Download ACMA Chapter Exam Prep Booklet

ACMA Chapter Exam Prep Booklet
Contents
ACM Exam Overview ..................................................................................................................................................3
Handbook Overview ...............................................................................................................................................3
How to do your Best on the ACM ...............................................................................................................................6
Study Tips ...............................................................................................................................................................6
Test Taking Tips ................................................................................................................................................... 10
Study Schedule .................................................................................................................................................... 12
CORE Knowledge Refresher..................................................................................................................................... 14
Simulation Knowledge Refresher ............................................................................................................................ 14
Test Questions (created by ACM holders) ............................................................................................................... 15
Screening & Assessment ..................................................................................................................................... 15
Planning ............................................................................................................................................................... 15
Care Coordination & Intervention ....................................................................................................................... 15
Evaluation ............................................................................................................................................................ 15
Simulation Questions (created by ACM holders) .................................................................................................... 16
Full ACM Study Review ............................................................................................................................................ 23
Appendices .......................................................................................................................................................... 65
Standards of Practice and Scope of Services ................................................................................................... 65
Content Outline ............................................................................................................................................... 65
What the Pro’s Say (COMPILATION OF EMAIL RECEIVED SUGGESTIONS) ...................................................... 65
STANDARDS OF PRACTICE AND SCOPE OF SERVICES .......................................................................................... 66
American Case Management Association – Final Detailed Content Outline ...................................................... 77
Specialty Simulation Component .................................................................................................................... 80
ACMA Chapter Exam Prep Booklet
ACM Exam Overview
Handbook Overview
Introduction:
Preparing to take the ACM Certification Examination

The ACM Accredited Case Manager Examination is designed to test a well-defined
body of knowledge representative of professional practice in health care delivery
system case management.

Successful completion of a certification examination verifies broad-based knowledge in
the discipline being tested and critical thinking skills as relevant to the practice of
Health Care Delivery System Management.

The examination has been developed through a combined effort of qualified subjectmatter experts and testing professionals, who have constructed the examination in
accordance with the ACM Accredited Case Manager Examination content outline.

Examination Fee – $325
Retest Fee – $325
Candidates deemed ineligible to sit for the examination will receive a refund of the
examination fee less a $75 processing fee.
 The examination is available to registered nurses and social workers. However, there are
specific eligibility requirements necessary to take the examination. These requirements
include a blend of both experience and professional practice:
o A Registered Nurse applicant must possess a valid and current nursing
license. RN applicants must provide a nursing license number, state and
expiration date.
o Social Worker applicants must have a Bachelors or Masters degree from
an accredited school of social work OR a valid social work license. Social
Worker applicants must provide the degree, name of school and year of
completion OR a current social work license number, state and
expiration date.
o All applicants must have at least two (2) years of full time experience in
Health Care Delivery System Case Management or 4,160 work hours in
Health Care Delivery System Case Management.
o If you hold both a RN and SW license, you must indicate which exam
you wish to take and provide the applicable eligibility documentation.
 You may submit your application at any time, but there are four deadlines each year.
Properly completed applications that are received including payment by the ACMA
office on or before the dates shown below will allow candidates to test during the
applicable months shown (i.e., within one of four testing quarters).
Application Deadlines:
November 15
January, February, or March test date
February 15
April, May, or June test date
May 15
July, August, or September test date
August 15
October, November, or December test date
 You will receive two score reports. Each report will indicate if you have passed or
failed the portion (core and specialty). Additional detail is provided in the form of raw
scores by major content category on the core, and a raw score for Information
Gathering (IG) and Decision Making (DM) on the specialty portion. A raw score is the
number of questions (points) you answered correctly. Your pass/fail status is
determined by your raw score. Passing scores for test candidates who did not
successfully pass both the Core and Simulation Examinations, but did pass one of
them, will be kept on file for six months from date of issue. If retesting has not
occurred within six months, or if you do not successfully pass both portions of the
exam within six months, the original passing score will not be applicable toward
certification and you will be required to sit for the entire examination. You can reapply to take only the portion of the examination that you did not pass. If you do not
pass the retest, you can submit another Request to Retest Form to ACMA. There is no
limit to the number of times you can retest during the six (6) month period.
 The ACM credential is valid four (4) years. To recertify, forty (40) hours of continuing
education are required. Thirty (30) of the 40 hours must be specific to Case
Management and ten (10) hours can be non-Case Management related. The 10 hours
of non-case management specific continuing education must be related to the
practice of healthcare in the certificant’s field of practice. All continuing education
credits must be applicable to the performance of the individual’s job. All continuing
education must be from an approved provider as designated by ACMA. One (1)
continuing education credit is defined as 60 minutes of education provided by an
approved provider.
 Approved ACM educational programs must be sponsored or presented by ACM
approved providers, and include courses for which the content/subject matter is
specific to either (A) Hospital Case Management or (B) related to the practice of
healthcare in the certificant’s field of practice.
Approved CE providers are:
American Nurses Credentialing Center (ANCC)
National Association of Social Workers (NASW)
National Institute for Case Management (NICM)
American Case Management Association (ACMA)
All state nursing and social work board approved educational courses
 The recertification fee is $140. ACMA randomly audits recertification applications;
therefore all individuals should retain documentation of proof of attendance for all
continuing education activities. Certification must be successfully renewed prior to
the individual’s expiration date. Once a certification expires without recertification
the individual must meet all eligibility requirements and successfully pass the exam in
order to reinstate certification.
How to do your Best on the ACM
General Tips
1. Think “generic” Case Management. The test is designed to measure minimum competency. No
style points are awarded
2. Don’t multitask during the test. Think of each question independently.
3. Read the instructions and perhaps read the instructions a second time. The simulation portion
of the exam
Study Tips
 Review the content outline. This provides an outline of the different topics that will be
on the exam. It will help you determine what you need to study, what you may need to
spend more time on, and what to expect to see on the exam.
 Read the candidate handbook. This can be one of the most important tools that you
use. It will answer all of your questions about the exam and what you need. It will give
examples of the format of the questions and what is expected in the answers. It explains
how the exam is graded and all of the guidelines. Please read and reread the candidate
handbook.
 .
 Give yourself enough time to study. Don't leave it until the last minute. While some
people do seem to thrive on last-minute 'cramming', it's widely accepted that for most
of us, this is not the best way to approach an exam.
 Schedule your study time. Typically candidates should start studying 90 days prior to
the exam. Set up a consistent timetable that allows you to study at least a few hours per
week throughout the three months.
 Organize your study space. Make sure you have enough space to spread your
textbooks and notes out. Have you got enough light? Is your chair comfortable? Are
your computer games out of sight? Try and get rid of all distractions, and make sure you
feel as comfortable and able to focus as possible. For some people, this may mean
almost complete silence; for others, background music helps. Some of us need
everything completely tidy and organized in order to concentrate, while others thrive in
a more cluttered environment. Think about what works for you, and take the time to get
it right.
 Take notes. Write down your strengths and your weaknesses that you come across
when studying. Take notes when studying with others to get feedback on how they
might answer a question differently.
 Review your notes every day. This suggestion is one which we have all heard a
thousand times. Unfortunately, most of us never really believe it until we actually try it.
Spend 30 minutes or so each evening going over notes. The first time you hear a lecture
or study something new, if you review the material that same day or within 24 hours,
you prevent yourself from forgetting up to 80% of what you learned. After a week it
takes only 5 minutes to retain 100% of the info.
 Listen to music. According to researchers at Stanford’s School of Medicine, if you will
set Pandora to play “obscure 18th century composers,” you’ll engage the parts of your
brain that help you pay attention and make predictions. Listening to music can also put
you in a better mood about studying and could even change your perception of studying
(and the world in general).
 Snack on 'brain food'. Keep away from junk food! You may feel like you deserve a treat
or that you don't have time to cook, but what you eat can really have an impact on
energy levels and focus. Keep your body and brain well-fuelled by choosing nutritious
foods that have been proven to aid concentration and memory, such as fish, nuts,
seeds, yogurt, and blueberries.

 Organize study groups with friends. Get together with friends for a study session. You
may have questions that they have the answers to and vice versa. As long as you make
sure you stay focused on the topic for an agreed amount of time, this can be one of the
most effective ways to challenge yourself.
 Practice sample questions. One of the most effective ways to prepare for exams is to
practice sample questions. Work with study partners to create practice questions based
on the content outline for the exam.
 Explain your answers to others. Family members don't have to be annoying around
exam time! Use them to your advantage. Explain an answer to a question to them. That
will help you to get it clear in your head, and also to highlight any areas where you need
more work. Explain your answers to practice questions created from the content outline
and listen to how your study partner would explain that same answer.
 Exercise a little. Scientific evidence supports the notion that physical exercise can have
beneficial effects on brain function and health. Exercise increases circulation which can
have profound effects on learning ability. An additional benefit of physical exercise is its
effects on stress management. When you are stressed, you may find it hard to focus on
what you're doing. Exercise can help relieve your stress --- which can improve your
ability to function better.
 Drink plenty of water. It is known that 85% of our brain tissue is water. Hence, water is
a vital component for the smooth function of our brain. According to research, if a
person is dehydrated, their brain releases a hormone called cortisol that has a shrinkage
effect to the brain, which then leads to the deterioration of the cognition function of
brain and decreases its memory power. Studies have shown that if you are only 1
percent dehydrated, you will likely have a 5 percent decrease in cognitive function. If
your brain drops 2 percent in body water, you may suffer from fuzzy short-term
memory, experience problems with focusing, and have trouble with math computations.
Inadequate water in the brain is also the culprit of being forgetful, restless and sluggish.
Take water with you for during the test.
 Take regular breaks. While you may think it's best to study for as many hours as
possible, this can actually be counterproductive. If you were training for a marathon,
you wouldn't try and run 24 hours a day! Likewise studies have shown that for longterm retention of knowledge, taking regular breaks really helps.
 Relax. UC Irvine researchers found that even stress that lasts as briefly as a couple hours
can engage corticotrophin-releasing hormones that disrupt the process of creating and
storing memories. So taking study breaks to exercise or draw a few deep breaths will
help your studying if they lower your stress level.
 Plan your exam day. Make sure you get everything ready well in advance of the exam don't leave it to the day before to suddenly realize you don't know the way or what
you're supposed to bring. Check all the rules and requirements, and plan your route and
journey time. If possible, do a test run of the trip; if not, write down clear directions.
 Repeat: Review the content outline. Do a brain dump on each of the listed topics.
Visually review your created list. Identify your weak areas and spend the last time
before the exam shoring up your self-identified weak areas
 Repeat: Read the candidate handbook. Take the time to reread the candidate
handbook before
Test Taking Tips

Get plenty of sleep. Get a full night’s sleep before the test. Do not pull an all-nighter
cramming before the test. In a paper published by the National Center for
Biotechnology Information, Paula Alhola and Päivi Polo-Kantola state that sleep
deprivation negatively impacts several aspects of memory, including attention, working
memory, long-term memory, and decision-making. They note that inattentiveness,
slowed responses, and decreased alertness are considered direct results of sleep
deprivation.

Eat a healthy breakfast. Eat a good meal before the test, based on foods that will
provide a slow release of energy throughout. Sugar may seem appealing, but it won't
help when your energy levels crash an hour or so later. High-protein foods like
scrambled eggs are often best for aiding concentration and minimizing fatigue.

Drink plenty of water. Being well hydrated is essential for your brain to work at its
best. Make sure you keep drinking plenty of water throughout your revision, and also
on the exam day. The University of Wales conducted a study on the impact of water
consumption on memory recall. The study included 50 female college students in an
attempt to determine the differences in “immediate and delayed recall of the concrete
and the verbal”. Evidence showed that recall was significantly better on the occasions
when water had been consumed.

Work out how long it will take to get there - then add on some extra time. You really
don't want to arrive having had to run halfway or feeling frazzled from losing your
way. You could also make plans to travel to the exam with friends or coworkers.

Go to the bathroom before walking into the exam room. You don't want to waste any
time worrying about your bodily needs during the test.

Read instructions carefully. Take a deep breath and read the instructions for beginning
the exam. If you are unsure about how the test is set up, ask the proctor for assistance.

Read each question carefully, paying attention to details. Don’t spend too much time
on one question. If you are having difficulties with a question, skip it and return later.
You have 2 hours to complete the core section of the exam which consists of 110
multiple choice questions. You have 90 minutes to complete the 5 questions in the
simulation portion of the exam.

Don’t panic. If you start getting anxious, take slow deep breaths. Don’t worry about
other people finishing early. Smart people know to use all available time to doublecheck their work.

