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The Case Manager's Handbook

by: Mullahy, Catherine M.

The Case Manager's Handbook

by: Mullahy, Catherine M.

ISBN 13:
9780763731885
ISBN 10:
0763731889
Edition: 3rd
Format: Hardcover
Copyright: 03/01/2004
Publisher: Jones & Bartlett
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Summary

Written by an active and nationally recognized case management consultant, The Case Manager's Handbook, Third Edition is the ultimate how-to guide for Case Managers. It is designed to define good case management, examine the case management process, and present practical procedural information. Virtually every chapter has been revised. Packed with tried-and-true approaches to care and claims management, you'll find this book to be an excellent daily reference or a resource for a different approach. It can be used as a training guide for new case managers, or a teaching tool for client groups. Earn CE's in Case Management Now! CE Contact Hours based on this title are now available through Athena Forum! Visit http://www.athenaforum.com for more information. Instructor's Resources Online Now Available. Click on the additional resources button for access. Contact your sales representative for log in information.

Foreword

Preface

Acknowledgments

xxi

PART I PROFILE OF A CASE MANAGER

(164)

The Case Manager as Catalyst, Problem Solver, Educator

(22)

The Case Manager's Role

(1)

Case Management Is Not Equivalent to Managed Care

(2)

Medical Credentials and Expertise

(3)

A Definition of Case Management

(1)

Case Management Role and Functions

(3)

A Case Manager's Education, Clinical Preparation, and Life Experience

(3)

Appendix 1-A: CCM Eligibility Criteria for Certification as a Case Manager

(2)

Appendix 1-B: CCM Acceptable Employment Experience for Certification as a Case Manager, Essential Activities of Case Management, and Core Components of Case Management

(4)

Appendix 1-C: CCM Acceptable Case Management Employment Flowchart

(1)

The Case Manager's Universe

(14)

Important Contacts Among Health Care Providers

(1)

HMOs, PPOs, MCOs, IPAs, PHOs, IDSs, HCOs, and EPOs

(3)

Managed Care

(2)

Managed Competition

(1)

Complementary and Alternative Care

(3)

Standards of Care

(4)

Insurance Providers and Administrators

(8)

Basic Insurance and Administrative Company Players

(3)

Administrative and Customized Services

(1)

The Case Management Delivery System and Report Cards

(3)

Insurance Lines and Health Benefit Plans

(30)

Workers' Compensation

(10)

Auto Insurance

(1)

Indemnity Plans

(1)

Group Medical Plans

(2)

Disability Plans

(2)

Point-of-Service Plans

(1)

Consumer-Driven Health Care Plans

(2)

Diagnosis-Specific Benefits

(1)

Traditional Insurance Versus Self-Funded Plans

(2)

Stop-Loss Insurance Plans

(1)

Multiple-Employer Benefit Plans and Trusts

(1)

Viatical Settlements

(2)

Nontraditional Policies

(2)

Riders to Life Insurance Policies

(1)

Coordination of Benefits

(3)

Legal Responsibilities of the Case Management Profession

(40)

Patient Bill of Rights and Patient Confidentiality

(7)

Consent/Disclosure and Consent Authorization Forms

(3)

Medical Records

(1)

The Right To Know Versus the Need To Know

(1)

Disclosure Issues

(1)

Adequate Information

(1)

Contracts and Letters of Agreement

(1)

Legal Issues in Case Management

(7)

Legislation

(6)

Day-to-Day Practices

103

(1)

Getting Legal Information

104

(2)

Appendix 5-A: Written Agreement: Some Typical Provisions

106

(3)

Appendix 5-B: Legal Issues in Case Management Checklist

109

(4)

Appendix 5-C: AMA Evidence-Based Principles of Discharge and Discharge Criteria

113

(4)

Ethical Responsibilities of the Case Management Profession

117

(28)

Patient Rights and Case Manager Responsibilities

121

(7)

Codes of Ethical Conduct

128

(1)

Look to Your Resources

129

(2)

Appendix 6-A: CMSA Statement Regarding Ethical Case Management Practice

131

(3)

Appendix 6-B: Excerpts from the CCMC Code of Professional Conduct for Case Managers

134

(8)

Appendix 6-C: CMSA Ethics Survey

142

(3)

HIPAA: The Health Insurance Portability and Accountability Act

145

(20)

Title I and Title II

145

(1)

Resources

146

(2)

Appendix 7-A: Summary -- Notice of Privacy Practices

148

(17)

PART II CASE MANAGEMENT PROCEDURES

165

(210)

Communications

167

(26)

Communicating with Physicians

167

(8)

Communications with Patients and Families

175

(8)

Communications with Payer Sources

183

(3)

Communications with Legal Professionals

186

(2)

Communication Subtleties

188

(1)

The Right Mind-Set

189

(1)

