CCMC Gloassary

  1. Community Alternatives
    Agencies outside an institutional setting, which provide care, support,&/or services to people with disabilities.
  2. Community Skills
    Those abilities needed to function independently in the community. They mayinclude telephone skills, money management, pedestrian skills, use of public transportation, mealplanning & cooking.
  3. Community-Based Programs
    Support programs which are located in a community environment,as opposed to an institutional setting.
  4. Accessible
    A term used to denote building facilities that are barrier-free thus enabling all membersof society safe access, including persons with physical disabilities.
  5. Activity Limitations
    Difficulties an individual may have in executing activities. An activity limitation may range from a slight to a severe deviation in terms of quality or quantity in executing the activity in a manner or to the extent that is expected of people without the health condition.
  6. Barrier-Free
    A physical, manmade environment or arrangement of structures that is safe & accessible to persons with disabilities.
  7. Disability CM
    A process of managing occupational & nonoccupational diseaseswith the aim of returning the disabled employee to a productive work schedule & employment.
  8. Disability Income Insurance
    A form of health insurance that provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury, or disease.
  9. H&icap
    The functional disadvantage & limitation of potentials based on a physical or mental impairment or disability that substantially limits or prevents the fulfillment of one or more major life activities, o
  10. H&icapped
    Refers to the disadvantage of an individual with a physical or mental impairment resulting in a h&icap.
  11. Learning Disability
    A lack of achievement or ability in a specific learning area(s) within the range of achievement of individuals with comparable mental ability. Most definitions emphasize a basic disorder in psychological processes involved in underst&ing & using language, spoken or written.
  12. SSDI
    Social Security Disability Income. Federal benefit program sponsored by the Social Security Administration. Primary factor
  13. Total Disability
    An illness or injury that prevents an insured person from continuously performing every duty pertaining to his/her occupation or engaging in any other type of work.
  14. Adverse Events
    Any untoward occurrences, which under most conditions are not natural consequences of the patienfs disease process or treatment outcomes.
  15. Affect
    The observable emotional condition of an individual at any given time.
  16. Algorithm
    The chronological delineation of the steps in, or activities of, patient care to be applied in the care of pts as they relate to specific conditions/situations.
  17. Alternate Level of Care
    A level of care that can safely be used in place of the current level & determined based on the acuity & complexity of the patient's condition & the type of needed services & resources.
  18. Anclllarv Services
    Other diagnostic & therapeutic services that may be involved in the care of pts other than nursing or medicine. Includes respiratory, laboratory, radiology, nutrition, physical & occupational therapy, & pastoral services.
  19. Appropriateness of Setting
    Used to determine if the level of care needed is being delivered in the most appropriate & cost-effective setting possible.
  20. Assessment
    The process of collecting in-depth information about a person's situation & functioning to identify individual needs in order to develop a comprehensive CM plan that will address those needs.
  21. Care Management
    A healthcare delivery process that helps achieve better health outcomes by anticipating & linking clients with the services they need more quickly. It also helps avoid unnecessary services by preventing medical problems from escalating.
  22. CM
    A collaborative process that assesses, plans, implements, coordinates, monitors, & evaluates the options & services required to meet an individual's health needs, using communication & available resources to promote quality, cost-effective outcomes.
  23. CM Plan
    A timeline of patient care activities & expected outcomes of care that address the plan of care of each discipline involved in the care of a particular patient. It is usually developed prospectively by an interdisciplinary healthcare team in relation to a patient's diagnosis, health problem,surg procedure.
  24. CM
    responsible for coordinating the care delivered to an assigned group of pts based on diagnosis or need. Other responsibilities include pt ed, advocacy, delays management, outcomes monitoring & management. CMs work with people to get the healthcare & other community services they need, when they need them, at best value.
  25. Case-Based Review
    The process of evaluating the quality & appropriateness of care based on the review of individual medical records to determine whether the care delivered is acceptable. It is performed by healthcare professionals assigned by the hospital or an outside agency (e.g., Peer Review Organization [PRO]).
  26. Caseload
    The total number of pts followed by a CM at any point in time.
  27. Clinical Pathway
    See CM Plan.
  28. Coding
    A mechanism of identifying & defining patient care services/activities as primary & secondary diagnoses & procedures. The process is guided by the IC0-9-CM coding manual, which lists the various codes & their respective descriptions. Coding is usually done in preparation for reimbursement for services provided.
  29. Communication Skills
    Refers to the many ways of transferring thought from one person to another through the commonly used media of speech, written words, or bodily gestures.
  30. Consensus
    Agreement in opinion of experts. Building consensus is a method used when developing CM plans.
  31. Continuous Quality Improvement (CQI)
    A key component of total quality management that uses rigorous, systematic, organization-wide processes to achieve ongoing improvement in the quality of healthcare services & operations. It focuses on both outcomes & processes of care.
  32. Continuum of Care
    The continuum of care matches ongoing needs of the individuals being served by the CM process with the appropriate level & type of health, medical, financial, legal & psychosocial care for services within a setting or across multiple settings.
  33. Coordination
    The process of organizing, securing, integrating, & modifying the resources necessary to accomplish the goals set forth in the CM plan.
  34. Custodial Care
    Care provided primarily to assist a patient in meeting the activities of daily living but not requiring skilled nursing care.
  35. Delay in Service
    Used to identify delays in the delivery of needed services & to facilitate & expedite such services when necessary.
  36. Discharge Outcomes (criteria)
    Clinical criteria to be met before or at the time of the patient's discharge. They are the expected/ projected outcomes of care that indicate a safe discharge.
  37. Discharge Planning
    The process of assessing the patient's needs of care after discharge from a healthcare facility & ensuring that the necessary services are in place before d/c This process ensures a pts timely, appropriate, & safe d/c to the next lvl care or setting including use of resources necessary for ongoing care.
  38. Discharge Status
    Disposition of the patient at discharge (e.g., left against med advice, expired d/ced home, transferred to a NH).
  39. Disease Management
    A system of coordinated healthcare interventions & communications for those w/ chronic conditions in which pt self-care efforts are significant. It supports the doc/pt relationship. The DM plan of care emphasizes prevention of exacerbations & complications utilizing evidence-based practice guidelines...
  40. Effectiveness of Care
    The extent to which care is provided correctly (i.e., to meet the patient's needs, improve quality of care, & resolve the patient's problems), given the current state of knowledge, & the desired outcome is achieved.
  41. Efficacy of Care
    The potential, capacity or capability to produce the desired effect or outcome, as already shown, e.g. through scientific research (evidence-based) findings.
  42. Efficiency of Care
    The extent to which care is provided to meet the desired effects/outcomes to improve quality of care & prevent the use of unnecessary resources.
  43. First-Level Reviews
    Conducted while the patient is in the hospital, care is reviewed for its appropriateness.
  44. Hospice
    A system of inpatient & outpatient care, which is supportive & palliative familycentered care, designed to assist the individual with terminal illness to be comfortable & maintain a satisfactory lifestyle through the end of life.
  45. Implementation
    The process of executing specific CM activities &/or interventions that will lead to accomplishing the goals set forth in the CM plan.
  46. Independent CM
    Also known as private CM or external CM, it entails the provision of CM services by CMs who are either self-employed or are salaried employees in a privately owned CM firm.
