Your FREE CCM Flashcards 2026 – 200+ Cards

A collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy to meet a client's needs through communication and available resources to promote quality, cost-effective outcomes.

Evaluation of the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and facilities.

The process of preparing a patient for transition from one care setting to the next to ensure safe, continuous care and prevent readmission.

The movement of a patient between care settings or providers; high-risk for errors and readmissions, requiring coordination and communication.

Comparing a patient's current medications across transitions to avoid omissions, duplications, dosing errors, and interactions.

Evidence-based clinical decision-support criteria used to determine medical necessity and appropriate level of care.

Milliman Care Guidelines — evidence-based clinical guidelines used for utilization management and level-of-care decisions.

Screening, assessing, stratifying risk, planning, implementing, following-up, transitioning, communicating post-transition, and evaluating.

The initial step to identify clients who would benefit from case management services based on risk and need.

Systematic collection of physical, psychosocial, functional, and financial information to identify a client's needs and resources.

Categorizing clients by acuity and risk level to target resources and intensity of case management appropriately.

Developing measurable, client-centered goals and interventions to address identified needs across the care continuum.

Organizing client care activities and sharing information among all participants to achieve safer, more effective care.

A group of professionals from different disciplines who collaborate to plan and deliver coordinated patient care.

The full range of healthcare settings and services a patient may use, from acute care through home and community-based care.

Short-term, intensive treatment for severe injury, illness, or surgery, typically in a hospital setting.

Care for patients who no longer need acute hospital intensity but require more skilled services than long-term care provides.

Skilled Nursing Facility — provides skilled nursing and rehabilitation services for patients needing ongoing post-acute care.

Long-Term Acute Care — hospital-level care for medically complex patients needing extended stays, often on ventilators.

Skilled medical services delivered in a patient's home, such as nursing, therapy, and aide services.

Comfort-focused care for terminally ill patients with a prognosis of about six months or less, emphasizing quality of life.

Specialized care focused on relieving symptoms and stress of serious illness at any stage, alongside curative treatment.

Utilization review conducted before care is delivered (e.g., preauthorization) to confirm medical necessity.

Utilization review conducted during an active hospital stay to assess ongoing medical necessity and level of care.

Utilization review conducted after care is completed to evaluate appropriateness and support payment decisions.

Evaluation of medical necessity and efficiency of healthcare services using prospective, concurrent, and retrospective review.

Services or supplies that are reasonable and necessary to diagnose or treat a condition per accepted standards of care.

A coordinated approach to managing chronic conditions through education, self-management support, and evidence-based care.

Improving the health outcomes of a defined group by addressing needs across the continuum and reducing disparities.

Asking patients to restate information in their own words to confirm understanding of instructions.

A transfer of care conducted in person between providers, often with the patient present, to improve communication and safety.

An unplanned return to the hospital within 30 days of discharge; a key quality and reimbursement penalty metric.

Case Management Society of America's professional framework defining the role, functions, and standards of case managers.

Ongoing review of the care plan to ensure interventions are implemented and goals are progressing, adjusting as needed.

A primary care provider who coordinates care and authorizes referrals to specialists, common in HMO models.

The number of days a patient remains in a facility; a core utilization and efficiency metric.

Outpatient medical services provided without an overnight hospital stay.

The number of clients assigned to a case manager, which affects the intensity and frequency of contact possible.

Consistent, coordinated care over time and across settings to avoid gaps and duplication.

Delivery of healthcare services and information remotely via telecommunications technology.

A framework for improving chronic illness care through community resources, self-management, decision support, and delivery design.

The level of severity and complexity of a patient's condition, used to determine resource and care intensity.

Approval obtained from a payer before a service is delivered to confirm coverage and medical necessity.

A payer's determination that a requested service is not covered or medically necessary, which the case manager may appeal.

A formal request to reconsider a denied authorization or claim, supported by clinical documentation.

A discussion between the treating physician and the payer's medical director to resolve a coverage or denial dispute.

