Case Management Flashcards

Question

Plan for the stay:

Answer 1

Anticipating and setting a target for the stay, or duration of hospitalization, requires the case manager to understand the clinical condition, medical necessity and expected length of time it should take to complete the workup and provide the hospital phase of treatment. This planning happens early in the admission, if not during preadmission. At this time, begin setting expectations for the patient and family, in terms of length of stay and expected day and time for discharge, with the understanding that all target dates are anticipated and dependent upon patient progress. Outlining these expectations is helpful for the patient, family and care team to provide a clear timeline to mark progress and an end point for hospitalization. Although each patients experience and plan of care should be individualized, most medical conditions and reasons for hospitalization fall within expected parameters for diagnosis, treatment and length of stay, and these expectations should be shared with patient and family at the earliest possible point. Patient conditions, however, may take unexpected clinical turns, or may be highly complex due to trauma or underlying diseases. In these cases, the patient may not follow the generally expected path for hospitalization. The care team, as well as the patient and family, should review and revise the plan of care accordingly with frequent updates provided to the entire care team. The level of care within the hospital, or the plan for testing or treatment, may need to be accelerated or altered, in order to address the change in condition in a timely manner.

Answer 2

The transition through and from the hospital includes the discharge plan and requires knowledge essential to development of effective planning, including the: Full continuum of services beyond the hospital setting, Eligibility criteria, Likelihood that the patient's insurance will provide coverage, and Patient's level of engagement in helping to select the post-hospital care provider. The post-hospital level of care requires an appropriate match between services and a patient's clinical, functional and behavioral needs, as well as financial resources and insurance coverage. A patient's clinical condition is the first factor driving the progression through the hospital and to the post-acute level of care.

Answer 3

1- Why is the patient hospitalized? 2- why is the patient STILL hospitalized? 3- What has to happen for patient to safely leave hospital? 4- Where will patient be discharged to SAFELY?

Answer 4

autonomy, beneficence, non-maleficence and justice

Answer 5

doing no harm and is yet another of the four basic ethical principles. Ensuring that they receive treatment with human dignity and respect is one incredibly important way to protect them. Proper management of pain, respect for privacy and attending to spiritual needs are examples that may fall within this domain

Answer 6

When weighing options, the case manager and interdisciplinary team generally focus on the benefits, weighing risks versus benefits in the attempt to do what is best for the patient.

Answer 7

Fairness- access to needed high quality services may be limited due to financial or other barriers. Learning how to navigate or advocate for patient is important role.

Answer 8

federally mandated law from 1990 that requires hospitals and health systems participating in Medicare/Medicaid programs to inform patients of their right to self-determination in healthcare decisions. The federal law requires that decisional patients be informed of their right to execute advance directives such as a living will or durable power of attorney for healthcare. The law also specifies that the patient may not be discriminated against regardless of their particular healthcare decision, including the decision to accept or reject treatment or care."

Answer 9

enacted in 2000 to uniformly address, across all states, who could act on behalf of an individual who lacks legal capacity and a clearly executed advance directive/healthcare power of attorney. For parents of minor children and legally appointed guardians, the courts clearly delineate the line of authority that can be relied upon by healthcare providers. For patients that had not formally appointed a healthcare proxy, and who lack the ability or capacity to do so, this law provides for a uniform approach to determining who could step in and act on behalf of, and in the best interest of, the patient

Answer 10

1-The individual patient with decision-making capacity. 2- The patient designated health care power of attorney. 3-A court-appointed guardian, or a surrogate/proxy decision-maker (based on the priority list).

Answer 11

Competence is a legal term and a determination made by a judge in a court of law.

Answer 12

Capacity in this regard generally includes the patients ability to: -Understand the information being disclosed, including the risks, benefits and alternatives. -Weigh the consequences and evaluate the impact of the decision on his or her life. -State his or her choice and do so consistently over time. Decision making capacity is situation specific. For example, a patient may be able to make a decision about what type of medical treatment he/she wishes to have or understand the consequences of not accepting a particular treatment. This same patient, however, may not have the capacity to manage his or her financial affairs.

Answer 13

federal law passed in 1986 that applies to hospitals participating in Medicare and Medicaid programs. Under this law, hospitals are required to provide emergency healthcare treatment to all individuals who present themselves to a hospital emergency department, regardless of their ability to pay or citizenship status. The care rendered must include an appropriate medical screening examination, and if an emergency medical condition is identified, the patient must be treated and stabilized, or if safe and appropriate or patient requests, the patient may be transferred.The transfer of unstable individuals to another medical facility can only occur if a physician certifies that the medical benefits outweigh the risks, or the patient requests the transfer in writing after being informed of the obligations under EMTALA and risks.

Answer 14

Conditions of Participation

Answer 15

To qualify for Medicare certification, health providers/systems must comply with a minimum set of health and safety standards termed Conditions of Participation? (CoPs). CoPs outline a broad range of standards including those for: Utilization management. Discharge and transition planning processes that apply to all patients. A single standard of care/care planning process applicable to all patients. Processes to address pain management. Processes to ensure patient confidentiality. Patient rights (which include rights to execute advance directives, informed consent, participate in plan of care and discharge plan or rights to choose post-acute care providers, such as HHC or SNF).

Answer 16

CMS requires that all Medicare patients, upon admission (or within 2-days of admission) to the hospital, receive an Important Message from Medicare (IMM) letter. If hospital discharge occurs after the first 2-days, a second IMM is required to be given between 2-days of discharge, but not later than 4-hours prior to discharge. This is to ensure that the patient is aware of the rights related to discharge appeal and is fully informed of the plan for discharge. If the patient, family, or even physician, do not agree with the plan and timing for discharge, they may follow the CMS process for discharge appeal.

Answer 17

For patients or families who disagree with the plan and time for discharge and wish to appeal, a Detailed Notice of Discharge will be issued to the patient. If the patient proceeds with filing an appeal with the hospitals regional CMS Quality Improvement Organization/Independent Peer Review Organization (QIO/IPRO) and their appeal is overturned (i.e., the patient does not win his/her appeal), a Hospital Issued Notice of Non-Coverage (HINN) is issued. This essentially means that a patient no longer meets medical necessity for the continued hospital stay, and a safe plan for discharge has been identified. All notices must be communicated both orally and in writing. Notices should also be documented in the chart.

Answer 18

If the patient proceeds with filing an appeal with the hospitals regional CMS Quality Improvement Organization/Independent Peer Review Organization (QIO/IPRO) and their appeal is overturned (i.e., the patient does not win his/her appeal), a Hospital Issued Notice of Non-Coverage (HINN) is issued. This essentially means that a patient no longer meets medical necessity for the continued hospital stay, and a safe plan for discharge has been identified. All notices must be communicated both orally and in writing. Notices should also be documented in the chart.

Answer 19

standardized notice of status used to explain to Medicare beneficiaries their status as an outpatient in observation, not an inpatient. It includes an explanation as to why the patient is not inpatient and the implications of observations services related to cost-sharing and SNF coverage. This is not a notice of non-coverage and must be received within 36 hours of the 24 hours of observation services. An oral explanation is also required when delivering the MOON notice and hospitals must maintain a signed copy

Answer 20

1. To proceed with care, have Medicare billed and if denied, appeal to Medicare 2. To proceed with care and pay privately 3. To forego the service

Answer 21

Last minute delivery of an ABN can be construed as coercion. Last minute delivery is defined as, "after the beneficiary is likely to feel that the service has already begun and they have no choice but to continue the service." For example, the beneficiary may have been connected to testing equipment or may have been placed in a testing machine (CAT scan).

Answer 22

1-Manage and navigate the hospital/healthcare system on behalf of the patient for the protection of their rights, safety and health. Hospitals and health systems can give the impression of foreign, fragmented and unfriendly places for patients and their families/caregivers. At a time when patient and caregiver should be focused solely on getting through the current health crisis and moving towards recovery and wellness or transition to rehabilitation or palliation, they are oftentimes met with a barrage of clinicians they have never before met, confusing medical terminology, worrisome costs, impossible insurance battles and a setting that seems light years away from a healing environment. 2-Negotiate with payers, post-acute providers, internal providers and others to secure the needed services and benefits on behalf of the patient. This includes knowing facts, organizing arguments, analyzing how cost of benefit outweighs cost of potential readmission, as well as preparing for counterpoints and compromise. 3-Represent the patients voice when the patient faces barriers to speaking up for him or herself speak up for what the patient wishes. This is especially important for patients facing life limiting illness. 4-Help identify and/or secure the appropriate surrogate decision-maker when the patient is unable to demonstrate decision-making capacity. 5- Assess for biases- your own, those of the care team, those of the patient/family - and then support the patients values and choices within a context of informed consent/informed decision-making. Develop community agency collaboration to smooth care transitions, develop innovative approaches to complex patient discharges and to ensure bidirectional communication.