  47. Independent Living
    A service delivery concept that encourages the maintenance of control over one's life based on the choice of acceptable options that minimize reliance on others performing everyday activities.
  48. Indicator
    A measure or metric that can be used to monitor & assess quality & outcomes of important aspects of care or services. It measures the performance of functions, processes, & outcomes of an organization.
  49. Injury
    Harm to a worker subject to treatment &/or compensable under workers' compensation. Any wrong, or damages done to another
  50. Integrated Delivery System (IDS)
    A single organization or group of affiliated organizations that provides a wide spectrum of ambulatory & tertiary care & services. Care may also be provided across various settings of the healthcare continuum.
  51. Intensity of Service
    An acuity of illness criteria based on the evaluation/treatment plan, interventions, & anticipated outcomes.
  52. Intermediate Outcome
    A desired outcome that is met during a patient's hospital stay. It is a milestone in the care of a patient or a trigger point for advancement in the plan of care.
  53. Intervention
    Planned strategies & activities that modify a maladaptive behavior or state of being & facilitate growth & change. Intervention is analogous to the medical term TREATMENT. Intervention may include activities such as advocacy, psychotherapy, or speech language therapy.
  54. Level of Care
    The intensity of effort required to diagnose, treat, preserve or maintain an individual's physical or emotional status.
  55. Levels of Service
    Based on the patient's condition & the needed level of care, used to identify & verify that the patient is receiving care at the appropriate level.
  56. License
    A permit to practice medicine or a health profession that is
  57. Managed Competition
    A state of healthcare delivery in which a large number of consumers choose among health plans that offer similar benefits. In theory, competition would be based on cost & quality & ideally would limit high prices & improve quality of care.
  58. Management Service Organization
    A management entity owned by a hospital, physician organization, or third party. It contracts with payers & hospitals/physicians to provide certain healthcare management services such as negotiating fee schedules & h&ling administrative functions, including UM, billing, & collections.
  59. Medical Loss Ratio (MLR)
    The ratio of healthcare costs to revenue received. Calculated as total medical expense divided by total revenue.
  60. Medical Necessity on Admission
    A type of review used to determine that the hospital admission is appropriate, clinically necessary, justified, & reimbursable.
  61. Medically Necessary
    A term used to describe the supplies & services provided to diagnose & treat a medical condition in accordance with nationally recognized st&ards.
  62. Minimum Data Set (MDSJ
    The assessment tool used in skilled nursing facility settings to place pts into Resource Utilization Groups (RUGs), which determines the facilities reimbursement rate.
  63. Monitoring
    The ongoing process of gathering sufficient information from all relevant sources about the CM plan & its activities &/or services to enable the CM to determine the plan's effectiveness.
  64. Multidisciplinary Action Plan (MAP)
    See CM Plan (CMP).
  65. Nondisablinq Injury
    An injury which may require medical care, but does not result in loss of working time or income.
  66. Nursing CM
    See also CM. A process model using the components of CM in the delivery aspects of nursing care. In nursing CM delivery systems, the role of the CM is assumed by a registered professional nurse.
  67. Outcome
    The result & consequence of a healthcare process. A good outcome is a result that achieves the expected goal. An outcome may be the result of care received or not received. It represents the cummulative effects of one or more processes on a client at a defined point in time.
  68. Outcome & Assessment Information Set (OASIS)
    A prospective nursing assessment instrument completed by home health agencies at the time the patient is entered for home health services. Scoring determines the Home Health Resource Group (HHRG).
  69. Outcome Indicators
    Measures of quality & cost of care. Metrics used to examine & evaluate the results of the care delivered.
  70. Outcomes Management
    The use of information & knowledge gained from outcomes monitoring to achieve optimal patient outcomes through improved clinical decision making & service delivery.
  71. Outcomes Measurement
    The systematic, quantitative observation, at a point in time, of outcome indicators.
  72. Outcomes Monitoring
    The repeated measurement over time of outcome indicators in a manner that permits causal inferences about what patient characteristics, care processes, & resources produced the observed patient outcomes.
  73. Outlier
    Something that is significantly well above or below an expected range or level.
  74. Outlier Threshold
    The upper range (threshold) in length of stay before a patient's stay in a hospital becomes an outlier. It is the maximum number of days a patient may stay in the hospital for the same fixed reimbursement rate. The outlier threshold is determined by the Centers for Medicare & medicaid Services (CMS),
  75. Overutilizatlon
    Using established criteria as a guide, determination is made as to whether the patient is receiving services that are redundant, unnecessary, or in excess.
  76. Partial Disability
    The result of an illness or injury which prevents an insured from performing one or more of the functions of his/her regular job.
  77. Performance Improvement
    The continuous study & adaptation of the functions & processes of a healthcare organization to increase the probability of achieving desired outcomes & to better meet the needs of pts.
  78. Physical Disability
    A bodily defect that interferes with education, development, adjustment or rehabilitation generally refers to crippling conditions & chronic health problems but usually does not include single sensory h&icaps such as blindness or deafness.
  79. Planning
    The process of determining specific objectives, goals, & actions designed to meet the client's needs as identified through the assessment process. The plan should be action-oriented & time-specific.
  80. Practice Guidelines (Guidelines)
    Systematically developed statements on medical practices that assist a practitioner in making decisions about appropriate diagnostic & therapeutic healthcare services for specific med conditions. Practice guidelines are usually developed by authoritative professional societies & AMA
  81. Premature Discharge
    The release of a patient from care before he or she is deemed medically stable & ready for terminating treatmenVcare (e.g., discharging a patient from a hospital when he or she is still needing further care &/or observation).
  82. Primary Care
    The point when the patient first seeks assistance from the medical care system. It also is the care of the simpler & more common illnesses.
  83. Principal Diagnosis
    The chief complaint or health condition that required the patient's admission to the hospital for care.
  84. Principal Procedure
    A procedure performed for definitive rather than diagnostic treatment, or one that is necessary for treating a certain condition. It is usually related to the primary diagnosis.
  85. Prospective Review
    A method of reviewing possible hospitalization before admission to determine necessity & estimated length of stay.
  86. Protocol
    A systematically written document about a specific patient's problem. It is mainly used as an integral component of a clinical trial or research. It also delineates the steps to be followed for a particular procedure or intervention to meet desired outcomes.
  87. Provider
    A person or entity that provides health care services. This includes both practitioners & facilities.
  88. Quality Assurance
    The use of activities & programs to ensure the quality of patient care. These activities & programs are designed to monitor, prevent, & correct quality deficiencies & noncompliance with the st&ards of care & practice.
  89. Quality Improvement
    An array of techniques & methods used for the collection & analysis of data gathered in the course of current healthcare practices in a defined care setting to identify & resolve problems in the system & improve the processes & outcomes of care.
  90. Quality Indicator
    A predetermined measure for assessing quality
  91. Quality Management
    A formal & planned, systematic, organizationwide (or networkwide) approach to the monitoring, analysis, & improvement of organization performance, thereby continually improving the extent to which providers conform to defined standards, the quality of patient care & services provided
  92. Quality Monitoring
    A process used to ensure that care is being delivered at or above acceptable quality st&ards & as identified by the organization or national guidelines.
