CCM (Other exams) cheat sheet

Case management is a collaborative process of assessment, planning, implementation, coordination, monitoring, and evaluation of options and services to meet health needs.

The case management process commonly includes intake, assessment, planning, implementation, coordination, monitoring, evaluation, and transition.

Case managers match member needs to resources while considering benefits, cost, quality, and member preference.

Core case manager roles include advocate, broker, coordinator, educator, and facilitator; prescribing treatment is outside the role.

Caseload allocation considers acuity, complexity, geography, and time required, not member count alone.

Transitional care planning begins at admission or enrollment and addresses medication reconciliation, follow-up, warning signs, and support needs.

Outcome measurement includes clinical, functional, satisfaction, and cost indicators.

Documentation should be timely, objective, and specific enough to support care coordination, continuity, and reimbursement.

Cultural competence requires adapting communication and care planning to the member's language, values, beliefs, and health practices.

Autonomy respects a competent member's right to choose; beneficence promotes benefit; nonmaleficence avoids harm; justice requires fair allocation.

Valid informed consent requires capacity, disclosure, understanding, and voluntary choice without coercion.

HIPAA permits disclosure of protected health information without authorization for treatment, payment, and health care operations.

Confidentiality may be breached only when required or permitted by law, such as imminent danger or mandatory abuse reporting.

Professional boundaries keep the case manager-member relationship focused on professional goals and prevent personal or financial exploitation.

Conflicts of interest must be disclosed and managed because they can bias resource recommendations and care decisions.

Delegation requires verifying task legality, competency, and supervision while the case manager retains accountability.

Documentation should record facts, interventions, member responses, and rationale rather than opinions presented as fact.

Trauma-informed practice recognizes trauma, promotes safety and trust, supports choice, and avoids re-traumatization.

Medicare Part A covers inpatient hospital and some post-acute care; Part B covers outpatient and physician services; Part C is Medicare Advantage; Part D covers drugs.

Medicaid is a federal-state program with income and eligibility rules that vary by state and often covers long-term services and supports.

Managed care uses provider networks, care coordination, and utilization controls to manage cost, quality, and access.

Utilization review evaluates medical necessity and appropriateness of care before, during, or after services.

Levels of care include inpatient, observation, skilled nursing, home health, outpatient, and community-based services.

Value-based payment links reimbursement to quality, outcomes, and cost performance rather than volume alone.

Social determinants of health include income, housing, food, transportation, education, and social support.

The care continuum spans prevention, acute care, rehabilitation, long-term care, and end-of-life care.

The Affordable Care Act expanded coverage through marketplaces, Medicaid expansion, and protections such as no denial for preexisting conditions.

Psychosocial assessment covers support, housing, finances, mental health, substance use, safety, coping, and cultural factors.

Stages of change are precontemplation, contemplation, preparation, action, maintenance, and relapse.

Grief responses vary and may include denial, anger, bargaining, depression, and acceptance, but they are not linear or universal.

Social support includes emotional, informational, instrumental, and appraisal support.

Crisis intervention prioritizes safety, stabilization, emotional support, and connection to services.

The PHQ-9 screens for depression severity; the GAD-7 screens for anxiety severity; positive screens require clinical follow-up.

Substance use assessment considers pattern, consequences, readiness, withdrawal risk, and treatment options.

Family systems view members as interdependent, so illness affects roles, communication, caregiving, and coping.

Harm reduction reduces risks of substance use without requiring abstinence as a precondition.