Answer 23

RAC and MACs represent reimbursement recovery arms of CMS. In particular, the rules and guidelines which apply to medical necessity for observation status, acute care admission and continued hospital stay can be difficult for the interdisciplinary team to determine or attend to. The financial risk to the hospital, and potentially to the patient, can be substantial if an admission or continued stay is not properly managed in the eyes of CMS.

Answer 24

Case Management in Hospital/Health Care Systems is a collaborative practice model including patients, nurses, social workers, physicians, other practitioners, caregivers and community. The Case Management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of Case Management include the achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patients right to self-determination.

Answer 25

states the hospital must have in effect a Utilization Management Plan (UM Plan) that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs

Answer 26

Specific -simply written and clearly defined Measurable- tangible result that demonstrates the goal was achieved Achievable- attainable, agreed upon, adequate resources Relevan- is the goal worthwhile and aligned with other goals Time-bound - timeframe is realistic yet creates a sense of urgency

Answer 27

Create a shared need for the change. Understand and deal with resistance from stakeholders. Build an effective influence strategy and communication plan for the change

Answer 28

Instructions given by individuals specifying what actions should be taken for their health in the event they are no longer able to make decisions on their own behalf. Examples include: Living Will: one form of an advance directive that leaves instructions for treatment. Power of Attorney/Health Care Proxy: someone appointed by the individual to make decisions on his or her behalf when he or she is incapacitated. Individuals may also have a combination of both documents, which is often encouraged to provide the most comprehensive guidance regarding a patient's care.

Answer 29

Acute Inpatient Rehabilitation (AIR):Level of care where patients must have had a recent event altering functional abilities, have the strength and endurance to participate in three hours of therapy per day and have the cognitive abilities to learn progressively.

Answer 30

To agree or concur. Used with regard to a minor making healthcare decisions. Minors do not have a legal right to consent to healthcare treatment and require parents or guardians to do so on their behalf. However, a knowledgeable, mature minor may have the ability to understand his/her treatment risks, options, choices, prognosis, etc. and participate in the decision-making process by offering agreement with recommendations or "assent"

Answer 31

is action that is done for the benefit of others, or a group of norms pertaining to relieving, lessening, or preventing harm and providing benefits and balancing benefits against risks and costs

Answer 32

Within the healthcare setting, this term refers to a patient's ability to make independent decisions about his/her healthcare treatment. Capacity in this regard generally includes the patients ability to: -Understand the information being disclosed, including the risks, benefits and alternatives. -Express the decision, and to do so consistently over time. -Weigh the consequences and evaluate the impact of the decision at-hand.

Answer 33

A hospital measurement representing the average diagnosis-related group (DRG) relative weight for a given facility. The CMI is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges.

Answer 34

A cluster of related abilities, commitments, knowledge and skills that enable a person to act effectively in a variety of situations. Competence is also a legal term and a determination made by a judge in a court of law. Decision-making capacity is not the same as competence.

Answer 35

A code describing a change in status when specific criteria are met. Under hospital Conditions of Participation (COPs), Medicare requires that all hospitals conduct utilization reviews (UR) to ensure that all requirements are met. When the hospital UR committee reviews the case and, in consultation with the admitting or treating practitioner, determines the admission is not medically necessary, however observation services are appropriate, the admission may be changed from inpatient to outpatient status. This is called Condition Code 44. The change is permissible if all of the following conditions are met: -The change in patient status from inpatient to outpatient (observation) is made prior to discharge or release while the member is still a patient of the hospital." -The hospital has not submitted a claim for inpatient admission -A physician concurs with the utilization review committee's decision. -The physician and utilization review committee's decision is documented in the patient's medical record. The medical record should contain orders and notes that indicate why the change was made, the care that was furnished to the patient and the participants making this decision to change the status. The patient must be informed of this change in status.

Answer 36

Sections of the Code of Federal Regulations that pertain to health and safety standards that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. These health and safety standards are the foundation for improving quality and for protecting the health and safety of beneficiaries. There are two sections of CoPs particularly important to Case Managers - Utilization Review and Discharge Planning. CoPs can also be the basis for other best practice standards, such as The Joint Commission

Answer 37

Provides a full explanation of the reasons for hospital discharge and/or why services received are no longer covered by Medicare.

Answer 38

A patient classification system used to identify resources expended for hospital services without taking into account the therapeutic approaches employed. In the DRG system, patient records are categorized into homogenous groups according to the diagnosis and healthcare expenses involved. The DRG system uses the following data for hospital performance evaluation: average length of stay, average patient load, comparative performance index and case mix index

Answer 39

Terminology used for outpatients in a bed who do not meet either Inpatient or Observation status requirements. These patients may be boarding after an uncomplicated procedure, or this classification is also used for social admissions. Generally, room and board charges are not billable

Answer 40

The face-to-face encounter must occur within the 90 days prior to the start of home healthcare, or within the 30 days after the start of care."

Answer 41

?Written notices given by a hospital to tell a patient that Medicare may not cover his or her admission, inpatient status or continued stay while at the hospital. This allows patients to be fully informed about decisions they must make that are affected by their Medicare coverage as well as payment for an inpatient stay at the hospital. HINN letters are delivered to beneficiaries prior to admission, at admission, or at any point during an inpatient stay when the hospital determines services the patient is receiving, or about to receive, are not covered because the services are not medically necessary, not delivered in the most appropriate setting or are custodial in nature.

Answer 42

The day before the patient is discharged is the last inpatient day.

Answer 43

An inpatient admission is generally appropriate when a patient is expected to need two or more midnights of medically necessary hospital care, but the doctor must order such admission and the hospital must formally admit the patient in order to be termed inpatient

Answer 44

A specialized care facility designed to treat acutely ill patients who benefit from a prolonged LOS for a minimum of 25 days. LTACHs differ from nursing homes and inpatient rehabilitation facilities. The significant difference is LTACHs are inpatient facilities with full-time registered nurses and physicians who provide care 24-hours a day, seven days a week. LTACHs are equipped to provide the same level of care as acute care hospitals with the exception of emergency medical services, obstetrics and gynecology services. LTACHs are needed because they help free beds in acute care hospitals, particularly in intensive care units."

Answer 45

A contractor responsible for ensuring that paid claims were for (1) services provided and properly documented, (2) services billed properly, using correct and appropriate procedure codes and (3) covered services. MICs additionally insure that claims are paid according to Federal and State laws, regulations, and policies. There are three types of MICs - review, audit and education.

Answer 46

Medicare Part A covers inpatient hospital services Medicare Part B covers outpatient medical services Medicare Part C consists of Medicare Part A and Part B benefits that offer a choice between an open-network single-payer plan (traditional Medicare) and a network plan (Medicare Advantage), where the federal government pays for private health coverage." Medicare Part D covers outpatient prescription drugs exclusively through private plans, either standalone prescription drug plans or through Medicare Advantage plans."

Answer 47

A Medicare hospital spending claim that includes all of Medicare Part A and Part B claims paid during the period from three days prior to a hospital admission through 30 days after discharge

Answer 48

A Medicare.gov website that stores detailed information about every Medicare and Medicaid-certified nursing home in the country. States may collect and post additional information that is not collected by the federal government

Answer 49

The Office of Inspector General (OIG) investigates allegations of fraud, waste, abuse or misconduct within the executive branch of federal government. The office also assists residents with locating the proper agencies to address concerns, when necessary. Furthermore, the OIG assists executive branch entities in identifying and correcting operational deficiencies.

Answer 50

A written authorization to represent or act on another's behalf in private affairs, business or some other legal matter. The person authorizing the other to act is the principal, grantor or donor of the power, and the one authorized to act is the agent, donor or attorney, or in some common law jurisdictions, the attorney-in-fact. Formerly, a power referred to an instrument under seal while a letter was an instrument under hand, but today both are under hand (i.e., signed by the donor), and therefore there is no difference between the two.Durable Power of Attorney simply means that the document stays in effect if you become incapacitated and unable to handle matters on your own. (Ordinary, or "nondurable," powers of attorney automatically end if the person who makes them loses mental capacity.)Healthcare Power of Attorney is a legal form that allows an individual to empower another with decisions regarding his or her healthcare and medical treatment. Healthcare power of attorney becomes active when a person is unable to make decisions or consciously communicate intentions regarding treatments."

Answer 51

Under State and Federal Law, PASSR applies to individuals who are: (1) being considered for admission to a nursing facility or (2) are already residents of a nursing facility and have a significant change in their physical or mental condition

Answer 52

risk assessment tool kit developed by the Society for Hospital Medicine."

