To provide you with a better understanding of long term care and the issues we and our Members face, here is a comprehensive glossary of terms that we use every day:
Acronyms
Activities you usually do during a normal day such as getting in and out of bed, dressing, bathing, eating and using the bathroom. The inability to perform two or three of these activities is generally used to determine level and kind of home health or nursing home care needed.Acute Care
Immediate, short-term medical treatment for a serious illness or injury, usually in a hospital or skilled nursing facility. May be contrasted with chronic care.Adult Day Care
Care inside or outside the home provided for adults who require assistance with the activities of daily living or other largely non-medical supervision, but can include minimal medical-related services such as supervising the taking of medicine. Other services frequently included are social, recreational programs and, sometimes, occupational and physical therapy. Program is primarily care during the hours that family members or other informal caregivers are at work, rather than care on a 24-hour basis.Adult Day Care Facilities
Community -based centers that provide comprehensive services ranging from health assessment and care to social programs for older persons who need some supervision. They may be operated by hospitals, nursing homes, local governments or private groups. Out of pocket costs vary. Medicare does not cover adult day care.ADvantage Program
Medicaid waiver for long term care in Oklahoma; administered by the Long Term Care Authority, under contract with the Oklahoma Department of Human Services.- C - Capitation
A specified amount of money paid to a health plan or doctor. This is used to cover the cost of a health plan member's health care services for a certain length of time.Caregiver
A non-specific term describing either a skilled or nonskilled person who provides some type of care for another. A person who helps care for someone who is ill, disabled, or aged. Some caregivers are relatives or friends who volunteer their help. Some people provide caregiving services for a cost.Case Management
A process used by a doctor, nurse or other health professional to manage health care. Case managers make sure that you get needed services, and track use of facilities and resources. A professional service which arranges and coordinates health and/or social services through assessment, service plan development and modification, monitoring and quality assurance.Case Manager
A nurse, doctor or social worker who arranges all services that are needed to give proper health care to you.Centers for Medicare & Medicaid Services (CMS)
The federal agency that runs the Medicare program. In addition, CMS works with the states to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality health care. Formerly known as the Health Care Financing Administration (HCFA).Chronic Care
Continuous, long-term care for persons suffering from chronic conditions. May be contrasted with acute care.Custodial Care
Nonskilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving and using the bathroom. It may also include care that most people do themselves, like using eye drops. In most cases, Medicare doesn’t pay for custodial care.Custodial Care Facility
A facility that provides room, board and other personal assistance services, generally on a long-term basis and which does not include a medical component.Custodial Nursing Care
Also called Maintenance Nursing Care or simply Maintenance Care; it is care which is primarily done for the purpose of meeting an individual’s daily personal needs such as bathing, eating or taking medications. It may be provided by persons without special training or skills. If given in a hospital or nursing home, the care will usually be under the direction of a doctor. Also called custodial care.- D - Disability
For Social Security purposes, the inability to engage in substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or to last for a continuous period of not less than 12 months. Special rules apply for workers aged 55 or older whose disability is based on blindness. The law generally requires that a person be disabled continuously for 5 months before he or she can qualify for a disabled worker cash benefit. An additional 24 months is necessary to qualify under Medicare.- E - Eldercare
Public, private, formal, and informal programs and support systems and government laws that find ways to meet the needs of the elderly, including: housing, home care, pensions, Social Security, long-term care, health insurance and elder law.Eligibility
Refers to the process whereby an individual is determined to be eligible for health care coverage through the Medicaid program. Eligibility is determined by the State. Eligibility data are collected and managed by the State or by its Fiscal Agent. In some managed care waiver programs, eligibility records are updated by an Enrollment Broker, who assists the individual in choosing a managed care plan to enroll in. Eligibility/Medicare Part A You are eligible for premium-free (no cost) Medicare Part A (Hospital Insurance) if: · You are 65 or older and you are receiving, or are eligible for, retirement benefits from Social Security or the Railroad Retirement Board, or · You are under 65 and you have received Railroad Retirement disability benefits for the prescribed time and you meet the Social Security Act disability requirements, or · You or your spouse had Medicare-covered