Health Care Coordination

Front 1

Public health - community health - population health- communication health

Back 1

PUBLIC-protecting and improving health of people and their communities

COMMUNITY-focuses on people and their role in their own and others health

POPULATION-treating patients in groups

COMMUNICATION-health education. Risk communication, health literacy

Front 2

List the resources (strategic partners) that are needed to meet individual healthcare needs.

Back 2

-Primary Care physicians-Outpatient clinics-Specialty care providers-Women’s Health (preventive care, Ob/Gyn services)-Therapists (e.g., physical, occupation, mental health)-Pharmaceutical support (traditional and specialty pharmacies)-Social workers

Front 3

Define health literacy

Back 3

The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions

Front 4

What is the goal for care coordination?

Back 4

Achieving the “Quadruple Aim”

-Improved physician experience-Improved patient outcomes-Lower Cost of Care-Improved Patient Experience

Front 5

What is the role of the care coordinator?

Back 5

Using resource partnerships not to just connect patients with the key services and levels of care necessary to achieve their healthcare goals, but also to help patients understand why these services are important. When cost is a barrier, the care coordination process also involves seeking low or no-cost public health options, or the services of organizations that receive private or government funds to provide care and services to various patient populations.

Front 6

Identify the goals of the ACO’s

Back 6

ahieving the "Triple AIM"

-Improving care quality

-Enhancing the patient experience

-Decreasing healthcare costs

Front 7

Identify and define clinical-community linkages.

Back 7

Resources that “help to connect health care providers, community organizations, and public health agencies so they can improve patients' access to preventive and chronic care services”.

Front 8

Discuss how health information technologies are used in a variety of care coordination activities.

Back 8

-Accurate and complete information about a patient's health, so providers can give the best possible care, whether during a routine visit or a medical emergency-The ability to better coordinate the care given, which is especially important if a patient has a serious medical condition-A way to securely share information with patients and their family caregivers over the internet, for patients who opt for this convenience; this means patients and their families can more fully take part in decisions about their healthcare-Information to help diagnose health problems sooner, reduce medical errors, and provide safer care at lower costs

Front 9

What are case management models?

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Case management models are based clinical reasoning skills that involve health care providers’ ability consider multiple value points in a patient’s care, based upon the clinical focus of the provider, clinical knowledge, and patient-specific factors

Front 10

What are the four steps the AIMS Model encompasses?

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-Patient engagement-Assessment and care plan development-Case management-Ongoing care as needed

Front 11

What kind of coordination does the Wraparound Care Model provide? For whom?

Back 11

Provide team-based care coordination for children and youth with complex behavioral health needs.

Front 12

Broker Case Model

Back 12

Provides very little direct service to the client

Front 13

Clinical Case Management Model

Back 13

Integrate the clinical acumen, personal involvement and environmental interventions needed to address the overall maintenance of the patients physical & social environment

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Strengths-Based Clinical Case Management Model

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Focus on empowering patients & their families

Front 15

What is the PCMH Medical Neighborhood Collaborative Care Model?

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An approach to providing high-quality, safe, continuous, coordinated, comprehensive care, with a partnership between patients and their personal health care team

Front 16

What is the greatest challenge of care coordination and case management?

Back 16

The fragmented nature of care transitioning, in which patients and providers may not always have the same information

Front 17

What is the case management process flow?

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-Patient engagement activities-Interview with the patient to gain their medical history as well, gain demographic information and learn the patient’s goals and needs-Construction of a Coordinated Care Conference for the assembly of a coordinated care team that will be led by a Lead Care Coordinator-Management of the care team and collaborative efforts as part of the case management process

Front 18

How do you set the stage using appropriate communication skills?

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-Greet patient appropriately and acknowledge the wait time if needed-Find out how the patient is feeling about the consultation-Introduce the computer into the coordinator-patient triad-Explain and reassure the patient of confidentiality of EMR

Front 19

Discuss and define the key communication skills used by health services coordinators.

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-Set the stage

-Elicit information

-Give information

-Understand the patient’s perspective

-End encounter

Front 20

Explain the importance of active listening.

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-Shows the patient that you care-Establishes trust in a healthcare professional-patient relationship-Lessens your chance of erroneous information capture or decision-making, based on your own assumptions-Increases the chances that you will procure pertinent information

Front 21

Define motivational interviewing and provide 2 strategies of when it would be useful and what you would say?

