Commission Glossary of Case Management Terms

Comprehensive vocabulary terms and definitions related to the practice of case management based on the official commission glossary.

AAPM&R

American Academy of Physical Medicine and Rehabilitation

Access to Care

The ability and ease of clients to obtain healthcare when they need it.

Accessible

A term used to denote building facilities that are barrier-free thus enabling all members of society safe access, including persons with physical disabilities.

Accountable Care Organization (ACO)

A set of healthcare providers including primary care physicians, specialists, and hospitals that work together collaboratively and accept collective accountability for the cost and quality of care delivered to a population of patients.

Accreditation

A standardized program for evaluating healthcare organizations to ensure a specified level of quality, as defined by a set of national industry standards.

Actionable Tort

A legal duty, imposed by statute or otherwise, owing by defendant to the one injured.

Active Listening

A structured way of communication and interacting in which one is actively engaged with the speaker primarily through focused attention and suspension of one’s own frame of reference, biases, distractions and judgment.

Activities of Daily Living (ADLs)

Routine activities an individual tends to do every day for self-care and normal living, including eating, bathing, grooming, dressing, toileting, transferring (such as walking, bed to chair) and continence.

Activity Limitations

Difficulties an individual may have in executing activities, ranging from a slight to a severe deviation in terms of quality or quantity compared to people without the health condition.

Actual Value

Also referred to as real value; it measures the worth one derives from using or consuming a good, product, service or an item, representing its utility.

Actuarial Study

Statistical analysis of a population based on its utilization of healthcare services and demographic trends, used to estimate healthcare plan premiums or costs.

Actuary

A trained insurance professional who specializes in determining policy rates, calculating premiums, and conducting statistical studies.

Acuity

Complexity and severity of the client’s health/medical condition.

Acute Care

Care delivery systems focused on treating sudden and acute episodes of illness such as medical and surgical management or emergency treatment.

Adaptive Behavior

The effectiveness and degree to which an individual meets standards of self-sufficiency and social responsibility for his/her age-related cultural group.

Adherence

The extent to which a person’s behaviour—taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.

Adhesive Contract

A contract between two parties where one party with stronger bargaining power sets the terms and conditions and the other party must adhere to the contract in a ‘take it or leave it’ position.

Adjusted Clinical Group® (ACG) System

Developed by Johns Hopkins University, this system clusters clients into $102$ discrete homogenous groups based on morbidity to improve accuracy in evaluating provider performance and identifying high-risk clients.

Administrative Services Only (ASO)

An insurance company or third-party administrator (TPA) that delivers administrative services to an employer group while the employer remains at risk for the cost of healthcare services.

Admission Certification

A form of utilization review assessing the medical necessity of a client’s admission to a hospital or other inpatient facility to ensure levels of care and length of stay are appropriate.

Admission Review

A review occurring within $24$ hours of admission (or as contractually required) to ensure inpatient care is necessary based on intensity of services needed.

Advance Directive

A legally executed document that explains the client’s healthcare related wishes and decisions, drawn up while the client is still competent for use if they become incapacitated.

Adverse Events

Any untoward occurrences which under most conditions are not natural consequences of the client’s disease process or treatment outcomes.

Advocacy

The act of recommending, pleading the cause of another; to speak or write in favor of.

AHRQ

Agency for Healthcare Research and Quality

Algorithm

The chronological delineation of the steps in, or activities of, client care to be applied in the care of clients as they relate to specific conditions/situations.

Ambulatory Payment Classification (APC) System

An encounter-based classification system for outpatient reimbursement (e.g., emergency departments, ambulatory surgery) where payment rates are based on categories of services similar in cost and resource utilization.

Ancillary Services

Diagnostic and therapeutic services involved in client care other than nursing or medicine, including respiratory, laboratory, radiology, nutrition, and various therapies.

Assessing

The process of collecting in-depth information about a client and her/his support system in order to identify needs and decide upon the best case management services.

Assignment of Benefits

Paying medical benefits directly to a provider of care rather than to a member, generally requiring a contractual agreement or written permission from the subscriber.

Assistive Technology

Any item, piece of equipment, or product system used to increase, maintain, or improve functional capabilities of individuals with disabilities.

Assumption of Risk

A doctrine based upon voluntary exposure to a known risk, involving a comprehension that a peril is to be encountered and a willingness to encounter it.

Autonomy

Agreement to respect another’s right to self-determine a course of action; support of independent decision making.

