About the Book

Written by renowned author, Catherine M. Mullahy, The Case Manager’s Handbook, Fifth Edition is the ultimate how-to guide for case managers. This practical resource helps case managers build fundamentals, study for the Certified Case Manager (CCM) exam, and most importantly, advance their careers after the exam.

Perfect for all professionals in all practice settings in case management, this text uses real- life examples and an easy-to-read, conversational style to examine the case management process while presenting practical procedural information. An excellent daily reference and training guide for new case managers and seasoned professionals in various settings, The Case Manager’s Handbook, Fifth Edition is the “go-to” resource for facing the day-to-day challenges of case management.

Significantly updated and revised, this text contains eight new chapters:
• Hospital Case Management: Changing
• Roles and Transitions of Care
• Patient-Centered Medical Homes
• Evidence-Based Practice
• Public Sector Reimbursement
• Predictive Modeling
• Pain Management
• Health Technology, Trends, and Implications for Case Managers
• The Affordable Care Act of 2010: Implications for Case Managers

About the Author

Catherine M. Mullahy, RN, BS, CRRN, CCM- is a nationally recognized leader in advancing “Best in Class” case management. She is the recipient of many awards recognizing her considerable contributions to the field of case management. Her educational programs are widely valued for their content and have been honored “” with prestigious awards such as the Case in Point Platinum Award for Mullahy & Associates “Best-in-Class Case Management” program. In her multiple positions as an officer, board member, task force member, and executive committee member for leading professional associations (CMSA, CCMC). she has played a, vital role in shaping key initiatives to raise the standards of the case management profession. A former editor of The Case Manager, she continues to be a prominent contributor to other leading professional publications and books. Currently in high demand on the national speaker circuit, Mullahy is actively sharing many of the ideas and principles put forth in this latest edition of The Case Manager’s Handbook. Through her spirited writing, she continues to capture the critical role of case managers, empowering them with leadinq-edqe information and insights to take their rightful position in a rapidly changing healthcare continuum. By sharing her knowledge and experience gained over a three and a half decade career as a dedicated nurse, compassionate case manager, and a successful entrepreneur and consultant, Mullahy has made it her mission to provide case managers with the information and motivation they need to effectively face the day-to-dav challenges of case management, as well as to make the best decisions for their patients, their employers, and themselves.