Executing the agreed interventions and coordinating services to carry out the client's care plan.

Ongoing contact to confirm services were delivered, evaluate effectiveness, and revise the plan as needed.

Coordinating a safe move to the next level of care, including services, equipment, follow-up, and education.

Helping clients gain the skills and confidence to manage their own conditions day to day.

Intensive coordination for high-risk clients with multiple comorbidities and significant resource needs.

An evidence-based model (Coleman) that coaches patients in self-care skills during the post-hospital transition.

Accurate, timely recording of assessments, interventions, and communication to support continuity and accountability.

A primary care model delivering comprehensive, coordinated, accessible, team-based care centered on the patient.

Measuring whether care plan goals and outcomes have been met, and documenting results to guide future care.

An outpatient designation for short stays under monitoring; affects billing and SNF coverage eligibility.

Matching available services and funding to the client's needs in a cost-effective, equitable manner.

A professional who guides patients through the healthcare system, removing barriers to timely care.

A standardized, evidence-based plan outlining expected care steps and timing for a condition.

The presence of two or more chronic conditions in a patient, increasing care complexity.

A patient with frequent, costly use of services (e.g., repeat ED visits) who benefits from targeted case management.

The case manager serving as one consistent coordinator across the client's providers and services.

A CMS program that penalizes hospitals for excess Medicare readmissions for select conditions.

Goals that are Specific, Measurable, Achievable, Relevant, and Time-bound.

Approval that a payer will cover a specific service for a member.

The process of identifying and enrolling a client into case management services.

The case manager's role bridging communication and coordination across providers, payers, and settings.

Prioritizing clients by urgency of need to direct resources to those who need them most.

A case management model focused on linking clients to services rather than providing direct care.

Using data analytics to identify clients at high risk of poor outcomes or high costs for proactive intervention.

Hospital insurance covering inpatient hospital stays, skilled nursing facility care, hospice, and some home health care.

Medical insurance covering physician services, outpatient care, preventive services, and durable medical equipment.

Medicare Advantage — private health plans that bundle Parts A and B (and usually D) benefits, often with managed care features.

Prescription drug coverage offered through private plans approved by Medicare.

Joint federal-state program providing health coverage to low-income individuals and families; eligibility and benefits vary by state.

Diagnosis-Related Group — inpatient prospective payment classification that pays a fixed amount per case based on diagnosis, regardless of length of stay.

A reimbursement model paying a provider a fixed amount per member per month (PMPM) regardless of services used.

A payment model reimbursing providers for each individual service rendered, which can incentivize volume.

Health Maintenance Organization — a managed care plan requiring members to use network providers and obtain referrals from a primary care provider.

Preferred Provider Organization — a plan allowing care from in- or out-of-network providers, with lower cost for in-network use and no referral required.

Rules determining the order in which multiple insurers pay when a person has more than one plan.

An individual enrolled in both Medicare and Medicaid, often with complex needs and special coordination programs.

Exclusive Provider Organization — a plan covering only in-network care (except emergencies) but typically without referral requirements.

Point-of-Service plan — a hybrid combining HMO and PPO features; uses a primary care provider but allows out-of-network care at higher cost.

Accountable Care Organization — a group of providers jointly accountable for the cost and quality of a population's care, sharing savings.

Inpatient Prospective Payment System — Medicare's DRG-based method for paying acute hospitals a fixed amount per discharge.

Ambulatory Payment Classification — Medicare's prospective payment system for hospital outpatient services.

Resource Utilization Groups — the former SNF payment classification based on resource use, replaced by PDPM.

Patient-Driven Payment Model — the current SNF payment system based on patient characteristics rather than therapy minutes.

A payment method reimbursing a fixed amount per day of care regardless of actual services provided.

Linking provider payment to quality and outcomes rather than volume of services.

A single payment covering all services for an episode of care, encouraging coordination and efficiency.

An arrangement where providers and payers share financial gains or losses based on cost and quality performance.

State-mandated insurance covering medical care and lost wages for employees injured on the job.

