Case management - ANSWER a collaborative process that assesses, plans, implements,
coordinates, monitors and evaluates the options and services required to meet the client's
health and human services needs.
Case Management Characteristics - ANSWER characterized by advocacy, communication,
and resource management and promotes quality and cost-effective interventions and
outcomes.
Glagow Coma Scale - ANSWER Client assessment tool that measures level of coma in the
acute phase of injury it is an objective way of recording the conscious state of a person. Eye
opening, Best verbal, best motor. < 8 coma, 13-15 mild injury.
Strengths Based Model - ANSWER assesses clients capacities and potential resources as
well as problems and current unmet needs. Eliciting capacities and potential resources as
well as problems and current unmet needs.
Independent Living Model - ANSWER sees a disability as a construct of society
Medicare Prospective Payment System - ANSWER hospitals paid a pre-determined rate
for each Medicare admission. Each patient is classified into a DRG.
PHQ-9 - ANSWER Client assessment tool for depression
Braden Scale - ANSWER Client assessment tool for pressure sore risk
1
,Clinical Pathway - ANSWER Structured multidisciplinary CM plan designed to support the
implementation of specific clinical guidelines and protocols. They are maps that guide the
healthcare team on usual treatment patterns related to common diagnoses, conditions and
procedures e.g., CHF
SF-36 - ANSWER Client assessment tool to measure physical and mental health.
Medicare - ANSWER Established in 1965 under Title XVIII or Social Security Act. Four
Parts A-hospital insurance, B-medical insurance (doctors visits), C-Medicare Advantage
program in a private plan such as HMO, D-prescription drug benefit
Medicare Benefits and Cost Sharing - ANSWER Not covered are: Acupuncture,
chiropractor, cosmetic, custodial home care, dental care, DME convenience, hearing aids,
eyeglasses, foot care, meals on wheels, personal convenience, prescription drugs, private
nurses, routine physical, vision
areas of accountability of case management - ANSWER clinical/outcome
financial
functional/outcome
satisfaction
behavior
process
*episode or continuum
**individual or population
Measuring performance: Process - ANSWER The measure of how many pts receive a
treatment or service i.e. vaccinations, screenings, ex. diabetic foot exam ALSO practitioner's
practice conforming to practice standards.
Measuring performance: Functional outcome - ANSWER The measure reflects the health
state of a patient as a result of health care ex. increased independency in ADLs, mobility
2
,Measuring performance: Clinical outcome - ANSWER The measure reflects the health
state of a patient as a result of health care ex. blood pressure goals ex. HgA1c level, wound
healing
Measuring performance: behavioral 'process' - ANSWER ex. self-monitoring of blood
sugar
Measuring performance: Financial - ANSWER ex. fewer ED visits, ALOS decreased
Women's Health and Cancer Rights Act of 1998 - ANSWER 1. Part of Omnibus
Appropriations Bill. 2. required group health plans to provide coverage for mastectomies and
provide certain reconstructive related services following mastectomies.
Women's health and cancer rights act coverage - ANSWER 1. reconstruction of the
breast. 2. surgery and reconstruction of the other breast 3. breast prothesis
4. treatment for physical complications attendant to the mastectomy
Women's health and cancer rights act prohibitions - ANSWER Health plans are not
allowed to deny anyone coverage for the sole reason of avoiding the requirements of the act
AND cannot induce a physician to limit the care that is required under the act by penalizing
or limiting reimbursement to the physician.
Can states modify HIPAA's portability requirement - ANSWER Yes. HIPAA requirements do
not supercede state requirements. Stricter laws prevail. States can 1. shorten the 6 month
look back period. 2. shorten 12 month maximum pre-existing condition exclusion period.3.
increase the 63 day/significant break in coverage 4. increase 30 day period for newborns,
adopted children, children placed in adoption and pregnant women. 5. Expand the
prohibitions on conditions and people to whom a pre-existing condition exclusion period
may be applied beyond exceptions. 6. reduce additional special enrollment periods. 7.
reduce maximum HMO affiliation period to less than 2 months.
3
, Break in coverage - ANSWER 63 days or longer that a subscriber has been without health
insurance coverage (not including waiting periods)
Waiting period - ANSWER period of time specified by health insurance contract that
occurs between signing up for insurance and the beginning of health insurance coverage.
Cannot be counted as creditible coverage time. Individuals can use COBRA from their
previous employers for health insurance
Establishing waiting period - ANSWER HIPAA does not prohibit plans from establishing a
waiting period. But the waiting period and the pre-existing conditions exclusions must start
at the same time and run concurrently.
Creditable Coverage - ANSWER For the purpose of the Health Insurance Portability and
Accountability Act, coverage under virtually any type indivual or group health care plan
without a break in coverage of 63 days or more. Cannot be taken into account when
determining a significant break in coverage. Only coverage after the 63 day break will be
counted. Any coverage before the 63 day break will not be considered.
COBRA - ANSWER Consolidated Omnibus Budget Reconciliation Act; law to provide
terminated employees or those who lose insurance coverage because of reduced work to be
able to buy group insurance for themselves and their families for a limited amount of time.
Certification of creditable coverage - ANSWER Documentation that is provided
automatically by the plan or issuer when the individual loses coverage or becomes entitled
to elect COBRA continuation coverage and when an individual's COBRA continuation
covearage ceases ; Be provided if requested before loss of coverage or within 24 months of
loss of coverage. May be provided through use of model certificate
Nondiscrimination requirements - ANSWER Inividuals cannot be excluded from coverage
under the terms of the plan based on specified factors related to health status. Health plans
cannot establish rules of eligibility based on healht status related factors" such as health
status, medical condition, claims experience, receipt of health care, medical history, genetic
information, evidence of insurability or disablity. Insurer cannot drop a patient from
4
coordinates, monitors and evaluates the options and services required to meet the client's
health and human services needs.