Answer 53

For a Medicare patient to access benefits for a skilled rehabilitation or nursing stay after discharge from an acute hospital, the patient must have a three-day, medically necessary, qualifying hospital inpatient stay."

Answer 54

A testing methodology where the test taker is presented with realistic, hypothetical scenarios and ask to identify the most appropriate response or to rank the responses in the order they feel is most effective.

Answer 55

A facility that provides healthcare when an individual requires skilled nursing or rehabilitation staff to manage, observe and evaluate a patient?s care. Medicare Part A provides payment for post-hospital care in SNFs for up to 100 days during each illness. An illness begins on the first day a patient receives Medicare-covered inpatient hospital care and ends when the patient has spent 60 consecutive days outside the institution, or remains in the institution but does not receive Medicare-coverable care for 60 consecutive days. Once met, the patient is entitled to full coverage of the first 20 days of SNF care. From the 21st through the 100th day, Medicare pays for all covered services except for a daily co-insurance amount, which is adjusted annually."

Answer 56

This Act consolidates various state laws dealing with all decisions about adult healthcare and healthcare powers of attorney. It aims at assisting individuals and the medical profession in better assuring a person's right to choose or reject a particular course of treatment. This act is designed to replace existing living will, power of attorney for healthcare and family health care consent statutes which are dealt with separately in most states."

Answer 57

1)Establish rapport. Establishing rapport is key to a thorough assessment as the patient is more likely to share detailed information if there is a level of trust. 2)Verify demographic information in the record. This is an important step in an assessment, since errors could result at the time of discharge (for example equipment being sent to the wrong address).

Answer 58

Insurance verification is not the job of the case manager. Patient Access/Registration will be pre-authorizing the surgery, and the case manager will want to know at a later stage the specific benefits for discharge planning. (this is in reference to what are the first steps in conducting an assessment?)

Answer 59

Evaluate ADLs The description of Ms. Xavier already states that she lives alone and is independent in all of her ADLs. There is no need to re-evaluate.

Answer 60

If the patient is awake, alert, and capable of making her own health care decisions, there is no need to invoke the provisions in the Healthcare Power of Attorney document. It may be a facility’s policy to have these documents on file prior to a surgery, but this should not be pursued without first talking with the patient.

Answer 61

“what is your understanding of the care you will need after this surgery?”

Answer 62

+2 Point out that after surgery, everyone requires some assistance, and address this need with the question, “will your children be willing, able and available to provide the physical assistance you will need and to stay with you until you progress to the point where you feel independent again?” Good answer, but the case manager also needs to know what the care needs will be to better assess the family’s ability to provide the care. +3 Ask the patient to describe what she understands about the care that will be required when she is discharged and returns home. This is the best answer as it allows the patient to tell the case manager what she thinks will be needed, and it allows the case manager the opportunity to correct/adjust those ideas (based on experience and the patient’s prior level of functioning) to a more realistic assessment, if necessary. (do NOT discuss SNF at this time)

Answer 63

+3 What are the number of steps to get into the house/apartment? This is more relevant than the question above and can also be phrased as, “will the patient have difficulty getting into her home?” +2 Are the bedroom and bathroom on the first floor? This is also important. The case manager will need to determine, once the patient is in the home, whether they will be able to get to the bathroom and bedroom or require some form of assistance. +1 Does the patient know if the doors in her home are wide enough for a walker to fit through? This will be important to know if getting around the home presents a safety issue. NO -2- wrong answer What is the patient’s insurance coverage? This will be asked later in the assessment, but not yet. NO -3- wrong answer Are there neighbors, or friends, willing to provide assistance? While friends could be a part of a discharge plan, at this point this is irrelevant since she has a caregiver.

Answer 64

+3 Determining the patient’s insurance coverage for post-acute services. At this point in the assessment, it is important to now assess the financial resources for needed services and open a conversation with the patient and/or family about limitations, if applicable. For example, the case manager knows that the patient has a Managed Medicare product and should share with the patient that access to home health or SNF will be based on therapy notes and need for rehab rather than the patient simply wanting to recover in a nursing home. Do remember that since she has Managed Medicare, her payer may allow SNF placement, if needed, without a 3-day stay. +2 Clarifying the patient’s prescription benefit, including co-pay requirements. The case manager knows that patients are discharged on anti-coagulants after joint surgery, and based on experience, the case manager knows these drugs can be expensive. +1 Exploring with the patient her available resources and ability to make co-payments. The patient may or may not have financial concerns, but education about how much these drugs could cost is important for all patients in order to prevent a surprise at discharge. -2- NO- wrong answer Determining who the patient’s primary care physician is. This information should be contained in the record and should have been verified with the patient earlier in the assessment. -1 NO- wrong answer Determining what home health agency the patient wants to use, if needed. Although a good question, this is not the next step. The case manager needs to check benefits, and since this is Managed Medicare, also check preferred providers before having this conversation. -3 NO- wrong answer Showing the patient how to use Medicare.gov to assist in choosing a SNF. SNF placement is not in the care plan at this point. If it becomes necessary, the case manager must check first for in-network providers with Managed Medicare payers. In most Medicare Advantage plans, the patient needs to use plan doctors, hospitals and other providers or pay more or all of the costs (Medicare.gov website).

Answer 65

-2 NO wrong answer Insist on seeing the patient on the day of surgery to get an assessment completed as soon as possible. The patient may not be alert enough to assess. +3 Ask the patient’s bedside nurse if the patient is alert and oriented, and visit with the patient on the day of surgery. If the patient is alert and oriented, an assessment on the day of surgery could be valuable in controlling the length of stay. +2 Confirm with the patient that the information in the pre-admission assessment is still accurate and complete. As soon as the patient is alert and oriented, the first thing the case manager will do is confirm that there are no changes since the pre-admission assessment was completed. -3 NO wrong answer Have a detailed conversation about the patient and her options with the patient’s daughter while the patient is in the recovery unit. Since the patient is not incapacitated, she is the one with which the case manager should confer.

Answer 66

-1 NO wrong answer Encourages the patient to speak with her nurse about the use of her Patient Controlled Analgesic (PCA) pump. While some pain is to be expected, it is possible that the patient is not using her PCA correctly. Proper use could control her pain much better; however, since she is confused, leaving it up to her to speak to her nurse is not the best solution. +1 Explains to the patient that participation in physical therapy is critical to achieving her goal of discharge to home. This is a good response. Perhaps the case manager could help patient understand that if she gets her pain under control, she will be more likely to participate in physical therapy and reach her goal of discharge to home. However, pain should be addressed first. -2 NO wrong answer Gives the patient the SNF list and tell her she will likely need rehab since she’s not up and about yet. The case manager should address this concern with the patient after conferring with the care team (including PT) at a time when the patient is no longer confused. +3 Reports the patient’s poor pain control and confusion to the patient care nurse. The case manager knows that the patient’s report of 8-10 pain, and the confusion that is quite evident, are not normal for post-op day 1 after joint replacement. The case manager must share this information with the patient’s nurse and/or physician if available. -3 NO wrong answer Requests that the attending physician order a pain consult. Orthopedic patients have pain that for the most part can be controlled with proper use of a PCA. The attending is not likely to order a pain consult on post op day 1. -1 NO wrong answer Asks PT to see the patient again. If she is confused and in pain, this is not the time for her to be seen by PT. +3 Collaborate with PT to see the patient again early the next day, and prompt PT to coordinate administration of pain medication with nursing so the patient is more likely to participate in therapy. This is a positive and proactive action to take and is a good example of collaboration with the multidisciplinary care team.

Answer 67

+3 Share the PT recommendation with the patient and her daughter, who is at the bedside. The information from PT should be shared as soon as possible to allow the placement process to begin. +2 Discuss the SNF placement process with the patient. Remind the patient/daughter that the patient has a Managed Medicare plan that does have in-network providers and a requirement to pre-authorize the placement. -3NO wrong answer Inform the patient that, since she has a Managed Medicare policy, she does not have a choice of facilities for SNF placement and will need to go to the facility approved by her payor. While this is true, if the patient wants her insurance to pay for placement, patients always have a right to choose – if Ms. Xavier chooses to not make use of her Medicare benefit as provided by this Managed Care plan, she is free to go wherever she chooses. +2 Realize that the patient may go beyond a 2-day stay, so asks her utilization management partner to give the Important Message from Medicare Second Notice (IM). While the utilization manager would not have needed to give an Important Message (IM) Second Notice because this procedure was planned for discharge within 48-hours of admission, the case manager now realizes that the patient may go beyond a 2-day stay, so she asks her utilization management partner to give the IM.

