Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

CCMC > Domain 1 - Care Delivery and Reimbursement Methods (Part 1) > Flashcards

Domain 1 - Care Delivery and Reimbursement Methods (Part 1) Flashcards

1
Q

What are the 5 domains?

A
  1. Care Delivery and Reimbursement Methods
  2. Psychological Concepts and Support Systems
  3. Quality, Outcomes Evaluation and Measurement
  4. Rehabilitation Concepts and Strategies
  5. Ethical, Legal and Practice Standards
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the three main objectives of Triple Aim?

A

Improve the experience of care
Improve the health of populations
Reduce the per capita cost of care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is automony?

A

A person’s ability to act on his or her own values and interests. The ability and right of a person to self-determine their actions, values, and goals, without undue influence or coercion from others.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is beneficence?

A

The ethical principle of doing good or acting in the best interest of the patient.

Example: providing comfort to a dying patient or assisting with tasks a patient cannot perform independently.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is nonmaleficence?

A

The avoidance or minimization of harm.

Example: holding a medication due to adverse reactions or taking steps to ensure a safe work environment.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is veracity?

A

Conformity with truth or fact.

Example: if a patient was starting chemotherapy and asked about the side effects, a nurse practicing veracity would be honest about the side effects they could expect with chemotherapy.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is justice?

A

In healthcare, justice refers explicitly to the philosophical concept of “distributive justice.” This principle asserts that all persons (patients) will be treated fairly and equitably.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the first duty of a case manager to a client?

A

To act as the clients advocate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What does HUDDLE stand for an what are they used for?

A

Health Care, Utilizing, Deliberate, Discussion, Link, Events

A strategy for the improvement of communication to facilitate better outcomes.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the 9 steps in the case management process?

A
  1. Screening
  2. Assessing
  3. Stratifying Risk
  4. Planning
  5. Implementing (Care Coordination)
  6. Following-Up
  7. Transitioning (Transitional Care)
  8. Communicating Post Transition
  9. Evaluating
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are the 8 steps in Screening in the case management process?

A
  1. Predictive Modeling or Risk Stratification
  2. Initial Contact
  3. Triage/Check eligibility
  4. Assume care
  5. Educate or redirect
  6. Client consent
  7. Make intake decisions
  8. Assign case
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are some triage indicators during the Screening phase of the case management process?

A

Age
Frequent ED visits or acute care admissions
Acuity
Complexity of illness or injury
Behavioral health history
Multiple care providers
Polypharmacy
Prior non-adherence
Eligibility
Social Determinants of Health

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is predictive modeling?

A

A process used to predict future events or outcomes by analyzing patterns. Predictive modeling typically involves using a software application to create a model of future behavior that forecasts probabilities and trends. The model contains predictors likely to influence future behavior or utilization of healthcare resources such as the client’s gender, age, number of chronic illnesses, access to healthcare services, and other identified factors.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the social determinants of health?

A

The conditions in which people are born, grow, live, work and age.

Economic stability
Education
Health and Health Care
Neighborhood and Built Environment
Social and Community Context

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are the 5 steps in the Assessing phase of the case management process?

A
  1. Assign case
  2. Engage client - introduce self as case manager, describe your role
  3. Gather relevant data - psychological, demographics, background, needs, safety, judgement
  4. Analyze data
  5. Identify problems - list of problems (actual and potential)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is the difference between adherence and compliance?

A

Adherence is an active process in which a patient takes responsibility for their overall well-being.

Compliance is a passive behavior in which a patient is following a list of recommendations from the doctor.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are the 7 steps in Stratifying Risk in the case management process?

A
  1. Define population and desired outcome of Risk Stratification
  2. Identify tool - predictive modeling
  3. Input data
  4. Run/Analyze data
  5. Validate data
  6. Determine client’s risk score - low, moderate, or high
  7. Get report to determine Risk Level Category
    Input information into Case Management Plan of Care
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What can risk stratification/classification be used for?

A

Allows the case manager to identify and focus on the client’s greatest needs and how best to create a plan and intervene to meet those needs.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are the 8 steps in the Planning step of the case management process?

A
  1. Identify problems
  2. Gather input data from stakeholder and interdisciplinary team
  3. Prioritize problems
  4. Identify interventions and counter-measures - select services
  5. Select interventions
  6. Obtain approval or authorization of plan or services if applicable
  7. Inform involved parties
  8. Document case management plan of care
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are SMART goals?

A

Specific
Measurable
Attainable
Relevant
Time-based

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is the Care Coordination vision?

A

The vision is health care providers, patients, and caregivers all work together to “ensure that the patient gets the care and support (they) need and want, when and how (they) need and want it”

22
Q

What are the 4 steps in the Implementing step of the case management process?

A
  1. Inform involved parties
  2. Assign tasks
  3. Execute individual interventions - arrange services, coordinate services, assure timeliness, follow up on referrals
  4. Document incremental progress
23
Q

What are the 5 steps in the Follow Up step of the case management process?

A
  1. Document incremental progress
  2. Reassess and measure effectiveness
  3. Client ready for transition? -IF YES - NEXT STEP.
    IF NO - a. Modify plan (if yes, go back to key problems in planning phase)
    b. Continue current plan
    c. Go to inform involved parties of implementing phase and return to step 2
  4. Identify next setting
  5. Gain approval, consent, and consensus
24
Q

What is the key in the Follow Up phase of the case management process?

A

Identifying the next level of care

25
Q

What are the 6 steps in the Transitioning Phase of the case management process?

