Certified Case Management Exam Review CCM

13 When a Patient is Incapable of Making Decisions

2010-12-22T09:05:00.000-08:00

When a patient becomes incapable of making medical decisions and has not completed any advance directive, a surrogate must be assigned (who may be a parent, spouse, adult son or daughter, domestic partner, adult brother or sister, close friend, or two physicians who may choose to consult a medical ethics committee) to make medical decisions. If a patient chooses, due to mental or physical incapability, a court may appoint a conservator to handle the patient’s financial affairs, who must annually report allocation of patient finances. If a court, after outside petition, determines a person incapable of making financial decisions (an inability to provide for food, clothing, and shelter, or inability to protect against loss of property), a patient may be assigned a conservator involuntarily. The conservator is still required to report annually to the court. With the assignment of conservator, the patient may no longer sign checks, use credit cards, buy or mortgage property, sign a lease or any contract involving finances- which may be performed by the conservator.

A guardian may be appointed by the court if a patient is unable to care for himself. A guardian manages a patient’s financial affairs, as well as necessary personal management (food, clothing, shelter, medical care, etc.) Once appointed a guardian, the patient may not vote, make contracts, choose residency, choose medical treatment, travel at will, or sign checks. Court consent must be obtained for any decision involving institutional commitment, treatment with antipsychotic drugs, or subjection to intrusive medical procedures. In such cases, a case manager is responsible for documenting objective facts only (avoid subjective descriptions or opinions), avoiding derogatory comments, maintaining good communication with patient and family, maintaining an understanding of diagnosis, allowing patient to be decision-maker, and maintaining consent and release forms.

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12 Bulimia Nervosa

2010-12-16T07:26:00.001-08:00

Bulimia Nervosa

Bulimia Nervosa is an eating disorder where the person binge eats and then uses a variety of compensatory behaviors to limit weight gain. A binge is defined as a larger than normal amount of food than most people would consume in a similar time period. The bulimic person usually binges alone, due to significant shame that is associated with their binging behavior. The bulimic individual often binges on high calorie and sweet foods.

While bulimia often includes purging behaviors (vomiting after a binging episode), this is only one of several possible “compensatory behaviors”. The individual suffering from bulimia often begins with attempts to diet and lose weight. The attempts result in extreme hunger and obsessions with food. The person then binges after a significant period of struggle to avoid consumption of food. The binging behavior results in significant shame and distress. The purging behavior often creates a significant relief from the distress. Other compensatory behaviors include use of laxatives, diuretics, enemas, or excessive exercise.

The theoretical approaches applied with this disorder are cognitive-behavioral (including dietary management) and interpersonal psychotherapy. Cognitive behavioral therapy is effective in addressing perfectionistic thinking that is characteristic of bulimic patients. They often strive for perfection and feel like complete failures if unable to achieve perfection. Psychodynamic group, psychoeducation, and family therapies are also included.

As with all eating disorders, a multimodal approach seems most effective. This might include nutritional counseling, psychotherapy and pharmacotherapy.

You want to establish normal eating habits with the patient. A meeting with a nutritionist is often helpful to work out healthy dietary plans. Cognitive-behavioral treatment can be useful in modifying binging and compensatory cycle. It is important to modify the patient’s thinking patterns so he or she can learn more realistic coping skills. If the individual purges, learning control over this impulse is important. This may be the first step in breaking the cycle and dealing with the underlying emotional issues.

Conduct an assessment of the patient and address any safety issues. You will also need to establish a therapeutic relationship with the patient so you can motivate him or her for treatment. A thorough clinical history, psychosocial, and medical workup is imperative. Make yourself aware of the signs of low self-esteem as well as deficits in self-regulation. A personality assessment may be useful. It is quite important to assess the individual’s social environment to understand how others may be maintaining or encouraging the bulimic behavior.

Finally, have the patients self monitor their eating habits as well as their feelings about weight and self-image. Emphasize goal setting at the very start of treatment. Set specific goals - such as resisting the impulse to purge for a specific period of time. Each week this period may be extended. Expect that the individual will slip- be patient. Work on small goals and focus on health. Since bulimia is usually less life threatening than anorexia, the clinician can be patient with slipping into old patterns. However, always monitor dangerous or unhealthy behaviors.

