation, 4 Action , 5 maintenance

GLOBE 9 dimensions

1. Power distance 2. Uncertainty avoidance 3. Humane orientation 4. Institutional collectivism 5. In-group collectivism 6. Assertiveness 7. Gender egalitarianism 8. Future orientation 9. Performance orientation

Hofstede's 6 dimensions

1. Power distance 2. Uncertainty avoidance 3. Individualism/collectivism 4. Masculinity/femininity 5. Time orientation 6. Indulengence/restraint

Stages of Change

1. Precontemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance

Risk Management Process

1. Risk Identification 2. Risk Assessment 3. Risk Response Development 4. Risk Response Control

Trompenaars' 7 dimensions

1. Universalism/particularism 2. Individualism/collectivism 3. Specific/diffuse 4. Neutral/affective 5. Achievement/ascription 6. Time perspective 7. Relationship with the environment

Medicare hospice benefit covers

1. routine home care 2. inpatient care for medical conditions/complications 3. continuous home care for complications that would require inpatient hospitalization 4. cost of all supplies & medication

Nar-Anon

12-step program for family members of narcotic addicts

Smoker's Anonymous

12-step program for nicotine addiction - disease out of person's control, must appeal to higher power

Family and Medical Leave Act (FMLA)

1993 Federal law requiring organizations with 50 or more employees to provide up to 12 weeks of unpaid leave after childbirth or adoption; to care for a seriously ill family member or for an employee's own serious illness; or to take care of urgent needs that arise when a spouse, child, or parent in the National Guard or Reserve is called to active duty

Measure law for performance improvement

1: process-what is actually done in giving/receiving care 2: structure- assess capacity of HC organization to provide services and for managed care organizations to ensure they have providers to meet clients need 3: outcomes- health status of client as results of HC

psychological, socio-cultural

2 adjustments which an expatriate must deal with to integrate properly Includes 4 different possibilities: marginalization, separation, assimilation, integration

habermas

2 foundational views of discourse strategic (means-end) discourse (competitive bargaining) communicative discourse (integrative bargaining)

incommensurability

2 paradigms meeting, they have no common measure, no impartial way to compare/evaluate ex: Newton and Einstein theories of gravity Denotes a double disparity between paradigms: Meaning variance: largely incompatible conceptual schemes (what the world should look like) Standard variance: provide divergent standards to assess relevance and quality of things Resulting in a translation failure: standards used which are incompatible with both standards biased towards one

Skilled Nursing Facility (SNF)

24 hour skilled nursing and personal care. Rehab services Patient must be medically stable and need care from a skilled professional on a daily basis

Newly disabled person under 65 can apply for Medicare with coverage beginning ---------- months after starting SS or RRB disability benefits

24 months however, can apply for part D between 21 and 27 months after receiving SS or RRB benefits (advise to apply at 21 months to avoid delay)

identity, worldview, values

3 elements of the acculturation index, home and host culture identification

Global Mindset

3 overarching skills for a global mindset (global approach leadership)-flexible and open minded, effective communicator and collaborator, balanced and emotionally resilient and autonomous

Mutual Trust Expectations

3 trust expectations: Competence-based: whether others can deliver Incentive-based: believes others are motivated Benevolence-based: others making good-faith efforts All 3 are weighed and overall trust is calculated. This trust judgement leads to trust behaviours and trust-related outcomes

symbols and behaviours, power distributions, problem solving processes

3 ways to identify the type of culture managers are dealing with

marginalization, separation, assimilation, integration

4 acculturation strategies: host culture identification/home culture identification 1: low/low 2: low/high 3: high/low 4: high/high (most adaptive)

character and integrity, altruism, collective motivation, encouragement

4 dimensions of ethical management. Character and integrity most universally endorsed

increases in national habitus

4 reasons: increased interdependence increasing density vertical diffusion of standards, tastes and practices we-feelings

global management model

4 steps to this model: developed targeted goals and objectives understand contextual demands and constraints identify managerial options and actions develop global management skills

Five core cultural dimensions

5 individualism vs collectivism power distance masculinity vs femininity uncertainty avoidance long vs short term orientation

goals, resources, culture, commitment, philosophical and operational

5 circumstances for successful global partnerships

If patient remains alive under medicare A hospice after 2 90-day periods, a doctor must re-certify every

60 days

Accident and Health Insurance

A broad term that covers specialty policies available through an employer. It's insurance coverage that pays benefits in case of sickness, accidental injury or accidental death. It sometimes pays for loss of income or for debt payment if it's in connection with a loan, may or may not include disability payments depending on type of policy

CIVIL CASE OR SUIT

A case brought by one or more individuals to seek redress ofsome legal injury (or aspect of an injury) for which there are civil (non-criminal) remedies.

BOARD-CERTIFIED CASE MANAGER

A case manager who has earned the certified case manager (CCM) credential offered by the Commission for Case Manager Certification (CCMC). This involves passing an evidence-based certification examination after meeting a set of criteria that qualifies the case manager to sit for the examination. Once certified, the case manager must maintain the certification by acquiring ongoing education through means of continuing education units (CEUs), and uphold the CCM Code of Professional Conduct for Case Managers.

Dementia

A chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by multiple cognitive defects that include memory impairment, personality changes, and impaired reasoning.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA)

A civil rights legislation that governs the portability andcontinuity of health insurance by protecting individuals against laws regarding preexisting health conditions and other restrictions especially when changing jobs or insurance carriers and plans. See also Health Insurance Portability and Accountability Act's Privacy Rule.

Tort

A civil wrong, wrongful act, or infringement of a right leading to civil legal liability

GAG RULES

A clause in a provider's contract that prevents physicians orother providers from revealing a full range of treatment options to clients or, in some instances, from revealing their own financial self-interest in keeping treatment costs down. These rules have been banned by many states.

EPISODE OF CARE

A client's access to healthcare services or encounter with a healthcare provider. It is individual client-specific, time-limited and always has a beginning and end. The length of the client's encounter with care varies based on the client's health need(s), the type and intensity of the required services to effectively address the need, the care/practice setting where the client receives these services, and level of care. Time of the encounter may be measured in minutes (e.g., in a provider's clinic or office), hours (e.g., in the emergency department, ambulatory surgery center or a dialysis center), days (e.g., in a hospital setting) or weeks to months (e.g., in a skilled nursing or rehabilitation facility). A client suffering from an illness may require one or multiple episodes of care before the illness is resolved or client is considered stable.

Current Procedural Terminology (CPT)

A comprehensive list of codes used by physicians to bill for procedures and services

CASE MANAGEMENT PLAN OF CARE

A comprehensive plan of care for an individual client that describes the (1) problems, needs and desires determined based upon findings of the client's assessment; (2) strategies such as treatments and interventions to be instituted to address the problems and needs; and (3) measurable goals including specific outcomes to be achieved to demonstrate resolution of the problems and needs, the timeframe(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. (CMSA, 2010)

CASE MANAGEMENT BODY OF KNOWLEDGE (CMBOK)

A comprehensive resource of essential knowledge in the field of case management that a case manager is expected to master and become knowledgeable, skilled, as well as experienced in, to effectively care for clients and their support systems and be considered a competent case management practitioner.

CASE MANAGEMENT MODEL

A conceptual or graphic representation of the practice of case management in an organization. It usually depicts the relationships among the key functions and stakeholders of case management, and the roles and responsibilities of case managers. IE:

CAPACITY

A construct that indicates the highest probable level of functioning a person may reach. Capacity is measured in a uniform or standard environment, and thus reflects the environmentally adjusted ability of the individual.

ADHESIVE CONTRACT

A contract between two parties where one party with stronger bargaining power sets the terms and conditions and the other party, which is the weaker of the two with little to no ability to negotiate, must adhere to the contract and is placed in a "take it or leave it" position.

DEVELOPMENTAL RETARDATION

A disability characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills that originates before age 18. The term that has been suggested as a replacement for mental retardation. (Intellectual disability)

a

A disadvantage in a particular situation, sometimes caused by a disability-condition that interferes with a person's ability to function normally

CASE MANAGEMENT DEPARTMENT

A division within a healthcare organization (e.g., provider, employer, or payor) responsible for the provision of case management services to clients and their support systems.

ASSUMPTION OF RISK

A doctrine based upon voluntary exposure to a known risk. It is distinguished from contributory negligence, which is based on carelessness, in that it involves a comprehension that a peril is to be encountered and a willingness to encounter it.

Medicare

A federal program of health insurance for persons 65 years of age and older, certain younger people with disabilities and people with ESRD; pays under prospective pay system.

Discount fee for service

A financial reimbursement system when a provider agrees to supply services on a FFS basis with the fees discounted by a certain percentage from the physician's usual and customary charges.

CAPITATION

A fixed amount of money per-member-per-month (PMPM) paid to a care provider for covered services rather than based on specific services provided. The typical reimbursement method used by HMOs. Whether a member uses the health service once or more than once, a provider who is capitated receives the same "lump-sum" payment regardless of how many services are rendered.

DIAGNOSIS-RELATED GROUP (DRG)

A fixed fee schedule used as a basis of payment for hospital inpatient services. Combines ICD-10 codes with demographics, comorbities etc. A patient classification scheme that provides a means of relating the type of patient a hospital treats to the costs incurred by the hospital. DRGs demonstrate groups of patients using similar resource consumption and length of stay. It also is known as a statistical system of classifying any inpatient stay into groups for the purposes of payment. DRGs may be primary or secondary; an outlier classification also exists. This is the form of reimbursement that the CMS uses to pay hospitals for Medicare and Medicaid recipients. Also used by a few states for all payers and by many private health plans (usually non-HMO) for contracting purposes.

DISABILITY INCOME INSURANCE

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.

ADMISSION CERTIFICATION

A form of utilization review in which an assessment is made of the medical necessity of a client's admission to a hospital or other inpatient facility. Admission certification ensures that clients requiring a hospital-based level of care and length of stay appropriate for the admission diagnosis are usually assigned and certified, and payment for the services are approved.

COMPLAINT

A formal expression of concern that a board-certified case manager's behavior(s) does not adhere to CCMC's Code of Professional Conduct for Case Managers with Standards, Rules, Procedures, and Penalties.

CASUALTY INSURANCE

A general class of insurance and workers' compensation insurance. Mainly liability coverage of an individual or organization for negligent acts or omissions.

IMPAIRMENT

A general term indicating injury, deficiency or lessening of function. Impairment is a condition that is medically determined and relates to the loss or abnormality of psychological, physiological, or anatomical structure or function. Impairments are disturbances at the level of the organ and include defects or loss of limb, organ or other body structure or mental function, e.g. amputation, paralysis, mental retardation, psychiatric disturbances as assessed by a physical.

AGGREGATED DIAGNOSIS GROUPS (ADG)

A grouping of diagnosis codes that are similar in terms of severity and likelihood of persistence in a client's health condition over time. An individual client can suffer more than one health condition and therefore may have more than one ADG (total of 32 ADG clusters). Individual diseases or conditions are placed into a single ADG based on a set of criteria including likely persistence of diagnosis, severity of illness, etiology, diagnostic certainty, and need for specialty care interventions. System developed by Bloomberg School of Public Health at Johns Hopkins University.

EX PARTE

A judicial proceeding, order, injunction, and so on, taken or granted at the instance and for the benefit of one party only, and without notice to, or contestation by, any person adversely interested.

CONTINUOUS QUALITY IMPROVEMENT (CQI)

A key component of total quality management that usesrigorous, systematic, organization-wide processes to achieve ongoing improvement in the quality of healthcare services and operations. It focuses on both outcomes and processes of care.

HEALTHCARE PROXY

A legal document that directs the healthcare provider/agencyin whom to contact for approval/consent of treatment decisions or options whenever the client is no longer deemed competent to decide for self.

Actionable Tort

A legal duty, imposed by statute or otherwise, owing by defendant to the one injured

ALTERNATE LEVEL OF CARE

A level of care that can safely be used in place of the current level and determined based on the acuity and complexity of the client's condition and the type of needed services and resources.

FORMULARY

A list of prescription drugs that provide choices for effective medications from which providers may select, that are covered under a specific health plan.

FEE SCHEDULE

A listing of fee allowances for specific procedures or services that a health plan will reimburse.

HEARING

A live proceeding done before a formal body with decision-making authority (e.g., CCMC's Committee on Ethics and Professional Conduct) for the purpose of presenting evidence about an issue (e.g., a complaint of an alleged ethical violation by a case manager) where concerned opposing parties (e.g., complainant and person complained against) are given the opportunity to share their side of the issue (e.g., experience, documentation of evidence, witnesses). This procedure ultimately allows the decision-making body to determine the outcome and share its conclusions with the opposing parties.

DECISION RULE

A logical statement of characteristics, conditions, or attributes (e.g., effectiveness, worthiness, financial savings) that explain the appropriateness of making a specific decision or choice. For example, a healthcare executive concludes that a case management intervention is of positive return on investment if it demonstrates cost savings.

HMO (Health Maintenance Organization)

A managed care organization that provides comprehensive medical services for a predetermined annual fee per enrollee. PCP is gatekeeper

EXCLUSIVE PROVIDER ORGANIZATION (EPO)

A managed care plan that provides benefits only if care is rendered by providers within a specific network.

CODING

A mechanism of identifying and defining client careservices/activities as primary and secondary diagnoses and procedures. The process is guided by the ICD-9-CM coding manual, which lists the various codes and their respective descriptions. Coding is usually done in preparation for reimbursement for services provided.

CONCURRENT REVIEW

A method of reviewing client care and services during ahospital stay to validate the necessity of care and to explore alternatives to inpatient care. It is also a form of utilization review that tracks the consumption of resources and the progress of clients while being treated.

GLOBAL ASSESSMENT LENS

A multidimensional assessment that affords case managers the ability to be thorough and organized with respect to designing an individualized case management plan of care for each client to meet the client's unique situation. It includes an overview of the biophysical, psychological, sociological, and spiritual dimensions care. It functions as a care approach for case management assessment, which provides a comprehensive overview of eight essential domains to be considered when contemplating a client's needs and opportunities. These domains include physical health, behavioral health, functional capacity, client engagement and self-management, social determinants of health, health information technology, data analytics and decision support, and transdisciplinary healthcare team.

CASE CONFERENCE

A multidisciplinary healthcare team meeting that is held to discuss a client or client's support system situation such as conflict in decision making between the client and client's support system, clarification of plan of care and prognosis, end of life issues, or an ethical dilemma. Depending on the purpose of the conference, the client and client's support system may or may not participate in the meeting. Other participants are the case manager, social worker, physician of record or primary care provider, specialty care provider, registered nurse, registered dietitian, physical therapist, occupational therapist, ethicist (if the purpose is an ethical dilemma) and others as necessary.

