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Case Management Certification Exam: Key Concepts and Practice Questions, Exams of Nursing

Bryant and Stratton College-AlbanyNursing

An overview of case management, including definitions, standards of care, clinical guidelines, and pathways. It covers various screening tools used in case management, such as the sf36, patient activation measure, and health risk assessments like the rose q and arthritis impact measurement scales. Additionally, it includes information on cognitive development theories (piaget, erickson) and key aspects of utilization management and resource management. The document also presents questions related to medicare coverage and goals in patient care, offering a comprehensive look at the multifaceted aspects of case management in healthcare settings. It is a useful resource for students and professionals in healthcare management, nursing, and social work, providing a structured approach to understanding and applying case management principles in practice.

Typology: Exams

2024/2025

Available from 05/20/2025

Nurseexcel
Nurseexcel 🇺🇸

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Case Manager Certification Exam with Test Questions and elaborated Answers
1. casehmanagement:hthehdynamichandhsystematichcollaborativehapproachhtohpro-
hvidinghandhcoordinatinghhealthhcarehserviceshtohahdefinedhpopulation.
-
hparticipativehprocesshtohidentifyhandhfacilityhoptionshandhserviceshforhmeetinghindividualhhealthc
arehneedshwhilehdecreasinghfragmentationhandhduplicationhofhcarehandhincreasinghqualityhandhco
stheffectivehclinicalhoutcomes.
2. standardshofhcare:hparametershtohmeasurehthehqualityhofhhealthcare
3. clinicalhguidelines:hstatementshtohhelphmakehdecisionshabouthhealthhspecifichcircumst
ances.
4. clinicalhpathway:hstructuredhmulti-
disciplinedhplanhofhcarehtohsupporthclinicalhguidelineshandhprotocolhtohimprovehcontinuityh
andhcoordination.
5. 4hpartshofhclinicalhpathway:h1.htimeline
2. categorieshofhcare/activitieshandhinterventions
3. intermediatehandhlonghtermhoutcomehcriteria
4. variancehtrackinghar
eh4hpartshofhwhat?
6. decisionhtree:husedhtohselecththehbesthcoursehofhactionhinhdecisionshwherehtherehishnohclearh
decisions.
7. descriptivehscreeninghtool:hidentifieshcharacteristicshabouthahpopulationhtohshowhhealthhpre
vention.
8. predictivehscreeninghtool:hshowshwhathmayhhappenhtohahspecifichpopulation.
9. evaluativehscreeninghtool:hevaluateshthehunderstanding/effectiveness
10. SF-
36:hpredictivehscreeninghtoolhtohassesshfunctionalhhealthhandhwellhbeing.hAssesseshphysic
alhandhmentalhhealth.
- usedhinhhealthheconomics,hcost-effectivenesshofhhealthhtx
-evalshindividualhpatienthhealthhstatus.
- doeshnothconsiderhsleep
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Case Manager Certification Exam with Test Questions and elaborated Answers

  1. casehmanagement:h thehdynamichandhsystematichcollaborativehapproachhtohpro- hvidinghandhcoordinatinghhealthhcarehserviceshtohahdefinedhpopulation.

hparticipativehprocesshtohidentifyhandhfacilityhoptionshandhserviceshforhmeetinghindividualhhealthc arehneedshwhilehdecreasinghfragmentationhandhduplicationhofhcarehandhincreasinghqualityhandhco stheffectivehclinicalhoutcomes.