Answer 68

-3 NO wrong answer The utilization manager takes the “Detailed Notice of Discharge” into the patient and her daughter. The Important Message from Medicare that the patient received earlier gives the patient/family the phone number for appeal. The “Detailed Notice of Discharge” is provided after the appeal is confirmed. +3 The utilization manager awaits a call from the QIO that an appeal has been filed. This is appropriate because any next steps should not be taken until the appeal is official. +1 The case manager notifies the SNF that the patient is appealing her discharge, so she will not be transferred today. This may be premature since the appeal is still not officially filed. +1 The case manager notifies the physician that the patient is appealing her discharge. Again, this may be premature until the QIO notifies the utilization manager that the appeal has been filed.

Answer 69

+3 Take the “Detailed Notice of Discharge” into the patient's room and deliver to the patient and her daughter. This is the first thing that should happen after receiving notice from the QIO. +2 Call the Managed Medicare Company to alert them to the discharge appeal and to let them know the patient will not be leaving today for the SNF. The payor needs to know the discharge is not happening today. They will want an update from PT prior to approving a transfer to SNF given this delay. -3- NO wrong answer Tell the patient that she is likely to lose the SNF bed and that may result in her discharge to home instead. This would not necessarily be true. The patient may still not be safe to discharge home, and it could be perceived as a retaliatory statement because of the appeal. -3 NO wrong answer Tell PT that the patient has appealed her discharge so they don’t need to see the patient again in the morning. PT needs to see the patient even if she has appealed her discharge because the case manager knows a PT update will need to be provided to the payor, as well as to the physician, as alternate plans may need to be made if the payor denies SNF placement. +1 Document delivery of the “Detailed Notice of Discharge” and the appeal in accordance with hospital policy and Medicare regulations. Requirements for documentation of this process are defined by CMS regulations as well as department policy.

Answer 70

+1 Current mental status. Current status is listed as “anoxic brain injury and not following commands.” It would be important to know the mental status as patient may not respond appropriately to questions or have ability to write answers. 0 Review labs, tests and procedure reports. This data is unlikely to provide information needed to complete a case management assessment. +1 Current clinical status. Overall clinical status may help determine a timeline towards readiness for discharge. 0 Current ventilator support needs. The patient has failed a ventilator wean three times at the outside hospital. His current status is unlikely to provide additional necessary information for assessment. +2 Contact brother. The brother is the only known living relative and is listed as emergency contact. -2- no wrong answer Tell the receiving facility they are required to take the patient back after the pacemaker is inserted, and arrange for disposition. There is no such legal requirement. There may be a contractual agreement between the referring and receiving facility; however, this has not been disclosed to the candidate.

Answer 71

+2 Schedule a family meeting with the brother, healthcare team and the Medicaid eligibility counselor. As Mr. Jones’ discharge readiness approaches, the financial aspects of the discharge plan must be settled. +1 Request that the legal and/or risk management department call the construction company. This may be a viable source of funding for the hospital and post-acute care. +1 Make referrals to skilled nursing facilities with tracheostomy care capability. This is the identified appropriate level of care at discharge. +1 Approach hospital leaders to inquire if the hospital would cover the cost of SNF care until Mr. Jones is eligible. At this moment, Mr. Jones has no identified source of funding, limiting his disposition options. +1 Discuss the option of guardianship. Mr. Jones cannot communicate his wishes, and Jerry indicates he is tiring of being Mr. Jones’ decision maker. Someone must be identified to represent Mr. Jones’ interests. +1 Confer with the physician to discuss any less expensive alternatives for medications and treatment plans. Identifying potentially less costly medications and treatment plans may increase the chances a SNF will accept Mr. Jones with potential Medicaid funding. 0 Call the transferring hospital about sending the patient back for completion of care. This does not resolve any disposition problems for Mr. Jones.

Answer 72

+2 Make referrals to SNFs with a Medicaid pending status. Mr. Jones’ care needs make him an appropriate SNF candidate. -2 -NO Tell Jerry if he leaves on a trip, an Adult Protective Services (APS) report will be filed for abandonment. Jerry has no legal responsibility for Mr. Jones’ care. +2 Encourage the legal department to proceed with a guardianship hearing. Mr. Jones must have a legally appointed decision maker. -2 NO Request that durable power of attorney paperwork be completed. Mr. Jones does not have the capacity to sign this document. -2 NO Call the workers compensation case worker and indicate the patient may file suit if benefits are not approved. This is untrue.

Answer 73

+1 Electrolyte abnormalities Dr. Murray’s confusion and agitation could have a metabolic source. Electrolyte abnormalities could also be a major determiner in the criteria assessment for inpatient/outpatient status. +2 Current mental status It is vital to assess Dr. Murray’s mental status before beginning a discussion with him to ascertain his current capacity for providing accurate information and understanding communication. -2 Color of urine This is not vital to either a discharge planning or utilization management assessment. +1 Intake and output since admission Information about intake and output is crucial to the utilization management assessment of Dr. Murray’s situation and may be predictive of his anticipated length of stay. +2 Current living situation Dr. Murray’s presentation suggests he has not been receiving adequate hydration and nutrition and may have a medication compliance concern. This information, along with the recent death of Dr. Murray’s wife, should compel the case manager to know more about Dr. Murray’s current living situation. +2 Medication history and compliance Dr. Murray’s symptoms could be related either to medication non-compliance or a medication side effect. Understanding what medications he is taking is vital to planning for his care during and after hospitalization. -2 Current stage of grieving process This is an inappropriate evaluation goal in an initial meeting. The case manager has not yet met the patient, and no rapport or relationship of trust has been established. +1 Family and social supports Just as with assessing Dr. Murray’s current living situation, it is vital to understand what family and social supports are present. -2 Request a blood and urine toxic substances screen At this point, there is no evidence of any exposure to toxic substances, and screening for toxins is not indicated. -1 Monthly income and level of savings It is known that Dr. Murray is a retired physician with Medicare A/B and a supplement policy. It is not likely that financial problems are the root of his malnutrition and possible medication noncompliance. Probing financial questions from the case manager, at this point, may hamper attempts to build rapport and trust.

Answer 74

+2 Request a Social Work consult There is evidence of complex psychosocial concerns that could be better explored with a social work consultation. +2 Confer with a physician and/or pharmacist on their assessment of the patient's current medications. Inquire about a possible medication reaction. This is a crucially important step, as Dr. Murray’s confusion and agitation could be related either to not taking prescribed medications or be a side effect of his medications. +1 Use the available hospital electronic medical records’ function to determine the status of prescription refills. Many electronic medical record applications have the ability to report frequency and status of medication refills. This information would be important to understanding the etiology of Dr. Murray’s presentation and post discharge needs. -2 Call both children and suggest they come visit their father. The case manager has only received permission to call Dr. Murray’s son and should not contact other family members without permission. Without understanding the full family dynamic, the case manager should not be making recommendations that family members travel to visit. Doing so could jeopardize rapport and trust between Dr. Murray and the case manager. -2 Request a consult from Adult Protective Services. There is no information, thus far, to indicate this is warranted.

Answer 75

+1 Refer to the hospital’s compliance and information security protocol for any special expectations regarding handling patient information regarding behavioral health issues. Many hospitals have information security policies surrounding behavioral health information that are more restrictive than federal and state guidelines. +2 Call local psychiatric facilities to see if they have inpatient adult beds. Send demographics and psychiatry consult notes to those that indicate availability. Under HIPAA, protected health information necessary to payment, treatment and healthcare operations does not require specific patient permission for transmittal between entities. In this situation, demographic and psychiatry consult notes are essential for a potentially accepting facility to determine whether they can make an offer to accept Dr. Murray in transfer. -2 Ask Dr. Murray which facilities he would consider transferring to, and obtain his written consent to send referral information to those facilities. Dr. Murray is under an involuntary commitment order. He does not have the right to refuse appropriate care and treatment. -1 Issue a Hospital Issued Notice of Non-Coverage (HINN), as the medical criteria for continued stay are no longer met. Dr. Murray’s hospital stay was entirely on Observation status, and a HINN is not called for in this situation. HINNs are also only issued when there is a safe and appropriate discharge plan in place, which is not the case here. -1 Disclose to the psychiatric hospitals that make a bed offer that this will be a self-pay transfer, as there is not a three day qualifying stay. Three day qualifying stays are only required for transfer to a lower level of care, such as a skilled nursing facility (SNF). Dr. Murray’s proposed transfer to an acute psychiatric hospital does not require a three day qualifying stay.

Answer 76

-2 Call the local police/sheriff to transport Dr. Murray to an accepting facility. The case manager cannot order a discharge. 0 Try to convince Dr. Murray to change his mind about which facilities he will go to. Depending on the level of rapport the case manager has developed with Dr. Murray, he/she may have some success, however it is unlikely. +1 Consult the Case Management Physician Advisor. This would be an appropriate escalation to a Physician Advisor to have a physician-physician level discussion of issues and concerns. +2 Request a meeting of the patient’s care team to discuss concerns. A care team conference would be appropriate to identify issues and barriers and discuss a way to plan for a safe and appropriate discharge for Dr. Murray.

