Free CCM Exam Flashcards

The six phases of the case management process are Assess, Plan, Implement, Coordinate, Monitor, and Evaluate, repeated throughout an episode of care. Do not confuse this with The Commission's other numbered lists: the 'Six Core Components' are the six exam domains (Care Management, Reimbursement Methods, Psychosocial, Quality, Rehabilitation, Ethical/Legal), and the 'Eight Essential Activities' are these six phases plus Outcomes and General.

The process of identifying which clients need case management, based on criteria like diagnosis complexity, cost, frequent utilization, or risk score. High-risk, high-cost clients are typically prioritized for active case management.

An individualized plan built collaboratively with the client (not imposed on them) that reflects the client's own goals, values, and preferences alongside clinical needs. Client buy-in improves adherence and outcomes.

Gathering in-depth information about a client's medical, social, behavioral, and functional status from multiple sources (client, caregivers, providers, records) to build a complete picture before care planning begins.

Categorizing clients by complexity and risk level (e.g., low, moderate, high acuity) to determine how intensive case management involvement should be. Higher acuity generally means more frequent contact and more resource-intensive planning.

Medicare's Two-Midnight Rule: inpatient admission is generally appropriate when the physician expects care to span at least two midnights; shorter stays are typically observation. Observation is billed as outpatient (Part B), and observation days do NOT count toward the 3 consecutive inpatient days Medicare Part A requires to qualify for SNF coverage after discharge, a common coverage trap for clients.

The range of settings a client may move through after a hospital stay: skilled nursing facility (SNF) for rehab/skilled nursing, inpatient rehabilitation facility for intensive therapy, group home for supported living, and home health for care at home.

The coordinated movement of a client between care settings or levels of care (e.g., hospital to home). Poorly managed transitions are a leading cause of preventable readmissions, so case managers verify follow-up appointments, medications, and support are in place.

Comparing a client's active medication orders against everything they are actually taking, at every transition of care, to catch omissions, duplications, incorrect dosing, or dangerous interactions before they cause harm.

Strategies that control healthcare spending without sacrificing quality, such as coordinating care to avoid duplicate testing, negotiating rates, steering clients to in-network or lower-cost sites of service, and preventing avoidable readmissions.

Palliative care manages symptoms and stress of serious illness and can be provided at ANY stage, alongside curative treatment. Hospice is end-of-life care for clients with a prognosis of roughly 6 months or less who have chosen to stop curative treatment.

A living will states treatment preferences in advance, while a durable power of attorney for healthcare (healthcare surrogate) names a decision-maker. These documents let a client's wishes guide care if they later lose the capacity to communicate.

Case managers coordinate across disciplines (physicians, nursing, social work, pharmacy, therapy) so the client receives a unified plan instead of fragmented, conflicting recommendations from each specialty working in isolation.

Applying case management approaches tailored to defined groups (e.g., pediatrics, geriatrics, maternity) rather than one-size-fits-all care, since risk factors, communication needs, and support systems differ significantly by population.

Using care/case management models and tools grounded in published research and validated outcomes data, rather than habit or intuition alone, to select interventions most likely to improve a specific client's results.

A reimbursement method where a payer (commonly Medicare) pays a predetermined, fixed rate for a service based on a classification system, such as Diagnosis-Related Groups (DRGs) for inpatient stays, regardless of the provider's actual costs.

A network of doctors, hospitals, and providers that voluntarily coordinates care for a defined patient population (often Medicare beneficiaries) and shares financial and quality accountability, earning shared savings if spending drops and quality targets are met.

TRICARE is the Department of Defense's health program for active-duty service members, retirees, and their families. VA health care (VHA) is a separate system for veterans, with eligibility and priority driven by service-connected disability rating rather than TRICARE enrollment. Case managers must route referrals and benefits verification to the correct system.

SSI (Supplemental Security Income) is a needs-based program funded by general tax revenue for aged, blind, or disabled people with limited income and resources. SSDI (Social Security Disability Insurance) is funded by payroll (FICA) taxes and requires enough work credits.

Utilization review (UR) is the evaluation of whether specific care meets medical-necessity criteria (pre-certification, concurrent, or retrospective review). Utilization management (UM) is the broader, ongoing process of planning and coordinating resource use across an episode of care.

Medicare is federal health insurance based on age (65 or older) or disability, with Part A (hospital, SNF, hospice), Part B (outpatient and physician services), Part C (Medicare Advantage, a private A+B alternative), and Part D (prescription drugs). Medicaid is a joint federal-state, means-tested program for low-income individuals; eligibility and covered benefits vary by state.

A behavior-change framework with five stages: precontemplation, contemplation, preparation, action, and maintenance. Case managers assess a client's stage to tailor interventions instead of pushing action-stage strategies on someone still in precontemplation.

A client-centered counseling style that helps clients explore and resolve their own ambivalence about change, rather than lecturing or persuading them. Core skills are open-ended questions, affirmations, reflective listening, and summarizing (OARS).

Short-term, immediate support aimed at stabilizing a client experiencing acute emotional, psychological, or physical distress, restoring safety and coping ability before longer-term case management planning resumes.

