Term
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Definition
| A collaboration 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 quality, cost-effective outcomes. |
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Term
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Definition
1-Focus on pt and family
2-Negotiateing, procuring, and coordinating services and resources
3-Use of the clinical reasoning process
4-Development of various relationships
Episode or continuum based |
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Term
| What is CMs orientation and focus? |
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Definition
People-oriented.
Focused on the disbursement of managed care systems in a manner that benefits everyone, especially the patient. |
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Term
| Targeted Populations for CM |
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Definition
1-Diagnostic Categories-Acute/chronic injury or illness, multiple dx, end stage disease processes.
2-Potential for high utilization of resources-financial and service
3-Age and health status-elderly and frail
4-Procedure-Organ transplantation, cardiac surgery and others.
5-Length of hospitalization-Frequent and/or prolonged hospitalizations and ER visits.
6-Psychological factors-Need for support system, financial resources, decision support, transportation issues.
7-Vocational support-disability and loss of work.
8-Fucntional impairments-Paralysis, loss of limb, need for ADL assistance
9-Disability-Mental retardation and developmental disorders. |
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Term
| Name the 6 domains of CM roles and functions. |
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Definition
1-Case Finding and Intake
2-Provision of Services
3-Evaluation and Case Closure
4-Utilization Mgmt
5-Psychosocial and Economic Issues
6-Vocational Issues |
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Term
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Definition
1-Identifying the patient who would benefit.
2-Obtaining informed consent for services.
3-Communicating patient needs to others.
4-Identifying patients who need alternate levels of care. |
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Term
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Definition
1-Facilitating and coordinating care activities.
2-Assuming responsibility for communication with other healthcare providers.
3-Montioring patient progress and care activities.
4-Reviewing and modifying healthcare services.
5-Coolaborating with stakeholders on a case management plan.
6-Advocating for patient and family.
7-Assuring adherence to various standards. |
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Term
| Evaluation and Case Closure |
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Definition
1-Colelcting, analyzing and reporting data.
2-Evaluating the quality of case management services.
3-Ensuring access to timely and necessary services.
4-Applying evidence-based practice guidelines in a plan.
5-Closing the case management patient relationship when appropriate.
6-Reporting the termination of services to stake holders.
7-Educating the patient regarding illness prevention. |
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Term
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Definition
1-Evaluating the appropriate level of care.
2-Communicating with payers and other healthcare providers.
3-Allocating resources based on patient needs.
4-Managing reimbursement appeals and denials.
5-Reviewing patient conditions for appropriateness of hospitalization.
6-Identifying cases that are at high risk for complications. |
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Term
| Psychosocial and Economic Issues |
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Definition
1-Reviewing patient's social and financial resources.
2-Assessing patient's support network.
3-Considering patient's culture in planning and delivering care.
4-Evaluating the ability of the caregiver outside the hospital setting.
5-Determining eligibility for insurance coverage and/or charity services. |
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Term
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Definition
1-Identifying need for changes in the home environment.
2-Eliminating access barriers.
3-Determining need for specialized services.
4-Coordinating job analysis to implement modifications.
5-Managing return-to-work activities.
6-Arranging vocational assessment and services. |
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Term
| Within the clinical-patient role dimension-The CMs are responsible are? |
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Definition
1-Identifying existing or potential health problems by assessing the patient's physical, psychosocial, functional, financial, cognitive and spiritual condition.
2-Develope a POC in collaboration with other healthcare providers on the interdisciplinary team. |
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Term
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Definition
| Key tasks, treatments, or events required for a patient's care foals and of learning the needs of the patient and family. |
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Term
| Typical job duties of the Clinical-Patient Care Role Dimension? |
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Definition
1-Discuss preventive services.
2-Direct patient care activities.
3-Assess the patient/caregiver's coping abilities, social support networks and financial/insurance status.
4-Intervene when a problem is identified.
5-Facilitate patient progress through the healthcare system.
6-Arrange for consultation with specialists or specialty services.
7-Arrange for consultations with specialists or specialty services.
8-Ensure transfer to appropriate level of care when necessary.