Ask proctor for help if you have any questions or concerns. Don’t hesitate to ask
questions or bring up concerns you may encounter. The proctor may be able to give
advice or resolve any issues you may have.
Study Schedule
Guidelines for creating an effective study schedule
 Make a list of routine activities
First of all, list all the major activities that are part of your daily life. These activities are
important because every individual has a unique list of activities as compared to another.
Ensure you enlist all the activities because sometimes people avoid listing activities such as
meal preparation and meal timings, personal grooming, or entertainment times. Always
remember that each and every activity has its own importance in your life. For an effective
and good study plan or schedule each activity must enlist clearly.
 Avoid over-estimation
Another very important thing is to avoid over-estimation. Many people when creating a
study schedule start over-estimation and assign lots of time to study and less for other
activities. Always remember that study is an intense activity and one can never study
continuously for several hours, therefore always try to assign appropriate hours that you
can really invest for study.
 Find the best time of the day
For specifying time for study, always choose the best time of the day. The best time means
a time when you feel yourself fresh and comfortable. Usually, the best times of the day are
the least crowded times when there are less chances of getting disturbed by others, such as
early in the morning and late night hours.
 Keep your study schedule flexible
Sometimes due to certain emergencies like urgent work, surprise guests, or health
issues people are not able to follow their designed study schedule. In such cases, a flexible
study schedule can benefit you a lot and saves you from extra panic and stress. For this
purpose, always try to keep some spare hours in your study schedule this will definitely help
you in replacing your study hours with spare hours and hence you will never lose
your routine.
 Set some goals and objectives
For checking the effectiveness of a study schedule, it is important for the
study schedule planner to have some goals and objectives to track their routine tasks. Check
your progress against your own created milestones and make amendments if you find any
issue.
8 Week Study Schedule and Daily Planner examples
Weekly
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Time
2 hours per week--1 hour on Sunday at 7pm; 1 hour on
Wednesday at 6pm
2 hours per week--1 hour on Sunday at 7pm; 1 hour on
Wednesday at 6pm
2 hours per week--1 hour on Sunday at 7pm; 1 hour on
Wednesday at 6pm
2 hours per week--1 hour on Sunday at 7pm; 1 hour on
Wednesday at 6pm
2 hours per week--1 hour on Sunday at 7pm; 1 hour on
Wednesday at 6pm
2 hours per week--1 hour on Sunday at 7pm; 1 hour on
Wednesday at 6pm
30 minutes/day--Monday-7pm, Tuesday-6:30pm,
Wednesday-6pm, Thursday-5pm, Friday-9pm
30 minutes/day--Monday-7pm, Tuesday-6:30pm,
Wednesday-6pm, Thursday-5pm, Friday-9pm
Focus Area
Screening and
Assessment
Planning
Care Coordination and
Intervention
Evaluation
Real Life
Scenarios/Simulation
Real Life
Scenarios/Simulation
Review All Sections
Review All Sections
Daily
Monday
7 a.m.
8 a.m.
9 a.m.
10 a.m.
11 a.m.
12 p.m.
1 p.m.
2 p.m.
3 p.m.
4 p.m.
5 p.m.
6 p.m.
7 p.m.
8 p.m.
9 p.m.
10 p.m.
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
CORE Knowledge Refresher
 ACM Examination consists of a 110-multiple-choice question core examination (90
scored questions and 20 pretest questions).
 Candidates are permitted 2 hours to complete the multiple-choice core portion.
 Multiple Choice Examination consists of four-option, multiple-choice questions written
at three different cognitive levels: recall-ability to recall or recognize specific
information is required; application-the ability to comprehend, relate or apply
knowledge to new or changing situations is required; and analysis-the ability to analyze
and synthesize information, determine solutions and/or to evaluate the usefulness of a
solution is required.
 Strategies—In the Multiple-Choice portion answers can be changed.
Simulation Knowledge Refresher
 ACM Examination consists of five (5) problem simulation portion (four scored and one
pretest problem).
 Each candidate has 90 minutes to complete the simulation specialty portion.
 Specialty Simulation Examination consists of five (5) separate case management
problems. The case management setting and situation for each problem are designed to
simulate reality and be relevant to the health care delivery system case management
practice. The portion is customized for either a nursing or social work background. They
provide comparable assessment regarding capabilities to manage client (patient)
situations. Each section asks a question that requires either Information Gathering (IG)
or Decision Making (DM).
 Strategies—In the Specialty Simulation portion responses cannot be changed. Each
option on the Simulation portion is assigned a specified number of points
corresponding to the degree to which the option contributes to appropriate
management of the situation described. Be very thoughtful about your responses. Rely
on your actual clinical experience. However, do not answer questions based on specific
hospital policies and procedures.
Test Questions (created by ACM holders)
(~175 Core Practice Questions; 51 multiple choice, 121 short answer questions)
Grouping of questions into Domains: WE NEED HELP REVIEWING THE QUESTIONS TO PLACE
THEM INTO THEIR CORRECT DOMAINS. PLEASE LET US KNOW IF YOU CAN ASSIST IN THIS SMALL
SCOPED PROCESS.
Screening & Assessment
When assessing a patient’s financial situation, which is the most important aspect of the
assessment?
A. Monthly income
B. Number of monthly bills a patient has.
C. Patient’s financial concerns
D. Does the patient own a house
Planning
A plan of care must be developed with the patient and health care team to ensure:
A. Individualized and collaborative care
B. Follows all requirements
C. Primarily physician focused
D. Clinically focused
Care Coordination & Intervention
A patient is admitted and only has Medicare A. The patient has a broken hip and the MD and
physical therapist anticipate the patient will need 4 weeks of therapy before returning home.
What is the best plan of care for the patient?
A. Remain in the hospital for continued care
B. LTAC
C. Skilled nursing setting
D. Home with home health and private home care
Evaluation
Evaluation methodology is important during a change process because:
A. Without evaluation, the data captured cannot be properly analyzed
B. Evaluation of any new plan depends upon input from every department and leaders
C. New processes cannot be put in place without proper evaluation
D. It is really not needed during process improvement
Simulation Questions (created by ACM holders)
(~9 Simulation Scenarios)
1. Mrs. Franks is an 84 year old widowed female brought to the ED by her oldest daughter with
a history of multiple falls. The patient is bruised, confused and reluctant to talk about her
latest falls. She reiterates her desire to go home however; the daughter is reluctant to take
her home until she is evaluated by a doctor.
Upon examination, the ED physician indicates to you that the patient has bruises indicative
of suspicious activity and would not necessarily result from a fall. The daughter states she
has a caregiver for 12 hours a day. The patient lives with a younger daughter in the same
city who works long hours. Medical indications are the patient is anemic, hypotensive,
confused and cachectic. There are no broken bones on this visit and the ED physician lets
you know he has taken a look back at her ED visits in the last twelve months. Each time it is
for some strange accident the patient has suffered.
The patient is admitted for rule out bleed as her H&H is 7.5 and 21. Her BP is 78/42 and
appears dehydrated with a BUN of 50 and a CR of 3.2. The physician starts fluids and admits
her to a medical unit.
Your next steps are to:
1. Try and talk to the patient alone and find out what’s happening during the day with the
caregiver.
2. Do a psych-social assessment of the patient.
3. Determine the plan of care.
4. Start discharge planning and get the patient back home ASAP.
5. Discuss the last few visits to the ED with the daughter.
2. You have talked with the patient and she indicates she is very dizzy and has not followed up
with her doctor because she is afraid something serious is wrong with her. She likes the ED
because they treat her and let her go home. This time, they are admitting her and her PMD
wants to work her up.
Your next steps are to:
1. Encourage the patient to stay and get some answers to why she is dizzy all the time.
2. Have her sign an obs letter.
3. Have a discussion with the patient and the daughter to assist in the transition to the
inpatient unit.
3. Mrs. Franks gets to her room, receives her blood, and is scheduled for more tests. She is less
confused after she has her transfusions and wants to go home.
Your next steps are to:
1. Address her fears from your previous visit.
2. Ask the patient if you can talk with her daughter and visit with both of them when she
arrives.
3. Start looking into the home situation with the caregiver.
4. Provide options for discharge.
4. You talk with the patient and the daughter and find out the younger daughter is rarely home
and the patient is home alone a great deal. The caregiver is not consistent with making
meals and getting the patient to the doctor.
The next steps are to:
1. Discuss discharge plans with the patient to keep her safe.
2. Start making plans for long term care.
3. Apply for Medicaid.
4. Ask the patient and daughter if you may contact the vendor the family uses for care
giving.
5. The physician says the patient is simply suffering from poor nutrition and needs to follow a
balanced diet. She asks you to do an in-depth discussion with the daughter who has been
with the patient and determine what is really going on at home.
Your next steps:
1. Call a family meeting.
2. Ask for a nutrition consult.
3. Discuss the perspective of the caregiver situation with the patient and the daughter.
4. Find out what the patient wants to do when she goes home.
6. Mr. Newcomb is a 54 year old carpenter admitted through the trauma service with multiple
injuries incurred while working on a construction site and falling thirty feet from scaffolding.
He suffered multiple fractures to both femurs, multiple rib fractures, and a possible subdural
hematoma. Mr. Newcomb is admitted through the emergency department, unresponsive
and was intubated in the field. Upon admission, he also shows signs of possible abdominal
injuries. The social worker in the ED contacts the wife after receiving information from the
co-worker who arrived with him. He is taken to surgery immediately for an evacuation of his
subdual hematoma, abdominal exploration, resulting in a splenectomy and pinning and
plating of his femurs. Post op he is taken to the ICU for further care. He is intubated, has
multiple drains and remains unresponsive. His wife indicated to the ED Case Manager that
she has been worried about her husband for the last few weeks. He has been putting in
several hours of overtime each week because she has lost her job and has been looking for
work for the last three months.
Registration notifies you the day you are reviewing Mr. Newcomb for the first time that his
insurance coverage is termed at the end of the month. The day you are reviewing him is the
third day of the month.
The first steps you must take in assessing the situation is to:
1. Determine the plan of care.
2. Assist the wife with making plans for the future.
3. Discuss long term care planning with the wife.
4. Address the wife’s fear of insurance coverage.
7. Mr. Newcomb starts waking up and is extubated. He is still confused and in a great deal of
pain. The wife becomes concerned that he will be this way and she will have to take care of
him.
Your next steps are to:
1. Assess the wife’s support system.
2. Speak with the physician about the patient’s condition and the possibility of acute rehab.
3. Ask open-ended questions of the wife about her concern for care for her husband.
4. Set up Medicaid as the patient will need long term custodial care.
8. Mr. Newcomb takes a turn in his recovery and is more alert and oriented. Physical therapy
sees him at his bedside and his physician states he can move out of the ICU onto an acute
care floor. He still has pain issues but is dealing with his present situation rather well.
Physical therapy is recommending acute rehab when the patient is ready for discharge. You
receive a call from workman’s comp for an update.
Your next steps are:
1. Speak with the patient and his wife about post-hospital care.
2. Set up an appointment to speak with the workmer’s comp carrier to set up a possible
acute rehab stay.
3. Assess the psychosocial events that may delay discharge.
4. Speak with the physician about possible home care.
9. Mr. Newcomb is ready for discharge. He still has pain issues that are resolving however the
issues will not keep him from moving to acute rehab. The physician has agreed to acute
rehab however, Mrs. Newcomb is reluctant to have the patient leave the hospital. Mr.
Newcomb will be ready for discharge in a few days.
Your next steps are:
1. Have continued discussions and assure her of the plan and acute rehab.
2. Set up transportation as the patient must go or worker’s comp will not pay for further
inpatient care in your facility.
3. Set up appointments for Mrs. Newcomb to visit the facilities.
4. Tell the patient and his wife that worker’s comp will not pay for a continued stay.
10. Mrs. A is a 71 year old female who lives with her daughter. She presents to the ED
disoriented and disheveled with some bruising on her arms and neck. What should the case
worker do immediately following his/her assessment?
A. Ask the nurse if he/she suspects elder abuse
B. File a report to the state agency responsible for elder abuse/neglect
C. Contact the daughter and ask about the home environment
D. Initiate referrals to Skilled Nursing Facilities
11. Mr. F presents to the hospital without insurance and is newly diagnosed with Acute Myeloid
Leukemia. The doctors would like to start chemotherapy. What should the case manager do
first?
A. Initiate Medicaid referral/application
B. Meet with the patient to discuss the role of the Case Manager and assistance available
C. Inform the doctor that the patient cannot be treated due to lack of insurance
D. Assist patient with transfer to another hospital
12. The case manager is puzzled by the number of conflicting recommendations from the team
for an elderly patient. She/he spent time contacting each physician to ascertain the specific
recommendations and then decided to schedule a patient care conference.
What would have been a more effective approach for the case manager to take?
A. Meet with the patient and family to seek their opinion
B. Identify and document the lead physician
C. Ask the charge nurse which physician should be contacted
D. Make a referral to risk management
13. Mr. G has decided to refuse the plan prescribed by his physician. The case manager has
recommended an alternate plan of care to the physician but, he/she disagrees with the
alternative. What should the case manager do next?
A. Schedule a team conference and ask the team what to do
B. Consult the medical director/physician advisor and request assistance
C. Meet with the physician to ensure that the physician fully understands the alternative
plan and discuss his/her objectives
D. Inform the patient that the physician will not accept the alternative plan
Clinical Simulation Scenario
Scenario: Mrs. Z is a 44 year old woman with bilateral AKA’s admitted to your facility with an untreated
stage 4 decubitus on her left buttock. The patient states she was unaware the ulcer was there until her
sister found it while bathing her this weekend. Her sister attempted to get her into the car to take her to
the MD, however was unable to do so. The MD’s office advised her to call 911 and to have her
transported to the ER. The patient has been admitted to the hospital for treatment. You receive a
referral for case management services as it appears this patient will require discharge planning.
Physical findings: Temp 102 F, HR 84, RR 29, BP 145/90 & O2 SAT 84% on room air. Patient is alert &
oriented but has poor hygiene. Shortness of breath noted, WBC is 18,000.
Medical record review reveals: Uncontrolled DM, Medicare primary with no secondary, 2nd hospital
admission in past 2 months. Patient is pleasant but she is non compliant with her plan of care. Absence
of an advance directive or designated healthcare agent.
A. As the case manager, select which one of the following should be your first step at this point:
1. Meet with the patient and conduct a thorough psychosocial assessment
2. Place this patient on the nursing home waiting list for placement at discharge
3. Request an OT/PT evaluation to determine functional level with transfers and ADL’s
4. Contact Adult Protective Services as given the patient’s poor hygiene and physical condition.
This has obviously been a form of neglect
Upon completing the psychosocial assessment, you learn the following:
The patient lives alone in a handicapped accessible apartment. She does not go out often due
to lack of transportation. Her sister does stop by every day after work to prepare dinner, breakfast and
lunch for meals the following day. Mrs. Z states she was aware there was something on her buttock but
had no idea how bad it was. She states that she doesn’t always take her medications, including insulin,
everyday as she has limited funds and needs to spend money a little at a time.
