CCMC Code of Ethics · HIPAA · Informed Consent · Advance Directives · HEDIS · Patient Safety · Quality Metrics
Ethics, legal compliance, and quality measurement anchor case management practice. The CCM exam tests application of ethical principles, privacy law, and outcomes measurement frameworks.
Establishes ethical standards for CCMs; includes duties to clients, employers, payers, and the profession; guides ethical decision-making.
CM serves both client (advocate) and employer/payer (cost containment); conflicts between roles require ethical navigation using established frameworks.
Autonomy, self-determination, informed consent, right to refuse treatment, privacy, access to information — CM protects and advocates for these rights.
Ongoing process of evaluating and enhancing care quality; CM contributes through outcomes measurement, process improvement, evidence-based practice.
Respect client's right to self-determination and informed decision-making; CM supports choices even when disagreeing; provide information to enable autonomous decisions.
Act in the client's best interest; pursue actions that promote wellbeing; core duty of CM to advocate for needed services.
"First, do no harm"; avoid actions that harm clients; consider unintended consequences of CM interventions and recommendations.
Fair and equitable treatment; equal access to resources; CM advocates for clients facing barriers due to race, income, language, disability, or other factors.
Honoring commitments, keeping promises, being truthful and reliable; clients must be able to trust their CM.
Truthfulness and honesty in all CM communications; do not deceive clients, payers, or providers; disclose conflicts of interest.
| Step | Action |
|---|---|
| 1. Identify | Recognize that an ethical issue exists |
| 2. Gather | Collect relevant facts, stakeholder perspectives |
| 3. Consider | Apply ethical principles; identify options |
| 4. Consult | Seek guidance from ethics committee, supervisor, or professional resources |
| 5. Decide | Choose the most ethically sound course of action |
| 6. Evaluate | Reflect on outcome; document decision-making process |
Employer wants CM to deny services to save costs, but client needs them clinically; CM must advocate for medically necessary care; use chain of command and ethics resources.
CM must disclose any financial or personal interests that could affect objectivity; recuse from cases where conflict exists.
Client has right to refuse even life-saving treatment if competent; CM provides information, documents refusal, ensures no coercion.
CM must report suspected child/elder abuse regardless of client's wishes; legal obligation supersedes confidentiality in these cases.
| HIPAA Component | Key Points |
|---|---|
| Protected Health Information (PHI) | Any individually identifiable health information (name, DOB, SSN, diagnosis, etc.) |
| Privacy Rule | Limits use/disclosure of PHI; patients have right to access records; minimum necessary standard |
| Security Rule | Safeguards for electronic PHI (ePHI); administrative, physical, and technical safeguards |
| Breach Notification | Covered entities must notify patients/HHS within 60 days of a breach |
| Permitted Disclosures | Treatment, Payment, Operations (TPO) — no authorization required; others need written consent |
| Minimum Necessary | Use/disclose only the minimum PHI needed for the purpose |
| Document | Purpose | Key Points |
|---|---|---|
| Living Will | Documents treatment preferences in writing | Specifies what interventions are/aren't wanted |
| Healthcare Proxy / DPAHC | Designates surrogate decision-maker | Activates when patient lacks decision-making capacity |
| POLST / MOLST | Physician order for life-sustaining treatment | Medical order; transfers across settings; more specific than living will |
| DNR / DNI | Do Not Resuscitate / Do Not Intubate | Physician order; must be documented at each setting |
| Five Wishes | Advance directive covering medical, personal, spiritual, emotional | Legally valid in most states; plain language format |
Disclosure of diagnosis and proposed treatment, risks and benefits, alternatives, likely outcomes if untreated; voluntary decision by competent patient.
Ability to understand, appreciate, reason about, and communicate a treatment decision; not the same as legal competence; can be diagnosis/task-specific.
When patient lacks capacity; surrogate applies "substituted judgment" (what would patient want?) not "best interest" (what does surrogate think is best?).
Emergency Medical Treatment and Labor Act; requires Medicare-participating hospitals to provide emergency screening and stabilization regardless of ability to pay; CM must know patient rights under EMTALA.
Mandatory reporting (child/elder abuse), public health reporting, court orders, research with IRB approval, law enforcement (limited), imminent threat to safety.
Special federal confidentiality protections for substance use disorder treatment records; STRICTER than HIPAA; requires separate specific authorization for disclosure.
CM must comply with state laws governing their professional license (nursing, social work, etc.); state laws may be stricter than HIPAA.
Healthcare Effectiveness Data and Information Set — NCQA's set of performance measures used by health plans; measures preventive care, chronic disease management, patient experience; CM impacts HEDIS scores through care gaps closure.
National Committee for Quality Assurance — accredits health plans and CM programs; HEDIS data; CCM credential recognized by NCQA.
Utilization Review Accreditation Commission — accredits UM and CM programs; health plan and specialty pharmacy accreditation; CM organizations seek URAC accreditation.
Accredits hospitals and healthcare organizations; sets standards for patient safety, care quality; sentinel event reporting.