Answer 77

-2 Explain that Medicare is Mr. Watson’s primary insurance, and a status determination must be made within CMS guidelines. Medicare is not the primary insurance for Mr. Watson. Under the coordination of benefits rules, the policy of an active working spouse is always primary. -1 Advise Mrs. Watson that this request will be shared with the attending physician. While not harmful, this action does not provide helpful information or a resolution to Mrs. Watson’s inquiry, and may create unrealistic expectations. -1 Explain that a patient with Medicare must be in the hospital at least two midnights to be classified as inpatient. This statement is not completely correct, as there may be appropriate inpatient hospitalizations of one day. Medicare is also not Mr. Watson’s primary insurer. +2 Advise that the commercial health plan is Mr. Watson’s primary insurance, and the insurance case manager has advised the plan will only approve observation status. Mrs. Watson’s commercial insurance policy is Mr. Watson’s primary policy, under the "Working Spouse Rule." The payer has made a determination that they will only approve observation status, and there is no reason for the case manager to advocate for a change.

Answer 78

+2 Confirming that Mr. Watson did not have an acute coronary event. Cardiac rehabilitation is generally not available for a patient who has not had a coronary event. It is important to know what Mr. Watson’s diagnosis and coronary status are before making an inquiry. +1 Mr. Watson’s understanding of his cardiac status and risk factors. Assessing Mr. Watson’s awareness of the nature of this event, and the potential for another one, may be key to his post-discharge compliance. +2 Mr. Watson’s level of interest in modifying his risk factors. Mr. Watson is likely being counseled by his physicians and nurses about smoking cessation and exercise. Exploring his responses to this information may identify points for reinforcement or opportunities to discuss ways Mr. Watson may choose to address these risks. -2 Determine if Mr. Watson if is depressed, since this often happens to retired males with working wives. There is no indication in the information the case manager has that this may be the case and no indication that rapport has been built to a level to explore this.

Answer 79

-1 Advise Mr. Watson to let his wife know about any symptoms he may have, as she is a nurse and can determine if 911 should be called. Mr. Watson should be given the same instructions as any patient. The fact that his wife is a nurse does not lessen the obligation to provide Mr. Watson with patient discharge instructions. +2 Confirm that Mr. Watson knows where and when he is to report for his cardiac cath and that he has transportation available. Confirming these instructions and available transportation supports Mr. and Mrs. Watson making plans for the catheterization. -2 Suggest that Mr. Watson look into gym memberships to become more active. The case manager is not aware of Mr. Watson’s activity instructions or limitations, particularly in advance of his cardiac cath. (This information was not presented, so the ACM candidate should not assume it). +2 Contact the commercial insurer to inquire if Mr. Watson can be approved for cardiac rehab or if any disease management programs to manage cardiac risk factors are available. It is likely that the commercial insurer requires prior authorization for cardiac rehab services, and since Mr. Watson has not had an acute coronary event, he may not be eligible for cardiac rehab. However, the care team and the insurer would like to prevent an acute coronary event, and support for managing risk factors, such as smoking, may be available.

Answer 80

-2 Discussion with the ED attending about discharge home with hospice since the patient’s clinical symptoms are borderline and he no longer wishes to continue aggressive treatment. The patient’s clinical presentation does not indicate criteria met for discharge. +2 Proceed with the patient/family assessment after full review of the patient’s medical record. This is a necessary first step before conducting the full assessment. The case manager needs to understand the clinical and patient demographic information in the medical record, any related healthcare team notes and documentation regarding presenting problems and initial steps in the plan of care. 0 Request an ethics consult to help evaluate the patient’s decisional capacity. There is no indication that this situation requires an ethics consultation to evaluate patient decisional capacity. As a minor, this patient will require an adult parent/guardian to serve as the healthcare decision maker; however, this patient demonstrates knowledge of his illness, and its impact on his life, and there does not appear to be conflict between him and his mother at this time. +1 Evaluate the patient’s and mother’s knowledge of the treatment plan, level of adherence and understanding of risks, benefits and options related to continued treatment. This is an appropriate choice in the assessment process and required before proceeding with the development of an initial plan of care or additional assessment questions. +1 Review the patient’s health insurance regarding coverage for potential admission and begin a discussion of plan of care options with the attending. This is an appropriate choice in the assessment process and is also required before proceeding with the development of an initial plan of care or additional assessment questions. -1 Refer the case for psychiatry consultation to evaluate the patient for clinical depression. While this patient’s condition may likely impact his emotional well-being, and potentially prompt a referral for mental health consultation, this is not the first step needed by the case manager. There is insufficient evidence to indicate clinical depression or a need for psychiatry at this time.

Answer 81

-2 Contact the physician advisor – the patient is ready for discharge from the ED (both the patient and family are requesting this), and the ED attending is not cooperating. This patient is not ready for discharge. Facilitating a discharge via the physician advisor would be inappropriate, especially before further communication and counseling is provided to parents/patient regarding hospitalization needs and treatment options. -2 Recommend observation status as an intermediate step since there is not agreement among the ED attending, patient and family. The use of observation services are to rule in/rule out specific medical conditions that may require the intensity of acute care hospital intervention, or to provide brief intervention for immediate remediation/treatment of a serious condition. Observation is not a “holding” area or status to be used as a default when there is conflict or disagreement between clinical team and patient/family. -2 Immediately make a referral to child protective services. This is not a good option at this point. The case manager is still talking with the family and patient, and they are still engaged in the discussion. As long as the case manager and team are able to communicate, and progress is possible, there is not yet a need to contact child protective services. +2 Discuss the plan with the patient and parents to treat the febrile part of illness now, through a hospital admission. During the admission, the case manager should let the patient and parents know he or she will help them to explore other options including continued treatment, phase 1 treatment protocols and/or hospice/palliative care. This is the best next step for the case manager at this phase in the patient’s hospital/ED visit. It compartmentalizes the treatment plan into something tangible and understandable and allows the patient/family to retain a sense of control over future steps in the development of the plan of care. +1 Confer with the pediatric palliative care team regarding options to support the patient’s and family’s quality of life, care, treatment and care decisions. This is an appropriate option. Even though the patient may continue with active treatment, understanding all options (of which palliative care is an important one), is necessary to make a fully informed decision. This will support the patient and family in their current decision, as well as inform them for decision-making in the days and months ahead.

Answer 82

+1 Plan to initiate a post-discharge follow-up call within 48-hours of discharge. This is an appropriate step for patient reassessment post-discharge, to ensure services are in place as planned, and to assess for any signs/symptoms or new problems. Discharge follow-up calls have been shown to be effective in reducing readmission. +2 Complete a comprehensive hand-off to next care provider/level of care. This is an appropriate step. A comprehensive hand-off communication is a critical step in care continuity and reducing readmission. -2 Arrange for hospice services. Hospice services not indicated at this time. -1 Arrange for transportation. Transportation needs have not been identified at this time. -2 Provide a HINN to the parents no later than 4 hours from discharge. This family is not appealing their discharge. There is no need to deliver a HINN (Hospital Issued Notice of Non-coverage). +1 Consult the pharmacy to provide medication management for the patient and family. Given the new plan of care and medication regime, a pharmacy consult could be beneficial. +2 Request that the palliative care team provide comprehensive, teachback education regarding signs/symptom management for cancer treatment and outpatient follow-up, as available. This is an appropriate step for current needs of the patient and offers a resource/source of support to the patient and family in the days/months ahead, especially if the patient’s clinical condition does not improve.

Answer 83

+2 “How does the breakfast you were served compare to the breakfast you were asking for? Let’s look at how they are alike and different.” This would be a good question to both assess the patient’s understanding of the dietary instructions he has received and act as an “ice-breaker” of sorts. Wording the question in this manner would also be more conversational, and not seem instructional or harshly judgmental. +1 “May I ask you some questions to confirm the information in your record about what brought you here?” This question conveys respect for the patient and identifies the objective for the line of questioning. +3 “How often have you been checking your blood sugar and taking your insulin shots?” This question seeks information from the patient and is more likely to result in truthful information than asking, “Have you been checking your blood sugar the way you are supposed to?” -2 “Did you take the time to fill your prescriptions the last time you were discharged?” While inquiring about whether prescriptions from the last discharge were filled is a worthy objective, the wording of this question, “did you take the time,” is judgmental and thus is not appropriate. -3 “Do you realize if you keep this behavior up you are going to end up on dialysis?” While this may be a real possibility, this is certainly not the way to start an assessment and is probably not a productive question to ask at any point. While the conversation may need to happen when describing the sequelae of his disease, tying it to his current behavior so directly would most likely result in the patient tuning the case manager out.