B. Select which of the following should not be done next:
1. Make a referral for Medical Assistance
2. Discuss completing an advance directive and identifying a healthcare agent with Mrs. Z
3. Request permission to include Mrs. Z’s sister in her plan of care and discharge planning
activities
4. Contact Mrs. Z’s landlord to ensure there are no concerns with her returning to her
apartment at discharge
5. Request a PT/OT assessment to determine functional status and get discharge
recommendations
You have now done the following
You have made a referral to Medical Assistance, assisted Mrs. Z in completing an advance
directive and have spoken with her sister. PT/OT have completed an assessment on Mrs. Z and
recommended a skilled nursing facility at discharge to receive rehab services prior to returning home.
C. Which of the following information should you gather at this time? Select as many:
1. Date Mrs. Z would like to go home
2. Plan of care for Mrs. Z during the remainder of her hospitalization
3. Number of Mrs. Z’s Medicare skilled benefit days
4. Mrs. Z’s willingness to transfer to a skilled facility
5. Advice from her sister
6. Mrs. Z’s choice of an SNF
You find out the following:
Mrs. Z hasn’t used any of her skilled Medicare days; however, she isn’t agreeable to transfer to
an SNF at discharge. Her sister explains it was previously recommended on her last admission that she
transfer to an SNF; however, she declined then as well. She states her sister tries very hard to remain
independent and is fearful that once she gets into a facility she will never return home. You spend some
time with Mrs. Z, as do other members of the health care team attempting to encourage Mrs. Z to
consider this option; however, she continues to decline. She states that she wants to return home and
will agree with home care services.
D. Which one of the following should be your next step?
1. Offer Mrs. Z a choice of home care agencies and make a referral
2. Ask the MD to write an order to transfer Mrs. Z to the SNF, as once the order is written Mrs.
Z won’t have a choice
3. Speak with Mrs. Z’s sister to ensure she is willing to continue assisting her at home & to be
her primary caregiver, as she will need someone to help care for her would if she is to
receive home care services
4. Encourage her sister to apply for guardianship, as it is clear that Mrs. Z is not able to make
good decisions for herself
You speak with Mrs. Z’s sister and find out the following:
She has agreed to continue providing support to her sister and will try to make one additional
visit on her way to work or during lunch each day. She is willing to learn wound care.
E. What information should you gather next? Select all that apply:
1. Wound care orders for home
2. Mrs. Z’s choice for a home care agency
3. Anticipated date of discharge
4. Sister’s address
5. Distance between sister and Mrs. Z’s house
6. Availability of Mrs. Z’s sister for time for education on wound care
F. You learn Mrs. Z will be discharged home on a wound vac & on all of her previous medications.
As the case manager, which of the following should you complete? Select all that apply:
1. Inform Mrs. Z of the anticipated discharge date
2. Inform the SNF that Mrs. Z is going home, however, suggest they keep her on the waiting list
as you anticipate she will fail at home
3. Ensure her sister is comfortable performing the wound care treatments
4. Coordinate the wound vac and home care orders
Answer Key
A.
B.
C.
D.
E.
F.
1
4
2, 3, 4, 6
3
1, 2, 3, 6
1, 3, 4
CORE QUESTION PRACTICE
1. A pre-admission assessment for a patient would include appropriateness of the
procedure, an authorization and:
A. Consultation with physician
B. Clinical appropriateness of the admission or transfer
C. Discussion with the patient and family
D. Current medication list
2. When assessing a patient’s financial situation, which is the most important aspect of the
assessment?
E. Monthly income
F. Number of monthly bills a patient has.
G. Patient’s financial concerns
H. Does the patient own a house
3. A comprehensive assessment includes all of the following except:
A. Clarifying patient choice
B. Assessing a patient’s reaction to illness
C. Prior functional level
D. Support system
4. Mrs. J. is being admitted to the hospital with vague symptoms of abdominal pain and to
rule out a disease process. The proper level of care is:
A. Inpatient
B. Observation
C. Emergency monitoring
D. Outpatient
5. Jayne is a newly diagnosed diabetic. The case manager is questioning the patient about
her disease, her support system, and how she is coping with her new diagnosis. In the
case management process this is called:
A. Assessing a patient’s reaction to her illness
B. Assessing the patient’s educational level
C. Assessing for home care
D. Assessing whether the patient can care for herself
6. A plan of care is always:
A. Changing daily
B. Patient centered and reflects patient’s choice
C. Directed by the physician
D. Focused on the length of stay and cost of the plan
7. A plan of care must be developed with the patient and health care team to ensure:
E.
F.
G.
H.
Individualized and collaborative care
Follows all requirements
Primarily physician focused
Clinically focused
8. A patient had decided to reject the plan of care the physician has ordered. The Case
Manager has offered an alternative to the plan of care to the physician and the
physician rejects it. The case manager should:
A. Meet with the MD to assure he/she knows the plan to the fullest extent.
B. Consult the Medical Director
C. Call the care team together and discuss the physician’s attitude
D. Let the patient know there is no plan of care.
9. At a patient care conference, the plan of care and discussion for discharge was very
productive with the family. The next step a case manager should take is:
A. Discuss with the patient with the family present
B. Document in the chart and have the physician write orders
C. Offer several alternatives to the plan of care
D. Establish goals for completion
E. A&D
10. Mrs. J is a non-compliant, non participatory patient in her own plan of care. The case
manager should:
A. Make a psychiatric referral
B. Develop a plan of care and tell the patient she has to comply or be discharged
C. Ask the patient open ended questions to ascertain why she is reluctant to
participate in her own care
D. Call a team conference
11. What is the most important first step in a performance improvement plan?
A. Data analysis
B. Root cause analysis
C. Benchmarking
D. Problem Identification
12. What is the most important first step in data collection?
A. describe the purpose or the reason for data collection
B. Analyze the variables
C. define the data collection process and time frame
D. analyze the data
13. Which federal law defines patient privacy and protection?
A. HIPAA
B. Patient Self-Determination Act
C. CMS rules of participation for hospitals
D. Social Security Act
14. The appropriate level of care is determined by all of the following except:
A. Evidenced based criteria
B. Unit admission requirements
C. Physician request
D. Presenting signs and symptoms
15. When developing a discharge plan of care, the case manager must consider all of the
following but:
A. Payer reimbursement
B. Patient preference
C. Safe, appropriate, and sustainable care
D. Physician preference
16. When a discharge plan of care is developed with the patient and the care team, it is:
A. Patient centered and collaborative
B. Determined by the physician and must be adhered to
C. Cannot be changed and is discharge dependent
D. Fluid and changes daily
17. When scheduling a patient care conference, who are the most essential persons
involved?
A. Patient, family, case manager, attending physician
B. Patient, family, nursing, and all physicians involved in the patient’s care
C. Nursing, all physicians attending to the patient, case manager and family
D. Patient, family, nursing, case manager and attending physician
18. Which term best describes a case manager’s role as an advocate?
A. Beneficence (Beneficence is action that is done for the benefit of others
B. Negotiator
C. Maleficence (Non-maleficence means to do no harm)
D. Benefactor
19. The Joint Commission uses which methodology when surveying?
A. Continuum
B. Continuity
C. Tracer
D. Holistic
20. Mandatory reporting is required in all of the following but:
A. Suspected child abuse
B. Elder abuse or neglect
C. Malpractice
D. A+B
21. CMS has the responsibility of:
A. Determining LOS
B. Assisting with SSI
C. Making certain an ESRD patient is covered for dialysis
D. Making certain patients’ rights are preserved during hospitalization
22. In which phase of the case management process does discharge planning begin:
A. Planning
B. Care Coordination
C. Screening and Assessment
D. Outcomes evaluation
23. When determining the next appropriate level of care for the patient, the case manager
should consider:
A. Family preference
B. Prognosis and patient choice
C. Insurance coverage
D. Physician preference
E. A, B & C
24. Medicare’s prospective payment is based upon:
A. Length of stay
B. Cost of case
C. Case Mix Index
D. Diagnostic Related Group
25. A Korean speaking patient comes in with her daughter who speaks English. You need to
interview the patient. The best approach to the patient is to:
A. Use the daughter to interpret
B. Let the daughter answer the health questions
C. Set up an appointment with an approved interpreter to speak with you and the
patient.
D. Use pictures to communicate
26. A patient is admitted and only has Medicare A. The patient has a broken hip and the MD
and physical therapist anticipate the patient will need 4 weeks of therapy before
returning home. What is the best plan of care for the patient?
E. Remain in the hospital for continued care
F. LTAC
G. Skilled nursing setting
H. Home with home health and private home care
27. A patient is admitted to your facility from out of state after a car accident while she is
on vacation. She has an HMO insurance plan and will need intensive rehab for multiple
broken bones and a head injury. The only in-network rehab facilities are not close by
and the patient will need careful continued follow up. The best solution is to:
A. Let the family take the patient home and admit her to a facility close to her
home.
B. Negotiate with the insurance carrier for a rehab facility near your hospital
C. Request the MD write for outpatient services
D. Let her stay in the hospital until she can travel home
28. The best indicator for appropriate resource utilization is:
A. Case mix index
B. Length of stay
C. Cost per case
D. Payer payments
29. A patient is in your ICU for 2 weeks in a vegetative state per the attending MD. The
patient is widowed and has a son and a daughter. The daughter wants everything done
and the son states his mother had a conversation with him about a month ago and
would not want to live on a machine. The case manager should:
A. Have the family request legal assistance
B. Have a family conference with the son and the daughter both present and the
attending MD
C. Have the attending physician write an order for vent weaning
D. See if the patient wakes up
30. You arrive on your floor on Monday morning and notice you have several observation
patients on your floor for 46 hours and some tests have not been completed. You
should:
A. Call the testing areas and request the patient be seen ASAP as discharge is
pending and the patients are in obs status
B. Place avoidable days in your reports and wait for the tests to be completed
C. Call the attending physician to discharge the patients
D. Notify the Hospital Administrator that you will not tolerate this on your unit
because it makes you looks bad
31. A Medicare patient enters the hospital from an acute inpatient rehab facility and has
suffered an ischemic stroke. The patient was hospitalized initially for a broken hip and
pelvis. The patient was hospitalized the first time for 4 days, transferred to an IRF and
stayed 18 days before returning to the hospital for CVA care. The patient had full
Medicare days with the primary admission. How many acute days has the patient used?
A. 60
B. 4
C. 22
D. 18
32. Medicare patient is admitted from a SNF with GI bleed and altered mental status.
Patient was transferred two weeks ago from an acute facility to the SNF for skilled care
for CVA rehab. Patient is now back in the acute care setting. How many SNF days did the
patient use assuming this is a new spell of illness?
A. 14
B. 20
C. 100
D. 60
33. A patient calls and asks if you can have his medical records sent to his new physician
from the time he was in the hospital. You state you would be happy to help him and
proceed into the medical record of the patient. You place them on a disc and send them
to the address the patient has requested. What law have you just violated?
A. Patient Protection and Affordable Care Act
B. Medicare
C. The Hill Burton Act
D. HIPAA
34. The Patient Self Determination Act states all but the following:
A. The patient has the right to refuse or accept treatment
B. The right to facilitate their own health care decisions
C. The right to make an advance directive
D. The right to activate a will during a lucid moment yet has been diagnosed with
dementia.
35. Medicare Part A covers all but the following:
A. Acute Care
B. Acute inpatient rehabilitation
C. Long term acute care
D. Custodial care in a nursing home
36. Utilization review is performed in the acute care setting for all but which one of the
following reasons:
A. Determine payment
B. Determine patient’s status
C. Review the severity of illness and the intensity of service
D. Assist the physician with the plan of care
37. When beginning an outcomes management project one should:
A. Gather as much data as possible
B. Define the time frame of the project and collect data pertinent to the project
C. Use benchmarking to determine whether the outcome is valid
D. B&C
38. Benchmarking is used to:
A. Validate outcomes
B. Used to determine whether Case Management is appropriate for all settings
across the continuum of care
C. Defines effectiveness of one institution against another
D. Define one institution’s effectiveness against the best standards in the industry.
39. Evaluation methodology is important during a change process because:
E. Without evaluation, the data captured cannot be properly analyzed
F. Evaluation of any new plan depends upon input from every department and
leaders
G. New processes cannot be put in place without proper evaluation
H. It is really not needed during process improvement
40. The difference between utilization review and utilization management is:
A. Nothing
B. One manages flow and one manages throughput
C. UR manages severity illness and intensity of service and UM manages costs and
throughput
D. Based on Physician Advisor input.
41. Your patient tells you he is having trouble affording his medications and tries to
“stretch” the pills from month to month. As a case manager you should:
A. Pay for the patients medications from an indigent fund
B. Tell the patient he must take his medication as ordered
C. Ask for a medication review from the physician and the pharmacist to determine
if there are substitute medications that are more affordable for the patient.
D. Sign the patient up for Medicaid
42. Managing throughput in the acute care setting requires:
A. Understanding clinical pathways
B. Appropriate and timely communication between the care team and ancillary
services assuring the patient is receiving the proper care and in the proper
timeframe.
C. Leadership understanding of case management
D. Case management and physician services being on the same page for patient
care.
43. An ABN (advance beneficiary letter) is given when:
A. Services requested by the physician are not indicated for the patient.
B. Services for the patient are not related to the medical condition and are usually
given by the lab and radiology.
C. Never given in the acute care setting
D. The physician and the patient request an experimental service
44. The Important Message from Medicare is given to insure:
A. The patient’s rights are not violated during the discharge planning process.
B. The patient knows the acute stay is covered by Medicare
C. The patient knows who to call when he/she wants to complain about the care
received.
D. The patient understands his/her rights and responsibilities if he/she feels
discharge is too soon.
45. Avoidable days and delays or lag days are captured by the case manager to:
A. Help the case management department prove they are worth the cost.
B. Assist the organization to become more efficient and understand where new
processes are needed.
C. Determine which physicians are not discharging timely
D. Assist the organization to determine which departments may need more help to
complete its work.
46. Your Chief Financial Officer calls you into his office and tells you denials are up and you
need to do a better job on managing the UR and getting the hospital paid. Your first
step is to:
A. Ask the CFO is he has data to support his observation
B. Determine if there is a particular payer that is denying.
C. Gather data on denials to determine if it is particular unit in the hospital or a
particular payer that is causing the increase.
D. Monitor the denials in the department from month to month
47. The best form of communication is:
A. Face-to-face using open ended questions.
B. Ask a few questions and give the patient a questionnaire to complete so you can
finish your assessment.
C. Open ended questions with the family
D. Ask everyone on the care team about the patient and then interview the patient
to determine whether the observations you are given are valid.
48. The Medicare two midnight rule allows:
A. Patients to be admitted to a SNF with two nights of observation and one night of
inpatient stay and have the SNF covered