1–5 star ratings for Medicare Advantage plans and Part D; based on quality and patient experience; financial incentives tied to rating.
| Concept | Definition | CM Application |
|---|---|---|
| Sentinel Event | Unexpected event causing death or serious harm; requires root cause analysis | CM participates in RCA process |
| Root Cause Analysis (RCA) | Systematic process to identify underlying causes of adverse events | Focuses on systems, not individuals |
| Near Miss | Event that could have caused harm but didn't | Report and analyze to prevent future events |
| Adverse Event | Unintended injury from medical care, not underlying disease | Medication errors, falls, HAIs |
| FMEA | Failure Mode and Effects Analysis — proactive risk assessment | Identify potential failures before they occur |
| QAPI | Quality Assessment and Performance Improvement (required in LTC/home health) | Systematic data-driven quality improvement |
| Goal | Focus Area |
|---|---|
| Identify patients correctly | Two patient identifiers; correct test results to correct patient |
| Improve staff communication | Read-back for verbal orders; critical test result reporting |
| Use medicines safely | Medication reconciliation; anticoagulation safety; look-alike/sound-alike drugs |
| Use alarms safely | Clinical alarm management; prevent alarm fatigue |
| Prevent infection | Central line, surgical site, MRSA, CDiff protocols |
| Identify patient safety risks | Suicide risk screening in applicable settings |
| Prevent mistakes in surgery | Universal Protocol: time-out, site marking |
Plan-Do-Study-Act — iterative QI model; Plan=identify problem and test, Do=implement small scale, Study=analyze results, Act=adopt/adapt/abandon; most common in healthcare QI.
Define, Measure, Analyze, Improve, Control — data-driven process improvement; reduces defects to <3.4 per million opportunities.
Eliminate waste (non-value-added steps); improve flow; originated in manufacturing; applied in healthcare to streamline processes.
Simultaneously improve population health, improve patient experience, reduce per capita cost — foundational framework for healthcare transformation.
Adds workforce wellbeing/provider satisfaction to Triple Aim; recognizes burnout as barrier to quality.
Did we do what we were supposed to do? (e.g., % patients receiving discharge education); measures adherence to evidence-based protocols.
Did the patient get better? (e.g., readmission rate, A1C reduction, functional improvement); ultimate measure of CM effectiveness.
Patient's own assessment of their health status, function, quality of life; CAHPS (patient satisfaction); increasingly important in value-based care.
CM demonstrates value by reducing hospitalizations, ED visits, readmissions; ROI calculated by comparing CM program costs to downstream savings.
Answer all 10 questions then check your score. Each question has one best answer.
1. A case manager's employer instructs the CM to deny continued services to a client who clinically requires them, citing cost concerns. The MOST appropriate ethical response is to:
2. Under HIPAA, which of the following disclosures does NOT require the patient's written authorization?
3. A competent adult patient with terminal cancer refuses a blood transfusion that the medical team believes is necessary. The case manager should:
4. Which of the following BEST describes the difference between a Living Will and a Healthcare Proxy (DPAHC)?
5. 42 CFR Part 2 provides enhanced confidentiality protections for records related to:
6. HEDIS measures are primarily used to:
7. A hospital conducts a Root Cause Analysis (RCA) after a patient fall resulting in a hip fracture. The PRIMARY purpose of the RCA is to:
8. The PDSA cycle in quality improvement stands for:
9. The ethical principle that requires a case manager to act in the client's best interest is:
10. The "Quadruple Aim" adds which dimension to the IHI's original Triple Aim framework?
Memory hooks make high-yield CCM concepts stick. Study the mnemonic, then connect it to the underlying content.
Click any card to flip it. Use the controls to navigate or shuffle.
Six ethical principles in case management
Autonomy, Beneficence, Non-maleficence, Justice, Fidelity, Veracity. Mnemonic: "A Beautiful Nurse Judges Fairly and Verifies"
HIPAA: what does TPO stand for and why does it matter?
Treatment, Payment, Operations — these three purposes allow PHI use/disclosure without written patient authorization. All other disclosures require consent.
Living Will vs Healthcare Proxy (DPAHC)
Living Will: written document specifying treatment preferences (WHAT). Healthcare Proxy: designates a surrogate decision-maker (WHO decides when patient lacks capacity).
What is HEDIS and who uses it?
Healthcare Effectiveness Data and Information Set — NCQA's performance measures for health plans. Measures preventive care, chronic disease management. CM impacts HEDIS by closing care gaps.
PDSA cycle steps
Plan (identify problem, design test) → Do (implement small scale) → Study (analyze results) → Act (adopt/adapt/abandon). Iterative QI cycle.
What is a sentinel event?
Unexpected event resulting in death or serious physical/psychological harm. Requires Root Cause Analysis (RCA) to identify system failures — focus on process, not individual blame.
42 CFR Part 2 — what does it protect?
Federal confidentiality law for substance use disorder (SUD) treatment records. STRICTER than HIPAA — requires specific written authorization for any disclosure, even to other treating providers.
Triple Aim vs Quadruple Aim
Triple Aim (IHI): improve population health + enhance patient experience + reduce per capita cost. Quadruple Aim adds: improve healthcare workforce wellbeing/reduce burnout.
Start with the 6 ethical principles (mnemonic: A Beautiful Nurse Judges Fairly and Verifies). Then master the difference between Living Will (WHAT) and Healthcare Proxy (WHO).
Study HIPAA TPO rule and exceptions, 42 CFR Part 2 for SUD records, and the PDSA quality improvement cycle. Know when mandatory reporting overrides confidentiality.
Focus on HEDIS, NCQA, URAC accreditation roles, National Patient Safety Goals, sentinel events vs near misses, Triple vs Quadruple Aim, and ethical dual-role conflict scenarios.
High-yield: Autonomy=patient self-determination, Beneficence=act in client's best interest, HIPAA TPO=no auth needed, Living Will=WHAT/Proxy=WHO, PDSA=QI cycle, 42 CFR Part 2=SUD stricter.
6 ethics: A/B/N/J/F/V; HIPAA TPO=no consent; Living Will=WHAT, Proxy=WHO; PDSA=Plan→Do→Study→Act; Quadruple Aim=Triple+Workforce; 42 CFR Part 2=SUD extra protection; RCA=system focus.
