26 terms

Business of Healthcare

Name 4 types of Healthcare providers
1. Acute care hospitals
2. Outpatient Agencies (ambulatory care)
3. Long Term Care (LTC)
4. Community health care agencies
non-profit facility
a hospital that is private non-profit, a facility that is owned and operated by a service organization (such as a church or charitable group) with the intention of fulfilling a need in the community
proprietary facility
A facility that is owned and operated by a for-profit corporation is a:
Health Maintenance Organization (HMO)
group insurance that entitles members to services of participating hospitals and clinics and physicians
Preferred Provider Organization (PPO)
PPO (in Networks); One in which the patient must use a provider under contract to the insurance company and the insurance company reimburses the provider at a discounted rate
Diagnostic Related Groups (DRG's)
government health care in the United States
acute-immediate care
rapid onset & a relatively short course of illness.
Medicare Part A
Non-voluntary; reimburses for in-patient services (hospitalization); includes 100 days of long term care if the pt. goes directly from the hospital.
Medicare Part B
Supplemental & voluntary; reimburses for physician office visits, outpt. services, home nursing care, ambulance services, etc. Pt. pays a small premium for this, as well as about 20% of the bill.
Medicare Part D
Medicare Prescription Drug Benefit Program- voluntary-Supplemental premium
Managed Care
Case Management
a collaborative process that involves assessing, planning, facilitating and advocating for health services to meet an individual's or family's needs through communication and use of available resources to promote cost-effective outcomes
Goal of Case Management
to provide quality care along a continuum, decrease fragmentation of care across many settings, enhance the patient's quality of live and contain cost
prospective payment system
accepting a fixed amount of money per enrolled person per enrollment period (usually one year), and agreeing to provide certain health care services to all plan members with no additional billing.
a point-of-entry physician who determines the need for additional services. Clients must go through this "gatekeeper" first. HMOs often use a Point of Service (POS) plan. In this plan:

*Primary care MD is the gatekeeper for hospital admission, specialist, emergency, & other services. The physician authorizes the referrals to these other physicians or service providers.
*There is a fixed fee for service.
*If client chooses to go outside of provider network, he pays the full cost.
point of service plan
community-based nursing
goals are to help individuals and families promote health, prevent illness, and manage acute or chronic health conditions in community and home settings as opposed to hospital settings.
public health nursing
nurses who improve health through a population focus
primary nursing
RN assigned and responsible for planning and coordinating care 24 hours/day.

a. Directs "Associate nurses" on other shifts or on days off.
b. BSN was primary; ADN was associate.
c. Expensive & pretty much a thing of the past!
d. Many of the responsibilities are now done by "Case Managers."
Team Nursing
a. Very common now.
b. Includes Licensed Vocational Nurses (LVNs) and nurse assistants (NAs or CNAs) AKA Patient Care Assistants (PCAs), "clinical partners" (CP's), or Patient Care Technicians (PCTs).
c. Always the RN is responsible for all members on his/her team. The RN must know the workers capabilities & delegate tasks appropriately but keeps ultimate responsibly for patient care & safety.
Total patient Care
a. Shift assignment only
b. RN assigned has primary responsibility for full care for the shift, but may have assistance.
c. Typically used in Critical Care Units.
d. 1:1 or often 1:2 patients (or rarely 2:1 patient)
case managers
oversee that standards of care are met and the care is within guidelines established by the group and by the contract.
clinical or critical pathway
a timeline that indicates when an activity needs to be completed, in order for the project to be accomplished in a certain time frame. Kind of like a schedule that predicts the routine care for a situation.
2) RN's role for clinical pathway: To keep the pt. on the predicted schedule!
RN's role for clinical pathway
to keep the pt. on the predicted schedule