Bad Faith

Generally involving actual or constructive fraud, or a design to mislead or deceive another.

Benchmarking

The act of comparing a work process with that of the best competitor to identify what performance measure levels must be surpassed and implement best practices.

Beneficence

Compassion; taking positive action to help others; desire to do good; a core principle of client advocacy.

Beneficiary

An individual eligible for benefits under a particular plan, also known as members in HMO plans or enrollees in PPO plans.

Body of Knowledge (BOK)

A prescribed aggregation of essential knowledge in a particular field or specialty an individual is expected to have mastered to effectively practice and be considered a practitioner.

Brain Injury

Any damage to tissues of the brain that leads to impairment of the function of the Central Nervous System.

Capitation

A fixed amount of money per-member-per-month (PMPM) paid to a care provider for covered services regardless of whether the member uses health services once or multiple times.

Care Coordination

The deliberate organization of patient care activities between two or more participants (including the patient) involved in patient’s care to facilitate the appropriate delivery of health care services.

Care Management

A healthcare delivery process that helps achieve better health outcomes by anticipating and linking clients with services needed quickly and avoiding unnecessary services.

CARF

Commission on Accreditation of Rehabilitation Facilities; a private non-profit organization establishing standards of quality for services to people with disabilities.

Case Law

The aggregate of reported cases forming a body of jurisprudence, in distinction to statutes and other sources of law.

Case Management

A dynamic process that assesses, plans, implements, coordinates, monitors, and evaluates to improve outcomes, experiences, and value.

Case Mix Index (CMI)

The sum of DRG-relative weights of all patients/cases seen during a $1$-year period in an organization, divided by the total number of cases treated.

Case Reserve

The dollar amount stated in a claim file representing the estimate of the amount unpaid.

Catastrophic Illness

Any medical condition or illness with heightened medical, social, and financial consequences that responds positively to systematic case management effort.

Certified Nurse Life Care Planner (CNLCP)

A registered professional nurse holding board certification who develops client-specific lifetime plans of care applying the nursing process to estimate current and future healthcare needs.

Chronic Care Model

A systems model proposing elements for improving health care at community, organization, practice, and individual levels, including self-management support and decision support.

Claims Adjuster

An insurance professional who investigates claims, reviews records to determine liability and damages, and ensures medical care accessibility based on injury.

Clinical Review Criteria

The written screens, decision rules, medical protocols, or guidelines used to evaluate medical necessity, appropriateness, and level of care.

Coinsurance

A type of cost sharing in which the insured person pays or shares part of the medical bill, usually according to a fixed percentage.

Collaboration

A process requiring openness, mutual trust, and respect where individuals work jointly together to achieve a mutual goal or improve a situation.

Comorbidity

A pre-existing condition (usually chronic) that causes an increase in the length of stay by about $1$ day in $75\%$ of clients.

Concurrent Review

A method of reviewing client care during a hospital stay to validate the necessity of care, track resource consumption, and explore alternatives to inpatient care.

Conflict of Interest

A situation where an individual is in a position to exploit a professional capacity for personal benefits at the expense of others in the same organization or community.

Continuous Quality Improvement (CQI)

A component of total quality management using systematic organization-wide processes to achieve ongoing improvement in quality focusing on outcomes and processes of care.

Cost-Benefit Analysis

A systematic process used to calculate and compare benefits and costs of an action or intervention to determine if benefits outweigh the costs.

Cultural Competency

A set of congruent behaviors, attitudes, and policies that enables systems or professionals to work effectively in cross–cultural situations.

Deductible

A specific amount of money the insured person must pay before the insurer’s payments for covered healthcare services begin.

Diagnosis-Related Group (DRG)

A patient classification scheme relating the type of patient treated to costs incurred, used by CMS to pay hospitals for Medicare and Medicaid recipients.

Disability Management Program

A program focusing on assisting workers who have suffered occupational health conditions return to work and facilitating workplace accommodations.

Discovery

The process by which one party to a civil suit can find out about matters relevant to the case, including testimony, documents, and physical examinations.

Disease Management

A system of coordinated healthcare interventions for populations with chronic conditions in which client self-care efforts are significant and evidence-based practice guidelines are utilized.

Distributive Justice

Deals with the moral basis for the dissemination of goods and evils, burdens and benefits, especially when making decisions regarding the allocation of healthcare resources.