  93. Report Card
    An emerging tool that's used by HC providers, purchasers, policymakers, gov agencies, & consumers to compare & understand the actual performance of health plans & other service delivery programs. Usually includes data in maj areas of accountability such as quality, utilization of resources, consumer stsfctn & cost.
  94. Resource Utilization Group (RUG)
    Classifies skilled nursing facility pts into 7 major hierarchies & 44 groups. Based on the MDS, the patient is classified into the most appropriate group, & with the highest reimbursement.
  95. Retrospective Review
    A form of medical records review that is conducted after the patient's discharge to track appropriateness of care & consumption of resources.
  96. Risk Management
    The science of the identification, evaluation, & treatment of financial (& clinical) loss. A program that attempts to provide positive avoidance of negative results.
  97. Root Cause Analysis
    A process used by healthcare providers & administrators to identify the basic or causal factors that contribute to variation in performance & outcomes or underlie the occurrence of a sentinel event.
  98. Second Opinion
    An opinion obtained from another physician regarding the necessity for a treatment that has been recommended by another physician. May be required by some health plans for certain high-costs cases, such as cardiac surgery.
  99. Severity of Illness
    An acuity of illness criteria that identifies the presence of significant/debilitating symptoms, deviations from the patient's normal values, or unstable/abnormal vital signs or laboratory findings.
  100. Skilled Care
    Patient care services that require delivery by a licensed professional such as a registered nurse or physical therapist, occupational therapist, speech pathologist, or social worker.
  101. Social Work
    promotes social change, problem solving in human relationships & the empowerment & liberation of ppl to enhance well-being. Utilizing theories of human behavior & social systems, social work intervenes at the points where ppl interact w/ environments. Principles of human rights & social justice
  102. Special Education
    A broad term covering programs & services for children who deviate physically, mentally or emotionally from the nml to an extent that they require unique learning experience, technology or materials in order to be maintained in the reg classrooms & specialized classes & programs of the problems are more severe.
  103. Subacute Care Facility
    A healthcare facility that is a step down from an acute care hospital & a step up from a conventional skilled nursing facility intensity of services.
  104. Telephone Triage
    Triaging pts to appropriate levels of care based on a telephonic assessment of a patient. CMs use the findings of their telephone-based assessment to categorize the patient to be of an emergent, urgent, or nonurgent condition.
  105. Telephonic CM
    The delivery of healthcare services to pts &/or families or caregivers over the telephone or through correspondence, fax, e-mail, or other forms of electronic transfer. An example is telephone triage.
  106. Total Quality Management
    See Quality Management.
  107. Transitional Planning
    process CMs apply 2 ensure apprpriate resources & srvcs are provided to pts & that these srvcs are provided in the appropriate setting or lvl of care as delineated in the st&ards & guidelines of regulatory & accreditation agencies-focuses on moving a patient from complex to less complex care setting.
  108. Treatment
    The course of action adopted to care for a patient or to prevent disease.
  109. Variance
    Any expected outcome that has not been achieved within designated timeframes. It also means delay of specific diagnostic or therapuetic intervention. Categories include system, patient, & practitioner.
  110. Access to Care
    The ability & ease of pts to obtain healthcare when they need it.
  111. Actionable Tort
    A legal duty, imposed by statute or otherwise, owing by defendant to the one injured.
  112. Actuarial Study
    Statistical analysis of a population based on its utilization of healthcare services & demographic trends of the population. Results used to estimate healthcare plan premiums or costs.
  113. Acuity
    Complexity & severity of the patient's health/medical condition.
  114. Actuary
    A trained insurance professional who specializes in determining policy rates, calculating premiums, & conducting statistical studies.
  115. Administrative Services Only (ASO)
    An insurance company or third party administrator (TPA) that delivers administrative services to an employer group. This usually requires the employer to be at risk for the cost of health care services provided, which the ASO processes & manages claims.
  116. Adjuster
    A person who h&les claims (also referred to as Claims Service Representative)
  117. Admission Certification
    A form of utilization review in which an assessment is made of the medical necessity of a patient's admission to a hospital or other inpatient facility. ensures that pts requiring a hospital-based level of care & length of stay appropriate for the admission diagnosis are usually assigned & certified
  118. Ambulatory Payment Classification (APC) System
    An encounter-based classification system for outpatient reimbursement, including hospital-based clinics, emergency departments, observation, & ambulatory surgery. Payment rates are based on categories of services that are similar in cost & resource utilization.
  119. Appeal
    The formal process or request to reconsider a decision made not to approve an admission or healthcare services, reimbursement for services rendered, or a patient's request for postponing the discharge date & extending the length of stay.
  120. Approved Charge
    The amount Medicare pays a physician based on the Medicare fee schedule. Physicians may bill the beneficiaries for an additional amount, subject to the limiting charge allowed.
  121. Assignment of Benefits
    Paying medical benefits directly to a provider of care rather than to a member. This system generally requires either a contractual agreement between the health plan & provider or written permission from the subscriber for the provider to bill the health plan.
  122. Assumption of Risk
    A doctrine based upon voluntary exposure to a known risk. It is distinguished from contributory negligence, which is based on carelessness, in that it involves a comprehension that a peril is to be encountered & a willingness to encounter it.
  123. Assurance/Insurance
    The term "assurance" is used more commonly in Canada & Great Britain. The term "insurance" is the spreading of risk among many, among whom few are likely to suffer loss. The terms are generally accepted as synonymous.
  124. Authorization
    See Certification. Beneficiary
  125. Benefit Package
    The sum of services for which a health plan, government agency, or employer contracts to provide. In addition to basic physician & hospital services, some plans also cover prescriptions, dental, & vision care.
  126. Benefits
    The amount payable by an insurance company to a claimant or beneficiary under the claimant's specific coverage.
  127. Capitation
    A fixed amount of money per-member-per-month (PMPM) paid to a care provider for covered services rather than based on specific services provided. The typical reimbursement method used by HMOs. Whether a member uses the health service once or more than once, a provider who is capitated receives the same payment.
  128. Captive
    An insurance company formed by an employer to assume its workers' compensation & other risks, & provide services.
  129. Carrier
    The insurance company or the one who agrees to pay the losses. A carrier may be organized as a company, either stock, mutual, or reciprocal, or as an Association or Underwriters.
  130. Carve out
    Services excluded from a provider contract that may be covered through arrangements with other providers. Providers are not financially responsible for services carved out of their contract.
  131. Case Rates
    Rate of reimbursement that packages pricing for a certain category of services. Typically combines facility & professional practitioner fees for care & services.
  132. Case Reserve
    The dollar amount stated in a claim file which represents the estimate of the amount unpaid.
  133. Casualty Insurance
    A general class of insurance & workers' compensation insurance.
  134. Certification
    The approval of patient care services, admission, or length of stay by a health benefit plan (e.g., HMO, PPO) based on information provided by the healthcare provider.
  135. Claim
    A request for payment of reparation for a loss covered by an insurance contract.
  136. Claimant
    One who seeks a claim or one who asserts a right or dem& in a legal proceeding.
  137. Claims Service Representative
    A person who investigates losses & settles claims for an insurance carrier or the insured. A term preferred to adjuster.
  138. Clinical Review Criteria
    The written screens, decision rules, medical protocols, or guidelines used to evaluate medical necessity, appropriateness, & level of care.
