CMGT-BC key terms

A systematic, collaborative approach in which the case manager screens, assesses, plans, facilitates, coordinates, monitors, and evaluates options and services to meet a person's health-related needs.

A proactive, systematic method of identifying individuals likely to benefit from case management, using data such as diagnoses, utilization patterns, referrals, and risk scores.

A brief, structured review of a person's health status, needs, and benefits used to decide whether a full comprehensive assessment and case management services are warranted.

The process of sorting a population into groups by predicted health risk or complexity so that case management resources can be directed to those with the greatest need.

The planned ending of case management services when goals are met, the patient no longer needs or wants services, benefits end, or the patient relocates or dies.

The range of roles, activities, and responsibilities a case manager is legally and professionally authorized to perform, set by licensure, certification, law, employer policy, and professional standards.

Authoritative statements that describe the expected level of care and professional performance for case managers, used to guide practice and to evaluate quality.

A voluntary credential granted by a professional body after an individual meets education, experience, and examination requirements, demonstrating competence in a defined specialty area.

Being answerable for one's decisions, actions, and outcomes, and for working within one's role, including knowing when to refer or escalate to another professional.

A thorough, systematic gathering of information about a person's physical, psychological, social, functional, financial, and environmental status, including strengths, preferences, supports, and available benefits.

A written plan developed with the patient and team that states prioritized problems, measurable goals, planned interventions, responsible parties, and timeframes, and reflects the patient's values and preferences.

Objectives that are Specific, Measurable, Achievable, Relevant, and Time-bound, used to make care plan goals clear and to allow progress to be evaluated.

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

The efficient and appropriate use of available health care, community, and financial resources to meet a patient's needs while controlling unnecessary cost and avoiding duplication of services.

Evaluation of the medical necessity, appropriateness, and efficiency of health care services, settings, and length of stay against established criteria and the patient's covered benefits.

A payer requirement that specified services be approved before they are delivered, based on documented medical necessity and the patient's benefit coverage.

The intensity and setting of services a patient requires, such as acute inpatient, subacute, home care, or outpatient, determined by clinical need and payer criteria.

A payer determination that a service is reasonable, necessary, and appropriate for diagnosing or treating a condition according to accepted standards of care.

Confirming a patient's coverage, including eligibility, covered services, exclusions, cost-sharing, authorization rules, and network requirements, before and during the course of care.

A payment model in which a provider receives a fixed amount per enrolled person for a period, regardless of how many services are used, shifting financial risk to the provider.

A process begun early in an episode of care to arrange the services, equipment, education, and follow-up a patient needs for a safe move to the next setting.

The movement of a patient between settings, providers, or levels of care, requiring coordination, communication, and preparation to prevent gaps in care and avoid harm.

A formal process of comparing a patient's current medication list with new orders and prior lists to identify and resolve discrepancies, omissions, and duplications at transitions.

A return hospital admission within a defined period after discharge, often used as an outcome and quality indicator and as a target for transitional care programs.

Measuring the results of case management and care interventions against expected or benchmarked outcomes, such as clinical status, function, satisfaction, cost, and readmissions.

Comparing a program's or provider's performance and outcomes with internal targets or external standards and best performers to identify opportunities for improvement.

A group of health professionals from different disciplines who share goals and collaborate, communicating and coordinating their work to deliver consistent, patient-centered care.

A collaborative conversation in which the patient and clinician discuss options, benefits, harms, and preferences, and the patient participates in choosing the plan of care.

A person's ability to obtain, understand, and use health information and services to make informed decisions; limited literacy calls for plain language, teach-back, and simplified materials.

A lifelong practice of self-reflection, openness, and respect for each person's culture, values, and beliefs, and of recognizing the limits of one's own cultural knowledge.

Acting on behalf of a patient to protect rights, safety, and access to needed care, including speaking up when care is unsafe or when the patient cannot self-advocate.

A collaborative conversation style that uses open questions, affirmation, reflection, and summary to strengthen a patient's own motivation and commitment to change.

The ethical and legal duty to protect a patient's private health information from unauthorized disclosure, including limiting access to those who need it to provide care.

A patient's voluntary agreement to a treatment or service after receiving and understanding information about its purpose, potential benefits, risks, and available alternatives.

A legal document, such as a living will or health care power of attorney, that states a person's treatment preferences or names a surrogate decision-maker for future incapacity.

The ethical principle that respects a person's right to make informed decisions about their own care, consistent with their values, even when others disagree with those decisions.

Failure to use the degree of care a reasonably prudent professional would use in similar circumstances, resulting in harm; it requires duty, breach, causation, and damages.

A legal obligation to report specified events, such as suspected abuse, neglect, or certain communicable diseases, to designated authorities regardless of the patient's objection.