Chapter 13: Health Care Delivery in the US

pesthouses

Operated by local government to serve as a place to isolate people who contracted infectious disease (cholera, smallpox, and typhoid)

internship year

first year of residency and physicians are referred to as interns or first year residents

providers

health care facilities or health professionals that provide health care services

integrative medicine

when mainstream medical therapies are combined with CAM therapies and there are some high quality evidence of safety and effectiveness

Hospital Survey and Construction Act of 1946 or Jill-Burton Act

- federal legislations that proved substantial funds for hospital construction - federal funds helped remedy hospital shortage caused by lack of construction during Depression and WW2 - a federal-state partnership - State agencies given grants to determine need for hospitals and construction. Major portion of construction dollars came from state and local sources. - Funds for additional constructions, modernization, and replacement of other health care facilities and for comprehensive health planning

primary medical care

- front line or first contact care - plays as a regular or usual source of care for patients and their families - Includes routine medical care to treat common illnesses or decide health problems in early stages (dental. check ups, annual physical exams, health screenings for hypertension, high blood cholesterol, breast or testicular cancer and sore throats culture - Physicians, nurse practitioners, physician assistants, and other people in the primary care team. Serve in practitioner's offices, clinic, and outpatient facilities. - Most difficult for poor and uninsured to obtain

Accountable Care Organizations ACOs

- groups of doctors, hospitals, and other health care providers, who come together voluntarily as a legal entity to five coordinated high-quality care to Medicare patients - Goal of coordinated care is to ensure the patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors and reduce the costs of care. - ACA enables ACOs to share in savings to the federal government based on ACO performance in improving quality and reducing heath care costs.

Health Care System: Structure

- health care delivered by an array of providers in variety of settings. reference made to spectrum of health care delivery. - Four levels of practice: population-based public health practice, medical practice, long term practice, and end-of-life practice

Physician Assistants

- health care practitioners trained to treat most standard cases of care - Health care professionals who practice medicine with physician supervision. Physician assistant began because of a shortage of primary care physicians. Bachelor's degree and complete 2 year accredited education program that leads to a master's. Must pass the national certifying examination. - Work under the direct supervision of licensed physician (known as the physician extenders). Take on duties like a physician: taking medical histories, examine patients, order and interpreting lab test and x-rays, counseling patients, making preliminary diagnoses, treating minor injuries, and prescribe medications (in some states). - Duties depend on: the setting in which they work, level of experience, speciality, and the laws in the state where they practice

Limited (or Restricted) Care Providers

- health care providers who provide care for a specific part of the body - much health care is provided through limited (or restricted) care providers - speciality allows them to provide care for a part of body - Dentist, optometrists, podiatrists, audiologists, and psychologists

End-of-Life Practice

- health care services provided to individuals shortly before death - primary for of end of life practice is hospice

Allied Health Care Professionals

- health care workers who provide services that assist, facilitate, and complement the work of physicians and other health care specialists - Allied health describes a group of health-related professions that fulfill necessary roles in the health care delivery system. - Constitute approximately 60% of the health care workforce. - Responsible for technical services and procedures. - Categorized: (1) lab technologists an technicians, emergency medical technicians, nuclear medicine technicians, operating room technicians, dental technicians and hygienist, and radiographers (2) therapeutic science practitioners (3) behavioral scientists (4) support services - Educational backgrounds range from vocational training to clinical doctoral degrees. Must pass a state or national licensing examination. - Growth in demand for allied health care workers because of the arrival of baby boomers as senior citizens

Limited-service hospitals

- hospitals that offer only the specific services needed by the population served; lack sophisticated technology - more common in rural areas; low volume of patients, a shortage of health care personnel, and finical distress

Full-service hospitals

- hospitals that offer services in all or most of the levels of care defined by the spectrum of health care delivery - known as general hospitals - most expensive hospitals to run and are usually found in metropolitan areas

Allopathic and Osteopathic Providers allopathic providers

- independent provider whose remedies for illnesses produce effects different from those of the disease - Practitioners who fall into this category are Doctors of Medicine (MDs). - Both allopathic and osteopathic providers us scientific modalities (drugs and surgery) in providing care for patients and both serve as primary care physicians or board certified specialists. Both complete a bachelor's degree, 4 years of medical education, and 3 - 7 Yeats of medical speciality training (residency). After completing the internship year, interns are eligible to sit for the third part of the licensing examination > if they pass, they are entitled to practice medicine without the supervision of licensed physicians. All interns will complete the remaining years of residency to be eligible to sit for the board speciality exams (and become board certified in their specialty)

