CCMC Glossary of Terms Flashcards
AAPM&R
American Academy of Physical Medicine and Rehabilitation
ACCESS TO CARE
The ability and ease of clients to obtain healthcare when they need it.
ACCESSIBLE
A term used to denote building facilities that are barrier-free thus enabling all
members of society safe access, including persons with physical disabilities.
ACCOUNTABLE CARE
ORGANIZATION (ACO)
A set of healthcare providers including primary care physicians, specialists, and
hospitals that work together collaboratively and accept collective accountability
for the cost and quality of care delivered to a population of patients. ACOs became popular in the Medicare fee-for-service benefit system as a result of the Affordable Care Act. ACOs are formed around a variety of existing types of
provider organizations such as multispecialty medical groups, physician-hospital
organizations (PHO), and organized or integrated delivery systems.
ACCREDITATION
A standardized program for evaluating healthcare organizations to ensure a
specified level of quality, as defined by a set of national industry standards. Organizations that meet accreditation standards receive an official authorization
or approval of their services. Accreditation entails a voluntary survey process that
assesses the extent of a healthcare organization’s compliance with the standards
for the purpose of improving the systems and processes of care (performance) and, in so doing, improving client outcomes.
ACTIONABLE TORT
A legal duty, imposed by statute or otherwise, owing by defendant to the one injured.
ACTIVE LISTENING
A structured way of communication and interacting in which one is actively
engaged with the speaker primarily through focused attention and suspension
of one’s own frame of reference, biases, distractions and judgment. A communication technique that improves personal relationships, fosters
understanding, and facilitates cooperation and collaboration and eliminates conflict.
ACTIVITIES OF DAILY LIVING
(ADLS)
Routine activities an individual tends to do every day for self-care and normal living. These include eating, bathing, grooming, dressing, toileting, transferring (such as walking, bed to chair) and continence. Assessment of an individual’s ability to perform these ADLs is important for determining an individual’s ability, independence, disability or limitations. This assessment determines the type of long-term care and benefit coverage the individual needs. care may include placement in a nursing home, skilled care facility or home care services. Benefit
coverage may include Medicare, Medicaid or long-term care insurance.
ACTIVITY LIMITATIONS
Difficulties an individual may have in executing activities. An activity limitation may range from a slight to a severe deviation in terms of quality or quantity in executing the activity in a manner or to the extent that is expected of people without the health condition.
ACTUAL VALUE
Also referred to as real value. Measures the worth one derives from using or consuming a good, product, service or an item, and represents the utility of the good, product, service, or item.
ACTUARIAL STUDY
Statistical analysis of a population based on its utilization of healthcare services
and demographic trends of the population. Results used to estimate healthcare
plan premiums or costs.
ACTUARY
A trained insurance professional who specializes in determining policy rates, calculating premiums, and conducting statistical studies.
ACUITY
Complexity and severity of the client’s health/medical condition.
ACUTE CARE
The acute care delivery systems focus on treating sudden and acute episodes of illness such as medical and surgical management or emergency treatment, which otherwise cannot be taken care of in a less intense care setting. Acute
care settings may include hospitals, acute rehabilitation centers, emergency care,
transitional hospitals, and follow-up long-term disease management settings.
ADA
Americans with Disabilities Act of 1990
ADA AMENDMENTS ACT
(ADAAA)
Americans with Disabilities Act Amendments Act of 2008
ADL
Activities of Daily Living. Routine activities carried out for personal hygiene and health and for operating a household. ADLs include feeding, bathing, showering, dressing, getting in or out of bed or a chair, and using the toilet.
ADAPTIVE BEHAVIOR
The effectiveness and degree to which an individual meets standards of self-
sufficiency and social responsibility for his/her age-related cultural group.
ADHERENCE
“The extent to which a person’s behaviour–taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations
[e.g., health regimen] from a health care provider” (Sabate, 2003).
ADHESIVE CONTRACT
A contract between two parties where one party with stronger bargaining power sets the terms and conditions and the other party, which is the weaker of the two with little to no ability to negotiate, must adhere to the contract and is placed in a “take it or leave it” position
ADJUSTED CLINICAL GROUP®
(ACG) SYSTEM:
Developed by the School of Public Health at Johns Hopkins University, this system clusters clients into homogenous groups (102 discrete groups) based on a unique approach to measuring morbidity to ultimately improve accuracy and fairness in evaluating healthcare provider performance, identifying clients at high risk, forecasting healthcare utilization, and setting equitable payment structure and
rates for the providers of care. The System accounts for the burden of morbidity in a client population based on disease patterns, age, and gender and relies on the diagnostic and/or pharmaceutical code information found in insurance claims or other computerized client health records
ADJUSTER
A person who handles claims (also referred to as Claims Service Representative).
ADLS
See activities of daily living.
ADMINISTRATIVE LAW
That branch of public law that deals with the various organizations of federal,
state, and local governments which prescribes in detail the manner of their
activities.
ADMINISTRATIVE SERVICES
ONLY (ASO)
An insurance company or third party administrator (TPA) that delivers administrative services to an employer group. This usually requires the employer
to be at risk for the cost of healthcare services provided, which the ASO processes and manages claims.
ADMISSION CERTIFICATION
A form of utilization review in which an assessment is made of the medical necessity of a client’s admission to a hospital or other inpatient facility. Admission certification ensures that clients requiring a hospital-based level of care and length of stay appropriate for the admission diagnosis are usually assigned and certified and payment for the services are approved.
ADMISSION REVIEW
A review that occurs within 24 hours of a client’s admission to a healthcare facility (e.g., a hospital) or according to the time frame required in the contractual
agreement between the healthcare provider and the health insurance plan. This
review ensures that the client’s care in an inpatient setting is necessary, based on the client’s health condition and intensity of the services needed.
ADVANCE DIRECTIVE
Legally executed document that explains the client’s healthcare related wishes and decisions. It is drawn up while the client is still competent and is used if the
client becomes incapacitated or incompetent.
ADVERSE EVENTS
Any untoward occurrences, which under most conditions are not natural consequences of the client’s disease process or treatment outcomes.
ADVOCACY
The act of recommending, pleading the cause of another; to speak or write in favor of.
ADVOCATE
A person or agency who speaks on behalf of others and promotes their cause.
AFFECT
The observable emotional condition of an individual at any given time.
AFFIDAVIT
A written statement of fact signed and sworn before a person authorized to administer an oath.
AGGREGATED DIAGNOSIS
GROUPS (ADGS)
A grouping of diagnosis codes that are similar in terms of severity and likelihood of persistence in a client’s health condition over time. An individual client can suffer more than one health condition and therefore may have more than one ADG (total of 32 ADG clusters). Individual diseases or conditions are placed into a single ADG based on a set of criteria including likely persistence of
diagnosis, severity of illness, etiology, diagnostic certainty, and need for specialty care interventions. This system was developed by the Bloomberg School of Public Health at Johns Hopkins University
AGREED MEDICAL
EXAMINATION
An evaluation conducted by a provider who is selected by agreement between an injured workers’ attorney and the insurance claims administrator and/or attorney. The parties agree to conduct a medical examination and prepare a medical- legal report to help resolve an existing dispute. The evaluation also serves to determine what portions of the work-related injury have contributed to the disability and
what portions have resulted from other sources or causation.
AHA
American Heart Association
AHRQ
Agency for Healthcare Research and Quality
ALGORITHM
The chronological delineation of the steps in, or activities of, client care to be applied in the care of clients as they relate to specific conditions/situations.
ALTERNATE LEVEL OF CARE
A level of care that can safely be used in place of the current level and determined based on the acuity and complexity of the client’s condition and the type of needed services and resources.
AMA
American Medical Association
AMBULATORY PAYMENT
CLASSIFICATION (APC)
SYSTEM
An encounter-based classification system for outpatient reimbursement, including hospital-based clinics, emergency departments, observation, and ambulatory
surgery. Payment rates are based on categories of services that are similar in cost and resource utilization.
ANA
American Nurses Association
ANCC
American Nurses Credentialing Center
ANCILLARY SERVICES
Other diagnostic and therapeutic services that may be involved in the care of clients other than nursing or medicine. Includes respiratory, laboratory, radiology,
nutrition, physical and occupational therapy, and pastoral services.
APC
Ambulatory Payment Classification.
APPEAL (CARE PROVISION
RELATED)
The formal process or request to reconsider a decision made not to approve an admission or healthcare services, reimbursement for services rendered, or a client’s request for postponing the discharge date and extending the length of
stay.
APPEAL (LEGAL IN NATURE)
The process whereby a court of appeals reviews the record of written materials from a trial court proceeding to determine if errors were made that might lead to a reversal of the trial court’s decision.
APPROPRIATENESS OF
SETTING
Used to determine if the level of care needed is being delivered in the most appropriate and cost-effective setting possible.
APPROVAL
To offer or receive affirmation, sanction, or agreement about a decision, action, service, treatment, or intervention. In the area of health insurance, it is the
act of authorizing or affirming a service to a client that implies agreement to be responsible for reimbursing the provider of the service the related cost of
providing the service to a client/support system.
APPROVED CHARGE
The amount Medicare pays a physician based on the Medicare fee schedule. Physicians may bill the beneficiaries for an additional amount, subject to the
limiting charge allowed.
ASO
Administrative Services Only
ASSESSING
The process of collecting in-depth information about a person’s situation and
functioning to identify individual needs in order to develop a comprehensive case management plan that will address those needs. In addition to direct client contact, information should be gathered from other relevant sources
ASSIGNMENT OF BENEFITS
Paying medical benefits directly to a provider of care rather than to a member. This system generally requires either a contractual agreement between the health plan and provider or written permission from the subscriber for the provider to bill
the health plan.
ASSISTIVE DEVICE
Any tool that is designed, made, or adapted to assist a person to perform a particular task.
ASSISTIVE TECHNOLOGY
Any item, piece of equipment, or product system, whether acquired commercially
or off the shelf, modified, or customized, that is used to increase, maintain, or
improve functional capabilities of individuals with disabilities.
ASSISTIVE TECHNOLOGY
SERVICES
Any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device.
ASSUMPTION OF RISK
A doctrine based upon voluntary exposure to a known risk. It is distinguished from contributory negligence, which is based on carelessness, in that it involves a
comprehension that a peril is to be encountered and a willingness to encounter it.
ASSURANCE/INSURANCE
The term assurance is used more commonly in Canada and Great Britain. The term insurance is the spreading of risk among many, among whom few are likely to
suffer loss. The terms are generally accepted as synonymous.
AUTHORIZATION
The approval of client care services, admission, or length of stay by a health benefit plan (e.g., HMO, PPO) based on information provided by the healthcare
provider.
AUTONOMY
Agreement to respect another’s right to self-determine a course of action; support of independent decision making.
BAD FAITH
Generally involving actual or constructive fraud, or a design to mislead or deceive another.
BARRIER-FREE
A physical, manmade environment or arrangement of structures that is safe and accessible to persons with disabilities.
BARRIERS
Factors in a person’s environment that, if absent or present, limit one’s functioning
and create disability. Examples are a physical environment that is inaccessible, lack of relevant assistive technology, and negative attitudes of people toward disability. Barriers also include services, systems, and policies that are either
nonexistent or that hinder the involvement of people with a health condition in any area of life.
BAS
Burden Assessment Scale
BENCHMARKING
An act of comparing a work process with that of the best competitor. Through this process one is able to identify what performance measure levels must be surpassed. Benchmarking assists an organization in assessing its strengths and weaknesses and in finding and implementing best practices.
BENEFICENCE
Compassion; taking positive action to help others; desire to do good; core principle of client advocacy.
BENEFICIARY
An individual eligible for benefits under a particular plan. In managed care organizations beneficiaries may also be known as members in HMO plans or
enrollees in PPO plans.
BENEFIT PACKAGE
The sum of services for which a health plan, government agency, or employer contracts to provide. In addition to basic physician and hospital services, some plans also cover prescriptions, dental, and vision care.
BENEFIT PROGRAMS
government agency, or employer to individuals based on some sort of an agreement between the parties; for example between an employer and an employee. Benefits vary based on the plan and may include physician and hospital services, prescriptions, dental and vision care, workers’ compensation, long-term
care, mental and behavioral health, disability and accidental death, counseling and other therapies such as chiropractor care.
BENEFITS
Principal Term: The type of health and human services covered by an insurance
company/health plan and as agreed upon between the plan/insurance company
and the individual enrollee or participant. Benefits also refers to the amount payable by an insurance company to a claimant or beneficiary under the claimant’s specific coverage as stipulated in the agreed upon health plan.
BEYOND (OUTSIDE)-THE-
WALLS CASE MANAGEMENT
Models where healthcare resources, services and case managers are based externally to an acute care/hospital setting, that is in the community.
BOARD-CERTIFIED CASE
MANAGER
A case manager who has earned the certified case manager (CCM) credential offered by the Commission for Case Manager Certification (CCMC). This involves passing an evidence-based certification examination after meeting a set of criteria
that qualifies the case manager to sit for the examination. Once certified, the case manager must maintain the certification by acquiring ongoing education
through means of continuing education units (CEUs), and uphold the CCM Code of Professional Conduct for Case Managers.
BODY OF KNOWLEDGE (BOK)
Widely recognized information, standards, methods, tools, and practices about a specific field. A BOK usually includes a comprehensive set of concepts,
terms, tools, and activities that make up a profession, as defined by a relevant professional society. While the term body of knowledge is used to describe
the document that defines that knowledge, the body of knowledge itself is a dynamic reference that “is more than simply a collection of terms and concepts;
a professional reading list; a library; a website or a collection of websites; a description of professional functions; or even a collection of information”. Therefore, one may then describe a BOK as a prescribed
aggregation of essential knowledge in a particular field or specialty an individual within the field is expected to have mastered to effectively practice and be considered a practitioner within the specialty
BOK
Body of Knowledge
BONA FIDE
Literally translated as “in good faith.”
BRAIN DISORDER
A loosely used term for a neurological disorder or syndrome indicating impairment or injury to brain tissue.
BRAIN INJURY
Any damage to tissues of the brain that leads to impairment of the function of the Central Nervous System.
BURDEN OF PROOF
The duty of producing evidence as the case progresses, and/or the duty to establish the truth of the claim by a preponderance of the evidence. The former may pass from party to party, the later rests throughout upon the party asserting the affirmative of the issue.
CAPACITY
A construct that indicates the highest probable level of functioning a person may reach. Capacity is measured in a uniform or standard environment, and thus reflects the environmentally adjusted ability of the individual.
CAPITATION
A fixed amount of money per-member-per-month (PMPM) paid to a care provider for covered services rather than based on specific services provided. The typical reimbursement method used by HMOs. Whether a member uses the health service once or more than once, a provider who is capitated receives the same payment.
CAPTIVE
An insurance company formed by an employer to assume its workers’ compensation and other risks, and provide services.
CARE CONTINUUM ALLIANCE
Previously known as the Disease Management Association of America (DMAA).
CARE COORDINATION
The deliberate organization of patient care activities between two or more participants (including the patient) involved in patient’s care to facilitate the
appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required
patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care”.
CARE COORDINATION HUB
The context of delivering integrated healthcare services to clients/support systems with special emphasis on collaboration, coordination and communication among multiple healthcare providers, care settings and agencies in an attempt to ensure client’s safety and the provision of quality, cost-effective case management services.
CARE GUIDELINES
Nationally recognized and professionally supported plans of care recommended for the care management of clients with a specific diagnosis or health condition and in a particular care setting. Usually developed based on the latest available evidence and modified as necessary by healthcare professionals upon
implementation for the care of an individual client.
CARE MANAGEMENT
A healthcare delivery process that helps achieve better health outcomes by anticipating and linking clients with the services they need more quickly. It also helps avoid unnecessary services by preventing medical problems from escalating.