  139. Coinsurance
    A type of cost sharing in which the insured person pays or shares part of the medical bill, usually according to a fixed percentage.
  140. Continued Stav Review
    A type of review used to determine that each day of the hospital stay is necessary & that care is being rendered at the appropriate level. It takes place during a patient's hospitalization for care.
  141. Contractor
    A business entity that performs delegated functions on behalf of the organization.
  142. Coordination of Benefits (COB)
    An agreement that uses language developed by the National Association of Insurance Commissioners & prevents double payment for services when a subscriber has coverage from two or more sources.
  143. Copavment
    A supplemental cost-sharing arrangement between the member & the insurer in which the member pays a specific charge for a specified service. Copayments may be flat or variable amnts/unit of service & may be for such things as physician office visits, RX, or hospital services. payment is incurred at the time of service.
  144. Current Procedural Terminology (CPT)
    A listing of descriptive terms & identifying codes for reporting medical services & procedures performed by health care providers & usually used for billing purposes.
  145. Days per Thous&
    A st&ard unit of measurement of utilization. Refers to an annualized use of the hospital or other institutional care. It is the number of hospital days that are used in a year for each thous& covered lives.
  146. Deductible
    A specific amount of money the insured person must pay before the insurer's payments for covered healthcare services begin under a medical insurance plan.
  147. Delegation
    The process whereby an organization permits another entity to perform functions & assume responsibilities on behalf of the organization, while the organization retains final authority to provide oversight to the delegate.
  148. Dem& Management
    Telephone triage & online health advice services to reduce members' avoidable visits to health providers. This helps reduce unnecessary costs & contributes to better outcomes by helping members become more involved in their own care.
  149. Denial
    No authorization or certification is given for healthcare services because of the inability to provide justification of medical necessity or appropriateness of treatment or length of stay. This can occur before, during, or after care provision.
  150. Diagnosis-Related Group (DRGJ
    A patient classification scheme that provides a means of relating the type of patient a hospital treats to the costs incurred by the hospital. DRGs demonstrate groups of pts using similar resource consumption & length of stay. I
  151. primary or secondary
    an outlier classification also exists. This is the form of reimbursement that the CMS uses to pay hospitals for Medicare & Medicaid recipients. Also used by a few states for all payers & by many private health plans (usually non-HMO) for contracting purposes.
  152. Disengagement
    The closing of a case is a process of gradual or sudden withdrawal of services, as the situation indicates, on a planned basis.
  153. Disenrollment
    The process of terminating healthcare insurance coverage for an enrollee/insured.
  154. Domestic Carrier
    An insurance company organized & headquartered in a given state is referred to in that state as a domestic carrier.
  155. Eligibility
    The determination that an individual has met requirements to obtain benefits under a specific health plan contract.
  156. Encounter
    An outpatient or ambulatory visit by a heatth plan member to a provider. It applies mainly to physician's office but may also apply to other types of encounters.
  157. Enrollee
    An individual who subscribes for a health benefit plan provided by a public or private healthcare insurance organization.
  158. Enrollment
    The number of members in an HMO. The process by which a health plan signs up individuals or groups of subscribers.
  159. Exclusive Provider Organization (EPO)
    A managed care plan that provides benefits only if care is rendered by providers within a specific network.
  160. Fee Schedule
    A listing of fee allowances for specific procedures or services that a health plan will reimburse.
  161. Fee-for-Service (FFS)
    Providers are paid for each service performed, as opposed to capitation. Fee schedules are an example of fee-for-service.
  162. Formulary
    A list of prescription drugs that provide choices for effective medications from which providers may select, that are covered under a specific health plan.
  163. Gatekeeper
    A primary care physician (usually a family practitioner, internist, pediatrician, or nurse practitioner) to whom a plan member is assigned. Responsible for managing all referrals for specialty care & other covered services used by the member.
  164. Global Fee
    A predetermined all-inclusive fee for a specific set of related services, treated as a single unit for billing or reimbursement purposes.
  165. Group Model HMO
    The HMO contracts with a group of physicians for a set fee per patient to provide many different health services in a central location. The group of physicians determines the compensation of each individual physician, often sharing profits.
  166. Health Benefit Plan
    Any written health insurance plan that pays for specific healthcare services on behalf of covered enrollees.
  167. Health Insurance
    Protection which provides payment of benefits for coverage for covered sickness or injury. Included under this heading are various types of insurance such as accident insurance, disability income insurance, medical expense insurance, & accidental death & dismemberment insurance.
  168. Health Maintenance Organization (HMO)
    An organization that provides or arranges for coverage of designated health services needed by plan members for a fixed prepaid premium. There are four basic models of HMOs
  169. Home Health Resource Group (HHRG)
    Groupings for prospective reimbursement under Medicare for home health agencies. Placement into an HHRG is based on the OASIS score. Reimbursement rates correspond to the level of home health provided.
  170. Hospital-Issued Notice of Noncoverage (HINNJ
    A letter provided to pts informing them of insurance noncoverage in case they refuse hospital discharge or insist on continued hospitalization despite the review by the peer review organization (PRO) that indicates their readiness for discharge.
  171. ICD-9-CM
    International Classification of Diseases, Ninth Revision, Clinical Modification, formulated to st&ardize diagnoses. It is used for coding medical records in preparation for reimbursement, particularly in the inpatient care setting. ICD-10 is expected to be published soon. (it is now, ST)
  172. Incentive
    A sum of money paid at the end of the year to healthcare providers by an insurance/managed care organization as a reward for the provision of quality & cost-effective care.
  173. Indemnity
    Security against possible loss or damages. Reimbursement for loss that is paid in a predetermined amount in the event of covered loss.
  174. Indemnity Benefits
    Benefits in the form of payments rather than services. In most cases after the provider has billed the patient, the insured person is reimbursed by the company.
  175. Individual Practice Association (IPA) Model HMO
    An HMO model that contracts with a private practice physician or healthcare association to provide healthcare services in return for a negotiated fee. The IPA then contracts with physicians who continue in their existing individual or group practice.
  176. Insurance
    A system/plan for a large number of people who are subject to the same loss & agree to have an insurer assess a premium, so when one suffers a loss, there is economic relief from the pooled resources. It also is known as protection by written contract against the financial hazards
  177. Insured
    The person, organization, or other entity who purchases insurance.
  178. Insurer
    The insurance company or any other organization which assumes the risk & provides the policy to the insured.
  179. Legal Reserve
    The minimum reserve which a company must keep to meet future claims & obligations as they are calculated under the state insurance code.
  180. Length of Stay
    The number of days that a health plan member/patient stays in an inpatient facility, home health, or hospice.
  181. Long-Term Disability Income Insurance
    Insurance issued to an employee, group, or individual to provide a reasonable replacement of a portion of an employee's earned income lost through a serious prolonged illness during the normal work career.
  182. Loss Control
    Efforts by the insurer & the insured to prevent accidents & reduce loss through the maintenance & updating of health & safety procedures.
  183. Loss Expense Allocated
    That part of expense paid by an insurance company in settling a particular claim, such as legal fees, by excluding the payments to the claimant.
  184. Loss Ratio
    The percent relationship which losses bear to premiums for a given period.
  185. Loss Reserve
    The dollar amount designated as the estimated cost of an accident at the time the first notice is received.
