ACM™ Certification Review: Case Management Process and Practice

ACM™ Certification Review: Case Management Process and Practice

Topics for Discussion Preparing for the ACM™ Examination
Structure of the ACM™ Examination Domain Introduction and Overview Screening and Assessment Planning Care Coordination, Intervention and Transition Management Evaluation ACM™ Examination Testing Strategy Applying Information Gathering and Critical Thinking Skills Applying for and Earning the ACM™ Credential

ACMA-Approved Trainer Bio
Name, Credentials Title, Company Background

Preparing for the ACMTM Examination
Determining Eligibility, Readiness and making a Plan

Are You Ready for the ACMTM Examination?
Are you a registered nurse or social worker? Do you have at least 1 year of experience in Health Care Delivery System Case Management? Do you know your strengths and weaknesses? Do you have good critical thinking skills? Am I Ready to Take the ACM Examination? One of your first questions may be whether you are at an appropriate point in your career to take the exam. Here are some questions that will help you decide: ☐ Are you a registered nurse or a social worker? A Registered Nurse (RN) applicant must possess a valid and current nursing license. RN applicants must provide a nursing license number, state and expiration date. Social Worker (SW) applicants must have a Bachelor's or Master's degree from an accredited school of social work OR a valid social work license. SW applicants must provide the degree, name of school and year of completion OR a current social work license number, state and expiration date. *If an applicant meets the eligibility requirements of both an RN and SW, they must indicate which exam they wish to take and provide the applicable documentation of eligibility. ☐ Have you been practicing in hospital or health system case management for at least one year? All applicants must have at least one (1) year**, or 2,080 hours, of full-time, supervised, paid work experience employed as a case manager, or in a role that falls within the Scope of Services and Standards of Practice of a case manager, by a Health Delivery System. **Candidates with less than two (2) years of experience must provide supervisor contact information and an attestation that they have at least one (1) year of supervised case management experience on the ACM™ application. The NBCM recognizes that because case management experience, supervision and education, some case managers may be qualified to sit for the exam after only one (1) year of experience. *Paid or unpaid internship experience does not count toward full-time work experience. ☐ Do you have a good understanding of regulations that impact case management practice? ☐ Do you have a good understanding of case management principles and processes across general patient populations and the health care continuum? ☐ Can you use critical thinking skills to apply knowledge to clinical situations? If you answered ‘yes’ to each of these questions, you are probably ready to prepare for the ACM exam. If you answered ‘no’ to any of these questions, you have identified a knowledge or skill gap that needs to be closed before you take the ACM exam, and you may wish to spend extra preparation time in that area.

Your Plan for Success Use a multi-component approach:
ACM Candidate Handbook Accredited Case Manager Certification Study Guide, 2nd Edition, Electronic Guide Exam Prep Workshop Practice tests and self-assessment exams Other reading/study materials Study groups with other candidates Relevant laws and regulations SG: CH 1, pg 3-4 (there are no page numbers in the second edition) This course should be one part of your preparation plan, and should be supplemented with: -Careful reading of the ACM Candidate Handbook- Step One -Reading the ACM Study Guide at least once- The Study Guide was written by a team of nurses and social workers who had their ACMs, is designed to teach to the test, or what they believe test would consist of. Each author has only seen the test that they were presented when they took the exam for ethical reasons. For the second edition, the authors incorporated user feedback from the first edition along with the experiences of those who recently took the exam. One of the questions we get a lot is “How come you don’t have a printed version of the ACM Study Guide?” It’s actually deliberate because the ACM Exam is exclusively electronic and we knew that for a lot of people the experience of an electronic exam would be new and our mission is to get you ready for the test, not to teach you case management practice, this isn’t Case Management 101. Part of that is giving candidates immersion therapy in electronic media. - Exam prep workshop - Practice Test and Self Assessment Exam- helps get you accustomed to the content and the format -Reading other materials, such as ACMA’s Compass, CMS documents, and materials for areas you have identified as a personal weakness. For example the CMS Conditions of Participation. -Possibly working with other ACM candidates in study groups -Relevant laws and regulations at a NATIONAL level, you will not need to know state laws for the exam.

Your Plan for Success Plan to study at least 5 days a week in short segments Time-spaced repetition in study is key to retention! ID strengths and weaknesses and dedicate study time accordingly SG: CH 1, pg 3-4 You should plan to -Adults learn better through time spaced repetition, so set aside time to study at least 5 days per week in short manageable segments - Start early and make a plan -Use the test questions to identify your weaknesses and seek out additional information -seek to understand why you missed a question- was it content or question wording that was your downfall?

www.ACMAweb.org What to Study SG: CH 1, pg 5
As you set out your study plan, here’s a list of what to make sure you cover. -The ACM Candidate Handbooks and Study Guide give you important core information about the exam and it’s content -CMS Conditions of Participation define the regulatory requirements and boundaries for case management practice. Some of you may know that there are new Conditions of Participation regarding Discharge Planning likely to come out this year. Those will not be reflected on the exam because they would not have been in the exam development cycle. Links to these documents can be found in the ACM Study Guide. -A comprehensive case management training source, such as Compass, or a reputable and up to date case management text. -The ACMA Standards of Practice and Scope of Services. -Additional material from areas you identify as needing more development. These areas will be unique to each individual, and you may identify additional areas where you may have gaps for this list as your study plan progresses.

What NOT to Study The ACMTM exam content is common to Health Care Delivery System Case Management nationwide. No need to study: State-specific Medicaid regulations Employer policies Proprietary products Local or state policies for specific populations Any very recent or proposed regulations i.e. Medicare Outpatient Observation Notice Rule (MOON) SG: CH 1, pg 6 Just as important as what to study, is knowing where not to spend your time and energies. -The ACM is a national exam, so state specific programs and policies, such as Medicaid programs, will not be on the test. Candidates should possess an understanding of how the Medicaid program works. For example, Medicaid is generally administered by the states with federal matching money (may be important to know). What are important are policies that apply at a national level. -Employer policies, including employer interpretation of federal guidelines. Remember that an employer may impose higher standard of stringency than what is prescribed by CMS and may incorporate state and corporate expectations into policies. Candidates should not equate familiarity with employer policies as knowledge of CMS regulations. -Proprietary products such as medical necessity criteria, such as Interqual. There may be questions about the existence of such products and how they are used, but there will not be any questions about the application of any proprietary criteria product. You may get a question about WHAT Interqual is, but you will not need to know the mechanics of it. -Local or state policies involving domestic abuse or child/adult protective services. Candidates should understand the role of a case manager in assessing, planning, intervening, and evaluating these situations, however there will be nothing regarding the application of local policies on the exam. -Because the exam is on an month revision schedule, very recent or proposed regulations will not be tested. For example, MOON.

ACM™ Domain Introduction and Overview

Case Management Screening and Assessment
Moving on to some of the didactic content- for most of you this should not be new content. This chapter also includes a brief introduction to Value Based Purchasing and Bundled Payment Initiatives and their impact on case management responsibilities for post-hospitalization needs and readmission risk. Programs and requirements within programs are changing frequently, so it is more likely an ACM candidate will see questions about Value Based Purchasing and Bundled Payment concepts rather than details of specific programs.

Case Management Process
Assessment Planning (fluid and ongoing) Care Coordination Execution Case Closing and Evaluation Five domains of case management Case Finding- some organizations use LACE, BOOST, RED Whatever you use for case finding, follow through is the most important. ACM candidates are unlikely to face questions about content or mathematical methodology of specific tools, but instead should be familiar that these tools exist and if given a list of these well-known tools be able to identify them as pertaining to Readmission Risk assessment. Screening is much like case finding- using census reports, hand off from staff nurse or physician, family member may ask for assistance Planning is always fluid Execution is the finalization of transitional planning. Closing the case- documentation is essential! Where the patient went How he/she got there Services used Services set-up Family members or care givers notification including names and phone numbers Transportation name and phone numbers Sharing with downstream providers. For example, SNF report of to whom and when

Communication Communication is key – both written and verbal
Proper assessments must be accompanied by accurate documentation Written communication should “tell the story” to all partners of care Patient and family should be kept informed with necessary information and ongoing updates Communication is key to getting the patient out the door, to the next level of care, and coordinating care between the members of the care team. Assessment is worthless if not documented Keeping the patient in the loop is essential. Communication and collaboration are key. Look for answers that focus on those.

What are Conditions of Participation?
Assessment What are Conditions of Participation? Conditions of Participation (COPs) and Conditions for Coverage (CfCs) are health and safety regulations which must be met by Medicare and Medicaid-participating providers and suppliers. They serve to protect all individuals receiving services from those organizations. Assessment required by CMS Conditions of Participation Pre-Admission Admission Ongoing Reassessment Generally case manager uses a “template” or form SG: CH 3, pg 10-13 The CMS Conditions of Participation for Hospitals set clear guidelines for Assessment The CoPs state that the discharge planning requirement applies to all patients, and hospitals must have in place a process to identify, early in the patient’s stay, those patients who are likely to suffer adverse events if they do not have adequate discharge planning. A discharge planning assessment must be provided for all patients identified through this process as well as those patients who request discharge planning or whose caregiver or physician requests discharge planning. Hospitals may choose to assess every patient for discharge planning needs or have a screening process in place to identify those patients who are considered to be at high risk for an adverse outcome if they do not receive adequate discharge planning. We are anticipating the release of new Conditions of Participation for Discharge Planning from CMS. Candidates should be mindful that the ACM exam development cycle takes more than a year, and thus it is unlikely content from newly released CoPs will be on the ACM exam for at least 12 months after release. However, it is anticipated the new CoPs will focus on developing a discharge/transition plan that is focused on the patient's goals of care and preferences and has an emphasis on smooth communication and handoffs through the care continuum. These concepts are consistent with ACMA Standards of Practice and should be incorporated into answer selection for any exam item. Times for assessment include Pre-Admission (in the case of planned surgeries); Admission and on-going reassessment Can you think of a time a pre-admission assessment could make a significant difference to a discharge plan? The Admission Assessment should verify all information gathered in a pre-admission assessment if it is present. Just because there was a pre-admission assessment, doesn’t mean we can skip this. What could have changed? On-going reassessment is required by the CoP and is necessary for effective discharge planning – name some of the things that may change that would have serious impact on the plan. Changes during the hospital course that changes the discharge plan. Template ensures all necessary information is gathered in an organized way to produce a thorough assessment

Interdiscip-linary teams
Patient Family Medical records Physicians Interdiscip-linary teams Comm. care providers 3rd Party Payors Delegated caregivers Information Sources Case managers should utilize all sources of information. Why might a community care provider’s input change the discharge plan? How might 3rd party payor information impact the assessment? SG: CH 3, pg 15 The first part of an assessment is gathering information – the CM will want to utilize all of these sources of information. Can you think of why a community care provider’s input might change the discharge plan? How would information from a third party payer impact an assessment? Do any of these sources contradict? Where are the contradictions in the assessment and needs- seek to find a consensus. This can also be part of the information gathering in a scenario if you use all these or a combination of these Patient Family Medical records Physicians Interdisciplinary teams Current community care providers Third party payors Delegated caregivers

Components for Thorough Assessment
Financial situation Environment Functional status Developmental level Current Medical Status and Level of Care Health Behaviors Response to Illness Belief and Value System Medical History Psychosocial History Health Literacy SG: CH 3, pg 21-27 A thorough assessment must include all of these areas: What is an example of how a patient’s belief and/or value system can impact an assessment? An opportunity may come up during an assessment of a patient’s belief or value system to explore the patient’s understanding of Advance Directives. While the presence or absence of an Advance Directive is a required question asked on the Nursing Admission Assessment, frequently the simple “yes I have one” or “no I don’t” is the end of the discussion. When the patient does not have an Advance Directive, a best practice is a process where someone, a case manager, a social worker, or a chaplain for example, has a more thorough discussion with the patient and caregivers if appropriate. Use an example of how not assessing health literacy could contribute to a failed discharge plan. Health literacy has to be assessed to make a good discharge plan.