B. Allows physicians to admit to inpatient if the stay will go over two midnights and
the care is medically necessary
C. Disregard of observation services
D. Is used only for inpatient only procedures
49. Medicare states discharge planning is:
A. A comprehensive service offered to all patients whether inpatient or outpatient
B. Should be made available to all inpatients to evaluate for transition
management and avoid re-hospitalization
C. Needs to be offered to patients only when identified by the case manager
D. Completed only on patients that the physician thinks will be re-admitted
50. Discharge planning should begin:
A. Upon admission
B. No later than 24 hours after admission
C. On all inpatient admissions
D. All of the above
51. A patient has appealed the discharge and requests a review. It is determined from
Medicare that the patient is ready for discharge and the discharge plan is in place.
Which letter do you give the patient apprising the patient of the financial liability?
A. ABN
B. HINN12
C. HINN10
D. HINN11
1-B
2-C
3-A
4-B
5-A
6-B
7-A
8-A
9-E
10 - C
11 - D
12 - C
13 - A
14 - C
15 - D
16 - A
17 - A
18 - A
19 - C
20 - C
21 - D
22 - C
23 - E
24 - D
25 - C
26 - C
27 - B
28 - C
29 - B
30 - A
31 - C
32 - A
33 - D
34 - D
35 - D
36 - D
37 - B
38 - D
39 - C
40 - C
41 - C
42 - B
43 - B
44 - D
45 - B
46 - C
47 - A
48 - B
49 - B
50 - D
51 - B
Short Answer Questions
1. What will provide evidence that case management services positively
impact the organization?
2. What is the first step in the data collection process?
3. What is always linked to a performance improvement process?
4. What is the first step in a performance improvement process?
5. What protects the disclosure and use of medical information?
6. Mr. G is an 80-year-old male who lives with a neighbor. He presents to
the ED disoriented and disheveled with some bruising on his arms and
neck. What should the case manager do immediately following his
assessment?
7. Identifying corrective action plans and creating solutions to address
issues requires what?
8. Recurring variances’ requires the development of a corrective action
plan. What issues are related to the timing of a corrective action plan?
9. What is important when monitoring a pattern/trend?
10. What does benchmark data provide?
11. The most effective method to evaluate case management interventions
is?
12. What is most reliable in determining whether a specific intervention
was effective?
13. Which federal law addresses information about patient rights?
14. What is the foundation for evidenced based practice guidelines?
15. A case management function is to ensure that care is delivered in
compliance with critical parameters. What is not considered a critical
parameter?
16. What best describes what action a case manager should take if there is
a potential risk or quality issue?
17. What best describes a well functioning and cohesive team?
18. At a minimum, what best describes the role of a case manager in core
measure performance?
19. The roles and responsibilities of case managers typically include care
coordination, utilization review, discharge planning, and what?
20. Preadmission assessment data does not include what?
21. What should the case manager explore during the screening and
assessment of a patient?
22. What accurately depicts the ideal timeframe for conducting a patient’s
screening and assessment?
23. Information on determining the appropriate level of care for a patient
does not include what?
24. Clarifying a patient’s expectations of their care during the assessment
process is which step in the case management process?
25. Building rapport with patients and families is often complicated by the
complexities of extended families and what else?
26. What does traditional Medicare coverage include?
27. In complex cases with multiple physicians involved, what is the role of
the case manager?
28. Assessing the patient’s definition of their health status will assist the
case manager in what?
29. In accessing a patient’s response to their illness, the case manager
would access all but what?
30. What should the psychosocial assessment of a patient include?
31. When gathering data about a patient’s financial situation, the case
manager should access what?
32. Which unit is not impacted by the ability of a patient to full perform
activities of daily living?
33. What is the most effective method of communication with physicians?
34. What best describes the plan of care?
35. What function is not related to case management planning?
36. What must the case manager consider when developing a plan of care?
37. The nurse case manager must demonstrate knowledge and skill in
what?
38. What is the case manager responsible for?
39. If the patient and/or family refuse to participate in the care planning
process, what is the most appropriate next step?
40. What best describes a plan of care that is developed with the patient
and the health care team?
41. What best describes how a case manager ensures collaborative
communication with the health care team?
42. What is not an appropriate reason to schedule a patient care
conference?
43. Who typically initiates a patient care conference?
44. What is most important to ensure the success of a post-acute plan of
care?
45. What best depicts the best time to develop a transitional care plan?
46. What is a typical job function of case managers?
47. In a situation where an alternative plan of care has been recommended
but the physician disagrees, what should the case manager’s next steps
be?
48. What best reflects the role of the case manager if a patient has multiple
needs for post-acute care?
49. What best describes why the case management practice includes a
patient educational component?
50. What deserves the most consideration when evaluating resource
utilization?
51. In selecting resources for patients who are elderly, terminally ill, or
require a transplant, what kind of issue does not typically require the
deliberation of the health care team?
52. What is the primary reason to develop a contingency plan?
53. During your assessment the patient informs you that they cannot afford
to buy all of their medications. What steps should you take as the case
manager?
54. What kind of scenario allows Medicare to cover the cost of an
ambulance transfer?
55. What should be included in the final communication of the care plan?
56. What is the first step in identifying common resource needs or
emerging resource trends for your patient population?
57. What best describes the case manager’s role as a patient advocate?
58. The coordination of a patients care on a day to day basis does not
include which service?
59. What best describes the components of a good outcome measure?
60. What best describes the value for a case manager to have clinical
expertise?
61. What best depicts the benefit of working collaboratively with diagnostic
departments?
62. Proactive discharge planning is critical to ensuring there are no delays
when the patient is clinically ready. What can often result in a delay?
63. What best describes the information to discuss with a family when
selecting a good nursing home?
64. What is the first step in establishing linkages with external systems?
65. Care planning for patients is much more complex due to what?
66. What best describes the Health Insurance Portability and Accountability
Act of 1996 (HIPAA)?
67. During an assessment, the case manager discovers an undocumented
patient’s insurance information on the medical record is listed
incorrectly. What department should be notified immediately?
68. When conducting the assessment of the patient, the case manager
should review patient information regarding advance directives. What
is the next step for the case manager?
69. JCAHO standards address ensuring the continuity of care across the
continuum. The method of survey utilized is called what?
70. What activity is not monitored by the Office of the Inspector General (OIG)?
71. Centers for Medicare & Medicaid (CMS) are responsible for oversight of
Medicare & Medicaid Beneficiaries, which includes coverage for services.
What is available to the case manager?
72. What service is the responsibility of CMS?
73. State law governs the mandatory reporting requirements and health care
practices when abuse/neglect or assault is suspected. What situation would
not be reported?
74. Reporting known r suspected victims of various types of abuse is the
responsibility of:
75. Incident reporting is an effective tool of a good risk management program.
The reports are not used for what?
76. The Patient Self Determination Act requires hospitals to comply with what?
77. In which phase does the discharge planning process actually begin?
78. The most frequent reason for payer’s to deny coverage of services is?
79. What is not the focus of interdisciplinary care rounds?
80. A number of issues can cause a variance to the initial plan of care. What is not
a variance?
81. The Joint Commission on Accreditation of Healthcare Organizations has
identified national patient safety goals. What is one of these goals?
82. Providing ongoing education to the health care team is a function of the case
manager. What topic is not the responsibility of the case manager?
83. What method is most effective when providing physicians education on case
management, resource management, and reimbursement?
84. What reason is appropriate to determine a patient’s movement to a lower
level of care?
85. What information is not included when communicating the patient’s status
and needs to the next level of care?
86. What is most important for a case manager to know when discussing health
assessment information with a patient?
87. What best indicates Medicare calculations in the prospective payment
system?
88. A 21-year-old Korean speaking patient is admitted to the hospital with a
broken pelvis following a fall from a ladder. The patient does not speak any
English but is accompanied by a friend who is bilingual in English and Korean.
What will facilitate a timely resolution to gathering assessment information?
89. During your assessment of a 77-year-old female, she informs you of 2
previous hip fractures sustained during falls at home. She states she is just
clumsy and wasn’t paying attention. What is the most appropriate thing for
the case manager to do?
90. Upon the initial case management interview with a patient, you learn the
patient is homeless, has a history of drug abuse, is unemployed, and without
any health insurance coverage. What case management processes have
occurred?
91. What is most important in determining discharge goals for a patient?
92. A 69-year-old patient will need to have dressing changes twice/day to a leg
ulcer wound until further healing and granulation occurs. The physician
estimates it will take approximately 4 weeks. The patient only has Medicare
Part A coverage. What option is most appropriate to consider as a discharge
plan?
93. A 34-year-old wheelchair bound paraplegic patient is frequently admitted to
your facility with sacral ulcers. The patient has no caregiver at home. The
patient’s twin brother is requesting the patient be placed in a nursing home.
The patient adamantly refuses placement. As the case manager in the
Neurology unit, you should inform the brother of what law?
94. What is the case manager not responsible for while preparing to arrange for a
patient to transfer to a Skilled Nursing Facility upon discharge?
95. A patient with commercial health insurance will require three weeks of
intensive inpatient occupational therapy to bilateral upper extremities. This is
a result of a serious burn received in an automobile accident. The in-network
Rehab facility Admissions Coordinator is on a 2-day leave of absence. What is
the most appropriate action for the case manager to take?
96. A Medicare patient is aware their discharge is planned for the following
morning. The next morning you learn from the staff nurse that the patient has
asked the physician if they could stay until the next day. The physician agreed
to keep the patient until the following day and cancelled the discharge. What
should the case manger do now?
97. As the case manager, you are reviewing discharge plans with a patient who is
scheduled for discharge in the morning and his wife informs you that he has
not been out of bed since the surgery. What is the most appropriate first
step?
98. A 45-year-old patient is admitted on Thursday afternoon by her primary care
physician with a diagnosis of pneumonia. Her chest X-ray revealed a spot on
her left lung. A pulmonologist was consulted on Friday morning. You are
working on Sunday and discover the pulmonologist has not seen the patient.
What is the most appropriate step for the case manager to take?
99. What indicator is best to monitor for decreased resource utilization?
100.
You are the case manager on a medical floor. The nurses on the day
shift do not attempt to have their discharge paperwork completed early in the
morning causing delays in patients leaving the hospital. You are aware that
patients are waiting in the Emergency Department for an available bed on the
medical floor. What best describes the most effective method of resolving this
issue?
101.
A Medicare patient has been on the Observation Unit for 22 hours to
rule out acute MI. As the case manager, you are reviewing the medical record
and discover there are no Troponin levels or cardiac enzymes results reported.
What is the most appropriate next step?
102.
During your initial assessment with a patient who has been in the
hospital for 3 days tells you they have not seen a physician for 2 days.
However, in reviewing the medical record you discover there are progress
notes for the last 2 days. What action is most appropriate?
103.
One of your case manager peers constantly complains that the case
management assistant isn’t doing his work and is always talking on the cell
phone. However, your experiences with the case management assistant are
different. He works diligently to complete all his tasks in a timely manner and
is always asking if he can help out in anyway. What is the most appropriate
suggestion for your peer?
104.
You are the case manager in the critical care unit and an 84-year-old
female who was in a MVA has been unresponsive on the ventilator for three
weeks. The neurologist states the patient has a poor prognosis and appears to
be in a persistent vegetative state. The patient is widowed and has one son
and one daughter. The daughter wants everything done and the son states his
mother had told him previously that she did not want to “exist on machines."
The physician has requested case management assistance to “deal with the
family dynamics.” What is the best approach to take with the family?
105.
A two-year-old girl has been admitted on the pediatric floor 4 times in
the last 3 months with exacerbation of asthma requiring aggressive
pulmonary treatment. The patient is on Medicaid and the mother is
unemployed. While meeting the mother, you smell cigarette smoke on her
clothing. As the case manager, what is the most appropriate follow up?
106.
You are the case manager in the critical care unit of a large hospital. You
typically have several patients with lengths of stay in excess of 20 days
because there is no advance directive. What is an example of an inappropriate
step to take?
107.
What is least relevant for a case manager to obtain during the initial
assessment?
108.
What method is best to assess pain?
109.
What test/procedures would be the most important to order in the
treatment of this patient?
110.
Patient has a history of seizure disorder with a subtherapeutic Dilantin
level at 3.7 for which she was given a bolus of 750mg IV Dilantin. What would
not be appropriate for the registered nurse case manager to do to prevent the
patient’s return to the ED for treatment of her seizure disorder?
111.
What discharge planning option is least appropriate for the patient?
112.
What question is not appropriate for the registered nurse case manager
to ask in order to assure appropriate resource utilization?
113.
What question would not be appropriate to evaluate as part of the
discharge plan?
114.
What intervention is inappropriate for the nurse case manager during
discharge planning?
115.
What type of information would you gather first?
116.
Based on the information gathered, what would be your first step you
take?
117.
Based on your review of the medical plan of care, what would you do
next?
118.
Based on the patient’s psychological situation, which professional would
you include in the care planning?
119.
The physician agrees to the discharge provided the living situation is
resolved. The issue of the patients bruising is discussed. What should you do
next?
120.
The daughter decides to temporarily place her father in a SNF but the
patient does not meet Medicare criteria for SNF care. What do you do first?
121.
The patient is ready for discharge. The daughter has agreed to pay for a
2-week stay in a local SNF. What should you do next?
Answers:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Measurable outcomes
Describe the purpose of the data collection process
Data collection and analysis
Problem identification
HIPAA
File a report to the state agency responsible for elder abuse/neglect
Discussion and collaboration with the interdisciplinary team
Urgency, risk, and outcomes
Compare the trend to similar organizations and benchmark data to
ascertain opportunities
Objective, statistically valid comparisons
Implement an evaluation process to demonstrate efficacy
Accurate and credible data
Patient Self Determination Act
Random control clinical trails
Case manager experiences
Evaluate the issue and make a referral to the risk, compliance, or quality
services
Trust and productivity
Document all interventions associ
Full ACM Study Review
Scope of Services
Standards of Practice
Utilization Management

