Ch 21: Care Management Flashcards
Domain 1: CM processes and services
Evaluate, assess, plan, facilitate/implement, coordinate, monitor
Domain 2: resource utilization and management
Appropriate and beneficial use of healthcare dollars on additional resources/care for pt
Domain 3: psychosocial and economic support
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
Identification of:
Environmental modifications to address accessibility barriers
Specialized services like Work hardening/return to work programs
Domain 5: outcomes
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
Adhere to a 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.
SSDI requirements: sufficient prior work experience to have paid into Social Security system
SSI 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
Home and community based Medicaid waivers
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
Rehab act of 1973
First federal civil rights legislation for people with disabilities because it prohibits discrimination on the basis of disability
Section 504 of the Rehabilitation act
Free and appropriate education
children eligible AND not eligible for special education
reasonable accommodations to ensure nondiscrimination and equal access
Americans with Disabilities Act of 1990
Prohibits discrimination against a person with a disability in employment, state and local government
mandates public accommodations in commercial facilities, transportation, and telecommunications
The olmstead decision
Unnecessary segregation a persons with disabilities in institutions may constitute discrimination based on disability
Provide services for persons with disabilities in the most integrated setting
Individuals with disabilities education act of 1990
All American children have a right to free and appropriate education
Individualized education program
Describes the students present academic performance and how the students disabilities affect that performance
No child left behind act
Provides financial incentives to states to improve their special ed services and services for all students
The TBI act of 1996
Grants for research
education on statistics/prevention
Advocacy/public policy
Why did mortality rates d/t TBI improve considerably in the 1970s?
Vehicle-related safety improvements and improvements and trauma care