CMGT-BC cheat sheet

Process sequence is cyclical: case finding/screening → comprehensive assessment → problem identification and care planning → implementation/coordination → monitoring and evaluation → outcomes, transition, or termination.

Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services that meet an individual's health needs.

The case manager role is coordination, advocacy, and facilitation; direct clinical care, prescribing, and diagnosing fall outside the role and are limited by the state nurse practice act.

Screening triggers for case management services commonly include two or more chronic conditions, an unplanned admission within the prior 6–12 months, five or more medications, functional decline, inadequate caregiver support, and a new complex diagnosis.

Caseload is acuity-weighted: as average patient complexity rises, the number of patients per case manager must fall; a single fixed caseload number is not a valid standard.

Intensity tiers range from low (periodic telephonic contact for stable patients) to high (frequent face-to-face contact for complex patients); the tier is reassessed at each evaluation.

Case manager, utilization reviewer, social worker, and discharge planner are distinct functions with overlapping tasks; role expectations are clarified in writing at the outset.

Documentation must show assessment findings, goals, interventions, patient response, and the rationale for continued services, because this record supports ongoing authorization and payment.

Program effectiveness is measured by goal attainment, avoidable admissions and readmissions, cost avoidance, functional status, and patient experience.

A complete assessment covers physical, functional (ADL/IADL), cognitive, psychosocial, behavioral, environmental/safety, financial/insurance, caregiver, and health-literacy domains.

Validated tools include Braden (pressure injury risk), Morse Fall Scale or Hendrich II (falls), Katz ADL and Lawton IADL (function), PHQ-9 (depression), MMSE or MoCA (cognition), and AUDIT-C (alcohol use).

Required care plan elements are the problem statement, a measurable goal with timeframe, specific interventions, the responsible discipline, the patient/caregiver role, and the evaluation date.

Goals are written in SMART terms - Specific, Measurable, Achievable, Relevant, Time-bound - and stated in observable behavioral language.

The plan is developed with, not for, the patient and caregiver; the patient's own goals and any disagreement with the team are documented.

Level-of-care determinations combine evidence-based criteria sets (InterQual, Milliman/MCG) with clinical judgment; criteria support but do not replace the clinician's assessment.

Care coordination means linking, scheduling, and monitoring multiple providers and services, with a named accountable owner and closed-loop confirmation that each service actually occurred.

Interdisciplinary team rounds review goal progress, barriers, and discharge trajectory; changes to the plan and their rationale are documented at that time.

Reassessment occurs at defined intervals and at any change in condition, setting, or payer source, with the care plan updated accordingly.

Medicare Part A covers inpatient hospital, skilled nursing facility (up to 100 days per benefit period after a qualifying stay of at least three consecutive inpatient midnights; days 1–20 fully covered, days 21–100 with daily coinsurance), hospice, and home health.

Medicare home health requires a homebound status, a skilled nursing or therapy need, and intermittent rather than continuous care, certified by a physician.

The two-midnight rule presumes inpatient status when the physician expects the stay to span two midnights; observation time does not count toward the SNF qualifying stay.

DRG prospective payment sets a fixed amount per discharge by diagnosis-related group, so length of stay and complications affect hospital margin, but payment rules never override clinical judgment.

Managed care arrangements require verification of eligibility, benefits, network status, and prior authorization before non-emergent services are arranged.

Denial categories are medical necessity, no authorization, eligibility lapse, and coding; appeals are filed within payer deadlines with clinical documentation that directly addresses the stated reason.

The Hospital Readmissions Reduction Program lowers Medicare payment for excess 30-day readmissions for specified conditions, and readmission rates also affect star ratings and value-based contracts.

Resource stewardship selects the least restrictive, lowest-cost setting that safely meets the clinical need, and documents the alternatives that were considered and why they were rejected.

Coverage information is not a guarantee: benefit statements are recorded as verified on a specific date with a named payer representative and confirmed in writing.

Discharge planning begins at admission; CMS Conditions of Participation require hospitals to maintain a discharge planning process that identifies patients likely to need post-acute services.

Core discharge bundle: medication reconciliation, written instructions in the patient's language, follow-up appointment (commonly within 7 days), home health or DME arranged, red-flag warning signs, and teach-back completed.

Teach-back confirms comprehension by having the patient restate the plan in their own words; asking whether the patient has questions does not confirm understanding.

The Care Transitions Intervention (Coleman) rests on four pillars: medication self-management, a personal health record, timely follow-up, and recognition of red flags.

Structured handoff formats (SBAR, I-PASS) reduce omission of critical information between settings and shifts.

High-risk transition indicators include five or more medications, a recent admission, limited health literacy, absence of a caregiver, multiple specialists, and social needs such as housing, transportation, or food insecurity.

A readmission within 30 days is treated as a possible transition failure and triggers review of medications, missed follow-up, caregiver capacity, and unresolved social determinants.

Outcome measures include readmissions, emergency department visits, length of stay, functional status, goal attainment, cost per case, patient experience (HCAHPS), and adverse events.

Outcomes are compared with baseline and stated goals; when goals are unmet, the plan is revised rather than the case closed.

SBAR (Situation, Background, Assessment, Recommendation) is the standard structure for handoffs and for escalating a concern up the chain of command.

Motivational interviewing core skills are OARS - open-ended questions, affirmations, reflective listening, and summarizing - and the intervention is matched to the patient's stage of change.

Stages of change are precontemplation, contemplation, preparation, action, maintenance, and relapse; confronting a precontemplative patient increases resistance.

Plain-language communication targets roughly a 5th–6th grade reading level, avoids jargon, and provides written materials in the patient's preferred language.

Title VI requires qualified interpreters for patients with limited English proficiency receiving federal financial assistance; family members, and especially minors, are not appropriate substitutes.

HIPAA permits disclosure of protected health information for treatment, payment, and health care operations, subject to the minimum necessary standard.

Team or family conflict is managed by separating stated positions from underlying interests and by neutral facilitation; the discussion and agreed plan are documented.

Advocacy includes protecting patient rights, removing access barriers such as cost, transportation, and scheduling, and escalating unsafe conditions.

Cultural humility means asking about health beliefs, decision-making preferences, and complementary therapy use rather than assuming them from group membership.

Core ethical principles are autonomy, beneficence, nonmaleficence, justice, fidelity, and veracity; conflicts among them are resolved through a documented ethics consultation or committee process.

Informed consent requires decision-making capacity, disclosure of risks, benefits, and alternatives, comprehension, voluntariness, and documentation before non-emergent procedures.

A negligence claim requires four elements - duty, breach of duty, causation, and damages - and all four must be established.

Advance directives include the living will, durable power of attorney for health care, and POLST/MOLST; the Patient Self-Determination Act requires hospitals to inform patients of these rights.

HIPAA obligations include safeguarding PHI and limiting disclosures to the minimum necessary; permitted disclosures include treatment, payment, operations, and reporting required by law.

Mandatory reporting duties commonly cover suspected child, elder, or dependent adult abuse, specified communicable diseases, and impaired practice by a colleague; specific lists vary by state.

EMTALA requires a medical screening examination and stabilization of an emergency medical condition regardless of insurance status or ability to pay.

Scope of practice is defined by the state nurse practice act and employer policy; delegated tasks require appropriate supervision and demonstrated competence.

Vendor gifts and conflicts of interest are disclosed and declined so that resource and placement decisions are not influenced by personal benefit.