CMSA's Core Curriculum for Case Management

by Powell, Suzanne K.; Ignatavicius, Donna D.

• ISBN13: 9780781724548
• ISBN10: 0781724546
• Format: Paperback
• Copyright: 2000-09-29
• Publisher: LWW

Summary

This text contains the core body of knowledge for case management practice as delineated by the CMSA (Case Management Society of America), the largest professional organization of case managers. The core curriculum contains essential elements, concepts and vision for current and future case management practice. Content is presented in a quick reference/outline format. Numerous U.S. and international case management practices also are presented. Key learning objectives, terms and concepts are provided, as well as updated information for case managers and hospital administrators.

Table of Contents

Introduction to Case Management Concepts	1	(19)
Marlys A. Severson
Introduction	2	(1)
Key Definitions	3	(2)
Case Management Models	5	(4)
Target Patient Populations	9	(1)
Case Management Philosophy	10	(1)
Case Management Role	10	(1)
Purpose and Goals of Case Management	10	(1)
Case Management Functions	11	(1)
Essential Job Activities	11	(2)
Core Components of Case Management---Case Management Domains	13	(1)
Case Management Knowledge Areas	14	(2)
Case Management Skill Set	16	(1)
Practice Settings	17	(1)
Case Management Practitioners	18	(1)
The Case Management Process	19	(6)
Patricia M. Pecqueux
Introduction	20	(1)
Key Definitions	20	(1)
Stages of the Case Management Process	21	(4)
Disease Management	25	(10)
Suzanne K. Powell
Introduction	26	(1)
Key Definitions	26	(1)
Driving Forces That Lead to Disease Management Programs	27	(2)
Components of a Successful Disease Management Program	29	(1)
Development and Design of a Disease Management Program	30	(2)
The Case Management and Disease Management Process	32	(3)
The Health Care Delivery System and Managed Care	35	(14)
Penny M. Burman
Introduction	36	(1)
Key Definitions	36	(2)
Driving Forces Behind Managed Care	38	(1)
Components of Managed Care	38	(1)
Health Care Delivery Systems	39	(4)
Reimbursement Methods	43	(1)
Objections to Managed Care	44	(1)
Legal Issues Facing Managed Care	45	(1)
Other Issues in Managed Care	45	(1)
Types of Insurance	46	(3)
Utilization Management/Resource Management	49	(16)
Carol Canada
Rufus Howe
Cheri Lattimer
Pat Stricker
UM Goals	50	(1)
History of Managed Medical Care	50	(1)
Impact of Managed Care	51	(1)
Basic Concepts of Reimbursement	52	(1)
UM Concepts and Definitions	53	(1)
Key Definitions	53	(1)
Tools and Strategies	54	(1)
Utilization Strategies and Modalities in the Acute Care Environment	54	(4)
HCIA Standards	58	(1)
Processes Within the UM Workflow	59	(1)
UM in the Acute Care Environment	60	(1)
UM in the Managed Care Environment	60	(1)
Program and Process Modalities	60	(1)
Utilization Strategies and Modalities in the Managed Care Environment	61	(1)
Appeal Process	61	(1)
Denials of Admission or Services	62	(1)
Appeals	62	(1)
Adverse Review Determination	62	(1)
Medical Review Outcomes	63	(1)
Key Regulatory and Accreditation Bodies Associated With the Process of UM	63	(1)
UM Regulatory and Accreditation Processes	63	(2)
Legal Issues in Case Management	65	(18)
Lynn Muller
Introduction	67	(1)
Background	68	(6)
Contracts	74	(1)
The Case Manager and the Legal Community	75	(2)
Frequently Asked Questions	77	(6)
Ethical Issues in Case Management	83	(6)
Patricia M. Pecqueux
Introduction	84	(1)
Key Definitions	84	(1)
Ethical Principles	85	(4)
Quality Reviews and Risk Management	89	(10)
Patricia M. Pecqueux
Nancy Claflin
Introduction	90	(1)
Key Definitions	90	(1)
Quality Improvement Activities	91	(1)
Risk Management	92	(1)
Similarities Between Quality Improvement and Risk Management	92	(1)
Risk Management Program	92	(3)