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11 Paraphrase

2010-12-08T07:52:00.000-08:00

PARAPHRASE

A.        One basic task is to hear the client clearly and let them know they have been heard.
B.        Paraphrasing is a special type of attending, which demands that you demonstrate your ability to accurately “give back” to a person what he/she has said.
C.        Distinguishing Paraphrasing from Interpreting
        1.        In listening, give the client prime attention and focus on their view of what happened.
        2.        Helping theory holds that it is best if the client can come to the interpretation on his/her own.
        3.        Paraphrases can serve three purposes:
                        a.        Convey to the client that you are with him/her
                        b.        Crystallize a client’s comment by making it concise
                        c.        Provide a check on the accuracy of the perceptions of the session
D.        Integrating Questions encourages Paraphrasing
        1.        Interviewing skills are sequenced so that you can integrate the skills as each new dimension is added.
        2.        As clients tell their stories & talk about important life events, they develop a new understanding enabling them to move on and sometimes rewrite their past history.

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10 Chronic Regional Pain Syndrome

2010-12-06T08:28:00.001-08:00

There are 2 forms of Chronic Regional Pain Syndrome (CRPS): Type I or Reflex Sympathetic Dystrophy (RSD) and Type II or Causalgia, both of which are nerve-related pain conditions. Causalgia is secondary to a nerve injury, with the pain continuing even after the cause of pain is no longer present; RSD is secondary to an on-going sympathetic nervous system response in an extremity of the body and often has psychological dimensions. It is also controversial as a diagnosis.

Although the reasons for RSD (CRPS, Type I) are not known, it has been associated with some of the following possible causalities: myocardial infarction, spinal cord disease, cerebral lesions, infections and repetitive motion disorder. It is also known to be often triggered by an injury to a body part and often to a minor injury.

In RSD, the sympathetic nervous system, regulating our “fight or flight” response has been activated by a stressor but fails to return to normalcy and “shut off” the response, sending of blood to the extremity with the concurrent dilation and constriction of the blood vessels. There are 3 phases of RSD: acute phase (1-3 months after injury), dystrophic phase (3-6 months after injury) and atrophic phase (6 and over months after injury). In all phases, pain is not proportional to the injury and does not follow along a nerve distribution. Patients recover in various phases, and the disorder is frequently misdiagnosed so that time ends up wasted since the condition can become chronic and permanent if not treated correctly in a timely manner, particularly within the first year.

RSD is diagnosed by various means, including bone scan, description of pain, X-ray, patient history, physical exam and sympathetic or stellate ganglion block. A positive result of the block is one way of confirming a diagnosis of RSD and is also therapeutic. Optimum treatment is considered to be a series of three sympathetic or stellate ganglion blocks together with pain medication most appropriately in a pain clinic under the care of an anesthesiologist. Neurologists and psychologists may also provide treatment, as well as biofeedback, acupuncture, and physical and occupational therapies.

Case management should include the appropriate selection of cases, assessment of the cases, the planning and implementation of treatment, education and pain management, and evaluation.

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09 Skilled and Unskilled Medical Care

2010-11-30T07:42:00.000-08:00

Medical and health care can be categorized as either skilled or unskilled. Skilled care is administered by a professional health care worker, with the expectation of improvement and achievement of treatment goals, and the implication of an eventual lack of requirement for care services. Unskilled care is mostly administered by nonprofessional workers, with the acknowledgement of an unlikelihood for improvement and an aim of maintaining the patient’s current health state (often care involves assistance with tasks of daily living, such as bathing, eating, etc.) Levels of care may be categorized as acute, sub acute, rehabilitation, skilled nursing, home health, and outpatient. Acute care is characterized by the requirement of ongoing skilled care. Sub acute care provides a lower intensity of care than acute, and daily skilled care is typically administered at a nursing home or SNF (skilled nursing facility.) Home care provides intermittent skilled care. If the patient meets a criterion which includes the ability to undergo three hours of rehab five days a week, he may qualify for inpatient rehabilitation care. If he fails to meet criteria, rehab may also be available in other facilities. An important aspect of a case manager’s job is the efficient progression through the levels of care and the treatment plan.