  1. standardshofhcare:h parametershtohmeasurehthehqualityhofhhealthcare
  2. clinicalhguidelines:h statementshtohhelphmakehdecisionshabouthhealthhspecifichcircumst ances.
  3. clinicalhpathway:h structuredhmulti- disciplinedhplanhofhcarehtohsupporthclinicalhguidelineshandhprotocolhtohimprovehcontinuityh andhcoordination.
  4. 4 hpartshofhclinicalhpathway:h 1.htimeline
  5. categorieshofhcare/activitieshandhinterventions
  6. intermediatehandhlonghtermhoutcomehcriteria
  7. variancehtrackinghar eh 4 hpartshofhwhat?
  8. decisionhtree:h usedhtohselecththehbesthcoursehofhactionhinhdecisionshwherehtherehishnohclearh decisions.
  9. descriptivehscreeninghtool:h identifieshcharacteristicshabouthahpopulationhtohshowhhealthhpre vention.
  10. predictivehscreeninghtool:h showshwhathmayhhappenhtohahspecifichpopulation.
  11. evaluativehscreeninghtool:h evaluateshthehunderstanding/effectiveness
  12. SF- 36:h predictivehscreeninghtoolhtohassesshfunctionalhhealthhandhwellhbeing.hAssesseshphysic alhandhmentalhhealth.
  • usedhinhhealthheconomics,hcost-effectivenesshofhhealthhtx
  • evalshindividualhpatienthhealthhstatus.
  • doeshnothconsiderhsleep
  • scoredh 00 - 100,hlowerhscore->hincr.hdisability
  1. patienthactivationhmeasure:h 13 hitemhpredictivehscreeninghtoolhtohevaluatehpa- htient'shknowledge,hskills,hconfidencehinhself-care.
  • higherhthehscorehthehbetterh(scoredh 0 - 52)
  • predictshhealthhcarehoutcomes,hmedicationhadherencehandhERhvisits.
  1. healthhriskhassessment:h predictivehscreeninghtool:hpatient'shselfhassessmenthofhtheirhhealt hhandhhowhlikelyhtheyhwillhseekhcare.
  • predictshfuturehhealthhcosts
  • predictshlikely-hoodhofhprogressionhofhtheirhillnesshtohahworsehcondition.
  • examples:hPHQ-9,hetc.
  1. rosehQ:h healthhriskhassessmenthforhangina,hMI,hcoronaryhhearthdisease.hdefinedhanginahp ectorishas,h"ahchesthpainhorhdiscomforthwithhthesehcharacteristics: (a) thehsitehmusthincludeheitherhthehsternumh(anyhlevel)horhthehleftharmhandhlefthanterior
  • Higherhscorehindicateshbetterhqualityhofhlife.
  1. BASIS-32:h healthhriskhassessment:h 32 - itemhBehaviorhandhSymptomhIdentifica- htionhScale.hbehavioralhhealthhassessmenthtool.
  • measureshthehchangehinhself- reportedhsymptomhandhproblemhdifficultyhoverhthehcoursehofhtreatment.
  • assesses:hRelationhtohSelfhandhOthers,hDepressionhandhAnxiety,hDailyhLivinghandhRolehFuncti oning,hImpulsivehandhAddictivehBehavior,hPsychosis.
  • higherhscorehpoorerhoutcome
  1. minihmentalhstatehexam:h healthhriskhassessment: 30 - pointhquestionnairehmeasureshcognitivehimpairmenthtohscreenhforhdementia.
  • higherhthehscore,hlesshdementia
  • 18 - 23 hishmildhdementia
  • 0 - 17 hishseverhdementia
  1. hopkinshsymptomhchecklist-25:h healthhriskhassessment:hself-reportinghques- htionnairehsymptomhinventoryhwhichhmeasureshsymptomshofhanxietyhandhdepression.

Thehscalehforheachhquestionhincludeshfourhcategorieshofhresponseh("Nothathall,"h"Ahlittle,"h"Quiteh ahbit,"h"Extremely,"hratedh 1 htoh4,hrespectively).hTwohscoresharehcalculated:hthehtotalhscorehishthehav eragehofhallh 25 hitems,hwhilehthehdepressionhscorehishthehaveragehofhtheh 15 hdepressionhitems

