HCQM - Clinical Resource Management: Questions With
Solutions
Pareto principle Right Ans - 20% of the population owns 80% of the
wealth.
Principle of factor sparsity Right Ans - Much like the Pareto principle -
accounts for why rescue care - the 20% of patients with significant chronic
illness using care in hospital consumes more than 80% of our health care
resources.
Clinical Pathways Right Ans - structured multidisciplinary plans of care
designed to support the implementation of clinical guidelines and
protocols. Support clinical management, clinical and nonclinical resource
management, clinical audit and financial management. Provide guidance
for each stage in management with a specific condition over a given time
period and include progress and outcome details.
Disease Management Right Ans - A system of coordinated health care
interventions and communications for a population with conditions in
which patient self care efforts are significant. Attempts to reduce health
care costs and improve quality of life for individuals by preventing or
minimizing the effects of disease through knowledge, skills, enabling a
sense of control over life and integrative care.
Medicare Health Support Project Right Ans - Authorized by the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003
provided for a disease management study that did not show improved
outcomes or cost savings.
Demand Management Right Ans - Combines patient empowerment
through self care and health promotion information with professional
support through 24 hour hotlines and triage services.
Transitions of Care Right Ans - Aims to facilitate a match between an
individual's care needs and his or her care setting.
, 7 strategies to improve transition of care according to Eric Coleman
Right Ans - 1. Foster greater engagement of patient and caregivers 2.
Elevate status of patients and caregivers as essential members of the team
3. Implement performance measures 4. Define accountability during
transitions 5. Build professional competency in care coordination 6.
Explore tech solutions to improve cross setting communication 7. Align
financial incentives to promote cross setting collaboration
Provider Profiling Right Ans - The collection, collation and analysis of
data to develop provider specific profiles
Provider profiling assists in decreasing Right Ans - Variation which
improves quality. Reducing variation and cost has the most improvement.
5 Provider Profiling Uses Right Ans - 1. Network Management 2. Quality
control 3. Credentialing 4. Volume of Business/Value Based 5. Utilization
Available transaction data sources for provider profiling Right Ans - 1.
Claims 2. Pharmacy 3. Government Data
Problems with claims data Right Ans - 1. Moving away from FFS reduces
claims transactions 2. Validity 3. Reliability 4. Coding Errors
3 Available Data Sources Right Ans - 1. Administrative Data 2. Medical
Records 3. Patient Derived Data (surveys)
Annual Medicare payment is more than Right Ans - $440 billion
annually
Medicare must pay claims within Right Ans - 14-30 days
Medicare reviews fewer than this percent of claims Right Ans - 3%
Percent of expenditures lost to fraud Right Ans - 3-10%
Medicare's 2010 improper payment error rate was Right Ans - 10.5%
($34.3 billion)
Solutions
Pareto principle Right Ans - 20% of the population owns 80% of the
wealth.
Principle of factor sparsity Right Ans - Much like the Pareto principle -
accounts for why rescue care - the 20% of patients with significant chronic
illness using care in hospital consumes more than 80% of our health care
resources.
Clinical Pathways Right Ans - structured multidisciplinary plans of care
designed to support the implementation of clinical guidelines and
protocols. Support clinical management, clinical and nonclinical resource
management, clinical audit and financial management. Provide guidance
for each stage in management with a specific condition over a given time
period and include progress and outcome details.
Disease Management Right Ans - A system of coordinated health care
interventions and communications for a population with conditions in
which patient self care efforts are significant. Attempts to reduce health
care costs and improve quality of life for individuals by preventing or
minimizing the effects of disease through knowledge, skills, enabling a
sense of control over life and integrative care.
Medicare Health Support Project Right Ans - Authorized by the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003
provided for a disease management study that did not show improved
outcomes or cost savings.
Demand Management Right Ans - Combines patient empowerment
through self care and health promotion information with professional
support through 24 hour hotlines and triage services.
Transitions of Care Right Ans - Aims to facilitate a match between an
individual's care needs and his or her care setting.
, 7 strategies to improve transition of care according to Eric Coleman
Right Ans - 1. Foster greater engagement of patient and caregivers 2.
Elevate status of patients and caregivers as essential members of the team
3. Implement performance measures 4. Define accountability during
transitions 5. Build professional competency in care coordination 6.
Explore tech solutions to improve cross setting communication 7. Align
financial incentives to promote cross setting collaboration
Provider Profiling Right Ans - The collection, collation and analysis of
data to develop provider specific profiles
Provider profiling assists in decreasing Right Ans - Variation which
improves quality. Reducing variation and cost has the most improvement.
5 Provider Profiling Uses Right Ans - 1. Network Management 2. Quality
control 3. Credentialing 4. Volume of Business/Value Based 5. Utilization
Available transaction data sources for provider profiling Right Ans - 1.
Claims 2. Pharmacy 3. Government Data
Problems with claims data Right Ans - 1. Moving away from FFS reduces
claims transactions 2. Validity 3. Reliability 4. Coding Errors
3 Available Data Sources Right Ans - 1. Administrative Data 2. Medical
Records 3. Patient Derived Data (surveys)
Annual Medicare payment is more than Right Ans - $440 billion
annually
Medicare must pay claims within Right Ans - 14-30 days
Medicare reviews fewer than this percent of claims Right Ans - 3%
Percent of expenditures lost to fraud Right Ans - 3-10%
Medicare's 2010 improper payment error rate was Right Ans - 10.5%
($34.3 billion)
