CCM sample test Flashcards
- A pediatric patient who is ventilator-dependent and has a gastrostomy button is scheduled to be discharged to home with visits from a home health nurse. Prior to discharge, the nursing case manager’s most critical action is to:
assess the patient’s long-term home care needs.
procure the required home medical equipment.
secure funding sources for home health care.
verify the safety of the patient’s home environment.
verify the safety of the patient’s home environment.
Which type of authorization is generated when services are rendered?
Concurrent.
Prospective.
Retrospective.
Subauthorization.
Concurrent.
- Managing clinical outcomes, studying variance trends, and evaluating actions taken to correct deviations from critical pathways are components of:
performance improvement.
risk management.
the nursing process.
utilization review.
performance improvement
- Medication errors, orders for unnecessary tests, and omission of standard tests or procedures are classified as which type of variance?
Community.
Operational.
Patient.
Practitioner.
practitioner
- To avoid hospital readmission, a patient requires services at a specialty clinic. Because the services are not covered under the patient’s healthcare plan, the nursing case manager intercedes with the patient’s insurance company. In this situation, the nurse is acting in the role of:
broker.
consultant.
negotiator.
provider.
negotiator
When using a utilization tool to perform a concurrent review, the nursing case manager recognizes that:
discharge is required whenever the tool so indicates.
exceptions exist because utilization tools reflect only average circumstances.
patients have the right to set length of stay without incurring nonreimbursable costs.
the use of utilization tools guarantees payment for services.
exceptions exist because utilization tools reflect only average circumstances.
Ideally, nursing case management planning identifies goals that are:
anticipated, acceptable, and appropriate.
challenging and timely.
patient focused and cost effective.
realistic, measurable, and specific.
realistic, measurable, and specific.
- A patient who is experiencing homelessness has been admitted to the hospital with multiple health care issues. The nursing case manager, physician, social worker, and clinical dietitian work together to care for the patient. This interprofessional interaction is referred to as:
collaboration.
consultation.
continuity.
coordination.
collaboration.
- The nursing case manager receives a referral to provide case management services for an adolescent mother who was recently diagnosed with HIV. Which statement indicates that the patient understands her illness?
“I can never have sex again, so I guess I will always be a single parent.”
“I will wear gloves when I’m caring for my baby because I could infect my baby with AIDS.”
“My CD4 count is 200 and my T cells are less than 14%. I need to stay at these levels by eating and sleeping well and staying healthy.”
“My CD4 count is 800 and my T cells are greater than 14%. I need to stay at these levels by eating and sleeping well and staying healthy.”
“My CD4 count is 800 and my T cells are greater than 14%. I need to stay at these levels by eating and sleeping well and staying healthy.”
- Which healthcare provider at a rehabilitation facility addresses the cognitive, behavioral, and psychological problems that result following a patient’s traumatic brain injury?
Medical social worker.
Neuropsychiatrist.
Neurosurgeon.
Psychologist.
neuropsychiatrist
- Authoritative statements addressing the foundational knowledge and skills of the nursing case manager’s actions are:
codes of conduct.
codes of ethics.
standards of practice.
state licensures.
standards of practice
- To treat an infected foot, a patient with Medicare Part A is prescribed a two-week course of IV antibiotics, wound care, and physical therapy for mobility training. The nursing case manager recommends discharge to:
a skilled nursing facility.
an acute care hospital.
an acute rehabilitation facility.
home with home health services.
a skilled nursing facility
- The nursing case manager reviews information about the number of patients with asthma who have received care from a specialist, those who have not, and the number of emergency department (ED) visits and inpatient hospitalizations for both groups. When comparing the data to develop interventions, the nurse engages in:
aggregate data analysis.
benchmarking.
collaboration.
integrated data solutions.
aggregate data analysis
- The nursing case manager meets with a 15-year-old patient with type 1 diabetes, who has a recent A1C of 8%. The patient reports smoking two to three cigarettes per day, denies using alcohol, and states, “I hate having diabetes; I just want to be like my friends.” Which referral will benefit this patient’s immediate needs?
