1.2 Roles and Functions of CM in Various Settings Flashcards
Many CM roles and functions are the same regardless of setting, such as_____, ______, _____, _____, _____, _____, and ______
Advocacy, Assessment, Planning, Empowerment, facilitation, collaboration and education.
The goal is to achieve the best outcome for the client, provider and payer. If a conflict arises, the ___ need takes priority
clients
Physician’s offices, ambulatory care clinics, accountable care organizations, corporations, and community based organizations including healthcare centers and university clinics- these roles are geared toward prevention.
- Wellness programs
- Screenings
- Health risk assessments
- Risk-Reduction strategies
- Telephonic triage
- disease management
- facilitating access to services
- referrals to community based resources
- coordination of medical and social services
- ensuring patient knowledge and compliance with treatment
- monitoring
Hospital roles are geared towards
- UR
- Discharge planning
- Resource management
- Coordination of care among team members
- Transition to post acute care
Acute inpatient rehab, subacute care, LTACH, and SNF roles are geared towards…
- Coordinate interdisciplinary team meetings
- verify benefits and authorization of services
- facilitate referrals
- discharge planning
Payer-based settings, including public health insurance programs (Medicaid and Medicare) and private health insurance programs (Occupational health, disability, group health insurance, managed care organizations) are geared towards….
- Liaise between providers, members, and insurance company
- Coordinate care
- ensure appropriate care
- negotiate for services
- monitor for compliance with treatment plan
- ensure appropriate LOC and care setting
- educate on healthcare benefits
- UM
- discharge planning
Palliative care, home care, and hospice care (this CM may have hands on nursing responsibilities) are geared towards
- Liaise with providers
- Communicate with treating physicians
- Provide patient and family education
- Assess for and coordinate additional services and DME
- Provide skilled nursing care
Workers’ Comp organizations are geared towards…
- Facilitate communication between the employer, claims adjuster, attorneys, union reps, state administrative agency, and providers
- Coordinate care b/w multiple healthcare providers
- Monitor progress
- UR
- Obtain pre-cert when necessary
- Perform job analysis
- Accompany injured workers during physician appointments
Goals and objectives of CM practice
- Achieving client goals
- Client autonomy
- Client knowledge of disease process, prognosis, and treatment options
- Optimum health and functioning for the client
- Client ability to self advocate
- Informed decision making by the client
- Appropriate use of services and resources
- Timeliness of services
- Quality of care
- Appropriate level of care to meet client needs
- Optimal level of client independence
- Achieving optimal outcomes
_____ is the reaching of an agreement through discussion and compromise.
Negotiation
There are two types of negotiation
Aggressive/hardball
cooperative
The aim of negotiation is to explore the situation and find a ___ ___ ___
mutually acceptable solution
Failure to agree upon _____ can make the negotiation process difficult.
goals
Case Managers use Negotiation to
- Develop a realistic plan of care with patient and care providers
- Obtain approval for needed services
- Control cost
- Obtain benefits outside of the benefit contract
- Determine length of stay
ADLs measure the level of independence on performing 6 basic activities
- Bathing
- Dressing-
- Toileting/continence
- Transferring
- Hygiene/grooming
- Feeding
