Nursing Case Management - ANSWER Is a dynamic and Systemic collaborative approach
to providing and coordinating healthcare services to a defined population.
Focus of Case Management - ANSWER A participative process to identify and facilitate
options and services for meeting individuals' health needs, while decreasing fragmentation
and duplication of care, and enhancing quality, cost effective clinical outcomes. Regardless of
political, cultural, or personal views of the case manager.
Demand Management - ANSWER Help reduce unnecessary costs from avoidable visit and
lead to better outcomes ex: phone triage or online health advice services
Key concept in case management - ANSWER Nursing is the dominant field that makes up
the practice if case management
Stakeholders - ANSWER Individual patients, families, caregivers, interdisciplinary team
(providers), payers (insurance companies), and communities
Components of Case Management - ANSWER Assessment
Planning
Implementation
Evaluation (monitoring)
Interaction
Case Management Assessment - ANSWER Involves in-depth evaluation of the patient and
their complete situation (including interviews and record review.
1
,Importance of financial assessment - ANSWER Identify available resources health care
and stability, assist patient/families to apply for additional benefits that may be necessary
for health care needs, and ensure any requisite pre-approvals for proposed health care
treatments and services.
Case Management Planning - ANSWER Process of developing patient-centered, evidence-
based, interdisciplinary plan of care based on complete analysis of data.
Case Management Implementation - ANSWER Is the execution of specific case
management activities and interventions that lead to accomplishing the goals set forth in
the plan of care. Requires critical thinking, knowledge, evaluation, negotiating (building
relationships and trust), contracting (organizations or vendors that provide services), goal
setting, and decision making.
Case Management Evaluation (Monitoring) - ANSWER Plan of care is continuously
monitored by gathering information from the providers involved to show that the patient is
effectively meeting goals. Proactive monitoring ensures that the patient is making progress
towards the desired outcome. If not, modifications or changes may need to be made.
"Pareto Principle" - ANSWER 80/20 rule: 80% of health resources are used by 20% of the
population
Erik Erikson - ANSWER Pediatric theorist who focused on the social environment of
children. Such as peer pressure, that may influence their willingness to adhere to prescribed
treatment regimens and medications.
B.F. Skinner - ANSWER Pediatric theorist that emphasizes behavioral issues that weee
treated with rewards, bargaining and other behavioral modification techniques.
Jean Piaget - ANSWER Pediatric theorist that developed cognitive theories on pediatric
interactions. Believed that children develop through a continuous drive to learn and adapt
schemas, which are mental templates that help them understand things.
2
,Health care "silos" - ANSWER Practices independently and without collaboration
Polypharmacy - ANSWER use of multiple medications in a single patient. Causing possible
increases in drug interactions, sensitivities, accidental overdoses, and unnecessary costs.
CMAG - ANSWER 1 of 2 tools that are useful for pathophysiological and psychological
assessments. Case Management Adherence Guidelines (CMAG) is a comprehensive model
based on patient information, motivation, and behavior skill needs.
IM-CAG - ANSWER INTERMED-Complexity Assessment Grid (IM-CAG) is an electronic tool
designed to provide a picture of risks and needs. 3 versions:adult, geriatric, and pediatric.
Pediatric IM-CAG - ANSWER 5 subjects to address: cognitive development, adverse
developmental events, caregivers health & function, and support
Evidence-Based Practice (EBP) - ANSWER Thoughtful integration of the best available
evidence, coupled with clinical expertise. Policy developed in 1997 by Agency for Healthcare
Research & Quality (AHRQ)
Systemic Reviews - ANSWER Best evidence based materials. Looks at publications, studies
and clinical trials to summarize evidence and analyze to find answer to a question
Nursing Case Management Documentation - ANSWER Is dictated by standards set by
profession, state legislators and regulators
Utilization Management (UM) - ANSWER Cost-based approach. Evaluation of the
appropriateness of the medical treatment and of the efficiency of healthcare services,
procedures and resources. This is based on established criteria or guidelines under the
requirements of the patient's individualized benefit plan.
3
, Utilization management goals - ANSWER Facilitate appropriate, safe,timely and effective
discharge to the most appropriate level of care and identifies potential participants in
disease management and case management
Utilization Management (UM) vs Utilization Review (UR) - ANSWER UM is a forward
looking process intended to manage healthcare resources efficiently and cost-effectively. UR
is preformed to ensure the patient's "five rights" (right: services, time, provider, setting and
cost) are observed.
Medicare - ANSWER Government program that provides health care for the aged.
Federally funded enacted in 1965 by Centers for Medicare & Medicaid Services (CMS) within
the US Department of Health and Human Services (HHS)
Medicare Part A - ANSWER is considered hospital insurance, covering inpatient hospital
services, skilled nursing facilities, approved home health services and hospice care.
Medicare Part B - ANSWER is considered medical insurance, covering physician services,
outpatient hospital services, and medical equipment/supplies. This is available providing
that the patient can pay the designated monthly premium established through the insurance
company.5 month waiting period
Medicare Part C - ANSWER Medicare Advantage Plans (HMO or PPO) offered by private
insurance companies approved by Medicare.
Medicare Part D - ANSWER Voluntary prescription drug benefit
Medicaid - ANSWER A federal and state assistance program that pays for health care
services for people who cannot afford them. Enacted in 1965 under Title XIX of the Social
Security Act
Critical thinking and problem solving - ANSWER Process of identifying key issues,
understanding each party's perspectives, considering possible solutions and outcomes,
4
to providing and coordinating healthcare services to a defined population.