Scope of Services
o Education, Care Coordination, Compliance, Transition Management, Utilization
Management

Standards of Case Management Practice
o Accountability, Professionalism, Collaboration, Care Coordination, Advocacy,
Resource Management, Certification
 To download the ACMA Scope of Services and Standards of Practice:
www.acmaweb.org/Standards

What is Case Management?
o The ACMA defines it as:
“Case Management in hospital and health care systems is a collaborative practice
model including patients, nurses, social workers, physicians, other practitioners,
caregivers and the community.”
o “The Case Management process encompasses communication and facilitates care
along the continuum through effective resource coordination. The goals of Case
Management include the achievement of optimal health, access to care and
appropriate utilization of resources, balanced with the patient’s right to self
determination.” http://www.acmaweb.org

Case Management Settings
o Hospitals
o Nursing Homes
o Clinics
o Assisted Living
o Public Health/Home Health and Mental Health
o Community Clinics
o Insurance Companies/Managed Care Organizations
o CMS/HHS
o Private Case Management Practices

Historical Perspective
o Worker’s Compensation- 1910
o Social Security Act of 1935
o Hospital Survey and Construction Act (Hill-Burton) -1946
o
o
o
o
o
o
o
Medicaid -1965
Prospective Payment System (PPS)
Patient Self Determination Act -1990
Health Insurance Portability and Accountability Act (HIPAA)
Medicare Modernization Act -2003
Patient Protection and Affordability Act -2010
Hospital Readmissions Reduction Act

Scope of Services
o Education
o Care Coordination
o Compliance
o Transition Management
o Utilization Management

Education
o Educate the patient education regarding disease process
o Provide information about available resources and benefits for acute and post acute
services
o Identify clinical/psychosocial learning opportunities and provide education to
address the issues

Utilization Management
o What is UM?
“Case Management is expected to advocate for the patient while balancing the
responsibility of stewardship for their organization and in general, the judicial
management of resources.” -ACMA Standards of Practice & Scope of Services 2013
o Utilization Management (UM) is the process for assessing the delivery of healthcare
services to determine if patient care is medically necessary, appropriate, efficient
and meets quality standards
o UM in a hospital setting includes the formal review of hospital inpatient or
observation status patients on a prospective, concurrent, or retrospective basis
o The UM process takes into account the following:
 Clinical presentation and clinical indicators of the patient’s illness
 What is the physician’s intent?
 Actual patient care being delivered
 Is the patient at the right level of care?
 What is the discharge plan?

UM Benefits to the Hospital
o Appropriate Level of Care/Bedding Orders
 Inpatient, Outpatient, Observation
o Decreased Length of Stay (LOS)
o Decreased Denials
o Decreased Health Care Costs

UM Benefits for the Patient
o Timely and efficient discharge
o Patient safety
o Advocacy

UM Criteria Guidelines
o InterQual Criteria® –enables the case manger to determine if the care is clinically
indicated and at the appropriate level of care
o Milliman Care Guidelines® –are evidence based clinical guidelines including care
pathways, quality measures and integrated medical evidence

Medical Necessity
o Includes having a defined method to ensure that the patient is at the appropriate
“status” and level of care for the patient’s clinical condition
o If medical necessity is not met, the Case Manager must first have a discussion with
the Attending Physician before referring the case to a Physician Advisor for
secondary review.

Payer Communication
o Insurance verification and authorization at time of admission
o Ensure timely notification and communication of pertinent clinical data to support
admission and continued stay
o Authorization of post acute services
o Negotiation for benefits that may be out of network

Physician Advisor
o PA’s contribute to:
 Decreased LOS and Avoidable Days
 Decreased denials, assistance with the appeals process
 Decreased hospital expenditures
 Improved clinical documentation
 Linkage between case management and the attending physician.

Avoidable Days
o Variances
 Tests or treatments not done on time
 Lack of available bed at a lower level of care
 Breakdown in communication with the healthcare team
 Physician delays/Hospital delays
 Patient refusal of services or discharge

Benefits of Avoidable Day Tracking
o Provides the ability to build and generate standardized reports
o Gives with opportunity to identify trends
o Work with providers to provide education as needed
o Identify areas for improvement
o Open communication with outside providers

Denials and Appeals
o Proactively prevent medical necessity denials by providing timely and accurate
information to payers
o Utilize escalation process as needed
o Provide the clinical information necessary for the appeals process of cases for which
medical necessity denial has been received

Standards of Practice
o Accountability
 What is Accountability?
 “Accountability is the ownership for the achievement of optimal
outcomes within their standards of practice.” -ACMA Standards of
Practice & Scope of Services 2013
o Professionalism
 What is Professionalism?
 “A professional case manager emulates the standards of practice of
case managers, their professional disciplines and the mission, vision
and values of their organization.” -ACMA Standards of Practice &
Scope of Services 2013
o Collaboration
o Care Coordination
o Advocacy
o Resource Management
o Certification

Professionalism
o Maintain appropriate licensure and certifications
o Lifelong learning
o Demonstrate commitment, initiative, integrity and flexibility
o Set goals for personal and professional development
o Accept responsibility as a financial steward
o Maintain a professional image, be aware of body language and communication
Care Coordination
Transition Management

Care Coordination
o Care Coordination—Case Management must have a defined method for
screening/identification and assessment of patients in need of case management
services. It requires ongoing monitoring and interventions that advance the
progression of care and must include the clinical, psychosocial, financial, and
operational aspects of care. -ACMA Standards of Practice & Scope of Services
o Education of patient and family about discharge plans.
o Involves community agencies when indicated.
o Looks beyond the hospital discharge for coordination of care in the community.
o Incorporates expectations of the patient and health care team for discharge.
(Patient’s right to self-determination)
o Identifies multi-facets of the patient’s ability to participate and expected outcomes.
o Case Management process, when completed appropriately Provides high patient satisfaction
 Best outcomes for the patient and family
 Safe and appropriate discharge
 Proper use of resources
 Partnership with community resources

Care Coordination
o Screening/Identification--Case Management will screen all patients for clinical,
psychological, financial, and operational factors that may affect the progression of
care and through the use of identification criteria, stratify patients at
risk/barriers/strengths or in need of case management services.
-ACMA Standards of Practice & Scope of Services
o Communication/Types of Questions—use open-ended questions
o Barriers to Communication—language, health literacy, patient’s state of mind, health
anxiety
o Cultural Diversity and Respect—keep an open mind so that you can hear all that is
being said. Sit at eye level when speaking with the patient.
o AIDET (Acknowledge, Introduce, Duration, Explanation, Thank You)

Care Coordination
o Information Sources
 Patient
 Family
 Medical Record
 Physician
 Interdisciplinary Teams
 Current Community Care Providers
 Third Party Payors

Care Coordination
o Assessment--Case Management must have a defined case management assessment
tool that expands the case managers’ knowledge of the risks identified in the
screening process and is complementary to the assessment of other clinical
disciplines. ACMA
-Standards of Practice & Scope of Services
o Initial Assessment:
 Cognitive
 Diagnosis/Medical Conditions/Past Medical History
 Medications/Compliance
 Care Access/Financial Barriers
 Health Behaviors
 Response to Illness
 Spiritual/Value System
o Assessment Functional Status
 Social Situation
 Nutritional Status
 Emotional Status
o Psychosocial Assessment Coping Skills
 Body Image concerns
 Pain assessments
 ADL performance
 Occupation
 Self-care assessments
 Environmental concerns
 Housing and Transportation concerns
 Family support

Care Coordination
o Plan of Care--Case Management will review and ensure the plan is clinically
appropriate and matches the patient’s care needs and is consistent with patient
choice and available resources.
-ACMA Standards of Practice & Scope of Services
o Patient Centered
o Remember HIPAA
o Continuity of Care
o Availability of Resources
o Case Manager is key driver/facilitator
o Family involvement and agreement
o Documentation for communication to the Team

Care Coordination
o Sequencing—Case Management will help ensure consults, testing and procedures
are sequenced in a manner that is appropriate to the patient’s clinical condition and
supports timely and efficient care delivery. Case Management will actively intervene
and resolve/escalate where barriers to service exist.
-ACMA Standards of Practice & Scope of Services
o Case Managers are essential to patient progression across the continuum of care.
o “Big picture” view
o Monitor achievement of expected outcomes during the hospital stay
o Keep in mind the expected trajectory of care in order to evaluate delays or variances
in care.
o Examples of Sequencing or “pacing the case”: daily huddles; obtaining orders to
transition medication from IV to PO; contacting the physician for reconsideration of a
consultation; working with ancillary departments to accelerate testing or therapy;
and working with nursing to advancing care.

Care Coordination
o Communication—Communication both verbal and written is the foundation on
which knowledge transfers, and collaboration and relationship building is based.
-ACMA Standards of Practice & Scope of Services
o Unbiased observations
o Accurate account of interventions—who, what, where, when, and how
o Plan must be fluid—ever-changing to patient’s needs and progression
o Regulatory—include patient choice, options provided, patient advised regarding risks
and benefits of choices
o Resources availability—benefit coverage, preferred providers, self pay options
o Identify POA/Decision Maker
o Tracking/trending of avoidable days/delays
o Medical necessity reviews
o Referral for secondary physician reviews
o SBAR (Situation, Background, Assessment, Recommendations)
o Rounding (formal, informal)
o Interdisciplinary/multi-disciplinary meetings (huddles)
o Patient Care Conferences/Patient Progression Meetings

Transition Management
o Transition Management—Based on the health care team’s assessment and patient
choice and available resources, the case manager is expected to integrate these key
elements and develop and coordinate a successful transition plan. Transition
management planning begins at the time of case management’s initial patient
encounter (preadmission, admission, emergency department, etc.) and is
reevaluated and adjusted throughout the patient’s hospital stay.
-ACMA Standards of Practice & Scope of Services
o Transitions of Care is the new terminology for Discharge Planning.
o Transition concept moves from discharge from the hospital to managing the
discharge process across the continuum of care.
o Increased focus on readmissions and financial penalties associated with a higher
than average readmission rate.
o Case Managers expected to manage the transition from the hospital to the next level
of care and beyond in order to prevent avoidable readmissions.
o The process requires comprehensive understanding of community resources and
agencies supporting alternative levels of care and how to network with these
resources.
o Handoffs are one of the highest risk points in the transition process. Communication
gaps are where the greatest potential for failure exists.
o Some key factors to keep in mind are: coordination of care across different levels of
care; high-risk patient in transition; post-discharge follow up; non-compliant patient;
frequent admissions; and frequent ED visits.

Transition Management
o Referrals & Resource Management Identifying available resources
 Resource consumption/benefit analysis
 Negotiation with payor
 Quality of resources available
 Vendor/Provider availability
 Expected outcomes of resource management
Resource Management

Resource Management
o OBJECTIVES:
 Identify key elements of resource management
 Discuss the components of benefit coverage, including charity care & indigent
care programs
 Describe resource utilization through appropriate management of tests,
diagnostics & secondary conditions, appropriate level of care decisions,
avoidance of duplication of services

Resource Management
o Diagnosis Driven
o Ensure appropriate Level of Care (bedding orders)
o External tools to guide setting and anticipated length of stay (ALOS)
o Avoid over and under utilization of resources

Resource Management
o Understanding Benefits
 Social Security / Social Security Disability / Supplemental Security Income

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
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
Railroad Retirement
Medicare
Medicaid
Medically Needy
Emergency Medicaid
Medicaid Waiver Program
Worker’s Compensation
Indian Health Service
Crime Victims
Rural Health Center Program
Undocumented Individuals
Understanding Benefits
o Social Security Administration
 Social Security Income:
 Based on credits earned by paying Social Security and Medicare taxes
on wages
 Social security income age is 65 and beginning with people born in
1938 or later, that age gradually increases until it reaches 67 for
people born after 1959; early social security age is 62 years.
 Social Security Disability Insurance (SSDI)
 Individual cannot work and cannot adapt to other work
 Disability expected to last at least one year or result in death
 Supplemental Security Income (SSI)
 Low income and few resources
o Age 65 or older
o Blind
o Disabled
 Disabled or blind children
o Railroad Retirement
 Retirement, survivor, unemployment & sickness benefits to railroad
employees and their families
 Similar benefits to Social Security
 Difference are in benefit structure and funding
 Tier II benefit designed to replicate a private pension
 Can invest portion of funds in equities
o Medicare
 Title XVIII of the Social Security Act of 1965
o Medicaid
 Title XIX of the Social Security Act of 1965
 Cooperative program between federal and state governments
 States set their own eligibility requirements and services it covers
 Income and asset limits as well as medical needs
o Medically Needy
o
o
o
o
 Available in some states
 Examples are:
 Qualified Medicare Beneficiaries (QMBs) – pays Medicare Part B
premiums a well as co-pays & deductibles
 Specified Low-Income Medicare Beneficiaries (SLIMBs) – pays only
Medicare Part B premiums
 Qualified Disabled and Working Individuals (QDWIs) – former
Medicare disabled beneficiaries who returned to work and their
incomes exceed minimum for that program; pays Medicare Part A
premium if income limit met
Emergency Medicaid
 Can be granted to immigrants who meet all eligibility requirements of
Medicaid except for the immigrant eligibility (immigrant with green cards not
here 5 years of more as well as individuals who are not legal immigrants)
 Covers the cost of emergency medical treatment; requires hospitals to screen
and stabilize individuals who seek care in an emergency room.
Medicaid Waiver Programs
 Home and Community Based Services (HCBS)
 HCBS Options
 1915(c) Home and Community-Based Waivers
 1915(i) State Plan Home and Community-Based Waivers
 1915(j) Self-Directed Personal Assistance Services Under State Plan
 1915(k) Community First Choice
 States can provide traditional long-term benefits (home health, personal
care) as well as non-traditional services (homemaker or adult day care
services)
Worker’s Compensation
 3 Separate programs for
 Longshore, harbor and maritime workers
 Federal employees
 Coal Miners
 Coverage exemptions
 Domestic service
 Agricultural employment
 Casual labor
Outside Worker’s Comp Coverage
 Railroad employees
 Employees involved in Interstate Commerce
 Seamen in Merchant Marine Service
 State Coverage Varies
 Includes cash payments
 Coverage of medical services
 Injury Reporting