Answer 84

+3 During interdisciplinary team rounds, propose that a more realistic regimen be considered. Interdisciplinary rounds with the care team would be an appropriate forum to introduce the concept of a more successful insulin regimen for Mr. Samuels. All members of the care team will need to be on board to teach and reinforce a new plan. +2 Enlist the care nurse’s assistance in assessing Mr. Samuels’ ability to draw up insulin accurately and correctly. Since Mr. Samuels is legally blind, it is important to assess his ability to accurately administer his medications. -2 Refer to Social Work to arrange a cognitive assessment of the patient for possible guardianship. The patient does not seem to be able to adhere to a very complicated insulin regimen and makes food choices that are not recommended, but there is no evidence that he lacks capacity for decision making. +2 Advise the patient that a referral to a social worker will be arranged to help him address his living situation and availability of food. The patient would definitely benefit from services in the community to assist him with housing and food. -3 Inform the patient that he has to do four insulin shots a day because that is what will give him the best possible outcome in the treatment of his disease. This is the least helpful answer – if he was capable and willing to manage his diabetes this tightly that would be ideal. However, this young man is either not cognitively able, or not willing to adhere to, this regimen. -2 Advise the patient that he needs to find one place to stay because it’s clear that moving from place to place is making it harder for him to adhere to his care plan. While this is obviously true, telling the patient to fix it without offering help in finding solutions is not at all helpful.

Answer 85

+2 Current living situation. Mr. Martinez’s presentation suggests he has not been receiving ongoing medical management for his diabetes and hypertension. Assessment of his current living situation will help the case manager with discharge planning needs. +2 Ability to afford medications. When a patient with a limited income must choose between paying bill, buying groceries or filling a prescription, the prescription is likely to go unfilled. The case manager can identify patient assistance programs (PAPs) or other forms of prescription assistance. -2 Financial savings and ability to pay for hospital stay. Mr. Martinez does not have health insurance through his employer and has yet to meet with a financial counselor. Financial questions from the case manager, at this point, may hamper attempts to build rapport and trust. -1 Color of urine. No indication that color of urine indicates renal failure improvement or worsening. +1 Electrolyte abnormalities. Electrolyte abnormalities and the initiation of emergent dialysis may indicate need for post discharge community dialysis arrangement. +1 Intake and output since admission. Information about intake and output is important to the utilization management assessment of Mr. Martinez. He presented with 2+ edema and required emergent dialysis. Imbalance in I&O may be predictive of his anticipated length of stay. +2 Medication history and compliance. Mr. Martinez reported a longstanding history of hypertension and diabetes, that he states has been controlled both with diet and exercise, although blood pressure elevation and HbA1c at >9% are noted at admission. The case manager assessment of history and compliance may provide additional information that will assist in discharge planning needs. +1 Family and social supports. A crucial part of assessment, especially as Mr. Martinez has a sudden illness and new diagnosis, is to understand what family and social supports are present. +2 Plan for post discharge care. Mr. Martinez has a new diagnosis of renal failure with a dialysis catheter placed for urgent dialysis in facility. Discussion of post discharge plan, location of local dialysis centers and transportation needs are important to consider early in stay.

Answer 86

+3 Look through the paperwork from the Assisted Living Facility to see if it identifies a Healthcare Power of Attorney or if there is an Advance Directive. The documentation could be available indicating the patient’s wishes and that should be consulted first. +2 Identify the next of kin. Identifying the NOK will point to the person who can make decisions on the patient’s behalf. -2 Call the Assisted Living Facility to ask them if they have ever heard the patient talk about her wishes related to code status. The ALF ‘s representative does not have decision-making ability for the patient and no providers would accept anecdotal statements as guidance in an emergency situation -3 Do nothing until the patient is stabilized. The ED CM has a responsibility to help clarify the patient’s wishes and/or code status now. +2 Confirm with ED Physician current condition of the patient and let him/her know you are calling the patient’s daughter. The daughter is in the appropriate next of kin category because the patient has been her own decision maker (so no guardian) and there is no documentation of a HCPOA in the record from the Assisted Living or in the Hospital EMR. -2 Hold off on calling the patient’s daughter until the HCPOA is confirmed. Absent evidence of a HCPOA, the daughter is the only identified NOK at this point so it is appropriate to call her. +3 Call the patient’s daughter and let her know her mother is in the hospital and ask if she has a HCPOA or Advance Directive. In the case that the patient has more than one child and there is disagreement among the siblings, having a written document would provide evidence of the patient’s own wishes

Answer 87

Confirm the patient’s current condition and contact patient’s son, the HCPOA. Inform the patient’s son of the current situation and ask him what the patient’s wishes are related to resuscitation If there was no HCPOA, the patient’s children would most likely have equal say in the decisions. +2 Facilitate a conversation between patient’s son and the ED physician to get the code status determined. In an ED, the physician is always going to go with aggressive treatment in the absence of a documented Advance Directive or HCPOA. In this case, the son states (and the daughter has agreed) that he has HCPOA and she will abide by his decision. This would be a witnessed conversation. +2 As Mrs. Long’s daughter is quite distraught and tearful, provide emotional support. As a nurse or a social worker, a case manager should have the skill set to provide crisis support at least until backup support arrives. -2 Talks with the patient’s daughter about Hospice in case the patient lingers. Daughter is unlikely to retain anything at this point. -3 Ask the patient’s daughter why she is not the HCPOA The patient made the decision to name her son HCPOA – inappropriate to ask the daughter why.

Answer 88

+2 Current medications Need to determine if Mrs. Taylor’s condition is related to her medications. +3 Living will or advance directive for healthcare. Since Mrs. Taylor is somnolent, a legal decision-maker needs to be identified. +2 Laboratory results Mrs. Taylor’s lethargy may be related to an electrolyte imbalance. +1 Social history Need to establish if Mrs. Taylor is in a safe environment with a responsible caregiver. 0 Dietary supplements Not relevant at this time. -1 Current pain score Patient’s confusion and somnolence makes this a non-relevant part of information gathering at this time. +2 Payer information Need to know payer status for admission status and discharge planning purposes.

Answer 89

+2 Review Mrs. Taylor’s current cancer treatment. Important to know the extent of Mrs. Taylor’s cancer for treatment and discharge planning. +2 Ask LaVonne the frequency of pain medication Mrs. Taylor has been receiving. Need to rule out over-sedation from pain medication as a potential contributing factor to somnolence and confusion. -2 Ask LaVonne if she would consider hospice care for her mother. The extent and severity of Mrs. Taylor’s condition have not yet been established. -3 Recommend vigorous intravenous hydration, then discharge the patient to home. Patient’s condition requires management in an acute care setting. +2 Recommend hospitalization. This is appropriate for addressing Mrs. Taylor’s condition.

Answer 90

-2 Suggest Mrs. Taylor take acetaminophen or ibuprofen for her pain. Mrs. Taylor should avoid acetaminophen pain medication due to her liver metastases. Given her extensive bone metastases and terminal condition, Mrs. Taylor will require a more effective pain medication than over-the-counter pain relievers. +2 Suggest a palliative care consult. Mrs. Taylor’s cancer is advancing and goals of care should be discussed. Palliative care could also provide suggestions for pain management. -1 Arrange transportation home. Transportation home is not needed. Mrs. Taylor was ambulatory prior to hospitalization and can be transported home by her daughter. +1 Request a dietary consult. Mrs. Taylor has progressive cancer and could benefit from improved nutrition. -2 Request a physical therapy evaluation. Mrs. Taylor is still lethargic and in pain. She may not require physical therapy and her pain should be controlled first.

Answer 91

-3 Does Mrs. Taylor wish to designate someone else for durable power of attorney for healthcare? There is no apparent reason to pursue this and distrust could develop between the case manager and the patient. -2 Should Mrs. Taylor pursue aggressive cancer treatment with a different oncologist? Mrs. Taylor has advanced disease, is already receiving palliative treatment, and will not likely benefit from aggressive treatment. +3 How is Mrs. Taylor responding to her current treatment? This is required to assess readiness for discharge. +3 What are Mrs. Taylor’s goals of care? Mrs. Taylor’s goals and preferences must be taken into consideration when planning for her post-discharge care.