Social Determinants of Health
Economic Stability Neighborhood and Built Environment Education Food Security Community and Social Context Health Care Social determinants may impact the patient's ability to adhere to a treatment plan and even how they view the importance of health in general. Social determinants has been a hot topic recently in case management and it they have a significant impact on health outcomes. They include: Economic Stability: Which is defined by employment, income, expenses/debt, medical bills, and support. Neighborhood and Physical Environment: Which includes housing, transportation, safety, presence of parks or greenspace, playgrounds and walkability. Education: Which is defined as literacy, language, early childhood education, vocational training and higher education. Food: Including hunger, food insecurity and access to healthy options. Community and Social Context: Defined as degree of social integration, presence of support systems, degree of community engagement and presence of discrimination Health Care System: Including health coverage, provider availability, provider competency in areas of language and culture and quality of care.

Psychosocial Assessment
Psychological Emotions/Attitude Learning Beliefs Stress Mgmt. Social Family Peers Culture Socioeconomics Biological Physiological Medications Neurochemistry Genetics Purpose: identify barriers to patient meeting his/her goals Body image concerns Coping skills ADL performance Occupation Self-care assessments Environmental concerns Housing and transportation concerns Family support SG: CH 3, pg 23 The purpose of a psychosocial assessment is to identify any barriers the patient may have to reaching his/her goals. It can also identify strengths and coping mechanisms used successfully by the patient in the past to help him/her get through the current illness. Talk about how these factors are interrelated – Body Image concerns could impact coping skills, occupation, even family support. ADL performance can impact occupation, self care Environmental concerns impact ADL performance, etc… Occupation is needed – if the patient cannot return to the work or profession they came from, can be devastating for the patient and family.

Screening for High Risk ReAdmission
Example: LACE SCORE Identification: Lace Score, 8Ps, Project Red Ed Utilization Admissions Readmissions Age Co-morbid Conditions Length of hospital stay L Acuity on admission A Comorbidity C Emergency department visits E Don’t get into the weeds on this- know that it is important to screen and there are several tools our there for this purpose. Won’t be asked the specific P of the 8Ps. Screening patients for risk of readmission is critical in today’s healthcare environment. Hospitals are penalized by Medicare if their readmission rates are higher than expected. Hospitals are often penalized by commercial payors in a similar manner to Medicare penalties. However, there is a whole new concern related to readmissions in the various bundled payment initiatives and Medicare Shared Savings Programs. There are several evidence based tools for assessing readmission risk – the LACE assessment which results in score that can point to a high risk for readmission, The 8 P’s which examines eight factors that may place a patient at a higher risk of readmission - for example, Psychological concerns, Problem medications, Principle Diagnosis, Poor health literacy, Poor social support, Physical limitations, Prior hospitalization and Palliative Care appropriate and Project RED which stands for Re-engineered Discharge and is an IHI initiative. ED over-utilization, advanced age, and certain specific, or many, co-morbid conditions all contribute to a higher risk of readmission.

Screening Tool Factors
Screening tools take into consideration: Cognitive status Diagnosis/medical conditions Medications and adherence to prescribed plan Care access and/or financial barriers Functional status Social situation Nutrition Emotion (unbiased observations) You will see that many of these are covered by the LACE and 8P’s assessments and all can increase the risk of readmission. So you can identify factors that may make a patient a higher risk for readmission. Cognitive impairment is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life. Cognitive impairment ranges from mild to severe and can be caused by many things including medications, endocrine or metabolic dysfunctions, delirium, depression or dementia. Some may be temporary or treatable by changing medications for example or a temporary delirium that clears when the cause of the delirium clears. Cognitive impairment may make autonomous decision making less reliable or impossible.

Documentation “If it wasn’t documented, it wasn’t done!”
Unbiased observations Family members POA/decision maker Barriers to planning Initial plan of care Changes to plan as appropriate Advance directives Resource availability Care team information SG: CH 5, pg 63 Documentation must be done according to your institution’s policies and procedures. Always remember the basic tenant however – “If it wasn’t documented, it wasn’t done!” Documentation is also important from a legal standpoint While the CM uses the assessments of others – RN, PT, H&P, - the CM assessment should be an independent assessment, verifying information when necessary but adding additional value. Documentation should be clear and concise so that someone else reading your notes has a clear picture of what the plan is for your patient and what the next steps are.

Documentation as a Bridge
Case management documentation is a bridge between the various settings across the continuum Whether shared electronically or on paper, accuracy, completeness and timeliness are vital to transitions SG: CH 5, pg 63 – CM communicates information that no other discipline documents and it is important information!

Case Management Planning

Planning Includes Early development of assessment and primary plan
Early involvement of patient and family in the planning process and identification of a spokesperson (Healthcare Power of Attorney) Removes barriers for effective and safe discharge Fosters teamwork and team development for initiation of steps towards discharge. Chapter 4 page 32 24 hours post admission or ED screening and preliminary planning Pre-admission planning Discover barriers early in the planning phase to break down- financial, psych-social, guardianship issues, Communication and collaboration is essential to care team, patient, POA Everyone on the same page Multi-disciplinary rounding

Planning Includes Match services and resources to assessed needs
Collaborate with stakeholders on an individualized care plan Establish goals and anticipated outcomes Actively participate in multidisciplinary care rounds/huddles Coordinate patient care conferences when appropriate Educate everyone about the care plan and about options for care Using information gathered from the assessment, begin planning as appropriate. Look for patient/family engagement early and work to discover barriers early in the process – for example, patient/family resistance to care plan (e.g., palliative care suggested but family refuses), patient’s lack of capacity for decision making in the absence of a DPOA or Health Care Decision Maker – move forward with guardianship asap, need for authorizations for the next level of care, etc. Your stakeholders in the discharge plan are the members of the interdisciplinary care team AND the patient and his/her family or caregivers. Each person needs to have input into making a comprehensive discharge plan with the greatest chance of success. If the patient doesn’t buy in, the plan cannot move forward. You as a case manager should stop the plan until the patient and family has buy in. The patient should be provided with a clear and simple description of the options available as well as the alternatives, if applicable. It is imperative that the patient have a solid understanding of each of the options available as well as the indications for why these services are necessary in order to make an informed decision that aligns with his/her goals, preferences, and situation. This is also an opportunity to help the patient understand the continuum of care and the goal of aligning him/her with the lowest and safest level of care that is appropriate. In addition to the available options for care, it is important for the case manager to inform and educate patients on potential limiting factors in the planning process. Examples of potential limitations in patient choice may be the result of bed or space availability at the facility, payer rules and regulations (such as the three-day qualifying stay for Medicare patients to receive post-acute skilled nursing services), authorizations needed for post-acute services or medications, and/or gaps in or a lack of insurance coverage.

Planning for Alternatives
Evaluate alternative treatment/therapies on: Patient choice Team recommendations Efficacy, cost, safety Potential adherence to the plan Anticipated outcomes It is your job, as a case manager, to help the patient evaluate their treatment options. One experience I have had many times, for example, is helping the patient and family think through a decision about choosing Hospice Care as opposed to more aggressive therapies. Another example could be helping the patient think about the limitations of their caregiver and helping them see the benefit of a short stay in a SNF or Acute Rehab to gain strength and mobility before returning home with that caregiver.

Planning for Post-Acute Needs
When post-acute care needs are present: Educate patient about options Obtain patient choice of providers Identify a contingency plan if/when needed As we move into the bundled payment initiatives that we are all dealing with now, patient choice is a trickier issue than it used to be. There will not be any specifics of bundled payment initiatives, but you want to be familiar with the concepts. For one thing, when it comes to patient choice, we want to be certain the patient knows which facilities, if you are in a bundled payment model, we have chosen to partner with and why we are partnering with them but we also have to balance the realistic options they have given their individual situation – the top three facilities on the Medicare.gov website may not be available options to them, for example. It is critical to controlling length of stay to have a contingency plan when the patient’s situation is not crystal clear. An example of this is the ortho patient who really wants to go to a SNF but who has a Medicare Advantage plan and fails to be authorized for SNF placement. The case manager needs to have been developing a parallel plan all along so there are no delays in discharge. Again, you will need collaboration and communication to implement that plan to make sure you have everyone’s buy in.

Communicating the Plan
Communication from the physician must be the same as the communication from case manager and from the rest of the team! Communicate with the payor to ensure authorization in place! Documentation counts! Look for exam answers and options that address communication and collaboration. Communication from the case manager must be congruent with the communication from the rest of the team. We all know that if we, as the Case Manager, tell the patient they are Observation Status and the bedside nurse goes into the room and says, “of course you need to be here, I’ll get that changed” we are in trouble! If we have a plan in place for the patient to go home and everyone is in agreement and the Attending changes and he/she goes into the room and says, “you need to go to a SNF” without knowing that the patient doesn’t qualify, can’t get authorized and has a perfectly safe discharge plan all arranged, we are in trouble! So what and when you document is critical! Huddles/Rounds are critical! Same message from all is critical! Look for answers on the test that address communication and collaboration when planning.

