Term
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Definition
System of patient care delivery that identifies timelines of holistic needs crossing all disciplines involved in the care of a client. |
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Term
How are short and long term goals viewed in
Case Management |
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Definition
| short and long term goals are out-come based, flexible and incorporate best practices clinically |
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Term
How does Case Management view the treatment of the pt? |
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Definition
Encompasses the entire episode of illness and levels of care but goes beyond just disease management |
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Term
What is Case Management Overall Purposes |
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Definition
Similar to primary nursing in the hospital
Acts as a “gatekeeper” for health care for an individual client by crossing all settings in which patient receives care
Streamlines a confusing, complex and fragmented system of care
Designs care to neither overwhelm the client nor overlook identified needs
Achieves quality care at a low cost in a time efficient manner |
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Term
What are the Roles of a case manager |
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Definition
Assists the client in assessing and planning for health services
Facilitates implementation of all needed services
Links clients with community resources
Delegates aspects of care to competent individuals
Monitors the care process
Collaborates with all disciplines as the client’s advocate
Communicates expected outcomes
Ensures that material resources are used appropriately
Minimizes hospitalization
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Term
What are the "6 rights" of a case manager |
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Definition
Right task
Right circumstance
Right person
Right communication
Right supervision
Right quality of the service |
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Term
What are the Indicators for Case Management |
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Definition
Functional Deficits – mental illness, strokes
Educational Deficits – developmental delays
Extensive Medical Management Needs – Alzheimer’s, severe burns, head injuries
Management of Chronic Diseases – AIDS, cancer, diabetes
Social Indicators – lack of support systems, family |
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Term
What Skills/knowledge that qualifies a nurse to be a Case Manager
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Definition
· Competent Focused Clinical Care
· Effective Interpersonal Relationships
· Needed Community Resources
· Client Advocacy
· Holistic Plan to Care Management
· Scope of Services Offered by an Interdisciplinary Approach
· Alternatives to Institutionalization
· Legal Issues and Services
· Client Eligibility and Benefits offered by Third Party Payer
· Teaching and Counseling Skills
· Age appropriate Issues
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Term
| What is Third Party Reimbursement |
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Definition
| cost for health services are paid for by someone other than the individual receiving health care such as private insurance or employee based group health plans that include premiums, co-payments and deductibles |
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Term
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Definition
| monthly payment for health insurance benefits |
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Term
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Definition
| fixed percentage client pays per service |
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Term
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Definition
| amount paid by client before insurance plan will pay for services |
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Term
| What is Retrospective Reimbursement |
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Definition
| payment by insurance companies is paid after the client receives those services. Has the disadvantage of providing services that may not be necessary and causes health care costs to rise at an alarming rate. |
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Term
| What is Prospective Reimbursement |
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Definition
| payment is predetermined and a fixed rate for a set of health care services that eliminates the incentive to over treat clients. This reimbursement system was instituted in 1983 by Medicare and was prompted by rising health care costs. Has led to shorter hospital stays and movement of services to outpatient settings to cut costs. Has the disadvantage of health care providers not giving adequate care to minimize costs |
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Term
| What are Managed Care Organizations |
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Definition
– health care delivery systems financially and clinically accountable for health care outcomes for contracted groups of people
Require authorization for specialty health services from primary care provider
Restriction on choice of primary care provider |
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Term
| What is an HMO’s Health Maintenance Organization |
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Definition
managed care- PCP gatekeeper, prepayment basis is a fixed amount regardless of volume or expense of services |
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Term
| What is a PPO’s Preferred Provider Organization |
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Definition
| discounts given to groups insured as negotiated by employment groups. Providers are monitored for quality and cost containment |
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Term
| What is Public Funded Insurance |
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Definition
costs of health care borne by the U.S. Government or Taxpayers
Medicare, Medicaid, SCHIP
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Term
| What is Medicare , part A, part B and part D |
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Definition
part of social security program for citizens in the U.S. who are <65/disabled – Pays 80% (US Government)
Part A – hospitalization, home health and hospice (funds from SS taxes)
Part B – Supplemental – physician and outpatient services
Part D – Prescription drug services |
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Term
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Definition
State run – Health Care Services for financially needy
Stringent qualification, differs from state to state |
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Term
| What is (SCHIP) State children’s Health Insurance Program |
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Definition
meets the needs of low income children who do not qualify for Medicaid |
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Term
What is The Affordable Care Act’s New Patient’s Bill of Rights |
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Definition
The Departments of Health and Human Services (HHS), Labor and Treasury have issued regulations implementing a new Patient’s Bill of Rights under the Affordable Care Act after September 23, 2010 |
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Term
What are the New Rules for insurance companies |
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Definition
Stop insurance companies from imposing pre-existing condition exclusions on children and will be extended to Americans of all ages starting in 2014
Prohibit insurers from rescinding coverage based on an unintentional mistake on an application
Ban insurers from setting lifetime limits on coverage renewed on or after September 23, 2010 and comes into full effect in 2014
Consumers are free to designate any available primary care doctor or pediatrician from the consumer’s plan’s provider network |
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Term
| Why should Nurses be influencing or making legislation |
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Definition
involvement in the formation of health policy to shape the future of health care
Nurses are patient advocates
Nurses should be watch dogs for:
a. Accessible health care
b. Equitable health care
c. Cost effective health care
d. Quality oriented health care |
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Term
The politically involved nurse has the following goals: |
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Definition
Promoting, protecting, preserving health of aggregates – (major segments of population have no access to quality health care. Health care is seen as a business that diverts public services away from community health)
Generating support for his or her views by communicating effectively to representatives at local, state and national level
Creating professional legitimacy by keeping abreast of current issues in health care
Being involved in professional nursing organizations, boards, etc.
Know opposing viewpoints well and be prepared to provide accurate but positive rebuttal information.
Be able and willing to negotiate and compromise with conflicting views or interest groups without compromising goals of the nursing profession. |
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Term
What are Special interest groups |
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Definition
Share a common goal
Politically active to get policy makers to support their goal
Groups include: business, labor, neighborhood, minority, religious environmental
Special interest groups employ many tactics to influence policy decisions:
Public hearings campaigns
Litigation
Protest
Public relations
Lobbying |
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