  1. mcgillhpainhquestionnaire:h scalehofhratinghpain.hIthishahself- reporthquestionnairehthathallowshindividualshtohgivehtheirhdoctorhahgoodhdescriptionhofhthehquali tyhandhintensityhofhpainhthaththeyharehexperiencing.hUsershfirsthselecthahsinglehwordhfromheachhgrou phthathbesthreflectshtheirhpain.hUsershthenhreviewhthehlisthandhselecththehthreehwordshfromhgroup sh 1 - 10 hthathbesthdescribehtheirhpain,htwohwordshfromhgroupsh 11 - 15,hahsinglehwordhfromhgrouph16,handhthenhonehwordhfromhgroupsh 17 - 20.hAfterhcompletinghthehquestionnaire,husershwillhhavehselectedhsevenhwordshthathbesthdescribeht heirhpain.
  2. A:h WhathparthofhMedicarehcovershskilledhnursinghfacility?
  3. B:h WhathparthofhMedicarehcovershdurablehmedicalhequipment?
  4. Goals:h 1.hPatienthfocused
  5. Measurable
  6. Attainable
  7. Relevant
  8. Timehoriented
  9. Piaget:h Developmentalhtheoryhforhcognitivehabilityhtohprocess/analyzehinforma-htion
  10. Assess,hplan,himplement/intervention,hmonitor/evaluation:h 4 hstageshofhcasehmanageme nt
  11. Sensorimotor:hobjecthperformancehandhseparationhanxiety.:h Piaget'shageh 0 - 2,
  12. Preoperational:hpretend,hegocentric:h Piaget'shstagehageh 2 - 6
  1. Intimacyhvs.hisolation:h Ericksonh 18 - 40
  2. Generativehvs.hstagnation:h Ericksonh 40 - 65
  3. Integrityhvs.hdespair:h Ericksonh65+
  4. Skinner:h Operationalhconditioning
  5. CMAG:h Casehmanagementhadherencehguidelines
  6. IM-CAG:h Interhmedh-hcomplexityhassessmenthgrid
  7. CMAG:h assessmenthtool.hComprehensivehapproachhtohchronichtherapyhissues,hex:hmedha dherence,hCOPD,hDVR,DM,HTN,
  8. IM-CAG:h Electronichtoolhthathprovideshriskshandhvulnerabilitieshofhcomplexhpa- htientshwithhactionablehinterventions. 4 hdomains:hbehavioral,hsocial,hhealthhsystem.
  9. evidencehbasedhpractice:h 1.hQuestion
  10. IDhresources
  11. Criticallyhappraisehresources
  12. Applyhevidence
  13. Reevaluatehapplicationhofhevidencehareh 5 hstepshofhwhat?
  14. IntegratedhCM:h Includeshwellhbeing,hdiseasehmanagement,hcasehmanagement,hpreventio n,htriage,hutilizationhmanagement
  15. Integratedhcasehmanagement:h 3 hfunctionshofh----
  16. Trackhpatienthselfhmanagement
  17. Tend/trackhpopulationhmanagement
  18. Reporting,hmonitoringhquality
  19. Patient:h Poorhattitude,hmemoryhloss,hliteracy,hpride,hfear,hsideheffects,hcan'th"see"hresults,hd ecreasedhchoices,hfinancesharehall ------------------------- barriers
  20. Patient:h Myhmedhlist,hreadinesshruler,hMotivationalhinterviewing,hmodifiedhmoriskyhscalehareh allhtoolshfor -------------------- barriers
  21. Provider:h Nohknowledgehofhpatient,hnothfamiliarhwithhfamilyhpreferences,hlackhofhaccounta bilityharehexampleshof --------------------- barriers
  22. System:h Poorhcommunication,hnothidentifiedhcarehcoordinatorshare ----------------- barriers
  23. GoalhofhCM:h Tohensurehpatientshhavehthehtoolshandhresourceshtohhelphmanagehtheirhneeds