Planning: Wrap it up with a bow
Before the patient “goes out the door,” make sure: Teaching is completed Medications are reconciled Payment is ensured. Patient/family are informed Receiving facility/agency is confirmed, if appropriate “Paperwork” goes with the patient Follow up care or appointment identified Prior to the patient getting on the elevator, not necessarily literally, the Case Manager is responsible for making sure the discharge education is complete, the discharge summary/after visit summary has all pertinent information on it related to care transitions, the patient/family are aware of the time if transportation has been arranged, the receiving agency or facility has formally accepted the referral/transfer and the paperwork, whether electronic or actually paper, goes to the next provider – PCP, Consultant if necessary, HH Agency, SNF, etc. Look for exam answers and options that address communication and collaboration.

Case Management Care Coordination, Transition and Intervention
Largest section in the multiple choice with 22 questions.

“Pace the Case” Right care to the right patient at the right time
Care Coordination Relationships: Nursing/Social Workers Physicians PT/OT/Speech Internal Hospital Systems External Systems Patient/Family “Pace the Case” Right care to the right patient at the right time and in the right place Chapter 5 – pg. 58 All of these relationships are critical to the care coordination and transition process! Communication may be through multidisciplinary rounds/huddles, documentation, use of “care-link” technology in your EMR, electronic referral systems, good old-fashioned conversation. What matters is that the content is delivered consistently, clearly and timely. Pace the Case: Making certain the patient gets the right care at the right time avoiding delays and gaps in care. Hastens the discharge in an appropriate time. Understanding the appropriate pacing can be found in the Compass modules

Discharge Planning Facilitating Referrals Home Healthcare (HHC)
Durable Medical Equipment (DME) Skilled Nursing Facility (SNF) Palliative Care Hospice Care LTACH Acute Rehab Facilitating Key Transition Checkpoints Pp 59-62 Won’t go through each of these because you do this every day, but spend a few moments thinking about “What are the steps that I do to facilitate referrals to each of these areas?” “Would I know how to make a referral to each of these areas?” Not looking at local policies, but looking at your understanding of who qualifies. What qualifies a patient for home health? Do I understand home bound criteria? What qualifies a patient for skilled nursing facility benefits? Do I understand Medicare and the three day stay rule? What qualifies a patient for hospice care? As you are preparing for the exam, think through each of these and identify what you know and what gaps you may have in what would qualify a patient for each of these dispositions. You will find more specifics about the qualifications for each of these in your study guide.

Hand-off vs. Hand-over Hand-off implies responsibility ends at discharge Hand-over recognizes that CM responsibility extends to ensuring patient is smoothly received by the post acute provider and/or caregiver Should be written and verbal Follow up appointments made Follow up phone calls Case Manager’s responsibility no longer ends when the patient “walks out the door.” We are part of the continuum now. The Case Manager is responsible for ensuring all information needed is communicated – whether to a post-acute provider or the patient and caregiver. Teach Back is one method to test a patient’s or caregiver’s understanding of the discharge plan. Asking the patient or family member to repeat in their own words what you just told them. Good method of ensuring comprehension. Best practice is to have appointments made prior to discharge and documented on discharge instructions. Follow up phone calls are a good way to confirm that discharge instructions are understood, prescriptions have been picked up, patient will be able to make f/u appointments, downstream agencies like HH has contacted the patient (if appropriate) and any signs or symptoms which could cause an ED visit or even a readmission, are addressed as soon as possible. Trying to get away from- How my facility does it and moving towards global concepts. In an ideal environment, the case manager would follow up with that patient and look for signs of a potential readmission.

Care Coordination Outcomes
Health care dollars are saved Proper use of resources Timely and appropriate care Case Management is the driver of cost containment and patient’s right to self- determination Prevention of abuse, fraud and waste through proper care coordination Uses the strength of all the team members to develop plan of care and keep the patient at the forefront of the plan of care Careful care coordination benefits the patient, the Hospital, all Healthcare consumers in all of these ways…

Ethical Considerations
Autonomy Beneficence Non-maleficence Justice Fidelity Veracity- truthfulness Chapter 5 Pages 69-70 Patient self-determination- right to decide on treatment or refuse treatment Beneficence- doing good- weighing options based on choice, resources, benefits and risks Non-maleficence- doing no harm- respecting wishes and education on the benefits and risks as we know them as case managers and providing the information to our patients to create the best transitional plan available Justice- Access to care such as through health plan benefits- restriction of benefits-negotiating with the payor if needed. Insurance benefits can affect this. Fidelity- true to your patients and your profession Veracity- truthfulness when dealing with patients. Being up front about what’s going on, explaining physician’s care plan, speaking frankly and honestly with patients

Legal Considerations Self-Determination Act Uniform Decision Act
Patient Decision Making Capacity Advance Directives Chapter 5 Pages 71-72 These are explained in more detail in the study guide so if you feel like this is an area you are more unfamiliar with, you may want to do some additional reading. Self-determination act Make an advance directive Right to refuse care Accept and choose type of care Might need to set up an alternate plan Uniform Decision Act- deals with patient capacity Who will act for patient when incapacity is determined or cannot speak for themselves Individuals are the one with decision making capacity, a patient designated spokesperson or a court appointed guardian Patient decision making capacity Ability to make decisions based on information given and understanding that information Understand the difference between capacity and competency Competency is usually decided by the courts and psychiatry, capacity is do you have the decision making ability to make the limited decisions weighing the consequences and evaluate impact of decisions state choice Advance Directives 5 Wishes POLST form Clear direction of health care decision making when cannot speak for themselves

Legal Considerations Victims of Violence EMTALA
Incident reporting- Risk management Chapter 5 Pages 72-73 When mandatory reporting is required but proper screening and identification first Victims of violence advocating for support for the victim and coordinating plans for safe transition plan- discharge plan is not only clinically appropriate, but has measures for patient safety Incident reporting (again, think global) - sentinel events, adverse patient reactions, errors in care- Department gathers information for performance improvement using data trends and outcomes. Way to improve care universally EMTALA (Emergency Medical Treatment and Labor Act)- patient presenting to the ED must be assessed and stabilized before a transfer is proposed. -anti-dumping law More about EMTALA in study guide

National Patient Safety Goals
ID patients correctly Improve staff communication Use medications safely Use alarms safely Prevent infection ID patient safety risks Prevent mistakes in surgery Chapter 5 Page 76-77 Self-explanatory Case managers should be aware that without following these guidelines, discharge can be delayed, the patient may be harmed, and length of stay and cost per case will increase. Safety is everyone’s job. If there is a medication error- it may be your responsibility to encourage others to report it

Fiscal Responsibilities
Managing to DRGs Optimizing resources Revenue Cycle Hospital Compliance Department Ancillary Departments Chapter 5 Page 79-81 Managing patients through the system-sequencing- assuring the patient is getting the correct care and no redundant services ordered un-necessarily Resource management- Use the resources of the hospital to accommodate the patient’s illness and physicians plan of care but don’t allow the patient to linger to receive more tests that can be done on an outpatient basis. Advocate for moving things that are appropriate for the outpatient setting to that arena. Ex: patient that cannot be weaned after 10 days on a vent, trach conversation. Redundant blood testing up until the day of discharge Know the denials in your department, administrative and clinical denials. Know the difference between the two. Administrative denials are sometimes called technical denials and include things like forgetting to call the managed care payor in time. There was a late notification, so you are imposed a denial. These are usually pretty cut and dry and rarely successfully appealed. Clinical denials, or medical necessity denials, have more wiggle room. The payor is telling you that the patient should not have been inpatient, and involves clinical decision making. Attempt to avoid a denial and if you have a denial attempt to resolve it while the patient is in the hospital when access to the medical record and the attending physician is readily available. Takes more time to defend a denial retrospectively than concurrently. You may not deal with denials, but in the ideal case management world you would want to get involved with the payor now instead of having to deal with it retrospectively. Ancillary departments: Avoiding a delay in MRI, CT, cardiac testing using good communication. Ex: patient is observation waiting for testing. Obs hours accumulate to over 24 hours waiting and delays.

MAC, RA & HEAT MAC: Medicare Administrative Contractors
RA: Recover Auditors (previously RAC) HEAT: Health Care Fraud Prevention and Enforcement Action Team Chapter 5 Page 80 Again, don’t get in the weeds on this. Understand generally what is going on with this slide. You see that we have Medicare Administrative Contractors who work with the Quality Improvement Organizations and the Office of the Inspector General. Different types of contractors work with audits. Understand some of the landscape that is going on with audits right now. Anything that is brand new (last 6 months to a year), however, will not be reflected on the exam. General understanding of RAs and MACs and a little bit about how our government looks at healthcare fraud prevention. How would you interface with these groups. A lot of these look at appropriateness and medical necessity.

MAC, RA & HEAT Medicare Administrative Contractors (MAC):
Function as Medicare oversight and payment Recovery Auditors Act as review coordinators to assure appropriate care is administered an no over or under payment has occurred HEAT task force has FBI and OIG oversight MACs deal with Medicare oversight and payment. Recovery Auditors look at levels of care, inp vs obs. Mainly- clinical denials HEAT- FBI and OIG oversight Understand who OIG is- arm of the federal government that looks at health care fraud.

Discharge Planning Medicare Regulations Screening Elements
Documentation Chapter 5 page 73 Discharge planning is required by Medicare Conditions of Participation. It is important for candidates to read the Discharge Planning chapter in the CoPs Was originally part of the SS act of 1965 when Medicare started. Discharge planning is formal process. Process required by law. Basically states that the patient, care giver, family member, or physician can request discharge assistance. 13 elements of DCP. Documentation of the plan and communication of the plan is essential. Make sure that you have read and have an understanding of the Conditions of Participation. Takes about 15 minutes to read them, but important foundation.

