Ch. 16: Case and population health management

17. Community health means meeting the: a. collective needs of a group by identifying problems and managing interactions. b. needs of an individual within the community by identifying problems and managing interactions. c. needs of the health care system within a population or area. d. needs of a population by identifying problems and managing interactions.

ANS: A Community health means meeting the collective needs of a group by identifying problems and managing interactions within the community and between the community and larger society.

1. The core element common to all provider interventions in case management (CM), disease management (DM), and population health management (PHM) is: a. disease preventative care. b. care coordination. c. client-centered. d. population-focused.

ANS: B Care coordination is the core element common to all provider interventions in CM, DM, and PHM.

14. A health care management continuum: a. deals strictly with health promotion. b. controls problems at the population level. c. is a linkage of health services across settings. d. provides another health care option for the homeless.

ANS: B The health care management continuum is better known as population health management (PHM). One definition of population health management is "the process of addressing population health needs and controlling problems at a population level" (Nash et al., 2016).

2. The nurse who uses collaboration to coordinate care for an individual's and family's comprehensive health needs through communication and available resources to promote patient safety and quality, cost-effective outcomes is performing: a. population health management. b. managed care. c. disease management. d. case management.

ANS: D Case management (CM) is "a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote patient safety, quality cost-effective outcomes" (Case Management Society of America, 2016a).

18. The Collaborative Care Model of CM is best used for: a. patients with co-occurring physical and mental health needs. b. individuals and small systems. c. hospital-based case management programs focusing on episodic care. d. the transition of high-risk clients from acute care to community or long-term care settings.

ANS: A In the Collaborative Care Model, dedicated team members address the needs of patients through a comprehensive and strategic care delivery process. Included in the team are a primary care provider, a case manager who is trained in behavioral health, and psychiatric consultants and/or behavioral health specialists (Unützer et al., 2013). This comprehensive approach to care serves as a proactive means to screen and track mental health conditions within the primary care setting.

4. Which of the following governmental agencies tracks population and health trends? (Select all that apply.) a. U.S. Census Bureau b. The Joint Commission c. CDC d. Bureau of Labor Statistics (BLS) e. Health Resources and Services Administration (HRSA)

ANS: A, C, D, E Population and health trends are tracked by governmental agencies such as the U.S. Census Bureau, CDC, BLS, and HRSA, as well as private foundations and organizations.

15. A population health approach: a. aims to improve the health of the entire population. b. is funded by local, state, and national governments. c. strives to care for people who already exhibit optimal health. d. treats community-acquired diseases in area clinics.

ANS: A Population health is an approach to health that aims to improve the health of the entire population and reduce health inequities among population groups.

8. Which of the following statements is true about the New England Medical Center (NEMC) case management model? a. It has a client-centered approach instituted during episodes of acute illness. b. It is known as a beyond-the-walls, medical-social, across-the-continuum of care model. c. It emphasizes the case manager's traditional linkage function. d. CM functions are undertaken as a part or an extension of therapeutic intervention.

ANS: A The NEMC model is a client-centered approach instituted during episodes of acute illness. It focuses on resource utilization, nursing accountability, and outcomes.

7. Nursing outreach programs are the core element of: a. population health management. b. disease management. c. case management. d. care management.

ANS: A The newest generation of PHM programs involves proactive outreach. Nursing outreach programs are the core element. Personal communications (usually via telephone) between an expert nurse and the health plan participant build a personal relationship, help identify knowledge deficits and counseling needs, facilitate close monitoring and progress toward goals, enhance treatment adherence, and promote clinical and cost stabilization.

5. _____ has garnered considerable attention in health care in part because of the publication Crossing the Quality Chasm, a health care quality initiative of the Institute of Medicine (IOM, now called the National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division). a. Disease management b. Development research groups c. Case management d. Diagnosis-related groups

ANS: A Two major forces triggered the rise of a DM perspective: (1) the abundance of managed care systems as a prevailing form of organized health care delivery (the influence of health plans), and (2) the national attention generated by Crossing the Quality Chasm, a health care quality initiative of the Institute of Medicine (IOM, now called the National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division).