Medicare only provides coverage for unskilled care when it is part of a skilled care treatment plan. Case managers must be familiar with the levels of care for their clients. Medicare provides coverage for SNF’s or nursing homes when assessed as medically necessary and within thirty days of a three-day hospitalization. The Medicare benefit period covers 100 days of skilled nursing, during which the patient is responsible for copays ($101.50 per day) for days twenty one through the duration of the covered period. Medicare coverage of home health services requires that the patient be home bound and need intermittent skilled services (such as nursing or respiratory assistance). Bathroom equipment is not covered, and equipment that is covered requires a 20% copay. Individuals diagnosed with terminal illnesses have the option of Medicare coverage of Hospice care, which includes: pain relief, physical therapy, nursing and supportive services, and symptom management; a $5 copay for medication and $5 copay for inpatient respite care is required.

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08 Schizophrenia, Symptom Characteristics and Diagnosis

2010-11-29T07:45:00.000-08:00

Schizophrenia, Symptom Characteristics and Diagnosis

Individuals with schizophrenia display odd, unusual and idiosyncratic behavior that results from defects in ego functioning. One aspect of this is loosening of ego boundaries. What I mean by fluid or loose ego boundaries is that there seems to be difficulties distinguishing internal fantasy and thoughts from external reality. Moreover, one’s internal world is not integrated. There appears to be internal chaos, confusion, and sometimes, overwhelming anxiety. This is the result of impairment in the primary autonomous ego functions. This constitutes basic contact with reality and integration of thought feelings, and perceptions.

In acute phase of schizophrenia, there are five areas of disturbance (symptoms) that should be assessed. These include a disturbance of:

1. Thought form
2. Thought content
3. Perception
4. Emotion
5. Behavior

Most of these symptoms will be readily apparent in an interview.

Disturbance of Thought Form: This may be a “formal thought disorder”. Thinking is illogical and often incomprehensible. Characteristics of a formal thought disorder include (among others):

1. Loose Associations: Disconnection of ideas- jumping from topic to topic, often midsentence.
2. Overinclusivness: use of irrelevant information that interrupts logical thought.
3. Neologisms: Creation of new words- may have meaning to client.
4. Blocking: Speech simply stops mid-sentence- speech may start again in a few minutes, often in another place. May be the interference of hallucinations.
5. Clanging: Choice of words based on sounds- often rhymes a primary word in one sentence with a word in a previous sentence.
6. Echolalia: repeating words without concern for meaning.
7. Concreteness: Lack of ability to think in abstract terms.
8. Alogia: Also called poverty of speech. Speaks little, without intentional resistance. Individuals with a formal thought disorder, (which is pathognomonic of schizophrenia) appear to be caught up in an idiosyncratic world and have a relatively “unique” way of communicating. Other psychotic disorders may exhibit formal thought disorder.

Schizophreniform Disorder is virtually identical in the initial clinical presentation to schizophrenia except (according to the DSM-IV):

1. there is a shorter duration
2. the diagnosis does not require impaired occupational or social functioning (however, it is hard to imagine how psychosis would not impair functioning).

In addition, symptoms are usually more turbulent and functioning after the acute episode is usually better. An individual who presents with Brief Psychotic Disorder may also have formal thought disorder, but duration can be as short as one day and no longer than one month.

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07 Classifying Jobs

2010-11-24T09:25:00.000-08:00

Physical demands of a job are described from the more demanding jobs that require strength for lifting to less physically demanding jobs that require skills such as seeing. Physical conditions vary from quiet indoor jobs with no extremes of temperature to noisy outdoor jobs with extremes of temperature, moisture, vibrations, and work hazards. Specific vocational preparation is symbolized by numbers ranging from 1 (short demonstration only) to 9 (10 years or more of training/education).

The Office of Employment Statistics rates skill levels in 3 categories:

unskilled (svp is 1-2)
semi-skilled (svp 3-6) and
skilled (svp 7-9).