CARE SETTING
See also practice setting, level of care. A place across the continuum of health and human services where a client may receive healthcare services dependent on need. Care settings vary based on intensity and complexity of the services
provided to clients; that is, from least complex (e.g., prevention and wellness) to most complex (e.g., acute and critical care services).
CAREGIVER
Principal Term: The person responsible for caring for a client in the home setting. Can be a family member, friend, volunteer, or an assigned healthcare professional.
CARF
Commission on Accreditation of Rehabilitation Facilities. A private, non-profit organization that establishes standards of quality for services to people with disabilities and offers voluntary accreditation for rehabilitation facilities based on a set of nationally recognized standards.
CARPAL TUNNEL SYNDROME
The name given to the symptoms that occur when the nerves and tendons running through the carpal tunnel of the wrist are compressed by tissue or bone
or become irritated and swell. The carpal tunnel itself is a narrow passage in the wrist comprised of bones and ligaments through which nerves and tendons pass into the hand. Also referred to as “Cumulative Trauma Injury/Disorder,”
“Repetitive Motion Injury,” and “Repetitive Stress Syndrome.”
CARRIER
The insurance company or the one who agrees to pay the losses. A carrier may be organized as a company, either stock, mutual, or reciprocal, or as an Association or Underwriters.
CARVE OUT
Services excluded from a provider contract that may be covered through arrangements with other providers. Providers are not financially responsible for
services carved out of their contract.
CASE-BASED REVIEW
The process of evaluating the quality and appropriateness of care based on the review of individual medical records to determine whether the care delivered is acceptable. It is performed by healthcare professionals assigned by the hospital or an outside agency.
CASE CLOSURE
Terminating the provision of case management services to aclient/support system.
The process of communicating the decision to terminate services to clients/support
systems, payor representative, and other healthcare professional involved.
CASE CONFERENCE
A multidisciplinary healthcare team meeting that is held to discuss a client or client’s support system situation such as conflict in decision making between the
client and client’s support system, clarification of plan of care and prognosis, end of life issues, or an ethical dilemma. Depending on the purpose of the conference, the client and client’s support system may or may not participate in the meeting. Other participants are the case manager, social worker, physician of record or primary care provider, specialty care provider, registered nurse, registered dietitian, physical therapist, occupational therapist, ethicist (if the purpose is an
ethical dilemma) and others as necessary.
CASE LAW
The aggregate of reported cases forming a body of jurisprudence, or the law of a particular subject as evidenced or formed by the adjudged cases, in distinction to
statutes and other sources of law.
CASE MANAGEMENT
Case Management is a dynamic process that assesses, plans, implements, coordinates, monitors, and evaluates to improve outcomes, experiences, and value.
The practice of case management is professional and collaborative, occurring in a
variety of settings where medical care, mental health care, and social supports are delivered. Services are facilitated by diverse disciplines in conjunction with the care recipient and their support system.
In pursuit of health equity, priorities include identifying needs, ensuring appropriate access to resources/services, addressing social determinants of health and facilitating safe care transitions. Professional case managers help navigate complex systems to achieve mutual goals, advocate for those they serve, and recognize personal dignity, autonomy, and the right to self-determination.
CASE MANAGEMENT BODY
OF KNOWLEDGE (CMBOK)
A comprehensive resource of essential knowledge in the field of case management that a case manager is expected to master and become knowledgeable, skilled, as well as experienced in, to effectively care for clients and their support systems and be considered a competent case management practitioner.
CASE MANAGEMENT
DEPARTMENT
A division within a healthcare organization (e.g., provider, employer, or payor) responsible for the provision of case management services to clients and their support systems.
CASE MANAGEMENT MODEL
A conceptual or graphic representation of the practice of case management in an organization. It usually depicts the relationships among the key functions and stakeholders of case management, and the roles and responsibilities of case managers.
CASE MANAGEMENT PLAN
A timeline of patient care activities and expected outcomes of care that address the plan of care of each discipline involved in the care of a particular patient. It is usually developed prospectively by an interdisciplinary healthcare team in relation to a patient’s diagnosis, health problem, or surgical procedure.
CASE MANAGEMENT PLAN
OF CARE
Principal Term: A comprehensive plan of care for an individual client that describes the
(1) problems, needs and desires determined based upon findings of the client’s assessment;
(2) strategies such as treatments and interventions to be instituted to address the problems and needs; and
(3) measurable goals including
specific outcomes to be achieved to demonstrate resolution of the problems and needs, the timeframe(s) for achieving them, the resources available and to be
used to realize the outcomes, and the desires/motivation of the client that may have an impact on the plan.
CASE MANAGEMENT
PROCESS
Principal Term: The context in which case managers provide health and human services to clients and their support systems. The process consists of several steps or sub- processes that are iterative, cyclical and recursive rather than linear
in nature and applied until the client’s needs and interests are met. The steps include screening, assessing, stratifying risk, planning, implementing, following-up, transitioning, post-transitioning communication, and evaluating outcomes. The
process, with special intervention by case managers, work together with clients and their support systems to evaluate and understand the care options available to the clients; identify what is best to meet their needs; and institute action to achieve their goals and meet their interests and expectations.
CASE MANAGEMENT
PROGRAM
An organized approach to the provision of case management services to clients and their support systems. The program is usually described in terms of (1) vision, mission and objectives; (2) number and type of staff including roles, responsibilities and expectations; and (3) a specific model or conceptual
framework that delineates the key case management functions which may include clinical care management, transitional planning, resources utilization and management, bed capacity management, clinical documentation enhancement,
quality and variance/delays management and others depending on the healthcare
organization.
CASE MANAGER
Principal Term: A health and human servcies professional who is responsible for coordinating the overall care, services and resources delivered to an individual client or a group of clients and their support systems based on the client’s health
and human services issues, needs and interests.
CASE MIX COMPLEXITY
An indication of the severity of illness, prognosis, treatment difficulty, need for intervention, or resource intensity of a group of clients.
CASE MIX GROUP (CMG)
Each CMG has a relative weight that determines the base payment rate for inpatient rehabilitation facilities under the Medicare system.
CASE MIX INDEX (CMI)
The sum of DRG-relative weights of all patients/cases seen during a 1-year period in an organization, divided by the number of cases hospitalized and treated during the same year.
CASE RATES
Rate of reimbursement that packages pricing for a certain category of services. Typically combines facility and professional practitioner fees for care and services.
CASE RESERVE
The dollar amount stated in a claim file which represents the estimate of the amount unpaid.
CASUALTY INSURANCE
A general class of insurance and workers’ compensation insurance.
CATASTROPHIC CASE
Any medical condition or illness that has heightened medical, social and financial consequences that responds positively to the control offered through a systematic effort of case management.
CATASTROPHIC CASE
MANAGEMENT
Specialized and intricate services reflective of the needs of individuals with complex and life-altering conditions (e.g., severe injury, multiple comorbidities,
and permanent disabilities). Often catastrophic case management includes a
full spectrum of services for the individual or worker with a catastrophic injury or illness – sometimes including both disability case management and life care planning.
CATASTROPHIC ILLNESS
Any medical condition or illness that has heightened medical, social, and financial consequences and responds positively to the control offered through a systematic effort of case management services.
CATASTROPHIC INJURY
A serious injury that results in severe and long-term effects on the individual who sustains it, including permanent severe functional disability. Examples are traumatic brain, spine, or spinal cord injury; multiple trauma; and loss of major
body parts.
CCMC
Commission for Case Manager Certification
CERTIFIED NURSE LIFE CARE
PLANNER (CNLCP)
A registered professional nurse who holds a board certification from the Certified Nurse Life Care Planner Certification Board. This health professional develops a client-specific lifetime plan of care, while applying the nursing process. The plan employs a comprehensive and evidence-based approach in the estimation of current and future healthcare needs of the client. Also included are the associated
costs and frequencies of items and services.
CERTIFIED VOCATIONAL
EVALUATOR (CVE)
A professional specialized in vocational assessment and rehabilitation who has the
met the minimum requirements for nationally recognized voluntary certification.
CERTIFIED VOCATIONAL
REHABILITATION PROVIDER
A vocational rehabilitation practitioner who is registered in the workers’ compensation agency or commission in the state/jurisdiction of employment.
This registration certifies that the rehabilitation practitioner is certified to provide vocational rehabilitation services to individuals with disabilities.
CHANGE MANAGEMENT
A structured and systematic approach or process organized to move an organization, program, or team of individuals from a current to a future desired state. The process employs strategies and tools similar to project management
through which change is formally introduced with a clearly stated goal. Some of the tactics applied in the change management process include but are not limited to ways to do the following: (1) communicate effectively, (2) empower staff, (3)
minimize resistance, (4) enhance adoption of change, (5) establish and execute a roadmap for change, (6) ensure sustainability, and (7) achieve success. Change
management is an organizational mandate that entails thoughtful planning, sensitive implementation, and consultation with – and involvement of – the people
affected by the change.
CHRONIC CARE MODEL
A systems model that proposes several basic and specific elements for improving
care in health systems at the community, organization, practice, and individual client levels. It ensures delivery of high-quality chronic disease care to clients with chronic illnesses. The elements of the model include the community, health system, self-management support, delivery system design, decision support, and use of clinical information systems. Evidence-based practices in each of
these elements foster productive interactions between informed clients/support systems and their providers.
CLAIMANT
One who seeks a claim or one who asserts a right or demanding a legal proceeding.
CLAIMS ADJUSTER
An insurance professional who investigates claims by interviewing the claimant
and other involved parties (e.g., employers and witnesses), reviews related records to determine degree of liability and damages, and assures that an
insurance policy exists and covers the claimed damages. In healthcare, a claims adjuster also assures that medical care is available to the worker as needed based on the injury or occupational illness.
CLAIMS SERVICE
REPRESENTATIVE
A person who investigates losses and settles claims for an insurance carrier or the insured. A term preferred to adjuster.
CLIENT SOURCE
The way a case manager comes in contact with a client to provide case management services, usually taking place either by a referral from another healthcare provider, the client or a member of the client’s support system. In
some case management programs, client source may be based on screening of the client during a healthcare encounter; in other organizations it is only based on a referral.
CLIENT-RELATED OUTCOMES
Consequences or results of care activities, processes, or services that are directly related to the client’s condition, health status, and/or situation.
CLINICAL REVIEW CRITERIA
The written screens, decision rules, medical protocols, or guidelines used to evaluate medical necessity, appropriateness, and level of care.
CMAG
Case Management Adherence Guidelines
CMBOK
Case Management Body of Knowledge.
CMG
Case Mix Group
CMI
case mix index.
CMS
Centers for Medicare & Medicaid Services: Formerly known as the Health Care Financing Administration (HCFA).
CMSA
Case Management Society of America
COB
Coordination of Benefits
COBRA
Consolidated Omnibus Budget Reconciliation Act
CODING
A mechanism of identifying and defining client care services/activities as primary
and secondary diagnoses and procedures. The process is guided by the ICD-9-CM coding manual, which lists the various codes and their respective descriptions. Coding is usually done in preparation for reimbursement for services provided.
COGNITIVE REHABILITATION
Therapy programs which aid persons in managing specific problems in perception, memory, thinking and problem- solving. Skills are practices and strategies are taught to help improve function and/or compensate for remaining deficits.
COINSURANCE
A type of cost sharing in which the insured person pays or shares part of the medical bill, usually according to a fixed percentage.
COLLABORATION
A process where two or more individuals work closely or jointly together to achieve a mutual goal or purpose such as resolving a problem or improving a
situation. This process requires openess, mutual trust and respect, sharing of knowledge and consensus.
COLLABORATIVE CARE
An evidence-based approach that involves the provision of mental health, behavioral health, and substance use services within a primary care setting.
COMMISSION ON
ACCREDITATION OF
REHABILITATION FACILITIES
(CARF)
A private non-profit organization that establishes standards of quality for services to people with disabilities and offers voluntary accreditation for rehabilitation facilities based on a set of nationally recognized standards.
COMMON LAW
A system of legal principles that does not derive its authority from statutory law, but from general usage and custom as evidenced by decisions of courts.
COMMUNITY ALTERNATIVES
Agencies, outside an institutional setting, which provide care, support, and/or services to people with disabilities.
COMMUNITY ASSESSMENT
RISK SCREEN (CARS)
An assessment tool used to determine the risk for rehospitalization or emergency
department admittance of elderly clients. The tool focuses on the client’s current health status and lifestyle behaviors similar to the health risk assessment (HRA) tool
COMORBIDITY
A preexisting condition (usually chronic) that, because of its presence with a specific condition, causes an increase in the length of stay by about 1 day in 75% of the clients.
CONCURRENT REVIEW
A method of reviewing client care and services during a hospital stay to validate the necessity of care and to explore alternatives to inpatient care. It is also a form
of utilization review that tracks the consumption of resources and the progress of clients while being treated.
CONDITIONAL
REHABILITATION
PROFESSIONAL
A rehabilitation professional who has not yet met all of the requirements to be a qualified rehabilitation professional.
CONTEMPT OF COURT
Any act that is calculated to embarrass, hinder, delay or obstruct the court in the
administration of justice, or that is calculated to lessen its authority of its dignity.
CONTINUED STAY REVIEW
A type of review used to determine that each day of the hospital stay is necessary and that care is being rendered at the appropriate level. It takes place during a client’s hospitalization for care.
CONTINUOUS QUALITY
IMPROVEMENT (CQI)
A key component of total quality management that uses rigorous, systematic, organization-wide processes to achieve ongoing improvement in the quality of
healthcare services and operations. It focuses on both outcomes and processes of care.
CONTINUUM OF CARE
The continuum of care matches ongoing needs of the individuals being served by the case management process with the appropriate level and type of health, medical, financial, legal and psychosocial care for services within a setting or
across multiple settings.
CONTRACTOR
A business entity that performs delegated functions on behalf of the organization.
CONTRACTUAL ETHICS
Terms and conditions in a contract that are ethical in context and must be adhered to by the involved parties. Sometimes these terms are not explicit and impose moral rather than legal obligations, for example, undue influence and
informed consent.
COORDINATION OF BENEFITS
(COB)
An agreement that uses language developed by the National Association of Insurance Commissioners and prevents double payment for services when a subscriber has coverage from two or more sources.
CORE THERAPIES
Basic therapy services provided by professionals on a rehabilitation unit. Usually refers to nursing, physical therapy, occupational therapy, speech-language pathology, neuropsychology, social work and therapeutic recreation.
CORF
Comprehensive Outpatient Rehabilitation Facility
COST-BENEFIT ANALYSIS
A technique or systematic process used to calculate and compare the benefits and costs of an action, intervention, service or treatment, and to determine how well, or how poorly, it will turn out. This analysis reveals whether the benefits outweigh
the costs, and by how much so that the involved party is able to make appropriate decision(s).
CPR
Computer-based patient record
CPT
Current procedural terminology: A listing of descriptive terms and identifying codes for reporting medical services and procedures performed by health care providers and usually used for billing purposes.
CQI
Continuous Quality Improvement
CREDENTIALING
A review process to approve a provider who applies to participate in a health
plan. Specific criteria are applied to evaluate participation in the plan. The review may include references, training, experience, demonstrated ability, licensure
verification, and adequate malpractice insurance.
CROSS EXAMINATION
The questioning of a witness during a trial or deposition by the party opposing those who originally asked him/her to testify.
CUSTODIAL CARE
Money awarded by a court to someone who has been injured (plaintiff) and that must be paid by the party responsible for the injury (defendant). Normal damages are awarded when the injury is judged to be slight. Compensatory damages are awarded to repay of compensate the injured party for the injury incurred. Punitive damages are awarded when the injury is judged to have been committed
maliciously or in wanton disregard of the injured plaintiff’s interests.
