CCM Certification: Conditions of Participation and Review
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Questions and Answers

What is the classification of a caregiver keeping a client with dementia sedated to the point of sleeping most of the day?

  • Standard care
  • Neglect (correct)
  • Proper sedation
  • Abuse

    • Which statement is incorrect regarding the coordination of benefits (COB)?

  • COB is mandated by the federal government (correct)
  • COB ensures that the total payment does not exceed 100% of the cost
  • COB prevents duplication of benefits
  • COB helps to determine the payment order of coverage

    • How do adaptive families manage responsibilities during a severe or extended illness?

  • Become overly dependent on one family member
  • Isolate themselves
  • Seek and accept help (correct)
  • Avoid discussing the illness

    • What is the primary purpose of a concurrent review for a hospitalized patient?

    <p>Assess the need for continued hospitalization</p> Signup and view all the answers

    Which process is used to identify the basic or causal factors contributing to a sentinel event?

    <p>Root cause analysis</p> Signup and view all the answers

    What should Mr. Kim be advised to do regarding the herbs and teas his sister brings him?

    <p>Inform his doctor about the herbs and teas</p> Signup and view all the answers

    Which of the following is a core measure for determining if a requested service is medically necessary?

    <p>Precertification</p> Signup and view all the answers

    What tool can case managers use to assess for substance abuse or addiction?

    <p>CAGE Tool</p> Signup and view all the answers

    How long does an individual have to elect COBRA after the termination of plan coverage?

    <p>Within 60 days</p> Signup and view all the answers

    Which criterion is essential for a patient to be eligible for hospice care?

    <p>A physician certifies a life expectancy of 6 months or less</p> Signup and view all the answers

    Conditions of Participation are standards identified by which organization?

    <p>Centers for Medicare and Medicaid Services (CMS)</p> Signup and view all the answers

    What is the primary use of outcome monitoring in clinical decision making?

    <p>To achieve optimal client outcomes</p> Signup and view all the answers

    Which factor does not directly evaluate a client's understanding of their medical conditions?

    <p>Illiteracy</p> Signup and view all the answers

    What is the purpose of the CMS Hospital Experience Survey?

    <p>To compare hospitals on important consumer topics</p> Signup and view all the answers

    What is the health insurance plan issued to an eligible retiree under Chapter 89 called?

    <p>Medicare Advantage plan</p> Signup and view all the answers

    Which benefit category is excluded from the Medicare Advantage (MA) program?

    <p>Long-term care services</p> Signup and view all the answers

    A Medicare managed care plan must operate under a written contract with which of the following entities?

    <p>Centers for Medicare &amp; Medicaid Services (CMS)</p> Signup and view all the answers

    Are Medicare beneficiaries enrolled in a Medicare Advantage (MA) plan eligible for traditional Medicare coverage?

    <p>False</p> Signup and view all the answers

    What is the primary responsibility of case managers assigned to Medicare Advantage (MA) plans?

    <p>Coordinating care</p> Signup and view all the answers

    Which is not a requirement for a Medicare Advantage (MA) plan to be approved by CMS?

    <p>Being offered by a for-profit insurance company</p> Signup and view all the answers

    Are Medicare beneficiaries enrolled in a Medicare Advantage (MA) plan required to pay a monthly premium?

    <p>True</p> Signup and view all the answers

    Which of the following is not considered a type of Medicare Advantage (MA) plan?

    <p>Indemnity plan</p> Signup and view all the answers

    Which assessment is used for psychological and neuropsychological status?

    <p>Minnesota Multiphasic Personality Inventory (MMPI)</p> Signup and view all the answers

    What should a health coach prioritize when helping a client set weight loss goals?

    <p>Assist the client to set goals that are meaningful to the client</p> Signup and view all the answers

    Which description best defines medical necessity?

    <p>A service identified in the proposed plan of care</p> Signup and view all the answers

    Which of the following is an example of a hard cost saving due to case management?

    <p>Avoidance of 30-day hospital readmission</p> Signup and view all the answers

    Regarding the psychosocial aspects of chronic illness, what is important for the case manager to understand?

    <p>All patients' goals is to help the client realize they will have similar psychological responses to help the client realize they will have similar psychological responses and encourage them to apply for social security disability insurance</p> Signup and view all the answers

    If a case manager finds that their client's cultural beliefs differ from their own, what should they do?

    <p>Respect the client’s beliefs, even though she may not agree with them</p> Signup and view all the answers

    Which of the following is not appropriate for case management services screening?

    <p>25-year-old female post motor vehicle accident who sustained pelvic and bilateral lower extremity fractures and has no family or support system</p> Signup and view all the answers

    Which tool measures a 6-year-old child’s level of functional independence post a motor vehicle accident?