government employment, or · You are under 65 and have End-Stage Renal Disease (ESRD). If you are not eligible for premium-free Medicare Part A, you can buy Part A by paying a monthly premium if: · You are age 65 or older, and · You are enrolled in Part B, and · You are a resident of the United States, and are either a citizen or an alien lawfully admitted for permanent residence who has lived in the United States continuously during the 5 years immediately before the month in which you apply. Eligibility/Medicare Part B: You are automatically eligible for Part B if you are eligible for premium-free Part A. You are also eligible for Part B if you are not eligible for premium-free Part A, but are age 65 or older AND a resident of the United States or a citizen or an alien lawfully admitted for permanent residence. In this case, you must have lived in the United States continuously during the 5 years immediately before the month during which you enroll in Part B.Emergency Care
Medical care given when health is in serious danger.Fee For Service
A plan or PCCM is paid for providing services to enrollees solely through fee-for-service payments, plus, in most cases, a case management fee.- G - Gatekeeper
In a managed care plan, this is another name for the primary care doctor. This doctor gives you basic medical services and coordinates proper medical care and referrals.- H - Health Care Financing Administration (HCFA)
The branch of the U.S. Department of Health and Human Services that formerly administered the Medicare program and provides information about long-term care and other health services. Now known as Centers for Medicare & Medicaid Services (CMS).Health Maintenance Organization (HMO)
A type of service provider that arranges for both health care services and payment for those services. Requires members to pay a pre-set monthly fee covering a broad range of services rather than payment for individual services. Members must use medical practitioners and facilities approved by the HMO, usually at a location the HMO owns and operates and using medical personnel employed by the HMO. HMOs may contract with Medicare to offer Medicare beneficiaries all services covered by fee-for-service Medicare. When a Medicare beneficiary joins an HMO, he or she must usually "sign over" their Medicare benefits to that HMO.Home and Community-Based Service Waiver Programs (HCBS)
The HCBS programs offer different choices to some people with Medicaid. Those who qualify to receive care at home and in the community so they can stay independent and close to family and friends. HCBS programs help people who are elderly and disabled, mentally retarded, developmentally disabled, and certain other disabled adults. These programs give quality and low-cost services.Home Health Agency
An organization that gives home care services, like skilled nursing care, physical therapy, occupational therapy, speech therapy and personal care by home health aides.Home Health Care
Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen and walkers), medical supplies and other services. A type of medical care that is gaining popularity as people attempt to stay out of nursing homes. It is growing rapidly as technology provides equipment that is more portable and personnel receive additional training. As the name implies, services are performed at an individual’s home, as opposed to an outside facility. Generally may refer to any level of care and a wide range of skilled and non-skilled services, including part-time nursing care, various types of therapy and assistance with activities of daily living and homemaker services such as cleaning and meal preparation. For Medicare purposes, this term refers specifically to intermittent, physician-ordered medical services or treatment and should not be confused with definitions contained in long-term care policies.Home Health Care Agency
Either a private commercial venture or a state-operated organization that is licensed to provide health care and/or homemaker services to individuals who need assistance but need not be institutionalized. Those who actually provide the services are commonly referred to as home health aides who may or may not have to be specifically trained and licensed or certified in particular states. Newer long-term care policies often pay for such services performed in an insured’s home.Homemaker Services
A variety of non-skilled at-home services, including shopping, meal preparation, laundry services, housekeeping and similar activities provided either by employees of private home health agencies or state agencies. Some long-term care policies pay a benefit for such services.Hospice
Hospice is a special way of caring for people who are terminally ill, and for their family. This care includes physical care and counseling. Hospice care is covered under Medicare Part A (Hospital Insurance). An organization which primarily provides pain relief, symptom management and support services for terminally ill patients and their families.Hospice Care
A special way of caring for people who are terminally ill, and for their families. This care includes physical care and counseling. Hospice care is covered under Medicare Part A (Hospital Insurance). Includes some medical assistance primarily for pain control and making the ill person comfortable, as well as counseling services for people who are ill and their families. May occur at home or in an institutionalized setting. Medicare provides benefits under Part A for this type of care; there are restrictions and qualifications that apply.- I - Intermediate Care
