Care Management
30%of exam
AssessmentCare planningCoordinationTransitionsMedication management
Reimbursement Methods
12%of exam
Public benefitsPrivate benefitsPayment methodsUtilization reviewCoding
Psychosocial Concepts and Support Systems
20%of exam
Behavior changeClient engagementSupport systemsSocial driversTrauma-informed care
Quality and Outcomes Evaluation and Measurements
10%of exam
Quality indicatorsAnalyticsPerformance improvementAccreditationValue-based care
Rehabilitation Concepts and Strategies
10%of exam
Functional capacityAdaptive technologyRehab settingsVocational rehabilitationReturn to work
Ethical, Legal, and Practice Standards
18%of exam
EthicsLegislationPrivacyDocumentationAdvocacy
Quick Facts
- Credential
- CCM
- Credential owner
- The Commission
- Total items
- 180 multiple-choice
- Scored items
- 150 operational
- Unscored items
- 30 pretest
- Exam time
- 3 hours
- Appointment
- 3.5 hours
- Scheduled break
- 10 minutes; clock pauses
- Exam sessions
- Two; Section 1 locks
- Answer choices
- Three or four
APICME Process
Assess Plan Implement Coordinate Monitor Evaluate
A — AssessP — PlanI — ImplementC — CoordinateM — MonitorE — Evaluate
Palliative Care vs Hospice
Palliative care
- Any serious illness stage
- May accompany disease treatment
Hospice
- Terminal prognosis criteria
- Comfort-focused benefit election
Goals and eligibility distinguish them
Choose the First Case Action
- Immediate safety threat→Stabilize and escalate(Safety precedes routine planning)
- Suspected abuse or neglect→Follow reporting law(Protect client promptly)
- New case referral→Complete comprehensive assessment(Start with client needs)
- Multiple unmet needs→Prioritize acuity and risk(Address highest risk first)
- Client remains uncertain→Elicit values and preferences(Use shared decisions)
- Plan stops progressing→Identify barriers and reassess(Revise measurable goals)
- Care setting changes→Reconcile and hand off(Close continuity gaps)
- Goals are achieved→Evaluate and close(Document follow-up plan)
Current Exam Blueprint
- Current administration
- Updated August 2025
- Care Management
- 45 scored items ±2
- Reimbursement Methods
- 18 scored items ±2
- Psychosocial Support
- 30 scored items ±2
- Quality and Outcomes
- 15 scored items ±2
- Rehabilitation
- 15 scored items ±2
- Ethical, Legal, Practice Standards
- 27 scored items ±2
- Exam sessions
- Two
- Scheduled break
- 10 minutes; clock pauses
- Section boundary
- Section 1 answers lock
- Exam time
- Three hours total
- Appointment
- Three and one-half hours
- Answer options
- Blend of three and four
SMART Goals
Specific Measurable Achievable Relevant Time-bound
S — SpecificM — MeasurableA — AchievableR — RelevantT — Time-bound
Case Management Process
- Assessment
- Identify strengths, risks, and needsStart
- Planning
- Set client-centered measurable goalsGoals
- Implementation
- Activate agreed interventionsAction
- Coordination
- Connect people, services, and settingsLink
- Monitoring
- Track progress and barriersTrack
- Evaluation
- Compare outcomes against goalsMeasure
- Reassessment
- Update needs after changeRepeat
- Transition
- Ensure safe care continuityHandoff
- Closure
- Document outcomes and follow-upClose
- Advocacy
- Advance informed client preferencesVoice
Care Planning Tools
- SMART goal
- Specific, measurable, achievable, relevant, time-bound
- Shared decision-making
- Combine evidence with client preferences
- Teach-back
- Client restates instructions
- Medication reconciliation
- Compare lists across transitions
- Red-flag education
- Teach symptoms requiring prompt action
- Warm handoff
- Directly connect receiving provider
- Follow-up visit
- Confirm timely post-transition care
- Caregiver readiness
- Assess ability, willingness, and burden
- Health literacy
- Match information to comprehension
- Least restrictive care
- Maximize safe client autonomy
Care Settings and Levels
- Inpatient
- Hospital admission for intensive care
- Observation
- Outpatient status under monitoring
- Outpatient
- Care without inpatient admission
- Acute rehabilitation
- Intensive multidisciplinary rehabilitation
- Skilled nursing facility
- Daily skilled nursing or therapy
- LTACH
- Extended hospital-level complex care
- Home health
- Skilled services in residence
- Hospice
- Comfort-focused terminal care
