Healthcare Management and Delivery Systems
This domain covers how care is organized, financed, and delivered - and how case managers function within those structures. You must understand payer types, care settings, and the incentives that shape decisions.
Concepts to master
- Payer models: Medicare (federal, 65+/eligible disabilities), Medicaid (state-federal, income-based), commercial insurance, and managed care (HMOs, PPOs).
- Delivery settings: acute inpatient, outpatient, home health, long-term care, skilled nursing, and community-based services.
- Care coordination models: patient-centered medical home, accountable care organizations, and transitions-of-care programs.
- Utilization management: prior authorization, concurrent review, and discharge planning - balancing cost and quality.
- Levels of care: matching intensity of service to acuity of need.
Traps in questions
- Confusing Medicare and Medicaid. Medicare is federal and age/disability-based; Medicaid is income-based and state-administered.
- Assuming cost drives every decision. The correct answer usually balances clinical appropriateness with resource stewardship - not cost alone.
- Skipping discharge planning. Transition planning begins at admission, not at discharge.
- Misreading levels of care. The least restrictive, clinically appropriate setting is generally preferred.
Worked example / rule of thumb
A hospitalized client needs ongoing skilled nursing but not acute care. The right answer is a skilled nursing facility placement, not continued acute stay or home alone. Rule of thumb: match intensity of service to acuity of need, using the least restrictive appropriate setting.