  186. Managed Care
    A system of healthcare delivery that aims to provide a generalized structure & focus when managing the use, access, cost, quality, & effectiveness of healthcare services. Links the patient to provider services.
  187. Medicaid
    A joint federal/state program which provides basic health insurance for persons with disabilities, or who are poor, or receive certain governmental income support benefits (i.e. Social Security I nco me or SSI) & who meet income & resource limitations. Benefits may vary by state. May be referred to as "Title XIX"
  188. Medicaid Waiver
    Waiver Programs, authorized under Section 1915(C) of the Social Security Act, provide states with greater flexibility to serve individuals with substantial long-term care needs at home or in the community rather than in an institution. The federal government "waives" certain Medicaid rules.
  189. Medicare
    A nationwide, federally administered health insurance program that covers the cost of hospitalization, medical care, & some related services for eligible persons.
  190. Network Model HMO
    This is the fastest growing form of managed care. The plan contracts with a variety of groups of physicians & other providers in a network of care with organized referral patterns. Networks allow providers to practice outside the HMO.
  191. Panel of Providers
    Usually refers to the healthcare providers, including physicians, who are responsible for providing care & services to the enrollee in a managed care organization. These providers deliver care to the enrollee based on a contractual agreement with the managed care organization.
  192. Payer
    The party responsible for reimbursement of healthcare providers & agencies for services rendered such as the Centers for Medicare & Medicaid Services & managed care organizations.
  193. Peer Review
    Review by healthcare practitioners of services ordered or furnished by other practitioners in the same professional field.
  194. Peer Review Organization (PRO)
    A federal program established by the Tax Equity & Fiscal Responsibility Act of 1982 that monitors the medical necessity & quality of services provided to Medicare & Medicaid beneficiaries under the prospective payment system.
  195. Per Diem
    A daily reimbursement rate for all inpatient hospital services provided in one day to one patient, regardless of the actual costs to the healthcare provider. The rate can vary by service (medical, surgical, mental health, etc.) or can be uniform regardless of intensity of services.
  196. Physician-Hospital Organization
    Organization of physicians & hospitals that is responsible for negotiating contractual agreements for healthcare provision with third-party payers such as managed care organizations.
  197. Point-of-Service (POS) Plan
    A type of health plan allowing the covered person to choose to receive a service from a participating or a nonparticipating provider, with different benefit levels associated with the use of participating providers. Members usually pay substantially higher costs in terms of increased premiums
  198. Preadmission Certification
    An element of utilization review that examines the need for proposed services before admission to an institution to determine the appropriateness of the setting, procedures, treatments, & length of stay.
  199. Preauthorization
    See Precertification.
  200. Precertification
    The process of obtaining & documenting advanced approval from the health plan by the provider before delivering the medical services needed. This is required when services are of a nonemergent nature.
  201. Pre-Existing Condition
    A physical &/or mental condition of an insured which first manifested itself prior to the issuance of the individual policy or which existed prior to issuance & for which treatment was received.
  202. Preferred Provider Organization (PPO)
    A program in which contracts are established with providers of medical care. Providers under a PPO contract are referred to as preferred providers. Usually the benefit contract provides significantly better benefits for services received from preferred providers,
  203. Premium
    The periodic payment required to keep a policy in force.
  204. Prepaid Health Plan
    Health benefit plan in which a provider network delivers a specific complement of health services to an enrolled population for a predetermined payment amount (see capitation).
  205. Primary Care Provider
    Assumes ongoing responsibility for the patient in both health maintenance & treatment. Usually responsible for orchestrating the medical care process either by caring for the patient or by referring a patient on for specialized diagnosis & treatment. Primary care providers include general or family practitioners, internists, pediatricians, & sometimes OB/GYN doctors.
  206. Prospective Pavment System
    A healthcare payment system used by the federal government since 1983 for reimbursing healthcare providers/agencies for medical care provided to Medicare & Medicaid participants. The payment is fixed & based on the operating costs of the patient's diagnosis.
  207. Rate
    The charge per unit of payroll which is used to determine workers' compensation or other insurance premiums. The rate varies according to the risk classification within which the policyholder may fall.
  208. Rating
    The application of the proper classification rate & possibly other factors to set the amount of premium for a policyholder. The three principle forms of rating are
  209. Reimbursement
    Payment regarding healthcare & services provided by a physician, medical professional, or agency.
  210. Relative Weight
    An assigned weight that is intended to reflect the relative resource consumptionassociated with each DRG. The higher the relative weight, the greater the payment/reimbursement to the hospital.
  211. Risk
    The uncertainty of loss with respect to person, liability, or the property of the insured OR Probability that revenues of the insurer will not be sufficient to cover expenditures incurred in the delivery of contracted services.
  212. \Risk Management
    A comprehensive program of activities to identify, evaluate, & take corrective action against risks that may lead to patient or staff injury with resulting financial loss or legal liability. This program aims at minimizing losses.
  213. Risk Sharing
    The process whereby an HMO & contracted provider each accept partial responsibility for the financial risk & rewards involved in cost-effectively caring for the members enrolled in the plan & assigned to a specific provider.
  214. Self-Insurer
    An employer who can meet the state legal & financial requirements to assume by him or herself all of its risk & pay for the losses, although the employer may contract with an insurance carrier or others to provide certain essential seNices.
  215. Short-Term Disability Income Insurance
    The provision to pay benefits to a covered disabled person/employee as long as he/she remains disable up to a specific period not exceeding two years.
  216. SSI
    Supplemental Security Income. Federal financial benefit program sponsored by the Social Security Administration.
  217. Staff Model HMO
    The most rigid HMO model. Physicians are on the staff of the HMO with some sort of salaried arrangement & provide care exclusively for the health plan enrollees.
  218. Supp/ementarv Medica/Insurance (SMI)
    A secondary medical insurance plan used by a subscriber to supplement healthcare benefits & coverage provided by the primary insurance plan. The primary & secondary/supplementary plans are unrelated & provided by two different agencies.
  219. Target Utilization Rates
    Specific goals regarding the use of medical seNices, usually included in risk-sharing arrangements between managed care organizations & healthcare providers.
  220. Third Party Administration
    Administration of a group insurance plan by some person or firm other than the insurer of the policyholder.
  221. Third Party Administrator (TPA)
    An organization that is outside of the insuring organization that h&les only admin functions such as utilization review & processing claims. Third party administrators are used by organizations that actually fund the health benefits but dont find it costeffective to administer the plan themselves.
  222. Third Party Paver
    An insurance company or other organization responsible for the cost of care so that individual pts do not directly pay tor seNices.
  223. Underutilization
    Using established criteria as a guide, determination is made as to whether the patient is receiving all of the appropriate seNices.
  224. Utilization
    The frequency with which a benefit is used during a 1-year period, usually expressed in occurrences per 1 000 covered lives.
  225. Utilization Management
    Review of seNices to ensure that they are medically necessary, provided in the most appropriate care setting, & at or above quality st&ards.
  226. Utilization Review
    A mechanism used by some insurers & employers to evaluate healthcare on the basis of appropriateness, necessity, & quality.
  227. Withhold
    A portion of payments to a provider held by the managed care organization until year end that will not be returned to the provider unless specific target utilization rates are achieved. Typically used by HMOs to control utilization of referral seNices by gatekeeper physicians.