Back 21

Gathering information, engaging the patient and family, and building a trusting relationship -

Strategy #1: Ask a question that will prompt change talk as an answer. For example, “What are some things you can do to make sure you take you medication regularly?”Strategy #2: Ask for the pros and cons of both changing and staying the same. For example, “How will taking for medication lower your risk of hospital readmission? How will another hospital readmission (i.e., continuing to miss medication doses) impact you?”

Front 22

What is telemedicine?

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remote healthcare

Front 23

What is culturally competent care?

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ability for healthcare professionals to demonstrate cultural competence toward patients w/diverse values, beliefs & feelings

Front 24

Know the key behaviors and approaches for culturally competent care

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Collaborative relationship - Effective communication - Respectful care - Holistic perspective - Individualized care - Interprofessional coordination - Self-awareness - Empowerment - Interpersonal relationship - Cultural knowledge - Cultural skills

Front 25

What is evidence-based practice (EBP)?

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The results from the integration of available research, clinical expertise, and patient preferences to individualize care and promote effective care decision-making.

Front 26

What are the six-steps of the care coordination process?

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1. Client identification and selection

2. Assessment and problem/opportunity identification

3. Development of the case management plan

4. Implementation and coordination of care activities

5. Evaluation of the case management plan and follow-up

6. Termination of the case management process

Front 27

What is transitional care?

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activities that “prevent repeated and avoidable re-admissions and negative health outcomes after a hospital discharge.”

Front 28

What are the phases and the definition of the phases of the population care coordination intervention process?

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>data analysis and selection

*data that have been gathered are analyzed through the development of grouping registries.>assessment *the full interview and assessment of a specific client are reviewed and considered.

>planning *occurs after the identification of the potential services needed

>interventions *move the client toward improving his or her quality outcomes (goals).

>evaluations *an analysis of the plan, the interventions, and the outcomes

>individualization

*individualization of the plan to meet the needs of the client, the family, the environment, and the community

Front 29

What is DICE?

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Duration, Integrity, Commitment, and Effort

Duration - how long, start to finish

Integrity - project team’s performance and ability to achieve project goals within the defined timeline.

Commitment - dedication level of leaders to a change initiative.

Effort - overall impact on project team members and employees over and above their usual day-to-day work responsibilities.

Front 30

What is SWOT?

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Strengths, Weaknesses, Opportunities, and Threats

Front 31

What is ADKAR? Know what each letter stands for and the components.

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>Awareness - Individual awareness of the need for change

>Desire - Individual desire to participate and support the change

>Knowledge - Individual knowledge regarding how to change

>Ability - Individual ability to implement new skills and behaviors

>Reinforcement - Individual-level reinforcement for keeping newly acquired skills and behaviors in place

Front 32

Who verifies patient eligibility for services and verifies that the most clinically appropriate interventions were selected?

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Care utilization management (UM)

>>department leaders (i.e., medical director or clinical director) clinical reviewers, the case manager, and other administrative and nonclinical staff

Front 33

What is the safety net medical home initiative?

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continuous quality improvement process created and designed by the consulting firm Qualis Health.

Front 34

What are the four steps of the safety net medical home initiative?

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1.laying the foundation

2.building relationships

3.changing care delivery

4.reducing barriers to care

Front 35

What are two key parts of change management?

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1.readiness assessment

2.conducting a SWOT analysis to determine internal and external factors that are influential on the case management in its current state.

Front 36

What are the factors to consider when assembling a case management plan of care?

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1.Data gathering format2.Development strategiesF3.actors in patient acuity determination4.Verification of the appropriate resources and case management plans that allow UM-driven evidence-based clinical guidelines and clinical pathways that will lead to optimal patient health outcomes.

Front 37

What is a form of cognitive-behavioral therapy that assists individuals in reframing their thinking about the stressors in their lives to promote positive rather than negative perspectives?

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Cognitive reframing (CR), or cognitive restructuring

Front 38

What is motivational interviewing?

Back 38

a collaborative person-centered form of guiding to elicit and strengthen motivation for change

Front 39

What is the OARS method?

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encourages the use of OPEN-ended questions, AFFIRMATIONS, REFLECTIONS, and SUMMARIES during a conversational interview.

