Ch 21: Care Management Flashcards
Domain 1: CM processes and services- Critical case management domains
Evaluate, assess, plan, facilitate/implement, coordinate, monitor
Domain 2: resource utilization and management- Critical case management domains
Appropriate and beneficial use of healthcare dollars on additional resources/care for pt, must develop strategies to oversee and protect limited health care dollars available
Domain 3: psychosocial and economic support-Critical case management domains
Education of the pt and family regarding services, accessibility, financial availability, identify resources/support, assess social supports and caregiver burden, ensure that caregivers are willing and able to assist
Domain 4: Rehabilitation-Critical case management domains
Vocational aspects of rehab
Identification of:
Environmental modifications to address accessibility barriers
Specialized services like Work hardening/return to work programs
Domain 5: outcomes- Critical case management domains
Collection, analysis, and reporting of actual outcome is against expected outcomes
** Quality and effectiveness of outcomes in a variety of areas including clinical, financial, and quality-of-life
Domain 6: ethical and legal practices- Critical case management domains
Adhere to pertinent regulatory requirements, accrediting standards, and legal requirements
HIPAA
Life care plan
Specific to the individual and his/her needs over the course of a lifetime (short and long term)
Reflect a complete understanding of the persons injuries and resultant disabilities
Consider the complications that can occur from sustained injuries and the steps necessary to prevent further complications
Social security act of 1935
Provides cash benefits and healthcare plans for individuals who are aged, disabled, and those with low income.
Social Security Disability Insurance requirements: sufficient prior work experience to have paid into Social Security system
Supplemental Security Income requirements: Prior work experience not necessary but only for individuals with very low income/minimal assets
4 parts of Medicare
Part A: covers hospitalization, SNF, HHC, and hospice (no cost)
PREMIUMS ARE CHARGED
Part B: covers physician services, outpatient, preventative/lab services, equipment/supplies
Part C: optional cost saving managed care plan
Part D: voluntary Rx drug program
Supplemental ins offered for gaps
Medicare eligibility
65+
individuals under 65 with serious disabilities (+work experience)
Medicaid
For people with low income, chronic illness, and disabilities who lack private health insurance
**primary payer of long term care for persons who are elderly or have disabilities
- can be used to assist low income Medicare enrollees with their premiums, out-of-pocket costs, and to cover services that Medicare excludes, such as long-term care
Omnibus budget reconciliation act of 1981
Established home and community based Medicaid waivers which allow states to provide medical and related services tailored to a unique population
State children’s health insurance program of 1997
Covers uninsured children in families with incomes that are modest but too high to qualify for Medicaid
Affordable care act
Response to skyrocketing cost of healthcare in the estimated 15 million Americans were uninsured or underinsured; mandates employers to provide insurance; state based health benefit exchanges
Rehab act of 1973
First federal civil rights legislation for people with disabilities because it prohibits discrimination on the basis of disability