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06 Orthopedic Disorders

2010-11-22T07:36:00.001-08:00

ORTHOPEDIC DISORDERS

Some common orthopedic terms include: abduction (the movement of a body part away from the midline), adduction (movement of a body part toward the midline), dorsiflexion (movement upward of the hand or foot), extension (movement of the joint ), flexion (bending the joint so its angle is lessened), hyperextension (an extension beyond what is normal), inversion (movement of the ankle forward) pronation (movement so as to place the palm facing down), rotation (movement of one bone turning on another), torsion (moving the bone on its axis) and valgus (causing outward turning of the foot and varus (causing inward turning of the foot).

The following are common orthopedic disorders. Rotator cuff tendonitis, caused by repeated overuse, diagnosed by sign of impingement, x-ray, MRI w/o tear and treated with rest, ICE/Heat, NSAIDs and cortisone injections. Acromioclavicular (AC) joint inflammation caused by repetitive overhead activity, diagnosed by impingement sign, X-ray and MRI, is treated by rest, heat/ice, NSAIDs, cortisone injection and arthroscopic depression. Adhesive capsulitis (AC Frozen shoulder) caused by no shoulder movement due to pain, diagnosed by a physical exam, is treated by ROM Exercises, pain management and manipulation under anesthesia. Ligament disorders range from anterior cruciate, to posterior cruciate, to median cruciate, to lateral cruciate (tears), diagnosed by physical exam, joint effusion, decreased ROM, edema, tests, X-ray and MRI, are treated by splint w/PT, reconstruction, repair (meniscus) and sometimes surgery.

Other orthopedic injuries include meniscus tear, hip fracture, ankle sprain, arthritis of joint, and various other fractures.

The Case Management process entails case selection, assessment, planning and implementation, and evaluation. The selection process considers:
a) does pain exceed injury
b) does disability exceed what is expected
c) will patient be out of work for over 4-6 weeks
d) is surgery recommended
e) in hip surgery cases, is the client over 70
f) is diabetes present?

Assessment considers:
a) history of injury
b) medical treatment to date
c)current diagnosis
d) treatment plan & recommendations
e)is the patient treating with an appropriate provider
f) is the treatment plan appropriate
g) is the patient improving
h)level of pain
i) presence of complications and more.

Planning and implementation consider a second opinion if appropriate, see to it that there is appropriate treatment for any medical conditions that may cause complications, coordinate the return to work of the patient, coordinate the return to PT or OT if needed, and ensure that there is a timely movement through the rehab process.

The evaluation component asks whether the patient is progressing in rehab, if the recovery is as expected, if complications are being avoided, if the effects of concurrent medical conditions are minimized, whether the treatment plan and provider are appropriate, and is the patient coping with functional changes, among other things.

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05 Traumatic Brain Injury

2010-11-18T08:01:00.000-08:00

Patients who have suffered TBI (traumatic brain injury) should be referred for case management. Assessment, planning and implementation, and evaluation must be taken into account in determining the case management package. Factors in assessment include, but are not limited to: type of injury, risk of complications, likelihood of permanent impairment, who in the family makes the decisions, whether the patient meets criteria for the level of care, and coping ability of patient.

Factors to be taken into account in planning include, but are not limited to: correct allocation of health care resources, coordination of benefits with various health care plans, determining appropriate level of care, identification/obtaining of available services, plans for movement through various levels to least restrictive level of care, plans for respite if necessary, home modifications, plans for continuing medical, transportation and psychological needs of patient and family members, and life care planning.

Questions to be asked in the evaluation component include, but are not limited to: Is the patient still progressing towards her/his goals at the maximum level of functioning? Is the setting the least restrictive setting possible? Are health care services being used effectively and efficiently? Are all the services for which the patient is eligible being offered? How is the family unit coping with the new situation? Is there depression or substance abuse present? Are there medical complications and is the family managing the complex medical needs?

