SOPWhitePaperandCrosswalk_final

The leading membership association providing professional collaboration across the health care continuum.
Case Management Society of America
6301 Ranch Drive | Little Rock, AR 72223
T 501.225.2229 F 501.227.5444 E cmsa@cmsa.org
www.cmsa.org
The Standards of Practice for Case Management ©, a Foundation
for Care Coordination across the Entire Care Continuum.
Mary McLaughlin Davis, DNP, MSN, APRN, ACNS-BC, CCM and Lori J. Schmitt RN, MBA
The root cause of many patient safety problems, high-cost medical care and unnecessary
readmissions can be traced to transitions of care, or the lack of meticulous planning in that area. Care
coordination is the linchpin that improves quality of care for patients. For case managers, safe and
secure care coordination has been a priority for over 20 years, and many have dedicated their
professional lives to improving care transitions. Organizations such as the National Transitions of
Care Coalition (NTOCC) are working to provide a platform for care coordinators with tools that are
easy to use and that make a difference in patient’s lives.
Determining how case managers can better perform care coordination is a topic which, up until
recently, has received little attention; however, it has gained national interest during this critical time
of healthcare reform. The National Quality Strategy Agenda spotlights care coordination as one of the
six priorities they wish to address, along with: safer care, patient engagement, effective prevention
and treatment, best practices in healthy living and the development of new healthcare delivery
models. Because of this laser focus, considerable time is devoted to determining how care
coordination will be defined and measured (Lamb, 2013). Care coordination is defined by The
National Quality Forum (NQF) as “a function that helps ensure that the patient’s need and
preferences for health services and information sharing across people, functions, and sites are met
over time” (NQF, 2006). The Agency for Healthcare Research and Quality (AHRQ) offers the
following description as a function of care coordination and states it is an essential component of a
medical home and/or Accountable Care Organization (ACO):
“Care is coordinated or integrated across all elements of the complex
healthcare system (e.g., subspecialty care, hospitals, home health
agencies, nursing homes) and the patient’s community (e.g., family,
public and private community-based services). Care is facilitated by
registries, information technology, health information exchange and
other means to assure that patients get the indicated care when and
where they need and want it, in a culturally and linguistically
appropriate manner” (McDonald et al., 2008).
Due to rapid changes and regulatory mandates, many healthcare organizations are developing an
integrated care coordination process throughout their institutions and levels of care delivery. Although
case managers have had a presence in hospitals since the early 1990s, they have been housed
literally and figuratively in the basement, and have been known primarily for their utilization review
expertise. Many experienced hospital nurses and social workers have assumed care coordination
roles and have been largely unrecognized. Insurance companies and workers’ compensation carriers
have provided care coordination services to patients, as well as clients often working in silos due to
the lack of collaboration between providers and payers. Professional certifying organizations as well

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Case Management Society of America | 6301 Ranch Drive | Little Rock, AR 72223 T 501.225.2229 F 501.227.5444 E cmsa@cmsa.org
as universities offering nursing and social work degrees did not previously deem care coordination as
a graduate level of expertise.
In today’s healthcare environment, case managers need both the tools to do their job as well as
national professional association standards in order to stay compliant with standards and improve
patient outcomes. The first course in the Case Management Society of America’s Career and
Knowledge Pathways educational program, CMSA Standards of Practice: The Foundation for
Professional Excellence in Coordination of Care Across the Continuum, addresses regulatory
compliance, helps to improve patient outcomes and establishes uniformity in the workplace. Since the
program is based on CMSA’s Standards of Practice for Case Management, proficiency in these
measures ultimately leads to decreased readmissions and better financial outcomes.
The current state of healthcare reveals that care coordinators are highly desirable and critical to
remedying medication errors and preventing unnecessary readmissions. The patient experience
survey by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
offers two domains for discharge and care
transitions that are directly related to the quality of
care coordination services provided.
Many physician practices and outpatient centers
do not formally provide care coordination, nor do
they have designated and licensed professionals
providing the service. The fee-for-service payment
system is a major detriment to care coordination
services in traditional practice settings. However,
with reimbursement for care coordination services
closer to becoming a reality, it is imperative to
establish accepted qualifications for care
coordinators (Hong, Abrams, Ferris, 2014; Marion,
2010).
In the past, nursing homes provided skilled and
long-term care by enlisting their social worker to
make arrangements for home care as well as the
necessary equipment for their patients’ discharge.
However, care coordination was not practiced
beyond making referrals to home care and durable
medical equipment companies. Nursing homes
infrequently made follow up phone calls or home
visits.
Care coordination is clearly outlined in integrated delivery networks where value-based healthcare is
the predominant paradigm. CMSA’s Standards of Practice for Case Management are reflective and
consistent with the integrated health networks’ overall mission and vision. CMSA’s Standards
includes language that emphasizes care coordinators’ role in care delivery of an integrated health
network. As an organization, CMSA is positioned to understand and interpret standards relating to
care transitions across the continuum.
CMSA membership extends across all
healthcare settings, including payer,
provider, government, employer,
community, and home. It is the largest
and most influential group of Case
managers in the country. - Cheri
Lattimer, RN, BSN, Executive Director,
Case Management Society of
America