Adult day care

A non-residential facility that supports the health, nurtirtional, social, and daily living needs of adults Most cost effective - avg about $65 / day

IMPORTANT MESSAGE FROM MEDICARE (IM) -

A notice of discharge from the acute care setting that hospitalsare required to deliver to all Medicare beneficiaries (original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospitalized, informing them of their hospital discharge appeal rights.

DEPARTMENT

A part, division, or program within an organization that has specific focus, objectives, function, or responsibility. For example, a materials management department within a hospital responsible primarily for the procurement and distribution of materials and supplies needed in a hospital for patient care services.

GUARDIAN

A person appointed by the court to be a substitute decision- maker for persons receiving services deemed to be incompetent of making informed decisions for themselves. The powers of a guardian are determined by a judge and may be limited to certain aspects of the person's life.

EXPERT WITNESS

A person called to testify because of recognized competence in an area.

ADVOCATE

A person or agency who speaks on behalf of others and promotes their cause. The main focus of Case Management.

ADJUSTER

A person who handles claims (also referred to as Claims Service Representative).

CLAIMS SERVICE REPRESENTATIVE

A person who investigates losses and settles claims for an insurance carrier or the insured. A term preferred to adjuster.

DISABILITY

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. 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. Inability or limitation in performing tasks, activities, and roles in the 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.

BARRIER-FREE

A physical, manmade environment or arrangement of structures that is safe and accessible to persons with disabilities.

GLOBAL FEE

A predetermined all-inclusive fee for a specific set of related services, treated as a single unit for billing or reimbursement purposes.

COMORBIDITY

A preexisting condition (usually chronic) that, because of itspresence with a specific condition, causes an increase in the length of stay by about 1 day in 75% of the clients.

GATEKEEPER

A primary care physician (usually a family practitioner, internist, pediatrician, or nurse practitioner) to whom a plan member is assigned. Responsible for managing all referrals for specialty care and other covered services used by the member.

COMMISSION ON ACCREDITATION OF REHABILITATION FACILITIES (CARF)

A private non-profit organization that establishes standards of quality for services to people with disabilities and offers voluntary accreditation for rehabilitation facilities based on a set of nationally recognized standards.

COUNSELING

A process of interaction that takes place in a safe, supportive, and comfortable environment between a case manager and a client or client's support system. During this process, the client shares distressing or stressful experiences, situations, emotions, or thoughts in an effort to feel better. These experiences may include present or past circumstances of loss, bereavement, separation, life-changing events, or coping with sudden or chronic illness. Clients may seek counseling to help them explore a general feeling or emotion they are experiencing, how best to cope with it, or as an opportunity to undertake personal development. The case manager's role in a client's counseling is to facilitate effective client self- exploration, offer support to the client, be an active listener, and act in a nonjudgmental manner.

Biofeedback

A process of learning/retraining to control bodily awareness or function, utilizing electrical and other natural signals generates by the body-example HR

DISABILITY CASE MANAGEMENT

A process of managing occupational and nonoccupational diseases with the aim of returning the disabled employee to a productive work schedule and employment.

COUNSELING PROCESS

A process that uses relationship and therapeutic skills to foster the independence, growth, development, and behavioral change of persons with disabilities through the implementation of a working alliance between the counselor and the client. It involves communication, goal setting, and beneficial growth or change through self-advocacy, psychological, vocational, social, and/or behavioral interventions.

CERTIFIED VOCATIONAL EVALUATOR (CVE)

A professional specialized in vocational assessment and rehabilitation who has met the minimum requirements for nationally recognized voluntary certification.

DISABILITY MANAGEMENT PROGRAM

A program that focuses on assisting workers who have suffered from occupational health conditions or job-related injuries return to work. It facilitates accommodations in the workplace to prevent impairment incidents of injured workers from becoming disability circumstances. It also employs the services of health professionals such as disability management specialists and/or disability case managers who are responsible for training and establishing tools for disability management personnel, employers, and others involved in keeping workers healthy, motivated, and productive.

EXPERIENCE REFUND

A provision in most group policies for the return of premium to the policyholder because of lower than anticipated claims.

CERTIFIED NURSE LIFE CARE PLANNER (CNLCP)

A registered professional nurse who holds a board certification from the Certified Nurse Life Care Planner Certification Board. This health professional develops a client-specific lifetime plan of care, while applying the nursing process. The plan employs a comprehensive and evidence-based approach in the estimation of current and future healthcare needs of the client. Also included are the associated costs and frequencies of items and services.

CONDITIONAL REHABILITATION PROFESSIONAL

A rehabilitation professional who has not yet met all of the requirements to be a qualified rehabilitation professional.

CLAIM

A request for payment of reparation for a loss covered by an insurance contract.

CREDENTIALING

A review process to approve a provider who applies to participate in a health plan. Specific criteria are applied to evaluate participation in the plan. The review may include references, training, experience, demonstrated ability, licensure verification, and adequate malpractice insurance.

ADMISSION REVIEW

A review that occurs within 24 hours of a client's admission to a healthcare facility (e.g., a hospital) or according to the time frame required in the contractual agreement between the healthcare provider and the health insurance plan. This review ensures that the client's care in an inpatient setting is necessary, based on the client's health condition and intensity of the services needed.

CATASTROPHIC INJURY

A serious injury that results in severe and long-term effects on the individual who sustains it, including permanent severe functional disability. Examples are traumatic brain, spine, or spinal cord injury; multiple trauma; and loss of major body parts.

CARE MANAGEMENT

A set of activities intended to improve patient care and reduce the need for medical services by enhancing coordination of care, eliminate duplication, and help patients and caregivers more effectively manage health conditions. (A healthcare delivery process designed to achieve better health outcomes by anticipating and linking clients with the services they need more quickly. It also helps avoid unnecessary services by preventing medical problems from escalating.)

CULTURAL COMPETENCY

A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations, providing care that is respectful and knowledgeable of cultural backgrounds.

FRAME OF REFERENCE

A set of ideas, evaluative criteria, rules, assumptions, or conditions a person uses to understand, perceive, and approach a situation or an issue. It is also the viewpoint or context within which a person's thinking about something seems to occur.

CATASTROPHIC ILLNESS

A severe illness, medical condition, or illness that requires prolonged hospitalization or recovery and has heightened medical, social, and financial consequences (Cancer, leukemia, Heart attack, or Stroke)

CONFLICT OF INTEREST

A situation where an individual (e.g., an employee, executive, or public official) in a public or private organization who is in a position to exploit a professional or official capacity in some way that results in personal benefits at the expense of others in the same organization, agency, or community at large.Therefore an individual, especially one in a position of power, must not make decisions that are based on favoritism, personal gain, exploitation, or violation of the public trust.Such actions are forbidden under the Political Reform Act of 1974, whose purpose is to prohibit employees, especially public employees, from personally benefiting at the expense of the public interest (Political Reform Act of 1974, Government Code Section § 81000 et seq.). Because there are some legal gray areas surrounding conflict of interest, it often falls on the individual to recognize potential problems before they interfere with his/her duties.

CONSENT

A situation where an individual (e.g., an employee, executive, or public official) in a public or private organization who is in a position to exploit a professional or official capacity in some way that results in personal benefits at the expense of others in the same organization, agency, or community at large.Therefore an individual, especially one in a position of power, must not make decisions that are based on favoritism, personal gain, exploitation, or violation of the public trust.Such actions are forbidden under the Political Reform Act of 1974, whose purpose is to prohibit employees, especially public employees, from personally benefiting at the expense of the public interest (Political Reform Act of 1974, Government Code Section § 81000 et seq.). Because there are some legal gray areas surrounding conflict of interest, it often falls on the individual to recognize potential problems before they interfere with his/her duties.

CONFIDENTIALITY

A situation where information is kept limited to the person having the authority or right to possess the information. For example, healthcare providers keeping a patient's personal health information private unless consent to release the information is provided by the patient. Healthcare providers assume the duty of protecting personal information about the patients they care for from others who do not have the right to access such information. In accordance with the Health Information Portability and Accountability Act of 1997 (HIPAA), healthcare organizations and providers are required to have policies to protect the privacy of patients' electronic information, including procedures for computer access and security (University of Washington School of Medicine, Ethics in Medicine, Bioethics Topics, Confidentiality, https://depts.washington.edu/bioethx/topics/ confiden.html, accessed 6/4/2015).

DEDUCTIBLE

A specific amount of money the insured person must pay before the insurer's payments for covered healthcare services begin under a medical insurance plan- out of pocket expenses.

Actuarial Study

A statistical analysis of a population based on its utilization of specific healthcare services and demographic trends of the population. Results used to estimate healthcare plan premiums and costs.

INCENTIVE

A sum of money paid at the end of the year to healthcare providers by an insurance/managed care organization as a reward for the provision of quality and cost-effective care.

COPAYMENT

A supplemental cost-sharing arrangement between the member and the insurer in which the member pays a specific charge for a specified service. May be flat or variable amounts per unit of service and may be for such things as physician office visits, prescriptions, or hospital services. The payment is incurred at the time of service.

DISEASE MANAGEMENT

A system of coordinated healthcare interventions and communications for populations with chronic conditions in which client self-care efforts are significant. It supports the physician or practitioner/client relationship. The disease management plan of care emphasizes prevention of exacerbation's and complications utilizing evidence-based practice guidelines and client empowerment strategies, and evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health. Focuses on groups of patients with conditions that have high financial costs and will benefit from integrated systematic management.

COMMON LAW

A system of legal principles that does not derive its authorityfrom statutory law, but from general usage and custom as evidenced by decisions of courts.

FUNCTIONAL CAPACITY EVALUATION (FCE)

A systematic process of assessing an individual's physical capacities and functional abilities. The FCE matches human performance levels to the demands of a specific job or work activity or occupation. It establishes the physical level of work an individual can perform. The FCE is useful in determining job placement, job accommodation or return to work after injury or illness. FCEs can provide objective information regarding functional work ability in the determination of occupational disability status.

CHANGE MANAGEMENT

A systems model that proposes several basic and specific elements for improving care in health systems at the community, organization, practice, and individual client levels. It ensures delivery of high-quality chronic disease care to clients with chronic illnesses. The elements of the model include the community, health system, self-management support, delivery system design, decision support, and use of clinical information systems. Evidence-based practices in each of these elements foster productive interactions between informed clients/support systems and their providers.

COST-BENEFIT ANALYSIS

A technique or systematic process used to calculate and compare the benefits and costs of an action, intervention, service or treatment, and to determine how well, or how poorly, it will turn out. This analysis reveals whether the benefits outweigh the costs, and by how much so that the involved party is able to make appropriate decision(s).

Active listening

A technique that is used in counseling and training. A structured way of communicating and interacting that requires the listener to fully engage with the speaker by listening to direct and indirect communications to understand, remember, and respond to what is being said while suspending your own frame of reference, biases, distractions, and judgement. Essential to negotiating, improving personal relationships, fosters understanding, and facilitates cooperation and collaboration, helps to solve disputes and eliminate conflict.

EXPERIENCE

A term used to describe the relationship, usually in a percentage or ratio, of premium to claims for a plan, coverage, or benefits for a stated period of time. Insurance companies in worker's compensation report three types of experience to rating bureaus: (1) Policy year experience: Represents the premiums and losses on all policies that go into effect within a given 12-month period. (2) calendar year experience: Represents losses incurred and premiums earned within a given 12-month period. (3) accident year experience: Represents accidents that occur within a given 12- month period and the premiums earned during that time.

Actuary

A trained insurance professional who specializes in determining policy rates, calculating premiums, and conducting statistical studies.

Hospice

A type of care for terminally ill patients; an organization that provides such care

COINSURANCE

A type of cost sharing in which the insured person pays orshares part of the medical bill, usually according to a fixed percentage.

PPO (Preferred Provider Organization)

A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan's network. Contains cost by negotiating discounts for services with in network provider

Ethnographic interview

A type of qualitative research that combines immersive observation and directed one-on-one interviews. Four typical stages 1. apprehension 2.exploration 3.cooperation 4.participation (goal is to uncover emic insights, not impose own culture/cultural screens, thick description)

CONTINUED STAY REVIEW

A type of review used to determine that each day of thehospital stay is necessary and that care is being rendered at the appropriate level. It takes place during a client's hospitalization for care.

DICHOTOMOUS VARIABLE

A variable known to have only two characteristics or options when evaluated in a particular study or predictive modeling. For example, characteristics may be high or low, true or false, yes or no, present or absent.

ENCOUNTER

A visit by a health plan member to a provider for the purpose of providing healthcare services or assessing the health status of a patient.

CERTIFIED VOCATIONAL REHABILITATION PROVIDER

A vocational rehabilitation practitioner who is registered in the workers' compensation agency or commission in the state/jurisdiction of employment. This registration certifies that the rehabilitation practitioner is certified to provide vocational rehabilitation services to individuals with disabilities.

Acuity

A way to measure complexity and severity of a patients health and medical condition or degree of illness

AFFIDAVIT

A written statement of fact signed and sworn before a person authorized to administer an oath.

HIPAA Title I

Ability to Transport Group Health plans w/ life events, divorce job loss, & pregnancy

Moral Agency

Ability to recognize needs and willingness to take action

Transitional work duty

Able to work but not regular job function; work at lower level until able to transition back to regular job.

ACO

Accountable Care Organization

Job Modification

Across the board change to the job description, targeting skills.

Rehabilitation Act of 1973

Act that prohibits discrimination based on physical or mental disabilities.

ADL

Activities of Daily Living. Routine activities carried out for personal hygiene and health and for operating a household. ADLs include feeding, bathing, showering, dressing, transferring in or out of bed or a chair, and using the toilet/continence.

ACOA

Adult Children of Alcoholics

COMMUNITY ALTERNATIVES

Agencies, outside an institutional setting, which provide care,support, and/or services to people with disabilities.

AHRQ

Agency for Healthcare Research and Quality

CONSENSUS

Agreement in opinion of experts. Building consensus is a method used when developing case management plans.

AUTONOMY

Agreement to respect another's right to self-determine a course of action; support of independent decision making without the influence of others personal desires or moral content.

Long Term Acute Care Hospital

Also called transitional hospitals Focus on patients who stay more than 25 days on avg Patients transferred from intensive care unit Treat people with 1 or more serious condition who may improve Rehab, head trauma to, pain mgmt

GOLD STANDARD

Also known as "ideal practice"; refers to the best availableknowledge, evidence, or benchmark under reasonable or similar conditions.

FIELD CASE MANAGEMENT (FCM)

Also known as onsite case management. A form of care coordination and management whereby a case manager works with a client (worker) in person rather than virtually via telephone or other electronic ways of communication. Field case managers usually visit the client, the client's employer, work environment, treating physician, and other involved parties and collaborate with them on the return of the client to work.

ACTUAL VALUE

Also referred to as real value. Measures the worth one derives from using or consuming a good, product, service or an item, and represents the utility of the good, product, service, or item.