Regulatory Issues Medicare A,B, MA Plans, Part D Medicaid Title XIX
Conditions of Participation Discharge planning (42 CFR ) Chapter 5 Pages 81-82 Discuss what each part of Medicare covers what Medicare is title 18, Medicaid is Title 19 Know that Medicaid is given a bundle of money by the feds and is distributed by states’ regulations Mandatory from CMS for discharge planning Elements: Every patient has access to a discharge planner and assistance with transition out of the hospital Anyone can request discharge planning assistance Must make available to any patient who wishes it, a viable discharge plan and assistance with resources and the case managers expertise. Refer to the elements of discharge planning on the CMS website

Medicare Coverage Medicare Part A
Inpatient care- acute, LTAC, Inpatient rehab Hospice SNF Home Health (following admission) Medicare Part B Pays the providers Outpatient care Chapter 5 Page 81 Medicare- what A,B,C, and D cover, what the parts are and what is covered Medicaid- federally funded and states distribute as indicated by states’ standards SNF coverage First 21 days with no deductible Day 21 start Home health covered under A if following inpatient hospital admission (otherwise under B) Hospice separate bucket of money with less than 6 months, can be renewed Medicare part B pays the providers for hospital care and pays for outpatient care

Part A Coverage per Benefit Period (2016)
Medicare Determination of status within 24- hours Conditions of Participation (CoPs) Acute Days versus SNF days Rules for placement Depends on available days Spell of illness Lifetime days -60 Example: Part A Coverage per Benefit Period (2016) Hospital Days 1-60 $1,288 first day Days 61-90 $322/day Days * $644/day SNF Days 1-20 Covered in full Days $161/day Home Health All days 20% of DME *60 “lifetime reserve days” can only be used once. Benefit periods- This is for Part A, traditional Medicare patients Chapter 5 Medicare coverage defined for problems Determine what is a spell of illness Starts the day of inpatient admission and ends when the patient has been home or discharged from the SNF. 60 days gets the “bank days” renewed. Lifetime days- patient must consent to sign Acute day 90 days upon admission if not hospitalized in the last 60 days Caveat to assigning days SNF Qualifying stay- 3 day rule- must have been in the hospital as an inpatient for 3 consecutive days and midnights Have to be out of hospital or SNF for 60 consecutive days to start a new benefit period even if it is a different diagnosis Secondary insurance may pick up some of those benefits. Days 1-60 is a deductible Days is a copay Days is also copay, but is higher Observation days do not count towards the benefit period because they are under Part B Managed Medicare Plans (Part C) does things differently- generally has part a and part b benefits

Case Example Patient is admitted to the hospital on October 1st as an inpatient and discharged on October 10th. 9 days of care. Patient is discharged to SNF and stays from October 10th to October 31st. 20 days of care. At this point, 29 days of the Part A benefit period have been used (9 days + 20 days). (Continued on next slide…)

Case Example Patient is readmitted to the hospital on November 15th and discharged on December 1st. 16 days of care. Patient is again discharged to a SNF and stays between December 1st and December 31st. 30 days of care. Since November 15th, the patient has received care for 46 days. (16 days + 30 days). The patient has not been out of the hospital/SNF for the required 60 days to ‘reset’ the 90-day Medicare coverage benefit. Q: The patient has now been readmitted to the hospital on January 15th. Is this still considered the same spell of illness? A: Yes – the patient has still not been out of the hospital/SNF for 60 days. Q: If the patient readmitted on February 27th, would this be considered the same spell of illness? A: Yes, because at this point, it has only been 59 days since being discharged from hospital/SNF. Q: If the patient is readmitted on March 15th, would this be considered the same spell of illness? A: No – now the ‘bank’ starts over because the patient has been out of hospital/SNF for 74 days (assuming this is not leap year)! * All inpatient days in acute care, including inpatient psychiatric are, rehab and long-term acute care. Between October 1st and December 31st, the patient has used 75 days ( ). These are all considered part of the same “spell of illness”.

ESRD Hemodialysis 3 months Peritoneal Dialysis
Self-care and home - one month (part B) Transplant 3 years (pts booklet) Chapter 5 Expansion of understanding of what is covered and why Try to keep out of the weeds here as well. Understand a little bit about Medicare coverage. Medicare now covers acute renal failure, but that is a relatively new development, so it will not be on the exam. Medicare covers ESRD. Patient must be on hemodialysis for at least 3 months. Does cover peritoneal dialysis for self care and at home- remember this is outpatient so is covered by Part B. Self-explanatory with links to the CMS website May pause here for doing Medicare problems.

Medicare Notifications
Code 44 Inpatient to Outpatient ABN/ HINN Letters/ Appeals IMM/ OBS letters Documentation Chapter 5 Page 74 Code 44- What are the four requirements to issue a Code 44? In the Study Guide Patient must still be in the hospital Bill must not have dropped Attending and UM committee must agree Types of letters discussed in details in the next slides IMM requirements – given within the first 48 hours and re-signed 4-48 hours prior to discharge (2 times that it has to be issued) Documentation is key to staying out of Medicare “jail” MOON is too new to be on the test, but best practice is to notify the patient that they are under Observation. Sample question: Your patient asks you what the difference between obs vs. inpat? Obs covered under Medicare Part B and Inp covered under Part A. Observation- out of pocket expenses could be higher than inpatient.

Condition Code 44 Specifics
Determined by a UM Committee physician Change from inpatient to outpatient is made prior to discharge A claim has not been submitted The treating physician concurs with the decision Physician concurrence is documented in the medical record SG: CH 6, p. 88 As promised, we’re going to touch on the requirements for a Condition Code 44 The change of a Medicare beneficiary’s condition from Inpatient to Observation is to be made by a physician on the Utilization Management Committee and requires four elements (read bullets on slide) All four of these elements must be in place for a Condition Code 44 to exist and a claim to be submitted for Observation status. If all four are not met, the hospital may not bill for either inpatient or observation services, and the hospital, as the provider, is liable for charges.

Medicare Notifications
HINN 10 – organization requests a review HINN 11 – when a given procedure or test is not covered during a covered stay HINN 12 – given after an appeal ABN – usually given in the OP area Chapter 5 page 74 HINN 10 given when an organization wants a review and patient decides not to leave also decides not to make a formal appeal HINN 11 self explanatory HINN 12 is given to the patient if the appeal that has been requested in decided in favor of the organization. Patient must be notified when the financial burden begins ABN- usually given in the outpatient area when a test, lab or procedure is not covered by Medicare. Can also be given when the patient request to be an inpatient and does not meet medical necessity. Appeals process Patient calls to request an appeal Appeal is considered Detailed notice of non-coverage is given Chart is sent to QIO Review is completed Hospital and patient is notified IF discharge is upheld, patient has until noon the next day to leave Secondary appeal Tertiary appeal

Medicare and You bs/pdf/10050.pdf coverage for patients Discharge planning guide Medicare.gov is a great source to use if you are uncomfortable with any of these concepts

Case Management Evaluation
Polling questions before the start of the second part: How much of the ACM Study Guide have you read? All of it More than 50% of it 25-50% of it Less than 25% Have you read the Candidate Handbook? Make a list of things that you need to be more comfortable on throughout this course, so you can go back and study that material. Evaluation- One of the differences about this chapter is that you may be asked to put yourself in the shoes of a case management leader and evaluating processes.

evaluation Why Measure? Quantify Success Identify Best Practices
Identify Improvement Opportunities SG: CH 6, p. 83 Cannot quantify success without measuring. Case Management is intended to improve patient outcomes through the achievement of optimal health, access to care, and appropriate utilization of resources. We benchmark against established standards and with each other to quantify our success, identify best practices, and identify opportunities to get better. Benchmarking would be a good thing to understand before you sit down to take your exam. We are never “done” with improving outcomes; rather we should always be searching for what we can do next to improve.

Outcome measurements Can be: Global (health care system)
Local (departmental/unit) Patient specific Part of practice for: Health care systems Case Management departments Individual Case Managers SG: CH 6, p. 85 Measurement strategies can be global, such as measuring readmission rates across a healthcare system, or more local , such as examining the discharge education process for patients on a particular unit; or even case specific, such as analyzing the chain of events that led to a sentinel even for a particular patient. While efforts at a healthcare system or departmental level may be formal and driven by data analysis, the professional case manager should make evaluation of outcomes a part of everyday practice. Observing what approaches, strategies, and interventions produce the best outcomes in daily practice, and modifying one’s practice accordingly is a part of a professional case manager’s job.

Data into Information Data – collection of values
Information- data with analysis and meaning Standard tools and processes Commonly understood parameters Analysis must be consistent to make comparisons meaningful SG: CH 6, p. 84 A collection of numbers or data values is meaningless, and furthermore can be dangerous, as each person who looks at the data can draw widely different conclusions. It’s when we apply standard tools and processes for analyzing data, and use commonly understood parameters such as exclusions, that data takes on meaning and useful information is found. For example, when analyzing length of stay data, some institutions will exclude length of stays over 30 days because these are outliers and will skew the data. Those parameters need to be clearly communicated and commonly understood. When information is shared between two entities, whether it’s measuring outcomes and performance between two case managers, two units, or two hospitals, the methods of collecting, sorting, filtering, and analyzing data must be consistent to be able to draw any meaningful conclusions.

Common National Benchmark Sources
CMS Core Measures The Joint Commission Leapfrog Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) SG: CH 6, p. 86 There are several sources of benchmarks for healthcare organizations to compare outcomes with each other. Four of the most common ones are listed here. You will not be tested on the specific measures of each organization’s benchmarks, but you should know these are common benchmarking agencies and that HCAHPS benchmarking is unique because it uses data from patients (hospital consumers) to establish ratings. These national standards apply more generally to healthcare delivery, and do not have a great deal of specific standards related to case management. The study guide has links to websites for each of these organizations if you wish to know more.

Other Sources for Benchmarks
ACMA Standards of Practice and Scope of Services Federal Conditions of Participation (CoP) State case management standards Health care system/Hospital policies UM Plan SG: CH 6, p. 86 If you are wishing to establish an case management outcome standard against which to measure a process, you may need a standard more specific than the national standards on the previous slide. You may wish to consider -ACMA standards of practice -The chapters of the CMS CoPs on Utilization Review and Discharge Planning -Any standards regarding case management that may exist in your state -Any pertinent policies and procedures in your institution One of the most important standard setting documents in a hospital or healthcare system is the UM Plan. Required as a condition of participation in the Medicare and Medicaid programs, this is such an important document, we’ve devoted a whole slide to it.

