Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 162Appendix C - DefinitionsVersion 3.0Medical Management Guideof the contractor’s clerical and automated systems components. The purpose of the benchmark is to identifyclerical and automated systems deficiencies which must be corrected before claims can be processed inaccordance with TMA requirements. The comprehensiveness of the benchmark will vary depending on thenumber and type of conditions tested.Benchmarking:• The practice of comparing outcomes against local, Service, or national industry standards. Benchmarkingallows for the identification of areas for improvement and goal-setting as well as recognition of bestpractices.• The comparison of like provider's performance. It is a standard from which to establish what "quality"medical care is and to develop measurements from which to evaluate providers and patient outcomes.Resources:TRICARE Operations Manual 6010.51-M, Appendix A, Acronyms and Definitions (Aug. 1, 2002):http://www.tricare.mil/to02/APPA.PDF.See CD-ROM Resource AppendixC-Def2DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf.See CD-ROM Resource AppendixC-Def1General definition as provided in Section IV, Disease ManagementCare CoordinationA comprehensive method of client assessment by Registered Nurses, designed to identify client vulnerability,needs identification, and client goals which results in the development plan of action to produce an outcomethat is desirous for the client. The goal is to provide client advocacy, a system for coordinating client services,and providing a systematic approach for evaluation of the effectiveness of the client’s Life Plan.Resources:TRICARE Operations Manual 6010.51-M, Appendix A, Acronyms and Definitions (Aug. 1, 2002):http://www.tricare.mil/to02/APPA.PDF.See CD-ROM Resource AppendixC-Def2Case Management (CM)• A collaborative process of assessment, planning, facilitation, and advocacy for options and services to meetan individual’s health needs through communication and available resources to promote quality, costeffectiveoutcomes.• A collaborative process under the population health continuum which assesses, plans, implements,coordinates, monitors, and evaluates options and services to meet an individual’s health needs throughcommunication and available resources to promote quality, cost-effective outcomes.
Medical Management Guide Version 3.0 Appendix C - DefinitionsPage 163• A method of managing the provision of health care to members with catastrophic or high cost medicalconditions. The goal is to coordinate the care so as to both improve continuity and quality of care as well aslower costs. This generally is a dedicated function in the utilization management department.Resources:Case Management Society of America www.cmsa.orgDoDI 6025.20, Medical Management Programs in the Direct Care System (DCS) and Remote Areas: http://www.dtic.mil/whs/directives/corres/pdf/602520p.pdf.See CD-ROM Resource MME-1Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199. Part 2 (199.2):http://www.tricare.mil/CFR/C2.PDF. See CD-ROM Resource AppendixC-Def3Case MixCategories of patients, classified by disease, procedure, method of payment, or other characteristics, in aninstitution at any given time, usually measured by counting or aggregating groups of patients sharing one ormore characteristics.Resources:DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdfSee CD-ROM Resource AppendixC-Def1CertificationThe process by which a governmental or non-governmental Agency or association evaluates and recognizesa person who meets predetermined standards; it is sometimes used with reference to materials or services."Certification" is usually applied to individuals and "accreditation" to institutions.Resources:DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf See CD-ROM Resource AppendixC-Def1Clinical Pathways/ ProtocolsTools that delineate the optimal sequencing and timing of interventions by providers for a particular diagnosisor procedure designed to minimize delays and resource utilization and maximize quality of care. They oftenhave a role in the clinical setting, in both the inpatient and outpatient arenas. Although they may be evidencebased,these protocols are distinguished from clinical practice guidelines (CPGs) in that they do not have the fullcomplement of additional resources to support them.Resources:Open Clinical: http://www.openclinical.org/clinicalpathways.html
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Medical Management Guide, 2009, Version 3.0 - Tricare

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