Consolidated Omnibus Budget Reconciliation Act — lets employees temporarily continue employer health coverage at their own cost after qualifying events.

Affordable Care Act — 2010 law expanding coverage through marketplaces, Medicaid expansion, and consumer protections.

Comparing the costs of an intervention to its monetary benefits to determine financial value.

Comparing the relative costs and clinical outcomes of two or more interventions.

The amount a member must pay out of pocket before insurance begins covering services.

A fixed dollar amount a member pays for a covered service at the time of care.

A percentage of the cost of a covered service that the member pays after meeting the deductible.

The most a member pays in a plan year before the insurer covers 100% of covered services.

Denial, Anger, Bargaining, Depression, and Acceptance — the five emotional stages people may move through when facing loss or terminal illness.

Non-medical conditions — such as housing, food security, income, education, and transportation — that influence health outcomes.

A client-centered counseling method that strengthens a person's own motivation and commitment to change by exploring ambivalence.

Precontemplation, Contemplation, Preparation, Action, Maintenance — stages describing how people modify behavior.

Short-term, immediate help to stabilize a person in acute distress and connect them to ongoing support.

Care addressing mental health and substance use conditions and their effect on overall well-being.

A condition involving compulsive use of substances despite harmful consequences, often requiring integrated treatment.

The degree to which individuals can obtain, understand, and use health information to make decisions.

The ability to provide care that respects and responds to clients' cultural and linguistic needs.

Resources, education, and respite that help family or informal caregivers sustain their caregiving role.

The physical, emotional, and financial strain experienced by those caring for a chronically ill or disabled person.

Temporary relief services that allow caregivers a break from ongoing care responsibilities.

The network of family, friends, and community resources a client can draw on for assistance.

Local services such as food banks, transportation, housing assistance, and support groups that address client needs.

Grief experienced before an expected loss, such as during a terminal diagnosis.

Prolonged, intense grief that impairs functioning and may require professional intervention.

A model ranking human needs from physiological and safety up through love, esteem, and self-actualization.

The stage of change in which a person is not yet considering changing a behavior.

The stage of change in which a person is aware of a problem and considering action but not yet committed.

The stage of change in which a person is actively modifying behavior and environment.

The stage of change in which a person works to sustain new behavior and prevent relapse.

A person's belief in their ability to succeed at a specific task or behavior change.

Helping clients gain control over decisions and actions affecting their own health.

Fully attending to and reflecting back a client's words and feelings to build rapport and understanding.

The patterns of interaction and roles within a family that influence a client's care and decisions.

Physical, emotional, financial, or neglectful harm to an older adult, requiring assessment and mandated reporting.

A professional legally required to report suspected abuse or neglect to authorities.

Use of validated tools (e.g., PHQ-9) to identify depressive symptoms for further evaluation and intervention.

A nine-item validated questionnaire used to screen for and measure the severity of depression.

Strategies a person uses to manage stress; may be adaptive (problem-solving) or maladaptive (avoidance).

Evaluating ideation, plan, intent, and means to determine risk and trigger safety interventions.

Communication techniques to calm an agitated or distressed person and reduce the risk of harm.

Strategies that reduce the negative consequences of risky behavior without requiring abstinence.

A model explaining health behavior through perceived susceptibility, severity, benefits, and barriers.

An approach recognizing the widespread impact of trauma and avoiding re-traumatization in care delivery.

Limited or uncertain access to adequate food, a social determinant affecting health outcomes.

Lack of stable, safe housing, which contributes to poor health and complicates care plans.

Lack of reliable transportation that prevents access to appointments, medications, and services.

Preventable differences in health outcomes among population groups linked to social and economic disadvantage.

Negative attitudes toward a condition (e.g., mental illness, addiction) that can deter people from seeking care.

A collaborative process where clinician and client weigh options and choose care aligned with the client's values.

The extent to which a client follows agreed treatment recommendations, such as medications or appointments.

A person's capacity to adapt and recover from adversity, stress, or illness.