AAPM&R

American Academy of Physical Medicine and Rehabilitation

AHA

American Heart Association

AMA

American Medical Association

ANA

American Nurses Association

ANCC

American Nurses Credentialing Center

ADA Amendments Act ADAAA

Americans w/Disabilities Act Amendments of 2008

ADA

Americans with Disabilities Act of 1990

BENCHMARKING

An act of comparing/evaluating a work process with that of the best competitor. Through this process one is able to identify what performance measure levels must be surpassed. Assists an organization in assessing its strengths and weaknesses and in finding and implementing best practices.

COORDINATION OF BENEFITS (COB)

An agreement that uses language developed by the National Association of Insurance Commissioners and prevents double payment for services when a subscriber has coverage from two or more sources. Determines which insurance plan is primary and secondary and establishes order of which claims are paid.

Administrative services only (ASO)

An arrangement by which an organization funds its own employee benefit plan (assuming responsibility for all the risk), such as a health plan, but hires an outside firm to perform specific administrative services.

HEALTH RISK ASSESSMENT (HRA):

An assessment of a client conducted to identify the presence of risk and determine how such risk may influence health-seeking behavior (e.g., access to healthcare services). This assessment may cover various aspects of a client's condition - e.g., level of physical activity and exercise; nutritional status; general health, safety, social, and environmental wellness; emotional awareness; mental, intellectual, and occupational wellness; and culture including values, spirituality, and beliefs

COMMUNITY ASSESSMENT RISK SCREEN (CARS)

An assessment tool used to determine the risk forrehospitalization or emergency department admittance of elderly clients. The tool focuses on the client's current health status and lifestyle behaviors similar to the health risk assessment (HRA) tool (Cesta and Tahan, 2003).

INCLUSIVE EDUCATION

An educational model in which students with disabilities receive their education in a general educational setting with collaboration between general and special education teachers. Implementation may be through the total reorganization and redefinition of general and special education roles, or as one option in a continuum of available services

AMBULATORY PAYMENT CLASSIFICATION (APC) SYSTEM

An encounter-based classification system for outpatient reimbursement, including hospital-based clinics, emergency departments, observation, and ambulatory surgery. Payment rates are based on categories of services that are similar in cost and resource utilization. (Procedures rather than diagnosis)

AGREED MEDICAL EXAMINATION

An evaluation conducted by a provider who is selected by agreement between an injured workers' attorney and the insurance claims administrator and/or attorney. The parties agree to conduct a medical examination and prepare a medical- legal report to help resolve an existing dispute. The evaluation also serves to determine what portions of the work-related injury have contributed to the disability and what portions have resulted from other sources or causation.

COLLABORATIVE CARE

An evidence-based approach that involves the provision of mental health, behavioral health, and substance use services within a primary care setting.

CASE MIX COMPLEXITY

An indication of the severity of illness, prognosis, treatmentdifficulty, need for intervention, or resource intensity of a group of clients.

BENEFICIARY

An individual eligible for benefits under a particular plan. In managed care organizations beneficiaries may also be known as members in HMO plans or enrollee's in PPO plans. A person who derives advantage from something- especially a trust, will, or life insurance policy.

ERGONOMIST

An individual who has (1) a mastery of ergonomics knowledge;(2) a command of the methodologies used by agronomists in applying that knowledge to the design of a product, process, or environment; and (3) has applied his or her knowledge to the analysis, design, test, and evaluation of products, processes, and environments.

DOMESTIC CARRIER

An insurance company organized and headquartered in a given state, under the laws in that state, is referred to in that state as a domestic carrier.

CAPTIVE INSURANCE

An insurance company owned and controlled by its insured. Typically a parent group or company creates a licensed insurance company to provide coverage for itself.

CLAIMS ADJUSTER

An insurance professional who investigates claims byinterviewing the claimant and other involved parties (e.g., employers and witnesses), reviews related records to determine degree of liability and damages, and assures that an insurance policy exists and covers the claimed damages. In healthcare, a claims adjuster also assures that medical care is available to the worker as needed based on the injury or occupational illness.

HEALTH MAINTENANCE ORGANIZATION (HMO)

An organization that provides or arranges for coverage of designated health services needed by plan members for a fixed prepaid premium. There are four basic models of HMOs: group model, individual practice association (IPA), network model, and staff model. Under the Federal HMO Act an organization must possess the following to call itself an HMO: (1) an organized system for providing healthcare in a geographical area, (2) an agreed-on set of basic and supplemental health maintenance and treatment services, and (3) a voluntarily enrolled group of people.

Network model

An organizational arrangement in which an HMO contracts with more than one medical group practice. A provider network

CASE MANAGEMENT PROGRAM

An organized approach to the provision of case management services to clients and their support systems. The program is usually described in terms of (1) vision, mission and objectives;(2) number and type of staff including roles, responsibilities and expectations; and (3) a specific model or conceptual framework that delineates the key case management functions which may include clinical care management, transitional planning, resources utilization and management, bed capacity management, clinical documentation enhancement, quality and variance/delays management and others depending on the healthcare organization.

DATABASE

An organized, comprehensive collection of client care data. Sometimes it is used for research or for quality improvement efforts.

COMPLICATION

An unexpected condition that arises during a hospital stay orhealthcare encounter that prolongs the length of stay at least by 1 day in 75% of the clients and intensifies the use of healthcare resources.

CONTEMPT OF COURT

Any act that is calculated to embarrass, hinder, delay orobstruct the court in the administration of justice, or that is calculated to lessen its authority of its dignity.

CATASTROPHIC CASE

Any complex medical condition or illness with multiple providers that has heightened medical, social, and financial consequences that responds positively to the control offered through a systematic effort of case management.

BRAIN INJURY

Any damage to tissues of the brain that leads to temporary or permanent impairment of the normal function of the Central Nervous System. (Loosely used term for neurological disorder indicating impairment or injury to brain tissue)

Change agent illness

Any illness that affects an individual's life, communication, education, in physical, social, or psychological ways

ASSISTIVE TECHNOLOGY

Any item, piece of equipment, or product, either acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities.

DEVELOPMENTAL DISABILITY

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.

ASSISTIVE TECHNOLOGY SERVICES

Any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device.

EVIDENCE

Any species of proof, or probative matter, legally presented at the trial of an issue, by the act of the parties and through the medium of witnesses, records, documents, concrete objects, and the like, for the purpose of inducing beliefs in the minds of the court or jury as to their contention.

Medicare patients admitted to skilled nursing or long-term care facility are eligible for Medicare Part D

Any time during stay or for 2 months after leaving - patients who have lived out of country can apply within 2 months of moving back - Patients who move out of their prescription drug plan's service area can change plans beginning 1 months before move or up to 2 months after

ASSISTIVE DEVICE

Any tool that is designed, made, or adapted to assist a person to perform a particular task or ADL

ADVERSE EVENTS

Any untoward occurrences, which under most conditions are not natural consequences of the client's disease process or treatment outcomes.

transferable skills analysis

Assessed current and projected employment based on skills, abilities, and aptitude of client

DISCHARGE SCREEN

Assessment of the client/support system's discharge needs using a set of criteria that results in identifying clients who are to benefit from healthcare services or resources after an episode of illness and/or to prevent need for acute care rehospitalization.

CORE THERAPIES

Basic therapy services provided by professionals on a rehabilitation unit. Usually refers to nursing, physical therapy, occupational therapy, speech-language pathology, neuropsychology, social work and therapeutic recreation.

Etic

Behavioral science that is studied from outside of the social group being studied by someone who is does not participate int eh culture being studied.

Ethnocentricity

Belief that your own cultural or ethnic group is superior to that of another.

indemnity

Benefits in the form of cash payments rather those services. Hospital bills patient and then insurance pays patient. Aka fee for service

Extra-contractual benefits

Benefits not covered under the health plan but are given to the insured for cost savings Ex: CHHA wound care after d/c from SNF

BATNA

Best Alternative To a Negotiated Agreement, allows CM to explore alternative solutions, alternative course of action a party can take if negotiations fail and an agreement cannot be reached. Having a strong alternative waiting in the wings to have the power to say "no" if need be.

Client engagement

Builds on client activation with behaviors like maintaining health and diet. Activation= tools and engagement= using tools

6 Domain for CM practice

Case Management Concepts Case Management Principles and practices/strategies Psychosocial & support systems Healthcare Management & delivery Healthcare Reimbursement Vocational concepts/strategies

CMSA

Case Management Society of America

CMG

Case Mix Group

DISABILITY CASH BENEFIT

Cash paid by a disability benefits insurance agency to a worker out on disability who has otherwise lost wages due to an inability to work. The cash is paid over a specific period of time and is equivalent to a predetermined percentage of the worker's weekly wages and is based on the average wages of the worker during a specific number of weeks (usually less than 10 weeks) most adjacent to the week during which the worker sustained the injury or illness. This benefit is also paid for a limited time period as stipulated by the disability insurance plan and based on state specific laws.

CONFIDENTIAL COMMUNICATIONS

Certain classes of communications, passing between personswho stand in a confidential of fiduciary relation to each other (or who, on account of their relative situation, are under a special duty of secrecy and fidelity), that the law will not permit to be divulged.

CCM

Certified Case Manager

Knights of Columbus

Charitable endeavors including needs of people with physical/developmental disabilities - Special Olympics

CHAMPVA

Civilian Health and Medical Program of the Veterans Administration

DME criteria

Client must have an office visit where the PCP must sign a prescription and create face-to-face documentation stating that the requested DME is to help a long lasting medical condition or injury, is for home use, used for medical reason.

DISCHARGE OUTCOMES (CRITERIA)

Clinical criteria to be met before or at the time of the client's discharge. They are the expected/ projected outcomes of care that indicate a safe discharge.

Disorientation

Cognitive disability where the senses of time, direction, and recognition of people and places become difficult to distinguish. A lack of awareness of self, place, and/or time seen in multitude of conditions

Family-Centered Model of Care

Collaborates with the family & healthcare team to support patient healthcare decisions

Guidelines for denial of hospital review committee determines an admission is not medically necessary

Committee must provide written notification to the hospital, patient, and practitioner responsible for the care of the patient

self-funded

Companies contract with TPA (third party administrator) or ASO (administrative services only) to hand out administrative aspects of insureance (ex:claims)

Analogous

Comparable or similar in certain respects, typically in a way which makes it clearer the nature of the things compared.

CORF

Comprehensive Outpatient Rehabilitation Facility

CPR

Computer-based patient record

FIRST-LEVEL REVIEWS

Conducted while the client is in the hospital, care is reviewed for its appropriateness.

avoid, compete, accommodate, collaborate, compromise

Conflict handling, 4 possible outcomes Importance of outcome/important of relationship 1 low,low 2 high,low 3 low,high 4 high,high 5 medium,medium

CLIENT-RELATED OUTCOMES

Consequences or results of care activities, processes, orservices that are directly related to the client's condition,health status, and/or situation.

Domains of Case Management

Consists of knowledge associated with SM process, resources, and skills needed to ensure the effective and efficient delivery of safe, quality health and human services to clients/support systems. Care delivery/reimbursement, psychosocial concepts, quality & outcomes, rehab, legal

COBRA

Consolidated Omnibus Budget Reconciliation Act- it requires employers to allow eligible employees, their spouses & dependents to maintain health insurance after loss of employment for 18 to 36 months, must elect coverage within 60 days of plan termination

Subrogation

Contractual right to recover payments made to a claimant for healthcare costs after the claimant has received payment for damages in legal action

Generalist Model of CM

Coordinates care with providers, maintains relationship with client but does not provide direct care

Appeal (legal in nature)

Court of appeals reviews written material from a trial court proceeding to determine if errors were made that might lead to a reversal of the courts decision

Behavioral Culture

Culture as a shared, learned human behavior, way of life- behaving a certain way merely because other persons do as well. Almost fully etic (culturally neutral)

CPT

Current procedural terminology: A listing of descriptive terms and identifying codes for reporting medical services and procedures performed by health care providers and usually used for billing purposes.

DISTRIBUTIVE JUSTICE

Deals with the moral basis for the dissemination of goods and evils, burdens and benefits, especially when making decisions regarding the allocation of healthcare resources. It assumes that there is a large amount of fairness in the distribution of goods. Equal work should provide individuals with an equal outcome in terms of goods acquired or the ability to acquire goods

DBA

Defense Base Act of 1941- an extension of the federal worker's compensation program that covers longshoremen and harbor workers.

1st step in developing healthcare management program

Define population to be served

Kubler Ross's 5 stages of grief

Denial anger bargaining Depression acceptance

Appeals

Denials of urgent care must be decided by insurance company within 72 hours. 30 days to review and make decision about non-urgent care that patient has not yet received 60 days for care already received

DOD

Department of Defense

DHHS

Department of Health & Human Services

Client activation

Describes the knowledge, skills, ability, willingness, and confidence a person has to allow him or her to become actively engaged in their own health needs

Durable Power of Attorney for Health Care

Designates someone to make decisions regarding medical & end of life care if the client becomes incapacitated and unable to handle matter on their own.

ADJUSTED CLINICAL GROUP (ACG) SYSTEM:

Developed by the School of Public Health at Johns Hopkins University, this system clusters clients into homogenous groups based on measuring morbidity to ultimately improve accuracy and fairness in evaluating healthcare provider performance, identifying clients at high risk, forecasting healthcare utilization, and setting equitable payment structure and rates for the providers of care. The System accounts for the burden of morbidity in a client population based on disease patterns, age, and gender and relies on the diagnostic and/or pharmaceutical code information found in insurance claims or other computerized client health records.

DSM-IV

Diagnostic and Statistical Manual of Mental Disorders. A guide used for the diagnosis of all currently recognized psychiatric and mental health disorders

ACTIVITY LIMITATIONS

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.

DMAA

Disease Management Association of America

DISCHARGE STATUS

Disposition of the client at discharge (e.g., left against medical advice, expired, discharged home, transferred to a nursing home).

Nonmaleficence

Do no harm

DNR

Do not resuscitate

DUAL RELATIONSHIP

Dual relationships exist when a case manager has responsibilities toward a third party other than the client (e.g., case manager/payor/client or case manager/ employer/client). Can also mean there exists multiple roles between the CM and client (e.g. client is also a family member/friend/student)

Patients who are already eligible because of disability and turn 65 can enroll for Medicare Part D

During period extending form 3 months prior to turning 65 to 3 months after

Life Care Plan

Dynamic document which provides an organized plan for current and future needs of a person who experienced a catastrophic injury chronic illness/life change

clinical pathways

EBP guidelines and treatment guidelines Apply. Eat research when making decisions about HC Provides outcome focused care within certain timeline Model that standardizes appropriate services and treatment within an appropriate length of stay

CASE MIX GROUP (CMG)

Each CMG has a relative weight that determines the base payment rate for inpatient rehabilitation facilities under the Medicare Perspective Payment System. See also IRF-PAI, RIC.

ERISA

Employee Retirement Income Security Act.- law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans.