In the context of long-term care and Medicare, refers to a level of nursing services performed intermittently, rather than around the clock, by professional medical personnel, usually a registered or licensed practical nurse or other medical practitioners such as licensed therapists.Instrumental Activities of Daily Living (IADL)
Activities such as shopping, cooking, cleaning, managing money, using a telephone, doing laundry, taking medication and accessing transportation. Levels of Care can include these three levels of long-term care: Skilled Care: 24 hour a day prescribed care provided by licensed medical professionals who are under the direct supervision of a physician. Intermediate Care: Prescribed care that can be provided on an intermittent, rather than continuous basis - for example, physical therapy. Custodial Care: Care that assists people with daily living requirements, such as dressing, eating and personal hygiene.- L - Long-Term Care (LTC)
A wide range of medical and non-medical services ranging from custodial help with activities of daily living to occasional nursing care to skilled nursing services provided to people who are physically or mentally unable to provide independent care for themselves. Usually used to describe care for the elderly although younger disabled persons also utilize long-term care services. Care may be needed while recovering from an accident or illness, during an extended period of disability, or simply as a result of the normal aging process. Home health care, adult day care, respite care and nursing home stays fall into the category of long-term care.Long-Term Care (LTC) Insurance
Insurance that covers expenses incurred when the insured receives specified services associated with extended care in a variety of settings including the individual’s home, nursing homes and community-based facilities such as assisted living facilities and adult day care centers- M - Maintenance Nursing Care
Also called simply Maintenance Care or Custodial Care; it is care which is primarily done for the purpose of meeting an individual’s personal needs (activities of daily living) such as bathing, eating, dressing or taking medications. It may be provided by persons without professional training or skills. Even so, this type of care is usually given under a doctor’s orders.Maximum Daily Benefit
The amount designated in a long-term care policy up to which it will pay benefits per day for nursing home care. It also determines the amount per visit payable for home health care.Medicaid
A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid. A joint federal-state welfare program that pays for medical care for those with very low incomes. It will cover nursing home costs and some very limited home health care but only after most assets and income have been exhausted. Being on Medicaid may reduce or limit the choice of nursing homes.Medical Insurance (Part B)
That part of Medicare which helps pay for medically necessary physicians’ services, outpatient hospital services, home health care services and a number of other medical services and supplies that are not covered by Medicare Part A. Part B is also called Supplementary Medical Insurance.Medicare:
The federal health insurance program for: people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD). The Federal government-sponsored health care program funded and operated by the Social Security Administration, providing medical benefits for individuals over the age of 65, some disabled persons and those with end-stage renal disease. Automatically includes Part A Hospital Insurance. Part B Supplementary Medical Insurance covers physicians’ services and other outpatient care and is optionally available for a monthly charge. . There are some co-payments and deductibles on both Parts A and B. The dollar amounts of these may change each year (check with your local Social Security office for current details). Medicare does not provide benefits for custodial or intermediate nursing home care, or long-term care. Part A: Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. That part of Medicare that covers inpatient hospital care, skilled nursing facility care, home health care, and hospice care. Also called Part A Hospital Insurance. Part B: Medicare medical insurance that helps pay for doctors’ services, outpatient hospital care, durable medical equipment, and some medical services that aren’t covered by Part A. That part of Medicare that covers physicians’ services, the cost of medical equipment and supplies, outpatient hospital services, and a variety of other medical services not covered by Medicare Part A. Also called Part B Medical Insurance.Morbidity
A diseased state, often used in the context of a "morbidity rate" (i.e. The rate of disease or proportion of diseased people in a population). In common clinical usage, any disease state, including diagnosis and complications is referred to as morbidity.Morbidity Rate
The rate of illness in a population. The number of people ill during a time period divided by the number of people in the total population.Mortality Rate
The death rate often made explicit for a particular characteristic (e.g. gender, sex, or specific cause of death). Mortality rate contains three essential elements: the number of people in a population exposed to the risk of death (denominator), a time factor, and the number of deaths occurring in the exposed population during a certain time period (the numerator).- N - Nursing Facility
