chapter 6/Health Care Delivery Systems

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Case management

a method for delivering nursing care in which the nurse is responsible for a caseload of clients across the health care continuum

Coinsurance

an insurance plan in which the client pays a percentages of the payment and some other group (e.g. , employer, government) pays the remaining percentage

Critical pathways

multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes

Diagnosis-related groups (DRGs)

a Medicare payments system to hospitals and physicians that establishes fees according to diagnosis

Differentiated practice

a system in which the besst possible use of nursing personnel is based on their educational preparation and resultant skill sets

Health care system

the totality of services offered by all health disciplines

Health maintenance organization

a group health care agency that provides basic and supplemental health maintenance and treatment services to voluntary enrollees

Independent practice associations (IPAs)

provide care in offices; clients pay a fixed prospective payment and IPA pays the provider earnings or losses are assumed by the IPA

Integrated delivery system (IDS)

a system that incorporates acute care services, home health care, extended and skilled care facilities, and outpatient services

Licensed vocational (practical) nurse (LVN/LPN)

a nurse who practices under the supervision of a registered nurse, providing basic direct technical care to clients

Managed care

a method or organizing care delivery that emphasizes communication and coordination of care among all health care team members

Medicare

a national and state health insurance program for U.S. residents 65 and older

Medicade

a U.S. federal public assistance program paid out of general taxes and administered through the individual states to provides health care for those who require financial assistance

Patient-focused care

delivery model that brings all services and care providers to the client

Preferred provider arrangements (PPAs)

similar to PPOs but PPAs can contract with individual health care providers; the plan can be unlimited or limited

Preferred provider organization (PPO)

a group of physicians or a hospital that provides companies with health services at a discounted rate

Supplemental Security Income benefits (SSI)

special payments for people with disabilities, those who are blind, and people who are not eligible for Social Security, these payments are not restriced to health care costs

Team nursing

the delivery of individualized nursing care to clients by a team led by a professional nurse

Health care services are described in a way?

correlated with levels of disease prevention

Description of health care services are?

primary prevention(health promotion and illness prevention), secondary prevention(diagnosis & treatment), tertiary prevention (rehabilitation, health restoration and palliative care.

How are health care services described?

a. primary prevention which consists of health promotion and illness prevention
b. secondary prevention which consists of diagnosis and treatment
c. tertiary prevention which consists of rehabilitation,health restoration and palliative care

WHO

based on the notion of maintaining an optimum level of well ness, developed Healthy People

WHOs primary goals

increase quality and years of healthy life, achieve health equity and elminiate health disparities, create healthy environments for everyone

Primary Prevention

based on Who, prevention

Secondary Prevention

diagnosis and treatment, hospital, surgery

Tertiary Prevention

rehabilitation, health restoration and palliative care

Subacute Care Facilities

variation of inpatient care designed for someone who has an acute illness or injury but do not depend heavily on high-techology monitorin or complex diagnostic procedures

Extended Long-Term Care Facilities

nursing homes

What is the fastest growing population?

frail elderly, over age 85, with only 5% not living at home

What source offers accurate information to consumers about health care information?

Agency for healthcare research and quality , website Guide to Health Care

How has the womens movement been instrumental in changing health care practices?

ex; provision of childbirth services in more relaxed settins, the need for research that examines women equally to men

What are two serious problems of health services in the U.S.?

uneven distribution and increased specialization

Case Method

a system in which the best possible use of nursing personnel is based on their educational preparation and resultant skill sets

Functional Method

focuses on the jobs to be completed, task-oriented approach, personnel with less preparation than the professional nurse perform less complex care requirements. based on production and efficiency model that give authority to the head nurse

Primary Nursing

a system in which one nurse is responsible for overseeing the total care of a number of hospitalized clients 24 hours a day, 7 days a week, a method or providing comprehensive, individualized and consistent care