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Unfortunately, readmissions are at the heart of value-based healthcare. Medication errors are a
predominant reason for unnecessary readmissions; clinically-significant medication errors affected
50.8 percent of patients during the first 30 days after hospital discharge. Patients discharged without
adequate medication dosing or an accurate understanding of how to take their prescribed
medications are at risk for avoidable hospital readmissions (Kripalani et al, 2012). The high
prevalence of medical errors associated with transitions of care from hospital to home is associated
with an increased risk of re-hospitalization (Moore, Wisnivesky, Williams, McGinn, 2003; Report to the
Congress, 2007).
The proposed 2012 Medicare Transitional Care Act mandates that each discharged hospital patient
must receive a comprehensive medication management plan. This plan includes assessment and
consultation with medical providers to ensure that medications are necessary and appropriate, as well
as free of discrepancies with potential allergies, co-morbidities and other prescribed medications. The
legislation includes required individual and family counseling about medications (Blumenauer, Petri, &
Scttakowsky, 2012).
In 2013, The Centers for Medicare and Medicaid Services (CMS) provided new outpatient coding
allowing the physician, advanced practice nurse or physician assistant to bill patients transitioning
from the hospital or nursing facility to home for transitional care management services. With the
advent of the increased scrutiny that care managers and coordinators face, the need to provide an
evidence-based foundation for care coordination practice is increasingly essential.
ACOs, hospitals, and insurance companies have a responsibility to provide a comprehensive
orientation and onboarding experience, as well as continuing education on every aspect of the case
manager’s or care coordinator’s job. This is especially true with their increased responsibility and
accountability for specific patient outcomes. Organizations that provide this all-inclusive commitment
to their staff demonstrate the value they place on their patients, employees, and practice (Gesme,
Towle, Wiseman, 2010). Standards of practice are authoritative statements that reflect the
commitment of the professional community to their patients, clients, organizations and constituents.
The document Nursing: Scope and Standards of Practice describes the level of care or performance
common to the profession of nursing by which the quality of nursing practice can be judged. CMSA’s
Standards of Practice for Case Management includes topics that influence the practice of case
management in the current healthcare environment. The Standards focus on transitions of care, and
facilitates complete transfers to the next care setting provider that are effective, safe, timely, and
complete (Hill, 2014; Marion, 2010). Standards of practice are required by all professionals and are
developed to assist the decisions of patients, clients, and practitioners about appropriate healthcare
for specific clinical circumstances (Graham, Harrison, 2005).
CMSA, established in 1990 with nearly 10,000 members today, is the recognized leader and trusted
professional association that exists to close gaps in healthcare performance by translating the best
science and knowledge into effective continuing professional development. CMSA’s educational
resources create uniformity and consistency in standards of practice for all case managers;
additionally, they allow case managers to obtain significant work-applicable continuing education to
address their scope of practice as defined by their job descriptions, standards of practice and legal
requirements. CMSA recognizes and works in tandem with the regulatory bodies that accredit all
levels of healthcare providers. The CMSA Standards compliment and support the principles of two

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important credentialing entities: the Centers for Medicare and Medicaid Services (CMS) and the Joint
Commission (CMS, 2013; Joint Commission, 2014). This alignment is demonstrated in the CKP
Crosswalk document, linking the CMSA Standards with the CMS and Joint Commission standards
and criteria for care coordination. The Standards of Practice for Case Management further detail the
role of the care coordinator and outline the specific practice standards that the legislators, regulator,
legal counsel, and the judiciary system can reference. CMSA’s Standards of Practice for Case
Management are also referenced by URAC in its interpretation of the standards.
CMSA’s Career and Knowledge Pathways® (CKP) educational program has the potential to break
new ground in care coordination, healthcare education and training. CMSA is the source of evidence-
based content for care coordination professionals, healthcare workers, students, caregivers, and
patients. Through CMSA’s careful planning and implementation, CKP uses contextual learning,
spurring learners to leverage their existing knowledge and advance opportunities for personal and
professional development. CKP incorporates learner reflection to consciously translate newly-
acquired information into long-term, integrated knowledge. Contextual learning is reality-based,
outside the classroom and offered within a defined context (McHugh, Lake, 2010; Baker, Hope,
Karandjeff, 2009).
The Standards of Practice for Case Management align with the regulatory compliance mandates
impacting the entire healthcare continuum. The interpretation and understanding of these standards
is paramount to obtaining successful outcomes in the care delivery of patients. Case managers new
to the profession benefit from learning the case management Standards through the interactive CKP
program. Experienced case managers benefit from CKP through a review of the CMSA Standards of
Practice in relationship to the standards of the credentialing bodies. CMSA’s Standards of Practice
are brought to life in the CKP program, and case managers as well as care coordinators that
purchase the course will become prepared to articulate to patients, clients, families, payers, and
credentialing organizations how the Standards define, drive, and enhance the practice of care
coordination.
To learn more about CMSA’s Standards of Practice for Case Management, visit www.cmsa.org/sop.
To watch a demo and receive more information about CMSA’s Career and Knowledge Pathways
educational program, visit www.cmsa.org/ckp.

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References
American Nursing Association, Professional Standards- information retrieved from website, September 19, 2014,
http://www.nursingworld.org/nursingstandards
Baker, E., Hope, L. & Karandjeff, K. (October, 12, 2014). Contextualized teaching and learning: A faculty
primer, RP group center for student success. http://www.cccbsi.org/Websites/basicskills/Images/CTL.pdf
Case Management Society of America, Standards of Practice for Case Management, Revised 2010 ©
CMS. (May 17, 2013). Revised appendix A, interpretive guidelines for hospitals, conditions of participation:
Discharge planning.http://www.cms.gov/medicare/provider-enrollment-and-
certification/surveycertificationgeninfo/downloads/survey-and-cert-letter-13-32.pdf
Gesme, D., Towle, E., & Wiseman, M. (2010). Essentials of staff development, and why you should care.
Journal of Oncology Practice, 6(2), 104-106.
Graham, I., & Harrison, M. (2005). Evaluation and adaption of clinical practice guidelines. Evidenced Based
Nursing, (8), October 12, 2014-68-72.
Hill, K. (2014). AACN scope and standards for acute care clinical nurse specialist practice. Aliso Viego,
California: American Association of Critical-Care Nurses.
Hong, C., Abrams, M., & Ferris, T. (2014). Toward increased adoption of complex care management. The New
England Journal of Medicine, 371(6), 491-492.
Kripalani, S., Roumie, C. L., Dalal, A. K., Cawthon, C., Businger, A., Eden, S. K., et al. (2012). Effect of a
pharmacist intervention on clinically important medication errors after hospital discharge: A randomized
trial. Annals of Internal Medicine, 157(1), 1-10.

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Lamb, G. (2013). Care coordination, quality, and nursing. In G. Lamb (Ed.), Care coordination: The game
changer how nursing is revolutionizing quality care (First ed., pp. 1-3, 8). Silver Springs, Maryland:
Nursebooks.org.
Marion, C. (Revised 2010). Standards of practice for case management (third Ed.). Little Rock, Arkansas:
Case Management Society of America.
McDonald, K., Schultz, E., Albin, I., Pineda, N., Lonhard, J., & Sundaram, C. (2010). Care coordination atlas
version 3. Rockville, MD: Prepared by Stanford University.
McHugh, M., & Lake, E. (2010). McHugh, M. D. and lake, E. T. [Understanding clinical expertise: Nurse
Education, experience, and the hospital context] Res. Nurse. Health, (33), October, 12, 2014-276-287.
McMahon, D., Certified Legal Nurse Consultant, retrieved from website, September 2014- Nursing Standards
of Practice, http://www.hgexperts.com/article.asp?id=6237
National Quality Forum. (2006). NQF-endorsed definition and framework for measuring and reporting care
coordination. Washington, DC:
The Joint Commission. (2014). The 2015 Hospital Accreditation Standards. Oak Brook, Illinois:
URAC, Standards interpretation as it relates to Case Management. Retrieved from website, October, 3, 2014.
https://www.urac.org/resource-center/standards-interpretations/

CMSA Standard of Practice for Case Management Crosswalk
CMS Conditions of Participation-Interpretive Guidelines / 2013 TJC Standards-Elements of Performance
CMSA definition of case management: Case management is a collaborative process of assessment, planning, facilitation, care coordination,
evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and
available resources to promote quality cost effective outcomes (CMSA, 2009).
CMSA CMS Joint Commission: Provision of Care,
Treatment, and Services
Standard A Client Selection Process for CM: The CM
should identify and select clients who can
benefit from CM services available in a
particular practice setting.
A-0800 §482.43(c) Identification of patients
in need of d/c planning
PC. .01.01.01: Assessing patients’ needs for d/c
and compliance with standard.
How Demonstrated Documentation of consistent use of
selection process within organizations
policies and procedures.
Evaluate hospital’s policy and procedure for
D/C planning
Accepting the patient for care and treatment.
Standard B. The CM should complete a health and
psychosocial assessment, taking into
account the cultural and linguistic needs of
each client.
A-0806 §482.43 D/C evaluation: The D/C
planning evaluation must include D/C
evaluation to patients identified in screening,
patient’s request, family request, and
physician request.
PC.01.02.01 Assessing and reassessing the
patient
How Demonstrated Documentation of client assessments using
standardized tools, when appropriate.
The hospital must include the D/C planning
evaluation in the patient’s medical record for
use in establishing an appropriate D/C plan.
Documentation of patient’s need for care,
treatment and service
Standard C. Problem/Opportunity Identification
The CM should identify problems or
opportunities that would benefit from CM
intervention.
A-0806 §482.43(b) D/C Planning evaluation:
Evaluate Patient’s care needs immediately
on admission. Assess if they remain
constant or decrease over time. Are they
permanent or temporary? Is equipment or
home modification necessary? Is the family
willing and able to be trained to assume
care? Can post-acute facility provide needed
services? Cost and out of pocket expenses
discussed with patient and family.
PC.01.02.01, PC.01.02.09: The hospital
provides assessment and screening for all
patients. The hospital assesses the patient who
may be a victim of abuse and neglect.
The hospital identifies any needs the patient
may have for psycho-social or physical care,
treatment, and services after D/C or transfer.
How Demonstrated Documentation of agreement among the
client, family, and other providers regarding
the problems/opportunities identified.
Documented identification of opportunities
for intervention.
In every unit with inpatient beds there is
evidence of D/C planning and evaluation
activities.
Patients who receive treatment for emotional
and behavioral disorders receive an
assessment that includes a history of mental,
emotional, behavioral, and substance use.
Standard D. Planning: The CM should identify short
and long term needs, as well as develop
appropriate CM strategies and goals to
address those needs.
A-0807 §482.43(b)(2) A RN, SW, or other
qualified personnel must develop, or
supervise development of the evaluation.
Planning Care: PC.01.01.03, PC.01.03.05;
The provider delivers interventions based on
the plan of care, including the education, or

instruction of patients regarding their care,
treatment, or services.
How Demonstrated Documentation of information using
interviews and research to develop a plan
of care.
Recognition of client’s diagnosis,
prognosis, and care needs role in decision
making, and outcome goals for plan of
care. Validation plan of care is consistent
with evidence based practice.
Establishment of measurable goals,
documentation of client’s support system.
Evidence of supplying the client with
information and resources necessary to
make informed decisions, awareness of
maximization of client outcomes by all
resources and services. Compliance with
payer expectations with respect to how
often to contact and reevaluate the client.
Review a sample of cases to determine if
D/C planning evaluation was developed by a
RN, SW, or other qualified personnel.
Documentation of providing education,
treatment, and services to the patient.
Standard E. Monitoring: The CM should employ
ongoing assessment and documentation to
measure the client’s response to the plan
of care.
A-0806 §48243(b) D/C Planning Evaluation:
The hospital must provide a D/C planning
evaluation to the patients on their request or
those requesting on behalf of patients.
PC.04.01.03 The hospital D/C or transfers the
patient based on his or her assessed needs and
the organization’s ability to meet those needs.
How Demonstrated Documentation of ongoing collaboration
with the client, family or caregiver,
providers, and other pertinent stakeholders,
so that the client’s response to
interventions is reviewed and incorporated
into the plan of care.
On every unit there is evidence of D/C
planning activities.
Documentation demonstrating the patient’s
family licensed independent practitioners,
physicians, clinical psychologists, and staff
involved in the patient’s care, treatment, and
services participate in planning the patient’s
D/C or transfer.
Standard F. Outcomes: The CM should maximize the
client’s health, wellness, safety, adaptation
and self-care through quality case
management, client satisfaction, and cost-
efficiency.
A-0818 §482.43(c) D/C Plan (1)- A RN, SW,
or other appropriately qualified personnel
must develop, or supervise the development
of a d/c plan if the discharge planning
evaluation indicates the need for a d/c plan.
PC.02.01.05: The hospital provides
interdisciplinary, collaborative care, treatment,
and services
How Demonstrated Demonstration of the efficacy, quality, and
cost-effectiveness of the CM’s interventions
in achieving the goals documented in the
plan of care
A sample of cases determine the d/c plan
was developed by an RN, SW, or other
qualified personnel,
Care, treatment, and services are provided to
the patient in an interdisciplinary, collaborative
manner.
Standard G. Termination of CM services: The CM
should appropriately terminate cm services
based upon case closure guideline.
A-0806 §482.43(b): D/C Planning Evaluation
The hospital must provide a d/c evaluation
to the patients , the request of a person
acting on the patient’s behalf, or the request
of the physician
PC.04.01.01: the hospital has a process that
addresses the patient’s need for continuing
care, treatment, and services after d/c or
transfer.

§483.3(e) Reassessment of d/c planning
process on an ongoing basis. This must
include a review of d/c plans to ensure that
they are responsive to d/c needs.
How Demonstrated Achievement of targeted outcomes or
maximum benefit reached
Change of health setting
Client refuses further medical/psycho-
social services
Death of client
In every unit, is there evidence of d/c
planning evaluation activities?
The hospital describes the reasons for and
conditions under which the patient is d/c or
transferred.
The hospital describes the method for shifting
responsibility for a patient’s care from one
clinician, hospital, program, or service to
another.
Standard H. Facilitation, coordination, and
Collaboration The CM should facilitate
coordination, communication, and
collaboration with the client and other
stakeholders in order to achieve goals and
maximize positive client outcomes
A-0823 §482.43(c)(6)-comprehensive rule
requiring list of SNF and HHAs provided to
patients
§482.43(c)(7) Inform patients of their right to
choose the facility or service post-
hospitalization
PC.02.02.01 Coordination of Care is a major
challenge in the safe delivery of care. The rise
of chronic illness means that a patient’s care,
treatment, and services likely include an array
of providers in a variety of health care settings,
including the patient’s home.
How Demonstrated Evidence of transitions of care, including:
A transfer to the most appropriate health
care provider/setting
The transfer is appropriate, timely and
complete
Documentation of collaboration and
communication with other health care
professionals, especially during each
transition to another level of care within or
outside of the client’s current setting
Evidence of collaborative efforts to optimize
client outcomes: working with community,
local and state resources, PCP, other
members of the health care team, the
payer and other relevant health care
stakeholders.
Assessment if patient’s post-d/c care needs
are being met in the environment from which
he or she entered the hospital. What are the
patient’s needs immediately after d/c? What
needs will lessen or worsen over time?
Assessment of the patient’s insurance
coverage and how it may or may not provide
for necessary services post-hospitalization.
Assessment if patient can perform ADL prior
to d/c.
The hospital has a process to receive or share
patient information when the patient is referred
to other internal or external providers of care,
treatment, and services
The process for hand-off communication
provides for the opportunity for discussion
between the giver and receiver of patient
information
The hospital coordinates the patient’s care,
treatment, and service for internal and external
resources
The PCP and the interdisciplinary team
incorporate the patient’s health literacy needs
into the patient education.
Standard 1.Qualifications for CM
CM should maintain competence in their
area of practice by having:
Current, active, and unrestricted licensure
or certification in a health or human
services discipline that allows the
professional to conduct an assessment
independently as permitted within the
scope of practice of the discipline
A-0818 §482.43(c)Discharge Plan
A RN, SW, or other appropriately qualified
personnel must develop, or supervise the
development of, a d/c plan
A-0807 §482.43(b)(2)-A RN, SW, or other
appropriately qualified personnel must
develop, or supervise the development of
the evaluation
PC.02.01.05: The hospital provides
interdisciplinary, collaborative care, treatment,
and services

Baccalaureate or graduate degree in SW,
nursing, or another health or human
services field that promotes physical,
psychosocial, and or vocational well-being
of the person being served. The degree
must be from an institution that is fully
accredited by a nationally recognized
educational accreditation organization and
the individual must have completed a
supervised field experience in CM, health,
or behavioral health as part of the degree
program
How Demonstrated Compliance with national and or local laws
and regulations that apply to the
jurisdictions and disciplines in which the
CM practices
Maintenance of competence through
relevant and ongoing continuing education,
study, and consultation
Practicing within the CM’s areas of
expertise, making timely and appropriate
referrals to and seeking consultation with,
others when needed
Determine which individual are responsible
for developing or supervising the
development of d/c plans. These should be
an RN, SW, or other qualified personnel,
supervised by them
manner
Standard J. Legal The CM should adhere to
applicable local, state, and federal laws, as
well as employer policies, governing all
aspects of CM practice, including client
privacy and confidentiality rights. It is the
responsibility of the CM to work within the
scope of his/her licensure
A-0811 §482.43(c)Standard: D/C Plan (1)- A
RN, SW, or other appropriately qualified
personnel must develop, or supervise the
development of, a d/c plan if the d/c
planning evaluation indicates a need for a
d/c plan.
PC.04.01.03: the hospital d/c or transfers the
patient based on his or her assessed needs and
the organization’s ability to meet those needs.
The patient, the patient’s family, licensed
independent practitioners, physicians, clinical
psychologists, and staff involved in the patient’s
care, treatment, and services participate in
planning the patient’s d/c or transfer. Note 1:
The definition of ‘physician” is the same as that
used by CMS.
How Demonstrated Compliance with national and or local laws
and regulations that apply to the
jurisdictions and disciplines in which the cm
practices
Maintenance of competence through
relevant and ongoing continuing education,
study, and consultation
Practicing within the cm’s areas of
expertise, making timely and appropriate
Determine which individual are responsible
for developing or supervising the
development of d/c plans. These should be
an RN, SW, or other qualified personnel,
supervised by them
manner

referrals to and seeking consultation with,
others when needed
Standard J. 1. Confidentiality and Client Privacy
The CM should adhere to applicable local,
state, and federal laws, as well as
employer policies, governing the client,
client privacy, and confidentiality rights and
act in a manner consistent with the client’s
best interest.
Privacy Act, 20 U.S.C. §1232g.
Protected Health Information. The Privacy
Rule protects all "individually
identifiable health information" held or
transmitted by a covered entity or its
business associate, in any form or media,
whether electronic, paper, or oral. The
Privacy Rule
calls this information "protected health
information (PHI).
(RI.01.01.01, EPs 4, 5, and 7), and privacy of
health information (IM.02.01.01, EPs 1 and 2)
Taking steps to ensure that patient rights are
respected, including communication, dignity,
personal privacy
How demonstrated Up-to-date knowledge of, and adherence
to, applicable laws and regulations
concerning confidentiality, privacy and
protection of client medical information
issues.
Evidence of good faith effort to obtain the
client’s written acknowledgement that
he/she has received notice of privacy rights
and practices.
Scrupulous protection of PHI during the
referral process to Nursing facilities, Home
health care agencies, and all outside
referrals
Secure permission from the patient or his or
her representative to make these referrals.
Scrupulous protection of PHI during the referral
process to Nursing facilities, Home health care
agencies, and all outside referrals
Secure permission from the patient or his or her
representative to make these referrals.
Standard J. 2 Consent for CM services The CM
should obtain appropriate and informed
client consent before CM services are
implemented
A-0130
§482.13(b)(1) The patient has the right to
participate in the development and
implementation of his or her plan of care.
482.11) The patient’s rights should be
provided and explained in a language or
manner that the patient (or the patient’s
representative) can understand.
In addition, according to the regulation at 42
CFR 489.27(b),(which cross references the
regulation at 42 CFR 405.1205), each
Medicare beneficiary who is an inpatient
must be provided a standardized notice, “An
Important Message from Medicare” (IM),
within two days of admission. Medicare
beneficiaries who have not been admitted
(e.g., patients in observation status or
receiving other care on an outpatient basis)
are not required to receive the IM. The IM is
a standardized, OMB-approved form and
cannot be altered from its original format.
The IM is to be signed and dated by the
RI 010101 The hospital protects, promotes, and
respects patient rights
RI.01.02.01
The hospital respects the patient's right to
participate in decisions about his or her care,
treatment, and services.

patient to acknowledge receipt. See Exhibit
16 for a copy of the IM. Furthermore, 42
CFR 405.1205(b)(3) requires that hospitals
present a copy of the IM in advance of the
patient’s discharge, but not more than two
calendar days before the patient’s
discharge. In the case of short inpatient
stays, however, where initial delivery of the
IM is within two calendar days of the
discharge, the second delivery of the IM is
not required.
The hospital must establish and implement
policies and procedures that effectively
ensure that patients and/or their
representatives have the information
necessary to exercise their rights
How Demonstrated Evidence client and family were completely
informed of: Proposed CM process and
services relating to the client’s health
conditions and needs
Possible benefits and costs of services
Alternatives to proposed services
Potential risks and consequences of the
services and alternatives
Client’s right to refuse the proposed CM
services and potential risks to refusal
Evidence the information was
communicated in a client-sensitive manner
allowing the client to make choices
This regulation requires the hospital to
actively include the patient in the
development, implementation and revision
of his/her plan of care. It requires the
hospital to plan the patient's care, with
patient participation, to meet the patient's
psychological and medical needs.
The patient’s (or patient’s representatives,
as allowed by State law) right to participate
in the development and implementation of
his or her plan of care includes at a
minimum, the right to: participate in the
development and implementation of his/her
inpatient treatment/care plan, outpatient
treatment/care plan, participate in the
discharge plan, and participate in the
pain management plan.
Standard K. Ethics CM should behave and practice
ethically, adhering to the tenets of the code
of ethics that underlies his/her professional
credential (e.g. nursing, SW, rehab
counseling, etc.).
How Demonstrated Awareness of the five basic ethical
principles and how they are applied:
Beneficence, non-malfeasance, autonomy ,
justice, and fidelity

Recognition that a CM’s primary obligation
is to his/her clients
Maintenance of respectful relationships
with coworkers, employers, and other
professionals.
Recognition that laws, rules, policies,
insurance benefits, and regulations are
sometimes in conflict with ethical principles.
CM is bound to address such conflict and
seek appropriate consultation.
Standard L. Advocacy: The CM should advocate for
the client at the service-delivery, benefits-
administration, and policy-making levels.
How Demonstrated Documentation demonstrating: Promotion
of client’s self-determination
Education of health care and service
providers in recognizing and respecting the
needs, strengths, and goals of the client.
Facilitation access to services and
education about available resources
Elimination of disparities due to race,
religion, and all other possible
discrimination.
Advocacy for expansion or establishment
of services and for client-centered changed
in organizational governmental policy.
Documentation indicates CM weighed
decisions with the intent to uphold client
advocacy vs. cost containment whenever
possible.
Standard M. Cultural Competency: The CM should
be aware of and responsive to cultural and
demographic diversity of the population
and specific client profiles.
ICN 908063 October 2013
Your ability to communicate effectively with
your patients will be more important as you
help them understand and take action on
health information. Effectively
communicating during the encounter may
result in Reduced patient anxiety during the
encounter; Increased adherence to
treatment protocols; More reports of patient
satisfaction about encounters;
Fewer medical malpractice lawsuits; and
better patient health outcomes, such as
EP 28 to Standard RC.02.01.01 The intent of
this EP is to collect data in order to identify
health care disparities, and hospitals have the
flexibility to determine which categories of race
and ethnicity are appropriate to their patient
population.

increased quality of care and safety and
reduced medical errors.
How demonstrated CM understands relevant cultural
information and communicates within the
client’s cultural contest
Assessment of client linguistic needs and
identifying resources to enhance proper
communication. This may include the use
of interpreters.
Review the patient’s medical history;
Review the patient’s language preference,
belief systems, values, and lifestyle choices
so that you can provide appropriate health
care services;
Recognize possible communication barriers;
and
Recognize that your culture, belief systems,
and values may affect how you interact with
patients.
Allow extra time as the patient’s primary
language
may not be English;
Provide a professional interpreter as
needed;
Provide signage and educational materials
that are
written in language(s) of commonly
encountered
group(s) of the service area;
Provide a list of agencies that can help with
multi-cultural issues; and
Learn about communicating with racially,
ethnically,
and culturally diverse patients.
Joint Commission standards do not specify
categories for the collection of race and
ethnicity data, many state reporting entities and
payors do specify these requirements.
Standard Resource Management and Stewardships
The CM should integrate factors related to
quality, safety, access, and evaluating
resources for the client’s care.
A-0806 §482.43(b): D/C Planning Evaluation
The hospital must provide a d/c evaluation
to the patients , on the request of a person
acting on the patient’s behalf, or the request
of the physician
§483.3(e) Reassessment of d/c planning
process on an ongoing basis. This must
include a review of d/c plans to ensure that
they are responsive to d/c needs.
PC.02.02.01 Coordination of Care is a major
challenge in the safe delivery of care. The rise
of chronic illness means that a patient’s care,
treatment, and services likely include an array
of providers in a variety of health care settings,
including the patient’s home.
How demonstrated Documentation of evaluating safety,
effectiveness, cost, and potential outcomes
when designing care plans to promote the
ongoing care needs of the client.
Evidence of follow through on care plans
The hospital describes the reasons for and
conditions under which the patient is d/c or
transferred.
The hospital describes the method for shifting
responsibility for a patient’s care from one

Evidence of utilizing evidence based
guidelines, and guidelines specific to the
CM’s practice setting in making decisions
about resource allocation and utilization
Demonstration of linking the client with
resources appropriate to the needs
identified in the care plan. Fully informing
the client of the length of time for which the
resource is available, their financial
responsibility, and the anticipated outcome
of resource utilization.
Documented communication of the client
and other providers when there is a
significant change in the client’s condition,
especially during transitions.
Evidence of promoting the most effective
and efficient use of hearth care resources
and financial resources
Documentation demonstrating that the
intensity of cm services corresponds with
the needs of the client
clinician, hospital, program, or service to
another.
Standard Q. Research and Research Utilization The
CM should maintain familiarity with current
research findings and be able to apply
them, as appropriate, in his/her practice
Agency for Health Care Research and
Quality (AHRQ)
AHRQ's mission is to produce evidence to
make health care safer, higher quality, more
accessible, equitable, and affordable, and to
work with the U.S. Department of Health and
Human Services (HHS) and other partners
to make sure that the evidence is
understood and used.
Targeted Solutions Tool (TST) is an application
developed by the Joint Commission Center for
transforming Health Care to: Simplify the
process for solving some of the most persistent
health care quality and safety problems.
Enhance the efforts already being made by
Joint Commission-accredited health care
organizations
Facilitate the spread and use of the learning’s
from the Center’s projects, including the
identification of root causes and the targeted
solutions that address causes of failures.
How Demonstrated Evidence of familiarization with current
literature pertaining to the CM’s expertise,
and regular participation in appropriate
training and/or conferences to maintain
knowledge and skills.
Compliance with legitimate and relevant
research efforts, to quantify and define
valid and reliable outcomes in CM
Incorporation of meaningful research
findings into practice as appropriate
CMs describe the revised Interpretive
Guidelines for Hospitals, Cop: discharge
Planning
CMs explain the purpose of the Joint
Commission’s Center for Transforming
Healthcare
CM’s describe the initiative: Improving
Transitions of Care: Hand-off Communications

Participation in identification of practical,
hands-on approaches to CM “best
practice.”

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