A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or on a regular basis, health related care services above the level of custodial care to other than mentally retarded individuals. Generally, nursing facility residents have physical or mental problems that keep them from living on their own. They usually require daily assistance. A non-specific term that refers to any of several types of facilities designed to provide one or more levels of care for persons who need assistance. May include skilled, intermediate, and/or custodial care facilities. Often called "nursing homes."Nursing Home
A residence that provides a room, meals, and help with activities of daily living and recreation. Generally, nursing home residents have physical or mental problems that keep them from living on their own. They usually require daily assistance. A non-specific term that refers to any of several types of facilities designed to provide one or more levels of care for persons who need assistance. May include skilled, intermediate, and/or custodial care facilities.Nursing Home Care
Is care provided in a skilled nursing facility where all three levels of care (skilled, intermediate and custodial) are provided. In order to be licensed, nursing homes must meet appropriate standards for the state in which they operate. They may or may not be Medicare approved.- P - Performance Measures
A gauge used to assess the performance of a process or function of any organization. Quantitative or qualitative measures of the care and services delivered to enrollees (process) or the end result of that care and services (outcomes). Performance measures can be used to assess other aspects of an individual or organization's performance such as access and availability of care, utilization of care, health plan stability, beneficiary characteristics, and other structural and operational aspect of health care services. Performance measures included here may include measures calculated by the State (from encounter data or another data source), or measures submitted by the MCO/PHP.Periods of Care (Hospice)
A set period of time that you can get hospice care after your doctor says that you are eligible and still need hospice care.Personal Care
Nonskilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in and out of bed or chair, moving around, and using the bathroom. It may also include care that most people do themselves, like using eye drops. The Medicare home health benefit does pay for personal care services.Primary Care Physician
Generally refers to HMOs or other types of member organizations; the doctor selected by the enrollee is called the Primary Care Physician since that doctor is in charge of managing that member’s health care needs.Primary Care Services
Under Medicare, they are designated to include consultation services, hospital in-patient services and psychiatric services. These services are often referred to as "Evaluation and Management Services."- R - Rehabilitative (Restorative) Care
Is skilled care provided by a trained medical person (physical therapist, R.N., speech therapist). Its purpose is to restore health following an accident, injury or illness. Medicare pays for a limited amount of this type of care.- S - Skilled Care
A type of health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care.Skilled Nursing Facility
A facility (which meets specific regulatory certification requirements) which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.Skilled Nursing Facility Care
This is a level of care that requires the daily involvement of skilled nursing or rehabilitation staff. Examples of skilled nursing facility care include intravenous injections and physical therapy. The need for custodial care (for example, assistance with activities of daily living, like bathing and dressing) cannot, in itself, qualify you for Medicare coverage in a skilled nursing facility. However, if you qualify for coverage based on your need for skilled nursing or rehabilitation, Medicare will cover all of your care needs in the facility, including assistance with activities of daily living.- W - Woodwork Effect
Individuals entering an HCBS program whom otherwise would not use nursing facility care.Acronyms AA - Administrative Agent ADL - Activities of Daily Living ASD - Aged Services Division (of Oklahoma Department of Human Services) CCM - Community-based Case Management CHC - Comprehensive Home Care CIS - Consumer Inquiry System CMS - Centers of Medicare & Medicaid Services CoPP - Conditions of Provider Participation CQI - Continuous Quality Improvement CSE - Consumer Sentinel Event (adverse event that was preventable) CAPM - Comprehensive Assessment, Planning and Management FFS - Fee For Service HCBS - Home- & Community-Based Services IADL - Instrumental Activities of Daily Living IDT - Inter-Disciplinary Team LTC - Long Term Care M&M - Morbidity & Mortality (review at occurrence of death or function of limb loss due to disease) MSQ - Mental Status Questionnaire NFLoC - Nursing Facility Level of Care OkDHS - Department of Human Services (Oklahoma) OKHCA - Oklahoma Health Care Authority PAS - Pre-Admission Screening PERS - Personal Emergency Response System QA/QI - Quality Assurance & Quality Improvement (HCBS initiative) QWEST - Quality Waiver Evaluation System Tracking RCA - Root Cause Analysis RCR - Retroactive Claims Review UCAT - Uniform Comprehensive Assessment Tool WMIS - Waiver Management Information System