Nonollopathic Providers

- independent providers who provide nontraditional forms of health care - practicing CAM or complementary/integrative medicine - Providers include: chiropractors, acupuncturists, naturopaths (use natural therapies), herbalists, and homeopaths (use doses of herbs, mineral and poisons for therapy)

Medical Practice

- medical practices that are provided under the supervision of a physician or the health care provider - services are offered at different levels: primary medical care, secondary medical care, and tertiary medical care - ranges from primary, secondary, acute, subacute, tertiary care and long term practice includes restorative care, long term care or chronic care; end of life practice (more on page 357).

Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)

- most notable change to US health care during George W. Bush - Components: voluntary outpatient prescription drug benefit for people on Medicare, known as Part D, and health savings account (HSAs). HSAs are tax free savings accounts that can be used to pay for near term medical expenses incurred by individuals, spouses, and dependents and to save for future longer term costs.

Voluntary Hospitals

- nonprofit hospitals administered by not-for-profit corporations or charitable community organizations - Make up one-half of all hospitals in the US

Patient-Centered Primary Care Collaborative (PCPPCC)

- not for profit - dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home - relates to Medicaid expansion, payment rates for primary care, primary care provider shortages, and Center for Medicare and Medicaid Innovation to test various service delivery and payment models

Freestanding non-hospital based, speciality facilities

- offers a single service - services include simple radiograph technology (x-rays) and computed tomography (CT) and magnetic resonance imaging (MRI -used for viewing the body's anatomical structures in serval planes

Registered nurses (RNs)

- one who has successfully completed an accredited academic program and a state licensing examination - Three educational paths: Bachelor's degree (BSN), associate degree (ADN), and diploma from an approved nursing program. - ADN takes 2 to 3 years and are offered by community or junior colleges. Diploma programs are offered by hospitals and last for 3 years.

retail clinics

- operated by outside company or hospital and are staffed with nurses, nurse practitioners, and physician assistants - Concept was born in 2000. Represent an entrepreneurial response to consumer demand for fast, affordable treatment of easy to diagnose conditions. - insurers now have contracts with clinics allowing patients to pay only copays

Health Insurance Marketplaces

- organizations established to create more organized and competitive markets for purchasing health insurance - Had the biggest impact on allowing the uninsured to gain access to insurance and access to care. It simplifies the search for health coverage by gathering options available for consumers in one place. Run by the state or federal government. Created for two groups: individuals buying insurance on their own and small business with up to 50 employees. - Marketplace for small business is called Small Business Health Options Program (SHOP) Marketplace - Marketplace consumers can compare plans based on price, benefits, quality, online, by phone/chat/or in person. - Insurance plans in Marketplaces are offered by private companies and must meet the same set of benefits called essential health benefits

Ambulatory surgery centers

- perform same-day surgeries where hospital stay following the surgery is not needed - most surgical procedures are performed in these types of facilities - advances in surgical equipment and materials, development of noninvasive or minimally invasive surgical and nonsurgical procedures and reduced coverage by insurance companies for hospital stays lead to increase in ambulatory surgical procedures as alternatives to inpatient surgery

Teaching hospitals

- responsibility to prepare new health care providers - medical schools, universities, and medical residency programs - Not affiliated with medical schools provide medical residency programs, clinical education for nurses, allied health personnel, and technical specialties