o
o
o
o
o
Time limits set: commonly not longer than 1-2 years after the injury
but can be extended
 Adjustors have 2 primary tasks
 Manage injured worker medical expenses
 Manage disability
Veterans Health Administration
 Dignified Treatment of Wounded Warriors Act of 2007
 Focus areas are the care, management and transition of service
members with serious injuries or illness and veteran matters.
 Veterans Millennium Health Care and Benefits Act, H.R. 2116
 Affords service members additional benefits
 Eligibility for Veteran’s Health Services Includes
 Active military service
 Not dishonorably discharged
 Certificate of disability
 Usually disabled for 24 continuous months
 Enhance Eligibility Status
 POW
 Recipient of Purple Heart or Medal of Honor
 VA awarded service-connected disability of 10% or more
 Receiving VA pension
 Services Covered
 Preventive Care
 Inpatient Care
 Ancillary Care
 Veterans Crisis Line – (available to all veterans regardless of enrollment
status) 1-800-273-8255, press 1 for veterans and someone who can help the
veteran will answer right away.
 National Call Center for Homeless Veterans is 1-877-424-3838. The call center
will connect a veteran with the closest VA Medical Center to best address his
or her specific needs.
Indian Health Service:
 Contract health services (CHS) funds are used to supplement and
complement other health care resources available to eligible Native American
and Alaskan Natives; most fund the highest medical priority cases.
Crime Victims:
 Designed to reimburse out of pocket expenses for victims of violent crimes or
their surviving family members
Rural Health Center Program:
 Established in 1977 to address an inadequate supply of physicians who serve
Medicare and Medicaid beneficiaries in rural areas.
 To find shortage areas by state and county go to http://hpsafind.hrsa.gov/.
Undocumented Individuals
 Enter US without an entry or immigrant visa, cross the border by avoiding
inspection, or who overstay the period of time allowed as a visitor, tourist, or
business person.
 Access care through emergency services that often lead to hospitalization

Resources
o US Social Security Administration – http://www.ssa.gov
o US Railroad Retirement Board – www.rrb.gov/
o US Social Security Administration, Benefits for People with Disabilities –
www.ssa.gov/disability
o Medicaid – www.medicaid.gov
o Indian Health Service – www.ihs.gov
o Office for Victims of Crime – www.ojp.usdoj.gov/ovc
o US Department of Veteran Affairs – www.va.gov/healthbenfits
o Health Resources and Services Administration (HRSA) –
http://findahealthcenter.hrsa.gov/Search_HCC.aspx
o US Immigration Services – www.immigrationdirect
Medicare
Conditions of Participation

Conditions of Participation (CoPs)
o Minimum health and safety standards with which providers and suppliers of health
services must comply to qualify for Medicare certification and reimbursement.
o Application of healthcare standards occurred in 1946 with passage of the Hill-Burton
Hospital Survey and Construction Act.
 Quality of service requirements
 Percentage of charity care
o Original publication date was June 17, 1986.
o Key areas of emphasis for the CoPs:
 Advance Directives
 Administration
 Basic Hospital Function
 Optional Hospital Services
 Patients’ Rights
 Quality Assessment and Performance Improvement
 EMTALA
o Specific Sections
 Utilization Review
 Discharge Planning

CMS – Centers for Medicare and Medicaid Services
o Medicare


 Hospital’s risk to manage
 As Medicare goes, so too go other payers
 Ultimate goal is to protect the Medicare Trust Fund
 Implementation of Recovery Audit Contractors (RACs)
 Tools to effectively manage care
 Admission screening
 Compliance with admission and concurrent review
 Appropriate use of outpatient services
 Medicare beneficiary with observation services
 Notices of non-coverage and advance beneficiary notices (ABNs)
 Condition Code 44
 Important Message (IM) from Medicare – hospital discharge appeal notice
 Care that is medically unnecessary
o Hospital Payment Monitoring Program (HPMP)
 Cases not correctly coded
 Non-covered services
 Documentation does not support services provided
o Eligibility
 Usually age 65 (exceptions include illegal aliens and those who have not
worked 40 consecutive quarters)
 End Stage Renal Disease (ESRD) – waiting period of 18 months
 Disabled individuals under the age of 65
 Contact Social Security 3 months prior to 65th birthday
 If not enrolled when deemed eligible, there are open enrollment
periods
 If not purchased when eligible, subject to higher premium
Medicare Parts
o Medicare Part A
 Hospital insurance – covers hospital, SNF, home health and hospice care
o Medicare Part B
 Covers physician services, some outpatient services, some preventative
services, ambulance, durable medical equipment
o Medicare Part C
 Medicare Advantage – Managed Medicare
o Medicare Part D
 Prescription drug coverage
Medicare Part A
o Premiums for Medicare Part A
 Qualify for Part A (65 years of age) – no premium
 Voluntary enrollees
 $234 /month (30 – 39 quarters of Social Security Coverage)
 $426/month (29 or fewer quarters of Social Security Coverage)
o Inpatient Hospital Care
 90 days coverage per spell of illness
 60 lifetime reserve days
 Subject to deductible and co-pays
 2014 Deductible - $1,216
 2014 Co-pay per day
o Day 1 – 60, $0
o Day 61 – 90, $304
o Day 91 – 150, $608 (Lifetime Reserve)
 Need 60 consecutive days out of inpatient setting for new benefit period (can
regain up to 90 days coverage)
 Supplemental or Medi-Gap Insurance
 Covers some or all of the deductible and co-pays
 Provides additional 365 days inpatient hospital coverage if all 150
days exhausts
o Skilled Nursing Facility Coverage
 Within 30 days of qualifying inpatient hospital stay
 Services must be similar to inpatient hospital care
 Must require daily skilled services
 7 days/week skilled nursing; or
 5 days/week PT, OT, or SLP; or
 Combination of therapies 5 days/week; or
 Combination of nursing and therapies 7 days/week
 Coinsurance
 Days 1 – 20, $0
 Days 21 – 100, $152 per day for 2014
o Home Health Care
 No deductible, co-pay or prior hospital stay required
 Must be ordered by a physician
 Must require skilled service (nursing, and/or PT/OT/SLP)
 Must be home bound
 Requires Face to Face Certification
 Always Part-Time and Intermittent
o Hospice
 Prognosis of 6 months or less

Medicare Part B
o Deductible for 2014 - $147/year
o Co-pay – 20% of Medicare approved charges
o Standard Premium - $104.90/month for individual with income < $85,000/year;
increases with higher income
o Supplemental or Medi-Gap insurance can cover all or part of the deductible and copays

Medicare Supplement Plans
o Licensed by Insurance Department in State
o Basic Benefits
 Hospitalization – Part A coinsurance plus coverage for 365 additional days
after Medicare benefits end
 Medical Expenses – Part B (generally 20% of Medicare-approved expenses) or
copayments for hospital outpatient services.
 Blood – first 3 pints of blood each year
o Hospice - Part A coinsurance

Spell of Illness
o Benefit Period
 A spell of illness/benefit period begins on the first day a beneficiary is
admitted to the hospital and does not end until the beneficiary has not
received a hospital or skilled nursing facility level of care for 60 consecutive
days.

Medicare Parts C & D
o Medicare Advantage Plans (Part C)
 Vary state to state
 Minimally must provide what Traditional Medicare provides, can provide
additional services (some plans provide, for instance, vision care)
 Provider bills Managed Care Company
o Medicare Part D
 Helps to pay for prescription drugs
 Recommend consulting pharmacist who knows beneficiary’s prescriptions
and can recommend plan that includes those drugs on their formulary.

Resources
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www.cms.gov
www.medicare.gov
www.medicare.com (consumer)
www.medicareadvocacy.org
Choices Hotline: 1-800-994-9422
RG’s
Observation
Two Midnight Rule

Diagnostic Related Groups
o Diagnostic Related Groups: a system implemented by the U.S. government for
determining how much Medicare should reimburse hospitals for medical care-Social
Security Amendment of 1983
o DRG takes ICD-9 codes and groups them into meaningful patient categories.
o DRG assignment is based on the principal diagnosis. Hospital is paid for the principal
dx which is the reason patient admitted to hospital.
o DRG 291
GMLOS
4.6
Heart Failure and Shock (MCC-major co-morbid condition)
AMLOS
RW
5.9
1.5031
o DRG 292
GMLOS
3.7
Heart Failure and Shock (CC-co-morbid condition)
AMLOS
RW
4.5
0.9938
o DRG 293
Heart Failure without a MCC/CC
GMLOS
AMLOS
RW
2.6
3.1
0.6723
 Exceptions: liver transplant, bone marrow transplant, tracheotomy. These
groups have their own DRG before the MDC assignment since they are
resource intensive.
 Important for case managers to manage costs; secondary work-ups will drive
up the cost of care without changing reimbursement.
o A relative weight is assigned to each DRG to indicate the average cost of resources
used to treat Medicare patients in that DRG relative to the national average cost of
resources used to treat Medicare patients.
o DRG relative weights are recalculated on an annual basis by CMS to make
adjustments for fluctuations reported in the previous year’s statistics.
o Blended rates (dollar amounts): each hospital given blended rate-adjusted annually
and reflects:
 Inflation
 Technical adjustments (wages, teaching vs non teaching)
 Budgetary constraints
 Geographic location (urban vs rural)

Transfer DRGs
o Pro-rated amount paid to the hospital based upon patient’s LOS
o Hospital does not get full DRG if patient moves to a post acute care setting.
o >200 transfer DRGs
o Of ~12 million Medicare discharges per year, 52% are transfer DRGs

Case Mix Index (CMI)
o Indicates the relative severity of the hospital’s patient mix and is proportional to the
DRG payment
o Why is all this important?
 Physician documentation must be complete and reflect the care needs of the
beneficiary so the coder can accurately capture the severity of illness and
assign an appropriate DRG
*The point is to maximize the DRG and manage the resources effectively.

Observation
o Definition:
 Observation services are services that are reasonable and necessary to
evaluate an outpatient’s condition to determine the need for admission.
 Examples- r/o MI; syncope; change in mental status
 Beneficiary incurs co-pay costs under Medicare Part B
 Observation time does not count toward the required three day hospital stay
requirement needed in order to place a patient in a skilled nursing facility
o
Bagnall vs Sebelius
 Nationwide Class Action Lawsuit 11/3/2011 filed by Centers for Medicare
Advocacy which states OBS status violates the Medicare Act
 CT Representative Joe Courtney introduced legislation 8/8/2012
asking Congress to consider eliminating the restriction for purposes
of calculating days required for a skilled nursing stay.
o Important to note that commercial payers and Medicare Advantage plans do not
require a three day inpatient hospital stay before allowing patient to transition to
SNF.

Condition Code 44 (specific to Medicare)
o Once an order for admission has been written it can be changed to outpatient with
observation services provided
o It is done before discharge
o When hospital has not already submitted the claim for the inpatient admission
o The attending physician must agree with a physician member of the UR committee
and the physician’s concurrence must be documented in the patient’s medical record
OR
o If the attending physician fails to present his or her views when afforded the
opportunity and the order is changed by a member of the UM committee

HINN 1
o Preadmission and/or Admission Denial Letter
 This notice is usually given in the ED (i.e. for a social situation), but can also
be issued on a unit to an observation patient who does not want to leave.
The notice is given and the patient is made inpatient.
 To hold the beneficiary liable for customary charges on the day of admission,
the notice must be given no later than 3 pm on the day of admission.
 If requirement is not met, beneficiary liability does not begin until the day
following the receipt of the HINN.
 For notices issued after the day of admission, the beneficiary is liable for
customary charges for all services furnished beginning the day following the
receipt of notice.


HINN 10
o This form is a tool that allows the hospital to request an independent third party
review, through the QIO, when the case manager and the physician advisor are
unable to reach consensus with the attending physician about the readiness of the
patient for discharge.
This scenario is rare.
HINN 11
o This form may be issued when a service not related to the primary reason for
inpatient admission is being ordered. An example would be a patient who presented
to the hospital with pneumonia and once that has been resolved, elects to have a
cholecystectomy. The chole has no correlation to the admission diagnosis and the
HINN 11 may be issued requiring the beneficiary to pay for the elective surgery since
it was not related to the admission diagnosis.

HINN 12
o This notice is used once the beneficiary has filed an appeal. The hospital is required
to provide the beneficiary with an explanation of the beneficiary’s potential liability
(dollars) should the case for discharge be supported by the QIO.

Medicare Important Message (IM)
o All traditional Medicare and Medicare Advantage plan beneficiaries must be given
the IM within two calendar days of admission and within two calendar days of
discharge.
o The IM informs patients that they have a right to covered services and that they also
have appeal rights should they disagree with their discharge.