Answer 92

-2 Request that physical therapy evaluate Mrs. Taylor in her home after discharge. Mrs. Taylor’s safety with ambulation should be established prior to leaving the hospital. +3 Discuss discharge options and preferences with Mrs. Taylor. It is essential to include Mrs. Taylor in planning for her post-hospital care and to document her preferences. +2 Arrange to receive her bisphosphonate for hypercalcemia at the outpatient oncology clinic. Mrs. Taylor will need ongoing bisphosphonate infusions to control her serum calcium levels. +3 Arrange home health services. Home health services will help support Mrs. Taylor and her daughter and decrease the chances of a readmission. -2 Obtain a prescription for oral hydromorphone at the same dosage strength that was being given intravenously. Mrs. Taylor needs to transition from intravenous to oral pain medication. Intravenous and oral narcotic dosages are not equivalent. -3 Arrange a transfer to an acute rehabilitation hospital. The intensity of services in an acute rehab hospital does not correspond to Mrs. Taylor’s condition. -2 Inform Mrs. Taylor that she does not need to follow up with palliative care. Mrs. Taylor would benefit from pain and symptom management, and palliative care will provide support for her disease progression. -3 Schedule a radiation therapy consultation. Further radiation would be costly, ineffective and potentially harmful. +3 Ask the physician to document that Mrs. Taylor recovered quicker than anticipated. Mrs. Taylor was admitted as an inpatient with an anticipated stay of greater than two midnights. Since she is being discharged earlier than planned, her physician needs to document that she recovered quicker than anticipated or convert her to an observation status prior to discharge.

Answer 93

+3 Patient understanding of hospitalization and post-hospitalization needs Patient understanding and active participation in hospitalization and discharge planning is extremely important in providing individualized and patient-centered care. -2 If he attended college. This information is not necessary in order to plan for his transition needs. -3 Contact information for his current employer so they can be notified This is not an appropriate action since Mr. Smith has not requested you contact them. +3 Current therapy progress note and recommendations Based on Mr. Smith’s functional impairment and needs, reviewing relevant therapy progress notes and recommendations is appropriate and necessary in planning for discharge needs. -1 Mr. Smith’s preference among local long-term acute care hospitals No indication that long term acute care is the appropriate level of care. +2 Available family or friend support. Establishing eventual discharge disposition and available family support will be an important component when planning for the transition to an acute rehabilitation hospital.

Answer 94

-2 Initiate referral to substance abuse program More information would be needed and at this time this action is not indicated -3 Discuss dangers of and risks associated with cocaine use with Mr. Smith and his parents It is inappropriate to discuss this with the patient’s family unless given permission +3 Provide an overview of the rehabilitation needs upon discharge and ask Mr. Smith to repeat that information in his own words. Patient education with the implementation of teach-back is important in ensuring the patient is informed and is an active partner in his care. +2 Educate Mr. Smith on the resources such as the website for Inpatient Rehabilitation Facility Compare when discussing acute rehabilitation hospitals This is a resource to help the patient make informed decisions based on quality reporting data across facilities +3 Initiate referral to available acute rehabilitation facilities. This is appropriate to prevent delays in discharge.

Answer 95

-3 Contact the employer to see if they will authorize using an out of network provider. The insurance provider, not the employer would be the party to talk to regarding this matter. +3 Coordinate patient and family meeting to discuss options and potential financial implications of in-network vs out of network provider. Communication with the patient and family is important regarding anticipated barriers or financial implications or constraints. This is also an opportunity to discuss any available contingency plans. -3 Tell Mr. Smith he can stay in the current hospital for the duration of his therapy and until he feels strong enough to return home independently. This is a potential misuse of resources, a lower level of care is indicated. -3 Encourage the patient to switch insurance providers as soon as possible This is not appropriate. -3 Deliver the Important Message from Medicare to the patient The patient does not have Medicare, this is not appropriate.

Answer 96

+3 Facilitate/Ensure request of Mr. Mozart’s previous PCP records Prior records needed to review patient’s baseline and confirm medication regimen and treatment plan -3 Make an Adult Protective Services referral because the Mozarts are overwhelmed and unable to cope. There is no evidence of a need for APS referral -3 Call the Mozarts’ son to inquire on what he is doing to provide support to his parents. Mr. Mozart has not given permission for this +2 Provide Mr. Mozart with a map and listing of the area locations of the chain pharmacy he uses. Offer to call and have his address updated. Supports medication continuity and compliance. -3 Advise the ED Physician Mr. Mozart needs to be a social admission until a more stable living situation can be established This would be an inappropriate admission. -2 Counsel the Mozarts on their inappropriate use of the ED for a non-emergency condition. The Mozarts are new in town and overwhelmed, so the use of the ED is understandable in this circumstance. +3 Ask Mr. Mozart what he believes would be the most helpful thing to get him back to his health baseline Incorporates respect for patient goals and preferences.

Answer 97

-2 Is there documentation that Mr. Mozart is competent to make his own decisions? There is no evidence that Mr. Mozart is not competent. +3 Are there any expected medication changes? Mr. Mozart is not yet established with a local pharmacy, will need assistance -2 Is Mr. Mozart eligible for a SNF waiver for short term placement? SNF placement is not indicated. +3 What are Mr. Mozart’s care needs for the next few days? Immediate post-discharge care needs drive the discharge plan

Answer 98

+3 Request a hospital dietitian consult in the ED to help the Mozarts strategize for appropriate food choices until their new kitchen is set up. The meets both the care team and the patient’s goals -3 Propose short term SNF placement to ensure management of his CHF while his home is unpacked and a local PCP is found. Not an appropriate action +2 Request an order for a home health visit tomorrow to monitor CHF status and medication management. Reinforcement of teaching is needed, and a home assessment will be helpful to future PCP. +2 Seek Mr. Mozart’s consent to reach out to his son to suggest increased emotional support and assistance getting the kitchen unpacked. Supports patient goals and care plan. -3 Insist Mr. Mozart choose a new PCP from the Hospital’s ACO panel and explain the advantages of affiliation with an ACO. The patient has the right to choice and already admits to being confused by healthcare jargon +1 Propose a Meals on Wheels referral to the Mozarts. This might be a useful bridge, but getting the new kitchen up and running would be more helpful. +3 Offer to make an appointment for follow up in two days in a hospital-based clinic and provide a list of area PCPs with new patient availability for Mr. Mozart’s consideration.

Answer 99

-1 When her last cardiac stress test was This is not a priority at this time +3 What previous discharge plan(s) consisted of. Reviewing previous plans to assess what worked well and what could be done differently is important to make sure an appropriate and individualized plan is prepared. 0 Vaccination history While vaccination and patient education around the pneumococcal vaccination when in a susceptible category (>65 years of age) is important, this is not a priority at this time. +2 Current insurance coverage. Understanding insurance coverage is instrumental in understanding resources and benefits available for planning purposes, including regulatory guidelines (i.e. SNF days or DME) . -1 Transportation to the hospital. While transportation will be important to address at some point to prepare for discharge, transportation to the hospital for this hospitalization is not a key piece of information to attain at this point. +1 Functional status Understanding the patient’s baseline functional status compared to current status is important in planning for post-hospitalization needs and goals. +2 Where she lives Since this patient arrived from a skilled nursing facility, it is important to establish her living situation and if she is residing there for short-term or long-term care. This information is also important when considering her Medicare benefits. -1 Preferred pharmacy This is not a priority at this time. It is also likely that she is using the pharmacy at the skilled nursing facility. +2 Family or friends in her life Understanding the support system for the patient and their involvement in her life will be helpful for discharge planning purposes. +3 Patient priorities for this hospitalization and post-hospitalization Establishing what the patient’s goals, preferences, and priorities are for hospitalization and post-hospitalization needs is key for patient-centered care. -2 Employment status This would not be a priority at this time. +3 Patient’s understanding of hospitalization. Patient understanding of hospitalization is a key factor in patient-centered care and engagement.

Answer 100

+3 Discuss the possibility of transitioning to oral antibiotics with the attending physician As a steward of resources, the case manager must make sure the patient is receiving the appropriate services based on their needs. If the patient can be transitioned to a lower intensity of service that is appropriate and safe (IV to PO) this should be arranged. -2 Request a referral for respiratory therapy and chest percussion therapy Information provided indicated an improvement in respiratory status with no indication this is necessary. +2 Update the accepting SNF with the most recent clinical information relevant to patient post-hospitalization needs The case manager must make sure that the accepting facility is appropriately notified and prepared for patient’s needs in order to prevent delays in discharge -2 Encourage Ms. Davis to acquire a Medicare Supplemental Plan. The patient has Medicare A, B, and D and Medicaid, no indication for this. -2 File a report with adult protective services No indication for this based on information presented. +3 Provide patient education around post-hospitalization needs The patient’s understanding of the discharge plan is key to set her up for success in the management of the health or disease process. This ensures the patient is an active participant in her care.

Answer 101

Deliver a Detailed Notice of Discharge to the beneficiary and to the Quality Review Organization (QRO) by noon the day after QRO notification.

