1.3 Different types of CM settings Flashcards
_____ diseases are characterized by rapid onset with a short duration
Acute
____ diseases require a lifetime of management, such as diabetes, lupus, heart failure and CKD
Chronic
Patients with multiple _____ are typically prescribed medication from multiple providers, leading to over medications or medication interactions.
comorbidities
Case managers should review all medications upon___, ___, ____
Opening a case, after each hospitalization, and after each visit to the doctor. (any change in status or level of care).
What are some options for patients struggling with medication costs?
- Medication samples from the doctor’s office
- Generic drugs when appropriate
- Co-pay assistance programs
- Disease-specific financial assistance
Poor adherence to the care regimen leads to:
- Decreased quality of life
- Higher healthcare costs
- Increased emergency dept visits
- Increased hospitalizations
- Avoidable nursing home admissions
- decreased productivity
- Poor clinical outcomes
- Premature death
_____ ______ is especially important for the long-term
management of chronic diseases, such as kidney disease, heart disease, and diabetes.
patient adherence
A patient’s ________ can be directly correlated to his understanding.
adherence
Especially when dealing with complex care regimens, client knowledge alone is not enough to
increase _________
Understanding the client’s beliefs, attitudes, support
system, and _______ will help the case manager communicatewith the client and foster collaboration.
adherence; self efficacy
For effective education:
- Use simple language; avoid medical jargon
- Limit instructions to 3-4 major points during each discussion
- Supplement teaching with written materials when appropriate
- Involve the client’s family or caregiver
- evaluate client understanding
- Reinforce concepts previously taught
_____ to medications takes many forms, including primarynonadherence, such as not filling the prescription, and secondary nonadherence, such as not
taking the prescription as prescribed (e.g., changing the dosage or frequency, stopping before completing the course of therapy, filling the prescription but never taking the medication,skipping or missing doses, or not refilling the prescription).
nonadherence
Reducing the ______ of pills or the _______ they are takencan also increase _____. The physician may be able to prescribe acombination medication and/or extended release medication to ______ the
_______ of pills taken.
number; frequency; adherence. decrease; number
As defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO),_______ _______ is “the process ofcomparing a patient’s medication orders to all of the medications that the patient has been
taking,” to include name, dosage, route, and frequency.
Medication reconciliation
The goal of _________ ________ is todecrease adverse drug events by reducing medication errors, such as omission, duplication,drug interactions, and dosing errors. Most errors occur during patient _______
____ ____, including changes in setting, level of care, or practitioner.
medication reconciliation: transition in care
When Should Medication Reconciliation Occur?
- Anytime the patient is moved within the hospital, such as from the ICU to the step down unit
- Upon transfer to another facility
- Upon discharge from any facility
- At each doctor office visit
_______ of care can occur ____ _____ ______, such as when a patient is transferred from the ICU to the step downunit; __________, such as from a hospital to
a skilled nursing facility; and ________, fromthe primary care physician to the specialist.
Transitions; within a facility, between facilities; within the community
A ___________ patient is at increased risk for an ______outcome, due to medication errors, failure to follow up on testing or procedures, and/or not
continuing prescribed treatments or therapies.
transitioning; adverse
The CMS recommends providers issue a _______
for all transitions of care or referrals.
summary of care
The _________ matches ongoing needs of the
individuals being served by the case management process with the appropriate level and type
of health, medical, financial, legal, and psychosocial care for services within a setting or across
multiple settings.
continuum of care
A case manager’s role is to ensure _______
when a patient transitions through the continuum of care.
continuity of care
The ________ is agroup of healthcare professionals from various professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient. Whenever possible thepatient and the patient’s family should be part of the team.
Interdisciplinary Care Team (ITC)
When referring a patient to a healthcare provider, the case manager should make sure the
provider is ___________ to treat the patient.
professionally qualified
A _______ is a person, such as a doctor or nurse, or a corporation ororganization.
“provider”
_____ ______is a sub-specialty of casemanagement and other professions. It provides a comprehensive care plan for the healthneeds of an individual who has experienced a catastrophic injury or has chronic healthcare
needs.
Life care planning
A __________ completes a comprehensive
assessment, data analysis, and research to provide an organized and concise plan for the
present and future needs of an individual.
life care planner
__________ case managers assist employees to return to work as quickly
as possible
Vocational
_________ provides end of life care, including palliative care, to patients with
terminal illness.
Hospice
The eligibility requirements for Medicare Hospice Benefit are:
- The patient has Medicare Part A
- The hospice program is Medicare approved
- The physician certifies tat the patient has a life expectancy of 6 months or less if the illness runs its normal course
- The patient must waive the normal Medicare hospital benefit to choose hospice care.