Durable Medical Equipment (DME)

Equipment needed by patients for self-care which must withstand repeated use, serve a medical purpose, and be appropriate for home setting use.

Efficacy of Care

The potential, capacity or capability to produce the desired effect or outcome, as shown through scientific research findings.

Eligibility

The determination that an individual has met requirements to obtain benefits under a specific health plan contract.

Emotional Intelligence

The ability to sense, understand, and effectively apply the power and acumen of emotions to motivate oneself, regulate mood, and empathize.

Episode of Care

A client’s access to healthcare services or encounter with a provider that is time-limited with a beginning and end.

Fidelity

The ethical principle that directs people to keep commitments or promises.

Fiduciary

A person in a special relationship of trust and responsibility who assumes a duty to act in the dependent’s best interest.

Functional Capacity Evaluation (FCE)

A systematic process of assessing an individual’s physical capacities to match human performance levels to the demands of a specific job or work activity.

Functional Independence Measure (FIM®)

An $18$-item instrument with an ordinal scale ranging from $1$ (total assistance) to $7$ (complete independence) used to evaluate the amount of assistance required by a client to perform basic life functions.

Gatekeeper

A primary care physician to whom a plan member is assigned, responsible for managing all referrals for specialty care and covered services.

Handoff

The act of passing accountability and responsibility for a client’s care from one clinician to another within a care setting or across care settings.

Health Risk Assessment (HRA)

An assessment conducted to identify the presence of risk and determine how such risk may influence health-seeking behavior.

Important Message from Medicare (IM)

A required notice delivered to Medicare beneficiaries hospitalized in acute care setting informing them of their hospital discharge appeal rights.

Independent Medical Examination

An evaluation completed by a healthcare professional not involved in the worker’s care to determine the cause, extent, and medical treatment of a work-related injury.

Informed Consent

Consent given for an intervention after the provision of sufficient information, based on knowledge of advantages, disadvantages, and implications.

Instrumental Activities of Daily Living (IADLs)

A set of skills necessary for independent living, including using a telephone, shopping for groceries, handling finances, meal preparation, and taking medications.

Interdisciplinary Care Team (ICT)

A team of professionals from different disciplines who share common care goals and have responsibility for complementary tasks and interventions to meet a client’s goals.

Justice

The ethical principle involving the idea of fairness and equality in terms of access to resources and treatment by others.

Knowledge Domain

A cluster of health and human services topics grouped together based on a common theme essential for the effective and competent performance of case managers.

Life Care Plan

A dynamic document based on published standards and data analysis providing an organized plan for current and future needs with associated costs for those with catastrophic injury.

Maximum Medical Improvement (MMI)

The point at which the medical condition of a worker who sustained a work-related injury has stabilized and further improvements are considered unlikely.

Medicaid

A joint federal/state program providing basic health insurance for persons with disabilities, who are poor, or who receive certain governmental income support benefits.

Medicare

A nationwide federally administered health insurance program; Part A covers inpatient hospital costs and Part B covers outpatient costs.

Medication Reconciliation

The process of examining all medications taken by a client to determine compatibility, necessity, and safety to reduce adverse drug affects.

Negligence

Failure to act as a reasonable person; behavior that is contrary to that of any ordinary person facing similar circumstances.

Never Events

Preventable healthcare events that are undesirable, rare, and devastating (resulting in death or serious disability), classified as medical errors.

Occupational Disease

A health condition or illness a worker experiences associated with job responsibilities or the work environment.

Outcomes Management

The use of information gained from outcomes monitoring to achieve optimal client outcomes through improved clinical decision making and service delivery.

Patient Centered Medical Home (PCMH)

An approach to providing comprehensive primary care that facilitates partnerships between individual clients, their support systems, and primary care providers.

Patient Self-Determination Act of 1991 (PSDA)

Refers to patients’ rights to specify if they want to accept or refuse specific medical care and identify a legal representative for urgent healthcare decisions.

Peer Review Organization (PRO)

A federal program monitoring the medical necessity and quality of services provided to Medicare and Medicaid beneficiaries under the prospective payment system.

PMPM

Per-member-per-month; the typical reimbursement method used by HMOs involving a fixed amount of money paid to a care provider for covered services.

Point of Service (POS Plan)

A managed care health insurance plan combining characteristics of HMO and PPO plans where members choose the approach at the point service is needed.

Predictive Modeling

An automated process using specialized software to create a statistical model of future behavior (such as healthcare utilization) based on predictors like age and gender.