CM terminology

Question 1

Client

Client

Answer 1

The recipient of case management as well as health and human services. “This individual can be a patient, beneficiary, injured worker, claimant, enrollee, member, college student, resident, or health care consumer of any age group” (CMSA, 2010, p. 24).
NOTE: In the CMBOK, the term client is sometimes intended to include the client’s support system.

Question 2

Client’s Support System

Answer 2

The person or persons identified by each individual client to be directly or indirectly involved in the client’s care. It “may include biological relatives [family members], spouses, partners, friends, neighbors, colleagues, or any individual who supports the client [caregivers, volunteers, and clergy or spiritual advisors]” (CMSA, 2010, p. 24).

Question 3

Caregiver

Caregiver

Answer 3

The person responsible for caring for a client in the home setting and can be a family member, friend, volunteer, or an assigned healthcare professional.

Question 4

Case Manager

Answer 4

The health and human services professional responsible for coordinating the overall care delivered to an individual client or a group of clients, based on the client’s health or human services issues, needs, and interests.

Question 5

Case Management Program

Answer 5

Also referred to as case management department.
An organized approach to the provision of case management services to clients and their support systems. The program is usually described in terms of: • Vision, mission, goals and strategic objectives
• Number and type of staff including roles, responsibilities, and expectations
• A specific model or conceptual framework that delineates the key case management functions within the department
• Reporting structure within the organization
Also referred to as case management department.
An organized approach to the provision of case management services to clients and their support systems. The program is usually described in terms of: • Vision, mission, goals and strategic objectives
• Number and type of staff including roles, responsibilities, and expectations
• A specific model or conceptual framework that delineates the key case management functions within the department
• Reporting structure within the organization

Question 6

Case Management Plan of Care

Answer 6

A comprehensive plan of care for an individual client that describes: • The client’s problems, needs, and desires, as determined from the findings of the client’s assessment.
• The strategies, such as treatments and interventions, to be instituted to address the client’s problems and needs.
• The measurable goals – including specific outcomes – to be achieved to demonstrate resolution of the client’s problems and needs, the time frame(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 (CMSA, 2010, p. 24).

Question 7

Payor

Answer 7

The person, agency, or organization that assumes responsibility for funding the health and human services and resources consumed by a client. The payor may be the client him/herself, a member of the client’s support system, an employer, a government benefit program (e.g., Medicare, Medicaid, TriCare), a commercial insurance agency, or a charitable organization.

Question 8

Practice Setting

Answer 8

(Also referred to as practice site, care setting, or work setting.) The organization or agency at which case managers are employed and execute their roles and responsibilities. The practice of case management extends across all settings of the health and human services continuum. These may include but are not limited to payor, provider, government, employer, community, independent/private, workers’ compensation, or a client’s home environment.

Question 9

Professional Discipline

Answer 9

Case managers’ formal education, training, and specialization or professional background that is necessary and prerequisite for consideration as health and human services practitioners. Also refers to the professional background – such as nursing, medicine, social work, or rehabilitation – that case managers bring with them into the practice of case management.

Question 10

Knowledge Domain

Answer 10

A collection of information topics associated with health and human services and related subjects. These topics are organized around common themes (domains) to form high-level/abstract concepts that are considered to be essential for effective and competent performance of case managers. Examples of case management knowledge domains are Principles of Practice and Healthcare Reimbursement.

Question 11

Health

Answer 11

An individual’s physical, functional, mental, behavioral, emotional, psychosocial, and cognitive condition. It refers to the presence or absence of illness, disability, injury, or limitation that requires special management and resolution, including the use of health and human services-type intervention or resource.
NOTE: Throughout the CMBOK, the term health implies all aspects of health as described in the principal term, reflecting a holistic view of the client’s condition.

Question 12

Health and Human Services Continuum

Answer 12

The range of care that matches the ongoing needs of clients as they are served over time by the Case Management Process and case managers. It includes the appropriate levels and types of care – health, medical, financial, legal, psychosocial, and behavioral – across one or more care settings. The levels of care vary in complexity and intensity of healthcare services and resources, including individual providers, organizations, and agencies.
NOTE: Throughout the CMBOK, the term healthcare refers to and incorporates “health and human services,” reflecting the broader community of professionals who serve clients and the continuum of services they provide.

Question 13

Level of Care

Answer 13

The intensity and effort of health and human services and care activities required to diagnose, treat, preserve, or maintain clients’ health. Level of care may vary from least to most complex, least to most intense, or prevention and wellness to acute care and services.

Question 14

Community Services and Resources

Answer 14

Healthcare programs that offer specific services and resources in a community-based environment as opposed to an institutional setting (i.e., outside the confines of healthcare facilities such as hospitals and nursing homes). These programs either are publicly or privately funded or are charitable in nature.

Question 15

Benefit Programs

Answer 15

The sum of services offered by a health insurance plan, government agency, or employer to individuals based on some sort of an agreement between the parties (e.g., employer and 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 chiropractic care.

Question 16

Benefits

Answer 16

The type of health and human services covered by a health insurance plan (sometimes referred to as health insurance benefits, health benefits, or benefits plan) and as agreed upon between an insurance company and an individual enrollee or participant. The term 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 health insurance plan.

Question 17

Services

Answer 17

Interventions, medical treatments, diagnostics, and other activities implemented to manage clients’ conditions, including health and human services issues and needs. The types of services implemented can be found in an individual client’s case management plan of care, medical treatment plan, or other related documents as applicable to the healthcare setting and the professional discipline of the provider of care and services.
NOTE: The term services is used generically in the CMBOK to include the various types of care and services described above.

Question 18

The Case Management Process

Answer 18

Screening, Assessing, Stratifying Risk, Planning, Implementing (Care Coordination), Following-Up, Transitioning (Transitional Care),Communicating Post Transition, and Evaluating. The overall process is iterative and cyclical, its phases being revisited as necessary until the desired outcome is achieved.

Question 19

Transitioning care process

Answer 19

1. Gain approvall, consent, consensus
2. Prepare transition packet: case summary, dc summary, f/up appts, continuity POC, self care management instructions, instructions for meds, name and contact infor of person to answer questions
3. Communicate POC to client and next provider
4. assess if next setting is ready
5. if no resolve barriers, if yes complete transition: transportation, DME, transtion summary, continuity POC, meds, health edu
6. close case
7. compliance documentation

Question 20

CM Process

Answer 20

screening
assessment
planning
implementation
follow up
trasitioning
evaluation

Question 21

Screening process

Answer 21

predictive modeling or risk stratification
initial contact by client, provider, payor
triage client including checking eligibility
assume care?
client concent
make intake decision
assign case

Question 22

Assessing process

Answer 22

Assign case
Engage client
gather info
analyze data
Id problems
List of problems (actual or potential)
risk stratification scores

Question 23

Stratifying risk process

Answer 23

Define population and desired outcomes
Id tool 
input data (claims, screening, assessment, um)
run/analyze data
validate data
determine risk score
get report to determine risk level or category
input infor into cm POC

Question 24

Planning process

Answer 24

Standards of care/guidelines
client inpur
id problement
gather input form stakeholder and interdisciplinary team
prioritizae problems
id goals
id interventions and countermeasures
select interventions
obtain approval or auth of POS
inform involved parties
approved documented cm POC
appropriate use of resources
doccument cm POC

Question 25

Implementing

Answer 25

Inform involved parties
assign tasks
execute individual interventions (care coordination)
document incremental progress

Question 26

follow up q

Answer 26

document incremental progress
reassess measure effectivness
id next setting
gain approval, consent