Hospice care is given in benefit periods. The first and second benefit periods are _______ days
each. These periods are followed by unlimited _______-day benefit periods. At the start of each
benefit period, a physician must certify that the patient is _____.
90; 60; terminally ill
Medicare pays a daily rate based on level of care. The levels of care include:
- Routine home care
- Continuous home care
- Inpatient respite care
- General inpatient care
Beginning March 23, 2010, with the enactment of the Affordable Care Act, Medicaid andChildren’s Health Insurance Program (CHIP) eligible individuals under age _________ who electthe hospice benefit no longer have to waive services for the cure or treatment of the terminalcondition and can receive both curative care and hospice care for the terminal condition.
21
____ ____programs provide long-term care services at
home and in the community to people who would otherwise be in an institution, nursing home,
or hospital.
Medicaid waiver
____ ____can provide a combination of standard medicalservices and non-medical services. Standard services include but are not limited to: case
management, homemaker, home health aide, personal care, adult day health services,habilitation (both day and residential), and respite care. States can also propose other servicesthat may assist in diverting and/or transitioning individuals from _______
_____ into their _______ and ______
Waiver programs; institutional settings; homes; communities.
A _______ ______ _____ is designed for beneficiarieswho are disabled, either physically or mentally. SNTs can be tailored to meet the unique
circumstances of each family.
Special needs trust
A properly prepared ____will allow the beneficiary to be eligible for need-based government benefits, such as Medicaidand Supplemental Security Income, while still receiving funds from the trust.
Supplemental Care SNT
Some life insurance policies have an ______ rider, allowing an insured person with a terminal illness to use someof the policy’s benefit prior to dying.
accelerated death benefit
There are restrictions on how the money can be used; generally it can be used for__________ and _______.
long term care; medical expenses
A _____ _______ sells the life insurance policy of a
person with a terminal or life-threatening illness and a life expectancy of less than five years toa third party for cash. There are ______ ______ on how this
money can be used
viatical settlements; no restrictions
Due to HIPAA protections, the money received from a ______________ isusually free from federal income tax. On the other hand, earnings may impact eligibility forsome means-based programs such as __________.
viatical settlement; medicaid
Under a ______ ________, the patient borrows against his orher home’s value without having to leave the home or make payments.
reverse mortgage
The payment structure of the proceeds may impact ___________eligibility.
Medicaid
The ________ is the most popular choice and often is not considered an asset when determining Medicaid eligibility.
line of credit
An _____ is a formal process or request to reconsider a healthcare decision,such as denial of hospital admission or reimbursement for healthcare services. An ___
can also request to extend the length of a hospital stay
appeal; appeal
________ benefits are benefits not covered
under the health plan but are given to the insured due to the cost savings for the health
insurance plan.
Extra-Contractual
Insurance will cover only healthcare that is ______.
medically necessary
To prevent double payment for services when a subscriber has coverage from two or more
sources, the National Association of Insurance Commissioners created ________ guidelines. Following these guidelines is not mandatory.
Coordination of benefits
_______ always pays last.
Medicaid
If an insurance plan does not have a COB provision, it must pay_______.
primary
The insurance plan covering the client as an _________ is the primary payer
over a plan covering the individual as a dependent, which pays secondary.
employee
If the parents are married, the _________ rules states that the parent whose_______ comes first in the year is primary for the children.
birthday; birthday
_____ __________ only covers ________
_______ injuries, while __________ and _________ cover loss of work dueto illness, injury, or accident that is not work-related.
Workers’ compensation; work related; STD and LTD
______ ________ provides replacement of lost wagesand a medical benefit for the work-related injury.
Workers’ compensation
______ and ___ only cover a portion of the wages, typically 50-70%, and beginafter a waiting period.
STD; LTD
Workers’ compensation is mandated to be paid by the ____.
employer
LTD purchased from an agent ___ taxed, whereas LTD as part of a benefits package ____ taxed.
is not; is
________ ________ laws protect employees who areinjured or disabled on the job.
Workers’ compensation
Work Compensation laws are designed to provide fixed __________ __________, eliminatingthe need for litigation.
monetary awards
Workers covered by workers’ comp______ sue their employer for work-related injuries.
cannot
Benefits include both _____ costs and ______ ____ andare awarded to the worker regardless of who was at fault for the accident.
medical; lost wages
The_______is 100% responsible for paying for workers’ compensation insurance
employer
The_______ is also responsible for filing the First Report of Injury with the insurance carrier and the state workers’ compensation agency, if required.
employer
Workers’ compensation always pays _______ to short-term disability (STD), long-term disability (LTD), and Social Security Disability Insurance (SSDI).
primary
Traditional insurance and Medicare ______ pay for long-term care (LTC).
do not