6. A disease management program usually focuses on patients with: a. chronic conditions. b. mental health issues. c. outpatient procedures. d. surgical diagnoses.

ANS: A While CM programs serve a smaller percentage of the overall population, enrollees are complex from a medical-behavioral, health-social vulnerability perspective. DM programs serve a larger percentage of patients whose main problem is one or more chronic condition(s). These individuals generally have similar primary needs regarding health condition education and accommodation strategies

5. The CM dyad team model—composed of a nurse case manager and social worker—has been widely adopted in hospitals. Through its unique structure, the nurse and social work dyad provides the implementation of collaborative interventions that focus on: (Select all that apply.) a. minimization of inpatient transitions. b. promotion of patient and family satisfaction through efforts of advocacy. c. maximization of health care benefits. d. reduction of cost by decreasing the length of stay. e. enhanced discharge planning.

ANS: A, B, D, E Through its unique structure, the nurse and social work dyad provides the implementation of collaborative interventions that focus on (1) minimization of inpatient transitions, (2) reduction of cost by decreasing the length of stay, (3) promotion of patient and family satisfaction through efforts of advocacy, and (4) enhanced discharge planning

1. Which of the following components are common to all case management models? (Select all that apply.) a. Client identification and outreach b. Population management c. Monitoring service delivery d. Individual assessment and diagnosis e. Evaluation f. Environmental management

ANS: A, C, D, E There are eight main service components common to all case management models. They are client identification and outreach; individual assessment and diagnosis; service planning and resource identification; linking clients to needed services; service implementation and coordination; monitoring service delivery; advocacy; and evaluation.

6. Population health management (PHM) is viewed as a major health care strategy to improve health outcomes. This is because effective population health management programs: (Select all that apply.) a. have proactive interventions. b. promote client satisfaction through advocacy. c. coordinate care for chronic conditions. d. have consistency of care for at-risk populations. e. customize care support. f. encourage adherence to treatment.

ANS: A, C, D, E, F PHM is now being viewed as a major health care strategy to improve health outcomes across multiple populations while lowering costs and improving patient satisfaction. PHM has demonstrated effectiveness across disease states, including integrated behavioral health, chronic illness (e.g., diabetes, congestive heart failure), and assorted payers (e.g., Medicare, Medicaid, third-party populations) (Fortney et al., 2015; Lyles, 2016; Rushton, 2015; Sidorov & Romney, 2016). Attractive features include effective population management, coordination of care for chronic conditions, consistency of care for at-risk populations, customization of care support, encouragement of adherence to treatment, and proactive interventions

12. Which of the following collaborative processes assesses, plans, facilitates, coordinates, advocates, and evaluates options and services required to meet an individual's comprehensive health needs? a. Care management b. Case management c. Disease management d. Population health management

ANS: B Case management (CM) is "a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote patient safety, quality cost-effective outcomes" (Case Management Society of America, 2016a).

4. A concept involving a system that guides and tracks patients over time through a comprehensive array of health services to span all levels of intensity of care is known as: a. transition of care. b. continuum of care. c. rounds. d. disease management strategies.

ANS: B Continuum of care is a concept involving a system that guides and tracks patients over time through a comprehensive array of health services to span all levels and intensity of care (Young et al., 2014). The services incorporated in each patient's unique continuum vary based on the individualized health and/or behavioral health needs of each person.

11. Which of the following scenarios would require disease management? a. A blood pressure screening clinic is started at the senior citizen center. b. A person with multiple chronic illnesses is admitted to the hospital. c. A program is started to address diabetes in the Native American population. d. An initiative is developed to promote fluoride treatments in schools.

ANS: B DM programs serve a larger percentage of patients whose main problem is one or more chronic condition(s). These individuals generally have similar primary needs regarding health condition education and accommodation strategies. Assessments focus on health condition-specific issues, and programs take a more standardized approach to education and resources (Chen et al., 2000).