Two Midnight Rule
2014 IPPS Rule effective 10/1/2013
CMS Definition of Two Midnight Benchmark
 An admission that crosses two midnights; or the patient requires a procedure
that is specified as inpatient only
 For hospital stays in which the MD cannot reliably predict the hospital stay is
greater than 2 midnights:
 MD should treat the patient as an outpatient
 Admit as an inpatient when additional information suggests a longer
stay or the passing of the second midnight is anticipated
o What are the review contractors looking for?
 All time after initiation of care
 Time patient spends as an outpatient prior to admit order will not be
considered IP time
 Time will count for 2-midnight benchmark
 MD judgment
 MD documentation
 Unforeseen circumstances

Two Midnight Presumption
o Presumption of >2 midnights with MD order for admission
o Assume reasonable and necessary for Part A payment
o Not a focus for medical review if no evidence of gaming system
o Difference between presumption and benchmark

Two Midnight Presumption vs Two Midnight Benchmark
o If patient doesn’t stay in the hospital for 2 midnights after the order is written
 CMS and the RACs will presume the inpatient status was not reasonable and
necessary
 MACs will evaluate the claim based upon the 2-midnight benchmark based
upon
 MD order for admission
 Documentation supporting care for 2-midnights
 Documentation supporting reasonable and necessary for hospital
admission

Physician Order/Certification
o Order for admission based upon the CoPs
 MD certification
 Reason for IP treatment or study
 Special or unusual services
 Estimated time
 Plans for post hospital care

Probe and Educate Program
o Extended through 9/30/2014
o MACs conducting prepayment probe
o Claims not in compliance will be denied
o Will offer one on one education
Advocacy
EMTALA
Conservatorship
Advanced Directives

Advocacy
o Key component of the Case Manager’s Role
o Described as the act of supporting or recommending on behalf of
patients/families/caregivers and the hospital for service access or creation, and for
the protection of the patient’s health, safety and rights.

ACMA Advocacy Framework
o Assures patients receive information
o Demonstrates CULTURAL AWARENESS
o Validates and provides resources for informed decision
o Optimizes safety
o Cognitive to limitations of autonomy/identifies legal decision maker
o Actively promotes Advance Directives
o Teaming with payers
o Effectively balances resources
o SELF-DETERMINATION for patient decision making

Patient Self Determination Act (PSDA) 1990
o Passed by Congress to address:
 Right to participate in and direct their own healthcare decisions
 Right to accept or refuse treatment
 Right to prepare Advance Directives

Negotiation
o Dialogue to reach an understanding or gain an advantageous outcome
 KEY ELEMENTS:
 Respect
 Trust
 Empathy
 Active Listening

End of Life Care Terminology
o Palliative Care
o Comfort Care
o Hospice Care

EMTALA
o Emergency Medical Treatment and Active Labor Act- also referred to as the “AntiDumping “ statute
o An act of US Congress 1986 – requires hospitals to provide emergency treatment
regardless of citizenship, legal status, or ability to pay

Hospital Obligations Under EMTALA
o Must complete an exam to determine if EMC exists
o Must treat until the condition is resolved/stabilized
o Appropriate transfer if the hospital cannot treat the condition

Advanced Directives
o General term that refers to oral & written instructions about future medical care.
 A.D. TERMINOLOGY:
 Living Will
 Health Care Representative
 Durable POA

Guardianship/Conservator
o TERMINOLOGY:
 Capacity
 Competency
 Conservator of Person
 Conservator of Estate
Patient Rights
Organizational Ethics
Legal Issues

Topics to cover
o Patient rights
o Concept of consistency of care
o Management of patient information – HIPAA

Patient Rights
o Care that is free from discrimination.
o Be informed about the care that they will receive
o Make decisions about their care, including refusal of care.
o Know when something goes wrong with their care.
o Get a list of all current medications.
o Be listened to.
o Be treated with courtesy and respect.
o Have a personal representative (advocate)
 http://www.jointcommission.org/Speak_Up__Know_Your_Rights/
 http://www.jointcommission.org/multimedia/speak-up-know-your-rights/

Goal of Patient Rights and Organizational Ethics
o Improve patient outcomes by respecting each patient’s rights and conducting
business relationships with patients and the public in an ethical manner.
o Patients have a fundamental right to considerate care that safeguards their personal
dignity and respects their cultural, psychosocial and spiritual values (JCAHO, 2013)

Discharge Planning Influences
o Patient values
o Cultural beliefs
o Care needs
o Preferences
o
Reality

Case Managers “Push – Pull”
o CM ethical dilemmas
o Want vs. Need
o Medical necessity
o Criteria
o Patient preferences/Choice
o Length of stay vs Patient benefit
o Patient values conflict with yours

Consistency of Care
o Must provide consistency of care regardless of payer class
o Illegal to differentiate care based on payer class
o Cannot provide different levels of service based on insurer
o Office of Inspector General (OIG) monitors for this issue
o Amenities may vary as long as it does not impact quality of care.
 ie., patient may pay extra for private room, TV, other services
 Case manager serves as an advocate; addresses inconsistencies (to avoid
litigation)

Health Insurance Portability Accountability Act (HIPAA)
o Patients have a right to access their medical information, unless it will cause them
harm
o Minimum use- request or provide only necessary information to accomplish the
intended purpose
o Patient Health Information (PHI) disclosure is allowed for:
 Treatment
 Payment
 Healthcare Operations
http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/privacysummary.pdf
(pp. 7-13)

Malpractice
o Based on Fault or Negligence of the Case Manager.
o Not acting within standards or scope of CM job description
o Three elements that identifies malpractice:
 There must be a duty owed (existing case manager-patient relationship).
 A breach of that duty (breach occurred to exercise a reasonable standard of
practice and this breach caused harm).
 Injury or actual damage (injury to patient, property or rights).

Patient Abandonment
o Definition -Termination by the provider without informing the patient or failing to
provide adequate medical care in the absence of the provider.
o Must ensure another competent provider to assume care
o Important actions prior to closing a case:
 Documentation is essential.
 Document all interactions, non-compliant behavior, missed
appointments, etc
 Follow-up: Both written and verbal (also sent via Certified Mail)
 Ensure the attending physician is aware

Negligent Referrals
o When making a referral the CM needs to consider:
 Licensure
 Accreditation
 Staffing components
 Geographical capabilities
 Provider endorsement
 History of complaints or lawsuits

Negligence
o CM must act within their scope of their licensure and their own competence and
education.
o CM must not conduct their activities in a way that corrupts medical judgement.
o CM role is as a consultant to clients and physicians (who make the final medical
decision).
o CM should not interfere with the doctor-patient relationship.
o CM may also be liable for failure to refer when warranted.
o CM must meet a reasonable standard of care.
o If known violations related to quality of care, communicate in unbiased way. ie, refer
to databases where survey info is displayed
o Must offer choice.

Termination of Non-Therapeutic Relationship
o Relationship is not constructive; patient refuses to follow recommendations of the
provider to improve their health.
o Must present official notification in person when possible
o Follow-up with official letter to the patient and also via certified mail to the home.
o Notify the attending physician
o Presentation to ED for emergency treatment supersedes their termination
notification.
UM Audits

Objectives
o Define roles of Auditors
o Explain impact of Auditors on healthcare organizations
o Know strategies to proactively minimize risk

Auditors
o RAC-Recovery Audit Contractors
o MAC-Medicare Administrative Contractors
o MIC-Medicaid Integrity Contractors
o ZPIC-Zone Program Integrity Contractors

Recovery Audit Contractors
o Started in 2002 – Demonstration project
o Federally mandated under the following acts:
 Improper Payment Information Act of 2002
 Medicare Modernization Act of 2003
 Tax Relief and Health Care Act of 2006
o Became a permanent program in 2010
o Contractors receive a percentage of recovery
o Recovery Audit Contractor
o Purpose:
 Detect and correct past improper payments
 Provide information that will assist in preventing future improper payments
o Task:
 Detect improper Medicare payments
 Correct Improper payments
 Collect overpayments
 Pay back underpayments??

Medicare Administrative Contractors
o Fiscal intermediary
o Audit medical necessity and DRG probe audits
o No time limitation on charts that can be reviewed
o No contingency fee
o Medicare Administrative Contractors
o Ability to cross check claims
o Will impact physician compliance and revenue integrity, ie, IP vs Obs
o Set up automated edits
o Hospital-Physician claims concordance will be upcoming OIG target