,hincreasehselfhconfidencehandhcontrolhandhselfhmanagement

  1. Physiological,hsafety,hlove,hesteem,hself-actualization:h Maslow'shhierarchyhofhneeds
  2. Resourcehmanagement:h Processhofhidentifying,hconfirming,hcoordinating,hne- hgotiatinghresourceshtohmeethneeds
  3. Millimanhcarehguidelines:h Softhware,hevidencehbasedhguidelines/toolhforhtreatinghcommonhc onditions,hchronichcare,hBH
  1. UtilisationhmanagementhRN:h Thesehpeoplehdohnothhavehthehauthorityhtohdenyhclaims
  2. Appeal:h Ahformalhwayhofhlodginghahdisagreementhwithhahclaimhpaymenthorhbenefithdenial
  3. Fairhhearing:h Ifhdeniedhanhappealhyouhhavehthehrighthtoha
  4. Physicianhofhthehsamehspecialty:h Anhappealhmusthbehreviewedhbyhwho?
  1. Grievance:h Ahformalhwayhofhlodginghahcomplainthagainsthahproviderhorhorganiza-htion
  2. Externalhreview:h HandledhbyhanhoutsidehInsurancehCompanyhwhenhthehbenefithresulthishno thwhathwashdesired.hAdversehbenefithdeterminationh.hNeedshtohbehrequest-hed
  3. Expeditedhexternalhreview:h canhbehrequestedhifhthehpatient'shhealthhstatushwouldhbehjeop ardizedhduehtohthehtimehframe.halsohpossiblehifhithconcernshadmissionhavailabilityhofhcare,hconti nuehtohstayhorhahhealthcarehitemhbuththehpatienthhashnothbeenhdischargedhfromhthehfacility
  4. Casehmanagement:h Ensurehpatientshreceivehqualityhcost- effective,hsafe,hhighhquality,hevidence-basedhcarehinhthehleasthrestrictivehsetting
  5. Acutehcare:h AhhospitalhthehlargesthHealthcarehsettinghinhthehUnitedhStates.hCasehmanagersh needhtohensurehtestsharehdonehinhahtimelyhmeanderhresultsharehgivenhtohproviderhandhHealthcar ehteamhdetermineshthehnexthstep.
  6. Rehabilitation:h TypehofhcarehusedhforhCVAhspinalhcordhinjuries,hTBIhcanhbehusedhoutpatientho rhinpatient.hTherehishahcriteriahforhadmission
  7. Respitehcare:h Temporaryhreliefhforhthehpatient'shfamilyhorhcaregiver.hThishishcoveredhb yhMedicarehwaiverhorhlonghtermhinsurancehandhveterans
  8. Hospice:h Usedhwhenhsomeonehhashlesshthanh 6 hmonthshtohlive.hPhilosophyhnothahplace. MedicarehparthAhcovershmedicalhsupplieshequipmenthmedicationshnurseshdoctorshdietitianshuse dhduringhthishtime.
  9. PrivatehdutyhNursing:h One-on- onehcarehwhenhahchildhorhadulthishimpairedhbyhahcatastrophicheventhorhchronichillness.hUsuallyh nothcoveredhbyhinsurance
  10. Subhacutehcare:h Whenhthehpatienthdoeshnothmeethcriteriahforhinpatienthbuthishunablehtoh gohhomeheither
  11. Yes:h IshahSkilledhNursinghFacilityhCoveredhbyhMedicarehparthA
  12. Custodialhlong-termhcare:h Nothskilledhhelpshwithhadl'shandhmedicationhmanage- hment.hThehgoalhishtohmaximizehIndependence.
  13. No:h IshlonghtermhcarehcoveredhbyhMedicare?
  14. Palliativehcare:h ahtypehofhcarehforhsomeonehwithhahserioushillnesshandhneedshhelphwithhsympt omhmanagemenththeyhdohnothhavehtohbehterminallyhillhandhtherehishnohtimehlimit.hMayhbehcoveredh underhMedicarehParthB
  15. Medicareheligibility:h 1.hOlderhthanh 65
  1. Lesshthanh 65 hwithhkidneyhdiseasehthathappearshtohbehirreversiblehorhpermanenthrequiringhr egularhdialysishorhkidneyhtransplanthtohmaintainhlife.hKidneyhtransplant
  2. Hospital SkilledhnursinghfacilitieshHospice ApprovedhHomehHealth:h MedicarehparthAhcovers:
  3. 80%:h MedicarehParthBhonlyhcovershwhathpercent?
  4. Yes:h DoeshMedicarehParthBhcoverhoxygen?
  5. PhysicianshServiceshOutpati enthhospitalhservices Medicalhequipmenthandhsupplies:h MedicarehParthBhcovers:
  6. MedicarehParthC:h AlsohknownhashthehMedicarehAdvantagehplanhoperatedhbyhprivatehco mpanies.hCovershmedicationshtransportationhexxtra
  7. Medicaidheligibility:h Basedhonhincomehandhfinancialhresources.hIfhyou'veh alreadyhbeenhreceivinghgovernmenthSocialhSecurity Ifhahchildhlesshthanh 21 hyearsholdhandhhashahdisabilityhseverehenoughhtohmeethdisabilityhstandardshun derhSocialhSecurityhdisability.hParentalhincomehishdisregarded
  8. Skilledhhomehhealthhcarehandhlong-termhcare:h Medicaidhcovers
  9. SCHIP:h Statehchildren'shhealthhinsurancehprogram
  10. SCHIP:h administeredhbyhthehcenterhforhMedicarehandhMedicaid.hGovernmenthgiveshmon eyhtoh 2 happrovedhStatehprogramshuphtohthehagehofh 19
  11. subsidy:h financialhassistancehthathyouhdohnothhavehtohpayhback
  12. premium:h amounththathyouhpayhmonthlyhforhinsurance
  13. costhsharing:h amounthofhmoneyhpaidhouthofhpocket,hincludeshcopays,hdeductible.hDoeshnothi ncludehpremiums.
  14. tricarehprime:h forhactivehdutyhmilitaryhmembershtohhelphthemhbeh"fithforhduty"
  15. tricarehstandard:h fee-for- servicehinsurancehoption.hYouhcanhseehanyhtricarehauthorizedhproviderhinsidehorhoutsidehofhn etwork.
  16. tricarehextra:h insurancehoption,hyouhdon'thhavehtohpainhanhannualhfeehbuthyouhhavehanhan nualhdeductible.houtpatienthdiscountshonhcost-sharing.
  17. deductible:h amounthofhmoneyhthathyouhmusthpayhbeforehthehinsurancehwillhpayhahclaim.
  1. healthhmaintenancehorganizationh(HMO):h ahhealthhinsurancehproviderhforhahgrouphofhp eoplehinhahgeographicalhareahthathdelivershagreedhtohsethofhservicesh andhproductshtohanhenroll edhgrouphforhahpredeterminedhperiodichpaymenth(usuallyhmonthly).hPatientshhavehtohseehinhne tworkhproviders.hYourhPCPhhashtohgivehyouha referralhforhoutsidehspecialistshexcept:hinternists,hOB/GYNhandhpediatrics.hRequireshpreauthoriza tionhforhoutsidehproviders.

