ACM Prep. ACM Certification: Your gift to yourself

Transcription

1 ACM Prep ACM Certification: Your gift to yourself

2 Hints O Prep Handbook O Think globally O Study Buddy O Scenarios First

3 Definition Case Management is defined as a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual s health needs through communication and available resources to promote quality effective outcomes. CMSA, 2002

4 Social Work The National Association of Social Workers defines case management as a method of providing services whereby a professional social worker assesses the needs of the client and the client s family, when appropriate, and arranges, coordinates, monitors, evaluates, and advocates for a package of multiple services to meet client specific needs. NASW 2007

5 Scopes and Standards of Practice O Advocacy and Education O Clinical Care Coordination/Facilitation O Continuity/Transition Management O Financial Management O Performance & Outcomes Management O Psychosocial Management O Research & Practice Development O Utilization Management

6 Advocacy and Education Patient education for self determination and health management Physician, Staff and Community Education Case manager continuing education Risk management Legal assistance and coordination Patient relations Ethical: beneficence, no malfeasance, autonomy, and fidelity

7 Clinical Care and Coordination Plan of care & Outcomes Management Patient Care Integration Resource Management Patient/Family Care Conference Interdisciplinary Communication and Coordination Continuity of Care Planning Management

8 Continuity/Transition Management Capacity/Access Management/Throughput Discharge planning Dialysis Coordination and Arrangements Pharmaceutical Authorization/Management Community Resource Management Advance Directives Palliative/End of Life Care/Hospice

9 Financial Management Health Care Resources Management/Clinical Cost Efficiency Financial Assistance/Referrals Appeals Management Entitlement Program Coordination Patient Benefits Coordination Medicare, Medicaid, SSI Commercial payers

10 Outcomes Management O Federal/State/Local Regulatory Agency Compliance O Joint Commission Standards Compliance O Clinical Documentation Management O Core Measures Utilization/Compliance O Patient Safety Compliance O Clinical Guidelines/Pathways/Evidenced Based Practice O Quality Improvement Practice Standards O Organizational Financial Performance/Management O LOS O Cost/Case O Denial Management

11 Research and Practice Development O Clinical Practice Improvement O Evidenced Based Clinical Practice O Case Management Best Practice O Case Management Competency O Certification

12 Utilization Management O ADD Identification and Management O UR SI/IS Medical Necessity Clinical Presentation O Pre-admission planning O 3 rd party Communication O LOC O Status determination O Denial Prevention

13 Practice Integration O Daily processing O Discharge planning O Utilization Review O Community Resources O Caring for the under & uninsured O Negotiating O Prioritizing

14 Tools O Communication: written and verbal/nonverbal O Proper assessments with accurate documentation O Written communication should tell the story to all partners of care O Patient and family information and updates

15 Facilitation O Early development of assessment and primary plan O Early involvement of patient and family in the planning process and identification of a spokesperson, POA. O Removes barriers for effective and safe discharge O Fosters teamwork and team development for initiation of steps towards discharge.

16 Advocacy O Promotes the right of self-determination O Education on benefits, risks, financial responsibilities O Alternate plans for discharge, mirrored plans, choice of discharge. O Evaluates the efficacy of the community services, SNFs, Home Health and other agencies directly involved in the patients care O No decision about me without me

17 Resource Management O Cost of care: impact on the patient, financial impact of their decisions for post acute care. O Manages costs through proper identification of tests, duplication of services and high cost diagnostics, O Manages LOS: progresses patient through the inpatient stay for optimal care within the optimal time. O Prevents readmissions through proper education and partnering with the payer and/or community resources for disease management. O Community resources and agencies to keep patient in the community and involved in care in the outpatient setting.

18 Accountability O Recognizes the decisions made are based on patient choice and best practice in collaboration with the health care team and the patient. O Integral team member for MDRs. O Maintains network of colleagues to contribute to the decision making process and decision support. O Takes responsibility for all actions taken for the patient and follows through on their commitments. O CM accountable for their on going education and development.

19 Professionalism O Aligns goals with the organization's goals, mission and vision O Maintains licensure and certification O Adheres to professionals standards O Commitment to the profession of case management O Sets goals for personal and professional development O Realizes the need for mentorship with new staff and assists in training.