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04 Disability

2010-11-16T08:15:00.001-08:00

Returning to work after a disability claim may be therapeutic for the worker. Studies have shown that early return to work is beneficial in that it may improve worker self-esteem and confidence, re-establish the employer-employee relationship, and decrease the cost of the claim. Disability management is a process aimed at limiting a disabling event and returning the patient to work as soon as possible. In some large companies, there are specific disability management programs; however, in many companies, a case manager handles the aims of disability management and the return to work process. Because of the large cost of worker’s compensation (medical bills, sick time, cost of replacing workers, loss of productivity), many companies have a high need for case managers or their own disability management programs.

It is important to recognize the difference between an impairment and a disability. An impairment is a complete loss of a body part, function or system. A disability is the difference between the requirements of a job and the worker’s physical capacity and only relates to the patient’s status at work. An individual with an impairment may not be disabled at all from his or her particular vocation, and a minor impairment may result in a big disability for an individual with a particular type of vocation. After each physician visit, an injured worker must obtain the physician’s description of what he is physically capable of (documentation of work capacity).

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03 Medicaid

2010-11-11T07:35:00.001-08:00

Medicaid, brought into effect by Title XIX of the Social Security Act, provides medical assistance for uninsured children, low-income population members, the disabled, and the elderly, as well as a large portion of long-term nursing home care. Many state Medicaid plans intitially functioned as indemnity plans; however, due to increasing health care costs and growth of Medicaid-eligible population, many Medicaid plans are now managed care plans. Medicaid is funded by both federal and state governments and is generally in the responsibility of CMS. SCHIP (State Children’s Health Insurance Program) was a result of with the 1997 Balanced Budget Act and implements a Federal agreement to match state funds for Medicaid (given a state plan for enrollment of uninsured children).

Unlike Medicare, Medicaid does provide for long-term custodial care; however, to financially qualify, a recipient must deplete his assets and income. Income and assets cannot exceed $707 per month in income with $2000 in assets, or for a couple, $942 in income with $3000 in assets (assets do not include the recipient’s home, car, personal possessions like clothing, furniture or jewelry). A Medicaid enrollee is not permitted to give away assets or income (unless they are given to a spouse, a blind or disabled child, or a trust for a blind or disabled child). If the recipient gives away assets or income, a transfer penalty (length of time during which recipient is ineligible for Medicaid) will be incurred; duration of transfer penalty is relative to amount given away.

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02 Psychotic Disorders

2010-11-09T07:47:00.000-08:00

Psychotic Disorders

Psychosis is a term that describes severe mental disturbance not a specific disorder. Many disorders have symptoms of psychosis including: Schizophrenia, Schizophreniform Disorder, Brief Psychotic Disorder, Schizoaffective Disorder, Shared Psychotic Disorder, Delusional Disorder, Psychotic Disorder Due to a General Medical Condition, Substance Induced Psychotic Disorder, and Psychotic Disorder NOS. These disorders are clinical syndromes not discrete diseases.

Most Psychotic disorders do not have clear etiology. Of course, the disorders related to medical conditions and substance withdrawal are more easily traced to a precipitating factor and are therefore more likely to be easily diagnosed.

Evaluation of persons suspected of having a psychotic disorder requires a good history and a physical examination by a physician. Generally, non-organic disorders present with disturbances in thought and emotion, while organic disorders tend to present with mental clouding, confusion, and disorientation because of some degree of delirium. This is not a hard and fast rule and in practice, there are many exceptions. The following are some characteristics that suggest the presence of an organic disorder:

1. No personal or family history of mental illness. Someone who presents with schizophrenia like psychotic symptoms will undoubtedly have some family or personal history of psychiatric treatment. This is particularly true if the subject is well into adulthood. First time psychotic breaks usually occur in early adulthood (early 20’s of men, late twenties for woman). The lack of history makes it more likely that there is some organic factor operating.

2. There is a history of serious medical illness with periodic relapses. This suggests organic etiology, especially if the subject is an elderly person.

3. There is very rapid onset. If the onset is in a few hours of days, this is a strong indicator of organic etiology. With symptoms that are not organically based, family members usually report some period of time that the client is acting “strange”.

4. The client presents with significant memory loss, confusion, disorientation, and clouding of consciousness (that may fluctuate rapidly- within hours).