ADA Title I

Employers with 15 or more employees are prohibited from discriminating against people with disabilities.

Utilization management

Ensures that services provided are medically necessary and provided at appropriate level and reduced cost level Prospective reviews Concurrent reviews Retrospective reviews

DURABLE MEDICAL EQUIPMENT (DME)

Equipment needed by patients for self-care. Usually it must withstand repeated use, is used for a medical purpose, and is appropriate for use in the home setting.

Transitional subacute

Est stay 3-30 days 5-8 hours nursing services/day

Long-term transitional subacute

Est stay >25 days rehab/nursing 6-9 hours/day Often transferred to long term care facilities

Vocational Rehabilitation

Fed-state eligibility based on career development program. Provides services to individuals with disabilities Acquire skills needed to get/keep job

Medicare Hospice Benefit

Federal program for medicare-eligible patients Life expectancy 6 mos or less Multiple settings - home, outpatient, inpatient Can return to regular medicare at any time

Financial Resources alternatives

Financial service provided outside traditional means to pay for insurance and fees patients may use; long-term care insurance, accelerated death benefits, viatical settlements, reverse mortgages

Core Cultural Dimensions 5 (Basic Idea)

Five main questions concerning global managers, derived from the old models 1. Power distribution 2. Social relationships 3. Environmental relationships 4. Time and work patterns 5. Uncertainty and social control

Rotary international

Focuses on 6 areas for grants, 2 that focus on health: disease prevention and treatment (combat spread of HIV/AIDS)

Subacute care/transitional care

For patients who are stable and do not require hospital acute care but who require more intensive skilled nursing care, therapy, and physician services than are provided in SNFs. Ex: TPN, IV therapy, wound care

FAM

Functional Assessment Measure

FAST

Functional Assessment Staging Tool

DISABILITY BENEFIT

Funds from public or private sources provided for an individual who has a disability. Disability benefits for most Americans are covered and paid by the Social Security Administration (a government agency) through either of two main programs: (1) Social Security Disability Insurance (SSDI), for those who have worked in recent years; or (2) Supplemental Security Income (SSI), for low-income individuals who are disabled or who have become disabled and are unable to return to work

Social security disability insurance SSDI

Given to those unable to work bc disability 18 years but less than 65 5 month waiting period After have for 2 years, eligible for medicare

Axis V

Global Assessment of Functioning that allows the clinician to rate the level of danger to one's self and functioning. GAF 0-100 with 100 exhibiting no symptoms.

BENEFIT PROGRAMS

Government agency, or employer to individuals based on some sort of an agreement between the parties; for example between an employer and an employee. Benefits vary based on the plan and may include physician and hospital services, prescriptions, dental and vision care, workers' compensation, long-term care, mental and behavioral health, disability and accidental death, counseling and other therapies such as chiropractor care.

Kiwanis

Grants to clubs/organizations that support children

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

Group of agencies that establish standards for hospitals and health organizations which they apply during inspections that lead to accreditation

Medicare ACO

Group of drs, hospitals, HC providers who voluntarily come together to give coordinated, high quality care, to Medicare fee-for-service beneficiaries (cost saving) Patient centered

Quality improvement organization (QIO)

Group of health quality experts to improve the care delivered by Medicare

Performance Improvement (PI)

HC organizations fxns and processes and how they affect the ability to reach desired outcomes and meet clients needs

HEALTH INSURANCE PORTABILITY ANDACCOUNTABILITY ACT'S PRIVACY RULE

HIPAA's Privacy Rule was initially published in 2000 as a national law that ensures clients' medical information is kept confidential. The Rule offered clients greater rights for protection of individually identifiable health information and files and demands that all healthcare providers maintain strict confidentiality and privacy (Department of Health and Human Services, Federal Register, 45 CFR, Parts 160 and 164, 2000).

a

HMO contracts with a group of physicians to provide services for a fixed monthly fee per enrollee

Ergonomic approach

Handling the client in a way that is comfortable and efficient for you and the client. End user: Client is leader of CM decision making process

EMPLOYABILITY

Having the skills and training that are commonly necessary in the labor market to be gainfully employed on a reasonably continuous basis, when considering the person's age, education, experience, physical, and mental capacities due to industrial injury or disease.

HCFA

Health Care Financing Administration. See CMS.

HIPAA stands for

Health Insurance Portability and Accountability Act of 1996

Adult day healthcare programs

Health focused programs with RNs and therapists

Creditable coverage

Health insurance, prescription drug, or other health benefit plan that meets a minimum set of qualification. Medicare expectations is that a supplemental prescription drug coverage pays on average as much as the standard Medicare prescription drug coverage.

Birthday rule

Health plan uses the parent whose birthday is 1st to determine child's primary and secondary insurance policy

HEDIS

HealthCare Effectiveness Data Information Set- performance measurement set for MCO to set quality of systems

Intensity of Service

Healthcare cost trend factor that can be mostly directly impacted by case manager CM needs to be aware of how intensity of service affects the clients plan of care

Targeted approach of CM

Healthcare management focuses on needs of specific patient or group of patients with similar problems.

HCC

Hierarchical conditions category-a risk-adjustment model originally designed to estimate future health care costs for patients.

Ethical principals

Higher order norms or fundamental assumptions that are consistent with a society's moral principles and constitutes higher standards of moral behavior

HHA

Home health aide

Under Medicare, eligibility for home health care

Homebound does not literally mean patient is never able to leave home

Red flag concerns

Homelessness poor living conditions limited financial and insurance resources dependency on others for care

impairment, disability, handicap

I: problem with structure of organ or body (can't move legs) D: functional limitation to activity (can't walk) H: disadvantage is n filling a role (cant work)

Integrative model of care

IDT model of care that encompasses medical, psychosocial and social needs of the patient

Basic idea - Hofstede

Idea that people have the same hardware, but different thinking and behavioral patterns- how a society handles inequalities among people, belief, and behavior and are intolerant of unorthodox behavior and ideas. 4 dimensions- individualism-collectivism, uncertainty avoidance, power distance, and masculinity-femininity.

Healthcare Analytics

Identify at risk people who could benefit from CM services

malpractice

Improper care or treatment by health care professional. Wrong conduct, negligent.

Palliative care is meant to

Improve QOL, relieve suffering. Does not include treatments to prolong life

IMPEACH

In the law of evidence, it is to call in question the veracity of a witness, by means of evidence adduced for that purpose.

Polypharmacy in Older Adults

Inadvertent prescriptions from multiple medications from multiple providers

drivers of globalization

Include technological advancement, international trade, and international investment making it easier for people, goods, and ideas to move across borders. Based on increased customer demands, increased technological innovation, and a growing role for emerging markets increased use of shared R&D, global sourcing increasingly global financial markets evolving government trade policies ALSO: ideology, power relations

DME

Includes but is not limited to- cane, brace, commode chair, crutches, hospital bed, wheelchair, walkers, ventilators, oxygen, pressure mattresses, lifts, etc.

FUNERAL EXPENSE BENEFIT

Includes financial support for funeral expenses survivors of the diseased worker may incur. This benefit is payable to the deceased worker's family or dependent(s) up to the maximum allowed under the law at the time of the worker's injury resulting in death.

FUNDING SYSTEMS

Individuals or agencies that provide financial resources to support the care of those who are poor, vulnerable, lack health insurance coverage or unable to independently assume such responsibility. These may include charitable or religious organizations, and public or private agencies.

IHI

Institute for Healthcare Improvement

Accelerated Death Benefits

Insurance policy rider allowing insured person with terminal illness to use some of policy's benefits prior to death for LT care and medical expenses

Core components of Case Management

Intake, Needs Assessment, Service Planning, and Monitoring and Evaluation. The process if to assess a client's relationships, healthcare management, community resources and support, service delivery, and psychological intervention.

BAD FAITH

Intentional dishonest act by not fulfilling legal or contractual obligations, misleading another, entering into an agreement without the intention or means to fulfill it, violating basic standards of honesty in dealing with others. Helpful if an insurance company violates a good faith deal letting the policy holder sue the company on a tort claim in addition to a standard breach of contract, policyholder may recover an amount larger than the initial claim.

Case Management Society of America

International not for profit organization dedicated to support the advancement of case management

Vocational rehab

Job requirements must be the focus, not individual worker's skills

FRAUD

Knowingly and willfully executing, or attempting to execute a scheme or artifice to defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any healthcare benefit program. Fraud is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment.

Cross Cultural Competence

Knowledge of other beliefs, values and attitudes, the ability to appreciate and respect other feelings, the capacity to adapt one's own behavior, the ability to reflect on one's own sensitivities.

Cross Cultural Sensitivity

Knowledge, awareness, and acceptance of other cultures, combines cognitive and affective skills to reduce misunderstandings and avoid inappropriate behavior through heightened tolerance of different cultural attitudes.

ADVANCE DIRECTIVE

Legally executed document that explains the client's healthcare related wishes and decisions. It is drawn up while the client is still competent and is used if the client becomes incapacitated or incompetent. Can include a living will, personal directive, advance directive, medical directive, or advance decision.

Skilled Nursing Facility (SNF) rehab

Less intense level. Patient tolerated 3 hours of therapy per day

Intermediate Care

Level of care for patients who require more assistance than custodial care and may require nursing supervision but do not have skilled need. Insurance companies don't pay

Viatical Settlements

Life insurance is personal property & can be sold. Terminally ill pt sells policy to a 3rd party for cash

Kinds of Advanced Directives

Living will Medical power of attorney General power of attorney

2 essential components of risk management program

Loss control and loss prevention Helps to minimize costs

Medicare Part B

MD services, outpatient services, some home health, DME, ER care, outpatient PT/OT, labs

BONA FIDE

Made with earnest intent, without intention to deceive. Literally translated as "in good faith"

Clinical quality measures (CQMs)

Measure health outcomes, clinical process, cl safety

Quality Indicator

Measures of outcomes

Quality indicator

Measures of structure, processes, outcomes. Provide hospital/providers as starting point to improve care EB and identifies variations in quality of care Types: clinical, financial, productivity, utilization, quality, client experience

Functional capacity assessment

Measures persons ability to perform specific work related tasks

Cost-effectiveness analysis

Measures the effectiveness of an intervention rather than monetary savings

Medicare Part C is also called

Medicare Advantage Plan (private insurance through HMO, PPO etc)

Prospective Payment System (PPS)

Medicare reimbursement fixed payment based upon DX & standard function assessment-Payment made based on predetermined fixed amount.

Hospice

MedicareA covers two 90day & unlimited 60day benefit periods, with physician revert every 60days

Resource utilization groups (RUGs)

Method of classification for health care reimbursement for SNF pt's

Ambulatory Payment Classification (APC)

Method of paying for a facility outpatient services for the Medciare program- Outpatient Perspective Payment System for Hospitals only

AIA model

Model which highlights three key ingredients in effective interpersonal communication, stresses conveying meaning: Attention Interpretation Action

BEYOND (OUTSIDE)-THE WALLS CASE MANAGEMENT

Models where healthcare resources, services and case managers are based externally to an acute care/hospital setting that is in the community. A way to meet the needs of high-risk patients through clinical outcomes, member satisfaction, and cost containment.

DAMAGES

Money awarded by a court to someone who has been injured (plaintiff) and that must be paid by the party responsible for the injury (defendant). Normal damages are awarded when the injury is judged to be slight. Compensatory damages are awarded to repay of compensate the injured party for the injury incurred. Punitive damages are awarded when the injury is judged to have been committed maliciously or in wanton disregard of the injured plaintiff's interests.

COMPENSATION

Money that a court or other tribunal orders to be paid, by a person whose acts or omissions have caused loss or injury to another, in order that the person demnified may receive equal value for the loss, or be made whole in respect to the injury.

Savings report

Most common method of assessing the effectiveness of case management Cost saving analysis is used to show effectiveness of CM work

acute care

Most intensive level of care Patient is treated for a brief sudden but severe episodes of illness such as medical and surgical management or trauma/emergency treatment which cannot be taken care of in a less intense setting. Usually provided in a hospital, LTACH, IRF, ER, transitional hospitals.

Hospice under Medicare A

Must have less than 6 months to live (2 90-day periods)

CCM certification

Must meet once qualification from both sections 1. Rx, RN, or LCSW, 2. work supervised by CCM for 12 months, work supervised for 24 months by CM without CCM, or supervise CM department for 12 months.

Core Measures

National standards of care and treatment processes for common conditions shown through scientific evidence to improve client outcomes. 8 core measures: Cardiology, Gastroenterology, HIV/Hepatitis C, Medical Oncology, Obstetrics/Gynecology, Orthopedics, Pediatric

CARE GUIDELINES

Nationally recognized and professionally supported plans of care recommended for the care management of clients with a specific diagnosis or health condition and in a particular care setting. Usually developed based on the latest available evidence and modified as necessary by healthcare professionals upon implementation for the care of an individual client. See also case management plan.

indemnity plan

No INN/ONN, NO PCP, mbr pays deductible, no referrals needed

DENIAL

No authorization or certification is given for healthcare services because of the inability to provide justification of medical necessity or appropriateness of treatment or length of stay. This can occur before, during, or after care provision.

National Quality Forum (NQF)

Non profit membership organization to improve quality of HC When a measure is endorsed by NQF it can be used in hospitals, HC SYSTEM, govt agencies Endorse consensus stnds, increase quality performance info to public

Commission on Accreditation of Rehabilitation Facilities (CARF)

Nonprofit accreditation of health/human services Focuses on improving outcomes, client satisfaction Accreds:rehabs,DME, aging services etc

Precontemplation

Not intending to change behavior.

BENEFICENCE

Obligation and duty to promote good or to support a patients legitimate interests and decisions. Compassion; taking positive action to help others; desire to do good; core principle of client advocacy. Actively preventing or removing harm.

APPROVAL

Offer or receive affirmation, sanction, or agreement about a decision, action, service, treatment, or intervention. In health insurance, it is the act of authorizing or affirming a service to a client that implies agreement to be responsible for reimbursing the provider of the service the related cost of providing the service to a client/support system.

FAIR HEARING

One in which authority is executed fairly; that is consistent with the fundamental principles of justice embraced within the conception of due process of law.

CLAIMANT

One who seeks a claim or one who asserts a right or demandin a legal proceeding.

Case load calculation

Online tool which takes into account several factors to determine the appropriate caseload for CM setting, complexity of cases, experience of CM, types of contact

FreshStart

Online-based hypnotehrapeutic approach to nicotine addiction, for INDEPENDENT USE

Diversity Management

Organizational actions that aim to promote greater inclusion of employees from different backgrounds into an organization's structure, intended to create and maintain a positive work environment where the similarities and differences of individuals are valued.

ANCILLARY SERVICES

Other diagnostic and therapeutic services that may be involved in the care of clients other than nursing or medicine. Includes respiratory, laboratory, radiology, nutrition, physical and occupational therapy, and pastoral services.