CULTURAL COMPETENCY
A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross–cultural situations.
DAMAGES
Money awarded by a court to someone who has been injured (plaintiff) and that must be paid by the party responsible for the injury (defendant).
DAYS PER THOUSAND
A standard unit of measurement of utilization. Refers to an annualized use of the hospital or other institutional care. It is the number of hospital days that are used in a year for each thousand covered lives.
DBA
Defense Base Act of 1941
DEATH BENEFIT
The benefit payable to eligible dependent(s) of the worker (i.e., spouse, children) whose occupational disease or on-the- job injury has resulted in the worker’s death. This benefit may be payable at the rate of two-thirds of the deceased worker’s average weekly wage at the time of the accident, not to exceed the
maximum allowed under the law for all eligible dependents.
DECISION RULE
A logical statement of characteristics, conditions, or attributes (e.g., effectiveness,
worthiness, financial savings) that explain the appropriateness of making a specific decision or choice. For example, a healthcare executive concludes that a case
management intervention is of positive return on investment if it demonstrates cost savings.
DEDUCTIBLE
A specific amount of money the insured person must pay before the insurer’s payments for covered healthcare services begin under a medical insurance plan.
DEFENDANT
The person against whom an action is brought to court because of alleged responsibility for violating one or more of the plaintiff’s legally protected interests.
DELAY IN SERVICE
Used to identify delays in the delivery of needed services and to facilitate and expedite such services when necessary.
DELEGATION
The process whereby an organization permits another entity to perform functions
and assume responsibilities on behalf of the organization, while the organization retains final authority to provide oversight to the delegate.
DEMAND MANAGEMENT
Telephone triage and online health advice services to reduce members’ avoidable visits to health providers. This helps reduce unnecessary costs and contributes to better outcomes by helping members become more involved in their own care.
DENIAL
No authorization or certification is given for healthcare services because of the inability to provide justification of medical necessity or appropriateness of
treatment or length of stay. This can occur before, during, or after care provision.
DEPOSITION
The testimony of a witness taken upon interrogatories not in open court, but in pursuance of a commission to take testimony issued by a court, or under a
general law on the subject, and reduced to writing and duly authenticated, and intended to be used upon the trial of an action in court.
DHHS
Department of Health & Human Services
DIAGNOSIS-RELATED GROUP
(DRG)
A patient classification scheme that provides a means of relating the type of patient a hospital treats to the costs incurred by the hospital. DRGs demonstrate
groups of patients using similar resource consumption and length of stay. It also is known as a statistical system of classifying any inpatient stay into groups for the purposes of payment. DRGs may be primary or secondary; an outlier classification also exists. This is the form of reimbursement that the CMS uses to pay hospitals for Medicare and Medicaid recipients. Also used by a few states for all payers and by many private health plans (usually non-HMO) for contracting purposes.
DIAGNOSTIC AND
STATISTICAL MANUAL OF
MENTAL DISORDERS, 5TH
EDITION (DSM-5)
The most recent edition of the American Psychiatric Association’s manual that is used by clinicians and researchers to diagnose and classify mental disorders (American Psychiatric Association, 2013).
DICHOTOMOUS VARIABLE
A variable known to have only two characteristics or options when evaluated in a particular study or predictive modeling. For example, characteristics may be high or low, true or false, yes or no, present or absent.
DIFFUSION OF INNOVATION
The spread of new technologies, ideas, or ways of doing things in a particular culture. It is the process of communicating change for the purpose of increasing the rate of its adoption and acceptance.
DIRECT EXAMINATION
The first interrogation or examination of a witness, on the merits, by the party on whose behalf he/she is called.
DISABILITY CASE
MANAGEMENT
A process of managing occupational and nonoccupational diseases with the aim of returning the disabled employee to a productive work schedule and employment.
DISABILITY CASH BENEFIT
Cash paid by a disability benefits insurance agency to a worker out on disability who has otherwise lost wages due to an inability to work. The cash is paid over a specific period of time and is equivalent to a predetermined percentage of the worker’s weekly wages that have been lost due to inability to work. The amount is determined based on the average wages of the worker during a specific number of weeks (usually less than 10 weeks) most adjacent to the week during which the worker sustained the injury or illness. This benefit is also paid for a limited time period as stipulated by the disability insurance plan and based on state specific
laws.
DISABILITY INCOME
INSURANCE
A form of health insurance that provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury, or disease.
DISABILITY MANAGEMENT
PROGRAM
A program that focuses on assisting workers who have suffered from occupational health conditions or job-related injuries return to work. It facilitates accommodations in the workplace to prevent impairment incidents of injured
workers from becoming disability circumstances. It also employs the services of health professionals such as disability management specialists and/or disability case managers who are responsible for training and establishing tools for disability management personnel, employers, and others involved in keeping workers healthy, motivated, and productive.
DISCHARGE OUTCOMES
(CRITERIA)
Clinical criteria to be met before or at the time of the client’s discharge. They are the expected/ projected outcomes of care that indicate a safe discharge.
DISCHARGE PLANNING
The process of assessing the client’s needs of care after discharge from a healthcare facility and ensuring that the necessary services are in place before discharge. This process ensures a client’s timely, appropriate, and safe discharge
to the next level of care or setting including appropriate use of resources necessary for ongoing care.
DISCHARGE SCREEN
Assessment of the client/support system’s discharge needs using a set of criteria that results in identifying clients who are to benefit from healthcare services
or resources post an episode of illness and/or to prevent need for acute care rehospitalization.
DISCHARGE STATUS
Disposition of the client at discharge (e.g., left against medical advice, expired, discharged home, transferred to a nursing home).
DISCLOSURE
Written authorization regarding the sharing of a client’s information with other parties or in proceedings such as a complaint of an alleged ethical violation, which otherwise parties have no business being aware of such information.
DISCOVERY
The process by which one party to a civil suit can find out about matters that are relevant to his/her case, including information about what evidence the other side has, what witnesses will be called upon, and so on.
DISENGAGEMENT
The closing of a case is a process of gradual or sudden withdrawal of services, as the situation indicates, on a planned basis.
DISENROLLMENT
The process of terminating healthcare insurance coverage for an enrollee/insured.
DISTRIBUTIVE JUSTICE
Deals with the moral basis for the dissemination of goods and evils, burdens and benefits, especially when making decisions regarding the allocation of healthcare resources.
DMAA
Disease Management Association of America
DME
Durable Medical Equipment
DNR
Do not resuscitate
DOD
Department of Defense
DOMESTIC CARRIER
An insurance company organized and headquartered in a given state is referred to in that state as a domestic carrier.
DUAL RELATIONSHIP
Dual relationships exist when a case manager has responsibilities toward a third
party other than the client (e.g., case manager/payor/client or case manager/ employer/client).
DURABLE MEDICAL
EQUIPMENT (DME)
Equipment needed by patients for self-care. Usually it must withstand repeated use, is used for a medical purpose, and is appropriate for use in the home setting.
EARLY RETURN-TO-WORK
When a worker who had suffered a job-related injury or illness resumes work before complete recovery and while still suffering some sort of a partial disability.
Usually the early return of the worker may involve the same job but with modified responsibilities or another job altogether.
EBP
Evidence-Based Practice
EDSS
Expanded Disability Status Scale
EF
Executive Function
EHR
Electronic health record
EFFECTIVENESS OF CARE
The extent to which care is provided correctly (i.e., to meet the client’s needs, improve quality of care, and resolve the client’s problems), given the current state of knowledge, and the desired outcome is achieved.
EFFICACY OF CARE
The potential, capacity or capability to produce the desired effect or outcome, as already shown, e.g. through scientific research (evidence-based) findings.
EFFICIENCY OF CARE
The extent to which care is provided to meet the desired effects/outcomes to improve quality of care and prevent the use of unnecessary resources.
ELECTRONIC MEDICAL
RECORD
A computerized medical and health record a healthcare organization (e.g., a hospital, rehabilitation facility, physician’s office or home care agency) uses as part of a health information system that allows documentation of important
information about a client’s status and care provision. It also allows storage, retrieval, and modification of records specific to the individual client the
organization is caring for. Other terms used to refer to EMIR are electronic patient record (EPR), electronic health record (EHR) and computer-based patient record (CPR).
EMOTIONAL INTELLIGENCE
The ability to sense, understand, and effectively apply the power and acumen of emotions as a source of energy, information, connection, and influence. It also
is the ability to motivate oneself and persist in the face of frustration; control impulse; regulate one’s mood; and keep distress from swamping the ability to think, empathize, and hope.
EMR
Electronic Medical Record
EMTALA
Emergency Medical Treatment and Active Labor Act
ENCOUNTER
An outpatient or ambulatory visit by a health plan member to a provider. It applies mainly to a physician’s office but may also apply to other types of encounters.
END-RESULT OUTCOMES
Outcomes that occur at the conclusion of an episode of care and indicate the achievement of target goals. For example, deciding to transition a client from the acute care to home setting after successful tolerance of oral antibiotics or transitioning a workers’ compensation client back to work after successful job
modification intervention(s).
ENROLLEE
An individual who subscribes for a health benefit plan provided by a public or private healthcare insurance organization.
EPISODE OF CARE
A client’s access to healthcare services or encounter with a healthcare provider. It is individual client-specific, time-limited and always has a beginning and end. The length of the client’s encounter with care varies based on the client’s health need(s), the type and intensity of the required services to effectively address the need, the care/practice setting where the client receives these services, and level of care. Time of the encounter may be measured in minutes (e.g., in a provider’s
clinic or office), hours (e.g., in the emergency department, ambulatory surgery center or a dialysis center), days (e.g., in a hospital setting) or weeks to months (e.g., in a skilled nursing or rehabilitation facility). A client suffering from an illness may require one or multiple episodes of care before the illness is resolved or client is considered stable.
EPO
Exclusive provider organization
EPR
Electronic patient record
ERGONOMICS (OR HUMAN
FACTORS)
The scientific discipline concerned with the understanding of interactions
among humans and other elements of a system. It is the profession that applies theory, principles, data and methods to environmental design (including work environments) in order to optimize human well-being and overall system performance.
ERGONOMIST
An individual who has (1) a mastery of ergonomics knowledge; (2) a command of
the methodologies used by ergonomists in applying that knowledge to the design
of a product, process, or environment; and (3) has applied his or her knowledge to
the analysis, design, test, and evaluation of products, processes, and environments.
ERISA
Employee Retirement Income Security Act.
EVALUATING OUTCOMES
The final step of the case management process, which is achieved by measuring the results and consequences of the case management services provided to clients and their support systems.
EVALUATION
The process, repeated at appropriate intervals, of determining and documenting
the case management plan’s effectiveness in reaching desired outcomes and goals.
EX PARTE
A judicial proceeding, order, injuction, and so on, taken or granted at the instance and for the benefit of one party only, and without notice to, or contestation by, any person adversely interested.
EXCHANGE VALUE
The tradability of a good or service and its associated price (i.e., what it is traded or exchanged for). Most often, exchange value is expressed using money (Smith, 2011).
EXCLUSIVE PROVIDER
ORGANIZATION (EPO)
A managed care plan that provides benefits only if care is rendered by providers within a specific network.
EXECUTIVE FUNCTION
Capacity of a person’s working memory which relies on one’s state of cognition, attention, aptitude, intellectual capacity, mental processes, ability to maintain focus, and ability to handle a breadth of ideas and facts (Cowen, Elliott, Scott Saults et al., 2005).
EXPERIENCE
A term used to describe the relationship, usually in a percentage or ratio, of premium to claims for a plan, coverage, or benefits for a stated period of time.
EXPERIENCE RATING
The process of determining the premium rate for a group risk, wholly or partially on the basis of that group’s experience.
EXPERIENCE REFUND
A provision in most group policies for the return of premium to the policy holder because of lower than anticipated claims.
EXPERT WITNESS
A person called to testify because of recognized competence in an area.
EXTERNAL BENCHMARKING
The act of comparing or evaluating the current performance of an organization or program against externally available data, standards, performance of competitors,
national databases, or ideal practices.
FAIR HEARING
One in which authority is executed fairly; that is consistent with the fundamental principles of justice embraced within the conception of due process of law.
FAM
Functional Assessment Measure
FCE
Functional capacity evaluation
FECA
Federal Employees Compensation Act.
FAST
Functional Assessment Staging
FFS
Fee for service
FEE SCHEDULE
A listing of fee allowances for specific procedures or services that a health plan will reimburse.
FEE-FOR-SERVICE (FFS)
Providers are paid for each service performed, as opposed to capitation. Fee schedules are an example of fee-for-service.
FIDELITY
The ethical principle that directs people to keep commitments or promises.
FIDUCIARY
Person in a special relationship of trust, confidence or responsibility in which one party occupies a superior relationship and assumes a duty to act in the
dependent’s best interest. This includes a trustee, guardian, counselor or institution, but it could also be a volunteer acting in this special relationship.
FIELD CASE MANAGEMENT
(FCM)
Also known as onsite case management. A form of care coordination and management whereby a case manager works with a client (worker) in person
rather than virtually via telephone or other electronic ways of communication. Field case managers usually visit the client, the client’s employer, work
environment, treating physician, and other involved parties and collaborate with them on the return of the client to work.
FIRST-LEVEL REVIEWS
Conducted while the client is in the hospital, care is reviewed for its appropriateness.
FOLLOWING-UP
The step of the case management process when case managers review, evaluate, monitor and reassess the client’s health condition, needs, ability for self-care, knowledge of health condition and case management plan of care, outcomes of the implemented treatments and interventions, and continued appropriateness of the plan of care.
FORMULARY
A list of prescription drugs that provide choices for effective medications from which providers may select, that are covered under a specific health plan.
FRAME OF REFERENCE
A set of ideas, evaluative criteria, rules, assumptions, or conditions a person uses to understand, perceive, and approach a situation or an issue. It is also the
viewpoint or context within which a person’s thinking about something seems to occur.
FRAUD
Knowingly and willfully executing, or attempting to execute a scheme or artifice to defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property
owned by, or under the custody or control of, any healthcare benefit program.
FUNCTIONAL CAPACITY
EVALUATION (FCE)
A systematic process of assessing an individual’s physical capacities and functional abilities. The FCE matches human performance levels to the demands of a specific job or work activity or occupation. It establishes the physical level of work an individual can perform. The FCE is useful in determining job placement, job accommodation or return to work after injury or illness. FCEs can provide objective information regarding functional work ability in the determination of occupational disability status.
FUNCTIONAL INDEPENDENCE
MEASURE (FIM)
An 18-item instrument with an
ordinal scale ranging from 1 (total assistance) to 7 (complete independence) that is used worldwide in the in-patient medical rehabilitation setting to measure a client’s ability to function with independence. The instrument allows healthcare
professionals to evaluate the amount of assistance required by a client to safely and effectively perform basic life functions. An FIM score is collected within 72 hours after a client’s admission to a rehabilitation unit, within
72 hours before discharge, and between 80 to 180 days after discharge. Items of the FIM address a client’s level of independence in the areas of eating; grooming; bathing; dressing (upper body), dressing (lower body); toileting; bladder management; bowel management; transferring (to go from one place to another) in a bed, chair, and/or wheelchair; transferring on and off a toilet; transferring into and out of a shower; locomotion (moving) for walking or in a wheelchair; and locomotion going up and down stairs. The FIM instrument is also used to assess a client’s cognitive abilities such as comprehension, expression, social interaction, problem solving, and memory.
FUNDING SYSTEMS
Individuals or agencies that provide financial resources to support the care of those who are poor, vulnerable, lack health insurance coverage or unable to
independently assume such responsibility. These may include charitable or religious organizations, and public or private agencies.