The UM Plan UM Committee with at least two physicians
Delineate roles and responsibilities for UM Outline standard and outlier review processes Monitor resource utilization Process for coverage determinations, denials, appeals, and peer review Framework for reporting corrective action and documentation requirements SG: CH 6, p If UM is not part of your normal job duties, we suggest that learning more about UM needs to be on your learning plan. The UM Plan is part of that. While the UM Plan is a Medicare and Medicaid requirement, may commercial payers require compliance with CMS Conditions of Participation, so this effectually becomes a document required for hospital existence. The UM plan essentially requires that a hospital must review services provided by the institution and the medical staff to patients Essential components of a UM Plan are outlined here (cover points on slide)

Key Performance Indicators
Length of Stay (LOS) Case Mix Index (CMI) Potentially Avoidable Delays/Days Initial UM Review determinations Condition Code Continued Stay Reviews Denials Appeal Outcomes SG: CH 6, p Some key reports common to most hospitals and commonly reported to UM Committees are Length of Stay, typically monitoring the number of hospital days accrued by the average inpatient. Length of stay data are typically sliced and diced in many different ways, so it’s important to understand what information each report presents. Case Mix Index , monitoring the acuity and complexity of patients treated, as quantified by the billed DRGs. This measurement is heavily dependent on physician documentation, and often efforts to improve documentation to capture patient acuity and complexity can lead to a higher CMI. Potentially Avoidable Delays or Days, are a mechanism to identify delays or preventable events over the course of hospitalizations that may identify improvement opportunities. This data is typically directional, and not scientifically specific, so it is more of a general benchmark. Initial UM Review determinations provides an assessment of appropriateness of admission. If a significant number of patients admitted are determined to be inappropriate, further investigation into admitting practices may be warranted. Condition Code 44 reports, hand in hand with Initial UM Review determinations, are another marker of admission appropriateness. Our next slide has more information on this Continued Stay review information, along with Avoidable Delay data, can identify opportunities to improve efficiency in care delivery and potentially reduce LOS Denials and Appeals metrics have value as well, and we will discuss them more in a later slide

Denials and Appeals Medical Necessity Not clinically justified
Billing requirements not met Missing or incorrect orders Incomplete Condition Code 44 Documentation requirements not met Analyzing denial patterns and comparing with appeal success can identify improvement opportunities SG: CH 6. p Know the difference between a medical necessity denial and a technical denial Example: CFO comes to you and asks you why denials are up Questions to ask Is it one provider? Is it one payer? Is it one unit or case manager that is trending with increased denials? Are there administrative denials, Medical necessity?

Performance Improvement Methods and Models
Lean Six Sigma DMAIC Lean Six Sigma FADE PDCA/PDSA SG: CH 6, p. 89 Remember that as an ACM candidate, you will not be responsible for knowing specifics about proprietary products, such as the details for a specific performance curriculum. We are going to cover some highlights of basic performance improvement tools in the next few slides and the important take away for an ACM candidate, is knowing a bit about which tool might be reasonable to use for a particular problem.

Change Management Principles
8-step Change Model Create sense of urgency Create guiding coalition Create vision for change Comm-unicate vision Remove obstacles Create short-term wins Consoli-date improve-ments Anchor changes Create shared need for change Understand and manage resistance Build influence strategy and communication plan SG: CH 6, p. 89 Key to any performance or process improvement is managing change. There are three key areas to which a successful leader must attend to successfully manage change. Create shared need for change Understand and manage resistance Build influence strategy and communication plan Change cannot happen without managing the human reactions of resistance and input.

Lean Process Improvement
Efficiency Improvement SG: CH 6 p. 90 Lean is one of the more popular methods of process improvement today. It focuses on improving processes, not people, and seeks to break down silos. Lean promotes a simple, error proof system. Many people think of LEAN as a tool to improve efficiency. This diagram is in your study guide, and it’s probably worth spending a minute to understand the general principles and steps. Again you will probably not see questions about specific steps on the ACM exam, but may get a scenario and be asked to identify what kind of process improvement method would be best suited. When you look over this diagram, think about a case management scenario that would be suited to Lean. LEAN’s weakenss: Doesn’t do a lot of measurement to identify sources of process variation. Audience participation- who can think of one? (If no audience participation, suggest a project to streamline the steps and timeline between the decision to discharge and the patient leaving the hospital) Six Sigma on the other hand looks to improve quality. Lean Six Sigma is a marriage between the two- about quality, cost and accountability improvement.

Plan Do Study (or Check) Act Plan, Do, Study and Act
Continuous Quality Improvement Plan Do Study (or Check) Act SG: CH 6, p. 92 PDSA, or Plan, Do, Study, Act, is also referred to as PDCA, or Plan, Do, Check, Act. PDSA is a method that emphasizes continuous quality improvement, so getting to the end of a quality improvement project doesn’t mean things are done- it just means it’s time to start over. PDSA lends itself to processes that are subject to frequent changes, perhaps from regulations. Can you think of a process that would lend itself to PDSA cycles? (suggest the process of training a new case manager- as regulations and technology change practice, we must keep evaluating our processes to improve them)

Performance Improvement Methods
Beginning a PI Project: Define the problem Identify the stakeholders Delineate the scope Describe the desired outcomes Identify gaps and barriers Identify contributing factors Creating a New Process Develop interventions Develop work plan Determine measures Develop communication plan Implementing the project: Stabilize new process Evaluate effectiveness Revise as needed SG: CH 6, p. 92 Before setting out to collect data for process improvement, a period of thought and planning is essential. When beginning a PI initiative, start by defining the problem- keep it simple and concise. Stakeholders should agree on the purpose of the data collection up front, that is, what is important to be measured to define the problem and/or measure the improvement. Delineate the scope- What areas will be affected and which areas will not? Describe the desired outcome- What should happen as a result of this change? Identify gaps and barriers- What is keeping the desired state from occurring? Identify contributing factors- a detailed look at everything that is contributing to the current state Then develop your interventions- What tactics will achieve the desired outcome? Develop the work plan- WHAT needs to be done, WHO will do it, WHEN will it be accomplished The variables essential to this measurement must be established so the data needed for decision making is available without rework. The timeframes for the measurement, as well as the timeframes for collection must be established, again with stakeholder consensus. The collection process, how data is collected, which data is excluded, must also be established. Develop a communication plan- Communication is essential! Who is impacted by the change, what do they need to know, and what communication methods will be used? After all of this work is done, it’s time to actually gather the data. Stabilize new processes- develop standard work, monitor the process, provide coaching Once the data has been gathered, the purpose and core variables previously identified can drive the analysis to determine the scope of the assumed problem or the improvements made. Did the process achieve the desired outcome? Evaluate what did and did not work and make revisions as needed. Your ACM Study Guide provides a great example of using data collection and analysis to improve the discharge planning process compliance with Conditions of Participation requirements. In this example, data is collected to determine the timeliness of initial case management assessments and readmission prevention Take a look at those examples and make sure you understand how data is collected and used in each scenario.

Communicating Findings
Education of the issue Data supporting the issue Intended process changes Planned interventions Goals of interventions Stakeholder involvement and needs SG CH 6, p. 97 As a process improvement project is beginning, involving stakeholders is crucial to success. Identifying those stakeholders, understanding each stakeholder’s need and desire for involvement, and establishing a communication plan up front saves time and expenditure of political capital later. Resistance to change is natural, so it is important to get buy in. Communicating with stakeholders may involve building a case for the proposed change or intervention, following some of the steps seen here. This slide is by no means an exhaustive list of considerations, but each is key to establishing stakeholder support.

Creating Solutions Monitoring and patterns Stakeholder involvement
Planning and implementing interventions Measuring improvement SG: CH 6, p After a potential problem and key stakeholders are identified, and pertinent data is collected, the performance improvement leader or team monitors data to identify trends and patterns that may warrant intervention. Stakeholders are again involved in planning and implementing interventions, and measuring improvements to quantify success and identify further improvement opportunities. Communication and interdisciplinary collaboration are key to the success of most projects.

Evaluating Effectiveness
Experienced case managers should be able to answer: How do I know my interventions are effective? How do I know my staff is effective? SG: CH 6, p A case management leader should be able to speak to measures that quantify the effectiveness of his or her staff and the work they do. If stopped in the hall by the CEO, a case management leader should be able to speak to these two questions by covering the points on the next slide

Case Management Effectiveness
Identified opportunities for performance improvement, including non-value added processes Compliance with key metrics Orientation and continuing education programs Resource allocation (people and time) SG: CH 6, p. 101 A case management leader should be able to speak to currently identified opportunities for improvement, including those non-value added processes that are opportunities for elimination or streamlining. Likewise, a case management leader should be able to speak to the department’s compliance with key metrics in Conditions of Participation, federal/state/local regulations, and organizational policy. The effective leader should be able to identify how orientation and continuing education programs are contributing to the department’s goals, and any metrics that support the value of those programs. A leader should also be able to explain why resources of people and time are allocated the way they are and how resource allocation is monitored and adjusted as needed.

Quality Improvement Denials process Less Avoidable days and delays
Staffing justification Utilization of services Aligning best practices with patient safety measures Falls risk Hand hygiene

Culture of Continual Improvement
Continually elevate performance expectations Energize and empower staff when participating in PI activities On-going department education Break down silos between work areas Message in a non-judgmental manner that there are always ways to improve Training for PI and Change Management should be provided as on-going department education. PI provides opportunities for collaboration with other departments. This is helpful for breaking down silos between work areas and promoting stronger relationships and communication that lead to improved patient outcomes.

ACMTM Examination Testing Strategy
Strategies and Recommendations for Success When you are taking the exam, you need to think of yourself as an ideal case manager, on an ideal day, with an ideal work load. No one has called in sick, there are no meetings to attend, every patient will be in their room, and the family will be available to talk to you. Don’t get into the trap of thinking, “That is not realistic in the world we live in today”.

An Explanation of the ACMTM Examination
Read the ACM Candidate Handbook! Two sections: 2 hours: General multiple choice (110 items) 90 minutes: Discipline-specific (RN or SW) simulation case studies (5 studies) 10 minute break between sections Scoring: Each section scored separately Each section includes unscored “pretest items” being evaluated for future exams SG: CH 2, pg 7-8 The ACM Candidate handbook does a good job of explaining how the exam works. Read and re-read those sections to make sure you understand them. The exam itself is divided into two sections 1. A general multiple choice section 2. Simulation case studies- very unique to this exam At the end of the day, we will spend some time on test taking strategies to maximize your chances of success. Each of these sections is scored separately, and the successful ACM candidate must pass both sections. Each section also has some test items “under construction” and being evaluated by the committee that writes the test. Those evaluation items are dispersed throughout the exam, and it will be impossible for a candidate to distinguish them. They have no positive or negative impact on scoring.