  228. Workers' Compensation
    An insurance program that provides medical benefits & replacement of lost wages for persons suffering from injury or illness that is caused by or occurred in the workplace. It is an insurance system for industrial & work injury, regulated primarily among the separate states, but regulated fed sometimes
  229. Workers' Compensation Commission
    One of many terms identifying the state public body which administers the workers' compensation laws, holds hearings on contested cases, promotes industrial safety, rehabilitation, etc. It is often located within the state labor department.
  230. ADA
    The federal Americans with Disabilities Act of 1990.
  231. Administrative Law
    That branch of public law that deals with the various organs of federal, state, & local governments which prescribes in detail the manner of their activities.
  232. Advance Directives
    Legally executed document that explains the patient's healthcare-related wishes & decisions. It is drawn up while the patient is still competent & is used if the patient becomes incapacitated or incompetent.
  233. Advocacy
    Acting on behalf of those who are not able to speak for or represent themselves. It is also defending others & acting in their best interest. A person or group involved in such activities is called an advocate.
  234. Affidavit
    A written statement of fact signed & sworn before a person authorized to administer an oath.
  235. Appeal
    The process whereby a court of appeals reviews the record of written materials from a trial court proceeding to determine if errors were made that might lead to a reversal of the trial court's decision.
  236. Autonomy
    A form of personal liberty of action in which the patient holds the right & freedom to select & initiate his or her own treatment & course of action, & taking control for his or her health- that is, fostering the patient's independence & self-determination.
  237. Bad Faith
    Generally involving actual or constructive fraud, or a design to mislead or deceive another.
  238. Beneficence
    The obligation & duty to promote good, to further & support a patient's legitimate h'><' interests & decisions, & to actively prevent or remove harm
  239. Bona Fide
    Literally translated as "in good faith" Burden of Proof
  240. Case Law
    The aggregate of reported cases forming a body of jurisprudence, or the law of a particular subject as evidenced or formed by the adjudged cases, in distinction to statutes & other sources of law.
  241. Civil Case or Suit
    A case brought by one or more individuals to seek redress of some legal injury (or aspect of an injury) for which there are civil (non-criminal) remedies.
  242. Common Law
    A system of legal principles that does not derive its authority from statutory law, but from general usage & custom as evidenced by decisions of courts.
  243. Compensation
    Money that a court or other tribunal orders to be paid, by a person whose acts or omissions have caused loss or injury to another, in order that the person demnified may receive equal value for 1he loss, or be made whole in respect to the injury.
  244. Competence
    The mental ability & capacity to make decisions, accomplish actions, & perform tasks that another person of similar background & training, or any human being, would be reasonably expected to perform adequately.
  245. Confidential Communications
    Certain classes of communications, passing between persons who st& in a confidential or fiduciary relation to each other (or who, on account of their relative situation, are under a special duty of secrecy & fidelity), that the law will not permit to be divulged.
  246. Contempt of Court
    Any act that is calculated to embarrass, hinder, delay or obstruct the court in the administration of justice, or that is calculated to lessen its authority of its dignity.
  247. Cross Examination
    The questioning of a witness during a trial or deposition by the party opposing those who originally asked him/her to testify.
  248. Damages
    Money awarded by a court to someone who has been injured (plaintiff) & that must be paid by the party responsible for the injury (defendant). Normal damages are awarded when the injury is judged to be slight. Compensatory damages are awarded to repay of compensate the injured party for the injury incurred.
  249. Defendant
    The person against whom an action is brought to court because of alleged responsibility for violating one or more of the plaintiff's legally protected interests.
  250. Deposition
    The testimony of a witness taken upon interrogatories not in open court, but in pursuance of a commission to take testimony issued by a court, or under a general law on the subject, & reduced to writing & duly authenticated, & intended to be used upon the trial of an action in court.
  251. Direct Examination
    The first interrogation or examination of a witness, on the merits, by the party on whose behalf he/she is called.
  252. Discovery
    The process by which one party to a civil suit can find out about matters that are relevant to his/her case, including information about what evidence the other side has, what witnesses will be called upon, & so on. Discovery devices for obtaining testimony, requests for documents or other tangibles, or PE/MH exam & benefits, especially when making decisions regarding the allocation of healthcare resources.
  253. Evidence
    Any species of proof, or probative matter, legally presented at the trial of an issue, by the act of the parties & through the medium of witnesses, records, documents, concrete objects, & the like, for the purpose of inducing beliefs in the minds of the court or jury as to their contention.
  254. Ex Parte
    A judicial proceeding, order, injuction, & so on, taken or granted at the instance & for the benefit of one party only, & without notice to, or contestation by, any person adversely interested.
  255. Expert Witness
    A person called to testify because of recognized competence in an area.
  256. Fair Hearing
    One in which authority is executed fairly
  257. Fiduciarv
    Person in a special relationship of trust, confidence or responsibility in which one party occupies a superior relationship & assumes a duty to act in the dependent's best interest. This includes a trustee, guardian, counselor or institution, but it could also be a volunteer acting in this special relationship.
  258. Fraud
    Knowingly & willfully executing, or attempting to execute a scheme or artifice to defraud any healtlhcare benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any healthcare benefit program.
  259. Gag Rules
    A clause in a provider's contract that prevents physicians or other providers from revealing a full range of treatment options to pts or, in some instances, from revealing their own financial self-interest in keeping treatment costs down. These rules have been banned by many states.
  260. Guardian
    A person appointed by the court to be a substitute decision-maker for persons receiving services deemed to be incompetent of making informed decisions for themselves. The powers of a guardian are determined by a judge & may be limited to certain aspects of the person's life.
  261. Healthcare Proxy
    A legal document that directs the healthcare provider/agency in whom to contact for approval/consent of treatment decisions or options whenever the patient is no longer deemed competent to decide for self.
  262. Hearsay
    Evidence not proceeding from the personal knowledge of the witness, but from the mere repetition of what has been heard from others.
  263. Impeach
    In the law of evidence, it is to call in question the veracity of a witness, by means of evidence adduced for that purpose.
  264. Informed Consent
    Consent given by a patient, next of kin, legal guardian, or designated person for a kind of intervention, treatment, or service after the provision of sufficient information by the provider. A decision based on knowledge of the advantages & disadvantages & implications of choosing a particular course of action.
  265. Interrogatories
    A set or series of written questions composed for the purpose of being propounded to a party in equity, a garnishee, or a witness whose testimony is taken in a deposition.
  266. Justice
    Maintaining what is right & fair & making decisions that are good for the patient. Liability
  267. Lien
    A charge or security or encumbrance upon property. Limitation, Statute of
  268. Litigation
    A contest in a court for the purpose of enforcing a right, particularly when inflicting harm on another person.
  269. Living will
    A legal document that directs the healthcare team/provider in holding or withdrawing life support measures. It is usually prepared by the patient while he or she is competent, indicating the patient's wishes.
  270. Malpractice
    Improper care or treatment by a healthcare professional. A wrongful conduct. Medical Durable Power of Anornev
  271. Motion
    A request to the court to take some action or to request the opposing side to take some action relating to a case.
  272. Negligence
    Failure to act as a reasonable person. Behavior is contrary to that of any ordinary person facing similar circumstances.