A smoking cessation group for adolescents.
A support group for adolescents with diabetes.
An education session about insulin, aimed at adolescents.
Family counseling.
A support group for adolescents with diabetes
- Which ethical principle is grounded in truth?
Autonomy.
Beneficence.
Fairness.
Veracity.
veracity
- To cover the cost of durable medical equipment, a patient who is enrolled in Medicare is required to:
appeal for coverage.
request coverage.
seek supplemental insurance.
share in the cost.
share in the cost
- When developing a program for patients who are newly diagnosed with diabetes, the nursing case manager demonstrates an understanding of learning styles by:
administering a pre- and post-test assessment.
allowing attendees time to voice their opinions.
providing a snack with a low glycemic index.
utilizing a variety of educational materials.
utilizing a variety of educational materials.
Which primary resource guides the nursing case manager’s practice?
American Case Management Association’s Member Code of Conduct.
Case Management Society of America’s Standards of Practice for Case Management.
American Nurses Association’s Nursing: Scope and Standards of Practice.
American Nurses Association’s Nursing’s Social Policy Statement: The Essence of the Profession
Case Management Society of America’s Standards of Practice for Case Management.
The nursing case manager, who refers a 67-year-old patient to a skilled nursing facility for rehabilitative care, knows that it will be billed under which component of Medicare?
Medicare Part A.
Medicare Part B.
Medicare Part D.
Medigap.
Medicare part A
Which right is a provision in the American Hospital Association’s Patients’ Bill of Rights?
Competent patients must be informed about advance directives and be able to accept or refuse treatment.
Patients must have access to an interpreter or translation services to effectively communicate concerns and discuss the treatment plan, provide consent, and receive discharge information.
Patients must receive a timely response following a request of care and appropriate, professional care as ordered by a physician.
Patients must receive any necessary examination and treatment during any emergency or when female patients are in labor, dependent on their ability to pay.
Patients must have access to an interpreter or translation services to effectively communicate concerns and discuss the treatment plan, provide consent, and receive discharge information.
A doctor wants to order a brand-name fibromyalgia medication that is not covered by a patient’s insurance provider. As the patient has failed multiple agents prior to this prescription, the nursing case manager:
advises the doctor that the medication is not covered and suggests revisiting some medications that were ordered before.
directs the patient to the website of the drug company’s patient assistance program for alternative medications.
negotiates the self-pay cost for the brand name medication with the pharmacy.
submits the request for prior authorization to the insurance company with accompanying medical justification.
submits the request for prior authorization to the insurance company with accompanying medical justification.
A patient with hypertension resides in a homeless shelter 30 minutes from the patient’s primary clinic. The patient’s physician recommends checking their blood pressure three times per week to determine efficacy of the patient’s antihypertensive medications. The nursing case manager:
contacts a clinic more accessible to the patient for followup.
has the patient purchase a blood pressure machine to self-monitor.
informs the patient that they have to provide their own transportation.
instructs the patient to use a blood pressure machine at a local store.
contacts a clinic more accessible to the patient for follow up
The nursing case manager is concerned about the increase in the number of falls requiring hospitalization among older adults in the community. In order to identify those patients at greater risk for readmission, the nurse:
administers the Short Form 36 Health Survey at a community health fair.
interviews individual patients with their families present.
requires in-home evaluations by physical and occupational therapists.
reviews the patients’ daily nutrition diaries and medication lists.
administers the Short Form 36 Health Survey at a community health fair.
In synthesizing data for a disease management program, the nursing case manager uses which source of data triangulation to validate a conclusion?
Cost, containment, and length of stay.
Method, cause, and reaction.
Reason, rationale, and resolution.