Front 40

What is a care intervention that can be used with individuals and families and focuses on looking at a problem-focused story of a client’s life?

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Narrative-based therapy

Front 41

What does cognitive and dialectical-based therapies focus on?

Back 41

Establishing the client’s biopsychosocial history through interviewing and asking open-ended questions. It allows the client to express his or her life events in the client's own words and provide insight to the interviewer on his or her thought processes.

Front 42

What is screening, brief intervention, and referral to treatment (SBIRT)?

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Short-term intervention that has been proven effective in a variety of healthcare settings and has led to a reduction in healthcare costs when successfully integrated into a healthcare practice's patient-centered care home model that provides both medical and behavioral healthcare and services.

Front 43

What is an effective means for defining short, intermediate, and long-term objectives of the care plan?

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Goal setting

Front 44

What should motivational interviewing (MI) promote?

Back 44

Increasing phases of change talk (open posture and increased motivation to change), while minimizing discord or sustained talk (closed posture and inclination toward reasons to resist change).

Front 45

Define information security.

Back 45

“the protection of information and information systems from unauthorized access, use, disclosure, disruption, modification, or destruction.”

Front 46

When should risk be assessed?

Back 46

based on where IT systems are physically located and how they are used, on an ongoing basis.

Front 47

How do employees protect the security of their system?

Back 47

Logging out when not in use and never sharing log-in information with another person.

Front 48

Accountable care organizations (ACOs) and the Health Information Technology for Economic Clinical Health Act (HITECH) provide guidance for?

Back 48

meeting specific standards, and they are evolving to standardize data to improve quality outcomes and cost containment, and to better meet the needs of the nation.

Front 49

What do care coordinators and IT professionals do after completing their risk assessment?

Back 49

implement administrative, physical, and technical safeguards to mitigate risks

Front 50

Define confidentiality, integrity, and availability.

Back 50

>>Confidentiality – the property that electronic health information is not made available or disclosed to unauthorized persons or processes.>>Integrity – the property that electronic health information have not been altered or destroyed in an unauthorized manner.>>Availability – the property that electronic health information is accessible and useable upon demand by an authorized person.

Front 51

List examples of administrative, physical, and technical safeguards.

Back 51

>>Examples of Administrative Safeguards• Continual risk assessment of your health IT environment.• Continual assessment of the effectiveness of safeguards for electronic health information.• Detailed processes for viewing and administering electronic health information.• Employee training on the use of health IT to appropriately protect electronic health information.• Appropriately reporting security breaches (e.g., to those entities required by law or contract) and ensuringcontinued health IT operations.

>>Examples of Physical Safeguards• Office alarm systems.• Locked offices containing computing equipment that store electronic health information.• Security guards.

>>Examples of Technical Safeguards• Securely configured computing equipment (e.g., virus checking, firewalls).

Front 52

Define EHR

Back 52

“an electronic record of health-related informationon an individual that conforms to nationally recognized interoperability standards and that can becreated, managed, and consulted by authorized clinicians and staff across more than one healthcare organization,”

Front 53

The HIPAA privacy rule covers information designated as patient protected health information (PHI), which is information that?

Back 53

>>Relates to a person’s physical or mental health, the provision of healthcare, or the payment for healthcare>>Identifies the person who is the subject of the information>>Is created or received by a covered entity>>Is transmitted or maintained in any form (paper, electronic, or oral)

Front 54

Healthcare organizations have a legal and ethical obligation to?

Back 54

protect their health information systems from security breaches both inside and outside of their organizations

Front 55

Regulatory oversight related to the unauthorized disclosure of an individual’s health information might come from one of three sources?

Back 55

>>Federal Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security, and Breach Notification rules (Titles I and II)>>State privacy laws>>Federal Trade Commission (FTC) Act for consumer protection protects against unfair or deceptive practices1

Front 56

There are several practical measures that care coordinators may employ to protect patient data and the devices that access or store this information, including?

Back 56

follow all the protection requirements of an organization to prevent the breach of information. Securing mobile devices with a password or bio print is a good method of securing them.

Front 57

What is the difference between Fee-for-service and value-based financial models?

Back 57

Value-based care models shift the healthcare system to rewarding physicians for quality of care provided, rather than a fee-based system with a quantity over quality focus.