FUNERAL EXPENSE BENEFIT
Includes financial support for funeral expenses survivors of the diseased worker may incur. This benefit is payable to the deceased worker’s family or
dependent(s) up to the maximum allowed under the law at the time of the worker’s injury resulting in death.
GAG RULES
A clause in a provider’s contract that prevents physicians or other providers from revealing a full range of treatment options to clients or, in some instances, from revealing their own financial self-interest in keeping treatment costs down. These
rules have been banned by many states.
GATEKEEPER
A primary care physician (usually a family practitioner, internist, pediatrician, or nurse practitioner) to whom a plan member is assigned. Responsible for managing all referrals for specialty care and other covered services used by the member.
GLOBAL ASSESSMENT LENS
A multidimensional assessment that affords case managers the ability to be thorough and organized with respect to designing an individualized case
management plan of care for each client to meet the client’s unique situation. It includes an overview of the biophysical, psychological, sociological, and
spiritual dimensions care. It functions as a care approach for case management assessment, which provides a comprehensive overview of eight essential domains to be considered when contemplating a client’s needs and opportunities. These domains include physical health, behavioral health, functional capacity, client engagement and self-management, social determinants of health, health
information technology, data analytics and decision support, and transdisciplinary healthcare team.
GLOBAL FEE
A predetermined all-inclusive fee for a specific set of related services, treated as a single unit for billing or reimbursement purposes.
GOLD STANDARD
Also known as “ideal practice”; refers to the best available knowledge, evidence, or benchmark under reasonable or similar conditions.
GROUP MODEL HMO
The HMO contracts with a group of physicians for a set fee per client to provide many different health services in a central location. The group of physicians
determines the compensation of each individual physician, often sharing profits.
GUARDIAN
A person appointed by the court to be a substitute decision- maker for persons receiving services deemed to be incompetent of making informed decisions for themselves. The powers of a guardian are determined by a judge and may be limited to certain aspects of the person’s life.
HABILITATION
The process by which a person with developmental disabilities is assisted in acquiring and maintaining life skills to: (1) cope more effectively with personal
and developmental demands; and (2) to increase the level of physical, mental, vocational and social ability through services. Persons with developmental
disabilities include anyone whose development has been delayed, interrupted or stopped/fixed by injury or disease after an initial period of normal development,
as well as those with congenital condition.
HANDICAPPED
Refers to the disadvantage of an individual with a physical or mental impairment HANDOFFresulting in a handicap.
HANDOFF
The act or an instance of passing something or the control of it from one person or agency to another. In healthcare context, handoff is passing of accountability and responsibility for a client’s care from one clinician to another within a care
setting or across care settings. This act is especially necessary during a transitions of care situation.
HCC
Hierarchal conditions category
HCFA
Health Care Financing Administration.
HEALTH AND HUMAN
SERVICES CONTINUUM
Principal Term: The continuum of care that matches ongoing needs of case management clients and their support systems with the appropriate level and type of health, medical, financial, legal, psychosocial, behavioral and sprirtual care and services across one or more care settings. The continuum includes multiple
levels that vary in complexity and intensity of healthcare services and resources including individual care providers and organizations or agencies.
HEALTH BENEFIT PLAN
Any written health insurance plan that pays for specific healthcare services on behalf of covered enrollees.
HEALTH INSURANCE
PORTABILITY AND
ACCOUNTABILITY ACT
(HIPPA)
A civil rights legislation that governs the portability and continuity of health
insurance by protecting individuals against laws regarding preexisting health
conditions and other restrictions especially when changing jobs or insurance carriers and plans.
HEALTH INSURANCE
PORTABILITY
AND ACCOUNTABILITY ACT’S
PRIVACY RULE
HIPAA’s Privacy Rule was initially published in 2000 as a national law that ensures clients’ medical information is kept confidential. The Rule offered clients greater
rights for protection of individually identifiable health information and files and
demands that all healthcare providers maintain strict confidentiality and privacy
HEALTH MAINTENANCE
ORGANIZATION (HMO)
An organization that provides or arranges for coverage of designated health services needed by plan members for a fixed prepaid premium. There are four basic models of HMOs: group model, individual practice association (IPA), network model, and staff model. Under the Federal HMO Act an organization
must possess the following to call itself an HMO: (1) an organized system for providing healthcare in a geographical area, (2) an agreed-on set of basic and
supplemental health maintenance and treatment services, and (3) a voluntarily
enrolled group of people.
HEALTH RISK ASSESSMENT
(HRA)
An assessment of a client conducted to identify the presence of risk and determine how such risk may influence health-seeking behavior (e.g., access to healthcare services). This assessment may cover various aspects of a client’s
condition – e.g., level of physical activity and exercise; nutritional status; general health, safety, social, and environmental wellness; emotional awareness; mental, intellectual, and occupational wellness; and culture including values, spirituality, and beliefs.
HEALTHCARE CONTINUUM
Care settings that vary across a continuum based on levels of care that are also characterized by complexity and intensity of resources and services
HEALTHCARE DELIVERY
SYSTEM
A comprehensive model or structure used in the delivery of healthcare services to individuals–for example, integrated delivery system (IDS).
HEALTHCARE HOME
The usual setting or level of care the client/support system selects to use on a routine basis to receive healthcare services such as a large or small medical group,
a single practitioner, a community health center, or a hospital outpatient clinic. This is the central point for primary clinician caring for the client to coordinate necessary care and services based on the client’s needs and preferences and
among various care settings and providers.
HEALTHCARE PROXY
A legal document that directs the healthcare provider/agency in whom to contact for approval/consent of treatment decisions or options whenever the client is no longer deemed competent to decide for self.
HEALTHCARE TRILOGY
The quality, cost, and outcomes aspects of healthcare delivery. This term is attributed to the works of Donabedian.
HEARING
A live proceeding done before a formal body with decision making authority for the purpose
of presenting evidence about an issue where concerned opposing parties are given the opportunity to share their side of the issue.
This procedure ultimately allows the decision-making body to determine the outcome and share its conclusions with the opposing parties.
HEARSAY
Evidence not proceeding from the personal knowledge of the witness, but from the mere repetition of what has been heard from others.
HEDIS
Healthcare Effectiveness Data and Information Set
HHA
Home health aide
HHRG
Home Health Resource Group
ICD-9-CM
International Classification of Diseases, Ninth Revision, Clinical Modification
ICT
Interdisciplinary care team
IDS
Integrated delivery system
IHI
Institute for Healthcare Improvement
IM
Important Message from Medicare
IMPAIRMENT
A general term indicating injury, deficiency or lessening of function. Impairment is a condition that is medically determined and relates to the loss or abnormality of psychological, physiological, or anatomical structure or function. Impairments are disturbances at the level of the organ and include defects or loss of limb, organ or other body structure or mental function, e.g. amputation, paralysis, mental retardation, psychiatric disturbances as assessed by a physical.
IMPEACH
In the law of evidence, it is to call in question the veracity of a witness, by means of evidence adduced for that purpose.
IMPLEMENTATION
The process of executing specific case management activities and/or interventions that will lead to accomplishing the goals set forth in the case management plan.
IMPLEMENTING
The step in the case management process during which case managers execute
specific case management activities and/or interventions to accomplish goals set forth in the case management plan of care and during the planning step.
IMPORTANT MESSAGE FROM
MEDICARE (IM)
A notice of discharge from the acute care setting that hospitals are required to deliver to all Medicare beneficiaries (original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospitalized, informing them of their hospital
discharge appeal rights.
INCENTIVE
A sum of money paid at the end of the year to healthcare providers by an insurance/managed care organization as a reward for the provision of quality and cost-effective care.
INCLUSIVE EDUCATION
An educational model in which students with disabilities receive their education in a general educational setting with collaboration between general and special education teachers. Implementation may be through the total reorganization and
redefinition of general and special education roles, or as one option in a continuum of available services.
INDEMNITY
Security against possible loss or damages. Reimbursement for loss that is paid in a predetermined amount in the event of covered loss.
INDEMNITY BENEFITS
Benefits in the form of payments rather than services. In most cases after the provider has billed the client, the insured person is reimbursed by the company.
INDEPENDENT CASE
MANAGEMENT
Also known as private case management or external case management, it entails the provision of case management services by case managers who are either self- employed or are salaried employees in a privately owned case management firm.
INDEPENDENT LIVING
A service delivery concept that encourages the maintenance of control over one’s life based on the choice of acceptable options that minimize reliance on others
performing everyday activities.
INDEPENDENT MEDICAL
EXAMINATION/EVALUATION
An examination or evaluation that is completed by a healthcare professional (e.g., physician, physical therapist, psychologist) who has not been involved in the care of a worker who has sustained a work-related injury or illness. An employer or an insurance provider may request such an examination for a worker who is out of work on disability. The purpose of this examination is to determine the cause, extent, and medical treatment of a work-related or other injury where liability is
at issue. It also assists in determining whether a worker has reached the maximum
benefit from treatment and whether any permanent impairment remains after treatment.
INDICATOR
A measure or metric that can be used to monitor and assess quality and outcomes of important aspects of care or services. It measures the performance of functions,
processes, and outcomes of an organization.
INDIVIDUAL PRACTICE
ASSOCIATION (IPA)
A health maintenance organization (HMO) model of insurance that contracts with a private practice physician or healthcare association to provide healthcare services in return for a negotiated fee. The IPA then contracts with physicians who continue in their existing individual or group practice.
INDIVIDUAL WRITTEN
REHABILITATION PROGRAM
(IWRP) An official document that clearly describes the individualized services that will enable a person with a disability to obtain and maintain suitable employment and/or to maximize independence in daily living. The formality of this document
allows the vocational rehabilitation professional (e.g., counselor) and the person
with the disability to translate findings of a vocational evaluation into specific
rehabilitation goals and objectives. This document also includes the medical, social,
psychological, educational, vocational, counseling, and employment services needed to accomplish the goal of the rehabilitation plan.
INDIVIDUALIZED PLAN FOR
EMPLOYMENT (IPE)
A written plan that outlines an individual’s vocational goal and the services to be provided to reach the goal. It formalizes the planning process through which the vocational goal, service delivery, and time frames for service delivery are determined. It also identifies the individual’s employment objective, consistent
with his/her unique strengths, resources, priorities, concerns, abilities, and capabilities, while providing a plan for monitoring progress toward achievement of
the goal.
INFORMED CONSENT
Consent given by a client, next of kin, legal guardian, or designated person for a kind of intervention, treatment, or service after the provision of sufficient information by the provider. A decision based on knowledge of the advantages and disadvantages and implications of choosing a particular course of action.
INPATIENT REHABILITATION
FACILITIES PATIENT
ASSESSMENT INSTRUMENT
(IRF-PAI)
A diagnostic used to classify patients into distinct groups based on clinical characteristics and expected resource needs. The PAI determines the Case Mix
Group (CMG) classification.
INSTRUMENTAL ACTIVITIES
OF DAILY LIVING (IADLS)
A set of skills necessary for an individual to maintain independent living. These skills require cognitive, emotional, and physical capacity for successful
performance. They include the ability to use a telephone, shop for groceries, handle finances, perform housekeeping tasks, prepare meals, do laundry, take
medications, and transportation use. These daily life functions are necessary for maintaining an individual’s independent living. They also are affected by
the presence of disease, injury, or developmental disability. Similar to ADLs, assessment of an individual’s ability to perform these skills is important for
determining an individual’s ability, independence, disability, or limitations. This assessment determines whether an individual needs personal care services and the benefit coverage required.
INSURED
The person, organization, or other entity who purchases insurance.
INSURER
The insurance company or any other organization that assumes the risk and provides the policy to the insured.
INTAKE
The decision a case manager makes about the provision of case management services to a client or client’s support system.
INTEGRATED BEHAVIORAL
HEALTH
The care a patient experiences as a result of a team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical
illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization
INTEGRATED CARE
A concept that brings together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation, and health promotion. Integration is a means to improve services in relation to access, quality, user
satisfaction, and efficiency
INTEGRATED CASE
MANAGEMENT
A process by which a single case manager assists clients/support systems with all barriers to health, including those related to physical illnesses or mental health and substance use disorders (mental conditions). Handoffs among case managers
and care providers are minimized, and total health outcomes for clients are the
responsibility of each individual case manager
INTEGRATED DELIVERY
SYSTEM (IDS)
A single organization or group of affiliated organizations that provides a wide spectrum of ambulatory and tertiary care and services. Care may also be provided across various settings of the healthcare continuum.
INTENSITY OF SERVICE (IS)
An acuity of illness criteria based on the evaluation/treatment plan, interventions, and anticipated outcomes.
INTERACTIVE VOICE
RESPONSE (IVR)
A type of communication technology that allows individuals to interact with others (e.g., representatives of a company such as a health insurance plan) through the technology rather than actual people and via a telephone keypad or voice recognition system. During the automated interaction, individuals are able
to address their own inquiries by following the automated IVR dialogue. The IVR technology employs prerecorded audio to further direct users on how to proceed usually following a menu of choices. Interactions proceed in a simple way from
general options at first to more specific options later on in the dialog.
INTER-DISCIPLINARY
Collaboration occurs among different disciplines that address inter-connected aspects of the client’s defined health problem or needs. The members of the team bring their own theories and frameworks to bear on the problem and connections
are sought among the disciplines to improve client outcomes.
INTERDISCIPLINARY CARE
TEAM (ICT)
A team of healthcare professionals and paraprofessionals from different
disciplines or departments within an organization who are involved in the care of a client/support system, share common care goals, and who have responsibility for complementary tasks, interventions, and/or treatments necessary to meet
the client’s goals. The team is interdependent and participates in ongoing communication among the team members and with the client/support system to
ensure the various aspects of the client’s needs and wishes are addressed.
INTERMEDIATE OUTCOME
A desired outcome that is met during a client’s hospital stay. Itis a milestone in the care of a client or a trigger point for advancement in the plan of care.
INTERNAL BENCHMARKING
The act of comparing or evaluating the current performance of an organization or program against its past performance and improvement standard(s) or target(s).
INTERNATIONAL
CLASSIFICATION OF
DISEASES,NINTH REVISION,
CLINICAL MODIFICATION
(ICD- 9-CM)
A text formulated to standardize diagnoses. It is used for coding medical records in preparation for reimbursement, particularly in the inpatient care setting.
INTERQUAL CRITERIA
Nationally recognized standards that describe when and how an individual client with a specific health condition is expected to progress through the continuum
of healthcare and human services. They are developed applying a rigorous content process that ensures the criteria offer the best possible support for appropriateness of care and related clinical decision making. The criteria are of three types (acute care/hospitals, behavioral health, and payor) and focus on
care planning, level of care, clinical evidence summaries, and retrospective monitoring.
INTERROGATORIES
A set or series of written questions composed for the purpose of being propounded to a party in equity, a garnishee, or a witness whose testimony is
taken in a deposition.
INTERVENTION
Planned strategies and activities that modify a maladaptive behavior or state of being and facilitate growth and change. Intervention is analogous to the
medical term TREATMENT. Intervention may include activities such as advocacy,
psychotherapy, or speech language therapy.
IOM
Institute of Medicine
IPA
Individual Practice Association
IPE
Individual plan for employment
IRF
Inpatient rehabilitation facility
IRF-PAI
See Inpatient Rehabilitation Facilities Patient Assessment Instrument
IS
Intensity of service
IT
Information technology
IV
Intravenous
JCAHO
Joint Commission on Accreditation of Health Care Organizations
JCI
Joint Commission International
JOB ACCOMMODATION
A reasonable adjustment to a job or work environment that makes it possible for an individual with a disability to perform job duties. Determining whether to provide accommodations involves considering the required job tasks, the functional limitations of the person doing the job, the level of hardship to the employer, and other issues.