Multiple Choice on the ACM Exam
Presented first, but candidate can choose to take simulation portion first. It’s okay to guess - no points deducted It’s okay to skip questions and come back If you don’t know an answer to a question, look for clues in an earlier/later question on the same topic SG: CH 7, p 104

Core Multiple Choice Screening and Assessment (21)
Domains Structure Time & Quantity Platform/ Environment Screening and Assessment (21) Planning (20 items) Care Coordination, Intervention, Transition Mgmt (34) Evaluation (15) Non-scored, pretesting (20) A, B, C or D options Test ability to recall, apply and analyze relevant information. Two hour time limit 110 questions 90 questions scored Candidates can skip questions Candidates can go back and review or change responses ~1 min. per question SG: CH 2, pg 7 General Multiple Choice Questions This section of the exam includes 110 items that are taken by all ACM exam candidates. Questions are categorized into the below areas: TIP: Candidates should skip questions they are uncertain about and return to them for review after completing the rest of the exam. Screening and Assessment (21 questions) Planning (20 questions) Care Coordination, Intervention and Transition Management (34 questions) Evaluation (15 questions) Non-scored, pretesting (20 questions) Each of the questions has four answer options that test the candidate’s ability to recall, apply and analyze relevant information. The questions are multiple choice, with a, b, c, or d answer options; however, there may be some “all of the above” or “none of the above” answer choices. The twenty pretesting questions are used to validate items that may be used on future exams. Those questions are not scored, and they may be randomly dispersed throughout the exam. You will not be able to tell the difference between a scored question and a pretest question. The multiple choice portion of the exam has a two hour time limit (or about 1-minute per question), and candidates can skip questions and go back (within this section only). The last chapter of this guide provides strategies for taking multiple choice tests.

Multiple Choice Pointers
Read the instructions carefully to understand what the question is asking and what kind of choice is needed Look for qualifier words: Always, Never, Most, Least Read the WHOLE question before thinking about an answer; rephrase in your own words If the question is unclear, read through the answers carefully and evaluate which do or don’t fit with the question stem SG: CH 7, p. 104

More Pointers Eliminate known incorrect answers first
If two choices directly contradict each other, at least one is incorrect Look for question-answer relationship Judge answers against the question stem, not against each other Sometimes the most specific (longest) choice is the correct answer SG: CH 7 p. 104 -Eliminate known incorrect answers first -If two choices directly contradict each other, at least one is incorrect -Look for question-answer relationship -Judge answers against the question stem, not against each other -Sometimes the most specific (longest) choice is the correct answer

Discipline Specific Simulation Case Studies
Domains Structure Time & Quantity Platform/ Environment Information Gathering (IG) Decision Making (DM) Three parts: Clinical Scenario Information Gathering Assessment Decision Making Questions 90 minute time limit 5 studies 4 studies scored Candidates cannot skip questions Candidates cannot go back to change responses SG: CH 2, pg 8-9 Discipline Specific Simulation Case Studies The second section of the ACM exam consists of five case management scenarios presenting situations and problems common to healthcare system case managers. One of these scenarios will be a non-scored, pretest item. The simulation section is discipline-specific, with social work and nursing candidates receiving slightly different vignettes and questions. The simulation content for both disciplines provides comparable assessments of a case manager’s ability to manage patient situations. The social work simulations will assess the candidate’s ability to identify and address key biopsychosocial elements while the nursing simulations will be more focused on clinical aspects of the patient’s situation more common to the nursing case management domain. Each simulation consists of three parts: Clinical Scenario A clinical scenario is presented providing important information about the patient and his/her circumstances. The presentation will also identify the point in the patient’s hospital stay in which the scenario takes place. This scenario stays open in a window on the computer screen throughout all sections of the simulation. Information Gathering Assessment The simulation will present a list of possible information/data elements, and the candidate will be expected to identify and select those elements pertinent to the scenario in question. This section assesses the candidate’s ability to discern the most relevant information. Each item on the information/data element list is either (a) necessary, (b) acceptable, but not relevant or (c) not relevant. Decision Making Questions Decision making questions assess the candidate’s ability to take the patient’s situation presented in the clinical scenario, incorporate the additional relevant information gathered and apply critical thinking skills to develop and implement a case management plan for and with the patient. Questions may be presented involving a single decision or questions may have the option for making multiple decisions. It is crucial that the candidate carefully read the question for phrases such as “Choose only one,” or “Choose all that apply.” It is vital to read all options carefully at this stage of the exam and to be certain about selecting a given option. Once an option is selected, the candidate cannot reconsider and deselect it. Once choices are selected on the first decision making screen, the candidate will then be taken to the next screen, where the results of those decisions are presented and the next options in decision making are identified. The candidate cannot go back and modify any previous answers.

Discipline Specific Simulation Case Studies
SG: CH 2, pg 8-9 It is important that candidates understand the scoring system when determining whether to guess on a simulation answer. If you select an element that is considered: Then you will be scored by having: Necessary Points ADDED (+) Acceptable, but not relevant No Points (+0/-0) Not relevant Points DEDUCTED (-)

Simulation Scenarios 5 simulations, only 4 graded
90 minutes (about 18 minutes per scenario) Time management is essential No skipping and coming back Differences in Nurse and Social Work tests Case management process the same Discipline-specific focus applied in available choices SG: CH 7, p. 106 Something that we recently changed about the practice test is that we now provide a snippet of feedback for each answer choice, which better simulates the actual ACM Exam. For example if you choose “current medications” you will be given the feedback “Lasix, ace inhibitors”. Note to Presenter: use this slide to talk about simulation structure and use image to demonstrate what the computer screen will look like and the panel sections available. DO NOT try to run through the actual simulation text provided in the screenshot.

Scenario Scoring Each option has a point weight
1 to 3 points for appropriate answer 0 points -1 to -3 points for incorrect answers. Higher weights for answers that are more critically appropriate or more serious errors Questions designed to assess Information gathering- identifying key components Decision making- critical thinking skills

Scenario Tips A click will stick - make sure before making a selection
Don’t read too much into the scenarios Understand the setting - it’s not your workplace Be sure you know what’s being asked Keep the case management process in mind Assessment Planning Care Coordination Evaluation A click cannot be undone- so be absolutely sure before making a selection. You also cannot skip a question and come back. Read scenarios carefully to understand them, but don’t read too much into them. Remember the test is looking for best practices at a national level and resist the temptation to think of the scenario in the setting where you work. Pay attention to the setting you are given in the scenario to understand your perspective. This can make a difference in the information you gather and the decisions you make. Just as with the multiple choice questions- be sure you know what’s being asked If you feel you are losing your way in a scenario, come back to the case management process- Assessment, Planning, Care Coordination, and Evaluation. Think about what stage you are in with the scenario and think about what’s important to that phase.

More Tips Watch out for question phrasing
Choose the “most important” actions Choose the “most relevant” information Don’t think ahead! SG: CH 7, p. 106 Since any click cannot be undone, read the question stem carefully to understand your instruction. All of your choices may be relevant, but the exam may be asking you to only select the most relevant answers. Many case managers are multitaskers, and can almost project the final discharge plan as the assessment is progressing. Resist the temptation to do that here. Confine your answers to only those that are relevant to the particular stage of the case manager engagement that’s identified.

Scenario Management Strategy
Start the scenario and note the time. Allot about 18 minutes per scenario. Read scenario carefully, noting: Setting of the scenario Stage of the CM engagement Key information or risk factors What is the essential information required to move to the next stage? DON’T CLICK

Consider each question carefully, noting: What exactly is being asked? Identify answer parameters (choose all, best, sequence, etc.) DON’T CLICK Read the response choices, noting: Do two choices contradict each other? (at least one is wrong) Do any choices not pertain to the setting or scenario? (consider for elimination) Are any choices outside the CM practice? (consider for elimination) Which choice(s) most closely addresses the issue, setting and stage in question? (consider for selection) DON’T CLICK © 2016 American Case Management Association. All rights reserved.

Decide on your response: Use scratch paper to note your proposed answer(s) Review your proposal against the question Revise as needed Carefully Click on Your Selection(s) Progress to the next stage of the scenario. Repeat the process. © 2016 American Case Management Association. All rights reserved.

Applying Information Gathering and Critical Thinking skills

Ms. Jane Xavier (Part 1) Ms. Jane Xavier is scheduled for a total knee replacement. Her surgeon has agreed to participate in a pilot to study the effectiveness of a pre-surgical assessment for discharge planning needs on the length of stay for total joint patients. Ms. Xavier is 75-years old, a widow, with 2 adult children living nearby. Ms. Xavier’s daughter is very involved in her care and the patient wants her daughter included in all discussions about her care. She lives alone, is independent in all activities of daily living (ADLs), drives, does all of her own grocery shopping and participates in a weekly bridge club. She has a Managed Medicare health plan, a secondary policy through a former employer, and a long-term care insurance policy. The case manager is meeting with Ms. Xavier during a clinic visit 10 days prior to her surgery for a pre-procedure assessment and education. Note to Presenter: this is a simulation directly from the practice test of the ACM Study Guide. It is meant to be generic enough for both RNs and SWs and will allow you to demonstrate the process of working through the model during a live testing experience. You may not want to run through all parts of the simulation if you are short on time. Part 1: Information Gathering

Ms. Jane Xavier (Part 1) What are the first steps in conducting an assessment? (Select all that apply.) Verify insurance coverage Evaluate ADLs Establish rapport Verify demographic information in the record Contact the Healthcare POA to request verification documents -1 +1 +3 +2 -2 -1 Verify insurance coverage. Insurance verification is not the job of the case manager. Patient Access/Registration will be pre-authorizing the surgery, and the case manager will want to know at a later stage the specific benefits for discharge planning. +1 Evaluate ADLs Getting a pre-op level of functioning will be important in the discharge planning process. If the patient has a high level of functioning prior to the surgery, the payor is more likely to support aggressive rehab if needed. +3 Establish rapport. Establishing rapport is key to a thorough assessment as the patient is more likely to share detailed information if there is a level of trust. +2 Verify demographic information in the record. This is an important step in an assessment, since errors could result at the time of discharge (for example equipment being sent to the wrong address). -2 Contact the Healthcare Power of Attorney to request verification documents. If the patient is awake, alert, and capable of making her own health care decisions, there is no need to invoke the provisions in the Healthcare Power of Attorney document. It may be a facility’s policy to have these documents on file prior to a surgery, but this should not be pursued without first talking with the patient.