Table of Contents:
Preface • Foreword • Acknowledgments PART I: INTRO BIO OF A CASE MANAGER • CHAPTER 1: The Case Manager as Catalyst, Problem Solver, Educator • The Case Manager’s Role • Case Management Is Not Equivalent to Managed Care • Medical Credentials and Expertise • A Definition of Case Management • Case Management Role and Functions • Certification, Accreditation, and Standards of Practice • CHAPTER 2: The Case Manager’s Universe • Healthcare Providers • Managed Care: HMOs, PPOs, MCOs, IPAs, PHOs, PSOs, and • EPOs and Now ACOs and PCMHs! • Managed Care: The Times Are Changing • Complementary and Alternative Care • Standards of Care PART II: CASE MANAGEMENT PROCESS: THE MICROSYSTEM LEVEL • CHAPTER 3: The Case Management Work Format and Process • Case Management Defined • CCM Domains of Knowledge • Screening • Stratifying Risk • Assessing • Planning • Implementing Care Coordination • Following Up • Transitioning • Communicating Post- Transition • Evaluating • Screening and Stratifying Risk Discussion • Referral Sources • Assessing Discussion • Talking with the Patient • Talking with the Family • Talking with the Treating Physician • Telephonic Case Management • Talking with Other Professionals • Initial Phone Contact with Medical Professionals to Set Up Personal Consultation • Planning Discussion • Reporting • Obtaining Approval • Implementing Care Coordination: Putting the Plan into Action • Follow-Up (Ongoing) Discussion • Transitioning (Transitional Care) Discussion • Communicating Post- Transition Discussion • Evaluating the Plan Discussion • Repeating the Process • Communications in Various Settings • Stay on Point • CHAPTER 4: Communications and Patient Engagement • Back to the Basics • What Is Patient Engagement? • Motivational Interviewing • Changes in How We Communicate • Communications Within New Models of Care • Engaging Patients and Their Families in New Ways • Communicating with Physicians: Challenges and Strategies • Practical Steps to a Win-Win Relationship Between Case Managers and Physicians • Communications with Patients and Families • Communications with Payer Sources • Communications with Legal Professionals • Communication Subtleties • The Right Mind-Set Communications and Caring Overload: Burnout Red Flags for Case Managers PART III: PRACTICE SETTINGS AND MODELS OF CARE • CHAPTER 5: Hospital Case Management: Changing Roles and Transitions of Care • CHAPTER 6: ACOs, PCMHs, and State Health Exchanges • Accountable Care Organizations • Patient-Centered Medical Homes • Case Managers Serving in the PCMH • A Case Study of Case Management in the PCMH • State Health Exchanges • CHAPTER 7: The Growing Need for Direct-to-Consumer, Community-Based Case Managers: Our Changing Times • Independent, Disciplined, Proactive • The Case Manager as Change Agent • Opportunities Are Waiting, Are You Ready? • CHAPTER 8: Care at Home • Consumer Demand-and Ambivalence • The Case Manager as a Pivotal Link • Cases in Profile • Ongoing Support at Home • Importance of Feedback and Communication • Payment Concerns • Tools to Help You Assess the Quality of Care You Are Getting • CHAPTER 9: Managing a Long-Term Case • Informing the Client • Level of Involvement • Importance of Ongoing Involvement • Changes in Long-Term Cases • Negotiating for Long-Term Care • Employing all Possible Resources • Long- Term Care of the Elderly • Implications of Long- Term Care for the Family • Implications of a Long-Term Case for the Case Manager • From Acute Care to Home Care: A Case History • CHAPTER 10: Integrated Care Management: Preadmission, Concurrent Review, Utilization Review, Disease Management, and Case Management • Introducing Utilization Review to Client Groups and Plan Participants • The Preadmission and Concurrent Review Process • Timing Disease Management and Case Management Intervention • Preadmission and Concurrent Review Reports • Establishing an Effective Preadmission Review, Concurrent Review Case Management, and Disease Management System • Preadmission Review, Concurrent Review, Disease Management, and Case Management Checklist • Fees: Capitated, Hourly, or Per Case PART IV: THE CASE MANAGEMENT PROFESSIONAL • CHAPTER 11: Legal Responsibilities of the Case Management Professional • Malpractice • Potential Case Manager Liability • Other Legal Issues: Patient Bill of Rights and Patient Confidentiality • Medical Records, Electronic Health Records, and HITECH • The Right to Know Versus the Need to Know • Disclosure Issues • Adequate Information • Contracts and Letters of Agreement • Legal Issues in Case Management • U.S. Legislation Relevant to Case Management • CHAPTER 12: Ethical Responsibilities of the Case Management Professional • Patient Rights and Case Manager Responsibilities • Ethics and Medical Errors • Codes of Ethical Conduct • Objectivity and Common Sense • Look to Your Resources • CHAPTER 13: Evidence-Based Practice for Case Managers: Data-Driven Decision Making • What Exactly Is Evidence- Based Practice? • Evidence- Based Practice for Case Managers • The Evidence • Case Management-Specific Evidence-Based Resources • Applying Evidence-Based Case Management • CHAPTER 14: Case Manager Credentialing • Certified Case Manager (CCM) • The CCMExam • Before CCM, to the Wide Array of Credentials Now Available • Concerns and Questions PART V: REIMBURSEMENT • CHAPTER 15: Reimbursement Resources and Challenges • Insurance Providers and Administrators • Basic Insurance and Administrative Company Players • Administrative and Customized Services • Employers and Case Managers