The non-clinical conditions that shape health outcomes: economic stability, education access, health care access, neighborhood and environment, and social/community context. Addressing SDOH gaps, like transportation or food insecurity, is core to case management.

An approach that recognizes the widespread impact of trauma, watches for its signs, and actively avoids re-traumatizing the client. Core principles include safety, trustworthiness, peer support, collaboration, and empowerment.

Case managers are trained to watch for unexplained injuries, poor hygiene, sudden withdrawal, fear of a caregiver, or unexplained financial changes, and to know their jurisdiction's mandatory reporting duty when abuse or neglect is suspected.

The simultaneous presence of a mental health disorder and a substance use disorder in the same client. Treating only one condition while ignoring the other typically leads to poor outcomes and relapse.

A client's capacity to obtain, process, and understand basic health information and services well enough to make appropriate health decisions. Low health literacy is linked to poorer adherence and higher readmission risk, so case managers assess and adapt communication accordingly.

The physical, emotional, and financial strain experienced by a client's informal, unpaid caregiver. Unaddressed caregiver burden can lead to caregiver burnout and jeopardize the client's own care plan, so case managers assess and support caregivers directly.

The ability to understand and respectfully respond to a client's cultural, spiritual, and religious beliefs when they affect care decisions, including awareness of the case manager's own cultural assumptions and biases.

A standardized set of performance measures, developed and maintained by NCQA, that health plans use to report on quality of care across areas like preventive screening, chronic disease management, and access to care.

The Joint Commission accredits hospitals and health systems. NCQA accredits health plans and provider organizations, and develops HEDIS. URAC accredits utilization management and case management programs specifically. Knowing which body accredits which type of organization avoids mixing them up on exam items.

The percentage of clients readmitted to a hospital within 30 days of discharge, a widely used quality and outcomes indicator. High rates often signal gaps in discharge planning, follow-up, or care transitions, which case managers directly work to close.

Using data analytics, such as a health risk assessment or an Adjusted Clinical Group score, to forecast which clients are likely to have high future costs or poor outcomes, so case management resources can be targeted proactively rather than reactively.

A payment and delivery approach that rewards providers for patient outcomes and quality rather than volume of services. Case managers support value-based care by coordinating care, closing care gaps, and preventing costly avoidable events.

ADLs (Activities of Daily Living) are basic self-care tasks: bathing, dressing, toileting, transferring, continence, and eating. IADLs (Instrumental ADLs) are more complex independent-living tasks: managing finances, medications, transportation, shopping, and meal prep.

Services that help a client with a disability or injury prepare for, obtain, or return to employment, such as job analysis, workplace accommodations, retraining, and job placement support.

An LTACH (Long-Term Acute Care Hospital) serves medically complex patients needing extended acute-level care. An IRF requires patients to tolerate intensive therapy, around 3 hours a day, 5 days a week. A SNF (Skilled Nursing Facility) provides skilled nursing and rehab at a lower therapy intensity.

Devices and equipment that help a client with a disability perform daily tasks more independently, such as mobility aids, home modifications, and communication devices like TTY/TDD for individuals who are deaf or hard of hearing.

A comprehensive, dynamic document built from current research and a full client assessment that projects the future medical, rehabilitative, and support needs, and associated costs, of someone with a catastrophic injury or chronic illness.

HIPAA requires that only the minimum amount of protected health information necessary to accomplish a specific purpose be used, disclosed, or requested, protecting client privacy even during legitimate care-coordination communication.

Federal law, effective 2022, that protects clients from unexpected balance billing for out-of-network emergency care and for certain non-emergency services received at in-network facilities, a key coverage protection case managers should know when coordinating care.

Requires Medicare-participating hospitals with emergency departments to provide a medical screening exam and stabilizing treatment to anyone who presents, regardless of ability to pay, and prohibits transferring or discharging unstable patients. Sometimes called the anti-'patient dumping' law.

The legal obligation, which varies by jurisdiction, requiring certain professionals, often including case managers, to report reasonably suspected abuse or neglect of a vulnerable client (child, elder, or dependent adult) to the appropriate authority.

A competent client's right to decline recommended treatment, including at end of life, after being informed of the risks of refusal. The case manager's role is to ensure understanding and document the refusal, not to override the client's autonomous decision.

CMSA Standards of Practice (and NASW's equivalent for social work-based case managers) describe HOW case management should be practiced: voluntary professional guidance. The Commission's Code of Professional Conduct for Case Managers is different: it is the BINDING ethical code CCM certificants must follow, tied to eligibility and renewal, with disciplinary consequences, including revocation, for violations.

Practicing self-care and monitoring for compassion fatigue and burnout is treated as a professional practice standard, not an optional extra, because an exhausted case manager is more likely to make errors that put clients at risk.

The case manager's ethical duty to represent and support the client's and support system's best interests, including helping the client navigate complex systems and speak up on their behalf when their needs are not being met.

Case notes and case summaries must be objective, factual, timely, and free of speculation or blame. Good documentation protects both the client's continuity of care and the case manager's own legal and professional standing.