Medicare Part A

available to people with disabilities and people over 65 years of age, provides insurance towards hospitilization, home care and hospice

Medicare Part B

voluntary and provides partial coverage of outpatient and physician services to people who are eligible for part A

Medicare Part D

voluntary prescription drug plan

Medicaid

1965, title 19, federal public assistance program paid out of taxes, people with low incomes, paid by federal and state governments

SSI

persons with disabilities or those who are blind, available people not eligible for SS, not restricted to health care costs

CHIP

children's health care insurance program, provides insurance for ppo and working-class children. expands coverage for children under medicaid and subsidized low-cost state insurance alternatives

WIC

women, infants & children, provide supplemental nutrition

Independent Practice Associations (IPAs)

somewhat like HMOs and PPOs, clients pay a fixed payment to the IPA, at end of year any surplus money is divided among the providers

Physician/Hospital Organizations

joint ventures between a group of private physicians and a hospital, may be part of an intergrated delivery system, which incorporates all health care throughout the life span

what is an example of a primary prevention activity?

Nutrition counseling for young adults with a strong family history of high cholesterol

Who are public health agencies funded by and what do they do?

funded by governernments to investigate and provide health programs

In most cases, clients must have a primary care provider in order to receive health insurance benefits. If a client is in need of a primary care provider, it is most appropriate for the nurse to recommend what type of provider?

Family practice physician

The most significant method for reducing the ongoing increase in the cost of health care in the United States includes controlling what?

Numbers of uninsured and under insured persons

A client is seeking to control health care costs for both preventive and illness care. Although no system guarantees exact out of pocket expenditures, the most prepaid and predictable client contribution would be seen with?

A health mainteance organization (HMO)

Case-management

Range of models for integrating health care services for individuals or groups

Coinsurance

The percentage share of a government-approved charge that is paid by the client

Critical Path Ways

An interdisciplinary plan or tool that specifies interdisciplinary assessments, interventions, treatments, out-come for health-related conditions across a time line

Diagnosis-related groups (DRG)

A classification system that establishes pretreatment diagnosis billing categories

Preferred Provider (PPAs)

Health care plan that contracts with individual health care providers

Differentiated practice

System in which the best use of nursing personnel is based on their educational preparation and skill sets

Health maintenance organization (HMO)

A group health care agency that provides health maintenance and treatment to voluntary enrollees

Independent practice associations (IPAs)

Similiar to HMOs, care is provided in offices, where the client pays a fixed amount to the IPA

Integrated delivery system (IDS)

One the incorporated acute care services, home health care, extended and skilled care facilities and outpatient services

Licensed vocational (practical) nurse (LVN/LPN)

Provides direct client care under the direction of a registered nurse, physician or other licensed practitioner

Managed Care

A health care system whose goals are to rpovide cost-effective, quality care

Medicaid

Federal public assistance program that provides health care coverage to people who require financial assistance

Medicare

National and state health insurance program for older adults

What are the three types of health care services?

Primary prevention, Secondary prevention, Tertiary prevention

What is the purpose of primary prevention health care systems?

Health promotion and illness prevention

What is the purpose of secondary prevention?

Rehabilitation, health restoration, and palliative care

What is the purpose of tertiary prevention?

Rehabilitation, health restoration and palliative care

What are the primary goals of Health People 2012

a. increase quality and years of a health life
b. achieve health equity and eleminate health disparities
c. create healthy environments for everyone
d. promote health and quality life across the life span

What is an example of secondary prevention?

Physicians offices

____ is the official agency at the federal level for public health.

Public Health Service (PHS) of the U.S. Department of Health and Human Services

What is the function of occupational health clinics?

Important setting for employee health care, respsonsible for worker safety, health education, annual employee health screening for TB and mainteance of immunization information.

