CMGT-BC flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Case Management Definition

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

Case Finding

The process of identifying individuals who may benefit from case management, typically through risk stratification using frequent admissions, multiple chronic conditions, or polypharmacy.

Acuity-Based Caseload

Caseload size determined by patient complexity rather than a fixed number, because higher-acuity patients require more case manager time and therefore smaller caseloads.

Case Management Process Steps

Screening, assessment, problem identification and planning, implementation, monitoring and evaluation, and transition or termination, performed cyclically rather than as a one-time linear event.

Scope of Case Management Practice

Case managers coordinate, advocate, and facilitate care; they do not provide direct clinical care or prescribe, and they practice within limits set by licensure and employer policy.

Case Management Intensity Levels

Service tiers ranging from low-intensity periodic telephonic contact for stable patients to high-intensity frequent face-to-face contact for complex patients requiring close monitoring.

Braden Scale

A validated tool scoring six risk factors - sensory perception, moisture, activity, mobility, nutrition, and friction/shear - to predict pressure injury risk, with lower scores indicating higher risk.

SMART Goals

Care plan goals that are Specific, Measurable, Achievable, Relevant, and Time-bound, allowing objective evaluation of progress toward the desired health outcome.

Morse Fall Scale

A six-item screening tool scoring fall risk from history of falling, secondary diagnosis, ambulatory aid, intravenous therapy, gait, and mental status.

Care Plan Components

A documented problem statement, measurable goals with timeframes, specific interventions, responsible team members, and the patient's role, developed collaboratively with the patient and caregiver.

Katz ADL Index

A tool ranking independence in six basic activities - bathing, dressing, toileting, transferring, continence, and feeding - used to measure baseline and changing functional status.

InterQual and Milliman Criteria

Evidence-based proprietary criteria sets used to assess medical necessity and appropriate level of care, such as inpatient versus observation or skilled nursing facility placement.

Medicare SNF Benefit

Part A covers up to 100 days per benefit period after a qualifying inpatient stay of three consecutive midnights; days 1 to 20 are fully covered and days 21 to 100 require coinsurance.

Observation Versus Inpatient Status

The two-midnight rule presumes inpatient status when the stay is expected to span two midnights; observation time does not satisfy the qualifying stay for skilled nursing coverage.

Medical Necessity Denial Appeal

A payer's refusal to cover services judged not medically necessary is challenged through successive internal and external review levels using clinical documentation that addresses the stated denial reason.

DRG Prospective Payment

A fixed payment per discharge based on the assigned diagnosis-related group, regardless of the actual length of stay or resources consumed during that hospitalization.

Medicaid Coverage

A joint federal-state program for low-income individuals whose eligibility, benefits, and long-term services vary by state and which may cover services Medicare does not.

Teach-Back Method

A technique in which the patient restates information in their own words, allowing the clinician to confirm understanding and correct misunderstandings before discharge.

Care Transitions Intervention

Coleman's four-pillar model emphasizing medication self-management, a personal health record, timely follow-up with a clinician, and recognition of red-flag warning signs.

Medication Reconciliation

A formal process comparing the patient's current medication list with newly ordered medications at each transition to identify and resolve omissions, duplications, and dosing errors.

30-Day Readmission Rate

The percentage of discharged patients readmitted to any hospital within 30 days, used as a risk-adjusted quality and outcome measure and tied to payment penalties.

SBAR Handoff

A structured communication format - Situation, Background, Assessment, Recommendation - used to transfer accurate, complete patient information during transitions and escalations.

Motivational Interviewing OARS

Core skills of open-ended questions, affirmations, reflective listening, and summarizing, used to strengthen a patient's own motivation and commitment to behavior change.

Stages of Change

Prochaska's model of precontemplation, contemplation, preparation, action, maintenance, and relapse, in which interventions are matched to the patient's current stage.

Health Literacy

The degree to which individuals obtain, process, and understand health information to make informed decisions; limited literacy requires plain language, visuals, and teach-back.

Title VI Interpreter Requirement

Federal law requires language assistance, including qualified interpreters, for individuals with limited English proficiency who receive services from federally funded programs.

Patient Advocacy

Acting to protect and promote a patient's rights, preferences, and access to care, including voicing concerns and removing barriers within the health care system.

Informed Consent Elements

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

Minimum Necessary Standard

The HIPAA requirement to limit protected health information accessed, used, or disclosed to the least amount needed to accomplish the intended purpose.

Negligence Four Elements

Duty owed to the patient, breach of that duty, causation linking the breach to harm, and damages; all four must be proven in a malpractice claim.

POLST Form

A portable medical order signed by a clinician documenting a seriously ill patient's preferences for CPR, intubation, and other life-sustaining treatments across care settings.

Mandatory Reporting Duties

Legal obligations to report suspected child, elder, or dependent adult abuse, specified communicable diseases, and impaired practice by a colleague to designated authorities.