CCM (SEC) cheat sheet

Six core steps in order: screening and identification, assessment, care planning, implementation/coordination, monitoring and follow-up, evaluation and closure.

Screening criteria are objective triggers (risk score, diagnosis, utilization threshold, referral source); assessment then collects clinical, functional, psychosocial, financial, and environmental data.

Goal statements must be measurable: a behavior or status, a target value, a timeframe, and an accountable party. 'Improve mobility' fails; 'walk 50 ft with walker in 4 weeks' passes.

SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound.

Level of care decision rule: choose the least restrictive setting that can safely deliver the required interventions; escalate only when safety or complexity exceeds that setting's capacity.

Transition-of-care elements: medication reconciliation, follow-up appointment scheduled before discharge, written self-management plan, and a named contact for questions.

Caseload formula: available direct-care hours per week divided by average hours per case per week equals a defensible caseload ceiling.

Documentation must link each intervention to a plan goal; an intervention with no linked goal is not billable as case management in most payer models.

Closure criteria: goals met, patient declined or moved, benefits exhausted, or a safety event requiring a different level of care; document the reason in every case.

Stages of change (Prochaska): precontemplation, contemplation, preparation, action, maintenance; interventions differ by stage and mismatching the stage predicts dropout.

Motivational interviewing core: open questions, affirmations, reflections, summaries (OARS); the goal is to elicit change talk, not to argue for change.

Grief models: Kubler-Ross (denial, anger, bargaining, depression, acceptance) is descriptive, not a required sequence; Worden's tasks (accept reality, process pain, adjust, relocate the relationship) are task-based.

Crisis intervention order: ensure safety, establish rapport, identify the problem, explore feelings, generate alternatives, formulate an action plan, follow up.

Screening tools: PHQ-9 for depression severity, GAD-7 for anxiety, AUDIT-C for alcohol use, C-SSRS or ASQ for suicide risk; a positive screen requires a clinical assessment, not a diagnosis.

Suicide risk factors include prior attempt, access to lethal means, substance use, recent loss, and social isolation; protective factors include social support, reasons for living, and engagement in care.

Health literacy rule: use teach-back ('tell me how you will take this') and a reading level near 5th-6th grade for patient materials.

Caregiver burden screening (e.g., Zarit) matters because caregiver collapse is a leading cause of avoidable readmission and institutional placement.

Cultural humility: elicit the patient's explanatory model ('what do you think is causing this?') and negotiate a plan that fits beliefs, family roles, and language preference.

Donabedian framework: structure (resources, staffing), process (what is done), outcome (result); process measures are used when outcomes are rare or delayed.

QI model: Plan-Do-Study-Act (PDSA) cycles; small rapid tests precede system-wide spread.

Root cause analysis uses repeated 'why' questioning and a fishbone (cause-and-effect) diagram; it is retrospective and event-focused.

Failure mode and effects analysis (FMEA) is prospective: identify steps, score severity x occurrence x detection (risk priority number), and act on the highest scores.

Measure types: rate = numerator / denominator; for a percentage, multiply by 100 and state the population and time period explicitly.

Benchmarking compares performance to an internal baseline, an external peer group, or a published standard; a benchmark without a defined denominator is not a valid comparison.

Validity vs reliability: validity is measuring what is intended; reliability is consistency across raters or occasions. Inter-rater reliability is reported as kappa or percent agreement.

Run charts and control charts distinguish common-cause from special-cause variation; a single data point outside control limits signals special cause.

Patient-reported outcome measures (e.g., PROMIS, SF-36) capture function and quality of life; they complement, not replace, clinical and utilization data.

Functional outcome instruments: FIM (18 items, motor and cognitive subscales, 1-7 each), Barthel Index (10 ADL items), and the Berg Balance Scale (14 tasks, 0-56; scores under 45 indicate increased fall risk).

ADL vs IADL: ADLs are self-care (bathing, dressing, toileting, transfers, feeding); IADLs are community tasks (medication management, finances, shopping, transport, cooking).

Therapy intensity rule: more frequent, task-specific practice improves motor relearning after stroke; distributed practice with rest outperforms massed practice for retention.

Restraint reduction: least restrictive intervention first; a restraint requires a physician order, time-limited duration, monitoring, and periodic reassessment.

Pressure injury prevention: repositioning schedule, support surface selection, moisture and nutrition management, and skin inspection; staging uses the NPUAP/EPUAP system (Stage 1-4, unstageable, deep tissue injury).

Contracture and deconditioning prevention: daily range of motion, positioning, and early mobilization; bed rest beyond medical necessity accelerates functional loss.

Durable medical equipment (DME) justification requires a documented functional deficit, a realistic goal the device supports, and evidence the patient or caregiver can use and maintain it.

Home safety priorities: lighting, grab bars, throw-rug removal, stair railings, bathroom modifications, and medication storage; assess before discharge, not after a fall.

Discharge destination decision: home with services, home without services, assisted living, skilled nursing, or inpatient rehab, driven by functional status, caregiver capacity, and safety.