CCM (Other exams) key terms

A collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet a person's health needs, using communication and available resources to promote quality and cost-effective outcomes.

Deliberately organizing care activities among multiple providers and settings so the right services arrive at the right time, without duplication, gaps, or conflicting instructions.

Acting in support of a client's rights, preferences, and access to services, including speaking up when policies, costs, or conflicts threaten the person's health, safety, or dignity.

Planning and delivering services around the individual's own goals, values, culture, and life situation rather than around provider convenience or a fixed program design.

Identifying people who may benefit from case management using referrals, registries, screening tools, or data triggers, before untreated needs become a crisis or avoidable cost.

A systematic gathering of information about a person's health, function, strengths, resources, values, and environment that becomes the foundation for the plan of care.

A written, mutually agreed set of goals, interventions, responsibilities, timelines, and measurable targets that guides the work of the client and the care team.

Professionals from different disciplines who share goals, communicate regularly, and blend their contributions, together with the client, into one integrated plan of care.

Reaching agreement among client, family, providers, and payers about goals, services, or timelines by clarifying underlying interests and trading options instead of imposing a solution.

Tracking agreed indicators such as clinical status, function, satisfaction, cost, and goal attainment to judge whether interventions produced the intended change and to adjust the plan.

The planned ending of the case management relationship when goals are met, services end, or the client moves on, including a summary, transition plan, and follow-up arrangements.

A person's ability to obtain, understand, and act on health information; low health literacy calls for plain language, teach-back, and family or interpreter support.

The timely, factual, and complete record of assessments, interventions, communications, and client responses that supports continuity of care, accountability, and legal defensibility.

The duty to protect private health information, disclosing it only to those who need it for care or payment, or as the client authorizes or the law permits.

A person's voluntary agreement to a service or treatment after receiving understandable information about its purpose, risks, benefits, and alternatives, given without pressure or coercion.

Respecting a capable client's right to make his or her own choices, including choices the case manager disagrees with, after the person understands the likely consequences.

A situation in which competing obligations, such as client autonomy versus safety or cost versus quality, make every option a compromise; resolved through structured reasoning and consultation.

The limits that keep the case manager-client relationship focused on the client's needs, avoiding dual relationships, excessive self-disclosure, and personal or financial entanglement.

The activities a case manager is legally and professionally qualified and authorized to perform, defined by licensure, certification, employer policy, and state or federal law.

Sorting a population by likelihood of poor outcomes or high cost using diagnoses, utilization history, and social factors, so intensive case management goes to those most likely to benefit.

Conditions in the places where people live, learn, work, and age, such as income, housing, food security, transportation, and social support, that shape health and access to care.

A formal process that judges whether a service was medically necessary, appropriate, and delivered at the right level of care, often to authorize payment or continued treatment.

The full range of health and support services a person may need over time, from prevention and acute treatment through rehabilitation, long-term care, and end-of-life services.

The movement of a person between settings or providers, such as hospital to home, with deliberate planning and communication to prevent errors, readmission, and lost follow-up.

A system that combines financing and delivery of care, using provider networks, prior authorization, and clinical guidelines to control costs while aiming to maintain quality.

Allocating limited services, benefits, and funding efficiently and equitably, matching them to assessed needs and documenting the rationale for what is approved or denied.

A return hospitalization that better discharge planning, medication reconciliation, timely follow-up, or social support could plausibly have prevented; a common target of transitional care programs.

A collaborative conversation style that helps people resolve ambivalence about change by drawing out their own reasons and confidence, rather than persuading, warning, or advising.

A model describing readiness to change as moving through precontemplation, contemplation, preparation, action, and maintenance, used to match interventions to a person's current readiness.

Recognizing one's own cultural assumptions and adapting communication and care to a client's language, beliefs, values, and practices, using interpreters and culturally appropriate resources.

An approach that assumes widespread trauma exposure, emphasizes safety, trust, choice, and empowerment, and avoids practices and language that could re-traumatize the person.

Immediate, short-term support aimed at restoring safety and stability during an acute emotional or situational emergency, followed by linkage to ongoing treatment and resources.

Evaluation of a person's emotional state, coping, support network, housing, income, legal status, and substance use to identify barriers, strengths, and needed supports.

Helping clients gain knowledge, skills, confidence, and access so they can make decisions and act on their own behalf, reducing dependence on the case manager over time.

Coaching and education that help a person with a chronic condition monitor symptoms, follow treatment, solve problems, and build confidence for managing daily life.

Emotional and practical responses to death, disability, or major life change; case managers screen for complicated grief and link people to bereavement, spiritual, or mental health support.