Front 58

Explain the purpose of Accountable care organizations (ACOs)?

Back 58

ACOs provide coordinated care services to patients with complex health issues, with the goal of reducing hospital readmission and improving patient compliance in community settings.

Front 59

Explain the rules and regulations of Patient Protection & Affordable Care Act (ACA).

Back 59

make health coverage more fair and easy to understand. also expands medicaid program to cover more people with low incomes.

Front 60

What are DRGs? How are they used? And what their purpose?

Back 60

Diagnostic Related Groups (DRGs) are a patient classification system that was first implemented by the Healthcare Financing Administration to help control and standardize costs for inpatient services billed to Medicare HMSA Providers Resource Center (2018)

Front 61

What is utilization management (UM)?

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Utilization Management is the responsibility of every member of the healthcare team, from the standpoints of quality of care and cost containment.

Front 62

Failure to meet utilization standards may result in what?

Back 62

may result in lower reimbursement rates or reimbursement claim denials

Front 63

Define chronic illness, palliative care, hospice care, and quality of life.

Back 63

>>Chronic illness lasts 1 or more year

>>Palliative care is a simple, focused care to improve the comfort of the client in a familiar environment.

>>Hospice care is a subset of palliative care that is focused on terminal patients at the end of life, usually terminal with six months or less to live.

>>quality of life (QOL) as the general well-being of individuals and societies, outlining negative and positive features of life.

Front 64

Compare and contrast palliative and hospice care?

Back 64

both provide comfort - palliative care can begin at diagnosis & at the same time as treatment - hospice care begins after treatment of the disease is stopped and when it is clear that the person is not going to survive the illness.

Front 65

When is palliative care used?

Back 65

when someone is living with a serious illness

Front 66

Explain the parts of Medicare and qualifying for Medicare Hospice benefits.

Back 66

>>Medicare Part A is very rarely paid for, as many people qualify for free Part A coverage as a result of working, or a spouse working, for at least 10 years in the United States and paying Medicare taxes.

>>Medicare Part B is medical insurance and helps cover the costs associated with doctor’s visits, medical equipment, outpatient hospital care, and other services.

>>Medicare Part C concerns Medicare Advantage plans. Medicare Advantage plans offer all Part A and Part B benefits and include additional offerings such as vision, dental, and hearing, with some plans including prescription drug coverage as part of their offerings.

>>Medicare Part D is prescription drug coverage. Part D is a standalone program offered by private Medicare-approved plans. Many Part D offerings are bundled with Part A and Part B to form Medicare Advantage plans.

>>>>>Your loved one must have Medicare Part A coverage to quality for the Medicare hospice benefit.>>>>>Your loved one’s and the hospice’s medical director must certify that your loved one has 6 months or less to live.

>>>>>Your loved one, your loved one’s family, or the person legally designated to speak on your loved one’s behalf, must state the acceptance of palliative care instead of seeking curative measures for the terminal illness.

>>>>>Your loved one must formally elect to pursue hospice care with a specific hospice organization.

Front 67

Identify costs that Medicare Hospice benefits do not cover.

Back 67

Curative treatments-Care not provided by or arranged by the hospice care organization-Emergency room care unrelated to the terminal illness-Inpatient facility care unrelated to the terminal illness-Ambulance transportation-Room and board costs

Front 68

What is an important part of the decision to pursue hospice or palliative care?

Back 68

has to do with payer sources and the level of hospice care a patient wishes to receive.

Front 69

What is the difference between certified and credentialed?

Back 69

Credentialed means being appointed to work in the field of care management. Certification is a process whereby a person must prove that they have completed the necessary prerequisite education by taking and passing a certification exam.

Front 70

Who sets regulatory and practice standards for those possessing credentials in the healthcare environment?

Back 70

Certifying bodies and agencies that govern healthcare organizations set regulatory and practice standards for those possessing credentials in the healthcare environment.

Front 71

What are ethical standards and ethical training?

Back 71

Ethical standards allow individuals to apply moral values to our behaviors and decision-making, and ethics training is essential to ensure healthcare professionals are aware of these standards.

Front 72

What are the ethical principles of beneficence, non-maleficence, autonomy, and justice?

Back 72

>BeneficenceThis principle requires that everything should be done in the best interest of the patient.

