ACA CCM key terms

A collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet a person's health needs, using communication and available resources to promote quality and cost-effective outcomes.

The deliberate organization of patient care activities and information sharing among participants to achieve safer, more effective, and more efficient care delivery.

A written, individualized document that states a client's goals, the interventions to reach them, responsible parties, and target timeframes, updated as needs change.

A structured gathering of medical, functional, psychological, social, financial, and environmental information about a client that forms the basis for planning services.

A brief, standardized procedure used to identify people who may need further evaluation or services, without providing a full diagnosis.

Sorting a population into groups by likelihood of poor outcomes or high resource use so that case management intensity can be matched to need.

A set of coordinated actions designed to ensure continuity and safe handoff of care when a person moves between settings, such as hospital to home.

A return hospital stay for the same or a related condition shortly after discharge, often used as a marker of care transition quality.

A process begun early in an episode of care that prepares a client and family for leaving a facility with appropriate services, equipment, and follow-up in place.

A collaborative, goal-oriented counseling style that uses open questions, reflective listening, and affirmation to strengthen a person's own motivation and commitment to change.

A model describing readiness to change as progressing through precontemplation, contemplation, preparation, action, maintenance, and sometimes relapse, with interventions matched to the current stage.

A return to a previously reduced or stopped behavior, such as substance use or symptom recurrence, viewed as part of a change process rather than a failure.

A pragmatic approach that aims to reduce negative consequences of risky behavior without requiring abstinence as a precondition for receiving help or services.

A person's belief in their own capability to organize and carry out the actions needed to reach a goal, which predicts persistence in the face of obstacles.

A practice of building a client's confidence, skills, and control over decisions affecting their life, shifting the professional role from directing to supporting.

An approach that recognizes the widespread impact of trauma, avoids re-traumatization, and builds safety, trustworthiness, choice, collaboration, and empowerment into services.

A public health approach that uses brief validated screening for substance use, a short motivational conversation for those at risk, and referral for those needing specialized care.

A planning process directed by the client's own preferences, values, and life goals, with the professional providing information and support rather than prescribing outcomes.

A delivery model in which insurers contract with provider networks and use utilization controls to contain costs while delivering defined benefits to enrolled members.

Review activities that evaluate the medical necessity, appropriateness, and efficiency of care, including preauthorization, concurrent review, and retrospective review.

A determination that a service is reasonable, clinically appropriate, and required to diagnose or treat a condition, typically defined by payer policy and clinical criteria.

A payment method that gives a provider a fixed amount per enrolled person per period, regardless of how many services that person actually uses.

Payment arrangements that link financial reward or penalty to measured quality, outcomes, and cost performance rather than to volume of services delivered.

A formal request to a payer or plan to reconsider a denied or reduced service, governed by defined timelines, documentation requirements, and review levels.

A U.S. civil rights law prohibiting discrimination based on disability and requiring reasonable accommodations and accessible services in many settings.

A modification or adjustment to a job, service, or environment that allows a qualified person with a disability to participate, provided it does not create undue hardship.

A client's voluntary agreement to a service or treatment after receiving understandable information about its purpose, risks, benefits, and alternatives, and having capacity to decide.

The professional and legal duty to protect a client's health information from unauthorized disclosure, subject to defined exceptions such as imminent danger or mandated reporting.

A U.S. federal law establishing national standards for protecting identifiable health information and defining permitted uses and disclosures by covered entities and their business associates.

A privacy principle requiring that only the least amount of protected health information needed for a stated purpose be used, disclosed, or requested.

A written statement made while a person has capacity that records future treatment preferences or names a decision-maker to act if the person later cannot decide.

A legal arrangement in which a court appoints someone to make specified decisions for a person found unable to manage certain affairs, with authority limited to what the court grants.

A legal obligation for specified professionals to report suspected abuse, neglect, or exploitation of children, older adults, or dependent adults to the designated authority.

The ability to understand and respond effectively to clients whose cultural background, language, beliefs, and practices differ from the professional's own.

A lifelong stance of self-reflection, openness, and power-sharing that acknowledges the limits of one's cultural knowledge and treats the client as the expert on their own experience.

Unconscious associations or attitudes that can influence judgment and behavior toward groups of people, potentially producing disparities in assessment and service decisions.

Preventable differences in health status or access to care that are closely linked with social, economic, and environmental disadvantage among population groups.

The degree to which a person can obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Qualified language assistance provided to people with limited English proficiency, using trained interpreters rather than family members or untrained staff.

A communication technique in which the client explains information back in their own words so the professional can confirm understanding and correct misunderstandings.

The timely, accurate, objective written record of assessments, interventions, communications, and outcomes that supports continuity, accountability, and reimbursement.

Conditions of the environments where people live, learn, work, and age, such as income, housing, food security, and transportation, that shape health outcomes.

A systematic process of identifying, verifying, and cataloging local services and supports so clients can be connected to appropriate non-medical resources.

A live, personal transfer of a client to another provider or service, with introduction and shared information, to increase the likelihood the connection succeeds.

An evaluation of what a person can actually do in daily activities, such as bathing, lifting, or working, used to plan supports and determine eligibility for services.

A philosophy and set of services that support people with disabilities to live in the community with maximum autonomy, choice, and control over their own supports.

Acting to protect or advance a client's rights, preferences, and access to services, including representing their interests with providers, payers, or systems.

The limits on the professional relationship that keep the focus on the client's needs and prevent conflicts of interest, exploitation, or blurred personal roles.

Structured oversight and guidance provided by a more experienced professional to support skill development, quality of practice, and adherence to standards and ethics.

Ongoing learning required or pursued after initial certification to maintain competence, stay current with practice standards, and renew credentials.

A voluntary credential awarded by a professional body after verifying education, experience, and examination performance, distinct from a state-issued license to practice.

The systematic tracking of client status or program results against defined indicators to evaluate whether interventions achieved intended goals and to guide improvement.