A Brief History of Health Care Delivery in the US

- self-care and self-treatment - Colonial times through the latter portion of the 19th century health care and medical education in the US lagged compared to Great Britain and Europe. Health care provided was by family members and neighbors and home and fold remedies. Early medical education is not grounded in science. Prior to 1870, medical education was through apprenticeship with a practicing physician. Medical care was primitive and considered to be more of a trade profession and health care was provided in the patient's home. - Hospitals were in large cities and seaports like NY, Philly, and New Orleans. Worked as a social welfare function. Almshouses and penthouses. - Late 19th century, health care was from patient's home to office into hospitals. Main reasons was the building and staffing of many new hospitals (thought that setting should be about patient care, staffed with trained people, and equipped with medical supplies and instruments). Treat more patients in a central location. - Latter of the 19th century., medical procedures that were backed by scientific findings replaced rational hunches, good ideas, and home remedies. Germ theory of disease and identification of infectious disease agents lead to the control of communicable disease (leading health problems of that period). - 20th century communicable disease were leading causes of death. Mortality rates were declining because of public health measures. WW1 and influenza. - 1920s shift in the US as chronic disease moved past communicable disease as the leading causes of death. Changes in health care with new medical procedures (X-ray therapy, surgical procedures, chemotherapy, group medical practices), medical equipment and instruments (electrocardiograph). Training were improved and more specialized. 3.9% of all goods and services produced by the nation in 1929 was to health care. - US medicine was limited to patients and physicians. Diagnosis, treatment, and fees for services were confidential between patients and physicians. Simple and based on relationships. Payments varied. - 1940s WW2 effected health care > had to employers' use of health insurance to lure workers to their companies. Large number of men and women in armed forces lea to shortage of workers. Government put restrictions on wages that companies could pay their employees because of lack of resources. So, companies began to use health insurance to recruit and retain workers. - 1940s and 50s > medical procedures and processes developed applications in civilian medicine. health facilities to treat long term diseases. Improved procedures, equipment, and facilities and the increase of noncommunicable disease = cost of health care rise. End of the 1950s, shortage of quality health care in the US and maldistribution of health care services (metro areas were better served than rural) - 1960s > increase interest in health insurance and workers and their agents bargain fo better health benefits. Third-party payment system was a standard method of payment for health care costs now. Democrats led a federal policy change to increase access to health care through the 1965 authorization of Medicare and Medicaid of the SS Act. Government increased funds for medical research and technology to support transplants and life extension. - 1960-1970s > Hill Burton Act has stimulated growth of health care facilities and demand for health care services. Lead to the rise in health care costs and need for better planning in health care delivery. - 1980s > deregulation of health care delivery. 1981 Reagan said that the administration would let competitive market (not governmental regulation) shape health care delivery. Proliferation in medical technology and new health care issues like medical ethics and elaborate health insurance programs - 1990s > presidential campaign brought attention the problems with health care delivery. Clinton saw the system fail to cover everyone and costs threatened to bankrupt the government and American industry. Changes in organization and financing of health care. - Late 1990s > managed care was the dominate form of health care financing and delivery but it was not supported. Clinton offered the SCHIP

Speciality Hospitals

- subset of the private hospitals; stand alone, single specialty facilities not within the walls of a full-service hospital - a standalone single speciality (women's health, surgery, cardiac, or orthopedic) facility not within the walls of a full-service hospital - most are owned (knowns as physician-owned hospitals POHs). General hospitals say that it is a grab for money by the physicians. Physicians say that it allows them to practice medicine they way it should be practiced without answering to a hospital administrator who is trying to cut profits. - ACA put a band on building or expanding POHs. But, data showed that POHs do not select more profitable or less disadvantaged patients, or to provide lower value care. And ratings CMS and USDHHS that POHs did well in hospitals quality, costs, and consumer satisfaction. ACA lifted the ban.

managed care

A system that integrates the functions of financing, insurance, delivery, and payment and uses mechanisms to control costs and utilization of services. - Seeks to achieve efficiency by integrating four functions of health care delivery, employs mechanisms to control utilization of medical services, and determines the price at which searches are purchases and how much providers get paid - With managed care, the increase of health care costs slowed in the mid 1990s. Health care is a segment of US economy that continues to grow consistency faster than the cost of inflation. - Slowdown in health care costs that was attributed to managed care would be just a one-time savings.

open competition

Allowing consumers to regulate delivery by making choices about where and from whom they receive their care. Thought that the resulting competition would. help squeeze out costly waste and ineffective costs. Provide good care at a lower price. Competitive market approach cons: physicians do not advertise the cost of their services, physicians tells the patients which hospital to go and when to check out and in, providers offer more and more searches to entice the market to shop with us.

1964 amendments to the Hill-Burton Act

Called for comprehensive planning on regional level. Purpose was to make efficient use of federal funds by preventing duplication of facilities. Depended on good faith and could not be enforced. Showed that we need powerful legislations to control costs and coordinate and control growth in health care facilities.

National Health Planning and Resources Development Act of 1974

Combined pieces of previous legislations to put teeth into comprehensive planning efforts. Legislation led to the formation of health systems agencies throughout the entire country. Purpose was to put costs by preventing the building of unnecessary facilities or purchase of unnecessary equipment. 1980 Reagan eliminated the program because people saw it as a unnecessary government bureaucracy.

effective

Delivering health care based on scientific evidence

Medicare and Medicaid

Enacted to provide care for elderly, disabled, and the poor

National Health care Quality and Disparities Report (QDR)

Findings on health care quality and health care disparities was integrated into a single document. Both the NHQR and NHDR are built on.

