Podcast
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?
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)?
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?
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?
What is the primary purpose of a concurrent review for a hospitalized patient?
Which process is used to identify the basic or causal factors contributing to a sentinel event?
Which process is used to identify the basic or causal factors contributing to a sentinel event?
What should Mr. Kim be advised to do regarding the herbs and teas his sister brings him?
What should Mr. Kim be advised to do regarding the herbs and teas his sister brings him?
Which of the following is a core measure for determining if a requested service is medically necessary?
Which of the following is a core measure for determining if a requested service is medically necessary?
What tool can case managers use to assess for substance abuse or addiction?
What tool can case managers use to assess for substance abuse or addiction?
How long does an individual have to elect COBRA after the termination of plan coverage?
How long does an individual have to elect COBRA after the termination of plan coverage?
Which criterion is essential for a patient to be eligible for hospice care?
Which criterion is essential for a patient to be eligible for hospice care?
Conditions of Participation are standards identified by which organization?
Conditions of Participation are standards identified by which organization?
What is the primary use of outcome monitoring in clinical decision making?
What is the primary use of outcome monitoring in clinical decision making?
Which factor does not directly evaluate a client's understanding of their medical conditions?
Which factor does not directly evaluate a client's understanding of their medical conditions?
What is the purpose of the CMS Hospital Experience Survey?
What is the purpose of the CMS Hospital Experience Survey?
What is the health insurance plan issued to an eligible retiree under Chapter 89 called?
What is the health insurance plan issued to an eligible retiree under Chapter 89 called?
Which benefit category is excluded from the Medicare Advantage (MA) program?
Which benefit category is excluded from the Medicare Advantage (MA) program?
A Medicare managed care plan must operate under a written contract with which of the following entities?
A Medicare managed care plan must operate under a written contract with which of the following entities?
Are Medicare beneficiaries enrolled in a Medicare Advantage (MA) plan eligible for traditional Medicare coverage?
Are Medicare beneficiaries enrolled in a Medicare Advantage (MA) plan eligible for traditional Medicare coverage?
What is the primary responsibility of case managers assigned to Medicare Advantage (MA) plans?
What is the primary responsibility of case managers assigned to Medicare Advantage (MA) plans?
Which is not a requirement for a Medicare Advantage (MA) plan to be approved by CMS?
Which is not a requirement for a Medicare Advantage (MA) plan to be approved by CMS?
Are Medicare beneficiaries enrolled in a Medicare Advantage (MA) plan required to pay a monthly premium?
Are Medicare beneficiaries enrolled in a Medicare Advantage (MA) plan required to pay a monthly premium?
Which of the following is not considered a type of Medicare Advantage (MA) plan?
Which of the following is not considered a type of Medicare Advantage (MA) plan?
Which assessment is used for psychological and neuropsychological status?
Which assessment is used for psychological and neuropsychological status?
What should a health coach prioritize when helping a client set weight loss goals?
What should a health coach prioritize when helping a client set weight loss goals?
Which description best defines medical necessity?
Which description best defines medical necessity?
Which of the following is an example of a hard cost saving due to case management?
Which of the following is an example of a hard cost saving due to case management?
Regarding the psychosocial aspects of chronic illness, what is important for the case manager to understand?
Regarding the psychosocial aspects of chronic illness, what is important for the case manager to understand?
If a case manager finds that their client's cultural beliefs differ from their own, what should they do?
If a case manager finds that their client's cultural beliefs differ from their own, what should they do?
Which of the following is not appropriate for case management services screening?
Which of the following is not appropriate for case management services screening?
Which tool measures a 6-year-old child’s level of functional independence post a motor vehicle accident?
Which tool measures a 6-year-old child’s level of functional independence post a motor vehicle accident?
What is the primary goal of motivational interviewing (MI) in the context of case management?
What is the primary goal of motivational interviewing (MI) in the context of case management?
Which component is crucial in a proposed plan of care for it to be considered medically necessary?
Which component is crucial in a proposed plan of care for it to be considered medically necessary?
Which activity aims to systematically identify and address potential risks to prevent client or staff injury?
Which activity aims to systematically identify and address potential risks to prevent client or staff injury?
When managing clients with substance abuse, what is the primary role of the case manager?
When managing clients with substance abuse, what is the primary role of the case manager?
What technique focuses on the collection and analysis of data to enhance the quality of healthcare processes and outcomes?
What technique focuses on the collection and analysis of data to enhance the quality of healthcare processes and outcomes?
Which statement correctly describes a component of the Medicare Hospice benefit?
Which statement correctly describes a component of the Medicare Hospice benefit?
Evaluating the Social Determinants of Health involves assessing which of the following?
Evaluating the Social Determinants of Health involves assessing which of the following?
When the client is informed about all available options and makes a decision, which ethical principle is being demonstrated?
When the client is informed about all available options and makes a decision, which ethical principle is being demonstrated?
What is the nature of the Case Management process?
What is the nature of the Case Management process?
What defines standards of care?
What defines standards of care?
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?
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?
Which is the most accurate description of the Social Determinants of Health?
Which is the most accurate description of the Social Determinants of Health?