>Non-maleficencePrimum non-nocere, refrain from harm-Non-maleficence needs to be considered the moment the diagnosis is communicated.

>AutonomyPatient's sense of autonomy is a key issue of quality of life and goes beyond being physically autonomous to perform an action. Autonomy also encompasses the sense of capability to take decisions and the feeling of being an author of one's own action

>JusticeThis ethical principle of care requires that all patients are treated in an equal way without prejudice or social discrimination.

Front 73

What may be utilized to provide a care team member with guidance for navigating ethics issues or ethical dilemmas concerning their work?

Back 73

Resources, such as ethics committees or ethics consultant services

Front 74

What is effective communication and why is it important?

Back 74

Effective communication between patients and the critical care team is central to ensuring that a client’s needs are met and for continuity to be maintained throughout the care plan.

Front 75

What are the pros and cons of social media use?

Back 75

Social media communities have the capacity to disseminate information—positive and otherwise—at a scale that was never possible before. The only drawback of some forms of social media, like Twitter, is that the content must be brief in nature, which could create inaccurate perceptions of content. Additionally, social media content exposure is often tied to an individual’s demonstrated interest, so information may be siloed and not reach as wide an audience as possible.

Front 76

Discuss modes of communication that is not HIPPA compliant.

Back 76

the use of personal communication devices such as smartphones and tablets to relay messages, information, or images.

Front 77

Discuss care team supervision and why it is important.

Back 77

A key aspect of supervision is listening and observing to gain a clear picture of each employee’s capabilities, strengths, and opportunities for improvement. Supervision also entails providing regular performance reviews via effective coaching and instructive feedback on an employee’s work: what they are doing well and how they may improve when mistakes are made. These techniques provide employees with support, show them their value, and motivate them towards improvement.

Front 78

What is self-reflection and why is it important?

Back 78

Self-reflection is a means of improving and advancing one’s ability to provide the highest-level of quality care possible.

Front 79

What is constructive criticism and why is it important?

Back 79

Constructive criticism is based on providing an analysis of a personal skill set and then presenting them in a non-hurtful manner to assist the individual grow in their position or person.

Front 80

What is professional behavior and etiquette?

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Professional etiquette is important to ensure that members of the healthcare team present a professional image and treat patients and other staff with professionalism and courtesy.

Front 81

What is care coordination?

Back 81

Care coordination synchronizes the delivery of a patient’s health care from multiple providers and specialists.

Front 82

What is evidence-based practice and how can it help the patient?

Back 82

Evidence-based practice uses a variety of sources of clinical research expertise, and patient-specific factors as part of care decision-making.

Front 83

What is cultural sensitivity?

Back 83

being aware that cultural differences and similarities between people exist without assigning them a value

Front 84

What is Concierge Healthcare?

Back 84

focuses directly on the relationship between the physician and the patient through a set monthly payment, which does not involve any insurance payments.

Front 85

What is certification and credentialing?

Back 85

Certification is an assessment-driven validation of the knowledge and application of care coordination in the field and validation of knowledge and critical thinking skills to successfully implement a quality outcome for the client.Credentialing is an affirmation of the working knowledge of care coordination in the field with having met the requirements for certification.

Front 86

Medical-Surgical Nursing Certification Board (MSNCB)

Care Coordination and Transition Management (CCTM)

(2) two CCTM certifying bodies: the American Academy of Ambulatory Care Nursing (AAACN) and the American Ambulatory Credentialing Center for Care Coordination and Transformation.

Back 86

MSNCB - certificate for care coordination & transition management.

CCTM - certifying bodies for the AAACN & the American mbulatory Credentialing Center for Care coordination & transformation

Front 87

Population Health

Back 87

The health outcome of a group of individuals

Front 88

Public Health

Back 88

More focused on creating conditions in which individuals can be healthy - large scale concerns like tobacco & alcohol use, vaccination & disease prevention, injury & illness avoidance, healthy behaviors & minimizing outbreaks

Front 89

Community Health

Back 89

similar to population & public health, more geographically based, broader spectrum of issues like influincing public policy, creating shared community resources & holistic approach to healthcare.

Front 90

Empanelment

Back 90

The act of assigning individual patients to individual primary care providers (PCP) and care teams with sensitivity to patient and family preferenceThe basis for population health management and the key to continuity of care