- Palliative care
- Symptom relief during serious illness
- Group home
- Supported community residential setting
Medicare vs Medicaid
Medicare
- Federal health insurance
- Eligibility-based program
- Multiple coverage parts
Medicaid
- Federal-state partnership
- Needs-based eligibility
- Rules vary by state
Verify eligibility and coordination rules
Choose the Coverage Review
- Service has not started→Prior authorization(Verify plan requirements)
- Care is underway→Concurrent review(Assess continued necessity)
- Care already ended→Retrospective review(Evaluate delivered services)
- Coverage was denied→Follow appeal process(Meet notice deadlines)
- Benefit remains unclear→Verify plan documents(Avoid promising coverage)
- Network option is inadequate→Negotiate single-case agreement(Document clinical rationale)
- Condition is work-related→Review workers compensation(Coordinate return-to-work needs)
- Multiple payers apply→Coordinate benefit rules(Verify payer order)
Benefit Programs
- Medicare
- Federal eligibility-based health coveragePublic
- Medicaid
- Joint needs-based health coveragePublic
- SSI
- Needs-based disability cash benefitCash
- SSDI
- Work-credit disability cash benefitCash
- TRICARE
- Military health benefit programMilitary
- VA benefits
- Veteran health and benefit systemVeterans
- COBRA
- Temporary group coverage continuationPrivate
- PBM
- Manages prescription drug benefitsPharmacy
- Workers compensation
- Covers work-related injury or illnessEmployment
- Special needs trust
- Holds assets while preserving benefitsResource
- Waiver program
- Funds home and community servicesResource
Capitation vs Fee-for-Service
Capitation
- Fixed per-member payment
- Provider accepts utilization risk
Fee-for-service
- Payment per service
- Volume increases reimbursement
Follow when payment occurs
Payment and Utilization
- Fee-for-service
- Pays per delivered service
- Capitation
- Fixed payment per enrolled member
- Bundled payment
- One payment for episode
- Case rate
- Predetermined amount per case
- DRG
- Inpatient prospective payment category
- Value-based care
- Rewards outcomes and value
- Prior authorization
- Approval before covered service
- Concurrent review
- Review during ongoing care
- Retrospective review
- Review after care delivery
- Medical necessity
- Coverage-linked clinical appropriateness
- Deductible
- Member pays before plan coverage
- Copayment
- Fixed member service payment
- Coinsurance
- Member pays percentage share
Prior Authorization vs Concurrent Review
Prior authorization
- Occurs before service
- Checks prospective coverage
Concurrent review
- Occurs during care
- Checks continued necessity
Timing determines review type
PDSA Cycle
Plan Do Study Act
P — Plan changeD — Do testS — Study resultsA — Act next
Quality Improvement vs Research
Quality improvement
- Improves local processes
- Uses iterative testing
Research
- Creates generalizable knowledge
- Follows research oversight
Purpose drives classification
Quality and Analytics Tools
- Structure measure
- Measures resources and capacity
- Process measure
- Measures delivered care steps
- Outcome measure
- Measures resulting health status
- PDSA
- Test changes through iterative cycles
- Root cause analysis
- Examines causes after event
- FMEA
- Anticipates failures before harm
- Benchmark
- Comparison performance reference
- Readmission rate
- Returns after prior discharge
- Length of stay
- Time occupying care setting
- Denial rate
- Share of claims denied
- HEDIS
- Standardized health plan measures
- Predictive modeling
- Forecasts risk from data
- Cost-benefit analysis
- Compares benefits against costs
Core ADLs
Bathing Dressing Toileting Transferring Continence Feeding
Basic self-careAssess needed assistanceLink functional supports
Acute Rehabilitation vs Skilled Nursing
Acute rehabilitation
- Intensive coordinated therapy
- Rehabilitation physician oversight
Skilled nursing
- Daily skilled services
- Lower therapy intensity
Match intensity and tolerance
Choose the Rehabilitation Direction
- Intensive multidisciplinary therapy tolerated→Consider acute rehabilitation(Verify admission criteria)
- Extended hospital intensity required→Consider LTACH(Match complex medical needs)
- Daily skilled services required→Consider skilled nursing(Verify benefit criteria)