The Joint Commission

the predominant organization responsible for accrediting health care facilities - not-for-profit organization - Health care facilities/organizations that are accredited by the Joint Commission: ambulatory health care centers, behavioral health care organizations, independent or freestanding laboratories, home care agencies/organizations, hospitals, and long-term care facilities - Must complete an application and undergo an on-site survey (visit) by a Joint Commission survey team. They conduct an unannounced visit to accredited health care organizations to evaluate standards of compliance.

Accreditation

the process by which an agency or organization evaluates and recognizes an institution as meeting certain predetermined standards - The Joint Commission (Joint Commission on Accreditation of Health care Organizations JCAHO) are responsible for accrediting health care facilities.

medically indigent

those lacking the financial ability to pay for their own medical care - Some clinics are funded through tax dollars or run as for profit or not for profit facilities. Most clinics are located in urban areas or rural areas that are underserved by the private sector - Public health clinics and community health centers (CHCs) are two examples go these clinics. - Health care services of LHDs (local health department): range from prevention oriented programs to complete perusal health services

self-care or self-treatment

- category of health care in which people have tried to help or treat themselves; deals with minor emergencies, nursing care, and relief of minor pains or ailments - assumed that most people would engage in a type of self-care prior to seeking professional help

Long Term Care

- different kinds of help that people with chronic illnesses, disabilities, or other conditions that limit them physically or mentally need - time-intensive skilled nursing care may be needed - long term services and supports (LTSS) assist people in maintaining and improving functioning and quality of life and can include help from other people, special equipment, and assistive devices - LTSS should: fit the needs of different individuals, address changing needs, and suit their personal preferences - provided in nursing homes, facilities for mentally and emotionally disturbed, assisted-living facilities, and adult and senior day care centers - helps people live at home rather than institutions

Comprehensive Health Planning and Public Service Amendments of 1966

- Authorized funds for state and area wide Comprehensive Health Plantings Agencies. Failed.

Inpatient care facilities

- Patient stays overnight, such as a hospital. - Hospitals, nursing homes, and assisted living facilities. Main purpose is to provide a place for secondary and tertiary care.

State Children's Health Insurance Program (SCHIP)

- health care coverage for uninsured children

community health centers (CHCs)

- known initially as neighborhood health centers. - receive funding from the Public Health Service (PHS) Act are known as Federally Qualified Health Centers (FQHCs)

Kissick's triangle

Access is just as important as quality and cost containment and vice versa. AN expansion of any one of the angles compromises one or both of the other two.

almshouses

Called poorhouses. Funded by the local government to provide food, shelter, and basic nursing care for indigent people (elderly, homeless, orphans, ill, disabled) who could not be cared by their families.

Secondary Medical Care

specialized attention and ongoing management for common and less frequently encountered medical conditions, including support services for people with special challenges due to chronic or long-term conditions provided by physicians ideally upon referral from a primary care provider

Public Hospital

- a hospital that is supported and managed by governmental jurisdictions - Operated by agencies at all levels of government - Federal government operated include: military hospitals and many hospitals run by the Veterans Administration and Indian Health Service. States and local government operated: university hospitals, state mental hospitals, and local city and country hospitals

Types of Health Care Providers

- 2014, 12.4 million were employed in the health service industry. 1 of ever 12 employed civilians - Health care workers are projected to be the fastest growing occupational group during 2014 to 2024. 2.3 million new jobs, 1 in 4 of all new jobs in the the 10 year period. Heath care workers are needed in rural and inner city areas. - Two-fifths (39%) employees work in hospitals, more than one-fourth (26%) work in offices of health practitioners, one-fifth (20%) work in nursing and residential care facilities, and 8% work in home health services and outpatient, labs, and other ambulatory care services. Changes in work settings: fewer persons working in hospitals and more employed in nursing homes and ambulatory care settings. - Six different groups of health care workers: independent provides, limited care providers, nurses, nonphysical practitioners, allied health care professionals, and public health professionals

Nurses

- 4 to 5 million individuals who work in the nursing profession. - Registered nurses, licensed practical nurses, and ancillary nursing personnel (nurses' aides) - Nurse outnumber physicians, dentists, and any other single group of health care workers in the US - Separation based on their level of education and type of preparation.