9. The hospital's disease management program has gathered data collected from health assessments in order to categorize patients into like groups with the intention of providing population management interventions. This practice or strategy is referred to as: a. analogizing. b. stratification. c. comparing. d. data exchanging.

ANS: B In population health management, stratification has two meanings (PHA, 2015): a method of randomization and a process for sorting a population of eligible members into groups relating to their relative need for total population management interventions. The stratification process harvests information that can be used to divide the patient population into different levels to ensure a return on investment (ROI) based on resources allowed.

3. Case management and disease management are similar because both are interventions designed to coordinate care for better outcomes and lowered costs. Which statements are true regarding the differences between the two terms? (Select all that apply.) a. Disease management is client focused. b. Case management focuses on coordinating care of individuals and families. c. Disease management is more population-based than client-centered. d. Disease management is more episodic in its approach. e. Case management is more population-focused.

ANS: B, C Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote patient safety, quality cost-effective outcomes. Disease management is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant.

2. Which of the following statements accurately describe disease management? (Select all that apply.) a. Disease management is care coordination that is organized to achieve specific client outcomes, given fiscal and other resource constraints. b. Disease management is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant. c. Disease management relies on a structured system of interventions that focus on a specific condition. d. Disease management program content and interventions are evidence and guideline based. e. Disease management is the medical management of chronic disease.

ANS: B, C, D Disease management is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant. DM programs usually focus on a single condition, rely on a structured system of interventions that focus on a single condition; and program content and interventions are evidence and guideline based.

19. The first step in the development of a case management program is: a. to identify high-volume or high-risk case types. b. to develop a pilot program. c. to assess the organization and the client population served. d. to form an interdisciplinary care team.

ANS: C The general process for the development of a case management is to assess the organization and the client population served; identify high-volume or high-risk case types; determine the usual client care problems, issues, or difficulties related to the high-volume or high-risk case types, with desired goals; form an interdisciplinary care team of the interrelated care providers who will be involved with the case types; develop and design an interdisciplinary critical pathway for each selected case type; develop a pilot program or trial site; and then evaluate the pilot program and consider system-wide implementation

16. To be effective at population care management, both CM and DM need to: a. assess and plan health initiatives within an area. b. implement and evaluate health programs within a community. c. assess and define the populations to be served. d. organize and regulate health professions across the country.

ANS: C To be effective at individual and population-based care management, both CM and DM programs need to identify, assess, and define the populations to be served early in the program planning effort

20. According to the Centers for Disease Control (CDC), chronic diseases account for _____% of deaths in the United States. a. 20 b. 40 c. 50 d. 70

ANS: D Chronic diseases such as heart disease, cancer, and diabetes are the leading causes of death and disability in the United States. Chronic diseases account for 70% of all deaths in the United States, which is 1.7 million each year. These diseases also cause major limitations in daily living for almost 1 out of 10 Americans, a total of about 25 million people.

3. The brokerage model and the comprehensive service center model are examples of which type of care model? a. Collaborate b. Inter-professional c. Interdisciplinary d. Social work

ANS: D The brokerage model, the primary therapist model, the interdisciplinary team model, and the comprehensive service center model are all examples of social work models.

13. Which of the following factors best suggests an individual is motivated to engage in a disease management program? a. Mistrust of insurance companies b. Enrollment at initial contact c. Can afford the cost of enrollment d. Has a need that would benefit from the program

ANS: D The results of a 2014 study that examined factors driving engagement suggest that individuals most motivated to engage are those who are well informed of the program benefits and have a perceived need that would benefit from said program (e.g., living alone, needing a supportive person to discuss ideas) (Hawkins et al., 2014).

10. A patient has a history of diabetes mellitus, myocardial infarctions, and hypertension. His HgbA1c level dropped from 7.8% to 6.2% 2 months after he began a walking exercise program. The nurse case manager had provided diabetic education and suggested ways to enhance his cardiac reserve. This is an example of: a. nursing empowerment. b. nursing knowledge. c. patient expertise. d. patient participation in care.

ANS: D The scenario depicts an example of a case manager's intervention resulting in a positive clinical outcome. This is the result of the patient's participation in his own care.