Respond to Costs • CHAPTER 16: Healthcare Reimbursement: Private or Employer Sector Funding • Workers’ Compensation and Rehabilitation Management • Auto Insurance • Health Benefit Insurance: Employer-Sponsored or • Private Indemnity Plans • Group Medical Plans: HMOs, PPOs, and POS Plans • Disability Insurance Plans: Short Term (STD) and Long Term (LID) • Consumer-Driven Healthcare Plans • Diagnosis-Specific Benefits • Traditional Insurance Versus Self-Funded Plans • Stop-Loss Insurance Plans • Via tical Settlements • Nontraditional Policies • Riders to Life Insurance Policies • Coordination of Benefits • CHAPTER 17: Healthcare Reimbursement: Public Sector • New Directions in Public Sector Case Management • Funding Sources for Public Sector Health Benefits • Economic Impact and Government Response • A Case Manager in the Public Sector • CMS Population Groups Challenge Managed Care Industry and Providers • Challenges for Case Managers • Complications that Remain • Nonmedical Challenges Influence Outcomes • Military (Active and Veteran) Case Management • Indian Health Services • CHAPTER 18: Working Effectively with Claims Departments: Case Manage in Consulting Roles • Claims Department Structure and Operations • Computerization • Claims Issues • Indicators for Case Management • The Case Manager as Consultant • Tracking Claims by Group • Tracking Claims by Individual Claims Histories • Moving into the Consultant Role PART VI: LEADERSHIP AND MANAGEMENT: MACROSYSTEMS • CHAPTER 19: Outcomes Management with Analysis of Financial and Quality Assurance Reporting • Financial and Quality Assurance Reporting • Dollars and Health Care • Negotiating Skills • Nuances Between Negotiating with Providers and Payers • Negotiating in a Managed Care Environment • Documenting Negotiated Arrangements • Cost-Benefit Analysis Reports • The Cost-Benefit Analysis Summaries • Quality Assurance Programs • Explaining Difficult Situations • Feedback from Patients • Sharing Questionnaire Results • Communicating Success • CHAPTER 20: Managing a Case Management Department: Your Role as Case • Management Administrator • Becoming an Independent Case Manager • For Your Business or Department • Developing a Business Plan • Pricing the Market • Looking at the Competition • Networking and the Professional Community • The Business Community • Generating New Business • Hiring Additional Staff • The Search for Case Managers CHAPTER 21: Predictive Modeling and Case Stratification • What Is Predictive Modeling? • Why Use Predictive Modeling? • Implications for Case Management Practice PART VII: FOCUS ON CURRENT CHALLENGES AND EMERGING TRENDS • CHAPTER 22: The Aging Population, Medical Advancements, and New Case • Management Considerations • Our Graying Population • New Challenges • New Opportunities • Care Management • Additional Resources • CHAPTER 23: Dying in America • A Personal Story • Death Is Not an Option • Examining Your Own Feelings • Addressing the Issue of Death • DNR Orders • Pain Management • Hospice Care • Palliative Care • CMSA’s 2002 “Dying in America” Survey • Cultural Diversity and End-of-Life Issues • CHAPTER 24: Medications: Polypharmacy and Adherence • Medication Use Among the Elderly • Problems Associated with Multiple Medication Use • In the News • Tips on Managing Polypharmacy • Medication Reconciliation • Medication Nonadherence: • The Opposite Problem • Adherence Fact • The 10 Most Prescribed Drugs • The 10 Drugs on Which We Are Spending the Most Money • Pharmaceutical Industry Update • When Drugs Become Deadly • Marketing Drugs Direct to Consumers • Staying Abreast of Pharmaceuticals • CHAPTER 25: Pain Management • Types of Pain • Assessment of Pain • The Pain Treatment Management Spectrum • Evidence- Based Practice Implications • Implications for Case Managers • Case Management Resources • CHAPTER 26: Our Nation’s Multiculturalism and Challenges to Case Managers • Changing Demographics • Acculturation and Assimilation • Implications and Opportunities for Case Managers • Language and Communication Barriers Are Problematic • The Differences Matter • Family Values • Communication Considerations • Where You Are from Does Matter • Guidance and Standards • Cultural Competency: Defining it, Achieving it • The Role of Culture in Health Care • Case Managers Make a Difference • Developing Cultural Competency • And a 12-Step Program • CHAPTER 27: Health Literacy and Adherence Issues • Increased Need for Health Literacy • Economic Impact of Health Literacy • Literacy and Health Literacy • Day-to-Day Considerations • Health Literacy Manifestations • The Case Manager’s Vital Role • CHAPTER 28: Obesity: The New Epidemic • Obesity: A Simple Definition, A Complex Problem • Metrics to Determine Obesity • Etiology • Treatment Overview • Going Forward • CHAPTER 29: Behavioral Health • Chronic Disease and Depression • Chronic Mental Illness • Partnering Successfully with Behavioral Health Professional • Behavioral Health Disease Management Programs • CHAPTER 30: Healthcare Technology and Trends: Implications for Case Managers • Text Messaging • Mobile Health • Medical Advances and High-Cost Services • Remote Patient Monitoring • Telemedicine • Clinical and Business Analytics • The Macro View • And for Case Managers • CHAPTER 31: The Affordable Care Act of 2010: Implications for Case Managers • Individual Mandate and Increased Coverage • Implications for Behavioral Health • Implications for Health Literacy • Implications for Patients with Disabilities • Implications for Case Management Practice Index