    <p>Functional Independence Measure (FIM)</p> Signup and view all the answers

    What is the primary goal of motivational interviewing (MI) in the context of case management?

    <p>Enhancing a client’s motivation and commitment to change</p> Signup and view all the answers

    Which component is crucial in a proposed plan of care for it to be considered medically necessary?

    <p>Inclusion in the proposed plan of care</p> Signup and view all the answers

    Which activity aims to systematically identify and address potential risks to prevent client or staff injury?

    <p>Risk Management</p> Signup and view all the answers

    When managing clients with substance abuse, what is the primary role of the case manager?

    <p>Support the treatment plan and assist in finding resources</p> Signup and view all the answers

    What technique focuses on the collection and analysis of data to enhance the quality of healthcare processes and outcomes?

    <p>Quality Improvement</p> Signup and view all the answers

    Which statement correctly describes a component of the Medicare Hospice benefit?

    <p>Given in benefit periods of 90 days each for the first and second periods</p> Signup and view all the answers

    Evaluating the Social Determinants of Health involves assessing which of the following?

    <p>Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities</p> Signup and view all the answers

    When the client is informed about all available options and makes a decision, which ethical principle is being demonstrated?

    <p>Autonomy</p> Signup and view all the answers

    What is the nature of the Case Management process?

    <p>Collaborative</p> Signup and view all the answers

    What defines standards of care?

    <p>Statements that delineate care that is expected to be provided to all clients based on the best scientific knowledge, current outcomes data, and clinical expertise</p> Signup and view all the answers

    Considering the scenario where Amy is medically stable but requires assistance to ambulate and navigate stairs, what is the most appropriate post-hospitalization rehabilitation setting for her?

    <p>Acute inpatient rehabilitation</p> Signup and view all the answers

    Which is the most accurate description of the Social Determinants of Health?

    <p>Conditions in which people are born, grow, live, work, and age</p> Signup and view all the answers

    Which type of healthcare plan contracts a network of providers and pays them a fixed amount per member per month?

    <p>HMO</p> Signup and view all the answers

    What is the goal for a 60-year-old male following a work-related injury, to ensure the best utilization of his skills?

    <p>To return to the same employer in a different job using transferable skills</p> Signup and view all the answers

    What action should a case manager take if there is an objection after disclosing a conflict of interest?

    <p>Withdraw from further participation</p> Signup and view all the answers

    What is the first step in the negotiation process?

    <p>Preparation and understanding the other person's side</p> Signup and view all the answers

    Which process involves using data mining and specialized software to predict significant future medical expenses?

    <p>Predictive modeling</p> Signup and view all the answers

    An individual demonstrating self-advocacy is showing what kind of behavior?

    <p>Effective communication of interests and needs</p> Signup and view all the answers

    Which insurance program provides benefits and lost wages for workplace injuries?

    <p>Workers' Compensation</p> Signup and view all the answers

    Referring a client to an unqualified healthcare provider is known as:

    <p>Negligent Referral</p> Signup and view all the answers

    Which plan offers the most flexibility in choosing healthcare providers?

    <p>POS</p> Signup and view all the answers

    Which approach involves negotiating an acceptable arrangement for all parties affected by a case manager's conflict of interest?

    <p>Negotiating an acceptable arrangement with all affected parties</p> Signup and view all the answers

    Which of the following is not part of the case management process?

    <p>Diagnose</p> Signup and view all the answers

    By identifying the percentage of diabetic clients enrolled in case management who have had their HgA1c checked in the last 6 months, what aspect is the performance improvement team evaluating?

    <p>Compliance</p> Signup and view all the answers

    Which of the following is NOT required in all states as part of mandatory reporting statutes?

    <p>Financial coercion</p> Signup and view all the answers

    Which characteristic best defines an acute illness?

    <p>A health condition with a rapid onset and short duration</p> Signup and view all the answers

    What is a key feature of Advance Directives?

    <p>Always involve caregiver input</p> Signup and view all the answers

    What is the first step Mary, a case manager, needs to take when helping her patient with uncontrolled diabetes improve adherence to their care regimen?

    <p>Assess the patient's knowledge and understanding of their condition</p> Signup and view all the answers

    Which is an example of primary medication non-adherence?

    <p>Not filling the prescription</p> Signup and view all the answers

    Which of the following is true about the definition of medical necessity in insurance contracts?

    <p>Determined by the person reviewing, and all decisions are final</p> Signup and view all the answers

    Which source should a case manager consult to explore job accommodation options?

    <p>Job Accommodation Network's (JAN) Searchable Online Accommodation Resource</p> Signup and view all the answers

    What is a nationally recognized and professionally supported plan of care recommended for managing clients with a specific diagnosis or health condition in a particular care setting?