Focus of Case Management - ANSWER A participative process to identify and facilitate
options and services for meeting individuals' health needs, while decreasing fragmentation
and duplication of care, and enhancing quality, cost effective clinical outcomes. Regardless of
political, cultural, or personal views of the case manager.
Demand Management - ANSWER Help reduce unnecessary costs from avoidable visit and
lead to better outcomes ex: phone triage or online health advice services
Key concept in case management - ANSWER Nursing is the dominant field that makes up
the practice if case management
Stakeholders - ANSWER Individual patients, families, caregivers, interdisciplinary team
(providers), payers (insurance companies), and communities
Components of Case Management - ANSWER Assessment
Planning
Implementation
Evaluation (monitoring)
Interaction
Case Management Assessment - ANSWER Involves in-depth evaluation of the patient and
their complete situation (including interviews and record review.
1
,Importance of financial assessment - ANSWER Identify available resources health care
and stability, assist patient/families to apply for additional benefits that may be necessary
for health care needs, and ensure any requisite pre-approvals for proposed health care
treatments and services.
Case Management Planning - ANSWER Process of developing patient-centered, evidence-
based, interdisciplinary plan of care based on complete analysis of data.
Case Management Implementation - ANSWER Is the execution of specific case
management activities and interventions that lead to accomplishing the goals set forth in
the plan of care. Requires critical thinking, knowledge, evaluation, negotiating (building
relationships and trust), contracting (organizations or vendors that provide services), goal
setting, and decision making.
Case Management Evaluation (Monitoring) - ANSWER Plan of care is continuously
monitored by gathering information from the providers involved to show that the patient is
effectively meeting goals. Proactive monitoring ensures that the patient is making progress
towards the desired outcome. If not, modifications or changes may need to be made.
"Pareto Principle" - ANSWER 80/20 rule: 80% of health resources are used by 20% of the
population
Erik Erikson - ANSWER Pediatric theorist who focused on the social environment of
children. Such as peer pressure, that may influence their willingness to adhere to prescribed
treatment regimens and medications.
B.F. Skinner - ANSWER Pediatric theorist that emphasizes behavioral issues that weee
treated with rewards, bargaining and other behavioral modification techniques.
Jean Piaget - ANSWER Pediatric theorist that developed cognitive theories on pediatric
interactions. Believed that children develop through a continuous drive to learn and adapt
schemas, which are mental templates that help them understand things.
2
,Health care "silos" - ANSWER Practices independently and without collaboration
Polypharmacy - ANSWER use of multiple medications in a single patient. Causing possible
increases in drug interactions, sensitivities, accidental overdoses, and unnecessary costs.
CMAG - ANSWER 1 of 2 tools that are useful for pathophysiological and psychological
assessments. Case Management Adherence Guidelines (CMAG) is a comprehensive model
based on patient information, motivation, and behavior skill needs.
IM-CAG - ANSWER INTERMED-Complexity Assessment Grid (IM-CAG) is an electronic tool
designed to provide a picture of risks and needs. 3 versions:adult, geriatric, and pediatric.
Pediatric IM-CAG - ANSWER 5 subjects to address: cognitive development, adverse
developmental events, caregivers health & function, and support
Evidence-Based Practice (EBP) - ANSWER Thoughtful integration of the best available
evidence, coupled with clinical expertise. Policy developed in 1997 by Agency for Healthcare
Research & Quality (AHRQ)
Systemic Reviews - ANSWER Best evidence based materials. Looks at publications, studies
and clinical trials to summarize evidence and analyze to find answer to a question
Nursing Case Management Documentation - ANSWER Is dictated by standards set by
profession, state legislators and regulators
Utilization Management (UM) - ANSWER Cost-based approach. Evaluation of the
appropriateness of the medical treatment and of the efficiency of healthcare services,
procedures and resources. This is based on established criteria or guidelines under the
requirements of the patient's individualized benefit plan.
3
, Utilization management goals - ANSWER Facilitate appropriate, safe,timely and effective
discharge to the most appropriate level of care and identifies potential participants in
disease management and case management
Utilization Management (UM) vs Utilization Review (UR) - ANSWER UM is a forward
looking process intended to manage healthcare resources efficiently and cost-effectively. UR
is preformed to ensure the patient's "five rights" (right: services, time, provider, setting and
cost) are observed.
Medicare - ANSWER Government program that provides health care for the aged.
Federally funded enacted in 1965 by Centers for Medicare & Medicaid Services (CMS) within
the US Department of Health and Human Services (HHS)
Medicare Part A - ANSWER is considered hospital insurance, covering inpatient hospital
services, skilled nursing facilities, approved home health services and hospice care.
Medicare Part B - ANSWER is considered medical insurance, covering physician services,
outpatient hospital services, and medical equipment/supplies. This is available providing
that the patient can pay the designated monthly premium established through the insurance
company.5 month waiting period
Medicare Part C - ANSWER Medicare Advantage Plans (HMO or PPO) offered by private
insurance companies approved by Medicare.
Medicare Part D - ANSWER Voluntary prescription drug benefit
Medicaid - ANSWER A federal and state assistance program that pays for health care
services for people who cannot afford them. Enacted in 1965 under Title XIX of the Social
Security Act
Critical thinking and problem solving - ANSWER Process of identifying key issues,
understanding each party's perspectives, considering possible solutions and outcomes,
4