JOB ANALYSIS
A process to identify and determine in detail the particular job duties and requirements and the relative importance of these duties for a given job. Job analysis focuses on the specific job and not the person who occupies it at the time of analysis. It is conducted for purposes of a disabled worker’s work accommodation or training, identification of required skills, competencies and qualifications, and legal defense.
JOB BANK SERVICE
A computerized system developed by the Department of Labor that maintains an up-to-date listing of job vacancies available through the State Employment Service.
JOB CLUB
An organization of individuals who are seeking work, who join together to share information about employers, interviewing strategies, job seeking skills, and work opportunities.
JURISDICTION
An entity possessing official power to make legal decisions and judgments based upon the authority granted to it. Usually the entity represents a legal body that administers justice within a defined area of responsibility.
KNOWLEDGE DOMAIN
Principal Term: A cluster of health and human services or related topics (information) grouped together based on a common theme to form a high-level/abstract concept that is considered to be essential for effective and competent performance of case managers; for example, case management Principles of Practice or Healthcare Reimbursement.
KNOWLEDGE FRAMEWORK
What case managers need to know to effectively care for clients and their support systems. It includes a nine-step case management process and seven essential knowledge domains applicable in any care or practice setting and for the various healthcare professionals who assume the case manager’s role.
KPSS
Karnofsky Performance Status Scale
LEGAL RESERVE
The minimum reserve which a company must keep to meet future claims and obligations as they are calculated under the state insurance code.
LENGTH OF STAY (LOS)
The number of days that a health plan member/client stays in an inpatient facility, home health, or hospice.
LETTER OF INSTRUCTION
A written statement expressing concern with a board certified case manager’s actions in regard to the CCMC’s Code of Professional Conduct. The concern is not significant enough to warrant a more serious action or sanction; however issuing of the letter of instruction serves as a reminder for the case manager to adhere to the Code in his/her case management practice.
LEVEL OF CARE
Principle Term: The intensity and effort of health and human services and care activities required to diagnose, treat, preserve or maintain a client’s health. Level of care may vary from least to most complex, least to most intense, or prevention
and wellness to acute care and services.
LEVELS OF SERVICE
Based on the client’s condition and the needed level of care, used to identify and verify that the client is receiving care at the appropriate level.
LHWCA
Longshore and Harbor Workers’ Compensation Act
LIABILITY
Legal responsibility for failure to act appropriately or for actions that do not meet the standards of care, inflicting harm on another person.
LICENSE
A permit to practice medicine or a health profession that is: issued by a state or jurisdiction in the United States; and required for the performance of job functions.
LIEN
A charge or security or encumbrance upon property.
LIFE CARE PLAN
A dynamic document based on published standards of practice, comprehensive assessment, research, and data analysis, which provides an organized, concise plan for current and future needs [of the client and support system], with
associated costs, for individuals who have experienced catastrophic injury or have
chronic health care needs
LIFE CARE PLANNING
A holistic, person-centered approach to the management of healthcare and services of a person with complex, catastrophic, or life-altering condition or disability with the ultimate goal to promote and maintain the person’s good
health, safety, well-being, and quality of life. It applies a consistent methodology
for analyzing all of the actual present and potential future needs and their associated expenses dictated by the onset of a catastrophic disability through to the end of life expectancy.
LITERACY
Ability to read and write
LITIGATION
A contest in a court for the purpose of enforcing a right, particularly when inflicting harm on another person.
LIVING WILL
A legal document that directs the healthcare team/provider in holding or withdrawing life support measures. It is usually prepared by the client while he or she is competent, indicating the client’s wishes.
LOBBYING
A form of advocacy whereby an individual or group attempts to influence decisions made by those in positions of authority/power such as politicians, legislatures, regulators, government officials, agency executives, advocacy groups or others.
LOBBYIST
An individual, such as an advocate, who attempts to influence the decisions of those in positions of authority with the primary goal of promoting a special cause or agenda.
LONG-TERM DISABILITY
INCOME INSURANCE
Insurance issued to an employee, group, or individual to provide a reasonable replacement of a portion of an employee’s earned income lost through a serious
prolonged illness during the normal work career.
LORS
Level of Rehabilitation Scale
LOS
Length Of Stay
LOSS CONTROL
Efforts by the insurer and the insured to prevent accidents and reduce loss through the maintenance and updating of health and safety procedures.
LOSS EXPENSE ALLOCATED
That part of expense paid by an insurance company in settling a particular claim, such as legal fees, by excluding the payments to the claimant.
LOSS RATIO
The percent relationship which losses bear to premiums for a given period.
LOSS RESERVE
The dollar amount designated as the estimated cost of an accident at the time the first notice is received.
LOST WAGES
The income a worker does not earn due to an inability to return to work as a result of a work-related disability or extended absence.
LOST WAGES BENEFIT
Often in cases of lost wages due to a job-related disability and extended absence from work, the disabled worker is entitled to lost wages benefits. The amount of lost wages paid as a benefit to the worker while out on disability is determined based on state workers’ compensation and disability laws and the worker’s weekly income at the time the work-related injury or illness occurred. Other terms used to
describe this benefit include cash benefit, disability cash benefit, and lost income benefit.
MALPRACTICE
Improper care or treatment by a healthcare professional. A wrongful conduct.
MANAGED CARE
A system of healthcare delivery that aims to provide a generalized structure and focus when managing the use, access, cost, quality, and effectiveness of
healthcare services. Links the client to provider services.
MANAGED COMPETITION
A state of healthcare delivery in which a large number of consumers choose among
health plans that offer similar benefits. In theory, competition would be based on cost and quality and ideally would limit high prices and improve quality of care.
MANAGEMENT SERVICE
ORGANIZATION
A management entity owned by a hospital, physician organization, or third party. It contracts with payers and hospitals/physicians to provide certain healthcare management services such as negotiating fee schedules and handling administrative functions, including utilization management, billing, and collections.
MANDATORY OUTCOMES
REPORTS
Reports that consist of outcomes measures required by accreditation agencies such as The Joint Commission (TJC) or the National Committee for Quality
Assurance (NCQA) and regulatory bodies such as the Centers for Medicare & Medicaid Services (CMS) or the Department of Health & Human Services (DHHS). They often are publicly reported. Examples are core measures submitted to CMS,
or HEDIS measures submitted to NCQA.
MAP
Multidisciplinary action plan
MAXIMUM MEDICAL
IMPROVEMENT (MMI)
The point at which the health or medical condition of a worker who has sustained a work-related injury or illness has stabilized and further improvements are considered unlikely despite continued care and treatment. The treating physician at this time usually explains that no other reasonable treatment can be done to help the worker improve.
MCO
Managed Care Organization
MDS
Minimum Data Set
MEDICAL DISABILITY
ADVISOR
A reference that provides disability duration guidelines, mostly used as a source of accurate data for estimating the potential duration of a disability and therefore the timeframes of return to work for certain work-related diseases and injuries.
MEDICAL DURABLE POWER
OF ATTORNEY
A legal document that names a surrogate decision maker in the event that the patient becomes unable to make his or her own healthcare decisions.
MEDICAL HEALTH
Healthcare services provided to manage physiologic and functional health conditions that relate to a person’s biologic systems and organs.
MEDICAL HOME
A health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries,
information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want
it in a culturally and linguistically appropriate manner.
MEDICAL LOSS RATIO
The ratio of healthcare costs to revenue received, calculated as total medical expense divided by total revenue.
MEDICAL NECESSITY ON
ADMISSION
A type of review used to determine that the hospital admission is appropriate,
clinically necessary, justified, and reimbursable.
MEDICAL OUTCOMES STUDY
SHORT FORM 36 (SF-36)
A research instrument used to measure an individual’s perception of his/her own
health status and quality of life.
MEDICALLY NECESSARY
A term used to describe the supplies and services provided to diagnose and treat a medical condition in accordance with nationally recognized standards.
MEDICARE
A nationwide federally administered health insurance program that covers the cost of hospitalization, medical care, and some related services for eligible
persons. Medicare has two parts. Part A covers inpatient hospital costs (currently reimbursed prospectively using the DRG system). Medicare pays for
pharmaceuticals provided in hospitals but not for those provided in outpatient
settings. Also called Supplementary Medical Insurance Program. Part B covers
outpatient costs for Medicare clients (currently reimbursed retrospectively).
MEDICARE SECONDARY
PAYER
A term generally used when the Medicare program does not have primary payment responsibility – that is, when another payor/insurance company has the responsibility for paying before Medicare.
MEDICATION
RECONCILIATION
The process of examining and monitoring all medications taken by a client to determine their compatibility, necessity and safety in order to reduce the number of adverse drug affects and promote client’s adherence to the medication regimen.
MENTORING
A formal or informal relationship between two people, a senior mentor and a junior protégé.
The relationship aims to facilitate the professional development and advancement of the protégé. During this process the expert advises, guides, and further
develops the protégé to facilitate meeting the protégé’s career goals.
METABOLIC EQUIVALENT OF
TASK (MET)
A physiologic measure that expresses the energy cost of physical activities and is defined as the ratio of metabolic rate (or rate of energy consumption)
during a specific physical activity to a reference metabolic rate (rate of energy consumption during rest).
MILLIMAN CARE GUIDELINES
Nationally recognized guidelines that offer integrated, diagnosis-specific references, footnotes, and abstracts. Clinicians and payors use them as tools to
help drive higher- quality of care especially in the use of medical resources. The guidelines focus on reducing variances from best-practice care delivery, provide
tools that support discharge planning and care transitions, assist clinicians in the appropriate documentation of clients’ levels of care, and support the delivery of client-centered care.
MINIMUM DATA SET
The assessment tool used in skilled nursing facility settings to place patients into Resource Utilization Groups (RUGs), which determines the facility’s reimbursement rate.
MLR
Medical loss ratio
MMSE
Mini-Mental State Examination
MONITORING
The ongoing process of gathering sufficient information from all relevant sources and its documentation regarding the case management plan and its activities and/or services to enable the case manager to determine the plan’s effectiveness.
MOTIVATIONAL INTERVIEWING
An effective communication technique applied to gather important information and obtain insights into a client’s situation and health condition, focusing on the clinical, social, financial, mental, behavioral, and emotional aspects of the client’s status. It is a style of communication that is supportive, empathic, and counseling- like that helps clients/support systems move more easily toward a course of successful and desirable change.
MSP
Medical Secondary Payor
MULTIDISCIPLINARY ACTION
PLAN (MAP)
Also known as a case management plan. A timeline of patient care activities and expected outcomes of care that address the plan of care of each discipline involved in the care of a particular patient. It is usually developed prospectively by an interdisciplinary healthcare team in relation to a patient’s diagnosis, health problem or surgical procedure.
NACCM
National Academy of Certified Care Managers
NCQA
National Committee for Quality Assurance
NASW
National Association of Social Workers
NATIONAL QUALITY
MEASURES CLEARINGHOUSE
Also referred to as NQMC. It is a public resource for evidence-based quality measures and measure sets. The U.S. Department of Health & Human Services (HHS) sponsors this resource of quality measures through its affiliate, the Agency
for Healthcare Research and Quality (AHRQ). NQMC provides the public with an inventory of the measures that are currently being used by the HHS for quality
measurement, improvement, and reporting
NEGATIVE PREDICTIVE
VALUE (NPV)
The proportion of clients (also referred to as enrollees or members in a health insurance plan) who are predicted to experience low-cost services that turn out to be truly low cost.
NEGLIGENCE
Failure to act as a reasonable person. Behavior is contrary to that of any ordinary person facing similar circumstances.
NETWORK MODEL HMO
The fastest growing form of managed care, this plan contracts with a variety of groups of physicians and other providers in a network of care with organized referral patterns. Networks allow providers to practice outside the HMO.
NEVER EVENTS
Healthcare events that are undesirable, considered rare but devastating (resulting in death or serious disability) for the client when they occur, and are classified as medical errors. They are preventable in nature and healthcare organizations and
providers are pressured to eliminate or prevent their occurence. Never events
fall into six categories according to the National Quality Forum (NQF): surgical such as wrong site surgery, product of device such as contaminated drug, patient
protection such as suicide, care management event such as wrong dose drug, environmental such as electric shock, and criminal such as sexual assault.
NO EXPARTE
COMMUNICATION
Case managers under no circumstances can discuss the medical treatment plans with the treating physicians separate from the workers who suffered a work- related injury or illness. This extends not only to verbal but also to any written communications that the case manager may send to the treating physician.
NONADHERENCE
A person’s behavior that does not correspond with agreed upon recommendations from a healthcare provider or demonstrates inability or
indifference about following the recommendations (e.g., health regimen), such as continued tobacco use despite the instruction to give up smoking.
NONMALEFICENCE
Refraining from doing harm to others; that is, emphasizing quality care outcomes.
NPP
National Priorities Partnership
NQF
National Quality Forum
NURSE LICENSURE COMPACT
(NLC)
A legal agreement that allows nurses, based on enacted laws, to have one multistate license, allowing them the ability to practice in both their home and
other states that have agreed to belong to the compact. States that belong to the compact recognize the nurse’s licensure from the state of residence and eliminate the requirement of the nurse needing licensure in each of the states she/he chooses to work in as long as the state belongs to the compact.
NURSING CASE
MANAGEMENT
A process model using the components of case management in the delivery
aspects of nursing care. In nursing case management delivery systems, the role
of the case manager is assumed by a registered professional nurse.
OASIS
Outcome and Assessment Information Set: A prospective nursing assessment instrument completed by home health agencies at the time the patient is entered for home health services. Scoring determines the Home Health Resource Group
(HHRG).
OBSERVATION STATUS
A condition under which clients who appear in the emergency department (ED) but need a little more time after their ED stay to sort out whether they truly need
admission to an acute care/hospital setting as inpatients. Care for these clients
usually lasts less than 24 hours although sometimes may extend to a few days. Clients classified as observation status receive their care and services either in the
ED itself or another part of the acute care hospital.
OCCUPATIONAL DISEASE
A health condition or illness a worker experiences that is associated with the job
responsibilities or work environment (e.g., hearing loss, emphysema, chronic obstructive pulmonary disease).
ODG
Official Disability Guidelines
OIG
Office of Inspector General
OSHA
Occupational Safety and Health Administration
ONGOING RISK
STRATIFICATION
A process in which case managers assign clients to risk groups upon or after they access a healthcare practice setting or enrollment in a health insurance
plan and perhaps are receiving care. Case managers in this case update the risk stratification level of the client using administrative data such as claims data or assessments such as the health risk assessment (HRA) and various screening tools.
OUTCOME
The result and consequence of a healthcare process. A good outcome is a result that achieves the expected goal. An outcome may be the result of care received or not received. It represents the cumulative effects of one or more processes on a
client at a defined point in time.
OUTCOME INDICATORS
Measures of quality and cost of care. Metrics used to examine and evaluate the results of the care delivered.
OUTCOMES MANAGEMENT
The use of information and knowledge gained from outcomes monitoring to achieve optimal client outcomes through improved clinical decision making and The use of information and knowledge gained from outcomes monitoring to
achieve optimal client outcomes through improved clinical decision making and
service delivery service delivery.
OUTCOMES MONITORING
The repeated measurement over time of outcome indicators in a manner that permits causal inferences about what client characteristics, care processes, and resources produced the observed client outcomes.
OUTLIER
Something that is significantly well above or below an expected range or level.
OUTLIER THRESHOLD
The upper range (threshold) in length of stay before a client’s stay in a hospital becomes an outlier. It is the maximum number of days a client may stay in the hospital for the same fixed reimbursement rate. The outlier threshold is determined by the Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA).
OVERUTILIZATION
Using established criteria as a guide, determination is made asto whether the client is receiving services that are redundant, unnecessary, or in excess.