20 Coordination O Education of patient and family about discharge and 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 the health care team for discharge O Identifies multi-facets of the patients ability to participate and expected outcomes

21 End of the Day O High patient satisfaction O Best outcomes for the patient and family O Safe and appropriate discharge O Proper use of resources O Partnership with community resources

22 Screening and Assessment O Communication/ types of Questions O Barriers to Communication O Cultural Diversity and Respect O AIDET O How well we communicate is determined not by how well we say things but how well we are understood O Andree Grove, Co-founder of Intel

23 Information Sources O Patient O Family O Medical Record O Physician O Interdisciplinary teams O Current community care providers O Third Party Payers

24 Initial Assessment O Cognitive O Diagnosis/Medical Conditions O Medications/ Compliance O Care Access/Financial Barriers O Functional Status O Social Situation O Nutritional O Emotional O Unbiased observations

25 Initial Assessment O Health Behaviors O Response to illness O Spiritual/Value system O Past medical history O Functional status

26 Psychosocial Assessment O Body Image concerns O Coping Skills O Pain assessments O ADL performance O Occupation O Self-care assessments O Environmental concerns O Housing and transportation concerns O Family support

27 Documentation O Unbiased observations O Family members O POA/Decision Maker O Barriers to planning O Initial Plan of Care O Advance Directives O Resource availability O Care Team Information

28 Planning O Smart O Specific O Measurable O Achievable O Realistic O Timely

29 Planning O Patient centered O HIPPA O Continuity of Care O Availability of Resources O Medical Team as Coach O Family involvement and agreement O Documentation for communication to the team

30 Referrals and Resource Management O Identifying Available Resources O Resource consumption/benefit analysis O Negotiation with payer O Quality of resources available O Vendor availability O Expected outcomes of resource management

31 Care Coordination O Relationships: O Nursing O Physicians O PT/OT/Speech O Internal Hospital Systems O External Systems O Patient/Family Pace the Case

32 Care Coordination Outcomes O Health care dollars are saved O Proper use of resources O Timely and appropriate care O Case Management is the driver of cost containment and patient s right to selfdetermination. O Prevention of abuse, fraud and waste through proper care coordination. O Uses the strength of all the team members to develop plan of care and keep the patient at the forefront of the plan of care

33 Regulatory Issues O Mandatory Reporting O Abuse and neglect adult and children O Legal requirements O Ethical Considerations O Patient self-determination act O Health Care Decision Act

34 Regulatory Issues O Tax Equity and Fiscal Responsibility Act of 1982 O Pregnancy Determination Act O Mental Health Parity Act O Medicare 1965: Medicare A,B, MA Plans, Part D O Medicaid Title XIX O HIPPA O Release of Information O Mental Health Issues O HIV/AIDS O Communicable Diseases

35 Medicare O Determination of LOC within 24 hours O Conditions of Participation O Acute Days versus SNF days O Rules for placement O Caveat of available days O Lifetime days O Code 44 O ABN/ HINN Letters/ Appeals O ESRD O IMM/ Obs letters

36 Medicaid O Eligibility O Rules of Participation O Waivers/Definitions O Placement O ESRD

37 Court Case O Wickline vs. State of California O Physician determination O Denial based on cost O Case Management Involvement O Documentation

38 Outcomes Management O What we measure O How we measure O Vendor responsibility O HCAHPS O Data gathering O Data analysis What we measure gets done

39 Medicare and You O pdf/10050.pdf O Provides information for Medicare recipients in an easy to read and understandable version. O

40 Medicare Days O O O O O O Patient is admitted for a hip replacement and has not been hospitalized in the last 6 months. The last admission was for a syncopal episode. He is hospitalized for 6 days due to some complications and was admitted to an inpatient rehabilitation facility (IRF) for acute and intensive rehabilitation. He is discharged from the IRF after 22 days and is discharged home with family. What type of Medicare days has the patient used? How many Medicare days has the patient used? If readmitted in 30 days, how many days does the patient have remaining? Acute days SNF days

41 Medicare Days O Patient is admitted to an acute care facility for fever, sepsis and altered mental status. He is hospitalized for 58 days and is discharged to a SNF. The patient is in a SNF for 32 days and is released home with 24 hour care. After 3 days at home, the patient falls and suffers a CVA and is re-admitted for treatment for the condition and spends 8 more days in the acute care setting. The patient then returns to the SNF for rehab and medication management and uses 52 days. The patient does well and goes home again with 24 hour care. O How many acute days has the patient used? O How many SNF days has the patient used? O When does the co-pay begin in the SNF setting? O When does the co-pay begin in the acute care setting?

42 Medicare Days O O O O O The patient is admitted to the acute care setting with a diagnosis of acute renal failure. He is covered under a commercial payer at the time of admission. During this admission, it is determined the patient is end stage renal disease and will require three times a week dialysis. Is the patient eligible for Medicare at this time? What is the determination for a recipient of dialysis to be eligible for Medicare coverage? Once eligible, how long is the patient eligible? If patient receives a transplant, how long after the transplant does Medicare cover the patient?