National Committee for Quality Assurance (NCQA)

- A private not for profit organization that has been assessing and accrediting health care plans since 1990s - Assesses how well a health plan manages and delivers health care in four ways: through accreditation, through certification, through Health care Effectiveness Data and Information Set (used to measure the performance in key areas like immunizations and mammography and members' satisfaction with their care in areas, through physician recognition programs that identify physicians who provide quality care in areas like diabetes, back pain, and heart/stroke care - Participation is voluntary. Accredited health plans covers 109 million 70.5% of all Americans enrolled in health plans

Access to Health Care

- Access has been and continues to be a major health policy issue in the US.Health insurance coverage and generosity coverage are major determinants of access to health care. - Since act, number of uninsured has declined.91% of Americans now have health insurance. 28.8 million uninsured, they are adults in low-income working families and minorities. The uninsured numbers are greatest in states that did not expand Medicaid eligibility under ACA. Congressional Budget Office projected that the percentage of nonelderly population with health insurance will remain steady at 90%. - The uninsured do not lack emergency or urgent care. The uninsured are less likely than those with insurance to receive preventive care and services for major health conditions and chronic diseases.

Health care in the US

- Changes made in 20120 to improve access to health insurance - Health care delivered by array of providers and paid in different ways. - Does America have a health care delivery system? The phrase suggest order, integration, and accountability that do not exist. Communication, collaboration, or systems planning is limited and incidental to their operations. - We have a process where health care professionals provide services to deal with disease restoring health to citizens.

payments of the US health care bill

- Come from four sources: consumers themselves, third party payments (private insurance companies, governmental programs insurance programs) - out of pocket payments, federal government, other third parties, and private health insurance

Federally Qualified Health Centers (FQHCs)

- Community health center that receives funding under Section 330 of the Public Health Service (PHS) Act - Operates under the auspices of Bureau of Primary Health Care. Additional funding was given by the ACA. Served 22 million patients (some incomes at or below poverty level, uninsured, and those who depended on Medicaid)

Home health care

- Demand of home health care has been driven by restructuring of the health care delivery system, technological advances that enable people to be treated outside a hospital and to recover more quickly, and the cost containment pressures that have shortened hospitals stays - Care that is provided in the patient's residence for the purpose of promoting, maintaining, or restoring health while minimizing the effects of disability and illness. - Can be long term to help chronically ill patient avoid institutionalization. Can be short term to assist a patient following an acute illness and hospitalization until the patent is able to return to independent functioning. - Home health care can be provided either through a formal system of paid professional health caregivers or an informal system where the care is provided by family, friends, and neighbors. Medicare is the largest single payer for home health care (one-third of total annual expenditures) [and medicaid are the largest payers for home health care services] - The need for health caregivers is needed because older people are increasing and their expressed desire to rain in their homes for care.

Accreditation of Health Care Facilities

- Determine the quality of a health care facility is to find out if it is accredited by a reputable group

Urgent/emergent Care Centers

- Fill the gaps in delivery system created by private physician appointment and unavailability during nonbusiness hours. - Alternative to a hospital emergency apartment during hours when private physicians are not available. - Provide quicker service with less paperwork (cash and credit)

Health Care Facilities and Their Accreditation

- Health care facilities are physical settings in which health care is provided. Divided into inpatient and outpatient care facilities. - Hospitals are categorized by home ownership. Types of hospitals: Private hospitals, public hospital, voluntary hospitals - Classifying hospitals is dividing them into teaching and non teaching. - Classifying hospitals os by the services offered. Full service hospitals or limited service hospitals

Understanding the Structure of the Health Care System

- Health care system is big and complicated. Expensive because there are many stakeholders. Complicated because health care policy is intertwined with other policies and politics and ideological viewpoints of the decision makers. - Issues of health care system can be represented by cost containment, access, and quality triangle