OWCP
Office of Workers’ Compensation Programs
PANEL OF PROVIDERS
Usually refers to the healthcare providers, including physicians, who are responsible for providing care and services to the enrollee in a managed care
organization. These providers deliver care to the enrollee based on a contractual agreement with the managed care organization.
PARTIAL DISABILITY
The result of an illness or injury which prevents an insured from performing one or more of the functions of his/her regular job.
PATHOPHYSIOLOGY
The physiology of abnormal states; specifically: the functional changes that accompany a particular syndrome or disease
PATIENT CENTERED
MEDICAL HOME (PCMH)
An approach to providing comprehensive, holistic and integrated primary care for clients. It is a care setting that facilitates partnerships among individual clients, client’s support systems and their primary care providers. Healthcare services
in such setting is facilitated by disease registries, information technology, health information exchange and other means to assure that clients receive the necessary care when and where they need or desire it, in a culturally and linguistically
appropriate manner
PATIENT SELF-DETERMINATION ACT OF 1991 (PSDA)
Refers to patients’ (i.e., clients’) rights to specify if they want to accept or refuse specific medical care and identify a legal representative for urgent healthcare decision purposes (known as advance directive including healthcare proxy). Then
if they become unable to make decisions for themselves as a result of a serious illness (e.g., stroke resulting in a coma), the patients then receive healthcare
services based on their wishes which have already been clearly documented at an earlier point of time when patients were healthy or through their healthcare proxy’s decisions.
PATIENT’S BILL OF RIGHTS
A law that ensures that all clients receive individualized, patient/family-centered,
considerate, and respectful medical care and treatments. It also emphasizes the client’s right to be well informed of and educated about the diagnosis, prognosis, and indicated treatment and care options. In addition, it states that a client has the right to self-determination: to agree to or refuse treatment and be informed of the consequences of such decisions.
PAYER
The party responsible for reimbursement of healthcare providers and agencies for
services rendered such as the Centers for Medicare and Medicaid Services and
managed care organizations.
PAYOR
Principal Term: The person, agency, or organization that assumes responsibility for funding the health and human services and resources consumed by a client. The payor can be the client her/himself, a member of the client’s support system, an employer, a government benefit program (e.g., Medicare, Medicaid, TriCare), a commercial insurance agency, a charitable organization or others.
PAYOR REPRESENTATIVE
The person or organization representing the payor (healthinsurance agency).
This individual is able to speak and make decisions on behalf of the payor and can be a case manager, a physician, medical advisor, claims manager or a quality management specialist.
PAYOR SOURCES
The individual or agency responsible for the expenses incurred during a client’s healthcare encounter; either commercial insurance, government programs,
charitable organization, personal/self pay or others.
PECS
Patient Evaluation Conference System
PCP
Primary Care Provider
PEER REVIEW
Review by healthcare practitioners of services ordered or furnished by other practitioners in the same professional field.
PEER REVIEW
ORGANIZATION (PRO)
A federal program established by the Tax Equity and Fiscal Responsibility Act of 1982 that monitors the medical necessity and quality of services provided to Medicare and Medicaid beneficiaries under the prospective payment system.
PER DIEM
A daily reimbursement rate for all inpatient hospital services provided in one day to one client regardless of the actual costs to the healthcare provider. The rate can vary by service (medical, surgical, mental health, etc.) or can be uniform regardless
of intensity of services.
PERFORMANCE
IMPROVEMENT
The continuous study and adaptation of the functions and processes of a healthcare organization to increase the probability of achieving desired outcomes and to better meet the needs of clients.
PERITRANSITION
The period that surrounds a client’s transition: before, during, and after a transition.
PERMANENT AND
STATIONARY (P&S)
When the condition of a worker who is suffering from a work-related injury or illness has plateaued to the point that additional medical treatment is not likely to improve the worker’s condition. This point signals the end of temporary disability
benefits and the need to examine the likelihood of permanent benefits instead.
PERMANENT PARTIAL
DISABILITY (PPD)
Disability that is caused by either a work-related injury or an occupational illness resulting in some form of permanent impairment that makes a worker unable to perform at his/her full capacity. An example is loss of vision in one eye or amputation of a finger in one hand.
PERMANENT PARTIAL
DISABILITY BENEFIT
A benefit payable to the employee for a life-long disability resulting from an on-the-job injury or illness and loss of function that is partial in nature. It is payable based on a percentage loss rating given by the authorized treating physician
in accordance with current guidelines. The benefit percentage is calculated by a formula that contains number of weeks assigned by the State Workers’ Compensation or Disability Board multiplied by the percentage rating of the
permanent partial disability.
PERMANENT TOTAL
DISABILITY
The worker’s wage-earning capacity is permanently and totally lost as a result of a work-related injury or illness that has deemed the worker unable to completely recover and therefore unable to return to work in any capacity.
PERMANENT TOTAL
DISABILITY BENEFIT
The benefit payable to workers who are never able to return to gainful employment after a work-related injury or illness. In this case there may not be any limit on the number of weeks the benefit is payable. In certain instances an employee may continue to engage in business or employment if the earned
wages combined with the weekly benefit do not exceed the maximums set by law.
PER-MEMBER-PER-MONTH
(PMPM)
The typical reimbursement method used by HMOs, it refers to a fixed amount of money paid to a care provider for covered services rather than based on specific services provided. Whether a member uses the health service once or more than
once, a provider who is capitated receives the same payment.
PERSON-CENTERED CARE
Care being provided “that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions
PETITION
An application to a court ex parte paying for the exercise of the judicial powers of the court in relation to some matter that is not the subject for a suit or action, or for authority to do some action that requires the sanction of the court.
PH
Personal Health
PHR
Personal health record
PHYSICAL DISABILITY
A bodily defect that interferes with education, development, adjustment or rehabilitation; generally refers to crippling conditions and chronic health problems but usually does not include single sensory handicaps such as blindness or deafness.
PHYSICIAN-HOSPITAL
ORGANIZATION
Organization of physicians and hospitals that is responsible for negotiating contractual agreements for healthcare provision with third-party payers such as managed care organizations.
PLAINTIFF
A person who brings a suit to court in the belief that one or more of his/her legal right have been violated or that he/she has suffered legal injury.
PLANNED RISK
STRATIFICATION
A process in which case managers assign clients to risk groups– before the clients have the need to access a healthcare program or practice setting – to then accurately assess their needs and appropriately plan for their necessary care and services.
PLAUSIBILITY
Refers to something that has the appearance of being true but which actually might be deceptive – sometimes innocently deceptive and sometimes speciously so. Examining plausibility is necessary for determining whether observed change is a direct result of applied interventions.
PLAUSIBILITY CHAIN
The process of examining whether plausibility indicators (factors or a sequence of events) were present and affected the link between observed change and applied intervention(s). An unbroken plausibility chain validates that the applied
intervention(s) indeed contributed to the observed outcomes.
PLAUSIBILITY INDICATOR
A factor or sequence of events that if present usually interrupt the likelihood that the observations made are a direct by- product of the applied intervention(s). Plausibility indicators perform similar to how confounding variables act in a
research study and affect the observed outcomes.
PMI
Project Management Institute
POA
Present on Admission
POC
Plan of care
POS
Point of service
POINT OF SERVICE (POS
PLAN)
A type of managed care health insurance plan which combines characteristics of both the HMO and the PPO plans. Members of a POS plan do not make a choice about which approach or plan to use until the point at which the service is needed and is being or about to be used. This plan also requires members to choose a PCP who in turn is responsible to make necessary referrals to SCPs or other healthcare services needed even if outside the plan’s network of providers. Members usually pay substantially higher costs in terms of increased premiums, deductibles and coinsurance.
POLYPHARMACY
A term used to denote “many or multiple drugs.” It refers to problems that can occur either when a client is taking more medications than are actually needed or even when prescribed medications are clinically indicated. It is a particular
concern for older adults but also widespread in the general population. Most common issues are increased drug-to-drug interactions, adverse drug events, higher costs, and medication errors.
POSITIVE PREDICTIVE VALUE
(PPV):
Proportion of clients who are predicted to experience high-cost services that turn out to be truly high cost.
POST-ACUTE CARE
The post-acute care delivery systems focus on the provision of services needed by a client after experiencing an acute episode of illness. Post-acute care settings may include skilled care facilities, long-term care, home care services, rehabilitation and sub-acute care facilities, palliative care or hospice, as well as
residential, group homes or assisted living facilities.
POST-TRANSITIONING
COMMUNICATION
One of the nine steps of a case management process, it involves contacting the client and/or client’s support system to check on the client’s condition and
determine how the ongoing treatment is progressing after the initial transition process.
PPO
Preferred provider organization
Prospective Payment System (PPS)
A healthcare payment system used by the federal government since 1983 for reimbursing healthcare providers/agencies for medical care provided to Medicare and Medicaid participants. The payment is fixed and based on the operating costs of the patient’s diagnosis.
PRACTICE GUIDELINES
(GUIDELINES)
Systematically developed statements on medical practices that assist a practitioner in making decisions about appropriate diagnostic and therapeutic healthcare services for specific medical conditions. Practice guidelines are usually
developed by authoritative professional societies and organizations such as the
American Medical Association.
PRACTICE SETTING/SITE
Principal Term: The organization or agency (or work setting) at which case managers are employed and execute their roles and responsibilities. These may
include but not be limited to payor, provider, government, employer, community, independent/private, workers’ compensation or client’s home environment.
PRE-ACUTE CARE
The pre-acute care delivery systems focus on health maintenance and prevention
(primary and secondary) of illness or unnecessary progression/deterioration in a client’s health condition. They usually require the least complex and least costly services. Pre-acute care settings may include clinic or outpatient treatment
centers, community care, educational and health maintenance environments or
payor (health insurance plan) organizations. Examples of services offered in such settings are health screening, lifestyle behavioral modification (healthy living) and disease risk reduction.
PREADMISSION
CERTIFICATION
An element of utilization review that examines the need for proposed services before admission to an institution to determine the appropriateness of the setting, PRECEDENTprocedures, treatments, and length of stay.
PRECEDENT
A decision by a judge or court that serves as a rule or guide to support other judges in deciding future cases involving similar or analogous legal questions.
PRECERTIFICATION
The process of obtaining and documenting advanced approval from the health plan by the provider before delivering the medical services needed. This is
required when services are of a nonemergent nature.
PRECERTIFICATION REVIEW
Also known as preadmission review or prospective review. A review that occurs prior to the delivery of any healthcare services to a client to determine the appropriateness, necessity and relevance of the services and obtain authorization from the health insurance plan for the services to be rendered to the client.
PREDICTIVE MODELING
A process used in data mining, usually automated and employs specialized software application to create a statistical model of future behavior that forecasts
probabilities and trends. The model is made up of a number of variables or factors called predictors that are likely to influence future behavior or results. In case management, for example, factors may include client’s gender, age, frequency of
access to healthcare services, number of chronic illnesses, and lifestyle behavior.
PREDICTOR
A characteristic or variable that is likely to influence a client’s future access to, or utilization of, healthcare services and resources. It tends to project the pattern of utilization. Examples are gender, age, frequency of past access to healthcare
services (e.g., hospitalizations and visits to the emergency department), biometrics (e.g., cholesterol level), number of chronic illnesses, and lifestyle or
health risk behaviors (e.g., smoking, alcohol consumption, and use of controlled substances).
PRE-EXISTING CONDITION
A physical and/or mental condition of an insured which firstmanifested itself prior
to the issuance of the individual policy or which existed prior to issuance and for which treatment was received.
PREFERRED PROVIDER
ORGANIZATION (PPO)
A program in which contracts are established with providers of medical care. Providers under a PPO contract are referred to as preferred providers. Usually the
benefit contract provides significantly better benefits for services received from preferred providers, thus encouraging members to use these providers. Covered persons are generally allowed benefits for nonparticipating provider services, usually on an indemnity basis with significant copayments.
PREMATURE DISCHARGE
The release of a client from care before he or she is deemed medically stable and ready for terminating treatment/care (e.g., discharging a patient from a hospital when he or she is still needing further care and/or observation).
PREMIUM
The periodic payment required to keep a policy in force.
PREPAID HEALTH PLAN
Health benefit plan in which a provider network delivers a specific complement of
health services to an enrolled population for a predetermined payment amount.
PRIMARY CARE
The point when the client first seeks assistance from the medical care system. It also is the care of the simpler and more common illnesses.
PRINCIPAL DIAGNOSIS
The chief complaint or health condition that required the client’s admission to the hospital for care.
PRINCIPAL PROCEDURE
A procedure performed for definitive rather than diagnostic treatment, or one that is necessary for treating a certain condition. It is usually related to the primary diagnosis.
PRINCIPLE
A widely recognized and accepted rule of action, behavior, or conduct.
PRO
Peer Review Organization
PROFESSIONAL DISCIPLINE
Principal Term: The case manager’s formal education, training and specialization
or professional background that is necessary and pre-requisite for consideration as a health and human services practitioner. It is also the professional background
case managers bring with them into the practice of case management such as
nursing, medicine, social work, rehabilitation and others as deemed appropriate.
PROJECT MANAGEMENT
INSTITUTE (PMI)
The world’s leading not-for-profit organization for the project management
profession that offers a range of services such as the development of standards, research, education, publication, networking-opportunities,
conferences and training seminars, and multiple related credentials.
PROSPECTIVE PAYMENT
SYSTEM (PPS)
A healthcare payment system used by the federal government since 1983 for reimbursing healthcare providers/agencies for medical care provided to Medicare and Medicaid participants. The payment is fixed and based on the operating costs of the client’s diagnosis.
PROSPECTIVE REVIEW
A method of reviewing possible hospitalization before admission to determine necessity and estimated length of stay.
PROVIDER-RELATED
OUTCOMES
Consequences or results of care activities, processes, or services that are directly related to the provider of care (e.g., case manager, physician, or healthcare agency).
PSDA
Patient Self-Determination Act of 1991
PSYCHOPATHOLOGY
The study of psychological and behavioral dysfunction occurring in mental illness or in social disorganization
PSYCHOSOCIAL CONDITION
The client’s economic, educational, social, psychological, emotional, cultural, and religious attributes (e.g., values, beliefs, rituals, and habits) that affect the client’s health status and behavior.
PUBLIC POLICY
The course of action to address an issue of concern by the community at large in terms of laws, regulations, legislation, decision, or any action in general. Shaping public policy is a complex and multifaceted process that involves the interplay of numerous individuals and interest groups competing and collaborating to
influence policymakers to act in a particular way.
QOL
Quality of Life
QUALIFIED REHABILITATION
PROVIDER
PROVIDER
Also referred to as qualified rehabilitation counselor, vocational counselor,
rehabilitation nurse, or qualified rehabilitation professional. A vocational rehabilitation counselor who is registered with the workers’ compensation or
disability agency in the jurisdiction of employment (e.g., the Department of Labor
and Industry in Minnesota). Generally, an applicant for the qualified rehabilitation
provider professional status must show eligibility based on specific criteria such as certification as a certified rehabilitation counselor (CRC) or certified disability management specialist (CDMS), internship as a rehabilitation professional, and/or work experience.
QUALIFIED REHABILITATION
VENDOR (QRV)
An individual or business that provides vocational and/or general rehabilitation services to clients based on registration in a state or jurisdiction that grants
permission to provide such services to clients in that jurisdiction. Services provided aim mainly to secure gainful employment for the client and may include but are not limited to medical services, training opportunities, vocational
assessment and training, and/or use of specialized equipment that minimize the impact of the disability.
QUALITY ASSURANCE
The use of activities and programs to ensure the quality of patient care. These activities and programs are designed to monitor, prevent, and correct quality deficiencies and noncompliance with the standards of care and practice.