Major Depression and Bipolar Disorder may have psychotic symptoms that are secondary to affective symptoms. Affective disturbance always precedes psychosis in these cases. Individuals with severe personality disorders may have brief periods of psychosis, especially at times of severe stress. Psychotic symptoms usually resolve when the environmental stressors are stabilized, either through direct psychosocial intervention or by removing the individual from the environment and placing them into a stable and safe environment such as a hospital setting. Both Pervasive Developmental Disorder NOS and Autistic Disorder may have psychotic symptoms. Again, these symptoms appear to be secondary to the developmental impairment.

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01 Assessments

2010-11-04T13:27:00.000-07:00

A.        Aptitude Tests used to predict how well one will perform in various training/educational programs. They measure specific skills and proficiencies or one’s ability to acquire certain proficiencies.

Common Aptitude Tests: You might want to be familiar with the names of various batteries such as the following. (I would not suspect that you would need to know the specific subtests names; I would think just having a feel for the types of subtests that are included would be sufficient.

Differential Aptitude Tests (DAT) consists of the following 8 subtests.

Verbal Reasoning
                Abstract Reasoning
                Space Relations
                Mechanical Reasoning
                Clerical Speed and Accuracy
                Mechanical Reasoning
                Spelling
                Language Usage

General Aptitude Test Battery
                Intelligence
                Verbal Aptitude
                Numerical Aptitude
                Spatial Aptitude
                Form Perception
                Clerical Perception
                Motor Coordination
                Finger Dexterity
                Manual Dexterity

Army Services Vocational Aptitude Batteries (ASVAB)
                General Information
                Numerical Operations
                Attention to detail
                Word Knowledge
                Arithmetic Reasoning
                Space Perception
                Mathematics Reasoning
                Electronic Information
                Mechanical Comprehension
                General Science
                Shop Information
                Automotive Information

B.        Achievement Tests The purpose is to assess present levels of developed abilities. Typically used in schools following a course of study to ascertain the degree to which students have learned what was presented.

Three Categories

1. General Survey Batteries Tests knowledge of most subjects taught in schools
2. Single Subject Tests Measures one subject/content area
3. Diagnostic Batteries Proficiencies and deficiencies in areas of reading, math and spelling

        There are numerous achievement tests. One of the most widely used achievement batteries is the Wide Range Achievement Test (WRAT) which assesses Reading, Spelling, and Arithmetic.

C. Interest Inventories: Some of the most widely used include:

        Strong Interest Inventory (No specific population identified) It is based on Hollands 6 categories and includes 23 Basic interest and 124 occupational scales.

        Kuder Occupational Interest Survey (primarily for college students or college bound.) It has 77 occupational and 29 college major scales.

        Ohio Vocational Interest Survey (grades 8 12) It has 24 general interest scales that are related to people, data and things.

        Self Directed Search (high school and college and adults) It is based on Hollands categories and generates codes which correspond with occupations.

D.        Personality Inventories Some of the more common are:

        Sixteen Personality Factor Questionnaire lead the way for integrating personality tests into career counseling. Here traits are compared with occupational profiles:

        Edwards Personal Preference Schedules measures 15 personality variables related to needs (i.e., achievement, dominance, endurance, order).

        Myers Briggs Type Indicator measure preferences by personality types: extroversion or introversion; sensing or intuition; thinking or feeling; and judging or perceiving. Occupations are recommended based on a persons four letter code.

E.        Values Inventories These measure work values and values associated with broader aspects of life. Examples include:

        Work Values Inventory measures values such as altruism, aesthetics, creativity, intellectual stimulation.

        Work Environment Preference Schedule measure adaptability to a bureaucratic environment.

F.         Career Maturity Inventories These are for the most part based on Supers developmental theory. One example is the Career Development Inventory which measures planning orientation, readiness for exploration, information and decision making.

G.         Intelligence Tests
        These are also used in the career decision making process. The two most used are the Stanford Binet and the Wechsler series.

Toni-2 is a good assessment tool to use with the Multicultural because all responses are nonverbal.

The use of the Portfolio is a good assessment tool for students in planning their future career goals.

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