A facilitated gathering of people sharing a condition or experience for mutual emotional and practical support.

Counseling and resources offered to help survivors cope with loss after a death.

The Kubler-Ross stage in which a person comes to terms with the reality of a loss.

The Kubler-Ross stage in which a person refuses to accept the reality of a loss as a protective response.

The Kubler-Ross stage in which a person tries to negotiate or postpone the loss, often with 'if only' thinking.

Language assistance ensuring clients with limited English proficiency understand their care; supports equity and consent.

Core MI skills: Open-ended questions, Affirmations, Reflective listening, and Summarizing.

Acting on behalf of the client to protect their rights, promote autonomy, and ensure access to appropriate services and information.

Health Insurance Portability and Accountability Act — federal law protecting the privacy and security of individuals' protected health information.

Ethical principle of respecting a client's right to make their own informed decisions about their care.

Ethical principle of acting in the best interest of the client and doing good.

Ethical principle of doing no harm to the client.

Ethical principle of treating clients fairly and distributing resources and care equitably.

Voluntary agreement to treatment after being given adequate information about risks, benefits, and alternatives.

A legal document stating a person's healthcare wishes and/or naming a decision-maker for use if they become unable to decide.

Ethical principle of truthfulness and honesty in communication with clients.

Ethical principle of keeping commitments, being loyal, and maintaining trust with the client.

Emergency Medical Treatment and Labor Act — requires Medicare hospitals to provide a medical screening and stabilizing treatment regardless of ability to pay.

Americans with Disabilities Act — civil rights law prohibiting disability discrimination and requiring reasonable accommodations.

A legal document naming a person to make medical decisions if the client becomes unable to do so.

A legal arrangement giving a court-appointed person authority to make decisions for an incapacitated individual.

An advance directive specifying the medical treatments a person does or does not want at end of life.

Do Not Resuscitate — a physician order directing that CPR not be performed if the heart or breathing stops.

Physician Orders for Life-Sustaining Treatment — a portable medical order reflecting a seriously ill patient's treatment wishes.

The legally defined range of activities a licensed professional is qualified and permitted to perform.

Failure to provide the standard of care that a reasonable professional would, potentially causing harm.

Duty, breach of duty, causation, and damages — all four must be present to establish negligence.

Professional negligence by a licensed provider that fails to meet the standard of care and causes harm.

A situation where personal or financial interests could compromise the case manager's duty to the client.

The ethical standards governing CCM-certified case managers, including advocacy and avoidance of conflicts.

Protected Health Information — individually identifiable health data safeguarded under HIPAA.

Sets national standards for the use and disclosure of protected health information.

Sets standards for safeguarding electronic protected health information through administrative, physical, and technical controls.

HIPAA principle that only the least PHI needed to accomplish a purpose should be used or disclosed.

The duty to protect private client information from unauthorized disclosure.

Federal law requiring providers to inform patients of their rights to make advance directives and care decisions.

A person authorized to make healthcare decisions for a patient who lacks capacity.

A clinical determination that a patient can understand, appreciate, reason, and communicate a care choice.

A legal determination by a court regarding a person's ability to make decisions for themselves.

A situation in which competing ethical principles or values make the right course of action unclear.

Family and Medical Leave Act — grants eligible employees up to 12 weeks of unpaid, job-protected leave for medical or family reasons.

Entitlements including informed consent, privacy, access to records, and the right to refuse treatment.

A competent patient's legal right to decline recommended care, even if it may be life-sustaining.

The level and type of care a reasonably competent professional would provide under similar circumstances.

Legal obligation to report suspected abuse, neglect, or specific public health threats to authorities.

The obligation to warn or protect a third party when a client poses a serious threat of harm to them.

Identifying and reducing organizational and clinical risks to prevent harm and liability.

Intentional deception (fraud) or improper practices (abuse) that result in unauthorized payment or harm.

Federal law prohibiting physician self-referral for certain services to entities with which they have a financial relationship.