END-RESULT OUTCOMES

Outcomes that occur at the conclusion of an episode of care and indicate the achievement of target goals. For example, deciding to transition a client from the acute care to home setting after successful tolerance of oral antibiotics or transitioning a workers' compensation client back to work after successful job modification intervention(s).

Preferred Provider Organization

PPO, preferred provider group/ organization where group of medical providers provide medical services on a negotiated fee

Supported Employment

Paid employment in integrated setting with support for people with severe disability Provides training and a job coach to help severely disabled people succeed in meaningful job placement.

Accountable Care Organization (ACO)

Part of Medicare Shared Savings Program (MSSP) Volunteer group/network of providers including primary care physicians, specialists, other healthcare providers and medical facilities that form an organization to provide and coordinate care to groups of beneficiaries (minimum 5,000) who work together collaboratively and accept collective accountability for the cost and quality of care in return for financial incentives for improving/decreasing spending. - Must participate for minimum of 3 years - Must institute quality measures + cost containment strategies - receives percentage of savings ACOs became popular in the Medicare fee-for-service benefit system as a result of the Affordable Care Act. ACOs are formed around a variety of existing types of provider organizations such as multi specialty medical groups, physician-hospital organizations (PHO), and organized or integrated delivery systems.

Main role of Case manager

Patient advocate

True/False

Patients can have multiple benefits periods in 1 years, but have to pay deductible for each

ASSIGNMENT OF BENEFITS

Paying medical benefits directly to a provider of care rather than to a member. This system generally requires either a contractual agreement between the health plan and provider or written permission from the subscriber for the provider to bill the health plan.

Medicare Part A

Pays a 100% days 1-60 for each benefit period, patient pays deductible

Liability Insurance

Pays damages for bodily injury or loss of property (ex: injury resulting from unsafe conditions)

Indemnity Insurance

Pays in the form of predetermined payments for loss/damages rather than for healthcare services

FIDUCIARY

Person in a special relationship of trust, confidence, or responsibility in which one party occupies a superior relationship and assumes a duty to act in the dependent's best interest. This includes a trustee, guardian, counselor or institution, but it could also be a volunteer acting in this special relationship.

Axis II

Personality disorders and developmental disorders (OCD, Borderline personality)

Abuse

Physical, mental/emotional, or sexual mistreatment of one person by another

Staff Model HMO

Physicians are on the staff of the HMO and provide care exclusively for the health plan enrollees

the donut hole in medicare

Point of coverage when the participant and drug plan have spent a specified dollar amount; gives discounts on drugs

prejudice

Positive or negative belief held about an individual or group

Soft savings

Potential savings. Costa avoided due to CM intervention Ex: no hospital readmission

CASE LAW

Precedent or common law-the collected body of prior judicial decisions written by courts and similar tribunals in the course of deciding past cases and resolving ambiguities to determine outcomes for a current case, this must be followed until or unless a new law is created or a higher court rules differently

Medicare Part D

Prescription Drug Coverage

Patient safety indicator (PSI)

Preventable instances of complications resulting from exposure to HC system Ex: hemorrhages or foreign body left in body

CARE CONTINUUM ALLIANCE

Previously known as the Disease Management Association of America (DMAA) is an industry trade group of corporations and individuals that promotes the role of population health improvement in raising the quality of care, improving health outcomes, and reducing preventable health care costs for individuals with and at rick for developing chronic conditions.

CASE MANAGER

Principal Term: A health and human servcies professional who is responsible for coordinating the overall care, services and resources delivered to an individual client or a group of clients and their support systems based on the client's health and human services issues, needs and interests.

HEALTH

Principal Term: An individual's physical, functional, mental, behavioral, emotional, psychosocial and cognitive condition. Refers to presence or absence of illness, disability, injury or limitation which requires special attention for management and resolution including use of health and/or human services type intervention or resource.

COMMUNITY SERVICES AND RESOURCES

Principal Term: Healthcare programs that offer specific servicesand resources in a community-based environment as opposed to an institutional setting, that is, outside the confines of healthcare facilities such as hospitals and nursing homes. These programs are either publicly or privately funded or charitable in nature.

HEALTH AND HUMAN SERVICES CONTINUUM

Principal Term: The continuum of care that matches ongoing needs of case management clients and their support systems with the appropriate level and type of health, medical, financial, legal, psychosocial, behavioral and sprirtual care and services across one or more care settings. The continuum includes multiple levels that vary in complexity and intensity of healthcare services and resources including individual care providers and organizations or agencies.

CAREGIVER

Principal Term: The person responsible for caring for a client in the home setting. Can be a family member, friend, volunteer, or an assigned healthcare professional.

CLIENT'S SUPPORT SYSTEM

Principal Term: The person(s) identified by each individual client to be directly or indirectly involved in the client's care. It "may include biological relatives [family members], spouses, partners, friends, neighbors, colleagues, or any individual who supports the client [caregivers, volunteers, clergy, spiritual advisors]" (CMSA, 2010, p. 24).

Frequent Flyers

Principal management focus: short term face to face for specific expertise Mode of interaction: face to face and virtual Key success factors: moderate awareness of cultural differences, multilingual skills, deep understanding of global issues Typical cultural challenges: global myopia, overemphasis on global issues

Functional Job Analysis

Process of collecting specific data to define job requirements, both essential and non essential duties, helps to write job descriptions.

Root Cause Analysis (RCA)

Process used by providers and administrators to indentify the basic or causal factors that contribute to variation in performance and outcomes or that underlie the occurrence of a sentinel event An analytical technique used to determine the basic underlying reason that causes a variance or a defect or a risk. A root cause may underlie more than one variance or defect or risk. determines underlying cause of adverse events; used after incident to uncover primary cause

Alateen

Program for teens with alcoholic parent - includes tutoring, mentoring, counseling

Value Based Purchasing

Program offers financial incentives to hospitals to improve quality of care.

Purpose of stop-loss insurance

Protect insurance company against excessive payments

HEALTH INSURANCE

Protection which provides payment of benefits for coverage for covered sickness or injury. Included under this heading are various types of insurance such as accident insurance, disability income insurance, medical expense insurance, and accidental death and dismemberment insurance

Tuberculosis Medicaid program

Provdied by DSS Coverage for eval/tx of TB For uninsured or underinsured and do not qualify for regular medicaid Must be citizens or legal residents Must have lived in US for 5 years

Inpatient Rehabilitation

Provide intense, multidisciplinary therapy to patients with functional loss Patient must be able to tolerate a minimum of 3 hours of therapy a day, 5-7 days a week and be medically stable

National Committee for Quality Assurance (NCQA)

Provides a systematic review of managed care organizations for accreditation

National Committee for Quality Assurance (NCQA)

Provides accreditation fo HC organizations and manages care organizations CM acced: comprehensive and EB dedicated to quality improvement, PCSP Care coordination, patient centered, quality of care HEDIS

Children's health insurance program (CHIP)

Provides health insurance coverage for uninsured and underinsured children who have household income above the Medicaid qualifying income

CHAMPVA for Life

Provides healthcare benefits to families of permanently disabled veterans, or soldiers killed in line of duty, not eligible for Tricare. Covers 65 or older, is a Medicare supplement.

Indian Health Service

Provides helath services to members of any federally recognized tribes and Alaska natives directly or through contracted services

Private CM model

Provides individual care focusing on needs of patient

Axis IV

Psychosocial and environmental problems that may affect the mental disorder (housing, education, legal, economic)

contemporary truisms

Public vs Private sector: public sector provides technologies, private companies rely on these, should the state stay out of the private sector? Innovation is a force of good: not for all stakeholders Knowledge economy: contemporary organizations use advanced knowledge, or do they limit their knowledge to what limits their doubt Fast-changing international environment: is the environment actually changing rapidly, growth has been stable for 40 years and the most influential new technologies are in the past Trickle-down economies: attracting large financial institutions leads to increased prices before the wealth reaches lower levels Flexible labor market: even though the workforce is more skilled than ever, there is polarization in earnings, lower-skilled work is less secure, social contract between employer and employee is broken Technological solutionism: technology does not have all the answers because institutions are too hypocritical, corrupt and bureaucratic. Overton window: the current policy

Utilization review accreditation commission URAC

Puts consumer at center of HC decisions and ensure client gets right car, in the right setting, at the right time. CM standards applied across the HC setting CM standards: policy, quality mgmt, compliance, oversight of fxns, credentialing

pediatric quality indicator (PDI)

Quality of care for neonatal and children under 17 in hospital or identify avoidable hospitalization

inpatient quality indicators (IQI)

Quality of care in hospital, inpt mortality, misused utilization of procedures

CASE RATES

Rate of reimbursement that packages pricing for a certain category of services. Typically combines facility and professional practitioner fees for care and services. also known as Bundled or Episode based payment.

Goal of risk management

Reduce adverse events, decrease malpractice claims, and minimize finical loss.

FUNCTIONAL INDEPENDENCE MEASURE (FIM[TM])

Referred to today as FIM[TM] instrument, it is an 18-item instrument with an ordinal scale ranging from 1 (total assistance) to 7 (complete independence) that is used worldwide in the in-patient medical rehabilitation setting to measure a client's ability to function with independence. The instrument allows healthcare professionals to evaluate the amount of assistance required by a client to safely and effectively perform basic life functions. An FIM[trademark sign] score is collected within 72 hours after a client's admission to a rehabilitation unit, within 72 hours before discharge, and between 80 to 180 days after discharge. This instrument is copyrighted and maintained by the Uniform Data System for Medical Rehabilitation (UDSMR), which is a division of the University of Buffalo Foundation Activities, Inc (UBFA), the not- for-profit corporation that developed and owns the FIM[trademark sign] instrument. (Medfriendly, 2010)

Impairment

Refers to a problem with a structure or organ of the body.

HANDICAPPED

Refers to the disadvantage of an individual with a physical or mental impairment resulting in a handicap.

COMMUNICATION SKILLS

Refers to the many ways of transferring thought from oneperson to another through the commonly used media of speech, written words, or bodily gestures.

Family Model

Regional organizing model: principal emphasis on extended family members as both investors and principal beneficiaries based on confucianism- Related Chinese cultural characteristics: 5 cardinal virtues: filial piety, absolute loyalty, strict observance of seniority, mutual trust 1 Guanxi: strong personal relationship with continual exchange of favors face: dignity, prestige rank & harmony 2 Flat informal structure, centralized top-down (human orientation, collectivism, high power distance) 3 Relationship based (collectivism, universalism) 4 Importance of guanxi-government (reliance on implicit social rules & lack of stable legal environment) 5 Family management (harmony) 6 Business as a property and revenue for family (collectivism, ingroup)

Work hardening

Rehab real/simulared work activities designed to restore physical function

Bundled reimbursement

Reimbursement of health care providers according to expected cost for a clinical episode of care in one single payment for all services performed for that episode of care.

GLOBE project basic idea

Relationship between culture and succesful leadership

Medicare Select

Requires use of specific providers form of managed care Provides same 12 basic programs as Medigap, but premiums usually lower because patients have less flexibility

work conditioning

Restore function so client can return to work under direction of PT 2-4 times a week

Hospital risk management departments

Role is to anticipate potential malpractice claims

ACTIVITIES OF DAILY LIVING (ADLS)

Routine activities an individual tends to do every day for self-care and normal living. These include eating, bathing, grooming, dressing, toileting, transferring (such as walking, bed to chair) and continence. Assessment of an individual's ability to perform these ADLs is important for determining an individual's ability, independence, disability or limitations. This assessment determines the type of long-term care and benefit coverage the individual needs. care may include placement in a nursing home, skilled care facility or home care services.Benefit coverage may include Medicare, Medicaid or long-term care insurance.

Health coaching

Secondary prevention; already suffering from chronic didease (ie. disease management)

CQI

See Continuous Quality Improvement.

FIM INSTRUMENT

See Functional Independence Measure (FIM).

HHRG

See Home Health Resource Group

ICD-9-CM

See International Classification of Diseases, Ninth Revision,Clinical Modification

CARE SETTING

See also practice setting, level of care. A place across the continuum of health and human services where a client may receive healthcare services dependent on need. Care settings vary based on intensity and complexity of the services provided to clients; that is, from least complex (e.g., prevention and wellness) to most complex (e.g., acute and critical care services).

HEALTH POLICY

See also public policy. The course of action to address a healthcare issue of concern by the community at large or specific group(s) within the community. This process involves the interplay of numerous individuals and interest groups collaborating to influence health policymakers to act in a particular way.

EPO

See exclusive provider organization.

FCE

See functional capacity evaluation.

IDS

See integrated delivery system.

Composite view of self

Self concept Collection of beliefs, preferences, opinion, attitudes of oneself in an organized manner

honor culture

Self worth: internal and external, socially claimed, dynamic Power and status: hierarchical, dynamic, contested Sensitivity and response to insults: high, DIY Confrontation style: direct and indirect, expressive Reconciliation, warmth: short-term irrationality, hospitality, exceed expectations of close circle

dignity culture

Self worth: mostly internal, self reliant, stable Power and status: egalitarian, dynamic Sensitivity and response to insults: low, ignore, refer to rule of law Confrontation style: direct, rational (cost/benefit) Reconciliation, warmth: rational, express positivity

Viatical Settlement

Selling of one's life in insurance policy to a 3rd party before one's death. Policy holder benefits rather than beneficiaries. Usually sold 40-90% face value depending on life expectancy (< time = > $) Life expectancy is less than 5 years Sale of life insurance policy by policy owner BEFORE the policy matures

Ergonomic studies of workstation

Serve to Breyer fit equipment to the employees

EFFECTIVENESS OF CARE

Services that are of proven value and have no significant tradeoffs- the benefits so far outweigh the risks that all patients with a specific medical condition should receive them. The extent to which care is provided correctly (i.e., to meet the client's needs, improve quality of care, and resolve the client's problems), given the current state of knowledge, and the desired outcome is achieved.

State health exchange

Shared group insurance for individuals and small businesses

Face culture

Sociological concept linked to the dignity and prestige that a person has in terms of their social relationships- more meaning within the context of Chinese culture

CATASTROPHIC CASE MANAGEMENT

Specialized and intricate Case Management services for individuals with complex and life-altering conditions (e.g., severe injury, multiple comorbidities, and permanent disabilities). Often includes a full spectrum of services for the individual or worker with a catastrophic injury or illness to assist the individual to secure optimal care and achieve full recovery.

Broker model

Standard model of Case Management, designed to identify needs of the client in one or two contact & assess to identify needs and resources.

Culturally mandated protocols

Standards of behaviors used by people to show respect to one another and other cultures. Includes appropriate topics for discussion, messaging formatting, conversational formalities.

Surgical site infections are most commonly cause by

Staphylococcus aureus Enterococcus spp S epidermidis

Maximum medical improvement

States further treatment will not substantively change the medical outcome.