CM Strategies to reduce risk
o Ensure proper assignment of patient status
o Collaborate with physician to determine admission status
o Communication to patient
o Advocacy for patient and hospital
o Appeals when appropriate
Appendices
Standards of Practice and Scope of Services
Content Outline
What the Pro’s Say (COMPILATION OF EMAIL RECEIVED SUGGESTIONS)
STANDARDS OF PRACTICE AND SCOPE OF SERVICES
PREFACE
Case management in hospitals and health care delivery systems represents a wide range of
services and diverse methods of organizational structure. The concept of case management conveys
different meanings to individuals and to organizations. ACMA describes case management in the
following context:
“Case Management in hospital and health care systems is a collaborative practice model including
patients, nurses, social workers, physicians, other practitioners, caregivers, and the community. The
Case Management process encompasses communication and facilitates care along a continuum through
effective resource coordination. The goals of Case Management include the achievement of optimal
health, access to care and appropriate utilization of resources, balanced with the patient’s right to selfdetermination.”
Approved by ACMA Membership, November 2002
CONTEXT
In an effort to describe the varied functions that are considered case management services, a
task force was assembled to compile a collective of what ACMA considers to be the Scope of Services for
Health Care Delivery System Case Management. The task force solicited input from ACMA members and
created a representative listing intended to describe and associate the vast nature of case management
in various facilities throughout the country. The Scope of Services Task Force presents this list with the
caveat that it is not intended as a “mandated” list of expected case management services for all to
provide, but rather a compilation of case management services typically provided by health care
delivery systems. ACMA does not intend that this Scope of Services be a description of a case
management department’s responsibilities. ACMA recognizes that organizational structures frequently
designate a service as a department. The ACMA Scope of Services represents the functions and
responsibilities associated with the case management services that are provided to our patients. These
services may be provided either primarily by case managers or secondarily by others. However, all are
closely aligned with case management as defined by ACMA.
The following categories best reflect this concept:
• Education
• Care Coordination
• Compliance
• Transition Management
• Utilization Management
The following further describes the functions of each service:
Education
• For all patients requiring active case management services, case management is expected to ensure
and provide education relevant to the effective progression of care, appropriate level of care and safe
patient transition.
Specifically:
• Ensure that education regarding the injury/clinical/disease process has been provided by the health
care team
• Provide information to the health care team, patient/family/caregiver regarding available resources
and benefits for acute and post acute services that ensures patient choice and a safe and timely
transition
• Identify clinical, psychosocial and/or operational learning opportunities that negatively affect care or
reimbursement and provide the health care team, community partners, patient/family/caregivers
education that will address or resolve the issues
Care Coordination
• Case management is expected to have a defined method for screening/identification and assessment
of patients in need of case management services. Additionally, case management must have defined
standards for ongoing monitoring and interventions that advance the progression of care and must
include the clinical, psychosocial, financial and operational aspects of care.
Screening/Identification
• Case management will screen all patients for clinical, psychosocial, financial and operational factors
that may affect the progression of care and through the use of identification criteria stratify patients at
risk/barriers/ strengths or in need of case management services
Assessment
• Case management must have a defined case management assessment tool that expands the case
managers’ knowledge of the risks identified in the screening process and is complementary to the
assessment of other clinical disciplines
Plan of Care
• Case management will review and ensure the plan is clinically appropriate and matches the patient’s
care needs and is consistent with patient choice and available resources
Sequencing
• Case management will help ensure consults, testing and procedures are sequenced in a manner that is
appropriate to the patient’s clinical condition and supports timely and efficient care delivery. Case
management will actively intervene and resolve/escalate where barriers to service exist
Communication
• Communication both verbal and written is the foundation on which knowledge transfers, and
collaboration and relationship building is based.
• Case management organizational structure and staffing, policies and procedures must meet the
Centers for Medicare & Medicaid Services (CMS) Conditions of Participation
• Case management is responsible for documenting information that is not duplicative but instead is
complementary and contributes to the progression of care
Compliance
• Case management will be knowledgeable of and ensure compliance with the federal, state, local
hospital and accreditation requirements that impact their scope of services.
• Case management organizational structure and staffing, policies and procedures must meet the
Centers for Medicare & Medicaid Services (CMS) Conditions of Participation
• All disciplines practice within the scope of practice as defined by state licensing regulations
Transition Management
• Based on the health care team's assessment and patient choice and available resources, the case
manager is expected to integrate these key elements and develop and coordinate a successful transition
plan. Transition management planning begins at the time of case management’s initial patient
encounter (preadmission, admission, emergency department, etc.) and is reevaluated and adjusted
throughout the patient’s hospital stay
Transition Coordination – Identification
• Based on assessment, case management will identify patients with post-acute needs including
those at risk for readmission and prioritize as well as intervene as needed
• For those patients at risk for readmission, case management will apply interventions to
proactively prevent readmissions and evaluate those who are readmitted to identify and
implement strategies for improvement
Community Partnerships
• Case management will identify available community resources/potential partners and
advocate for resolution of gaps in the available resources and processes
• Case managers will be knowledgeable of and provide available information for patients to
make an informed choice regarding resources/providers
Transition Coordination
• Case management will arrange/ensure all elements of the transition plan are implemented
and communicated to key stakeholders including, but not limited to, the health care team,
patient/family/caregiver, and post-acute providers
• Case management will convey all necessary information for continuity of care and patient
safety, verify receipt and provide a venue for additional questions and/or information
requests/needs
Follow-Up
• Case management will provide electronic, telephone, in person method of contacting the
patient/family to validate the success of the transitional care plan within 72 hours
Utilization Management
• Case management is expected to advocate for the patient while balancing the responsibility of
stewardship for their organization and in general, the judicial management of resources.
Medical Necessity
• Case management will have a defined method to ensure the patient is in the appropriate
“status” and level of care for the patient’s clinical condition. The process must include a method
for secondary physician review when warranted
Payer Interface
• Case management with respect to payer requirements will ensure timely notification and
communication of pertinent clinical data to support admission, clinical condition, continued stay
and authorization of post-acute services. When a lack of concurrence exists between the
patient’s needs and the payer’s authorization, Case management will advocate securing
reimbursement/resources needed for patient care. When no payer authorization requirements
exist, case management accepts the role as a patient and organizational advocate to manage
the utilization of resources
Avoidable Delays/Days
• Case management will utilize a validated system/defined methodology for tracking avoidable
delays/days and use this information to identify and communicate opportunities for
improvement. Case management will participate in the development of performance
improvement activities relevant to identified opportunities
Denials/Appeals
• Case management will proactively prevent medical necessity denials by providing education to
physicians, staff and patients, interfacing with payers and documenting relevant information
• Case management will provide the clinical information necessary for the appeals process of
cases for which medical necessity denial has been received
• Case management will utilizes escalation process as needed
STANDARDS OF PRACTICE
I. ACCOUNTABILITY
Accountability is ownership for the achievement of optimal outcomes within their standards of practice.
The case manager:
• Recognizes and demonstrates shared accountability, both at the individual and the team levels, that
joint responsibility and joint accountability is inherent in collaborative practice
• Follows through on his/her own commitments and expects/prompts others to follow through on their
commitments
• Contributes to decision-making and decision support as a member of the interdisciplinary team
• Ensures timely sequencing through the case management encounter
II. PROFESSIONALISM
A professional case manager emulates the standards of practice of case managers, their professional
disciplines and the mission vision and values of their organization.
The case manager:
• Aligns practice with the mission, vision and values of their health care organization
• Emulates the standards of practice for both case management and their professional discipline
• Maintains appropriate licensure and certifications
• Commits to lifelong learning and strives to improve competence in all areas of practice
• Advances the application of research and evidence-based practices
• Participates in the orientation and training of students and new department members
• Demonstrates commitment, initiative, integrity and flexibility
• Regularly evaluates his or her own performance and sets goals for personal and professional
development
• Maintains current knowledge of health care economics, trends and reimbursement methodologies
and applies this knowledge to daily practice
• Utilizes data to drive performance improvement
• Maintains current knowledge of health care economics, trends, and reimbursement methodologies
and applies this knowledge to daily practice. Accepts responsibility as financial steward
III. COLLABORATION
Collaboration is working with patients/families/caregivers and the health care team to jointly
communicate, problem solve and share accountability for optimal outcomes. These outcomes respect
patient preferences and their available resources.
The case manager:
• Respects and values the contribution of all disciplines
• Communicates and collaborates with patients/families/caregivers and members of the health care
team
• Builds and maintains relationships that foster trust and confidence
IV. CARE COORDINATION
A case manager facilitates the progression of care by advancing the care plan to achieve desired
outcomes and integrates the work of the health care team by coordinating resources and services
necessary to accomplish agreed-upon goals.
The case manager:
• Ensures the development of a safe and effective plan of care through early identification and thorough
assessment of the patient’s needs and the resources available
• Assures the designation of primary responsibility among the team members for each aspect of the
plan, avoiding duplication and fragmentation
• Carries out individual responsibilities according to the plan
• Monitors progress toward the goals of the plan and ensures revisions in response to changes in
patient needs and condition
• Proactively identifies, communicates and resolves barriers that impede the progression of care
• Utilizes an organizationally defined escalation process to refer facets of the care plan beyond the
control or influence of the team
• Evaluates the patient’s/caregiver’s level of understanding and comfort with the progress towards goals
and incorporates findings into the plan of care
• Arranges services among community agencies, physicians, patient/family/caregivers, and others
involved in the plan of care
• Ensures timely sequencing of interventions for optimal results and smooth transition along the
continuum
• Identifies clinical, psychosocial and/or spiritual needs and addresses/refers to attain expected
outcomes
• Elicits and incorporates the realistic expectations of patients/family/caregiver health care team
members and payers in the planning process
• Identifies barriers to achieving recommended goals identified in the plan of care
V. ADVOCACY
Advocacy is the act of supporting or recommending on behalf of patients/family/caregivers and the
hospital for service access or creation, and for the protection of the patient’s health, safety and rights.
The case manager:
• Identifies the legal decision maker (patient or surrogate)
• Ensures patient or surrogate receives information on benefits, risks, costs and treatment alternatives
including the option of no treatment
• Promotes the patient’s self-determination in all decisions and assists the health care team’s
understanding of and respect for the patient’s or surrogate’s choice
• Promotes culturally competent care
• Partners with payers to ensure the patient can access their full benefits and negotiates for benefit
exceptions as needed
• Provides patient/family/caregivers available tools/resources to make informed choices
• Demonstrates the ability to balance resources with patient preferences
• Ensure that suspected cases of abuse, neglect or exploitation have been referred to the appropriate
individual and/or agencies
• Utilizes the ethics committee or other resource to resolve conflict or challenges regarding patient care.
• Promotes the understanding and use of advanced directives and ensures patient wishes are respected
VI. RESOURCE MANAGEMENT
Resource management assures prudent utilization of all resources (fiscal, human, environmental,
equipment and services) by evaluating the resources available to the patient and balancing cost and
quality to ensure the optimal clinical and financial outcomes.
The case manager:
• Evaluates cost of care with the benefits of patient safety, clinical quality, risk and patient satisfaction
to provide recommendations and decisions that ensure optimal outcomes
• Educates patients/families/caregivers and health care team on the economic impact of their care
options
• Facilitates timely progression to the appropriate level of care
• Identify and address avoidable delay practice patterns that may require modification to support costeffective care. Uses escalation process as needed
• Identifies and implements strategies for avoiding and/or managing unnecessary costs that impact
hospital
• Applies knowledge of hospital contractual arrangements to daily practice
• Secures the appropriate payer authorization to advance the plan of care
• Ensures appropriate medical necessity and manages under and over utilization
• Maintains awareness and complies with all regulatory requirements
• Recognizes situations that require referral to quality or risk management and makes a timely referral
• Manages patient/family/caregiver expectations for short- and long-term goals based on health status,
prognosis and available resources
VII.CERTIFICATION
Certification validates a case manager’s knowledge, competency and skills. Case managers holding an
Accredited Case Manager™ (ACM) credential have proven that they are especially equipped to provide
case management services within a health care delivery system.
Certification Position Statement (Approved December 7, 2012):
• Nurses and social workers with two or more years of health care system experience should have their
Accredited Case Manager (ACM) credential by December 31, 2016 to practice health care system case
management. Thereafter, because new case managers need 24 months of health care system case
management experience to be eligible to take the ACM exam, certification should be achieved by the
36th month of practice.
GLOSSARY
Assessment
The identification and documentation of the patient’s initial transitional care needs
within 24 hours of admission for the following elements:
• Medical necessity for patient status and level of care
• Psychosocial needs
• Clinical needs
• Anticipated discharge needs
• Spiritual needs
• Patient/family/caregiver health care level of understanding
And the amalgamation of the key elements into an initial transitional care plan with
alternatives.
Care Coordination
Process whereby assessment, planning and interventions effectively integrate, ensure
and advance the plan of care to support successful transitions.
Clinical Intervention
An intervention carried out to improve, maintain or assess the health of a person, in a
clinical situation.
Intervention
• Carries out individual interventions
• Communicates and resolves barriers
• Utilizes escalation process as needed
• Provide the necessary elements of clinical and psychosocial information that minimize
the potential for readmission
• Implement and continually modify as needed the transitional care plan
• Provide clinical and psychosocial interventions as needed
• Ensure and reinforces proactive patient/family/caregiver education
Live Follow Up
Electronic, telephone, in person method of contacting the patient /family/caregiver to
validate the success of the transitional care plan typically within 72 hours.
Monitoring
• The act of reassessing minimally every 48 hours
• Utilizing a high risk stratification system, ensure a post-discharge live follow-up within
in 72 hours for all identified patients
Planning
• Assures designation
• Ensures timely sequencing
• Elicits and incorporates elements necessary for transitional plan of care
• Develops the transitional care plan, incorporating patient’s short and long term goals
Professionalism
Consistently demonstrates behaviors that result in credibility and respect for the
individual and the case management practice.
Psychosocial Intervention
Assesses & intervenes to address psychosocial issues associated with hospitalization &
transition plans.
• Assesses & intervenes, focusing on emotional/coping style, identification of
patient/family resources and obstacles for complex psychosocial situations
• Utilizes clinical skill and expertise to provide assessment, intervention, and
where appropriate, reporting for complex abuse, neglect, domestic violence and
sexual assault situations
• Provides clinical social work assessment and intervention for complex crisis,
mental health, substance abuse, adjustment and grief/loss situations
• Provides specialized knowledge and expertise for complex resource and
benefit situations
• Assists other team members to understand and appreciate a patient and/or
family's reaction to a serious illness, injury, and/or chronic illness/disease as
well as family and other environmental dynamics affecting care, treatment and
compliance
• May develop and facilitate support groups
Reassessment
Ongoing reviews for medical necessity and adjustments to the transitional care plan as
needed and minimally within every 48 hours.
Resource Management
Balances cost and quality through the effective evaluation and utilization of fiscal,
human environmental, equipment and service options available to the patient.
Transitional Care Plan
The plan to move the patient along the care continuum including preadmission inpatient
post acute and community.
American Case Management Association – Final Detailed Content Outline
Core Examination Portion # of Items
1. Screening and Assessment - conduct screening and assessment activities for the purpose of
preadmission, admission, or following admission to an inpatient or outpatient setting – 11 questions
A. Obtain relevant, comprehensive information and data required for client assessment
from:
a. client
b. family and significant others (and/or legal guardians)
c. primary care physician/attending physician
d. consulting physician(s)/specialist(s)
e. other members of the interdisciplinary team
f. community providers
B. Assess and gather information regarding the client’s:
a. health behaviors
b. response to illness
c. belief or value system (e.g., cultural influences)
d. medical history
e. psychosocial history
f. financial situation
g. environment
h. functional status
i. developmental level
j. current medical status and level of care
C. Formulate and communicate assessment findings
2. Planning - apply assessment findings to prepare a client-centered plan of care – 25 questions
A. Identify hospital services and available resources to meet client needs
B. Identify continuum of care needs
C. Obtain client choice regarding aspects of care plan
D. Collaborate with team to develop a plan of care
E. Coordinate client care conferences
F. Establish goals and anticipated outcomes
G. Propose alternative treatment and therapeutic plans based on efficacy, cost, safety,
potential compliance, and anticipated outcomes
H. Integrate client choice, resources, and team recommendations into a plan of care
I. Evaluate resource consumption related to expected outcomes
J. Identify contingencies to the plan
K. Formulate and communicate the plan of care
L. Create or develop resources for emerging client populations where resources are
scarce
3. Care Coordination and Intervention – facilitate effective management of client care throughout
the identified continuum of care – 32 questions
A. Establish linkages with internal systems to provide resources, services, and opportunities
B. Establish linkages with external systems to provide resources, services, and opportunities
C. Apply regulatory requirements to practice
a. HIPAA
b. CMS
c. JCAHO
d. 4. other
D. Apply legal requirements to practice (e.g., mandated abuse reporting)
E. Apply ethical guidelines to practice (e.g., honoring client’s right to choose, self determination)
F. Coordinate timely and effective service delivery
a. Facilitate referral to continuum services (e.g., medication payment assistance,
SNF, DME, home health, community agencies)
b. Provide/reinforce appropriate client education
G. Communicate potential payor issues to client, health care team, and other internal services
H. Provide for clinical and therapeutic interventions
I. Manage variances to the plan
J. Negotiate with service providers, payors, and members of the health care team to meet
client care needs
K. Advocate on behalf of the client and/or facility for needed client resources and services
L. Create an environment to support client safety
M. Provide education to other health care providers (e.g., infection control, health care
economics, payor methods, discharge options, documentation, service utilization)
N. Document changes in the plan and responses to interventions
O. Communicate changes in the plan and responses to interventions
P. Communicate client status and needs to the next level of care
4. Evaluation - utilize outcome management and process improvement strategies to measure and
improve the quality and effectiveness of care and processes – 22 questions
A. Systematically collect timely and accurate data to evaluate interventions
B. Identify opportunities for improvement
C. Communicate opportunities and supporting data at all organizational levels
D. Collaborate with the interdisciplinary team to create solutions and take corrective action
to address issues
E. Monitor patterns and trends
F. Evaluate the effectiveness of the interventions
G. Evaluate practice trends against benchmarks to support best practice
H. Evaluate research studies and apply findings to improve case management practice
and service delivery
I. Identify quality and risk management issues
J. Resolve or refer quality and risk management issues for corrective action
K. Participate in team building activities
L. Lead team building activities to promote team cohesiveness and effective performance
Total Scored Items (plus 20 items added for pre-testing) 90
Specialty Simulation Component (Nursing and Social Work)
Specialty Assessment, Care Coordination and Intervention – facilitate effective management
of client care throughout the identified continuum of care as applied to social work/nursing
practice in case management
A. Perform client screening
B. Assess and gather information from the client
C. Obtain relevant, comprehensive information and data required for client assessment by
reviewing medical records
D. Conduct ongoing reassessment of client status and effectiveness of interventions, and
revise as necessary
E. Coordinate timely and effective service delivery
a. Facilitate diagnostic and treatment services (e.g. tests, consultations, procedures)
b. Identify and manage operational, clinical, and/or client/family barriers
F. Provide for clinical and therapeutic interventions
G. Monitor delivery of service against clinical practice guidelines or plan of care
H. Continuously reassess client and family response to care
I. Enhance client capacities (e.g., developmental, problem solving, coping, self care)
J. Conduct ongoing reassessment of the integration/interaction of all aspects of care
K. Review admissions and level of care with respect to the medical necessity, quality, and
appropriateness of care
L. Assure payor authorization for stay
M. Review, process, and issue notices of non-coverage to client/responsible party following
regulatory guidelines and facility protocols by informing client/responsible party of right of
appeal and appeal process
N. Participate in collaborative discussions with external organizations related to service
delivery utilization and contracting issues
a. payors
b. providers (e.g. SNFs, home health agencies)
O. Provide education to clients (e.g., safety, disease process, compliance, medication
management, plan of care)
Total of Four Scored Simulations (plus one pretest), each including 6 to 10 sections categorized
as shown on the outline.
WHAT THE PROs SAY
TBD