Federal law prohibiting payment for referrals of federally reimbursed healthcare services.

A patient's decision to decline care after being informed of the risks and consequences.

An ethical tension when doing what is best for a client conflicts with respecting the client's own choice.

Plan-Do-Study-Act — an iterative four-step quality improvement model for testing and implementing changes.

Healthcare Effectiveness Data and Information Set — NCQA's standardized performance measures used to compare health plan quality.

National Committee for Quality Assurance — accrediting body that evaluates and reports on health plan quality, including HEDIS measures.

An accrediting organization that sets and evaluates performance standards for hospitals and healthcare facilities.

Differences between recommended evidence-based care and the care a patient actually receives.

Systematic, data-driven efforts to improve healthcare processes and outcomes.

A data-driven quality methodology aiming to reduce variation and defects using the DMAIC framework.

A quality methodology focused on eliminating waste and maximizing value in processes.

A structured method for identifying the underlying causes of an adverse event to prevent recurrence.

Comparing performance metrics against standards or best-in-class organizations to identify improvement opportunities.

Examining deviations from expected outcomes or care pathways to identify causes and improvements.

Measurable results of care related to health status, such as symptom control or complication rates.

Measures of a person's ability to perform daily activities and roles after treatment.

Cost-related results of care, such as cost per case, savings, and avoided admissions.

Measures of patient and family experience and perceived quality of care.

Measures of a client's overall well-being and ability to live as they wish despite illness.

An accrediting body that certifies case management programs and other healthcare quality standards.

CMS's quality rating systems for plans and providers that inform consumers and affect payment.

Define, Measure, Analyze, Improve, Control — the Six Sigma improvement framework.

Plan-Do-Check-Act — a continuous improvement cycle synonymous with PDSA.

An unexpected event causing death or serious harm, signaling the need for immediate investigation and response.

The percentage of patients readmitted within a set period; a key outcome and penalty metric.

Tools such as HCAHPS that capture patients' perceptions of their care.

Donabedian's framework evaluating quality through the structure of care, processes used, and outcomes achieved.

Inpatient Rehabilitation Facility — intensive rehab setting providing at least 3 hours of therapy per day for patients able to tolerate it.

Functional Capacity Evaluation — a systematic assessment of a person's ability to perform work-related physical tasks.

Durable Medical Equipment — reusable medical equipment such as wheelchairs, walkers, and hospital beds ordered for home use.

Coordination of complex, high-cost cases such as TBI, spinal cord injury, severe burns, or amputation.

A physician specializing in physical medicine and rehabilitation who leads the rehab team.

A rehab professional who restores mobility, strength, and function through movement-based treatment.

A rehab professional who helps clients regain skills for daily living and work activities.

A rehab professional who treats communication, cognition, and swallowing disorders.

A nurse specializing in helping patients with disabilities maximize function and prevent complications.

Services that help people with disabilities prepare for, obtain, and maintain employment.

A coordinated plan to safely transition an injured worker back to suitable job duties.

Temporary adjusted job tasks that accommodate an injured worker's restrictions during recovery.

Coordinated efforts to minimize the impact of injury or illness on a person's function and work.

The point at which a person's condition has stabilized and is not expected to improve further with treatment.

Brain damage from external force, often requiring intensive, long-term rehabilitation and case management.

Damage to the spinal cord causing loss of function below the injury, requiring complex rehabilitation.

Devices or systems that help people with disabilities perform tasks they otherwise could not.

Modified tools that help people with disabilities perform daily activities more independently.

Basic self-care tasks such as bathing, dressing, eating, toileting, and transferring.

Complex tasks for independent living such as managing finances, medications, cooking, and transportation.

Rehab therapy delivered in a clinic without an overnight stay, for patients who can travel for care.

Rehab services provided in the patient's home for those unable to travel to a facility.

Medicare criterion that inpatient rehab patients generally must tolerate about 3 hours of therapy per day.

A standardized tool measuring a patient's level of disability and need for assistance in rehabilitation.