  273. Nonmaleficence
    Refraining from doing harm to others
  274. Petition
    An application to a court ex parte paying for the exercise of the judicial powers of the court in relation to some matter that is not the subject for a suit or action, or for authority to do some action that requires the sanction of the court.
  275. Plaintiff
    A person who brings a suit to court in the belief that one or more of his/her legal right have been violated or that he/she has suffered legal injury.
  276. Release
    The relinquishment of a right, claim, or privilege, by a person in whom it exists or to whom it accrues, to the person against whom it might have been dem&ed or enforced. Rem&
  277. Remedy
    The means by which a right is enforced or the violation of a right is prevented, redressed, or compensated.
  278. Respondeat Superior
    Literally, "let the master respond." This maxim means that an employer is liable in certain cases for the wrongful acts of his/her employees, & the principal for those of his/her agency.
  279. Settlement
    A "meeting of minds" of parties to a transaction or controversy which resolves some or all of the issues involved in a case.
  280. Statute
    An act of a legislature declaring, comm&ing, or prohibiting & action, in contrast to unwritten common law.
  281. \Stipulation
    An agreement between opposing parties that a particular fact or principle of law is true & applicable.
  282. Subrogation
    The right to pursue & lien upon claims for medical charges against another person or entity.
  283. Subpoena
    A process comm&ing a witness to appear & give testimony in court.
  284. Tort
    A civil wrong for which a private individual may recover money damages, arising from a breach of duty created by law.
  285. Tort Liability
    The legal requirement that a person responsible, or at fault, shall pay for the damages & injuries caused.
  286. Tort-Feasor
    A wrong-doer who is legally liable for damage caused.
  287. Veracity
    The act of telling the truth.
  288. Waiver
    The intentional or voluntary relinquishment of a known right.
  289. Brain Disorder
    A loosely used term for a neurological disorder or syndrome indicating impairment or injury to brain tissue.
  290. Case Mix Complexity
    An indication of the severity of illness, prognosis, treatment difficulty, need for intervention, or resource intensity of a group of pts.
  291. Case Mix Group (CMG)
    Each CMG has a relative weight that determines the base payment rate for inpatient rehabilitation facilities under the Medicare system.
  292. Case Mix Index (CMI)
    The sum of DRG-relative weights of all pts/cases seen during a 1-year period in an organization, divided by the number of cases hospitalized & treated during the same year.
  293. Catastrophic Case
    Any medical condition or illness that has heightened medical, social & financial consequences that responds positively to the control offered through a systematic effort of CM.
  294. Comorbidlty
    A preexisting condition (usually chronic) that, because of its presence with a specific condition, causes an increase in the length of stay by about 1 day in 75% of the pts.
  295. Complication
    An unexpected condition that arises during a hospital stay or healthcare encounter that prolongs the length of stay at least by 1 day in 75% of the pts & intensifies the use of healthcare resources.
  296. Concurrent Review
    A method of reviewing patient care & services during a hospital stay to validate the necessity of care & to explore alternatives to inpatient care. It is also a form of utilization review that tracks the consumption of resources & the progress of pts while being treated.
  297. Core Therapies
    Basic therapy services provided by professionals on a rehabilitation unit. Usually refers to nursing, physical therapy, occupational therapy, speech-language pathology, neuropsychology, social work & therapeutic recreation.
  298. \Deaf (Deafness)
    Defined as a condition in which the auditory sense is not the primary means by which speech & language are learned & the sense of hearing is so lacking or drastically reduced as to prohibit normal function as a hearing person.
  299. Developmental Retardation
    A term that has been suggested as a replacement for mental retardation. Removes confusion with mental health & mental illness.
  300. MEDICAL Durable Medical Equipment (DME)
    Equipment needed by pts for self-care. Usually it must withst& repeated use, is used for a medical purpose, & is appropriate for use in the home setting.
  301. Hearing Impairment
    Loss of or compromised hearing.
  302. Impairment
    A general term indicating injury, deficiency or lessening of function. Impairment is a condition that is medically determined & relates to the loss or abnormality of psychological, physiological, or anatomical structure or function. Impairments are disturbances at the level of the organ & include defects or limb loss
  303. Mental Retardation
    A broadly used term that refers to significantly sub-average general intellectual functioning manifested during developmental period & existing concurrently with impairment in adaptive behavior.
  304. Mobility
    The ability to move about safely & efficiently within one's environment.
  305. Occupational Disease
    Any disease or specified disease that is common to or a result of a particular occupation of specific work environment.
  306. Sensory Aphasia
    Inability to underst& the meaning of written, spoken or tactile speech symbols because of disease or injury to the auditory & visual brain centers.
  307. Sentinel Event
    An unexpected occurrence, not related to the natural course of illness, that results in death, serious physical or psychological injury, or permanent loss of function.
  308. Visual Impairment
    Educationally defined as deficiency in eyesight to the extent that special provisions are necessary in education.
  309. Accreditation
    A st&ardized program for evaluating healthcare organizations to ensure a specified level of quality, as defined by a set of national industry st&ards. Organizations that meet accreditation st&ards receive an official authorization or approval of their services.
  310. Benchmarking
    An act of comparing a work process with that of the best competitor. Through this process one is able to identify what performance measure levels must be surpassed. Benchmarking assists an organization in assessing its strengths & weaknesses & in finding & implementing best practices.
  311. Caregiver
    The person responsible for caring for a patient in the home setting. Can be a family member, friend, volunteer, or an assigned healthcare professional.
  312. Credentiallnq
    A review process to approve a provider who applies to participate in a health plan. Specific criteria are applied to evaluate participation in the plan. The review may include references, training, experience, demonstrated ability, licensure verification, & adequate malpractice insurance.
  313. Cultural Competency
    A set of congruent behaviors, attitudes, & policies that come together in a system, agency, or among professionals & enables that system, agency, or those professionals to work effectively in cross-cultural situations.
  314. Culture
    The thoughts, communications, actions, customs, beliefs, values, & institutions of racial, ethnic, religious, or social groups.
  315. Database
    An organized, comprehensive collection of patient care data. Sometimes it is used for research or for quality improvement efforts.
  316. Ergonomics (or human factors)
    The scientific discipline concerned with the underst&ing of interactions among humans & other elements of a system. It is the profession that applies theory, principles, data & methods to environmental design (including work environments) in order to optimize human well-being & overall system
  317. Ergonomist
    An individual who has (1) a mastery of ergonomics knowledge
  318. or environment
    & (3) has applied his or her knowledge to the analysis, design, test, & evaluation of products, processes, & environments.
  319. Internet
    A public, cooperative creation that operates using national & international telecommunication technologies & networks, including high-speed data lines, phone lines, satellite communications, & radio networks.
  320. JCAHO
    Joint Commission on Accreditation of Health Care Organizations. Licensure
  321. Life Care Plan
    A dynamic document based upon published st&ards of practice, comprehensive assessment, research & data analysis, which provides an organized, concise plan for current & future needs with associated costs for individuals who have experienced catastrophic injury or have chronic healthcare needs.
  322. Standard (Individual)
    An authoritative statement bu which a profession defines the responsibilities for which its practitioners are accountable.
  323. St&ard (Organization)
    An authoritative statement that defines the performance expectations, structures, or processes that must be substantially in place in an organization to enhance the quality of care.