Time, space, and person.
time, space and person
. A patient, covered by Medicare with limited financial means, was discharged from the hospital following total knee replacement surgery and will require six weeks of IV antibiotic therapy. The patient wants to go home. During the assessment, the nursing case manager discovers the patient lives alone, has no support at home, and lacks the dexterity to perform the infusion. What is the nurse’s next step?
Collaborate with the insurance company to extend the patient’s hospital stay.
Explain the barriers to going home and discuss other options with the patient.
Make a home-infusion referral to fulfill the patient’s request.
Order self-administered occupational therapy dexterity training.
Explain the barriers to going home and discuss other options with the patient.
The most common expectation of insurers is that an observation hospital stay will not exceed:
6hrs
12 hrs
24 hrs
48 hrs
24 hours
The case mgmt plan includes all the following components except:
Clients barriers/needs
Case mgmt interventions to address clients needs
Outcomes
Goals
Outcomes are achieved as a result of implementing the case mgmt plan.
Which are false about ho care infusion services?
In most cases, home infusion services can be safely administered
Home care patients must be stable to receive infusion services at home
It is always more cost effective to deliver infusion services at home vs a clinic or Md office
There does not always have to have a primary caregiver available
It is always more cost effective to deliver infusion services at home vs a clinic or Md office
The 5 tasks of the case manager in the chronic care model include which of the following
Assessment, planning and care coordination
Assessment, interventions, and f/u
Assessment, planning and f/u
Assessment, follow up and care coordination
Assessment, f/u and care coordination
The American association of managed care nurses (AAMCN) lists the components of managed care nursing as the clinical process, case management process, the utilization review process and which of the following?
Physician review process
Retrospective review process
Disease management process
Appeal process
Disease management process
(Also quality management and demand management processes is in their standards)
The type of insurance plan that offers the most
flexibility is the:
A) Point-of -Service Plan (POS)
B) Health Maintenance Organization (HMO)
C) Preferred Provider Organization (PPO)
D) Indemnity Plan
Indemnity plan
Which of the following is a system of healthcare
delivery whose goal is to maintain quality, cost-
efficient, and effective healthcare.
A) Managed Care
B) Preferred Provider Organization (PPO)
C) Health Maintenance Organization (HMO)
D) Utilization Review
Managed care
The case manager is working with a client in a weight loss
program. The client makes the statement, “ I have thrown
out all of the unhealthy food in the house. I also started
collecting healthy recipes and am ready to start my
new way of eating on Monday.” The case manager
knows the client is in which stage of change?
A) Pre-Contemplation
B) Action
C) Preparation
D) Contemplation
Preparation
Eligibility criteria for Social Security Disability
Insurance (SSDI) include the inability to work based
on a physical/ mental disability as well as
A) age 62 or older.
B) age 65 or older.
C) having a work history and accumulation enough
work credits.
• D) meeting income guidelines.
having a work history and accumulation enough work credits
-Earned benefit!
-Physical/medical impairment and cannot work and no be able to adjust to other work because of condition
-disability expected to last for at least 1 year or to result in death
Workers’ compensation pays for all of the following
except:
A) Benefits to survivors of workers who die of work-
related causes
B) Rehabilitation and training for workers who are
unable to return to pre-injury careers
C) Medical care for work-related injuries
D) Legal fees
Legal fees
Workman’s comp:
-pmt for medical tx and expenses
-pmt time off work for recovery
-pmt for any perm impairment
-voc rehab if worker can’t return to pre injury career
-payment of benefits in event of death. Dependents get burial expenses and lump sum pmt in most states
The percentage of billed charges that the member of
a health plan pays for covered services is the:
A) deductible
B) coinsurance
C) copayment
D) fee for service
Co insurance: a fixed percentage
Higher-order norms or fundamental assumptions that are consistent with a society’s moral principles and constitute
higher standards of moral behavior are:
societal mores.
codes of conduct.
ethical principles.
cultural values.
Ethical principles
The State Children’s Health Insurance Program (SCHIP)
provides health insurance coverage for uninsured and
underinsured children who:
• require additional health insurance coverage to
Medicaid.
have household income above the Medicaid qualifyin
income.