- Homebound skilled need exists→Consider home health(Assess home safety)
- Terminal comfort goals dominate→Consider hospice referral(Verify program eligibility)
- Serious illness symptoms persist→Consider palliative care(Concurrent treatment may continue)
- Job demands exceed function→Start vocational rehabilitation(Analyze essential duties)
- Daily function is unclear→Assess ADLs and IADLs(Match supports to deficits)
Rehabilitation Tools and Resources
- ADL
- Basic personal care activity
- IADL
- Complex independent living activity
- Functional capacity evaluation
- Measures work-related functional abilities
- Job analysis
- Defines essential job demands
- Reasonable accommodation
- Enables qualified worker participation
- Assistive technology
- Supports function and independence
- Life care plan
- Projects lifelong support needs
- Return-to-work plan
- Coordinates safe work reintegration
- Vocational rehabilitation
- Restores employment participation
- Substance-use rehabilitation
- Supports recovery and functioning
- Orientation and mobility
- Builds safe navigation skills
Ethics Compass
Choice Benefit No Harm Fairness Truth Trust
Choice — AutonomyBenefit — BeneficenceNo harm — NonmaleficenceFairness — JusticeTruth — VeracityTrust — Fidelity
Capacity vs Competence
Capacity
- Clinical decision ability
- Decision-specific and changeable
Competence
- Legal status
- Determined by court
Clinicians assess; courts determine
Ethical Principles
- Autonomy
- Respect informed client choices
- Beneficence
- Act for client benefit
- Nonmaleficence
- Avoid causing preventable harm
- Justice
- Promote fairness and equity
- Veracity
- Communicate truthfully
- Fidelity
- Keep commitments and trust
- Informed consent
- Voluntary decision after disclosure
- Self-determination
- Client directs personal goals
- Conflict of interest
- Disclose and manage competing interests
- Scope of practice
- Stay within authorized competence
Law and Documentation
- HIPAA
- Protects identifiable health information
- Minimum necessary
- Limit non-treatment disclosures appropriately
- EMTALA
- Requires screening and stabilization
- ADA
- Prohibits disability discrimination
- FMLA
- Provides qualifying job-protected leave
- Affordable Care Act
- Federal health coverage reforms
- No Surprises Act
- Limits qualifying surprise bills
- OSHA
- Sets workplace safety requirements
- Mandatory reporting
- Follow applicable reporting law
- Objective documentation
- Record observable relevant facts
- Late entry
- Label additions with actual date
- Incident report
- Supports organizational risk review
- Advance directive
- States future care preferences
- Health care proxy
- Designates surrogate decision-maker
- Capacity
- Clinical ability to decide
- Competence
- Legal status determined judicially
Common Traps
Operational vs Pretest Items
150 operational items are scored ≠ 30 pretest items are unscored
Coverage Is Never Guaranteed
Verify current plan terms ≠ Explain limitations clearly
Assessment Comes Before Intervention
Address immediate safety first ≠ Otherwise assess before planning
Client Choice Drives Planning
Provide informed options ≠ Respect capable refusal
Capacity Is Not Competence
Capacity is clinically assessed ≠ Competence is legally determined
Privacy Has Permitted Uses
Apply applicable privacy rules ≠ Limit unnecessary disclosures
Palliative Is Not Hospice
Palliative care spans illness stages ≠ Hospice requires qualifying criteria
Document Facts Not Conclusions
Use objective observable language ≠ Record actions and responses
Section 1 Locks at Break
Review Section 1 before break ≠ Earlier items cannot be revisited
Last Minute
- 1.Care 30%; psychosocial 20%; ethics 18%
- 2.Reimbursement 12%; quality and rehab 10%
- 3.Lead with safety and assessment
- 4.Center client goals and autonomy
- 5.Match review type to timing
- 6.Separate Medicare from Medicaid
- 7.Compare care setting intensity
- 8.Know ADLs versus IADLs
- 9.Use PDSA for improvement
- 10.Separate capacity from competence
- 11.Protect privacy and confidentiality
- 12.Document objectively and promptly
- 13.Escalate mandatory reporting duties
- 14.30 pretest items are unscored
- 15.Three exam hours; two sessions
- 16.Break = 10 paused minutes
- 17.Review Section 1 before break
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