Implications of Age and Culture for Risk Management	95	(2)
The Case Manager's Role in Quality and Risk Management	97	(2)
Credentialing, Accreditation, Standards, and Pathways in Case Management	99	(16)
Gary Wolfe
Introduction	100	(1)
Credentialing Case Managers	100	(2)
Certification for Case Managers	102	(1)
Specific Certifications in Case Management	103	(3)
Other Certifications	106	(1)
Accreditation of Organizations Performing Case Management	106	(5)
Standards of Practice for Case Management	111	(1)
Pathways	112	(3)
Case Management Tools and Technology	115	(30)
Nancy Nasuti Whipple
Introduction	116	(1)
Key Definitions	117	(6)
Goals of a Case Management Information System (CMIS)	123	(1)
Limitations of a CMIS	124	(1)
Benefits of a CMIS	125	(1)
CMIS Supporting Standards of Care	126	(2)
Features of a CMIS	128	(2)
CMIS Functional Requirements	130	(2)
CMIS Data Requirements	132	(1)
CMIS Data Content Requirements	133	(1)
CMIS Clinical Content Development	133	(2)
Selecting and Implementing a CMIS	135	(4)
Clinical Pathways	139	(1)
Clinical Protocols	140	(1)
Other Technology Tools Available to the Case Manager	141	(4)
Workers' Compensation Case Management	145	(36)
Sharon Brim
Introduction	146	(1)
Definitions	146	(1)
Historical Perspective	147	(1)
Basic Aims of All Workers' Compensation Programs	148	(1)
Understanding the Impact of Workers' Compensation Costs	148	(1)
Fitting the Pieces Together; Medical Case Management in the Workers' Compensation System	149	(1)
Historical Application of Medical Case Management in Workers' Compensation	149	(1)
Adapting Case Management Practices to Workers' Compensation Structure	150	(3)
Workers' Compensation Laws That Directly Affect Case Management Practice	153	(1)
State Workers' Compensation Laws That Directly Impact Case Management Practice	153	(2)
Practicing the Case Management Process Within a Workers' Compensation Structure	155	(1)
Medical Case Management Processes Used in Workers' Compensation	155	(2)
Frequently Encountered Requirements for Workers' Compensation Case Managers	157	(2)
Most Common Settings for Workers' Compensation Case Managers	159	(1)
Scope of Medical Management in Workers' Compensation Settings	160	(1)
Applying the Case Management Process	161	(13)
Ethical and Legal Considerations for Workers' Compensation Case Managers	174	(1)
Case Managers Are Guided by Ethical Principles	174	(1)
Applying Ethical Principles to Case Management	174	(2)
Legal Issues for the Workers' Compensation Case Manager	176	(1)
Trends in Workers' Compensation Case Management	176	(1)
Cost-Containment Programs	177	(1)
Relating Workers' Compensation Case Management to 1990s Federal Legislation	177	(2)
Documenting Quality of Services by Outcome Measurements	179	(2)
Disability Case Management	181	(14)
Lesley Wright
Martha Heath Eggleston
Deborah V. DiBenedetto
Introduction and History of the Disability Management Movement	182	(1)
Key Definitions	183	(2)
Important Terms and Concepts	185	(1)
Driving Forces That Led to Disability Management Programs	186	(2)
Building a Successful Disability Management Program	188	(1)
Factors Important in the Development and Design of a Disability Management Program	189	(2)
Stages of the Case Management and Disability Process	191	(4)
Occupational Health Case Management	195	(18)
Deborah V. DiBenedetto
Introduction	196	(1)
Key Concepts of Occupational Health Case Management	197	(4)
Maximizing Workforce Health and Productivity	201	(1)
Regulations That Impact OH Case Management and Return to Work	202	(1)
Purposes of the Occupational Health Case Management Program	203	(1)
Models of OH Case Management	203	(1)
Functions of OH Case Management	204	(1)
Structural Elements of the OH Case Management Process	204	(1)