What type of roles would a nurse play in a occupational health clinic?

other screenings for health concerns

Name four factors affecting health care delivery in today's health care environment?

a. increasing number of elderly
b. advances in technology
c. economics
d. womens health

According to the U.S. Census, the expected number of frail elderly (people over 85) will be the ______ growing population segment in the U.S. and will number over _____million by 2020 and _____million by 2030.

fastest, 76.5, 90

What impact does the Health Insurance Portability and Accountability Act of 1996 (HIPPA) have on the health care system?

major alteration in how health care is practiced, regulations protect privacy of individuals, violations can result in heavy fines

What is the definition of critical pathways, and how are critical pathways used in case management and managed care?

case management used as a cost-containment strategy in managed care, both systems often use critical pathways in an interdisciplinary plan or tool that specified interdisciplinary assessments, interventions, treatments and outcomes for health-related conditions across a time line

You are taking the health and physical assessment for an 80 year old blind client who has just been admitted to the unit. What type of health coverage could she have at this point?

could have private pay, Medicare, Medicaid or Supplemental Security Income

If the client's income is below the poverty level, what type of coverage could also be included in the health coverage plan?

Supplemental Security Income is available for persons with diabilities or those who are blind or not eligible for Socail Security

After caring for a client for 3 days, she is getting ready for discharge. The physician has written an order for physical therapy after discharge. In addition, he request that a dietitian follow up with additional education regarding the client's newly diagnosed type II diabetes. What roles do the two providers fufill?

The physical therapy could be performed by the physical therapist. Physical therapist treat movement dysfunction by means of heat, water, exercise, massage and electric current. They also assess client mobility and strength, provide therapeutic measures, and teach new skills. A dietitian has special knowledge about the diets required to maintain health and treat disease.

Where could the client receive the services, and what type of coverage could possibly pay for these services?

long-term health care facility that has rehabiliation services or home health care, medicare part B and the SSI could supplement it as needed

Refer to the Research Note in the textbook to answer the following questions regarding the types of nurses and delivery models in hospitals and how these factors influence patient outcomes? How was the quality of care measured?

measured through the patient outcomes; rates of medication errors, falls and certain infections

What types of models were used? Define each of these models?

total care (case method)-client centered, one nurse is assigned to and is responsible for the comprehensive care of a group of clients during an 8 to 12 hour shift.
team nursing-delivery of individualized nursing care led by a professional nurse, consists of registered nurses, licensed practical nurses, & unlicensed assistive personnel
primary nursing-one nurse is responsible for overseeing the total care of a number of clients 24 hours a day, 7b days a week, even if he or she does not personally deliver all the care

How were quality, coordination, and communication in the units affected?

The results were higher on units that had all registered nurses as opposed to staffing the included unlicensed personnel and practical nurses. The total care delivery model had the lowest quality.

Why is this research important in today's health care delivery systems?

shows a relationship between the composition of the nursing staff and the quality of patient care, important to examine delivery models to allow optimal deployment of registered nurses in a time of nursing shortage

Name two frameworks for care that are used for the delivery of nursing care that supports continuity of care and cost-effectiveness:

managed care and team nursing

Medicare is divided into two divisions, Part A and Part B. Another plan was added in January 2006. Part A is the

plan section providing insurance toward hopitalization, home care and hospice care

part B medicare is?

voluntary plan that provides partial coverage of outpatient and physician services to those who are eligible

Part D medicare is?

voluntary prescription drug plan that began in January 2006

Medicaid is decribed as?

a plan providing very limited financial coverage to low-income persons

What person is eligible for Supplemental Security Income?

blind, persons not eligible for social security, children from low-income families that are covered under medicaid, has recognized disabilities

What is the name of the classification system that prospective payment systems utilize?

Diagnosis-related groups (DRGs)

Third-party reimbursement refers to the insurance company that pays the client's (first party) bill to the provider (second party). This component is part of the ?

group health insurance plan

Prepaid group plans for insurance include?

HMOs, PPOs, PPAs, IPAs, and PHOs

What is an example of health promotion?

Immunizing children against chickenpox

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