QUALITY IMPROVEMENT
An array of techniques and methods used for the collection and analysis of data gathered in the course of current healthcare practices in a defined care setting
to identify and resolve problems in the system and improve the processes and outcomes of care.
QUALITY INDICATOR
A predetermined measure for assessing quality; a metric.
QUALITY MANAGEMENT
A formal and planned, systematic, organization wide (or networkwide) approach to the monitoring, analysis, and improvement of organization performance, thereby continually improving the extent to which providers conform to defined standards, the quality of client care and services provided, and the likelihood of achieving
desired client outcomes.
QUALITY MONITORING
A process used to ensure that care is being delivered at or above acceptable quality standards and as identified by the organization or national guidelines.
RAC
Recovery Audit Contractor
RATE
The charge per unit of payroll which is used to determine workers’ compensation
or other insurance premiums. The rate varies according to the risk classification within which the policyholder may fall.
RATING
The application of the proper classification rate and possibly other factors to set the amount of premium for a policyholder. The three principle forms of rating are (1) manual rating, (2) experience rating, and (3) retrospective rating.
REASONABLE
ACCOMMODATION
Making existing facilities used by employees readily accessible and usable by individuals with disabilities. This may include job restructuring, part-time or
modified work schedules, acquisition or modification of equipment or devices, and
other similar accommodations for individuals with disabilities.
REASONABLE AND PRUDENT
Reasonable refers to a situation where one exercises sound judgment and acts in a judicious and rational manner. Prudent refers to a situation when an individual is wise and careful in how he/she handles practical matters and exercises common
sense. “Reasonable and prudent” is a term used in legal matters to refer to the objective by which the conduct of others is judged, often in situations where a person’s actions and behaviors are suspect of negligence. In these cases the behaviors are judged against how a reasonable and prudent person would have
acted in a similar situation under similar conditions.
RECOVERY AUDIT
CONTRACTOR (RAC)
A national program within the Centers for Medicare & Medicaid Services (CMS) that aims to identify improper Medicare payments and fight fraud, waste, and abuse in the Medicare program and is designed to guard the Medicare TrustFund.
The Tax Relief and Health Care Act of 2006 required a permanent and national
RAC program that would be in place by January 1, 2010. This program was the outgrowth of a successful demonstration project that used RACs to identify
Medicare overpayments and underpayments to healthcare providers and suppliers
in California, Florida, New York, Massachusetts, South Carolina, and Arizona. The RACs review healthcare providers including hospitals, physician practices, nursing homes, home health agencies, durable medical equipment suppliers, and any other provider or supplier that bills Medicare Parts A and B.
REED MD GUIDELINES
Also referred to as RMDG because the Reed’s Group Medical Advisory Board is the primary contributor to these guidelines. They are nationally recognized disability management, workers’ compensation and return-to-work guidelines used by clients, employers, and clinicians to predict disability duration and thus return-to-work time for various diseases and injuries. Each guideline considers
the client’s risk (i.e., activity restrictions), capacity (i.e., activity limitations), and tolerance (i.e., the ability to put up with symptoms such as pain and fatigue that accompany doing work tasks) in recommending situation-specific return-to-
work activities. When applied effectively they enable healthcare providers (e.g., physician, case managers and vocational rehabilitation counselors) and employers to improve disability outcomes, employee health, and company’s productivity.
REHABILITATION
COUNSELING
A specialty within the rehabilitation professions with counseling being at its core. It is a profession that assists individuals with disabilities in adapting to the environment, assists environments in accommodating the needs of the individual, and works toward full participation of persons with disabilities in all aspects of
society, especially work.
REHABILITATION
COUNSELOR
A counselor who possesses the specialized knowledge, skills, and attitudes needed to collaborate in a professional relationship with persons with disabilities
to empower them to achieve their personal, social, psychological, and vocational
goals.
REHABILITATION
ENGINEERING
The field of technology and engineering serving disabled individuals in their rehabilitation. Includes the construction and use of a great variety of devices and instruments designed to restore or replace function mostly of the locomotion and
sensory systems.
REHABILITATION
IMPAIRMENT CATEGORIES
Represent the primary cause of the rehabilitation stay. They are clinically homogeneous groupings that are then subdivided into Case Mix Groups (CMGs).
REHABILITATION TEAM
A group of healthcare workers with backgrounds in rehabilitation who work
together to provide integrated, client- oriented care. A variety of specialists and other providers who combine resources to address each client’s physical,
mental, emotional and spiritual needs in order to minimize disability and resulting
handicaps.
REIMBURSEMENT
Payment regarding healthcare and services provided by a physician, medical professional, or agency.
RELATIVE WEIGHT
An assigned weight that is intended to reflect the relative resource consumption
associated with each DRG. The higher the relative weight, the greater the payment/reimbursement to the hospital.
RELEASE
The relinquishment of a right, claim, or privilege, by a person in whom it exists or to whom it accrues, to the person against whom it might have been demanded or enforced.
REMAND
To send back, as in sending a case back to the same court out of which it came for purposes of having some action taken on it there.
REMEDY
The means by which a right is enforced or the violation of a right is prevented, redressed, or compensated.
REPORT CARD
An emerging tool that is used by healthcare providers, purchasers, policymakers, governmental agencies, and consumers to compare and understand the actual performance of health plans and other service delivery programs. It usually includes data in major areas of accountability such as quality, utilization of resources, consumer satisfaction, and cost.
REPRIMAND
A written statement indicating that a board-certified case manager’s actions (or inactions) have been found, after careful review, to violate the Code in one
or more ways, and that the consequences either have or could have resulted in substantial harm to the client or public. Usually a reprimand is triggered by a review conducted because of a complaint filed to CCMC by a concerned party
(e.g., client) about a board-certified case manager.
RE-REVIEW
A case review that is completed based on a request from the health insurance plan after a denial of reimbursement or service has been recommended by the plan to the healthcare provider. The insurance plan conducts this type of review
in an effort to reconsider the denial decision especially after an appeal has been submitted by the provider of care on behalf of the client. A physician from the
provider agency (e.g., physician advisor) may perform the review with a physician from the health insurance plan (e.g., the medical director). A decision is then made
after concluding the re-review either to uphold or reverse the denial.
RESIDUAL FUNCTIONAL
IMPAIRMENT
An individual’s capacity to perform job-related tasks (physical and cognitive or mental) despite functional limitations that exist as a result of a job-related injury or illness. In the workers’ compensation field this is formally assessed by experts
to determine the worker’s ability of gainful activity and therefore return to work in some capacity.
RESOURCE UTILIZATION
GROUP (RUG)
Classifies skilled nursing facility patients into 7 major hierarchies and 44 groups. Based on the MDS, the patient is classified into the most appropriate group, and
with the highest reimbursement.
RESPONDEAT SUPERIOR
Literally, “Let the master respond.” This maxim means that an employer is liable
in certain cases for the wrongful acts of his/her employees, and the principal for those of his/her agency.
RETROSPECTIVE REVIEW
A form of medical records review that is conducted after the client’s discharge to track appropriateness of care and consumption of resources.
RETURN ON INVESTMENT
(ROI)
A performance measure used to evaluate the benefit (e.g., quality outcomes, revenue, and cost savings) of a product, service, or intervention, such as case
management relevant to its related expenses (cost). The result is expressed as a percentage or ratio.
RETURN TO WORK (RTW)
An organized and systematic way of managing employees’ absence from work due to illness or injury and the process for returning to work as soon as it is appropriate. This may include a formal assessment of the employee’s condition, need for enrollment in a RTW program, pre-illness or pre-injury health condition
and work description, potential suitable duties post injury or illness (may not be different from that prior to injury or illness), need for rehabilitation, and timeline for return to work setting.
RETURN TO WORK FULL
DUTY
Return to gainful employment in full work capacity and with complete responsibility for all the work duties assumed at the time the worker sustained a job-related injury or illness.
RETURN TO WORK WITH
ACCOMMODATIONS
Return to gainful employment assuming modified job responsibilities or expectations. Modifications reflect accommodations of the worker’s limitations based on the outcomes of the job-related injury or illness. These modifications usually relate to the set of job duties, tasks, or responsibilities, work schedule
(hours per day, days per week), physical demands, and type of equipment or tools applied.
RIC
Rehabilitation impairment categories
RISK
The uncertainty of loss with respect to person, liability or the property of the insured or the probability that revenues of the insurer will not be sufficient to
cover expenditures incurred in the delivery of contracted services.
RISK CATEGORY
Also referred to as risk class or risk level, it is the client’s health risk status, which can be described as low, moderate, or high.
RISK MANAGEMENT
The science of the identification, evaluation, and treatment of actual or potential financial or clinical losses. Usually occurs through a formal program that attempts to avoid, prevent or minimize negative results. The program consists of a comprehensive set of activities that aims to identify, evaluate and take corrective action against risks that may lead to client or staff injury with resulting financial loss or legal liability.
RISK SHARING
The process whereby an HMO and contracted provider each accept partial responsibility for the financial risk and rewards involved in cost-effectively caring
for the members enrolled in the plan and assigned to a specific provider.
RISK STRATIFICATION
A set of tools used to stratify a population, according to its risk, to identify opportunities for intervention before the occurrence of adverse outcomes (or deterioration in health condition and disease state) that result in increased medical
costs
ROI
Return on investment
ROOT CAUSE ANALYSIS
A process used by healthcare providers and administrators to identify the basic or causal factors that contribute to variation in performance and outcomes or underlie the occurrence of a sentinel event.
RTW
Return to work
RUG
Resource Utilization Group
RULE OF CONDUCT
A model behavior (or a set of behaviors) professionals such as case managers are expected to exhibit or emulate during their practice and when dealing with
clients/support systems and other professionals or members of the public. These usually reflect what is commonly understood as ethical behavior and/or good standing in the community; for example, maintaining professional behavior and being truthful.
SANCTION
A type of action CCMC imposes on a board-certified case manager cited in a complaint of an alleged violation to the Code of Professional Conduct for Case
Managers after a careful review of the complaint. The sanction may, for example, be in the form of a reprimand, suspension of the certified case manager credential, or placement of the case manager on probation.
SCHOLARLY ACTIVITIES
Creative work that is peer reviewed and publicly communicated or widely disseminated. Refer to achievements in knowledge acquisition, evaluation,
utilization, or application such as writing, publishing, teaching, research conduct, mentoring, public speaking, community engagement or obtaining a post-graduate level degree .
SCP
Specialty care provider
SEARCHABLE ONLINE
ACCOMMODATION
RESOURCE (SOAR)
A system that is designed in a way to allow users to explore various accommodation options for persons with disabilities in work and educational settings. The resource, provided by the Job Accommodation Network (JAN) of the Office of Disability Employment Policy of the U.S. Department of Labor, includes a search function by type of disability and provides recommendations for potential job accommodations.
SELF DETERMINATION
A person-centered and directed process where one decides what is necessary and desirable to create a personally meaningful and satisfactory life. This process
differs from person to person and acknowledges the rights of people, especially those who are ill or disabled. For example, the individual - not the service system - decides where he/she will live, and with whom; what type of services he/she requires, and who will provide them; how he/she will spend his/her time; and what care and services he/she desires, especially end-of-life, such as withdrawal of life support and nutrition.
SELF-CARE MANAGEMENT
is an individual’s ability to make day-to-day decisions about the management of own illness. It is also one’s self-efficacy and confidence to carry out certain
activities of daily care and demonstrate behaviors necessary to reach desired health goals
SELF-INSURER
An employer who can meet the state legal and financial requirements to assume by him or herself all of its risk and pay for the losses, although the employer may contract with an insurance carrier or others to provide certain essential services.
SENSORY APHASIA
Inability to understand the meaning of written, spoken or tactile speech symbols because of disease or injury to the auditory and visual brain centers.
SENTINEL EVENT
An unexpected occurrence, not related to the natural course of illness, that results in death, serious physical or psychological injury, or permanent loss of function.
SERIOUS MENTAL ILLNESS
(SMI)
A mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) that is diagnosable currently or within the past year. Such disorder must be of sufficient duration to meet diagnostic criteria specified within the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and has resulted in serious functional impairment, which substantially interferes with or limits one or more major life activities.
SETTLEMENT
A “meeting of minds” of parties to a transaction or controversy which resolves some or all of the issues involved in a case.
SEVERITY OF ILLNESS (SI)
An acuity of illness criteria that identifies the presence of significant/debilitating symptoms, deviations from the client’s normal values, or unstable/abnormal vital
signs or laboratory findings.
SF-36
Medical Outcomes Study Short Form 36.
SHARED CARE PLAN
A patient-centered health record designed to facilitate communication among members of the care team, including the patient and providers. Rather than relying on separate medical and behavioral health care
(treatment) plans, a shared plan of care combines both aspects to encourage a team approach to care.
SHORT-TERM DISABILITY
INCOME INSURANCE
The provision to pay benefits to a covered disabled person/employee as long as he/
she remains disabled up to a specific period not exceeding two years.
SIGNIFICANT EVENT
Also known as sentinel event. An unexpected occurrence that is unrelated to the natural course of illness, medical treatment, or case management interventions,
which results in death, serious physical or psychological injury, or permanent disability or loss of function.
SILOED CARE APPROACH
A way, mind-set, or perspective of care provision that involves an individual or care setting focusing on their own aspect of care, refraining from sharing
information with others, and expressing no interest in collaboration or integration
with other parties or care settings.
SKILLED CARE
Client care services that require delivery by a licensed professional such as a registered nurse or physical therapist, occupational therapist, speech pathologist, or social worker.
SME
Subject Matter Expert
SMI
Supplementary medical insurance
SNF
Skilled nursing facility
SOCIAL DETERMINANTS OF
HEALTH (SDH)
The conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at
global, national and local levels and usually either promote or hinder a person’s health status.
SOCIAL SECURITY
DISABILITY INSURANCE
Federal benefit program sponsored by the Social Security Administration. Primary factor: disability and/or benefits received from deceased or disabled parent; benefit depends upon money contributed to the Social Security program either by
the individual involved and/or the parent involved.
SPECIALTY CARE PROVIDER
(SCP)
A healthcare provider, physician or medical practitioner with a specific area of expertise such as cardiology, nutrition or behavioral health who assumes
care (other than primary care) of a client upon a referral from a PCP. The SCP coordinates care activities with the client’s PCP and obtains necessary authorizations/certifications before care is provided.
SS
Social Support
SSA
Social Security Act
SSDI
Social Security Disability Insurance
SSI
Supplemental Security Income
STAFF MODEL HMO
The most rigid HMO model. Physicians are on the staff of the HMO with some sort of salaried arrangement and provide care exclusively for the health plan enrollees.
STAKEHOLDER
A person, group, or organization that has direct or indirect stake in a program (e.g., case management) or organization (e.g., healthcare facility) because it can affect, or be affected by, the organization’s (or program’s) actions, objectives, policies, mission, vision and/or objectives. Key stakeholders in a healthcare
organization may include clients and their support systems, providers of care, payors for services, suppliers of goods, regulators, and others.
STANDARD (INDIVIDUAL)
An authoritative statement by which a profession defines the responsibilities for which its practitioners are accountable.
STANDARD (ORGANIZATION)
An authoritative statement that defines the performance expectations, structures
or processes that must be substantially in place in an organization to enhance the
quality of care.
STANDARDS OF CARE
Statements that delineate care that is expected to be provided to all clients. They include predefined outcomes of care clients can expect from providers and are accepted within the community of professionals, based upon the best scientific
knowledge, current outcomes data, and clinical expertise.
STANDARDS OF PRACTICE
Statements of acceptable level of performance or expectation for professional intervention or behavior associated with one’s professional practice. They are
generally formulated by practitioner organizations based upon clinical expertise and the most current research findings.