ntshthathimpedehthemhfromhemploymenthbyhassistinghwithhtraining,hhigherheducation,hrehab,hf inancialhsupport.hEligiblehifhbetweenhthehageshofh 16 handh70.

  1. 211:h federallyhfundedhsupporthreferralhserviceshandhcrisishmanagement.
  1. SNAPhforhseniors:h foodhstampshforhseniors
  2. 80%:h medicarehcovershwhathpercent?
  3. 55:h Medicarehwillhbeginhcoveragehofhhomehoxygenhwithhanharterialhbloodhgashresulthathor habovehahpartialhpressurehofh mmhHghwhilehathresthonhroomhair.
  4. 88:h medicarehwillhcoverhhomehoxygenhifhO2hsathishathorhbelowh %hwhilehathresthonhroomhair,hexercisinghonhroomhairhorhwhilehasleephorhahgreaterhthanhnorma lhfallhinhoxygenhlevelhduringhsleeph(ahdecreasehinharterialhPOh 2 hmorehthanh 10 hmmhHg,horhdecreas ehinharterialhoxygenhsaturationhmorehthanh5%)hassociatedhwithhsymptomshorhsignshreasonablyhat tributablehtohhypoxemiah(e.g.,himpairmenthofhcognitivehprocesseshandhnocturnalhrestlessnessho rhinsomnia).
  5. Dependenthedema:h MedicarehcovershhomehoxygenhforhpatientshwhoseharterialhPOh 2 hish 56 - 59 hmmhHghorhsaturationhish89%,hifhtherehishevidencehof suggestinghcongestivehHearthFailure.
  6. pulmonaryhhypertensionhorhcorhpulmonale:h Medicarehcovershhomehoxygenhforhpatientsh whoseharterialhPOh 2 hish 56 - 59 hmmhHghorhsaturationhish89%,hifhtherehishev-hidencehofh ,hdeterminedhbyhmeasurementhofhpulmonaryharteryhpressure,hgatedhbloodhpoolhscan,hech ocardiogram,horh"P"hpulmonalehonhEKGh(Phwavehgreaterhthanh 3 hmmhinhstandardhleadshII,hIII,horhA VFL
  7. Erythrocythemia,h56%:h MedicarehcovershhomehoxygenhforhpatientshwhoseharterialhPOh 2 hi sh 56 - 59 hmmhHghorhsaturationhish89%,hifhtherehishevidencehofh hwithhahhematocrithgreaterhthanh %
  8. qualityhmanagement:h thishfocusseshonhcustomerhsatisfaction,hpreventionhofherrors,hm anagementhresponsibility,hcontinuoushimprovement
  9. qualityhmetrics:h parametershorhwayshofhquantitativelyhmeasuringhquantity
  10. variancehtracking:h deviationshfromhahstandardhorhrecommendedhinterventions.hHelpshIDho pportunitieshforhimprovement
  11. Continuoushqualityhimprovement:h processhtohattempthtohoptimizehqualityhofhahsystem.
  12. planhdohstudyhact:h ahcyclich 4 hstephimprovementhprocesshthathincludeshgatheringhdata,hexpe rimenting,hanalyzinghthathdata,handhadaptinghimprovements.
  13. sixhsigma:h datahdrivenhqualityhmanagementhprocesshtoheliminatehdefects:hde- hfine,hmeasure,hanalyze,himprove/design,hcontrol/verify