    <p>Standards of care</p> Signup and view all the answers

    When a case manager is educating the client about treatment options, what is the ultimate goal?

    <p>Empower the client to be an informed and active decision-maker</p> Signup and view all the answers

    Which of the following statements regarding experimental treatments is correct?

    <p>There must be an equitable system to select who will participate in the experimental treatment</p> Signup and view all the answers

    Which Act allows a person extended time off from their job with protection they will not lose their job to care for a family member with a medical condition?

    <p>Family Medical Leave Act</p> Signup and view all the answers

    Which of the following results are used to calculate value-based incentive payments in the Hospital Value-Based Purchasing program?

    <p>Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey</p> Signup and view all the answers

    Which of the following best demonstrates veracity in case management?

    <p>Speaking on behalf of the client to the insurance company</p> Signup and view all the answers

    Which practice falls within the specialty of case management?

    <p>Care Coordination</p> Signup and view all the answers

    Which element of self-efficacy directly influences a client's perseverance when obstacles arise?

    <p>One’s belief in his or her own ability to succeed</p> Signup and view all the answers

    Which aspect of performance improvement focuses on evaluating and enhancing the current processes, structures, and outcomes?

    <p>Process, structure, and/or outcomes</p> Signup and view all the answers

    In the context of hospice and clinical trials, which statement correctly highlights the limitations imposed on Medicare patients?

    <p>You cannot choose curative treatment and hospice.</p> Signup and view all the answers

    Which pair of strategies are widely recognized in effective negotiation?

    <p>Collaboration and compromise</p> Signup and view all the answers

    What is the purpose of quality assurance in healthcare?

    <p>Activities and programs to monitor and rectify quality deficiencies</p> Signup and view all the answers

    Which important documents are recognized under the Patient Self Determination Act (PSDA)?

    <p>End of Life documents such as a Living Will and Durable Power of Attorney for Healthcare</p> Signup and view all the answers

    Which program specifically covers medical care costs for work-related injuries?

    <p>Workers’ Compensation</p> Signup and view all the answers

    Which group can benefit from health coaching?

    <p>Clients who want to prevent disease</p> Signup and view all the answers

    Which of the following best describes the primary focus of the Family Medical Leave Act (FMLA)?

    <p>Allowing employees to take unpaid, job-protected leave for specific family and medical reasons</p> Signup and view all the answers

    What is the most significant goal of case management?

    <p>Achieving optimal outcomes, quality care, and appropriate use of services</p> Signup and view all the answers

    What happens to Mrs. Smith's Social Security Disability Income (SSDI) when she turns 65?

    <p>Convert to Social Security Income</p> Signup and view all the answers

    Which of the following best describes the purpose of benchmarking in a healthcare organization?

    <p>Assessing performance against peers and identifying areas for improvement</p> Signup and view all the answers

    Which condition is NOT considered a disability under the Americans with Disabilities Act (ADA)?

    <p>Is unable to work despite recovering from an injury/illness</p> Signup and view all the answers

    Individuals at highest risk for low health literacy include all of the following except:

    <p>Those with chronic conditions</p> Signup and view all the answers

    What does NOT reflect a potential conflict of interest for case managers?

    <p>A Director of Case Management writing industry-focused journal articles</p> Signup and view all the answers

    The Americans with Disabilities Act protects individuals with drug addiction in which situation?

    <p>An employee with a recent history of drug use, who has been successfully rehabbed and is no longer using drugs</p> Signup and view all the answers

    Which employees are eligible for benefits under the Family Medical Leave Act (FMLA)?

    <p>Employees who have worked at least 1,250 hours over the past 12 months</p> Signup and view all the answers

    Case Management promotes which kind of outcomes?

    <p>Quality and cost-efficient outcomes</p> Signup and view all the answers

    Study Notes

    Conditions of Participation

    • A set of standards identified by the Centers for Medicare and Medicaid Services (CMS) based on scientific evidence of improved patient outcomes
    • Endorsed by both government and commercial payers

    Core Measures

    • Precertification: takes place prior to services being rendered to determine if the requested service is medically necessary
    • Concurrent review: determines if the requested service is medically necessary during services
    • Retrospective review: determines if the requested service was medically necessary after services
    • Review for referral to case management: determines if a client needs case management services

    Tool for Assessing Substance Abuse or Addiction

    • CAGE Tool: used to assess for substance abuse or addiction

    COBRA

    • Individual must elect COBRA within 90 days of termination of plan coverage
    • Individual has up to 60 days to decide on COBRA

    Outcome Monitoring

    • The use of information and knowledge gained from outcomes monitoring to achieve optimal client outcomes through improved clinical decision making and service delivery
    • Health literacy: asking the client questions to assess their understanding of their medical conditions