Decisional Managerial Roles (Mintzberg)

States that making decisions is the most crucial part of any managerial activity. 4 roles- entrepreneur, disturbance handler, resource allocator, negotiator

resocialized, alienated, proactive

Steers, 3 coping strategies for returning expatriates

Adaptation

Strategy for work in diverse groups to change process to suit different conditions-IE: conflict from decision making, misunderstanding from communicative differences. Team members attribute a challenge to culture and not to personality, higher-level managers not there and team members must be aware it takes time to implement changes.

Exit

Strategy for work in diverse groups: 1. team member cannot adjust to the challenge, unable to continue 2. team is permanent rather than temporary, emotions beyond point of intervention, too much face lost 3. talent and training costs are lost

Methadone

Strong opioid agonist used for the treatment of heroin addiction

Al-Anon

Support for ALL family members of person with alcoholism

COMMUNITY-BASED PROGRAMS

Support programs which are located in a community environment, as opposed to an institutional setting.

CARE COORDINATION HUB:

System of delivering integrated healthcare services to clients with special emphasis on collaboration, coordination and communication among multiple healthcare providers, care settings and agencies in an attempt to ensure client's safety and the provision of quality, cost-effective case management services.

Delphi Technique

Systematic Method of group decision-making and forecasting by obtaining professionals opinions for quality indicators. Uses rounds (series of questionnaires)

Health literacy

The ability to obtain, communicate, process, and understand and make basic health information. Signs that a patient may have low health literacy include making statements that another family member handles their medications, or deferring questions about their health history to a family member. Asking the client questions such as "Are you confident filling out medical forms by yourself?" and "How well do you understand your medical conditions?" are ways that the case manager assess for a patients health literacy

EMOTIONAL INTELLIGENCE

The ability to sense, understand, and effectively apply the power and acumen of emotions as a source of energy, information, connection, and influence. It also is the ability to motivate oneself and persist in the face of frustration; control impulse; regulate one's mood; and keep distress from swamping the ability to think, empathize, and hope.

EXTERNAL BENCHMARKING

The act of comparing or evaluating the current performance of an organization or program against externally available data, standards, performance of competitors, national databases, or ideal practices.

ADVOCACY

The act of recommending, pleading the cause of another; to speak or write in favor of. (CMSA Standards of Practice, 2010, p 24). Used to achieve the best outcome for the client, provider, and payer.

HANDOFF

The act or an instance of passing something or the control of it from one person or agency to another. In healthcare context, handoff is passing of accountability and responsibility for a client's care from one clinician to another within a care setting or across care settings. This act is especially necessary during a transitions of care situation.

Benefits

The amount payable by the insurance company to a claimant or beneficiary under claimant's specific coverage as stipulated in the agreed upon health plan

AUTHORIZATION

The approval of client care services, admission, or length of stay by a health benefit plan (e.g., HMO, PPO) based on information provided by the healthcare provider.

CERTIFICATION

The approval of client care services, admission, or length of stay by a health benefit plan (e.g., HMO, PPO) based on information provided by the healthcare provider

Ethnographic fallacies

The assumption that we can make inferences about society based on individuals- 3 Types 1) Behavior-ethnography cannot be reduced to behavior 2) Idealist-cultural analysis does not aim for mental schemes 3) Cognitivist-culture is not a monolithic logical cognitive structure to be analyzed

DEATH BENEFIT

The benefit payable to eligible dependent(s) of the worker(i.e., spouse, children) whose occupational disease or on-the-job injury has resulted in the worker's death. This benefit may be payable at the rate of two-thirds of the deceased worker's average weekly wage at the time of the accident, not to exceed the maximum allowed under the law for all eligible dependents.

ALGORITHM

The chronological delineation of the steps in, or activities of, client care to be applied in the care of clients as they relate to specific conditions/situations.

DISENGAGEMENT

The closing of a case is a process of gradual or sudden withdrawal of services, as the situation indicates, on a planned basis.

CASE MANAGEMENT PROCESS

The context in which case managers provide health and human services to clients and their support systems. The process consists of several steps or sub- processes that are iterative, cyclical and recursive rather than linear in nature and applied until the client's needs and interests are met. The steps include screening, assessing, stratifying risk, planning, implementing, following-up, transitioning, post-transitioning communication, and evaluating outcomes. The process, with special intervention by case managers, work together with clients and their support systems to evaluate and understand the care options available to the clients; identify what is best to meet their needs; and institute action to achieve their goals and meet their interests and expectations.

CONTINUUM OF CARE

The continuum of care matches ongoing needs of the individuals being served by the case management process with the appropriate level and type of health, medical, financial, legal and psychosocial care for services within a setting or across multiple settings. 5 factors: 1. Well-being/independence 2. Risk factors/behaviors 3. Clinical DX 4. treatment 5. Outcome

CARE COORDINATION

The deliberate organization of patient care activities between two or more participants (including the patient) involved in patient's care to facilitate the appropriate delivery of health care services.

ELIGIBILITY

The determination that an individual has met requirements to obtain benefits under a specific health plan contract.

ADAPTIVE BEHAVIOR

The effectiveness and degree to which an individual meets standards of selfsufficiency and social responsibility for his/her age-related cultural group.

FIDELITY

The ethical principle that directs people to keep commitments or promises. Loyalty, faithfulness

Adherence

The extent to which a persons behavior corresponds w/agreed recommendations. Taking medications, following diet, exercising, or executing lifestyle changes.

EFFICIENCY OF CARE

The extent to which maximum care is provided to meet the desired effects/outcomes to improve quality of care and prevent the use of unnecessary resources.

EVALUATING OUTCOMES

The final step of the case management process, which is achieved by evaluating the results and consequences of the case management services provided to clients and their support systems.

APPEAL (CARE PROVISION RELATED)

The formal process or request to reconsider a decision made not to approve an admission or healthcare services, reimbursement for services rendered, or a client's request for postponing the discharge date and extending the length of stay.

HANDICAP

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 activities, otherwise considered normal for that individual based on age, sex, and social and 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.

CULTURE

The historical thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups regarded collectively as a group of people passed on by to the next generation.

Act of Omission

The intentional or unintentional neglect to perform an act or fulfill a duty that has been agreed on or required by law, where there is a duty to an individual or the public to act

COMPETENCE

The mental ability and capacity to make decisions, accomplish actions, and perform tasks that another person of similar background and training, or any human being, would bereasonably expected to perform adequately.

In regard to the psychosocial aspects of chronic illness and disability it is important for the case manager to know:

The more self-efficacy a client has, the more likely he or she will persevere when obstacles arise.

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 5TH EDITION (DSM-5)

The most recent edition of the American Psychiatric Association's manual that is used by clinicians and researchers to diagnose and classify mental disorders (American Psychiatric Association, 2013).

Length of stay

The number of days a person stays in a healthcare facility.

ENROLLMENT

The number of members in an HMO. The process by which a health plan signs up individuals or groups of subscribers.

Burden of proof

The obligation of a party in a dispute to provide sufficient warrant for their position or prove that a change from current policy is necessary. May pass from party to party.

AFFECT

The observable emotional condition of an individual at any given time.

COMPLAINANT

The party who files a complaint or on whose behalf a complaint is filed. A client, a member of the client's support system, an employer, a payor representative, or another case manager may file a complaint with CCMC.

DEFENDANT

The person against whom an action is brought to court because of alleged responsibility for violating one or more of the plaintiff's legally protected interests.

EFFICACY OF CARE

The potential, capacity or capability to produce the desiredeffect or outcome, as already shown, e.g. through scientific research (evidence-based) findings.

HABILITATION

The process by which a person with developmental disabilities is assisted in acquiring and maintaining life skills to: (1) cope more effectively with personal and developmental demands; and (2) to increase the level of physical, mental, vocational and social ability through services. Persons with developmental disabilities include anyone whose development has been delayed, interrupted or stopped/fixed by injury or disease after an initial period of normal development, as well as those with congenital condition.

DISCOVERY

The process by which one party to a civil suit can find out about matters that are relevant to his/her case, including information about what evidence the other side has, what witnesses will be called upon, and so on. Discovery devices for obtaining testimony, requests for documents or other tangibles, or requests for physical or mental examinations.

DISCHARGE PLANNING

The process of assessing the client's needs of care after discharge from a healthcare facility and ensuring that the necessary services are in place before discharge. This process ensures a client's timely, appropriate, and safe discharge to the next level of care or setting including appropriate use of resources necessary for ongoing care.

EDUCATION

The process of assisting clients and their support systems to learn to behave in a manner conducive to the promotion, maintenance, or restoration of health. It entails formal and/or informal learning experiences that provide clients/support systems the opportunity to acquire information and skills needed to make quality health decisions, improve health literacy, and develop lifestyle behaviors that are conducive to health and wellness.

ASSESSING

The process of collecting in-depth information about a client and her/his support system in order to identify the needs and decide upon the best case management services to address these needs. Similar to screening, however to a greater depth.

ASSESSMENT

The process of collecting in-depth information about a person's situation and functioning to identify individual needs in order to develop a comprehensive case management plan that will address those needs. In addition to direct client contact, information should be gathered from other relevant sources (patient/ client, professional caregivers, non-professional caregivers, employers, health records, educational/military records, etc.).

EXPERIENCE RATING

The process of determining the premium rate for a group risk, wholly or partially on the basis of that group's experience.

CASE-BASED REVIEW

The process of evaluating the quality and appropriateness of care based on the review of individual medical records to determine whether the care delivered is acceptable. It is performed by healthcare professionals assigned by the hospital or an outside agency (e.g., Peer Review Organization [PRO]).

IMPLEMENTATION

The process of executing specific case management activities and/or interventions that will lead to accomplishing the goals set forth in the case management plan.

COORDINATION

The process of organizing, securing, integrating, and modifying the resources necessary to accomplish the goals set forth in the case management plan.

McDonaldization theory

The process of rationalization, taken to extreme levels, substituting logically consistent rules for traditional rules by breaking them down into the most basic tasks to find the single most efficient method for completing each task. 4 components- efficiency, calculability, predictability, control (Ritzer, cultural convergence theory)

DISENROLLMENT

The process of terminating healthcare insurance coverage for an enrollee/insured.

Risk Stratification

The process to see what level of risk a person might have when exercising. Factors include: Known diseases Sign or symptoms Cardiovascular risk factors Is person low, moderate, high risk

DELEGATION

The process whereby an organization permits another entity to perform functions and assume responsibilities on behalf of the organization, while the organization retains final authority to provide oversight to the delegate.

EVALUATION

The process, repeated at appropriate intervals, of determining and documenting the case management plan's effectiveness in reaching desired outcomes and goals. This might lead to a modification or change in the case management plan in its entirety or in any of its component parts.(CCMC Certification Guide, p 7)

Cultural Retooling

The psychological process of adaptation to another culture, the process of incorporating new behaviors into ones cultural repertoire. 2 forms of this: instrumental integrative

return on investment

The ration of care costs to savings

Dignity

The right of a person to be values and respected for their own sake and to be treated ethically. trust: high mindset: analytical/linear negative emotions: suppress dominant strategy: Q&A

ERGONOMICS (OR HUMAN FACTORS)

The scientific discipline concerned with the understanding of interactions among humans and other elements of a system. Applies theory, principles, data and methods to environmental design (including work environments) in order to optimize human well-being and overall system performance.

Episodes of Care

The set of services provided to treat a clinical condition or procedure, value based bundle payment is a single payment for treating a patient with a specific medical condition across the continuum of care. Pays predetermined amount in lump sum-Bundled/case rate -Prospective payment system PPS

DIFFUSION OF INNOVATION

The spread of new technologies, ideas, or ways of doing things in a particular culture. It is the process of communicating change for the purpose of increasing the rate of its adoption and acceptance.

ASSURANCE/INSURANCE

The spreading of risk among many, among whom few are likely to suffer loss. The terms are generally accepted as synonymous. The term assurance is used more commonly in Canada and Great Britain.

IMPLEMENTING

The step in the case management process during which case managers execute specific case management activities and/or interventions to accomplish goals set forth in the case management plan of care and during the planning step.

FOLLOWING-UP

The step of the case management process when case managers review, evaluate, monitor and reassess the client's health condition, needs, ability for self-care, knowledge of health condition and case management plan of care, outcomes of the implemented treatments and interventions, and continued appropriateness of the plan of care.

CASE MIX INDEX (CMI)

The sum of relative weights assigned to a DRG of all patients/cases seen during a 1-year period in an organization, divided by the number of cases hospitalized and treated during the same year. CMI is used in determining the allocation of resources to care for and/or treat the patients in that group.

BENEFIT PACKAGE

The sum of services for which a health plan, government agency, or employer contracts to provide. In addition to basic physician and hospital services, some plans also cover prescriptions, dental, and vision care.

Surgical Site Infections are most commonly found in

The superficial incision and are most commonly caused by bacteria on patient skin

DEPOSITION

The testimony of a witness taken upon interrogatories not in open court, but in pursuance of a commission to take testimony issued by a court, or under a general law on the subject, and reduced to writing and duly authenticated, and intended to be used upon the trial of an action in court.

CASELOAD

The total number of clients followed by a case manager at any point in time

EXCHANGE VALUE

The tradability of a good or service and its associated price(i.e., what it is traded or exchanged for). Most often, exchange value is expressed using money (Smith, 2011).

HEALTHCARE HOME

The usual setting or level of care the client/support system selects to use on a routine basis to receive healthcare services such as a large or small medical group, a single practitioner, a community health center, or a hospital outpatient clinic. This is the central point for primary clinician caring for the client to coordinate necessary care and services based on the client's needs and preferences and among various care settings and providers.

CLIENT SOURCE

The way a case manager comes in contact with a client to provide case management services, usually taking place either by a referral from another healthcare provider, the client or a member of the client's support system. In some case management programs, client source may be based on screening of the client during a healthcare encounter; in other organizations it is only based on a referral.

CLINICAL REVIEW CRITERIA

The written screens, decision rules, medical protocols, orguidelines used to evaluate medical necessity, appropriateness, and level of care.

COGNITIVE REHABILITATION

Therapy programs which aid persons in managing specific problems in perception, memory, thinking and problem- solving. Skills are practices and strategies are taught to help improve function and/or compensate for remaining deficits.

geertz definition of culture

Thick description: does not assume functionality is historical allows internal paradox aims to uncover the emic self-understanding emphasizes language as vehicle of self-understanding Important: does not focus on our projections emphasizes symbols, stories

COMMUNITY SKILLS

Those abilities needed to function independently in thecommunity. They may include telephone skills, money management, pedestrian skills, use of public transportation, meal planning and cooking.

Nonconformance costs

Those related to errors, failures or defects (ex: malpractice, infections, staff shortages, service duplication

Conformance Costs

Those related to preventing errors (like monitoring and evaluation)

Ambiguity, interference, lack of equivalence

Three major constraints to successful knowledge transfer and translation

HIPAA

Title I guarantees health insurance access portability and renewal, prohibits discrimination based on health status

Agency for HC Research and Quality (AHRQ)

To produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the US Department of Health and Human Services and with other parnets to make sure that the evidence is understood and used appropriately. Publishes national clinical practice guidelines.

