Glossary of Terms

aftercare: Services following hospitalization or rehabilitation, individualized for each patient's needs. Aftercare gradually phases the patient out of treatment while providing follow-up attention to prevent relapse.
alternate care: Non-inpatient care received in a less intensive setting than a hospital or other inpatient facility (e.g., day-surgery center).
board certified: A physician who has completed an approved residency, passed an examination given by a medical specialty board, and who has been certified as a specialist in that medical area.
case management: The medical management process of identifying patients with specific health care needs and interacting with them and their physician(s) to assist with determining and coordinating a treatment plan that promotes optimal health outcomes and efficient use of health care resources.
case manager: A clinical professional (e.g., nurse, doctor or social worker) who works with patients, health care providers, physicians and insurers to determine and coordinate a plan of medically necessary and appropriate health care. Also referred to as care coordinator.
cognitive impairment: Impairment in a person's memory, reasoning or orientation to a person; or an impairment requiring a person to be supervised to protect himself or herself or others from harm.
continuum of care: A range of clinical services provided to an individual or group, which may reflect treatment rendered during a single inpatient hospitalization, or care for multiple conditions over a lifetime. The continuum provides a basis for analyzing quality, cost and utilization over the long term.
custodial care: Medical or non-medical services that do not seek to cure, are provided during periods when the medical condition of the patient is not changing, or do not require continued administration by medical personnel. For example, assistance in the activities of daily living.
dependent: An individual who relies on a member for financial support and/or obtains health coverage through a spouse, parent or grandparent who is the member.
disability: any condition resulting in functional limitations that interfere with an individual's ability to perform his/her customary work and that results in substantial limitation of one or more major life activities.
discharge planning: The evaluation of patients' medical needs in order to arrange for appropriate care after discharge from an inpatient setting. Discharge planning also is associated with identification of treatment alternatives to prevent hospitalization and to transition patients from one level of care to another.
employee assistance program (EAP): Services designed to assist employees, their family members, and employers in finding solutions for workplace and personal problems. Services may include assistance for family/marital concerns, legal or financial problems, elder care, child care, substance abuse, emotional/stress issues and other daily living concerns. EAPs may address violence in the workplace, sexual harassment, dealing with troubled employees, transition in the workplace and other events that increase the rate of absenteeism or employee turnover, or lower productivity. The EAP addresses issues that affect employee morale or an employer's productivity or financial success. EAPs also can provide the voluntary or mandatory access to behavioral health benefits through an integrated behavioral health program.
extended care facility: A nursing home or nursing center that is licensed to operate in accordance with all applicable state and local laws and provides 24-hour nursing care. Such a facility may offer skilled, intermediate or custodial care, or any combination of these levels of care.
facility: A physical location where health care/services are provided, such as a hospital, clinic, emergency room or ambulatory care center.
Geriatric care management-by medically trained professionals: Includes interviews with family and client, writing a comprehensive plan of care for aged person, can include placement assistance into facilities of different levels of care. Might include providing home care by care assistants known as caregivers.
Health Insurance Portability and Accountability Act (HIPAA): A federal law intended to improve the availability and continuity of health insurance coverage that, among other things, places limits on exclusions for pre-existing medical conditions; permits certain individuals to enroll for available group health care coverage when they lose other health coverage or have a new dependent; prohibits discrimination in group enrollment based on health status; guarantees the availability of health coverage to small employers and the renewability of health insurance coverage in the small and large group markets; and requires availability of non-group coverage for certain individuals whose group coverage is terminated.
home health agency (HHA): A facility or program licensed, certified or otherwise authorized according to state and federal laws to provide health care services in the home.
hospice: A facility or program engaged in providing palliative and supportive care of the terminally ill, and licensed, certified or otherwise authorized according to the law of jurisdiction in which services are received.
impairment: Any loss or abnormality of psychological, physiological or anatomical structure or function (such as cognitive impairment).
inpatient: An individual who has been admitted to a hospital as a registered bed patient for at least 24 hours and is receiving services under the direction of a physician.
intermediate care facility (ICF): a facility providing a level of care that is less than the degree of care and treatment that a hospital or skilled nursing facility (SNF) is designed to provide, but greater than the level of room and board.
long-term care: Assistance and care for people with chronic disabilities. Long-term care's goal is to help people with disabilities live as independently as possible. It is focused more on caring than on curing. Long-term care is needed by a person who requires help with the activities of daily living (ADLs) or who suffers from cognitive impairment.
Medicaid: A federal program administered and operated individually by active state and territorial governments that provides medical benefits to eligible low-income people needing health care. The program's costs are shared by the federal and state governments.
Medicare: A nationwide, federally-administered health insurance program that covers the costs of hospitalization, medical care, and some related services for eligible people, principally individuals age 65 and older and disabled individuals under age 65.
Medicare beneficiary: A person designated by Social Security as entitled to receive Medicare benefits.
mental health provider: A psychiatrist, licensed consulting psychologist, social worker, hospital or other facility duly licensed and qualified to provide mental health services under the law of the jurisdiction in which treatment is received.
outpatient: A person who receives health care services at a hospital or free-standing surgical center without being admitted to a hospital.
pre-existing condition: Any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person's effective date of coverage. Pre-existing conditions may not be covered for some specified amount of time as defined in the certificate of coverage (usually six to 12 months). As a result of HIPAA, an individual can be required to satisfy a pre-existing waiting period only once, so long as they maintain continuous group health plan coverage with one or more carriers.
prescription medication: A drug that has been approved by the Food and Drug Administration and which can, under federal or state law, be dispensed only according to a prescription order from a duly licensed physician or other practitioner with dispensing authority.
preventive care: Health care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examination, immunization and well-person care.
primary care: Basic or general health care, traditionally provided by family practice, pediatrics and internal medicine practitioners.
primary care physician (PCP): A physician, the majority of whose practice is devoted to internal medicine, family/general practice and pediatrics. An obstetrician/gynecologist sometimes is considered a primary care physician for women.
provider: A physician, hospital, group practice, nursing home, pharmacy or any individual or group of individuals that provides a health care service.
referral: The recommendation by a physician and/or health plan for a covered person to receive care from a different physician or facility. Sometimes required for treatment by specialists and for out-of-network treatment.
referral provider: A health care provider who renders a service to a patient who has been referred by a contracted provider or health plan.
second opinion: A medical opinion obtained from another health care professional, relevant to clinical evaluation, prior to the performance of a medical service or a surgical procedure. May relate to a formalized process, either voluntary or mandatory, used to help educate a patient regarding treatment alternatives and/or to determine medical necessity.
secondary care: Services provided by medical specialists, such as cardiologists, urologists and dermatologists, who generally do not have first contact with patients.
skilled nursing facility (SNF): A facility, either freestanding or part of a hospital, that accepts patients in need of rehabilitation and medical care that is of a lesser intensity than that received in a hospital.
treatment facility: A residential or non-residential facility or program licensed, certified or otherwise authorized to provide treatment of substance abuse or mental illness according to the law or jurisdiction in which treatment is received.
urgent care: An alternative to hospital emergency department care for use in non-emergencies. Used when health conditions are urgent, but are not health, or life-threatening.