80 hmeasureshandh 5 hdomainshincluding:heffectiveness,haccess,hexperience,hUR,hdescriptivehinfo

  1. HEDIS:h healthhcareheffectivenesshdatahinformationhset
  2. patienthcenteredhmedicalhhomeh(PCMH):h ahcarehdeliveryhmodelhwherebyhpatienthtreatm enthishcoordinatedhthroughhtheirhprimaryhcarehphysicianhtohensurehtheyhreceivehthehnecessaryhc arehwhenhandhwherehtheyhneedhit,hinhahmannerhtheyhcanhunderstand.
  3. nationalhqualityhforum:h nothforhprofithmembershiphorganizationhtohdevelophandhimpleme nthahnationalhstrategyhforhstandardizinghhealthhcarehqualityhmeasureshandhreporting.hThishorgan izationhwashchargedhbyhthehaffordablehcarehacthtohcreatehthehnationalhprioritieshpartnershiphan dhnursinghsensitivehcarehstandardsh(hdeathhofhsurgeryhpatients,hpressurehulcers,hfalls,hrestraints ,hUTIshurinaryhcatheters),hventilatorhassociatedhpneumonia,hsmokinghcessation)
  4. nationalhcommitteehforhqualityhassuranceh(NCQA):h privatehnothforhprofithorganizationht hathaccreditshcertainhorganizationshifhtheyhmeethstandardshtohimprovehhealthhcarehquality.hincl udeshahqualityhcompasshtohscorehhealthhplans.
  5. utilizationhreviewhaccreditationhcommissionh(URAC):h Anhindependenthnon- hprofithorganizationhthathoffershqualityhbenchmarkhprogramshtohimprovehqualityhandhaccountab ilityhofhhealthhcarehorganizations.
  6. JointhCommission:h nothforhprofithorganizationhthathsethperformancehstandardshandhaccre dithhospitals,hnursinghhomes,handhambulatoryhcarehclinicshforhsafehandheffectivehcarehwithhsiteh visitsheveryh 3 hyears.hQualityhSeal.
  7. Magnet:h accreditationhdevelopedhbyhANCChdemonstratinghqualityhnursinghlead- hershiphandhexcellence.hIthfocuseshon:hQuality,hidentifyinghexcellencehinhnursing,handhdissemin atinghbesthpractice.
  8. InternationalhOrganizationhforhStandardizationh(ISO):h nothforhprofithorganiza- htionshthathidentifieshandhdevelopshstandardshforheverything.
  9. PeerhReviewhQualityhImprovementhOrganizationh(QIO):h privatehnothforhprofithorganizatio nhcontractedhbyhthehcenterhforhmedicarehandhmedicaidhserviceshconsistinghofhhealthhcarehprofes sionalshwhohreviewhcomplaintshabouthcarehandhimplementhchangeshforhmedicarehpatients.hThey hensurehthehpatienthrighthcarehforhthehrighthpersonhaththehrighthtimehishsafe,hpatienthcentered,htimel y,handhequitable.hParthofhthehUShdepartmenthofhhealthhandhhumanhservices.
  10. qualityhmanagement:h preventionhofhclienthcarehproblems
  11. riskhmanagement:h analyzeshproblemshandhminimizeshlosseshafterhanherrorhoccurs.heval

uateshoptions,hcost,hfeasibility,hsocialhandhselectshandhimplementshmea- hsureshtohdecreasehrisk

  1. riskhassessment:h evaluateshhazards,hcost,hfeasibility,hdose-responsehmodel.