Communication and Caring Overload: Burnout

189

(4)

The Case Management Work Format and Process

193

(106)

Gathering and Assessing Information

195

(1)

The R.I.P. Method of Conducting Interviews

196

(1)

Talking with the Referral Source

197

(11)

Case Finding and Targeting

208

(3)

Talking with the Patient

211

(18)

Talking with the Family

229

(2)

Talking with the Treating Physician

231

(6)

Telephonic Case Management

237

(9)

Independent Medical and Second Opinion Exams

246

(3)

Talking with Other Professionals

249

(9)

Planning

258

(4)

Reporting

262

(8)

Obtaining Approval

270

(5)

Coordination: Putting the Plan into Action

275

(6)

Follow-Up

281

(1)

Evaluating the Plan

282

(1)

Repeating the Process

283

(1)

Specific Case Management Activities

283

(2)

Stay on Point

285

(1)

Case Management Scenarios

286

(8)

Appendix 9-A: CMSA Standards of Practice for Case Management

294

(5)

Integrated Case Management: Preadmission, Concurrent Review, Utilization Review, Disease Management, and Case Management

299

(46)

Introducing Utilization Review to Client Groups and Plan Participants

301

(2)

The Preadmission and Concurrent Review Process

303

(11)

Timing Disease Management and Case Management Intervention

314

(2)

Preadmission and Concurrent Review Reports

316

(2)

Establishing an Effective Preadmission Review, Concurrent Review, Case Management, and Disease Management System

318

(18)

Preadmission Review, Concurrent Review, Disease Management, and Case Management Checklist

336

(2)

Fees: Capitated, Hourly, or per Case

338

(7)

Working Effectively with Claims Departments: Case Managers in Consulting Roles

345

(30)

Claims Department Structure and Operations

347

(3)

Computerization

350

(2)

Claims Issues

352

(1)

Indicators for Case Management

353

(6)

The Case Manager as Consultant

359

(3)

Tracking Claims by Group

362

(5)

Tracking Claims by Individual Claims Histories

367

(2)

Moving into the Consultant Role

369

(6)

PART III CASE MANAGEMENT ADMINISTRATION AND FINANCIAL CONSIDERATIONS

375

(146)

Financial and Quality Assurance Reporting

377

(86)

Dollars and Health Care

378

(4)

Negotiating Skills

382

(5)

Nuances between Negotiating with Providers and with Payers

387

(2)

Negotiating in a Managed Care Environment

389

(2)

Documenting Negotiated Arrangements

391

(6)

Cost-Benefit Analysis Reports

397

(6)

The Cost-Benefit Analysis Summaries

403

(1)

Quality Assurance Programs

404

(1)

Explaining Difficult Situations

405

(1)

Feedback from Patients

405

(10)

Sharing Questionnaire Results

415

(3)

Communicating Success

418

(2)

Appendix 12-A: Program Questionnaire and Facility Review for Case Managers

420

(6)

Appendix 12-B: Provider Service Agreements

426

(6)

Appendix 12-C: Expanded Cost-Benefit Analysis Summary

432

(19)

Appendix 12-D: Expanded Cost-Benefit Analysis Summary for Self-Funded Plan

451

(12)

Managing a Case Management Department: Your Role as Department Head or Independent Case Manager

463

(58)

Redefining Case Management

463

(3)

Becoming an Independent Case Manager

466

(1)

For Your Business or Department

467

(1)

Developing a Business Plan

468

(2)

Pricing the Market

470

(1)

Looking at the Competition

471

(3)

Networking and the Professional Community

474

(3)

The Business Community

477

(3)

Generating New Business

480

(8)

Hiring Additional Staff

488

(8)

The Search for Case Managers

496

(3)

Appendix 13-A: Sample Nurse Reviewer for Prenotification Department Position Description

499

(5)

Appendix 13-B: Sample Medical Case Manager Position Description

504

(6)

Appendix 13-C: Sample Director of Case Management Services Position Description

510

(6)

Appendix 13-D: Interview Evaluation Form

516

(1)

Appendix 13-E: Summary Evaluation Scale

517

(1)

Appendix 13-F: Competencies for Unit-Based Nurse Case Manager

518

(3)

PART IV TRENDS AND OPPORTUNITIES IN CASE MANAGEMENT

521

(60)

Case Manager Credentialing

523

(12)

Certified Case Manager (CCM)

523

(1)

The CCM Exam

523

(2)

Before CCM, to the Wide Array of Credentials

525

(1)

Certified Disability Management Specialist (CDMS)

525

(1)

Certified Occupational Health Nurse (COHN)

526

(1)

Certified Occupational Health Nurse-Specialist (COHN-S)

526

(1)

Certified Occupational Health Nurse/Case Manager - COHN/CM and Certified Occupational Health Nurse-Specialist/Case Manager (COHN-S/CM)