Characteristics of Integrated Disability Programs	205	(1)
The OH Case Management Process	205	(2)
Base of Knowledge Required for OH Case I Managers	207	(2)
Key Tools and Processes in OH Case Management	209	(2)
Return-to-Work Programs	211	(1)
Importance of OH Case Management to Business and the Nation	212	(1)
Behavioral Health Case Management	213	(18)
Susan Gregory
Introduction	213	(4)
Key Definitions	217	(1)
Commonly Occurring Behavioral Health Care Conditions and Their Implications for Case Management	217	(7)
Treatment Methodology	224	(1)
Assess for High-Risk Behavioral Health Disorders	225	(1)
Evaluate Treatment Effectiveness in Behavioral Health	226	(2)
Understand the Role of Alternative and Complementary Medicine (ACM) in the Treatment of Behavioral Health Disorders	228	(1)
Insurance Coverage and Financial Assistance	228	(1)
The Behavioral Health Patient and the Employer	228	(3)
Maternal-Infant Case Management	231	(14)
Lori A. Davis
Pat Orchard
Introduction to Maternal-Infant Case Management	231	(1)
Key Definitions	232	(1)
Role of the Maternal-Infant Case Manager	233	(1)
Assessment	233	(1)
Knowledge Domains	234	(1)
Case Management Concepts	235	(2)
Physical and Psychosocial Aspects	237	(1)
Benefit Systems and Cost-Benefit Analysis	237	(1)
Community Resources	238	(2)
Coordination and Service Delivery	240	(2)
Preterm Labor and Delivery	242	(3)
Pediatric Case Management	245	(16)
Lori A. Davis
Introduction	245	(1)
Key Definitions	246	(1)
Pediatric Case Management Models	246	(1)
The Case Management Team	247	(1)
The Child	248	(3)
The Nuclear Family	251	(1)
After Hospitalization	252	(3)
Identifying Cases With Potential High-Risk Complications	255	(2)
Cost-Benefit Analysis	257	(1)
Community Resources	258	(3)
Geriatric Case Management and Continuum of Care	261	(22)
Sherry L. Aliotta
Linda N. Schoenbeck
Introduction	262	(1)
Key Definitions	263	(1)
Aging in Place	263	(2)
Common Geriatric Problems	265	(5)
Identification of High-Risk Geriatric Patients	270	(3)
Comprehensive Geriatric Assessment	273	(1)
Geriatric Assessment for Placement of the Geriatric Patient	274	(1)
Levels of Care for the Geriatric Patient	275	(4)
Insurance Coverage	279	(1)
Financial Assessment	279	(1)
Resources	280	(3)
Leadership Skills and Concepts	283	(10)
Suzanne K. Powell
Donna Ignatavicius
Introduction	284	(1)
Key Definitions	284	(1)
Leadership Skills	284	(1)
Negotiation Skills	285	(2)
Critical Thinking and Decision-Making	287	(1)
Delegation Skills	288	(1)
Cost-Benefit Analysis	289	(1)
Case Management Outcomes and Budgetary Issues	290	(1)
Case Managers as Change Agents	291	(2)
Outcomes Management	293	(10)
Sherry L. Aliotta
Introduction	294	(1)
Key Definitions	294	(1)
Defining Outcome Measurement	295	(1)
The Rationale for Outcomes Measurement	295	(1)
Common Categories of Outcome Indicators	296	(1)
Characteristics of Effective Outcome Measures	296	(1)
Incorporating Outcome Measurement Into Practice	297	(2)
Resources and Initiatives for Outcome Measures	299	(2)
Key Issues in Outcomes Reporting	301	(2)
Continuous Quality Improvement	303	(18)
Suzanne K. Powell
Introduction	304	(1)
Key Definitions	304	(1)
The CQI Gurus	305	(1)
Tools for Process Improvement	306	(6)
Continuous Quality Improvement Problem-Solving Methodologies	312	(2)
Case Managers Working in Project Teams	314	(2)
Decision-Making Techniques for Process Improvement	316	(5)
Complementary and Alternative Medicine (CAM)	321	(16)
Janice E. Benjamin
Introduction	322	(1)
Alternative Whole Health Care Systems	323	(2)
Mind-Body Medicine	325	(1)
Musculoskeletal Therapies	326	(2)
Chiropractic Manipulation	328	(1)
Bio-energy Therapies	328	(1)
Herbal Medicine	329	(1)
Nutritional Supplementation	330	(1)
Clinical Integration of CAM	330	(3)
Implications for Case Managers	333	(4)
Index	337