The Cost of and Paying for Health Care

- In 2014, health expenditures grew 5.3% to $3.0 trillion and consumed 17.5% of gross domestic product (GDP). Estimated that health care spending will continue to grow at 5.8% per year through the next decade. - Spending is expected to reach 5.4 trillion and 19.6% of the GDP by 2024. $9,523 per person. - US health care system is the most costly in the world. - US spends more on health care than the next 10 biggest spenders combined: Japan Germany France China United Kingdom Italy Canada Brazil Spain and Australia - Actual costs of the service is not known until after the service. - Starting in 2013, to make the health care system more affordable and acceptable, the Centers for Medicare and Medicaid Service released data and information comparing the charges of the 100 most common inpatient services, 30 common outpatient services, all physicians and other supplier procedures and services, and all Part D prescription for Medicare patients. Data showed that there were variations across the country and within communities in what providers charged for common services. - Health care continues to grow at an unsustainable rate because: (1) major coverage expansions of Medicaid and private health insurance under the ACA (2) paying providers and hospitals in ways that reward doing more than being efficient (3) aging US population with chronic health conditions (4)demand for medical advances in the form of drugs, technologies, services, and procedures (5) price insensitive patients who have limited out of pocket costs (6) lack of evidence to make decisions on which medical care is best (7)hospital and providers that are gaining market share and are better to demand higher prices (8) supply and demand (9) legal issues - Payments for the US health care bill. In 2014, about one-tenth of all payments were direct or out of pocket payment. Other nine-tenths comes from third party payments. Private insurance companies paid about one-third (32.7%) of the health care bill in 2014 through premiums by employees and employers. Governmental insurance programs are funded by federal and state taxes and premiums and about two-fifths (40.9%) were paid for governmental insurance programs. - Cost savings from Medicare and Medicaid. Health care costs can be lowered because millions of people who were uninsured before the law will be paying premiums and many of them are young and healthy and will not use a lot of health care. - recent methods of reimbursement: packaged pricing, resource-based relative value scale, capitation, prospective reimbursement, and pay-for-performance - Current Procedural Terminology (CPT) code. Reimbursement of HMO, Managed care organizations, and PPO

Long-term Care Options

- Includes traditional institutional residential care, special units, halfway houses, group homes, assisted-living facilities, transitional (step-down) care in a hospital, day care facilities for patients of all ages with health problems that require special care, and personal home health care. - Elders are the biggest user of long-term care. Includes people with disabilities or chronic conditions, and those whit acute and subacute condition - Home health care

Public Health Practice

- Incorporates the development and application of preventive strategies and interventions to promote and protect the health of populations - Primary component is education - Health education will promote health and health of the community. Attempts to empower and motivate people to discontinue unhealthy behaviors and adopting healthy ones. - Takes place in governmental health agencies, voluntary health agencies, social service agencies, schools, businesses and industry, and traditional medical care settings

Components of the Affordable Care Act to Increase Access to Care

- Individual mandate - Expansion of public programs - health insurance marketplace - Changes to private insurance - employer responsibility provision

21st century health care delivery in the US

- Institute on Medicine (IOM) claimed that health care harms and fails to deliver benefits. - Health cares system lacked coordinated, comprehensive services. Lead to wasteful duplication of efforts and unaccountable gaps in care.

Training and Education of Nurses

- LPNs

American Medical Association (AMA) Physician Masterfile

- Lists more than 200 speciality categories. Primary care specialties make up the largest percentage of physicians (family medicine, general practice, internal medicine, pediatrics) - Worried that not enough primary care physicians will be trained. Bigger concern with the passage of ACA because it emphasizes on prevention and primary care.

National Quality Strategy

- Mandated by the ACA to serve as catalyst and compass for nationwide focus on quality improvements efforts and measuring quality - Aims is to provide better more affordable care for individuals and the community. Used to assess the efforts to improve quality care - NQS applies six priorities that address the most common health concerns that affect most Americans. - To assist stakeholders with their work for improving the quality, NQS includes nine levers that can be used by the stakeholders to align their work to the NQS.

Advanced Practice Registered Nurses (APRNs)

- Master's degree programs are aimed at specialties such as use practitioners. clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives. - Largest portion of APRNs is nurse practitioners. They asses patients, order, and interpret diagnostic test, make diagnoses, and initiate and manage treatment places (prescribing medications). They provide high quality care in a cost effective manner and considered as primary care providers in chronically medically underserved inner-city and rural areas. ACA funded to increase the number of those trained as NPs and number of clinics in which NPs practice. - Barriers to NPs: NPs in 20 states and District of Colombia have full practice authority. 19 states require NP to have a formal, written collaborative agreement with a physicians and restrict NP practice in at least one domain. 12 states require physician supervision or delegation. - Nurses with doctorates teach, conduct research, and prepare other nurses or hold administrative positions in their institution.