    Hospice Eligibility

    • A physician certifies that the patient has a life expectancy of 6 months or less
    • The patient has a signed DNR and needs palliative care

    Case Management Certification

    • Psychological and neuropsychological assessments are important in creating an appropriate case management plan
    • Assessments used: DSM-IV, Glasgow Coma Score (GCS), Motivational Interviewing (MI), and not Minnesota Multiphasic Personality Inventory (MMPI)

    Goal Setting

    • Assist the client to set goals that are meaningful to the client

    Medical Necessity

    • A service or treatment ordered by an in-network physician that is needed to diagnose and treat a medical condition as per recognized standards

    Hard Cost Savings

    • Avoidance of 30-day hospital readmission is an example of a hard cost savings as a result of case management

    Psychosocial Aspects of Chronic Illness and Disability

    • All patients' goals is to help the client realize they will have similar psychological responses to help the client realize they will have similar psychological responses and encourage them to apply for social security disability insurance

    Cultural Beliefs

    • Respect the client's beliefs, even if the case manager does not agree with them

    Case Management Process

    • Not part of the case management process: evaluate

    Acute Illness

    • A health condition with a rapid onset and short duration

    Case Manager's Role

    • Assess the patient's knowledge and understanding of their condition
    • Support the treatment plan and assist in finding resources for clients with substance abuse

    Medicare Hospice Benefit

    • Given in benefit periods of 90 days each for the first and second periods
    • A patient can keep the normal Medicare hospital benefit

    Social Determinants of Health

    • Can have a major impact on the ability of the client to reach optimal health and wellness
    • Assessing for the Social Determinants of Health may include: access to transportation, economic stability, and gender

    Ethical Principles

    • Respect for autonomy: respecting the client's decision
    • Non-malfeasance: doing no harm
    • Fidelity: being faithful to commitments and obligations
    • Justice: fairness and equality in the distribution of healthcare resources

    Case Management Process

    • Collaborative: case management is a collaborative process between the client, case manager, and other healthcare professionals

    Standards of Care

    • Statements that delineate care that is expected to be provided to all clients based on the best scientific knowledge, current outcomes data, and clinical expertise### Self-Advocacy
    • Self-advocacy involves advocating for oneself, feeling in control of a situation, and providing for one's physical needs.

    Performance Improvement

    • Performance improvement can focus on process, structure, and/or outcomes.

    Clinical Trials

    • A patient cannot choose curative treatment and hospice at the same time.
    • A clinical trial is not a standard treatment, so patients can participate in both.

    Negotiation Strategies

    • Two common negotiation strategies are collaboration and compromise.

    Quality Assurance

    • Quality assurance involves using techniques and methods to collect and analyze data to ensure quality.
    • It is also defined as the use of activities and programs to monitor, prevent, and correct quality deficiencies.

    Patient Self-Determination Act (PSDA)

    • The PSDA ensures that end-of-life documents such as Living Wills and Durable Power of Attorney for Healthcare are recognized.

    Workers' Compensation

    • Workers' Compensation pays for medical care for work-related injuries.

    Health Coaching

    • Health coaching is for clients who suffer from chronic diseases or want to prevent disease.

    Data Interpretation

    • When interpreting data, validity and reliability must be considered.
    • Quantitative data is considered the most reliable form of data.

    Family Medical Leave Act (FMLA)

    • The FMLA provides certain benefits for employees with family and medical needs.

    Goals of Case Management

    • Achieving optimal outcomes, quality of care, appropriate use of services, and optimum health and functioning for clients are examples of goals and objectives of case management.

    Social Security Disability Income (SSDI)

    • Once a person turns 65, their SSDI will convert to Social Security Income.

    Benchmarking

    • Benchmarking helps healthcare organizations assess their performance against their peers and identify areas for improvement.

    Americans with Disabilities Act (ADA)

    • The ADA defines a disability as a physical or mental impairment that substantially limits a major life activity.
    • It also protects individuals who have a record or history of a substantially limiting impairment or are regarded as having one.

    Health Literacy

    • Individuals at highest risk for low health literacy include older adults, those with less than a 4-year college education, those speaking English as a second language, and those with an income at or below the poverty level.

    Conflict of Interest

    • A potential conflict of interest for case managers includes being employed at multiple healthcare organizations.

    Americans with Disabilities Act (ADA) and Employment

    • The ADA protects individuals with drug addiction who are employed and have agreed to start a rehabilitation program, or have a history of drug use but are no longer using drugs.

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    Description

    This quiz covers the Conditions of Participation set by CMS, Core Measures, and types of review including concurrent, precertification, and retrospective review. Prepare for your CCM Certification exam with this assessment.

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