CCM (SEC) 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.

The professional who performs the case management process, acting as an advocate and coordinator who helps a client navigate health and social service systems while balancing client needs with payer and regulatory requirements.

The sequential phases of case management work: screening and intake, assessment, problem identification, planning, implementation, coordination, monitoring, evaluation, and closure or discharge from services.

A systematic gathering of information about a client's health status, functional abilities, psychosocial situation, support network, and resources, used to identify needs and set priorities for intervention.

A written, individualized plan that states goals, measurable objectives, interventions, responsible parties, time frames, and resources for meeting a client's identified needs.

The planned ending of case management services when goals are met, the client no longer needs or wants services, benefits end, or the client moves or dies; includes a summary and linkage to ongoing resources.

The initial step in which a referral is reviewed against program eligibility criteria to decide whether a client is appropriate for case management and to collect basic identifying and health information.

The deliberate organization of client care activities among two or more participants, including the client, to deliver services more efficiently and avoid duplication, gaps, and conflicting treatments.

Acting on a client's behalf to protect rights, obtain services, remove barriers, and ensure the client's preferences are heard, including appealing denials and addressing unsafe or unfair situations.

The ethical principle that clients have the right to make their own choices about care and services, even when the case manager disagrees, as long as the client has decision-making capacity and poses no serious risk to others.

A client's voluntary agreement to a service or treatment after receiving understandable information about its purpose, benefits, risks, alternatives, and the right to refuse.

The duty to protect a client's private health and personal information from unauthorized disclosure, sharing it only with those who need it for care, payment, or legally required reporting.

A situation in which two or more legitimate ethical obligations conflict, such as respecting a client's risky choice while also protecting the client's safety, requiring structured reasoning and often consultation with an ethics committee.

The ability to recognize and respond respectfully to cultural beliefs, values, language, and health practices that shape how clients understand illness, treatment, and help-seeking, and to adapt services accordingly.

A person's capacity to obtain, process, and understand basic health information and services in order to make informed health decisions; low health literacy calls for plain language, teach-back, and simplified materials.

A client-centered counseling style that uses open questions, reflective listening, and affirmation to strengthen a person's own motivation and confidence for behavior change, rather than directing or persuading.

A model describing readiness to change behavior in stages: precontemplation, contemplation, preparation, action, maintenance, and sometimes relapse, with interventions matched to the client's current stage.

Evaluation of a client's emotional state, coping skills, family and social supports, housing, finances, employment, substance use, and safety, to identify barriers and resources relevant to the care plan.

The conditions where people live, work, learn, and age, such as income, housing, food security, transportation, and social support, that strongly influence health outcomes and shape case management priorities.

Use of a brief validated questionnaire, such as the PHQ-9, to detect depressive symptoms, score severity, and trigger referral or follow-up; positive screens are not diagnoses and require clinical evaluation.

Use of a brief validated tool, such as AUDIT-C or a single-question screen, to identify risky alcohol or drug use and prompt brief intervention or referral to treatment.

Interventions that build a client's skills and confidence to manage chronic conditions, such as action planning, problem solving, symptom tracking, and linking to peer or education programs.

The physical, emotional, financial, and social strain experienced by family or friends who provide unpaid care, which can lead to burnout and place the care recipient at risk.

The systematic use of defined metrics to judge whether care is safe, timely, effective, efficient, equitable, and client-centered, and to compare performance against a benchmark or standard.

A specific, measurable statement of desired care or result, such as the percentage of clients with a follow-up contact within seven days of discharge, used to monitor and improve performance.

A metric that captures a change in a client's health or functional status attributable to care, such as readmission rate, hemoglobin A1c, or a functional improvement score.

A metric that assesses whether a recommended care activity was performed, such as whether an assessment was completed or a referral was made, rather than what happened to the client as a result.

Comparing an organization's or case manager's performance on a measure against internal targets, peers, or recognized standards to identify gaps and prioritize improvement.

A structured, cyclical effort to identify a gap between current and desired performance, test changes, measure results, and sustain what works, often using PDSA cycles or similar improvement models.

A team method for investigating an adverse event to find underlying system failures, not individual blame, and to design changes that reduce the chance of recurrence.

A measure of health, function, or experience reported directly by the client through a validated questionnaire, capturing what matters to the person rather than only clinical or administrative data.

The proportion of discharged clients readmitted within a defined period, commonly 30 days; a high rate signals gaps in discharge planning, care coordination, or self-management support.

Sorting a population by predicted risk of poor outcomes or high cost, using data such as prior admissions and chronic conditions, so intensive case management is directed to those who benefit most.

A goal-oriented process that helps a person with injury, illness, or disability achieve the highest possible function, independence, and participation in daily life and community roles.

Basic self-care tasks such as bathing, dressing, toileting, transferring, eating, and continence; difficulty with them signals need for personal assistance, equipment, or rehabilitation services.

Tasks needed to live independently in the community, such as managing money, shopping, cooking, using transportation, and handling medications; limitations drive community-based support planning.

A person's ability to perform self-care, mobility, and role activities safely and independently, measured at admission and discharge to show rehabilitation progress and plan for needed support.

A group including physician, nurse, physical and occupational therapists, speech-language pathologist, social worker, and psychologist who set shared goals and coordinate treatment for a rehabilitation client.

A structured review of a client's living environment for hazards such as poor lighting, loose rugs, stairs, and missing grab bars, followed by recommendations for equipment and modifications to prevent injury.

Reusable medical devices prescribed for home use, such as walkers, wheelchairs, hospital beds, and oxygen equipment, that require documentation of medical necessity for payer coverage.

Coordinated actions that ensure continuity and safe handoff of care when a client moves between settings, such as hospital to home or nursing facility, reducing errors and avoidable readmissions.

A process begun early in an admission that anticipates the client's needs after leaving a facility and arranges services, equipment, medications, follow-up, and caregiver support before departure.

Linking clients to needed services and benefits, such as housing programs, transportation, meal delivery, or financial assistance, by matching identified needs with available community resources.

A group of professionals from different disciplines who each contribute expertise to a client's care, meeting regularly to share information and align interventions toward common goals.