• require additional health insurance coverage to private
insurance.
have household income below the Medicaid qualifying
income.
“The best and correct answer is “have household income above
the Medicaid qualifying income”
A healthcare cost trend factor that can be most directly
impacted by case managers is:
case mix index.
• cost-shifting.
contract changes.
intensity of service.
“The best and correct answer is “intensity of service.”
•
MENO
comment
The client understands that the health coach functions as
a(n)
ally.
teacher.
medical authority.
resource specialist.
Ally
A key component of the Chronic Care Model is
strict adherence to prescribed medication
management.
focus on care for exacerbations or complications.
use of multiple specialty providers.
planned, regular interactions with caregivers.
The best and correct answer is “planned, regular interactions with
caregivers.”
In motivational interviewing theory, an individual in the
contemplation stage of change
• acknowledges there is a problem.
develops and implements a plan of change.
stops using drugs and alcohol.
becomes overwhelmed by the thought of making a
change.
The best and correct answer is “acknowledges there is a problem
Chape
MCUd
According to the Center for Medicare and Medicaid
Services (CMS), hospitals are required to provide a list at
discharge of post-discharge providers for patients to
choose a:
hospice provider.
home health agency.
parish nursing provider.
primary care physician.
The best and correct answer is “home health agency.”
Insert Table
Chart
Text
Shape
Media
Comment
Share
It is easier for a case manager to obtain the cooperation of
other disciplines if
the key player is a physician.
a non-threatening relationship has been developed.
the case manager develops the plan first.
an established team exists prior to case management.
The best and correct answer is “a non-threatening relationship has
been developed.”
Snape Media
Comment
Which of the following describes the role of hospital risk
management departments?
To identify employees that should be terminated
To rate clients based on their risk potential
To evaluate risks to prevent future loss
To use anecdotal reports to analyze events
The best and correct answer is “To evaluate risks to prevent future
loss”
Which of the following is used in most predictive modeling
tools to identify the severity levels of a population?
• Lab values.
• Paid medical claims.
• Health risk assessment results.
• Practice management.
• The best and correct answer is “Paid medical claims.”
In a workers compensation case, a field-based case
manager intervention may be required if the treating
physician
o prescribes short-term physical therapy.
labels the period of disability as indefinite.
• orders short-term chiropractic care.
reports that the injured worker can return to his or he
job.
The best and correct answer is “labels the period of disability as
indefinite.”
The main purpose of client involvement in developing a
rehabilitation plan is to
meet regulatory requirements.
organize the delivery of services and control costs.
improve precision in achievement of goals.
set long-term goals.
The best and correct answer is “improve precision in achievement
of goals.”
Which of the following is a term used to describe a learned,
progressive process or coping mechanism as a result of
reacting to the behavior of a substance abuser?
Co-dependency.
Repression.
Dysfunction.
Denial.
Codependency
According to the Rehabilitation Act of 1973, tasks that must
be performed on the job, even if the method differs between
employees with and without disabilities, are called
physical job demands.
essential job functions.
reasonable accommodations.
worker traits.
Essential job functions
Two essential components of a risk management program are
a, application of techniques and controls
B. fall prevention and fall, preparedness
C. loss control, and loss prevention
D, risk identification and compliance
Loss control and loss prevention
Higher-order norms or fundamental assumptions that are consistent with society’s moral principles and constitute higher standards of moral behavior are
a. Societal mores
B. Codes of conduct.
C. Ethical principles
D. Cultural values.
Ethical principles
Historically, senior programs in the US have not served older people well due to
a. lack of care coordination
B. Lack of community resources C. Cost of nursing home care.
D. Lack of family support.
Lack of care coordination
A client’s husband was recently hospitalized for cirrhosis of the liver and has accepted diagnosis of alcoholism. What is the most appropriate support group to refer her to a. NA.
B. A. A.
C. Al-Anon
D. OA.
Al anon