Milliman care guidelines

Took to ensure client is receiving correct level of service

American Nurses Association (ANA) staffing decisions

Tool developed to serve as guideline for determining RN staffing solutions, based on the needs of patients and qualifications of staff to allow RN to deliver safe, quality care at every practice level and setting. Acuity levels are important to balancing caseloads

FEE-FOR-SERVICE (FFS)

Traditional insurance billing method where providers are paid for each service performed, as opposed to capitation. Fee schedules are an example of fee-for-service.

TRICARE

U.S. government health insurance plan for all military personnel

Quality Assurance

Use of activities and programs ensuring quality of patient care

OASIS: prospective assessment

Used by HH agencies

BODY OF KNOWLEDGE (BOK)

Widely recognized information, standards, methods, tools, and practices about a specific field.

Collaboration

Working together to achieve better results

DISCLOSURE

Written authorization regarding the sharing of a client's information with other parties or in proceedings such as a complaint of an alleged ethical violation, which otherwise parties have no business being aware of such information.

Geriatric depression scale (GDS)

a 30 item self-report assessment used to identify depression in the elderly

a

a PCP that manages all referrals for speciality care and other services

patient centered medical home

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 (Model of care)

Point of Service (POS)

a combination of a PPO and HMO plan using a contracted network of providers and PCP as Gate Keeper to control referrals. out-of-network services incur higher deductible-I'm network providers are lower cost

Predictive Modeling

a data-mining technique used to predict future behavior and anticipate the consequences of change

Orthosis

a device used to support a weak or ineffective joint or muscle to restore function

Social Security disability insurance(SSDI)

a federal program that provides supplemental income to people who have employment restrictions due to disability

code of ethics

a formal statement of ethical principles and rules of conduct; CM's primary obligation- the client

vocational rehabilitation

a government service that provides training, career counseling, and job placement (Diverse Options)

global team

a group of heterogeneous employees from two or more countries (or companies) who work together to coordinate, develop or manage some aspect of a firm's global operations. Advantages: more creative and innovative ideas and solutions more comprehensive, realistic and acceptable sol. better understanding of culturally diverse markets effective with customers of different cultures Disadvantages: less close-knit groups more time needed to reach consensus culturally induced conflicts and misunderstandings

Medicaaid

a joint federal and state program that provides basic health insurance for persons with disabilities for or who received certain government benefits(ssi)

Medicaid

a joint federal and state program that provides basic health insurance for persons with disabilities for or who received certain government benefits(ssi)

Medical durable power of attorney

a legal document that names a surrogate decision-maker in the event the patient is unable to make decisions

Independent Practice Association (IPA) model

a legal entity(private practice) sponsored by physicians that contracts with HMO : bound by terms of contract

Outcome and Assessment information set OASIS

a nursing assessment instrument completed by Home Health agencies at the time the patient has entered for Home Health Services score determines Home Health Resource Group (HHRG)

Ticket to work program

a program that helps people with disabilities get back to work

Coinsurance

a provision under which both the insured and the insurer share the covered losses, cost-sharing

Neuropsychologist

a psychologist who studies how dysfunctions of the brain affect behaviors

I-QOL

a self-report instrument containing 22 items covering 3 domains of quality of life

benefit period

a specified amount of time during which benefits will be paid.

neoliberalism

a theory of political economic practices that proposes that human well-being can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterized by strong private property rights, free markets and free trade. The role of the state is to create and preserve an institutional framework appropriate to such practices" Ideology of pragmatists

Risk stratification

a tool for identifying and predicting which patients are high risk

Health risk assessment (HRA)

a tool to assess a patient's health status, risk of negative health outcomes, and readiness to change behaviors

Minnesota Multiphasic Personality Inventory (MMPI)

a well-researched, clinical questionnaire used to assess personality and psychological problems

unskilled

a worker that has not been trained or educated to do a specific type of job

Tort Liability

a wrongful act for which damages can be sought by the injured party

emic

accounts, descriptions expressed in terms of the conceptual schemes and categories regarded as meaningful and appropriate by the native members of a culture

Neglect

active or passive failure to provide the basic care supervision or services necessary to avoid physical or emotional harm

Goal of palliative care

adequate pain management relief of symptoms support patient and caregivers or family Psychosocial, spiritual, bereavement support

Medicare admission criteria for Inpatient Rehab

admitting Dx, recent loss of ADL, MD DX with potential Improvement, if previously in rehab has to have occurrence that shows pt can reestablish function

Medicare part C

allows participants to choose a Medicare Advantage plan, HMO type coverage

Newborns and Mothers Health Protection Act of 1996 (NMHPA)

an amendment to title VII of Civil Rights Act of 1964, that cover private/public hospitals length of stay following childbirth, pregnancy must be treated same as other employee related iilnesses

Self-insured

an employer that meets the state legal and financial requirements to assume all of its health care costs for its employees

CASE RESERVE

an estimate of the amount set aside by insurance companies to pay policyholders who have filed or are expected to file legitimate claims on their policies.

communication

an interactive process between senders and receivers in which senders encode their messages into a medium then transmit them to receivers, who in turn, decode the message, interpret them and respond appropriately

Reverse mortgage

an option for a patient who is a homeowner and 62 years of older to borrow against for health care needs

Third Party Administrator (TPA)

an organization separate from the insurer that handles administrative functions such as review claims & UR

Healthcare Maintenance Organization HMO

an organization that provides or arranges for coverage of health services for fixed fee

Rapid Estimate of Adult Literacy in Medicine (REALM)

assesses the ability of adult pt to read medical words& lay terms for illnesses & body parts

PHQ-9

assessment that evaluates degree of depression

Minimum Data Set (MDS)

assessment to used in SNF to place patients in RUG to determine reimbursement

Rancho Los Amigos

assessment to used to assess cognitive functioning after a traumatic brain injury

three faces of power

based on Schattschneider (Some issues are organized into human interaction, others are not) 3 faces of power: Overt power: decide an issue in one's favor Covert power: set agenda in favor of certain issues Ideological power: prevent issues from ever arising

Medicare Part A

basically covers inpatient hospital expenses for patients who meet certain conditions

Medicare benefit period

begins on admission, ends 60 days after discharge from inpatient status

Transtheoretical Model

behavioral model that describes stages of readiness for change

particularism

belief that what is right is in the eye of the beholder, situation dependent, and that people in different cultures may have different beliefs about it truth is subjective society can tolerate ambiguity right or wrong determined by circumstances and relationships, not just religion, rules and laws

sequential approach

both parties go through a proposed contract item by item and get agreement on each item sequentially

holistic approach

both parties work their way through the entire proposed agreement, but do not agree to anything until they have completed their review, discussion in its entirety

Mental Status Exam

broad preliminary assessment of behavior and mental state

Hospital length of stay

calculated in days, for newborn begins at the time of the delivery or last time of delivery in the event of multiple births. if the delivery occurs outside ohospital begins at time mother or newborn is admitted in hospital

Injured Workers

can change provider one time without prior approval from insurance company

Medical Home model

care focus on primary provider care and relationship between patient, family, and physician

Pallative care

care for seriously ill persons focused on providing relief from symptoms

Palliative care is

care that provides comfort rather than curative treatment

CMP

case management plan

CMI

case mix index

Supplemental Security Income (SSI)

cash assistance to people who are poor and older, or poor with disabilities

Home Health Agencies

charge hourly, avg $25 /hr

Reportable events requiring full CM services

child/elder abuse violent crime domestic violence

wang and huang

chinese "relationship" concept does not fit fit hofstede's individuality dimension chinese culture is not collectivistic emphasis on reciprocity, with individual agency "Self" is not independent but socially interdependent (cultivated) Exam: Able to bridge incommensurability through focusing on the differences between Western and Confucian rule-systems on placing individuals in society

moral relativism

claims that there are no absolute moral facts, on any topic or issue more than one position can be morally correct, depending on the situation or cultural environment. 2 forms: descriptive: people's moral beliefs differ from culture to culture normative: not just convictions but moral facts themselves can differ from culture to culture Challenges to this: no culture can be wrong external criticism is illegitimate limits the potential for moral progress

moral absolutism

claims that there are some moral facts in the world that are universally and indisputably true, irrespective of culture Challenges to this: problem of definition and application: we would need absolute knowledge (this would eliminate moral problems) value conflict (idea of a supreme good denies the possibility of moral conflict)

Resource utilization groups (RUGs)

classifiies SNF patients into 7 major hierarchies and 44 groups, based on MDS for reimbursement

requirements to achieve global team synergy

clear, engaging purpose performance goals and measures people results driven processes preparation and practice

Test of Functional Health literacy assessment (TOFHLA)

complex assessment consists of two parts (numbers/documents & reading comprehension) to assess health literacy

a

condition that interferes with a person's ability to function normally

Informed Consent

consent given by patient, next of kin, legal guardian for services

Milliman care guidelines

considered general recovery guidelines

Palliative care program

constant review of pt needs and tx, while noting their religious beliefs, cultures & values

Outcome and Assessment Information Set (OASIS)

contains data items developed for measuring patient outcomes for the purpose of performance Improvement in home healthcare, required for all Medicaid and Medicare beneficiaries

Soft savings

cost savings that can't be measured, ex: avoidance of hospital readmission

chronic care model

created to address deficiencies in chronic care, the Aging population and patients with chronic conditions. Can be applied to many chronic conditions in many healthcare settings

language and linguistic structures, selective participation, cognitive evaluation, cultural logic

culturally mediated cognitions (cultural screens)

Per diem

daily rate allowance for insurance payment to a faciltiy

Non-maleficence

deals with the practitioner (do no harm)

Goal of Medication Reconciliation

decrease med errors, omissions, duplication of drugs, drug interactions, & dosing errors

Hall

descriptive etic model of cultural dimensions: context (high vs low) space (center of power vs center of community) time (monochronic vs polychronic)

trompenaars

descriptive etic model of cultural dimensions: Layers: explicit culture, norms and values, implicit assumptions Dimensions: universalism vs particularism individualism vs collectivism specific vs diffuse neutral vs affective achievement vs ascription time perspective relationship with the environment

hofstede

descriptive etic model of cultural dimensions: power distance uncertainty avoidance individualism vs collectivism masculinity vs femininity time orientation indulgence vs restraint

schwartz

descriptive model conservatism vs autonomy hierarchy vs egalitarianism mastery vs harmony

a

descriptive model power distance, uncertainty avoidance, humane or.m institutional collectivism, in group collectivism, assertiveness, gender, future or., performance or.

steers

descriptive model power: hierarchical vs egalitarian social relationship: individualist vs collectivist environmental: master vs harmony time: monochronic vs polychronic uncertainty & social control: universalistic vs particularistic

individual

difference factors for expatriate success: Positive: cultural intelligence self-efficacy language ability previous international experience extraversion agreeableness Negative: neuroticism -

direct context

difference factors for expatriate success: Positive: job factors (role discretion and clarity) Negative: job factor (role conflict) cultural distance culture novelty

SSI supplemental security income eligibility

disabled, blind, retirement age

institutional facts

distinctive features of these facts (opposed to natural or social facts) are: they have a subjective ontology: must be collectively recognized they are functional they are symbolic: status is irrespective of their physical structure they create deontic powers (rights, duties) which have to be collectively recognized & accepted

functional, historical

edgar schein: "a pattern of shared basic assumptions that a group has learned as it solved its problems of external adaptation and internal integration...". Type of definition (2)? artifacts -> values -> assumptions

EHR

electronic health record

Inpatient Rehabilitation hospital

eligibility: tolerate 3 hours of therapy/day 5-7 days a week, require skilled service (pt, pt, st, etc) Intense therapy

Inpatient Rehabilitation

eligibility: tolerate 3 hours of therapy/day, require skilled service

respondant superior

employer is responsible for actions of employees

Chronic subacute

est stay 60-90 days 3-5 hours nursing services/day

Supremacy of values

feeling that one's own values reign supreme over all those involved

Rotary International

first focuses on six areas for grants:, two focus on Health disease and prevention( HIV/AIDs) maternal and child health.

Long Term Acute Care Hospital (LTAC)

focus on patients who require stay more than 25 days and treatment of serious conditions: may improve to go home

chronic care model

focused on proactive evidenced based, population based, & patient-centered care for patients with chronic medical conditions

LEAN approach (quality improvement technique)

focused on what's valuable to customers, pt, payers, providers, regulatory bodies

Public Health nursing model of care

focuses on an entire population that has similar health issues

Medical-social model of CM

focuses on needs of long-term care patients combine medical services with social services

Key component of Case Managers job

follow-up and monitoring

Medicare hospice benefit covers inpatient respite care...

for up to 5 consecutive days short-term relief to primacy caregiver

instrumental

form of cultural retooling: necessitating, suppressing transforms experienced emotions, but not experienced psychological states could feel inauthentic (as emotions suppressed)

integrative

form of cultural retooling: self-licensing, personalizing (more adaptive) transforms psychological states and experienced emotions

Retrospective review

form of medical records review that is conducted after the patient is discharged

Wickline vs. State of California

found the CM's are liable for damage if their referral is careless and leads to patient harm

mental

geert hofstede: "the collective programming of the mind that distinguishes one group or category of people from others". Type of definition (1)? [practices] symbols -> heroes -> rituals -> values

Contemplation stage

getting ready to change possibly within 6 months

globalists

globalization is real and tangible, new global structure with new rules Positive _______: stretched social relations improving quality of life, raise living standards, multicultural understanding, development of new technologies Pessimistic _______: world becomes less diverse and more homogenous, dominance of the global north, uneven development, pollution

Home Health Care

health care services provided in a patient's home, to qualify patient must be homebound

motivational interviewing

helps clients explore and resolve ambivalence and find the best possible solution

60% rule for Inpatient rehab facilities (IRF)

helps define IRF by requiring 60% of admissions have one of 13 qualifying medical conditions, tracked for the fiscal year

Descriptive Culture Models

hofstede, hall, steers, aslani, GLOBE, trompenaars, schwartz

Reintegration plan for patient with TBI should include

housing financial support job training family support medical support assistive devices environmental modifications safety follow up

OSHA

in the Department of Labor to maintain a safe and healthy work environment

Red Flag

indicator that the case is not routine and could benefit from a case manager: risk indicator

SSDI eligibility requires

individual must be unable to perform the work they previously did and the disability must be expected to last at least one year or result in death

monitor, disseminator, spokesperson

informational managerial roles (Mintzberg)

Maximum Medical aMMI

injured worker is at level physician determines further treatment will not change outcome

long term disability

insurance issue to an employee group or individual to replace a portion of an individual's income lost as a result of serious prolong illness during the normal work career

OASDI: Eligibility for Retirement

insurance program for Oasis virus and disability Center of Social Security Act

stop loss

insurance that is brought by insurers to limit loss for Catastrophic, unpredictable incidents

Malpractice Insurance

insurance to cover liability assumed during practice

Work hardening

intensive rehab offered 8 hrs a day for 5 days a week Intense structured program focused on specific tasks, designed to return worker to full employment Goals: increased confidence, control of manifestation of condition, increased work tolerance and rate Attainment of a level of competence that allows a client to return to work

liaison, leader, figurehead

interpersonal managerial roles (Mintzberg)

Handoffs

involves three types of transfers from one provider to another, one setting to another, or one level of care to another

Managed Care

is a Cost Containment Healthcare System overseen by an organization other than the physician or patient

TRICARE

is a U.S. government health insurance plan for active military personnel, national guard, reserves, retirees, their families and some former spouse's.

predictive modeling

is a data-mining technique used to predict future behavior and anticipate the consequences of change Predict outcomes for individual patients, identify risk early Mathematical process that quantifies a clients likely future health costs compared to others in the population

JCAHO stands for:

joint commission on accreditation of health care organizations

normative approach

leadership approach: leader as a global manager (global mindset, cultural intelligence)

contingency approach

leadership approach: leader as a local or regional manager (GLOBE project) seems most suited "When in Rome..."

universal approach

leadership approach: leader as a universal leader (mainly: charismatic or transformational leadership traits) Also: trustworthiness, integrity, visionary, inspirational, motivational, communicative, team builder

Sub-acute Care

level of care where patient doesn't require hospital care but more intensive than SNF services

Aggregate Limits

limits the amount that can be paid in a policy period/year, form of stop-loss

Long-term care facilities

mainly provide assistance and care for elderly patients, usually called residents

Reasonable Accommodation

make an existing facility accessible and usable for individuals with disabilities; can include job adaptation for individuals

Glasgow Coma Scale (GCS)

measures level of coma in the acute phase of an injury

a

measures level of coma in the acute phase of an injury

Concurrent review

method of reviewing patient care and services during a hospital stay to validate care necessity

Magnuson Model

model to determine the patient intensity or Acuity levels.