Ms. Jane Xavier (Part I1) After rapport is established and demographics have been verified, the first question the case manager asks is “what is your understanding of the care you will need after this surgery?” The patient states that she lives completely independently, still drives, grocery shops and attends a Bridge Club weekly. She expects to get back to her normal activities very quickly. Note to Presenter: this is a simulation directly from the practice test of the ACM Study Guide. It is meant to be generic enough for both RNs and SWs and will allow you to demonstrate the process of working through the model during a live testing experience. You may not want to run through all parts of the simulation if you are short on time. Part II: Information Gathering

Ms. Jane Xavier (Part 1I) What are the best next steps of the case manager? (Select all that apply.) Point out that after surgery, everyone requires some assistance, and address this need with the question, “will your children be willing, able and available to provide the physical assistance you will need and to stay with you until you progress to the point where you feel independent again?” Ask the patient to describe what she understands about the care that will be required when she is discharged and returns home. Show the patient how to use Medicare.gov in the event she needs SNF placement. +2 +3 -3 +2 Point out that after surgery, everyone requires some assistance, and address this need with the question, “will your children be willing, able and available to provide the physical assistance you will need and to stay with you until you progress to the point where you feel independent again?” Good answer, but the case manager also needs to know what the care needs will be to better assess the family’s ability to provide the care. +3 Ask the patient to describe what she understands about the care that will be required when she is discharged and returns home. This is the best answer as it allows the patient to tell the case manager what she thinks will be needed, and it allows the case manager the opportunity to correct/adjust those ideas (based on experience and the patient’s prior level of functioning) to a more realistic assessment, if necessary. -3 Show the patient how to use Medicare.gov in the event she needs SNF placement. There is no indication that the patient will need SNF placement, and directing the patient to this website may imply that this is an option for her. Depending on her progress after surgery, it may not be an option.

Ms. Jane Xavier (Part 1I) After establishing that the patient has a clear understanding of what her care needs will be and that her children are willing, able and available to help her, what are the next questions(s) the case manager will ask? (Select all that apply.) What is the patient’s insurance coverage? Are there neighbors, or friends, willing to provide assistance? What are the number of steps to get into the house/apartment? Are the bedroom and bathroom on the first floor? Does the patient know if the doors in her home are wide enough for a walker to fit through? -2 -3 +3 +2 +1 -2 What is the patient’s insurance coverage? This will be asked later in the assessment, but not yet. -3 Are there neighbors, or friends, willing to provide assistance? While friends could be a part of a discharge plan, at this point this is irrelevant since she has a caregiver. +3 What are the number of steps to get into the house/apartment? This is more relevant than the question above and can also be phrased as, “will the patient have difficulty getting into her home?” +2 Are the bedroom and bathroom on the first floor? This is also important. The case manager will need to determine, once the patient is in the home, whether they will be able to get to the bathroom and bedroom or require some form of assistance. +1 Does the patient know if the doors in her home are wide enough for a walker to fit through? This will be important to know if getting around the home presents a safety issue.

Ms. Jane Xavier (Part 1I) After assessing the physical environment, what is/are the case manager’s next concern(s)? (Select all that apply.) Determining the patient’s insurance coverage for post-acute services. Clarifying the patient’s prescription benefit, including co-pay requirements. Exploring with the patient her available resources and ability to make co-payments. Determining who the patient’s primary care physician is. Determining what home health agency the patient wants to use, if needed. Showing the patient how to use Medicare.gov to assist in choosing a SNF. +3 +2 +1 -2 -1 -3 +3 Determining the patient’s insurance coverage for post-acute services. At this point in the assessment, it is important to now assess the financial resources for needed services and open a conversation with the patient and/or family about limitations, if applicable. For example, the case manager knows that the patient has a Managed Medicare product and should share with the patient that access to home health or SNF will be based on therapy notes and need for rehab rather than the patient simply wanting to recover in a nursing home. Do remember that since she has Managed Medicare, her payer may allow SNF placement, if needed, without a 3-day stay. +2 Clarifying the patient’s prescription benefit, including co-pay requirements.The case manager knows that patients are discharged on anti-coagulants after joint surgery, and based on experience, the case manager knows these drugs can be expensive. +1 Exploring with the patient her available resources and ability to make co-payments. The patient may or may not have financial concerns, but education about how much these drugs could cost is important for all patients in order to prevent a surprise at discharge. -2 Determining who the patient’s primary care physician is. This information should be contained in the record and should have been verified with the patient earlier in the assessment. -1 Determining what home health agency the patient wants to use, if needed. Although a good question, this is not the next step. The case manager needs to check benefits, and since this is Managed Medicare, also check preferred providers before having this conversation. -3 Showing the patient how to use Medicare.gov to assist in choosing a SNF. SNF placement is not in the care plan at this point. If it becomes necessary, the case manager must check first for in-network providers with Managed Medicare payers. In most Medicare Advantage plans, the patient needs to use plan doctors, hospitals and other providers or pay more or all of the costs (Medicare.gov website).

Ms. Jane Xavier (Part III)
At the end of the previous assessment, the case manager knows that Ms. Xavier is independent in ADLs and Instrumental Activities of Daily Living (IADLs), drives her car, is cognitively able to play Bridge and has two adult children who she feels will be able to help her (which is her preferred plan). She lives in a single-level home with five steps to get into the house. The railing is on the left side. She knows her doorways are wide enough for a walker because her husband used one before he passed away. She feels she made a wise decision choosing a Managed Medicare policy and feels secure that her secondary policy will cover anything that Medicare does not cover. Her prescriptions are covered by this policy, and the normal copays are reasonable. Ms. Xavier tells the case manager she can pay whatever co-pay she needs to pay. She also has a long-term care policy that helped her when her husband required care prior to his death. Ms. Xavier is cleared for surgery and presents to the hospital on the scheduled date. Note to Presenter: this is a simulation directly from the practice test of the ACM Study Guide. It is meant to be generic enough for both RNs and SWs and will allow you to demonstrate the process of working through the model during a live testing experience. You may not want to run through all parts of the simulation if you are short on time. Part III: Decision Making

Ms. Jane Xavier (Part III)
Now that patient is in the hospital, and the surgery has been completed, what are the next best steps of the case manager? (Select all that apply.) Insist on seeing the patient on the day of surgery to get an assessment completed as soon as possible. Ask the patient’s bedside nurse if the patient is alert and oriented, and visit with the patient on the day of surgery. Confirm with the patient that the information in the pre-admission assessment is still accurate and complete. Have a detailed conversation about the patient and her options with the patient’s daughter while the patient is in the recovery unit. -2 +3 +2 -3 -2 Insist on seeing the patient on the day of surgery to get an assessment completed as soon as possible. Insist on seeing the patient on the day of surgery to get an assessment completed as soon as possible. +3 Ask the patient’s bedside nurse if the patient is alert and oriented, and visit with the patient on the day of surgery. If the patient is alert and oriented, an assessment on the day of surgery could be valuable in controlling the length of stay. +2 Confirm with the patient that the information in the pre-admission assessment is still accurate and complete. As soon as the patient is alert and oriented, the first thing the case manager will do is confirm that there are no changes since the pre-admission assessment was completed. -3 Have a detailed conversation about the patient and her options with the patient’s daughter while the patient is in the recovery unit. Since the patient is not incapacitated, she is the one with which the case manager should confer.

Ms. Jane Xavier (Part IV)
The case manager sees Ms. Xavier on Post-Op Day 1 and performs the Admission Assessment, confirming that the information provided at the pre-admission assessment has not changed. Ms. Xavier admits to 8/10 pain and states that she refused PT this morning because of the pain. The case manager notices the patient seems mildly confused and attributes that to anxiety and pain. Note to Presenter: this is a simulation directly from the practice test of the ACM Study Guide. It is meant to be generic enough for both RNs and SWs and will allow you to demonstrate the process of working through the model during a live testing experience. You may not want to run through all parts of the simulation if you are short on time. Part IV: Decision Making

Ms. Jane Xavier (Part IV)
What is the case manager’s best response? (Select all that apply.) Encourages the patient to speak with her nurse about the use of her Patient Controlled Analgesic (PCA) pump. Explains to the patient that participation in physical therapy is critical to achieving her goal of discharge to home. Gives the patient the SNF list and tell her she will likely need rehab since she’s not up and about yet. Reports patient’s poor pain control and confusion to the patient care nurse. Requests that the attending physician order a pain consult. Asks PT to see the patient again. Collaborate with PT to see the patient again early the next day, and prompt PT to coordinate administration of pain medication with nursing so the patient is more likely to participate in therapy. -1 +1 -2 +3 -3 -1 Encourages the patient to speak with her nurse about the use of her Patient Controlled Analgesic (PCA) pump. While some pain is to be expected, it is possible that the patient is not using her PCA correctly. Proper use could control her pain much better; however, since she is confused, leaving it up to her to speak to her nurse is not the best solution. +1 Explains to the patient that participation in physical therapy is critical to achieving her goal of discharge to home. This is a good response. Perhaps the case manager could help patient understand that if she gets her pain under control, she will be more likely to participate in physical therapy and reach her goal of discharge to home. However, pain should be addressed first. -2 Gives the patient the SNF list and tell her she will likely need rehab since she’s not up and about yet. The case manager should address this concern with the patient after conferring with the care team (including PT) at a time when the patient is no longer confused. +3 Reports the patient’s poor pain control and confusion to the patient care nurse. The case manager knows that the patient’s report of 8-10 pain, and the confusion that is quite evident, are not normal for post-op day 1 after joint replacement. The case manager must share this information with the patient’s nurse and/or physician if available. -3 Requests that the attending physician order a pain consult. Orthopedic patients have pain that for the most part can be controlled with proper use of a PCA. The attending is not likely to order a pain consult on post op day 1. -1 Asks PT to see the patient again. If she is confused and in pain, this is not the time for her to be seen by PT. +3 Collaborate with PT to see the patient again early the next day, and prompt PT to coordinate administration of pain medication with nursing so the patient is more likely to participate in therapy. This is a positive and proactive action to take and is a good example of collaboration with the multidisciplinary care team.