527

(1)

Certified Rehabilitation Counselor (CRC)

527

(1)

Continuity of Care Certification, Advanced (A-CCC)

527

(1)

Case Manager, Certified (CMC)

528

(1)

Care Manager Certified (CMC)

528

(1)

Registered Nurse-Nurse Case Manager (RN-NCM)

529

(1)

Certified Professional in Health Care Quality (CPHQ)

529

(1)

Case Management Administrator, Certified (CMAC)

529

(1)

Certified Rehabilitation Registered Nurse (CRRN)

530

(1)

Certified Social Work Case Manager (C-SWCM)

530

(1)

Certified Managed Care Nurse (CMCN)

530

(1)

Case Manager Associate (CMC-A)

531

(1)

Other Credentials and Credentialing Groups

531

(4)

Cultural Issues

535

(8)

Cultural Beliefs Will Affect the Delivery of Health Care Services

536

(1)

Integrating Linguistic Needs, Tribal Medicine, and Cultural Treatments

537

(1)

Health Care Funding

537

(1)

Developing Cultural Competency

538

(5)

Behavioral Health

543

(6)

Partnering Successfully with Behavioral Health Professionals

544

(1)

Behavioral Health Disease Management Programs

545

(1)

Resources

546

(3)

Dying in America

549

(20)

A Personal Story

549

(4)

Death Is Not an Option

553

(1)

Examining Your Own Feelings

554

(1)

Addressing the Issue of Death

555

(4)

DNR Orders

559

(2)

Pain Management

561

(1)

Hospice Care

561

(1)

Palliative Care

562

(1)

CMSA's 2002 ``Dying in America'' Survey

562

(3)

Appendix 17-A: Deciding about CPR: Do-Not-Resuscitate Orders (DNR): A Guide for Patients and Families

565

(4)

Industry Directions

569

(12)

E-Health

572

(2)

Demand Management: A Self-Care Case Management Model

574

(1)

24-Hour Coverage

575

(1)

Carve-Outs

576

(1)

Outsourcing

577

(1)

Lowering the Cost of Prescription Drugs

577

(1)

Case Managers Creating New Roles

578

(3)

PART V CASE MANAGEMENT IN ACTION: CASES IN PROFILE

581

(94)

Care at Home

583

(16)

Consumer Demand---and Ambivalence

585

(1)

The Case Manager as a Pivotal Link

586

(2)

Cases in Profile

588

(4)

Ongoing Support at Home

592

(1)

Importance of Feedback and Communication

593

(2)

Payment Concerns

595

(4)

Managing a Long-Term Case

599

(16)

Informing the Client

600

(1)

Level of Involvement

601

(1)

Importance of Ongoing Involvement

602

(1)

Changes in Long-Term Cases

603

(2)

Negotiating for Long-Term Care

605

(1)

Employing All Possible Resources

605

(1)

Long-Term Care of the Elderly

606

(2)

Implications of Long-Term Care for the Family

608

(1)

Implications of a Long-Term Case for the Case Manager

609

(2)

From Acute Care to Home Care: A Case History

611

(4)

Techniques for AIDS Cases

615

(20)

AIDS Remains with Us

615

(1)

The Disease Progression is Unique

616

(4)

Living with AIDS

620

(1)

New Drug Therapies - Every Dose, Every Day

621

(6)

Cases in Profile

627

(6)

Resources

633

(2)

Public Sector Case Management

635

(8)

New Directions in Public Sector Case Management

635

(2)

An Overview

637

(1)

Complications that Remain

638

(2)

Nonmedical Challenges Influence Outcomes

640

(3)

Cases in Profile

643

(32)

High-Risk Pregnancy

643

(2)

Long-Term Case Management for Chronic Disease Management

645

(3)

Pediatric Asthma

648

(3)

AIDS Management

651

(3)

Diabetes

654

(2)

Oncology Management

656

(3)

Morbid Obesity/Gastric Bypass

659

(5)

Pediatric: Long Term Feeding Disorder

664

(4)

Pediatric: Long-Term Rare Respiratory Disorder

668

(3)

Transplant Rejection of Small Bowel with Psychological Component

671

(4)

Appendix A Additional Resources

675

(20)

Appendix B Glossary

695

(24)

Appendix C Case Management and Health Care Web Sites

719

(4)

Index

723

(26)

About the Author

749

Amazon no longer offers textbook rentals. We do!

The Case Manager's Handbook

The Case Manager's Handbook

9780763731885

0763731889

Summary

Table of Contents

Supplemental Materials

Write a Review

Amazon no longer offers textbook rentals. We do!

The Case Manager's Handbook

The Case Manager's Handbook

9780763731885

0763731889

Summary

Table of Contents

Supplemental Materials

Write a Review

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