A
  1. Gain approval, consent, consensus
  2. Prepare transition package - case summary, continuity of care plan, instructions for medication regimen
  3. Communicate Plan of Care (POC) to client, next setting/provider
  4. Next setting/Provider/Client ready?
    IF NO - Identify & resolve barriers and go back to Transition Point in Follow-Up phase.
    IF YES - step 5
  5. Complete transition - transportation, medications, health education, durable medical equipment
  6. Close case - compliance documentation
26
Q

How does the Centers for Medicare & Medicaid Services (CMS) define transition of care?

A

The movement of a patient from one setting of care to another.

27
Q

What is transitional planning?

A

The process that case managers apply to ensure that appropriate resources and services are provided to clients, and that they are provided in the most appropriate setting or level of care. Focus is on moving the client from the most complex to less complex care settings.

28
Q

What is transitions of care?

A

Movement of clients from one practitioner or setting to another as their condition and care needs change.

29
Q

What are 4 strategies to avoid an unsuccessful transition?

A
  1. Medication management
  2. Summary of client’s health condition
  3. Clinical follow up
  4. Client self care management
30
Q

What is the teach-back method?

A

Involves asking client to state in their own words what they need to know or do about their health. It helps to ensure understanding of what has been taught.

31
Q

What are the 6 steps in Communicating Post Transition step of the case management process?

A
  1. Close case
  2. Contact client
  3. Obtain feedback
  4. Issues or concerns?
    If YES - Resolve issues during contact. Issue resolved?
    If YES - Go back to transition point in Follow Up Phase
    If NO issues or concerns - go to step 5
  5. Document progress - client’s feedback, experience, satisfaction, safety concerns
  6. Go to prepare reports in Evaluating Outcomes Phase
32
Q

What is the purpose of the Communicating Post Transition phase?

A

To ensure the client/support system is comfortable with the next level of care or self-care at home

33
Q

What are the 7 steps in the Evaluating step of the case management process?

A
  1. Close case
  2. Identify applicable report mode - case summary, billing report, utilization data
  3. Gather data
  4. Analyze data
  5. Prepare reports
  6. Client feedback, then back to step 4, then continue onto step 5 and 6
  7. Communicate to stakeholders - payor, provider, employer, insurance
34
Q

What is the final phase of the case management process?

A

Evaluating

35
Q

What are the 3 main types of Healthcare Delivery Systems for Levels of Care?

A

Pre-Acute
Acute
Post-Acute

36
Q

What does HMO stand for?

A

Health Maintenance Organization

37
Q

What does PPO stand for?

A

Preferred Provider Organization

38
Q

What are HMO’s comprised of?

A
  • An organization that provides for or arranges for coverage of designated
    health servicesfor a fixed prepaid premium
  • Providers receive predetermined payment (per member/per month)
  • Primary care provider is the gatekeeper
  • Access to specialists through primary care provider and limited to that which is necessary for the client’s condition
  • Out of Network coverage is very limited
39
Q

What are PPO’s comprised of?

A
  • Insurance product in which contracts are established with providers of care (preferred providers)
  • Contract provides better benefits when preferred providers
    are used as anencouragement for members to use them
  • Can use out of network providers with higher out of pocket costs
40
Q

What does POS stand for?

A

Point of Service Plans

41
Q

What are Point of Service (POS)’s comprised of?

A
  • Allows members to choose between participating and non-participating providers
  • Allows for blend of HMO and PPO
42
Q

What does IDS stand for?

A

Integrated Delivery Systems

43
Q

What are Integrated Delivery Systems (IDS) comprised of?

A
  • Partnerships between physicians, physician groups, hospitals, and other providers to manage care
  • Usually involves contact with payer
  • Provides services across the continuum
  • May become Accountable Care Organization (ACO)
  • Increasingly popular today – most common with academic medical centers partnering with other health care organizations across the continuum to create vertical integration (health delivery system that provides a complete spectrum of care – at a minimum, hospitals, a medical group, and a health plan within a single organization
44
Q

What is the Patient Protection and Affordable Care Act, 2010 (ACA)

A
  • Focused on increased access to healthcare services, reduced costs through payment reductions, and attention to wellness and prevention
  • Improved access to care and insurance; no limitations for pre-existing conditions; coverage to age 26 for dependent children
  • Rewards value-based care and quality, safe care delivery
  • Increased attention was placed on care coordination, the skill and proficiency of case managers, and case management beyond the acute care setting
  • Focus on improved care transitions, particularly those from hospital to the next level of care, and reducing hospital readmissions
  • Required changes to the health care delivery system by expanding public programs, creating health insurance exchanges (HIEs), and cost containment
  • Required new reimbursement models, and provided for financial incentives
45
Q

What does PCMC stand for?

A

Patient-Centered Medical Home

46
Q

What are Patient-Centered Medical Home (PCMH)’s comprised of?

A
  • Primary care organization
  • Emphasis on care coordination and communication
  • Goal is higher quality and lower costs, with improved patient and provider experience of care
47
Q

How does the American College of Physicians define the Patient-Centered Medical Home (PCMH)?

A

A care delivery model in which treatment is coordinated through the primary care physician to ensure the patient receives the necessary care when and where they need it, in a manner they can understand (includes behavioral health and medical care)

48
Q

Role responsibilities for case managers in PCMH:

A
  • Coordination of care and services
  • Facilitate timely access to care
  • Patient engagement in shared decision making
  • Health education/self-care management
  • Remote monitoring of care and adherence
  • Follow up re: tests, procedures, consults, appointments
  • Facilitation of long-term planning
  • Coordinating care transitions
49
Q

Does does ACO stand for?

A

Accountable Care Organization

50
Q

What are Accountable Care Organizations (ACO)’s?

A

Groups of physicians, hospitals, and other health care providers who are held jointly accountable to deliver care more efficiently, achieve measured quality improvements, and reduce the rate of spending growth

51
Q
A

CCMC (13 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions