A method of limiting payment to a provider for healthcare services to a fixed amount, regardless of the actual number or nature of services provided. Health maintenance organizations (HMOs) do this. It’s also a method of public support of health professional schools in which eligible schools receive a fixed grant for each student enrolled.
Care coordination services
Services such as information, advice, and arranging of long-term care by a professional care coordinator.
Also called “service plan” or “treatment plan.” Written documentation that outlines the specific types and frequencies of long-term care services a resident receives. May include goals over a certain period of time.
Care/case managers assess clients' needs, create service plans and coordinate and monitor services. Seen as a way to offer a single point of entry to senior services, these managers may operate privately or may be employed by social service agencies or public programs. Typically, case managers are nurses or social workers.
Person who provides support and assistance with various activities to an individual (family member, friend or neighbor). Caregiving may be done from long distance.
Commission on the Accreditation of Rehabilitation Facilities - A private accreditation agency.
Indicates a facility has been chosen to be reviewed by the Commission on the Accreditation of Rehabilitation Facilities (CARF), a private accreditation agency, and been found to be in compliance with the organization’s quality standards.
The overall status of the resident population in a facility, based on the various residents’ health conditions. Providers also may describe their case-mix based on age, medical diagnosis, severity of illness or length of stay. A nursing home or hospital's actual case mix influences the cost and scope of services provided by the facility to the patient, and case mix reimbursement systems adjust payment rates accordingly.
A shift in payment to a provider or health plan to prevent an inaccurate rating based on a resident’s health status, which might differ from the average.
Center for Medicare & Medicaid Services (CMS)
Formerly the U.S. Health Care Financing Administration (HCFA), CMS is an agency of the U.S. Department of Health and Human Services, which finances and administers the Medicare and Medicaid programs. Among other responsibilities, CMS establishes standards and regulations for nursing facilities receiving Medicare or Medicaid funding.
Certificate of medical necessity
A document completed and signed by a physician to certify a patient's need for certain types of durable medical equipment (i.e. wheelchairs, walkers, etc.).
Certificate of need (CON)
A certificate issued by a government body to a healthcare provider that is proposing to construct, modify or expand a facility, or to offer new or different types of health services. CONs are intended to prevent the over supply of beds or services in a given area. Granting the certificate signifies the change has been approved.
Certified home healthcare
An entity that provides, at a minimum, the following services which are of a preventative, therapeutic, health guidance and/or supportive nature to persons at home: nursing services; home health aide services; medical supplies, equipment and appliances suitable for use in the home; and at least one additional service such as, the provision of physical therapy, occupational therapy, speech/language pathology, respiratory therapy, nutritional services and social work services.
Certified nursing assistant (CNA)
The CNA provides direct, personal care to residents or patients. This could include help bathing, dressing, changing linens, transporting and other essential activities. CNAs are trained, tested, certified and work under the supervision of an RN or LPN.
(Civilian Health and Medical Program of the Uniformed Services) A Department of Defense program supporting private sector care for military dependents.
Care and treatment given to individuals whose health problems are of a long-term and continuing nature. Rehabilitation facilities, nursing homes and mental hospitals can be considered chronic care facilities.
Long-term or permanent illness (e.g., diabetes, arthritis) that often results in some type of disability, and that could require a person to seek help with various activities.
Chronic Obstructive Pulmonary Disease (COPD)
A group of chronic respiratory disorders characterized by the restricted flow of air into and out of the lungs. The most common example is emphysema.
A submitted request to an insurer to receive payment and/or reimbursement for expenses incurred due to disability, illness, etc. that are covered under said policy.
The process of knowing; of being aware of thoughts. The ability to reason and understand.
Deterioration or loss of intellectual capacity. Can result from a variety of conditions, including Alzheimer’s disease and other forms of dementia. Often leads to a need for continual supervision to protect the affected individual or others. Can be measured by clinical evidence and standardized tests that reliably measure impairments in the area of (1) short- or long-term memory, (2) orientation as to person, place and time, or (3) deductive or abstract reasoning.
Also called “copayment.” The specified portion (dollar amount or percentage) that Medicare, health insurance, or a service program might require an individual to pay toward his or her medical bills or services.
Locally based services (such as adult day care, transportation, visiting nurses or aides, meal delivery, etc.) that allow a person to remain independent in his or her home.
Multiple disease processes.
Nonmedical services that are provided in the patient's home to help his or her daily functioning. No medical care is provided.
Comprehensive outpatient rehabilitation facility
CORF - A nonresidential facility that is established and operated solely to provide diagnostic, therapeutic and restorative services to outpatients. They are for the rehabilitation of injured, disabled, or sick individuals at a single, fixed location. Car comes by order of, and under the supervision of, a doctor.
Conditions of participation (COP)
Standards a facility or supplier of services that wants to participate in the Medicare or Medicaid program is required to meet. Conditions include meeting a legal definition of the particular institution or facility, conforming to state and local laws and having an acceptable utilization review plan. Appropriate state health department agencies conduct inspections to determine whether facilities meet conditions of participation.
Congestive heart failure (CHF)
A common type of heart disease characterized by inadequate pumping action of the heart.
Individual apartments in which residents may receive some services, such as a daily meal with other tenants. Other services might be included, as well. Buildings usually have some common areas, such as a dining room and lounges, as well as additional safety measures such as emergency call buttons. This housing might be rent-subsidized (known as Section 8 housing).
Person appointed by the court to act as the legal representative of a person who is mentally or physically incapable of managing his or her affairs.
The ability of the body to control urination or bowel movements or both. One of the five “activities of daily living” measured to determine healthcare needs.
Continuing Care Retirement Community (CCRC)
A housing community that offers different levels of care -- from independent living apartments to skilled nursing care. Residents move from one setting to another based on their care needs but continue to remain a part of their CCRC's community. Typically, CCRCs require a significant payment (called an endowment) prior to admission, then charge monthly fees above that.
Continuum of care
The entire spectrum of specialized health, rehabilitative, and residential services available to the frail and chronically ill. The services focus on the social, residential, rehabilitative and supportive needs of an individual, as well as needs that are essentially medical in nature.
Another term often used for short-term, custodial care that refers to the recovery period after an injury or sickness. Some assistance might be needed but not to the level of skilled care.
Corporate Integrity Agreement (CIA)
An agreement (or “settlement”) imposed by the HHS Office of the Inspector General (OIG) on a healthcare provider suspected of fraud or abuse of government healthcare under the False Claims Act. A provider consents to these obligations as part of a civil settlement; in return, the OIG agrees not to exclude the provider from federal healthcare programs. Providers do not admit guilt. Typically, the program lasts for five years and requires a provider to implement a variety of compliance measures.
Cost of living adjustment (COLA)
An increase to a monthly long-term disability benefit, usually after the first year of payments. May be a flat percentage (e.g. 3%) or tied to changes in inflation. In some states, workers' compensation income replacement benefits also include annual COLAs.
The number of days for which a SNF is eligible for payment.
Care that does not require specialized training or services. See also personal care.
Refers to a cerebrovascular accident or stroke in which an area of the brain is damaged due to a sudden interruption of blood supply.