Licensed Practical Nurse (LPN)

- One who is prepared in 1 to 2 year programs to provide nontechnical bedside nursing care under the supervision of physicians or registered nurses - Complete 1 to 2 years of education in a vocational, hospital, or associate degree program and pass a licensure exam - Knowns as licensed vocational nurses (LVNs) - Care for people who are sick, injured, convalescent, or disabled under the supervision of physicians or registered nurses

chiropractors

- a nonollopathic independent health care provider who treated health problems by adjusting the simple column - approach to treatment: the identification of the misalignment through x-rays and realignment of the bones through series of treatments called "adjustments" - Educated in 4-year chiropractic colleges accredited at the Council on Chiropractic Education. Most allopathic and osteopathic program students enter in chiropractic programs after a bachelor's degree. Earn a Doctor of Chiropractic (DC) degree. - Chiropractors are licensed in all 50 states and must pass a state licensing exam or exam given by the National Board of Chiropractic Examiners.

Restorative Care

- care that is provided after successful treatment or when the progress of an incurable disease has been arrested (during the remission in cases of oncogenic, cancerous, disease) - includes follow up to secondary and tertiary care, rehabilitative care, therapy, and home care - settings include inpatient and outpatient rehabilitation units, nursing homes, assisted living facilities, halfway houses, and private homes

Outpatient care facilites

- Patient receives care and does not stay overnight. Patient receives ambulatory care without being admitted as an inpatient. - Care and procedures that were performed only on an inpatient basis are increasingly being performed in a variety of outpatient settings (like surgical procedures) Growth of outpatient care facilities have resulted from a combination of new medical and diagnostic procedures, technological advances, consumer demand for user-friendly environments, reimbursement process, and financial mandates from insurance companies and government - Found in communities with health care practitioner's offices, clinics, primary care centers, retail clinics, urgent/emergent care centers, ambulatory surgery centers, and freestanding service facilities - Outpatient care facilities that people are the most familiar are health care practitioners' offices that house private practices. These practices are referred to as group practices to distinguish them from solo practices. Two or more physicians practice as a group the facility in which they provide medical services is called a clinic. - Some clinics only provide care for individuals with special health needs; others accept patients with wide problems. Clinics do not have inpatient facilities and hospitals do. Some clinics have administrative relationship with inpatient facilities; other clinics may be freestanding or independent of all other facilities. - Outpatient care facilities include: retail clinics found in pharmacies, supermarkets, and retail stores. - Urgent/emergent care centers. Ambulatory surgery centers. Freestanding, non-hospital-based, speciality facilities. - In stable or shrinking communities where an adequate number of health providers exist, freestanding ambulatory care facility are viewed as unfriendly competition.

Health Care System: Function

- Purpose of ACA: expand health insurance coverage, hold insurance companies accountable, lower health care costs, guarantee more choices, and enhance the quality care for all Americans. Some parts of ACA went into effect (Patient Bill of Rights), some of its biggest parts were rolled out in 2014, and implementation of others parts have been postponed or delayed. Others have been repealed and final options will be implemented in 2020.

Patient Protection and Affordable Care Act and Health Care and Education Reconciliation Act of 2010

- Referred to as ACA - President Obama signed into law these two bills - Many portions have not been smooth.

Children's Health Insurance Program Reauthorization Act of 2009 (CHIP)

- Signed by Obama - Law was expanded to 4.1 million uninsured children and was funded by 62 cents increases in federal tax on cigarettes.

Quality of Health Care

- US health care system underperforms relative to other countries on most dimensions of performance and people in the US should be receiving better care. - Quality health care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. - Institute of Medicine (IOM) delineated that quality health care should be: effective, safe, timely, patient-centered, equitable, efficient - Agency for Health care Research and Quality and HHS have reported on progress and opportunities for improving health care quality as mandated by US Congress by publishing National Health care Quality Report (NHQR) and the National Health care Disparities Report (NHDR) - National Committee for Quality Assurance (NCQA) measures the health care quality. - Items that deal with quality in ACA: requiring health care plans to offer preventive services without charging a copay, co-insurance, or deductible; providing information about the quality of nursing homes and making it easier to file complaints about the quality of care provided; and incentivizing health care providers to use electronic medical records. - National Quality Strategy, accountable care organizations (ACOs), and the patient-centered medical home program aimed at improving the quality of health.

The World Health Report 2000 - Health Systems: Improving Performance

- World Health Organization's report; and the IOM provided recommendations to provide direction for changing the health care delivery. - US health system ranked 37th

Patient-Centered Medical Home (PCMH)

- a care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand - responsible for providing all patient's health care needs or appropriately arranging a patient's care with other qualifies providers - Agency for Health care Research and Quality identified five functions and attributes of a medical home: (1) comprehensive care (2) patent centered care (3) coordinated care (4) accessible services (5) quality and safety - Gained momentum in medical community and in 2006 Patient-Centered Primary Care Collaborative (PCPPCC) was created.