Case Management Characteristics - ANSWER characterized by advocacy, communication,
and resource management and promotes quality and cost-effective interventions and
outcomes.
Glagow Coma Scale - ANSWER Client assessment tool that measures level of coma in the
acute phase of injury it is an objective way of recording the conscious state of a person. Eye
opening, Best verbal, best motor. < 8 coma, 13-15 mild injury.
Strengths Based Model - ANSWER assesses clients capacities and potential resources as
well as problems and current unmet needs. Eliciting capacities and potential resources as
well as problems and current unmet needs.
Independent Living Model - ANSWER sees a disability as a construct of society
Medicare Prospective Payment System - ANSWER hospitals paid a pre-determined rate
for each Medicare admission. Each patient is classified into a DRG.
PHQ-9 - ANSWER Client assessment tool for depression
Braden Scale - ANSWER Client assessment tool for pressure sore risk
1
,Clinical Pathway - ANSWER Structured multidisciplinary CM plan designed to support the
implementation of specific clinical guidelines and protocols. They are maps that guide the
healthcare team on usual treatment patterns related to common diagnoses, conditions and
procedures e.g., CHF
SF-36 - ANSWER Client assessment tool to measure physical and mental health.
Medicare - ANSWER Established in 1965 under Title XVIII or Social Security Act. Four
Parts A-hospital insurance, B-medical insurance (doctors visits), C-Medicare Advantage
program in a private plan such as HMO, D-prescription drug benefit
Medicare Benefits and Cost Sharing - ANSWER Not covered are: Acupuncture,
chiropractor, cosmetic, custodial home care, dental care, DME convenience, hearing aids,
eyeglasses, foot care, meals on wheels, personal convenience, prescription drugs, private
nurses, routine physical, vision
areas of accountability of case management - ANSWER clinical/outcome
financial
functional/outcome
satisfaction
behavior
process
*episode or continuum
**individual or population
Measuring performance: Process - ANSWER The measure of how many pts receive a
treatment or service i.e. vaccinations, screenings, ex. diabetic foot exam ALSO practitioner's
practice conforming to practice standards.
Measuring performance: Functional outcome - ANSWER The measure reflects the health
state of a patient as a result of health care ex. increased independency in ADLs, mobility
2
,Measuring performance: Clinical outcome - ANSWER The measure reflects the health
state of a patient as a result of health care ex. blood pressure goals ex. HgA1c level, wound
healing
Measuring performance: behavioral 'process' - ANSWER ex. self-monitoring of blood
sugar
Measuring performance: Financial - ANSWER ex. fewer ED visits, ALOS decreased
Women's Health and Cancer Rights Act of 1998 - ANSWER 1. Part of Omnibus
Appropriations Bill. 2. required group health plans to provide coverage for mastectomies and
provide certain reconstructive related services following mastectomies.
Women's health and cancer rights act coverage - ANSWER 1. reconstruction of the
breast. 2. surgery and reconstruction of the other breast 3. breast prothesis
4. treatment for physical complications attendant to the mastectomy
Women's health and cancer rights act prohibitions - ANSWER Health plans are not
allowed to deny anyone coverage for the sole reason of avoiding the requirements of the act
AND cannot induce a physician to limit the care that is required under the act by penalizing
or limiting reimbursement to the physician.
Can states modify HIPAA's portability requirement - ANSWER Yes. HIPAA requirements do
not supercede state requirements. Stricter laws prevail. States can 1. shorten the 6 month
look back period. 2. shorten 12 month maximum pre-existing condition exclusion period.3.
increase the 63 day/significant break in coverage 4. increase 30 day period for newborns,
adopted children, children placed in adoption and pregnant women. 5. Expand the
prohibitions on conditions and people to whom a pre-existing condition exclusion period
may be applied beyond exceptions. 6. reduce additional special enrollment periods. 7.
reduce maximum HMO affiliation period to less than 2 months.
3
, Break in coverage - ANSWER 63 days or longer that a subscriber has been without health
insurance coverage (not including waiting periods)
Waiting period - ANSWER period of time specified by health insurance contract that
occurs between signing up for insurance and the beginning of health insurance coverage.
Cannot be counted as creditible coverage time. Individuals can use COBRA from their
previous employers for health insurance
Establishing waiting period - ANSWER HIPAA does not prohibit plans from establishing a
waiting period. But the waiting period and the pre-existing conditions exclusions must start
at the same time and run concurrently.
Creditable Coverage - ANSWER For the purpose of the Health Insurance Portability and
Accountability Act, coverage under virtually any type indivual or group health care plan
without a break in coverage of 63 days or more. Cannot be taken into account when
determining a significant break in coverage. Only coverage after the 63 day break will be
counted. Any coverage before the 63 day break will not be considered.
COBRA - ANSWER Consolidated Omnibus Budget Reconciliation Act; law to provide
terminated employees or those who lose insurance coverage because of reduced work to be
able to buy group insurance for themselves and their families for a limited amount of time.
Certification of creditable coverage - ANSWER Documentation that is provided
automatically by the plan or issuer when the individual loses coverage or becomes entitled
to elect COBRA continuation coverage and when an individual's COBRA continuation
covearage ceases ; Be provided if requested before loss of coverage or within 24 months of
loss of coverage. May be provided through use of model certificate
Nondiscrimination requirements - ANSWER Inividuals cannot be excluded from coverage
under the terms of the plan based on specified factors related to health status. Health plans
cannot establish rules of eligibility based on healht status related factors" such as health
status, medical condition, claims experience, receipt of health care, medical history, genetic
information, evidence of insurability or disablity. Insurer cannot drop a patient from
4