Which type of healthcare plan contracts a network of providers and pays them a fixed amount per member per month?
Which type of healthcare plan contracts a network of providers and pays them a fixed amount per member per month?
What is the goal for a 60-year-old male following a work-related injury, to ensure the best utilization of his skills?
What is the goal for a 60-year-old male following a work-related injury, to ensure the best utilization of his skills?
What action should a case manager take if there is an objection after disclosing a conflict of interest?
What action should a case manager take if there is an objection after disclosing a conflict of interest?
What is the first step in the negotiation process?
What is the first step in the negotiation process?
Which process involves using data mining and specialized software to predict significant future medical expenses?
Which process involves using data mining and specialized software to predict significant future medical expenses?
An individual demonstrating self-advocacy is showing what kind of behavior?
An individual demonstrating self-advocacy is showing what kind of behavior?
Which insurance program provides benefits and lost wages for workplace injuries?
Which insurance program provides benefits and lost wages for workplace injuries?
Referring a client to an unqualified healthcare provider is known as:
Referring a client to an unqualified healthcare provider is known as:
Which plan offers the most flexibility in choosing healthcare providers?
Which plan offers the most flexibility in choosing healthcare providers?
Which approach involves negotiating an acceptable arrangement for all parties affected by a case manager's conflict of interest?
Which approach involves negotiating an acceptable arrangement for all parties affected by a case manager's conflict of interest?
Which of the following is not part of the case management process?
Which of the following is not part of the case management process?
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?
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?
Which of the following is NOT required in all states as part of mandatory reporting statutes?
Which of the following is NOT required in all states as part of mandatory reporting statutes?
Which characteristic best defines an acute illness?
Which characteristic best defines an acute illness?
What is a key feature of Advance Directives?
What is a key feature of Advance Directives?
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?
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?
Which is an example of primary medication non-adherence?
Which is an example of primary medication non-adherence?
Which of the following is true about the definition of medical necessity in insurance contracts?
Which of the following is true about the definition of medical necessity in insurance contracts?
Which source should a case manager consult to explore job accommodation options?
Which source should a case manager consult to explore job accommodation options?
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?
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?
When a case manager is educating the client about treatment options, what is the ultimate goal?
When a case manager is educating the client about treatment options, what is the ultimate goal?
Which of the following statements regarding experimental treatments is correct?
Which of the following statements regarding experimental treatments is correct?
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?
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?
Which of the following results are used to calculate value-based incentive payments in the Hospital Value-Based Purchasing program?
Which of the following results are used to calculate value-based incentive payments in the Hospital Value-Based Purchasing program?
Which of the following best demonstrates veracity in case management?
Which of the following best demonstrates veracity in case management?
Which practice falls within the specialty of case management?
Which practice falls within the specialty of case management?
Which element of self-efficacy directly influences a client's perseverance when obstacles arise?
Which element of self-efficacy directly influences a client's perseverance when obstacles arise?
Which aspect of performance improvement focuses on evaluating and enhancing the current processes, structures, and outcomes?
Which aspect of performance improvement focuses on evaluating and enhancing the current processes, structures, and outcomes?
In the context of hospice and clinical trials, which statement correctly highlights the limitations imposed on Medicare patients?
In the context of hospice and clinical trials, which statement correctly highlights the limitations imposed on Medicare patients?
Which pair of strategies are widely recognized in effective negotiation?
Which pair of strategies are widely recognized in effective negotiation?
What is the purpose of quality assurance in healthcare?
What is the purpose of quality assurance in healthcare?
Which important documents are recognized under the Patient Self Determination Act (PSDA)?
Which important documents are recognized under the Patient Self Determination Act (PSDA)?
Which program specifically covers medical care costs for work-related injuries?
Which program specifically covers medical care costs for work-related injuries?
Which group can benefit from health coaching?
Which group can benefit from health coaching?
Which of the following best describes the primary focus of the Family Medical Leave Act (FMLA)?
Which of the following best describes the primary focus of the Family Medical Leave Act (FMLA)?
What is the most significant goal of case management?
What is the most significant goal of case management?
What happens to Mrs. Smith's Social Security Disability Income (SSDI) when she turns 65?
What happens to Mrs. Smith's Social Security Disability Income (SSDI) when she turns 65?
Which of the following best describes the purpose of benchmarking in a healthcare organization?
Which of the following best describes the purpose of benchmarking in a healthcare organization?
Which condition is NOT considered a disability under the Americans with Disabilities Act (ADA)?
Which condition is NOT considered a disability under the Americans with Disabilities Act (ADA)?
Individuals at highest risk for low health literacy include all of the following except:
Individuals at highest risk for low health literacy include all of the following except:
What does NOT reflect a potential conflict of interest for case managers?
What does NOT reflect a potential conflict of interest for case managers?
The Americans with Disabilities Act protects individuals with drug addiction in which situation?
The Americans with Disabilities Act protects individuals with drug addiction in which situation?
Which employees are eligible for benefits under the Family Medical Leave Act (FMLA)?
Which employees are eligible for benefits under the Family Medical Leave Act (FMLA)?
Case Management promotes which kind of outcomes?
Case Management promotes which kind of outcomes?
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.