9-Collaborate with the interdisciplinary healthcare team. |
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Term
| The Managerial-Leadership Role Dimension |
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Definition
| Refers tot he CM's duties of facilitating, coordinating and expediting the care of patients while they are ill. CMS also must collaborate with the interdisciplinary team to determine the projected length of stay, goals of treatment and necessary services. |
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Term
| Typical Job Duties of the Managerial-Leadership Role Dimension. |
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Definition
1-Evaluate the quality of care provided on a continual basis.
2-Conduct retrospective and concurrent chart reviews for utilization mgmt.
3-Guide patient care activities and nursing interventions.
4-Facilitate communication among the members of the interdisciplinary team.
5-Serve as preceptor for CMs who are training. |
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Term
| The Financial-Business Role Dimension |
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Definition
| CM must ensure that the patient receives adequate care while maintaining appropriate resource allocation through cost containment. Involves collaboration with other healthcare providers. |
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Term
| Financial Business Role Typical Job Duties |
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Definition
1-Assess variances such as deviation from norms and delays in care.
2-Ensure continuity, integration, and coordination of care activities to control any duplication of fragmentation in care.
3-Access information on case mix indexes, practice patterns, and consumption or resources.
4-Ensure the use of necessary treatments and completed procedures within reimbursable time frames. |
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Term
| The Information Mgmt-Communication Role Dimension |
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Definition
| CM uses applicable information to communicate, report, teach, reinforce and evaluate situations and functions of the healthcare system. There are 2 types of stakeholders concerned with this role 1-Internal (those involved with the interdisciplinary team) and 2-external (managed care organizations) |
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Term
| Typical Job Duties of Information Mgmt Communication Role Dimension |
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Definition
1-Data collection and analysis of variances, quality assurance and outcomes mgmt.
2-Communication and dissemination of info through ed sessions, case conference, rpts, managed care reviews, and authorizations.
3-Generation of rpts on case-managed pts, cost analysis, variances, denials and appeals, admission rates, cost-benefit analysis.
4-Presentaion of info by posters, public speaking, and storyboards.
5-Development and revision of policies and procedures.
6-Obtainment of authorizations for services from various managed care organizations.
7-Report findings of utilization review and mgmt activities. |
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Term
| The Professional Development-Career Advancement Role Dimension |
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Definition
1-Allows the nurse to network with other case managers to exchange info related to latest technologies in the foiled and to obtain professional support.
2-Maintain professional practice, standards and promote the ethic-based practice.
3-Allows case manager to have a political voice to advocate for health and to make public policy changes. |
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Term
| Typical Job Duties of The Professional Development-Career Advancement Role Dimension |
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Definition
1-Conduct research and utilize research findings.
2-Promote evidence based practice.
3-Advocate for pts and families.
4-Share info at foblic forums.
5-Train novice CMs,
6-Participate in CEs.
7-Remain up to date with the latest healthcare innovations and practices. |
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Term
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Definition
1-Maximize efficient use of resources.
2-Promote informed decision making by the pt and provide objectivity and info.
3-Work with pt/CG/MD and other healthcare providers to implement POC that meets pt's needs.
4-Make healthcare delivery system more effective.
5-Assist pt in meeting planned outcomes with measureable process through appropriate interventions.
6-Promote safe, cost-effective, accessible, and QOC.
7-Assist pts/CGs in arranging and managing complex resources required to maintain independent functioning an dadequate health
3- |
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Term
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Definition
1-Promote pt's wellness, autonomy, appropriate use of financial resources and services.
2-Assit pt in achieving an optimal level of functioning and health by facilitating and coordinating appropriate healthcare services.
3-Assit the pt to self-direct care, self-advocate, make informed decisions.
4-Ensure services are provided in cost-effective and timely manner.
5-Fcilitate organization by appropriately sequencing healthcare services in most cost-effective way without compromising QOC.
6-Help pt maintain highest level of independence and human dignity and enable them to reside in the most appropriate environment.
7-Provide comprehensive and coordinate response to the pts needs that addresses rehab, maintenance, and prevention.
8-Improve pt safety, satisfaction, productivity and quality of life.
9-Provide quality healthcare along a continuum that decreases fragmentation of care.
10-Promote human operation of systems that provide patients with resources, opportunities, services. |
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