Ms. Jane Xavier (Part V) While seeing other patients two hours later, the case manager hears an overhead page announcing a “Rapid Response” to Room 112. The case manager realizes this is Ms. Xavier who she assessed earlier today and should be going home on Post-Op day 2. The Rapid Response Team finds Ms. Xavier obtunded and unarousable, and she is moved quickly to the ICU. By the time the move is complete, the patient is slowly regaining consciousness so does not get intubated. She remains lethargic and confused. The case manager learns that the patient may have had too much pain medication, and that is what resulted in the loss of consciousness. Note to Presenter: this is a simulation directly from the practice test of the ACM Study Guide. It is meant to be generic enough for both RNs and SWs and will allow you to demonstrate the process of working through the model during a live testing experience. You may not want to run through all parts of the simulation if you are short on time. Part V: Decision Making

Ms. Jane Xavier (Part V) What are the next best steps of the case manager? (Select all that apply.) Contribute to the completion of an adverse drug event (ADR) report in the hospital’s safety reporting system with the bedside nurse on the Ortho Unit. Sees the patient’s daughter in the ICU waiting room, and having heard from the nursing staff that she has been very attentive to the patient and involved in her care, stops to reassure her that her mother is in the best of hands and asks the daughter what she has been told about her mother’s condition. The case manager talks with the daughter about the possibility that the discharge plan may need to change based on the current situation. Hands off the patient to the ICU case manager since Ms. Xavier is no longer on her unit. +1 +3 -2 +1 Contribute to the completion of an adverse drug event (ADR) report in the hospital’s safety reporting system with the bedside nurse on the Ortho Unit. While it is not the case manager’s responsibility to complete the ADR, what the case manager observed may be useful to add to the report. +3 Sees the patient’s daughter in the ICU waiting room, and having heard from the nursing staff that she has been very attentive to the patient and involved in her care, stops to reassure her that her mother is in the best of hands and asks the daughter what she has been told about her mother’s condition. The case manager talks with the daughter about the possibility that the discharge plan may need to change based on the current situation. Preparing the family for a change in plans is appropriate at this point. The patient’s daughter has been at the hospital on a regular basis and has been involved, with the patient’s permission, in all conversations about her care. -2 Hands off the patient to the ICU case manager since Ms. Xavier is no longer on her unit. This would be an inappropriate choice because it is highly likely that the patient will recover quickly and return to the Ortho Unit. Keeping the patient would ensure consistency and possibly prevent an increase in LOS while another case manager “catches up” with the case and patient/family.

Ms. Jane Xavier (Part VI)
On Post-op day 2, when many total knee replacement (TKR) patients are being discharged home, the case manager returns to visit with the patient (who has been transferred back to the Ortho Unit). PT was able to see the patient early in the morning in ICU, and at that time they recommended SNF placement due to slow recovery and continuing lethargy. Ms. Xavier has some residual lethargy and states that she has 5/10 pain but has learned to use the PCA to manage it. Note to Presenter: this is a simulation directly from the practice test of the ACM Study Guide. It is meant to be generic enough for both RNs and SWs and will allow you to demonstrate the process of working through the model during a live testing experience. You may not want to run through all parts of the simulation if you are short on time. Part VI: Decision Making

Ms. Jane Xavier (Part VI)
What are the next best steps of the case manager? (Select all that apply.) Share the PT recommendation with the patient and her daughter, who is at the bedside. Discuss the SNF placement process with the patient. Inform the patient that, since she has a Managed Medicare policy, she does not have a choice of facilities for SNF placement and will need to go to the facility approved by her payor. Realize that the patient may go beyond a 2-day stay, so asks her utilization management partner to give the Important Message from Medicare Second Notice (IM). +3 +2 -3 +3 Share the PT recommendation with the patient and her daughter, who is at the bedside. The information from PT should be shared as soon as possible to allow the placement process to begin. +2 Discuss the SNF placement process with the patient. Remind the patient/daughter that the patient has a Managed Medicare plan that does have in-network providers and a requirement to pre-authorize the placement. -3 Inform the patient that, since she has a Managed Medicare policy, she does not have a choice of facilities for SNF placement and will need to go to the facility approved by her payor. While this is true, if the patient wants her insurance to pay for placement, patients always have a right to choose – if Ms. Xavier chooses to not make use of her Medicare benefit as provided by this Managed Care plan, she is free to go wherever she chooses. +2 Realize that the patient may go beyond a 2-day stay, so asks her utilization management partner to give the Important Message from Medicare Second Notice (IM). While the utilization manager would not have needed to give an Important Message (IM) Second Notice because this procedure was planned for discharge within 48-hours of admission, the case manager now realizes that the patient may go beyond a 2-day stay, so she asks her utilization management partner to give the IM.

Ms. Jane Xavier (Part VII)
The patient and her daughter agree that “this is more than they expected,” and they are not as confident of their ability to manage at home. They agree they are fine with the change in discharge plan. The case manager contacts “ABC” Medicare to provide clinical information for pre-authorization. Given the patient’s functional status prior to admission, “ABC” quickly approves SNF placement with authorization to transfer today. The case manager reports back to the patient/family and lets them know that two of the facilities she mentioned earlier have availability, and they need to choose one now because the attending has written a discharge order for transfer to a SNF. The patient/family expresses concern that this is too soon. Ms. Xavier was just in the ICU this morning, and the family wants to go visit the facilities before making a decision. The family states they will contact the physician and their insurance company to appeal this decision. Note to Presenter: this is a simulation directly from the practice test of the ACM Study Guide. It is meant to be generic enough for both RNs and SWs and will allow you to demonstrate the process of working through the model during a live testing experience. You may not want to run through all parts of the simulation if you are short on time. Part VII: Decision Making

Ms. Jane Xavier (Part VII)
What are the appropriate next steps in this scenario? (Select all that apply.) The utilization manager takes the “Detailed Notice of Discharge” into the patient and her daughter. The utilization manager awaits a call from the QIO that an appeal has been filed. The case manager notifies the SNF that the patient is appealing her discharge, so she will not be transferred today. The case manager notifies the physician that the patient is appealing her discharge. -3 +3 +1 -3 The utilization manager takes the “Detailed Notice of Discharge” into the patient and her daughter. The Important Message from Medicare that the patient received earlier gives the patient/family the phone number for appeal. The “Detailed Notice of Discharge” is provided after the appeal is confirmed. +3 The utilization manager awaits a call from the QIO that an appeal has been filed. This is appropriate because any next steps should not be taken until the appeal is official. +1 The case manager notifies the SNF that the patient is appealing her discharge, so she will not be transferred today. This may be premature since the appeal is still not officially filed. +1 The case manager notifies the physician that the patient is appealing her discharge. Again, this may be premature until the QIO notifies the utilization manager that the appeal has been filed.

Ms. Jane Xavier (Part VIII)
The QIO notifies the hospital that the patient is appealing her discharge. They confirm that there is a discharge order on the chart and ask that the record be sent to them immediately. Note to Presenter: this is a simulation directly from the practice test of the ACM Study Guide. It is meant to be generic enough for both RNs and SWs and will allow you to demonstrate the process of working through the model during a live testing experience. You may not want to run through all parts of the simulation if you are short on time. Part VIII: Decision Making

Ms. Jane Xavier (Part VIII)
Take the “Detailed Notice of Discharge” into the patient's room and deliver to the patient and her daughter. Call the Managed Medicare Company to alert them to the discharge appeal and to let them know the patient will not be leaving today for the SNF. Explains to the patient that participation in physical therapy is critical to achieving her goal of discharge to home. Tell the patient that she is likely to lose the SNF bed and that may result in her discharge to home instead. Tell PT that the patient has appealed her discharge so they don’t need to see the patient again in the morning. Document delivery of the “Detailed Notice of Discharge” and the appeal in accordance with hospital policy and Medicare regulations. +3 +2 -3 +1 +3 Take the “Detailed Notice of Discharge” into the patient's room and deliver to the patient and her daughter. This is the first thing that should happen after receiving notice from the QIO. +2 Call the Managed Medicare Company to alert them to the discharge appeal and to let them know the patient will not be leaving today for the SNF. The payor needs to know the discharge is not happening today. They will want an update from PT prior to approving a transfer to SNF given this delay. -3 Tell the patient that she is likely to lose the SNF bed and that may result in her discharge to home instead. This would not necessarily be true. The patient may still not be safe to discharge home, and it could be perceived as a retaliatory statement because of the appeal. -3 Tell PT that the patient has appealed her discharge so they don’t need to see the patient again in the morning. PT needs to see the patient even if she has appealed her discharge because the case manager knows a PT update will need to be provided to the payor, as well as to the physician, as alternate plans may need to be made if the payor denies SNF placement. +1 Document delivery of the “Detailed Notice of Discharge” and the appeal in accordance with hospital policy and Medicare regulations. Requirements for documentation of this process are defined by CMS regulations as well as department policy.

Identify Areas of Strengths and Weaknesses
Which areas do you need more review? Which areas have you already mastered? Information Gathering Screening and Assessment Planning Decision Making Care Coordination, Intervention and Transition Management Evaluation

Applying for & Earning the ACMTM Credential
What Happens Before and After You Pass

How to apply Applications are: Completed online
Processed automatically Exams must be scheduled and confirmed for a date within 3 months of application/receipt of approval. Candidates may submit their application at any time. All applications must be accompanied by full payment of application fees to be considered complete and ready for approval. Upon receipt of approval, candidates will receive a scheduling notice from ACM's testing partner and will be directed to schedule their examination through the testing partner's online portal, or by contacting the testing partner by phone. All initial examinations must be scheduled and confirmed for a date within three (3) months following receipt of the application approval. (Example: If a candidate applies to take the initial exam on January 1st and receives approval, the candidate must schedule and take the exam by no later than March 31st.)

What are the Costs? With the ACMTM, you will: Initial Exam Fee: $325
Retest Fee: One Portion (Core or Simulation): $190 Both Portions (Core and Simulation): $325 Recertification (every 4-years): $140 With the ACMTM, you will: Validate your knowledge Earn professional respect Advance your career Demonstrate your commitment to provide the best plan of care

Where to Take the Exam Find a testing facility convenient to you!
ACM partners with PSI/AMP to administer exams, and testing facilities are available across the country.

Congratulations – you passed!
You will get your ACM-RN or ACM-SW Certificate from the National Board of Case Management (NBCM) You will be mailed a ACM Lapel Pin You can add the digital ACM credential to your resume, CV and signature

Maintaining Your Credential
The ACM™ credential is valid for a 4-year period To recertify, 40 hours of continuing education are required 30 hours must be specific to Healthcare Delivery Case Management. 10 hours can be non-case management related but must be related to the practice of healthcare in the certificant’s field of practice.

Approved CE Providers Approved ACM educational programs must be sponsored or presented by ACM approved providers, and include courses for which the content/subject matter is specific to either (A) Healthcare Delivery Case Management or (B) related to the practice of healthcare in the certificant’s field of practice. American Nurses Credentialing Center (ANCC) National Association of Social Workers (NASW) Association of Social Work Boards (ASWB) American Case Management Association (ACMA)* All state nursing and social work board approved educational courses *All ACMA courses are approved by both nursing and social work accrediting organizations. All of this can be found at ACM website.

Do: Access the ACM portal to keep up with your CEs Update your contact information regularly Don’t: Wait until the last minute to upload or take CEs The ACM portal is on located on the ACMA website at : Your username and password are the same as when you signed up to sit for exam. If you need help logging on please call the ACM Certification Department at

ACM™ Certification Review: Case Management Process and Practice

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ACM™ Certification Review: Case Management Process and Practice

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