Medication reconciliation

must be completed to avoid or prevent polypharmacy

Persons vulnerable for pitfalls in transitions of care

non English-speaking, different cultural backgrounds, children with special needs, frail elderly person, cognitive impairments, complex conditions, disabilities, low-income

Uilization Review Accreditation Commission (URAC)

non-profit organization that provides accreditation to Health Care organizations

Skilled Nursing Facility (SNF)

offers 24-hour skilled nursing and personal care also Rehab Services

Healthcare reimbursement

one major category of knowledge necessary for case manager

National Quality Forum (NQF)

organization that's set standards used to measure public report Healthcare quality

social constructionism

paradigm in social science: interpretive (hermeneutic) model, largely qualitative, social reality is not objective but intersubjective

positivism

paradigm in social science: preferably quantitative, natural and social reality are ruled by causal laws, social science must follow example of natural sciences

competitive bargaining

part of competitive negotiation, win-lose game Preparation: identify economic benefits and defense Relationship-building: weakness in opponent, reveal little Information exchange & 1st offer: little information as possible, explicit, hard offer (unrealistic) Persuasion: dirty tricks and pressure Concessions: high initial demands, slowly Agreement: sign only when winning and tight contract

problem solving bargaining

part of problem solving negotiation, win-win game Preparation: define long-term goals, overcome cross-cultural barriers Relationship-building: adapt to culture, separate people from the problems and goals Information exchange & 1st offer: give and demand, accept cultural differences in speed, make reasonable offer Persuasion: seek new and creative options in the interest of both parties Concessions: search for mutually acceptable criteria Agreement: sign when interests are met, adapt to cultural differences in contracts

When medication reconciliation should be done?

patient is moved within a hospital, transfer to another facility, discharge, & at each MD visit

Outlier payment

payment due to unusual variation in the type or amount of medically necessary care

No-fault auto insurance

pays for injury/damages resulting from driving care (coverage varies by state)

Indemnity Plan

pays predetermined payment for loss or damage rather than health care service

Spend down

people spend down assets on medical bills to qualify for medicaid

Medical Battery

performing the wrong medical procedure or performing a procedure without the patient's consent

forms of abuse

physical , emotional /psychological, Financial

Four key Functions of Case Manager

planner , assessor, facilitator , & advocate

Transtheoretical Model of Change

precontemplation, contemplation, preparation, action, maintenance

Stages of Change

precontemplation, contemplation, preparation, action, maintenance, termination

Common complications of SCI

pressure sores UTIs DVT Pulmonary emboli pneumonia automatic dysreflexia

TRICARE for Life

primarily a supplemental insurance with those with Medicare A & B coverage, &eligible for TRICARE in US. Is the primary insurance overseas.

Expatriate

principal management focus: long term face to face presence overseas mode of interaction: largely fact to face- key success factors: deep cultural knowledge of business practices, multilingual skills, understanding global issues- typical cultural challenges: regional myopia, overemphasis on local issues

virtual managers

principal management focus: remote technical management in specialized areas mode of interaction: largely virtual key success factors: modest awareness of cultural differences, multilingual skills useful (not crucial) typical cultural challenges: technological myopia, ignorance of cultural influence on communication

Predictive model

process used by Managed care organizations to identify target high costs/expenditures and services

Quality Improvement

process used to identify and resolve deficiencies and improve care outcomes

American with Disabilities Act

prohibits discrimination against people with disabilities in employment, Transportation, public accommodation, communications & governmental activities

American Disabilities Act

prohibits discrimination in employment , accommodatios of people with disabilities

Mental Health Parity Act of 1996

prohibits lifetime or annual dollar limits on Mental Health Care unless same limits apply to medical/surgical tx

home health care

provide care in a patient's home; nursing care, personal care, therapy, etc. person must be home bound to qualify

Primary care physician (PCP)

provider who assumes ongoing responsibility for overall health treatment of a patient

Workers Compensation

provides coverage of injury or illness that occurred while at work or work-related task

Knights of Columbus

provides funding for charitable endeavours with a focus on disabilities

western cultural biases in negotiation

rationality (analytical thought and logic) economic capital, pareto optimality (mastery, individualism, weak social ties) dispositional attributions (individualism) direct information sharing (low context) direct voice (individualism, egalitarianism)

Due diligence

reasonable steps taken by a person in order to avoid negligent action.

Hospice care requires

recertification of Hospice every days 60 days if patient remains alive after 6 months

Prophylactic broad-spectrum antibiotic therapy before and after surgery can

reduce infection by 40-80%

Within the walls (WTW)

refers to activities within the hospital

Beyond the Walls (BTW)

refers to case management in outpatient and Community settings

habitus

refers to learned practices and standards that have become so much part of ourselves that they feel self-evident and natural. Our culturally and socially shaped second nature. Becomes our self.

transitions of care

refers to the movement of patients between locations Healthcare Providers or different levels of care within same facility. Narrow subset of the broader concept of Transitional Care

ideology

refers to the relationship between ideas (whether implicit or explicit, whether dominant or marginal) and social reality (whether true in a narrow epistemological sense or in the sense of lived experience) and the mechanisms through which these ideas are formed.

investor model

regional organizing model: principal emphasis on stockholders and investors as principal beneficiaries Characteristics: mastery-oriented (achievement, mastery, individualism, universalism) powerful-CEOs (individualism, agreement) professional management (universalism, individualism) fluid org. design (looseness, individualism, specificity) low job security (low human orientation, high performance orientation, mastery)

mutual benefit model

regional organizing model: relative balance between stockholders and investors, most employees, local community and public Characteristics: supervisory and management boards (relative moderate individualism, long term orientation) Codetermination (individualism, low power distance) Meister & Technik (mastery, achievement, low power distance)

network model

regional organizing model: sequential emphasis on corporate network, individual company shareholders and permanent employees. Characteristics: Keiretsu: Japanese form of corporate organization, a network of affiliated companies (kaisha), form an alliance for mutual success Seniority & group -based rewards (human orientation, lower performance orientation, ascription, collectivism) Internal financing, Trading company, Weak executives (collectivism, uncertainty avoidance) Lifelong employment (collectivism, long term orientation, human orientation, paternalism)

Claims

request for payment or reparation for a loss covered by insurance contract.

Women's Health and Cancer Rights Act of 1998 (WHCRA)

requires insurance coverage of breast reconstruction following mastectomy

HIPAA Title II

requires written consent and permission from the patient to share information

world is spiky

richard florida: "surprisingly few regions truly matter in today's global economy" Due to: path dependence: current world still reflects traditional colonial powers location paradox: resilience of highly specialized regions (ex: silicon valley) coordination: required by complicated infrastructure states still matter

mental, behavioural

ruth benedict: "the personality of a society as expressed in its habits that distinguishes it form others". Type of definition (2)?

Health Coach

secondary prevention, already has chronic condition, focused on assisting them to attain their own healthcare goals

GUIDELINES

see practice guidelines

Pharmacy Benefit Management (PBM)

services used to control the cost of prescription drugs

Indirect costs

shared costs (ex: infrastructure costs, costs of custodial services)

Integrated delivery system

single group of organizations that provide care across a continuum of settings

Internationalists

skeptical of globalization, disputing evidence of a fundamental shit, emphasizes continuities, majority of economic and social activity is regional

universalism

some people believe that what they hold to be morally right is universally correct and true, and that people who disagree with their beliefs are simply wrong or misguided truth is absolute society requires certainty and predictability right or wrong determined by religion, laws etc.

global manager

someone who works with or through people across national boundaries to accomplish global corporate objectives. 3 categories: expatriates: long-term face-to-face, high cultural embeddedness, low tech dependence, overemphasis on local issues frequent flyers: short-term face-to-face, low-med cultural dependence and tech dependence, overemphasis on global issues virtual managers: low to no cultural embeddedness, high tech dependence, ignorance of impact of cultural differences on the local uses of communication and IT

HIPAA Title IV

specifies conditions for Group Health Plans regarding coverage of persons with pre-existing conditions

HIPAA Title III

standardized is the amount that may be saved per person in pre-tax HSA

State children's health insurance program (SCHIP)

state insurance for low income. uninsured children not eligible for medicaid

structural intervention

strategy for work in diverse groups: team is affected by emotional tensions relating to fluency issues or prejudice, perceived status differences inhibits certain members team or tasks can be subdivided to mix cultures or expertise sub groups can strengthen pre-existing differences, subgroups have to fit back together

managerial intervention

strategy for work in diverse groups: violations of hierarchy have resulted in loss of face, ground rules being absent have caused conflict high levels of emotion, stalemate reached, higher level management is willing and able to intervene team has become overly dependent on manager

mental retardation

subaverage intellectual functioning during developmental period

Reserves

sum of money insurance company or self-insured funds set aside to pay claims cost

Medigap

supplemental insurance plans that help pay expenses not covered by Medicare

Competence

the ability to do something successfully or efficiently, mental capacity

Transitional Care

the actions to assure coordination and continuity of care as patient transfer between different locations or different locations within same facility

normative control

the attempt to elicit and direct required efforts of members by controlling the underlying experiences, thoughts and feelings that guide their actions Most important aspect: identity regulation

context of global managers

the characteristics of the global environment that can limit what managers must do (demands), and what they must not do (constraints). 3 elements of complex environment surrounding a manager's job are identified: cultural environment (beliefs, values) organizational environments (stakeholders, structures) situation contingencies (people, goals, roles)

Comorbidity

the co-occurrence of two or more disorders in a single individual

Verocity

the duty to present information honestly and truthfully

transformationalists

the form of global social relations does not display a significant shift, the characteristics are distinctive. Autonomy of nation states is constrained, but globalization is not inevitable

Pooling risk

the grouping of high risk beneficiaries

Levels of Care

the intensity of effort required to diagnose, treat, preserve or maintain an individuals functional status

glocal

the local interpretation and translation of normative ideas, management practices, popular cultural imaginations, circulating within and between different action nets

psychological adjustment

the process of developing a way of life in the new country that is personally satisfying Stress/strain perspective: characterizes this through frustration, anxiety, depression etc. Through this also comes culture shock (Oberg), 4 stages: honeymoon, disillusionment, adaptation, biculturalism Stress-adaptation-growth model: spiral of stress and adaptation, leading to growth-over-time

socio cultural adjustment

the proficiency and ability an individual has to interact completely with the host culture. May go hand in hand with quality of life Made up of: Acculturation (acquiring new culture & language) Deculturation (letting go of old cultural practices)

Indemnity Benefits

the provider bills the patient for services, insurance reimburses patient

Ostensible Agency

the relationship that exists between the case manager(agent) and a referral provider

Primary nursing model of care

the same nurse provides comprehensive care for the member the entire period of care

meaningful use

the use of certified EHR technology to achieve health and efficiency goals

work hardening

therapy designed to simulate real job duties in order to build up strength and improve endurance 3-5/wk with a goal to return to work

job accommodations

things that help workers with disabilities to do their jobs

Goal of the URAC

to encourage continued Improvement in quality and efficient Healthcare Management to education and accreditation

honor

trust: low mindset: moderately linear negative emotions: express dominant strategy: hot S&O

symbolic

type of culture definition: based on arbitrarily assigned (sometimes even contradictory) meanings that are shared by a community thinking: 3/4, almost fully emic

structural

type of culture definition: consists of patterned and interrelated ideas, symbols, and behaviours acting: 3/4, very etic

historical

type of culture definition: culture as social heritage, passed onto future generations acting: 1/4, emic and etic

mental

type of culture definition: culture is a complex of ideas, or learned habits, that curtails impulses (social control) and distinguishes people from animals thinking: 4/4, emic and etic

topical

type of culture definition: everything on a list of "topics" considered culture, religion, economy etc. thinking: 1/4, very etic

normative

type of culture definition: primarily consists of ideals, values, norms, laws and rules for living thinking: 2/4, quite emic

functional

type of culture definition: the way humans solve problems of adapting to the environment (external) and of living together (internal) acting: 2/4, quite etic

low context

type of culture: overt message content, non-verbal cues often unimportant, medium<message, status difference rarely affect medium and message

high context

type of culture: subtle message content, non-verbal cues important, medium>message, status difference often affect medium and message

collaborative

type of organizational decision making (high participation): NL, DE, SWE moderate problem analysis, slow decision making moderate acceptance and implementation

consultative

type of organizational decision making (moderate participation): Japan slow problem analysis and decision making rapid acceptance and implementation

signs of abuse

unexplained bruising, malnutrition, unkempt, multiple ER visits

Work Adjustment

use of simulated work activity to develop work behaviors, attitudes, characteristics

Polypharmacy

using multiple medications, or more than medically necessary, common in elderly

Pre-admission Certification

utilization review process that examines proposed Services before admission

Trompenaars basic idea

variation in values and personal relationships across cultures

Lions club

vision resource, and disabilitie, diabetic prevention and treatment