STATUTE
An act of a legislature declaring, commanding, or prohibiting and action, in contrast to unwritten common law.
STATUTE OF LIMITATION
A statute prescribing limitations to the right of action on certain described causes of action; that is, declaring that no suit shall be maintained on such causes of
action unless brought within a specified period of time after the right accrued.
STIPULATION.
An agreement between opposing parties that a particular fact or principle of law is true and applicable.
STRATIFICATION GROUPS
Also referred to as stratification classes or stratification levels. Clients categorized into groups based on health risk status which may include low-, moderate-, and
high-risk stratification groups.
STRATIFYING RISK
A process that aims to classify clients into one of three health risk categories (low, moderate, and high) based on a set of pre-determined criteria and using health assessments and biomedical screening tools. The criteria are usually associated
with acuity of the client’s health condition, psychosocial and financial situation as well as type and amount of resources required for resolving the client’s
problems and meeting her/his needs. Stratifying risk is important for determining
an adequate level of intervention as appropriate to each client’s specific situation and treatment plan.
STRUCTURED CARE TOOLS
Formal approaches to streamlining care processes and activities for the purpose of reducing practice pattern variations among healthcare providers, avoiding unnecessary costs of healthcare services, and establishing best practice standards while maintaining and improving the quality of care provided. Structured care
methodologies are developed either based on evidence or experts’ consensus. Examples of structured care tools frequently used are critical or clinical pathways, algorithms, and practice guidelines.
SUBACUTE CARE FACILITY
A healthcare facility that is a step down from an acute care hospital and a step up from a conventional skilled nursing facility intensity of services.
SUBPOENA
A process commanding a witness to appear and give testimony in court.
SUBROGATION
The right to pursue and lien upon claims for medical charges against another person or entity.
SUPPLEMENTAL INCOME
BENEFITS (SIBS)
Income benefits an injured worker receives on a monthly basis after applying for and found deemed to meet the eligibility requirements, which include an impairment rating of 15 percent or more; and have not returned to work because
of impairment or have returned to work but earning less than 80 percent of the average weekly wage earned prior to the injury because of the impairment. SIBs
are paid only after impairment income benefits end.
SUPPLEMENTAL JOB
DISPLACEMENT BENEFIT
A form of benefit that is used to cover the cost of training an injured worker to return to an existing job or a new job altogether. It is a voucher of limited financial amount (often does not exceed $10,000) and may cover the cost of training or
education, skills enhancement, certification examination, and/or licensure.
SUPPLEMENTAL SECURITY
INCOME (SSI)
Federal financial benefit program sponsored by the Social Security Administration.
SUPPLEMENTARY MEDICAL
INSURANCE (SMI)
A secondary medical insurance plan used by a subscriber to supplement healthcare benefits and coverage provided by the primary insurance plan. The
primary and secondary/supplementary plans are unrelated and provided by two different agencies.
TARGET UTILIZATION RATES
Specific goals regarding the use of medical services, usually included in risk- sharing arrangements between managed care organizations and healthcare providers.
TBI
Traumatic Brain Injury
TDD
Telecommunication device for the Deaf
TELEPHONE TRIAGE
Triaging clients to appropriate levels of care based on a telephonic assessment of
a client. Case managers use the findings of their telephone-based assessment to categorize the client to be of an emergent, urgent or nonurgent condition.
TELEPHONIC CASE
MANAGEMENT
The delivery of healthcare services to clients and/or families or caregivers over the telephone or through correspondence, fax, e-mail, or other forms of electronic transfer.
TELEPHONIC CASE
MANAGEMENT (TCM)
Also referred to as tele-case management. The delivery of healthcare services to clients and/or families or caregivers where a case manager provides care coordination and management activities virtually via telephone or other modes of
electronic communication such as fax, e-mail, and videoconferencing. Usually TCM
programs are supported by state-of-the-art software systems, digital tools, and
communication technologies.
TEMPORARY PARTIAL
DISABILITY BENEFIT
A benefit payable to an employee when he/she returns to work in a job paying less as a result of an on-the-job accident. These benefits are payable for up to
350 weeks from the date of injury. This lost wage amount is two-thirds of the difference between the employee’s average weekly wage before and after the
injury. The maximum amount payable cannot exceed the maximum allowed under
the law.
TEMPORARY TOTAL
DISABILITY (TTD)
A disability that completely prevents an injured worker from returning to work after a work-related injury or illness for a limited period of time.
TEMPORARY TOTAL
DISABILITY BENEFIT
A benefit payable to an employee who is injured on the job and unable to work as determined by the authorized treating physician. The amount is two-thirds of
the employee’s average weekly wage at the time of the injury, not to exceed the maximum amount allowed under the law. For non catastrophic injuries, benefits are limited to 400 weeks from the date of injury if the injury occurred on or after July 1, 1992. For catastrophic injuries, benefits are unlimited.
THIRD PARTY
ADMINISTRATION
Administration of a group insurance plan by some person or firm other than the insurer of the policyholder.
THIRD PARTY
ADMINISTRATOR (TPA)
An organization that is outside of the insuring organization that handles only administrative functions such as utilization review and processing claims. Third party administrators are used by organizations that actually fund the health benefits but do not find it cost-effective to administer the plan themselves.
THIRD PARTY PAYOR
An insurance company or other organization responsible for the cost of care so that individual clients do not directly pay for services.
THIRD-PARTY WORKERS’
COMPENSATION CLAIM
A claim that involves a party other than or in addition to the worker’s employer but this party plays a role in the worker’s claim for benefits due to the injury-
related disability that prevents the worker from returning to gainful employment. For example, a worker suffers an injury inflicted by operating defective machinery, using a dangerous product, or unsafe work conditions on the part of
a subcontractor may have a claim (third-party claim) against the manufacturer of the machine, product, or the subcontractor’s behavior in addition to the workers’
compensation claim.
THREE-POINT CONTACT
Also referred to as 3-point contact. The three main persons a workers’ compensation case manager contacts upon getting engaged in a worker’s case.
These include the injured or ill worker (client), the worker’s employer, and the worker’s treating physician.
TRANSITION MANAGEMENT
Activities case managers engage in to ensure effective, safe, and quality transitions of clients from one care setting or provider to another. These may at a minimum include assessment of client’s needs and readiness to transition, planning safe transition, and evaluation of the outcomes of the transition.
TRANSITION PLAN
A plan for an individual client that describes the process
of transferring the client from one level of care, care setting, or provider to another. The process considers the health and human services the client needs to
effectively take care of the health condition and to meet the care goals described in the comprehensive plan of care.
TRANSITIONAL CARE NURSE
A nurse who, in Mary Naylor’s Transitional Care Model, helps to plan and execute smooth discharges for high-risk clients.
TRANSITIONAL PLANNING
The process case managers apply to ensure that appropriate resources and services are provided to clients and that these services are provided in the most
appropriate setting or level of care as delineated in the standards and guidelines
of regulatory and accreditation agencies. It focuses on moving a client from most complex to less complex care setting.
TRANSITIONING
The transitioning step of the case management process consists of activities such as assessing whether the client is ready for transfer to another level of care,
facility, provider, or discharge to home (if client were in an acute care setting); if the treatment plan justifies such transition; if the client and client’s support system are ready for transfer to the client’s home, to another healthcare facility or to a community-based clinician for further treatment; and follow-up.
TRANSITIONS COACH
A nurse, social worker, or trained volunteer who, in Eric Coleman’s Care Transitions Program, helps clients acquire self-management skills related to transitions of care.
TRANSITIONS OF CARE
The process[es] of moving patients [clients] from one level of care to another, usually from most to least complex; however, depending on the patient’s health condition and needed treatments, the transition can occur from least to most complex
TTY
Telephone typewriter or teletypewriter
UM
Utilization management
UR
Utilization review
URAC
Utilization Review Accreditation Commission
Utilization Review Accreditation Commission (URAC)
An independent, nonprofit organization that promotes healthcare quality through accreditation, education,
and measurement programs. Its main mission focuses on promoting continuous
improvement in the quality and efficiency of healthcare management through
processes of accreditation and education. URAC offers a wide range of quality benchmarking services, validates the commitment of healthcare organizations to quality and accountability through accreditation, and ensures that all stakeholders are represented in establishing meaningful quality measures for the healthcare
industry
USE VALUE
The utility of consuming a good or service and the satisfaction experienced as a result of its use
UTILIZATION
The frequency with which a benefit is used during a 1-yearperiod, usually expressed in occurrences per 1000 covered lives.
UTILIZATION MANAGEMENT
(UM)
Management of health services to ensure that when offered they are medically necessary, provided in the most appropriate care setting, and at or above quality standards.
UTILIZATION OF HEALTH
BENEFITS
The frequency with which a benefit is used during a 1-yearperiod, usually expressed in occurrences per 1000 covered lives.
UTILIZATION OF RESOURCES
Using established criteria as a guide, determination is made as to whether the client is receiving all of the appropriate services.
UTILIZATION REVIEW (UR)
A mechanism used by some insurers and employers to evaluate healthcare services on the basis of appropriateness, necessity and quality.
VALUE
The relative worth of something including its merit, importance, monetary return, impact on others or things, or contribution toward achieving a goal or purpose. It also may refer to an individual’s personal interests, desires or beliefs.
VARIANCE
Deviation from the norm, standard or what is expected. Depending on the
situation, it may result in an undesired outcome such as delay in care (e.g., a specific diagnostic or therapeutic intervention that was not achieved within the
designated timeframe), a medical error or a client’s dissatisfaction. Variance categories may include system, patient, practitioner and community.
VERACITY
Legal principle that states that a health professional should be honest and give full disclosure; abstain from misrepresentation or deceit; report known lapses of
the standards of care to the proper agencies.
VOCATIONAL ASSESSMENT
Identifies the individual’s strengths, skills, interests, abilities and rehabilitation
needs. Accomplished through on-site situational assessments at local businesses and in community settings.
VOCATIONAL COUNSELING
A process of assisting individuals to obtain work, especially those with a disability, whether developmental in nature or due to an injury or illness. The process consists of job-seeking counseling services that are provided by a vocational
counselor and include: evaluation of one’s skills; aptitudes values and areas of
interest; learning how to improve the skills; guidance on how to successfully search for a potential job; and developing strategies for effectively applying and interviewing for a job.
VOCATIONAL EVALUATION
The comprehensive assessment of vocational aptitudes and potential, using information about a person’s past history, medical and psychological status, and information from appropriate vocational testing, which may use paper and pencil
instruments, work samples, simulated work stations, or assessment in a real work
environment.
VOCATIONAL
REHABILITATION
A process that aims to return workers with some type of disability to work. It enables persons with functional, psychological, developmental, cognitive and/or emotional limitations or health disabilities to overcome the limitation(s) and return to employment in a prior or new job.
VOCATIONAL
REHABILITATION
COUNSELOR
A rehabilitation counselor who specializes in vocational counseling, i.e., guiding
handicapped persons in the selection of a vocation or occupation.
VOCATIONAL
REHABILITATION
PROFESSIONAL
A professional who works with an interdisciplinary healthcare team to help eligible individuals with disabilities attain and maintain competitive employment; and overcome psychological, developmental, cognitive, and health barriers
so that these individuals are able to obtain meaningful jobs and increase their independence.
VOCATIONAL TESTING
The measurement of vocational interests, aptitudes, and ability using standardized, professionally accepted psychomotor procedures.
VOLUNTARY OUTCOMES
REPORTS
Reports that consist of outcomes measures decided upon by the healthcare provider or organization and often used internally for productivity and
performance measurement or improvement opportunities. Examples are revenue and loss statements, cost per case, reimbursement denials, barriers to care, and client and staff satisfaction.
WAIVER
The process[es] of moving patients [clients] from one level of care to another, usually from most to least complex; however, depending on the patient’s
health condition and needed treatments, the transition can occur from least to most complex
WEEFIM
Functional Independence Measure for Children
WHOLISTIC CASE
MANAGEMENTTM
A contemporary approach to the delivery of comprehensive case management services to clients and their support system. It considers the client’s physical,
functional, social, emotional, behavioral, mental, cognitive, spiritual, financial/economic, cultural, and/or other conditions that impact the client’s situation,
to ultimately intervene in ways that enhance the client’s safety, well-being, engagement in own health, and care outcomes. In this approach to care, the wholistic case manager cares for the whole client as a human being to carefully orchestrate the necessary health and human services to meet all aspects of the client’s condition and diverse range of needs, without restriction. Most importantly
however, the services the wholistic case manager coordinates bring the social
and economic domains of care needs and resources to the center of the Case Management Process and services while considering the client’s culture, belief system, and individuality.
WITHHOLD
A portion of payments to a provider held by the managed care organization until year end that will not be returned to the provider unless specific target utilization rates are achieved. Typically used by HMOs to control utilization of referral services by gatekeeper physicians.
WITHIN-THE-WALLS CASE
MANAGEMENT
Models where healthcare resources, services, and case managers are based within the acute care/hospital setting.
WORK ADJUSTMENT
The use of real or simulated work activity under close supervision at a rehabilitation facility or other work setting to develop appropriate work behaviors, attitudes, or personal characteristics.
WORK ADJUSTMENT
TRAINING
A program for persons whose disabilities limit them from obtaining competitive employment. It typically includes a system of goal directed services focusing on improving problem areas such as attendance, work stamina, punctuality, dress and
hygiene and interpersonal relationships with co- workers and supervisors. Services
can continue until objectives are met or until there has been noted progress. It may include practical work experience or extended employment.
WORK CONDITIONING
A program that uses strengthening and conditioning techniques to enable a worker who has sustained a job-related injury or illness to regain function. The program consists of intensive job-related and goal-oriented treatments specifically
designed to restore a worker’s capacity to perform work tasks and duties in the environment they are intended to occur.
WORK HARDENING
A program that focuses on work endurance and uses real or simulated job tasks and duties and progressively graded conditioning exercises based on the worker’s measured tolerance to ultimately return the worker to gainful employment.
WORK MODIFICATION
Altering the work environment to accommodate a person’s physical or mental limitations by making changes in equipment, in the methods of completing tasks,
or in job duties.
WORK REHABILITATION
A structured program of graded physical conditioning/strengthening exercises and functional tasks in conjunction with real or simulated job activities. Treatment is designed to improve the individual’s cardiopulmonary, neuromusculoskeletal
(strength, endurance, movement, flexibility, stability, and motor control) functions, biomechanical/human performance levels, and psychosocial aspects as they relate to the demands of work. Work rehabilitation provides a transition between acute care and return to work while addressing the issues of safety, physical tolerances, work behaviors, and functional abilities.
WORKERS’ COMPENSATION
An insurance program that provides medical benefits and replacement of lost wages for persons suffering from injury or illness that is caused by or occurred in the workplace. It is an insurance system for industrial and work injury, regulated primarily among the separate states, but regulated in certain specified occupations
by the federal government.
WORKERS’ COMPENSATION
COMMISSION
One of many terms identifying the state public body which administers the workers’ compensation laws, holds hearings on contested cases, promotes industrial safety, rehabilitation, etc. It is often located within the state labor
department. The national organization is the International Association of Industrial Accident Boards and Commissions.
COUNSELING PROCESS
A process that uses relationship and therapeutic skills to foster the independence, growth, development, and behavioral change of persons with disabilities through the implementation of a working alliance between the counselor and the client. It involves communication, goal setting, and beneficial growth or change through self-advocacy, psychological, vocational, social, and/or behavioral interventions.
CLAIM
A request for payment of reparation for a loss covered by an insurance contract.
CIVIL CASE OR SUIT
A case brought by one or more individuals to seek redress of some legal injury (or aspect of an injury) for which there are civil (non-criminal) remedies.
CHRONIC ILLNESS
A health condition (disease) that lasts three months or longer.