  324. Standards of Care
    Statements that delineate care that is expected to be provided to all clients. They include predefined outcomes of care clients can expect from providers & are accepted within the community of professionals, based upon the best scientific knowledge, current outcomes data, & clinical expertise.
  325. St&ards of Practice
    Statements of acceptable level of performance or expectation for professional intervention or behavior associated with one's professional practice. They are generally formulated by practitioner organizations based upon clinical expertise & the most current research findings.
  326. Utilization Review Accreditation Commission (URAC)
    A not-for-profit organization that provides reviews & accreditation for utilization review services/programs provided by freest&ing agencies. It is also known as the American Accreditation Health Care Commission.
  327. Adaptive Behavior
    The effectiveness & degree to which an individual meets st&ards of selfsufficiency & social responsibility for his/her age-related cultural group.
  328. ADL
    Activities of Daily Living. Routine activities carried out for personal hygiene & health & for operating a household. ADLs include feeding, bathing, showering, dressing, getting in or out of bed or a chair, & using the toilet.
  329. Assistive Device
    Any tool that is designed, made, or adapted to assist a person to perform a particular task.
  330. Assistive Technologv
    Any item, piece of equipment, or product system, whether acquired commercially or off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. Examples are listening devices, speech production equipment & low vision devices.
  331. Assistive Technology Services
    Any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device.
  332. Barriers
    Factors in a person's environment that, if absent or present, limit one's functioning & create disability. Examples are a physical environment that is inaccessible, lack of relevant assistive technology, & negative attitudes of people toward disability. Barriers also include services, systems, & policies
  333. Capacity
    A construct that indicates the highest probable level of functioning a person may reach. Capacity is measured in a uniform or st&ard environment, & thus reflects the environmentally adjusted ability of the individual.
  334. CARF
    Commission on Accreditation of Rehabilitation Facilities. A private, non-profit organization that establishes st&ards of quality for services to people with disabilities & offers voluntary accreditation for rehabilitation facilities based on a set of nationally recognized st&ards.
  335. Cognitive Rehabilitation
    Therapy programs which aid persons in managing specific problems in perception, memory, thinking & problem-solving. Skills are practices & strategies are taught to help improve function &/or compensate for remaining deficits.
  336. Habilitation
    The process by which a person with developmental disabilities is assisted in acquiring & maintaining life skills to 1) cope more effectively with personal & developmental dem&s & 2) to increase the level of physical, mental, vocational & social ability through services.
  337. Inclusive Education
    An ed model in which students with disabilities receive their education in a gen ed setting with collaboration between gen & special ed teachers. Implementation may be through the total reorganization & redefinition of general & special education roles, or as one option in a continuum of available services.
  338. Inpatient Rehabilitation Facilities Patient Assessment Instrument (IRF·PAI)
    The Inpatient Rehabilitation Facilities Patient Assessment Instrument, used to classify pts into distinct groups based on clinical characteristics & expected resource needs.
  339. Rehabilitation Counseling
    A specialty w/in the rehab professions w/counseling being its core, profession assists individuals with disabilities in adapting to the environment, assists environments in accommodating the needs of the individual, & works toward full participation of pts w/ disabilities in all aspects of society.
  340. Rehabilitation Counselor
    A counselor who possesses the specialized knowledge, skills, & attitudes needed to collaborate in a professional relationship with persons with disabilities to empower them to achieve their personal, social, psychological, & vocational goals.
  341. Rehabilitation Engineering
    The field of technology & engineering serving disabled individuals in their rehabilitation. Includes the construction & use of a great variety of devices & instruments designed to restore or replace function mostly of the locomotion & sensory systems.
  342. Rehabilitation Impairment Categories (RIC)
    Represent the primary cause of the rehabilitation stay. They are clinically homogeneous groupings that are then subdivided into Case Mix Groups (CMGs).
  343. Rehabilitation Team
    A group of HC workers with backgrounds in rehabilitation who work together to provide integrated, patient-oriented care. A variety of specialists & other providers who combine resources to address each pts physical, mental, emotional & spiritual needs in order to minimize disability & resulting h&icaps.
  344. Universal Design
    The design of products & environments to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design.
  345. Vocational Evaluation
    The comprehensive assessment of vocational aptitudes & potential, using information about a person's past hx med & psych status, & information from appropriate vocational testing, which may use paper & pencil instruments, work samples, simulated work stations, or assessment in a real work environment.
  346. Vocational Rehabilitation
    Cost effective CM by a skilled professional who underst&s the implications of the medical & vocational services necessary to facilitate an injured worker's expedient return to suitable gainful employment with a minimal degree of disability.
  347. Vocational Rehabilitation Counselor
    A rehabilitation counselor, who specializes in vocational counseling, i.e. guiding h&icapped persons in the selection of a vocation or occupation.
  348. Vocational Testing
    The measurement of vocational interests, aptitudes, & ability using st&ardized, professionally accepted psychomotor procedures.
  349. RETURN-To-WORK Employability
    Having the skills & training that are commonly necessary in the labor market to be gainfully employed on a reasonably continuous basis, when considering the person's age, education, experience, physical, & mental capacities due to industrial injury or disease.
  350. RETURN-To-WORK Job Bank Service
    A computerized system, developed by the Department of Labor, which maintains an up-to-date listing of job vacancies available through the State Employment Service.
  351. Return to work Job Club
    An organization of individuals who are seeking work, who join together to share information about employers, interviewing strategies, job seeking skills, & work opportunities.
  352. RETURN-To-WoRK Job Coach
    An employment specialist who provides training & support to a person at the workplace.
  353. RETURN-TO-WORK Reasonable Accommodation
    Making existing facilities used by employees readily accessible & usable by those w/disabilities. This may include job restructuring, part-time or modified work schedules, acquisition or modification of equipment or devices, & other similar accommodations for those w/disabilities.
  354. RETURN-TO-WORK Vocational Assessment
    Identifies the individual's strengths, skills, interests, abilities &
  355. rehabilitation needs. Accomplished through on-site situational assessments at local businesses & in community settings.
  356. RETURN-To-WORK Work Adjustment
    The use of real or simulated work activity under close supervision at a rehabilitation facility or other work setting to develop appropriate work behaviors, attitudes, or personal characteristics.
  357. RETURN-To-WORK Work Adjustment Training
    A program for persons whose disabilities limit them from obtaining competitive employment. It typically includes a system of goal directed services focusing on improving problem areas such as attendance, work stamina, punctuality, dress & hygiene & interpersonal relationships etc
  358. RETURN-To-WORK Work Conditioning
    An intensive, work-related, goal-oriented conditioning prgm designed specifically to restore systemic neuromusculoskeletal functions - The objective of the work conditioning program is to restore physical capacity & function to enable the patient/cli
  359. RETURN-To-WORK Work Hardening
    A highly structured, goal-oriented, & individualized intervention prgm that provides pts with a transition between the acute injury stage & a safe, productive return to work. Treatment is designed to maximize each individual's ability to return to work safely with less likelihood of repeat injury.
  360. RETURN-To-WoRK Work Modification
    Altering the work environment to accommodate a person's physical or mental limitations by making changes in equipment, in the methods of completing tasks, or in job duties.
Card Set
CCMC Gloassary
CCMC Gloassary