Answer 102

The case manager must use reasonable due diligence to honor the patient’s right to choice, but if providers of choice are not available, the case manager may arrange services with other providers.

Answer 103

Higher pre-admission ADL and IADL scores increase the likelihood that a patient will qualify for acute rehab.

Answer 104

4 hours and patient must not be pressured to leave during that time

Answer 105

Must follow at least 3 consecutive medically necessary inpatient days, not counting the day of discharge, in the hospital. (WRONG choice: ED and observation time counts toward 3 day stay)

Answer 106

A) A discharge plan must be implemented before discharge. B) NOT TRUE-Only Medicare patient fall under these guidelines. C) Inpatients should be screened for their risk of not having proper discharge planning. D) Plans should be developed for high-risk patients or as requested by the patient or physician.

Answer 107

A) The treating physician must agree with the change to Observation in writing. B) The proposed conversion from inpatient to observation must be evaluated and approved by physician members of the hospital UM Committee. C) NOT TRUE-The patient has a right to appeal the decision and to delay the conversion until an appeal ruling has been made. D) The patient must be informed of the conversion from inpatient to observation prior to discharge.

Answer 108

A process to manage denials from Medicare and Medicaid.

Answer 109

If requested by the patient or person acting on the patient’s behalf.

Answer 110

Determine if inpatient admission is needed.

Answer 111

Refer for secondary physician review.

Answer 112

Physician consult, Patient and/or Caregiver request, and medical record review (NOT admission status or payor)

Answer 113

hospital inpatient for a medically necessary stay of at least 3 consecutive calendar days (COUNT OVERNIGHTS) Time spent in observation or in an emergency room doesn’t count toward a medically necessary 3-day qualifying inpatient hospital stay can be transferred to Medicare-certified SNF within 30 days after hospital discharge

Answer 114

For each benefit period, Part A covers up to 20 full days of care After that, Part A covers up to an additional 80 days, with the patient paying coinsurance for each day After 100 days, the SNF coverage available during that benefit period exhausts, and the patient pays for all care, except certain Medicare Part B services

Answer 115

Benefit Period We measure SNF coverage in benefit periods (sometimes called spells of illness), beginning the day a patient admits to a hospital or SNF as an inpatient A benefit period ends after a patient discharges from a hospital or has had 60 consecutive days of SNF skilled care Once a benefit period ends, a new benefit period begins when patient admits to a hospital or SNF New benefit periods don’t begin with a change in diagnosis, condition, or calendar year

Answer 116

Standard: Discharge planning process. The hospital's discharge planning process must identify, at an early stage of hospitalization, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient's representative, or patient's physician.

Answer 117

Document in the medical record the refusal of the patient or the patient’s legally responsible representative to participate in discharge planning or comply with a discharge plan.

Answer 118

No specific patient consent is required for releasing information related to treatment, payment, or healthcare operations

Answer 119

Inform the physician that the patient is uninsured, as this may be an important factor in determining the discharge medication regimen.

Answer 120

YES-Identification of primary caregivers and assessment of the discharge needs and barriers. NO- Discussion of expected length of stay and current insurance plan deductuctible. NO -Assessment of pet-sitting and barriers to discharge. NO -Patient's level of education and discussion of expected length of stay.

Answer 121

Spouse, adult child, parent, sibling

Answer 122

The geometric mean for the working DRG

Answer 123

The patient elects the Hospice benefit and identifies choice for hospice agency to provide services.

Answer 124

The inclusion of this information on the Home Health agency/SNF choice list. The answer is NOT "Providing patient choice."

Answer 125

Increased emphasis on preadmission screening

Answer 126

The hospital case manager. (NOT the patient)

Answer 127

The Utilization Management Plan the answer is NOT written hospital policy

Answer 128

All applicants to a Medicaid-certified nursing facility are to be evaluated for mental illness and/or intellectual disability.

Answer 129

Consecutive inpatient hospital stay

Answer 130

Ensure she has received her Important Message from Medicare.

Answer 131

Patients in a licensed inpatient bed on Observation status are considered outpatients.

Answer 132

Hospital Consumer Assessment of Healthcare Providers and Systems Project Team

Answer 133

Ask the payer for the appeals process and the name of their medical director for MD to MD review.

Answer 134

the hospital

Answer 135

When the utilization review committee determines and documents inpatient care is not required, the physician concurs, and the change in patient status occurs prior to discharge or release of patient.

Answer 136

Medicare does not cover this service in the home setting, and recommends consideration of short term skilled nursing facility placement.

Answer 137

People, environment, systems and equipment The answer is NOT - Physician issues, staff issues, administrative issues

Answer 138

Avoidable Day/Avoidable Delay The answer is NOT Risk management

Answer 139

Every 3 days, or more often when an update is indicated by change in patient condition or change in discharge planning. NOT daily

Answer 140

Current living situation and health insurance coverage

Answer 141

These products are written by clinical professionals based on reviews of best practices and regulatory expectations.

Answer 142

Evidence-based risk stratification tools such as BOOST, LACE, Project Red

Answer 143

Issue the Important Message from Medicare to the patient and family, reinforce that the patient is medically stable for discharge.

Answer 144

Obtaining prior authorization The answer is NOT developing discharge plan

Answer 145

Prospective Payment System/Diagnosis-Related Groups (PPS/DRG)

Answer 146

At inpatient admission or status change to Inpatient, and again if discharge occurs more than two days after delivery of the initial notice.

Answer 147

Utilization Management

Answer 148

Change from inpatient to observation is made before the patient is discharged and the patient has been informed.

Answer 149

Review the clinical condition and medical necessity criteria to determine the appropriate level of care.

Answer 150

A) A patient can appeal the doctor’s decision to discharge. . C) A patient has until midnight on the discharge day to appeal his or her discharge. D) The request may be in writing or by telephone and must be before the patient leaves the hospital. NOT- B) The patient’s financial liability begins on the day he or she appeals a discharge

Answer 151

Response to illness, functional status, and health behaviors The answer is NOT-level of education, psychosocial history

Answer 152

Screening/ Identification Assessment Plan of Care Sequencing Communication

Answer 153

transition Management Transition coordination- identification community partnerships transition coordination Follow up

Answer 154

medical necessity payer interface avoidable delays/ days denials/ appeals

Answer 155

accountability professionalism collaboration care coordination advocacy resource management

Answer 156

Patient population that is sicker and requires more resources

Answer 157

After the individual has been out of the hospital or SNF for 60 days in a row

Answer 158

Case management models

Answer 159

Contact the physician advisor to confer with the ordering physician to discuss the inappropriate use of resources

Answer 160

Any Emergency Department (the answer is NOT any public hospital

Answer 161

The nursing home facility is Medicaid certified

Answer 162

At least two times within 24 hours

Answer 163

Patient’s transfer to Skilled Nursing Facility (SNF) was delayed due to a lack of available transportation

Answer 164

Bundled payments

Answer 165

Patient self-determination (the answer is NOT utilization review)

Answer 166

To solve complex multidisciplinary patient care problems (the answer is NOT to plan and provide for optimal patient outcomes)

Answer 167

Notify the physician and issue a Detailed Notice of Discharge

Answer 168

During admission (the answer for this basic question is NOT before admission)

Answer 169

planning (the answer is NOT screening and assessment)

Answer 170

They will have to pay a co-pay each day

Answer 171

Remind the physician that Medicare beneficiaries require a 3-day qualifying inpatient hospital stay prior to transfer to SNF

Answer 172

PEPPER report

Answer 173

hospital (the answer is NOT case management or QIO)

Answer 174

Incentivize hospitals by determining percent increase or decrease in payment in the following year

Answer 175

Evaluation (the answer is NOT care coordination)

Answer 176

Population health

Answer 177

to do what is best for the patient

Answer 178

Day of discharge

Answer 179

Define project goals (the answer is NOT define the problem)

Answer 180

HMOs set a fee without regard to the amount or kind of services provided

Answer 181

Omnibus Budget Reconciliation Act of 1987

Answer 182

On admission, within 2 days of discharge but no later than 4 hours prior to discharge

Answer 183

Condition Code 44 ( answer is NOT MOON)

Answer 184

Quality and safety

Answer 185

Allocation of resources toward a specific patient population

Answer 186

Readmission penalties can be costly to the organization

Answer 187

The case manager forgets to call the managed care payor in time and there was a late notification

Answer 188

When the Utilization Review committee determines and documents inpatient care as not required, the physician concurs, and the change in patient status occurs prior to discharge or release of the patient

Answer 189

Patients who appeal discharges

Answer 190

Under the coordination of benefits rules, the policy of an active working spouse is always primary.

Case Management Flashcards

ACMA (221 cards)