Private (proprietary or investor-owned) hospital

- a for profit hospital; owned as a business for the purpose of making profit - most for-profit hospitals belong to one of the large hospital management companies

complementary/alternative medicine (CAM)

- a group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine - complementary/integrative medicine - complementary: non-mainstream approach together with conventional medicine - alternative: using a non-mainstream approach in place of conventional medicine - CAM is the fastest growing areas of health care today. - Natural products was the most commonly used complementary approach and pain was the condition for which most use a complementary approach - Percentage of CAM use increased with prayer. Americans pay for most CAM out of pocket ($33.9 billion). Two-thirds was spent on self-care purchases of CAM products, classes, and materials, and practitioner visits. - Coverage depends on state laws, regulations, and general statements about it. - Categories: natural products (botanicals- herbal medicines), mind-body medicine (mediation yoga acupuncture hypnotherapy tai chi), manipulative and body based practices (spinal manipulation and massage), and other practices (movement therapies, energy fields, healers, and whole medical systems)

Public Health Professionals

- a health care worker who works in a public health organization - support the delivery of health care by hands on providers as health physicians, dentists, nurses, and dietitians (fund by federal, state, local, and voluntary health agencies) - Ex. Environmental health workers, public health administrators, epidemiologists, health education specialists, public health nurses and physicians, biostatisticians, US Surgeon General, research scientists for the CDC - Make possible the care that is practiced in immunization clinics, WIC, dental health clinics, and sexually transmitted infection clinics. School nurses - Financed by tax dollars and serve the economically disadvantaged

Health Maintenance Organization (HMO) 1973

Provided loans and grants for planning, development, and implementation of combined insurance and health care delivery organizations and required minimum prescribed services be included in the HMO arrangement.

Heath Security Plan or American Health Security Act of 1993

The comprehensive health care reform introduced by President Clinton, but was never enacted. Point was to provide universal coverage. 6th time concept of universal coverage was defeated. Plan transformed the private health care system in the US.

1918-1919 influenza

WW1 and the 1918-1919 influenza pandemic lead to spikes in mortality rates. Deadliest pandemic in history that killed 100 million people.

Hospice Care

a cluster of special services for the dying that blends medical, spiritual, legal, financial, and family support services - admission is being terminally ill with a life expectancy of less than 6 months - first hospice program was in 1974

Rehabilitation centers

a facility in which restorative care is provided following injury, disease, or surgery - can be apart of a clinic or hospital but can be a freestanding facilities - can operate on both outpatient and inpatient basis - providers who work in rehabilitation centers include physical, occupational, and respiratory therapist and exercise physiologists

intern

a first year resident

third-party payment system

a health insurance term indicating that bills will be paid by the insurer and not the patient or the health care provider - Insurer is the government, private insurance companies, or self-insured (third party) and they reimburse (pays the bills) to the provider (second party) for health care given to the patient (first party) - Fourth party - purchaser of the insurance, often employer - Government and private insurers pay medical bills with tax dollars and collected premiums - Growth of third party system lead to the cost of health care to rise rapidly than before because patents enjoyed increased access to care without or with little out of pocket expenses.

resident

a physician who is training in a specialty

primary care

clinical preventive services, first-contact treatment services, and ongoing care for commonly encountered medical conditions - 80% of necessary medical care is provided by primary care

timely

delivering health care in a way that reduces waits and sometimes harmful delays

equitable

delivering health care that does not vary in quality because of characteristics of patients

efficient

delivering health care that maximizes resources and avoids waste

safe

delivering health care to patients that avoids injuries from the care

Long Term Practice

divided in two subcategories: restorative care and long term care

Independent Providers

health care professionals with the education and legal authority to treat any health problem - specialized education - divided into allopathic, osteopathic, and nonollopathic providers

Osteopathic providers

independent health care provider whose remedies emphasize the interrelationships of the body's systems in prevention, diagnosis, and treatment - Doctors of Osteopathic Medicine (DOs). Educational requirements and methods of treatment used by DOs have not remained consistent. - Practice of osteopathy was started in 1874 by Andrew Taylor Still. - Distinctive feature of osteopathic medicine is recognition of the reciprocal interrelationship between structure and function of the body. - They use more manipulation in treating health problems and there are more holistically orientated.

patient-centered

providing health care that is respectful of and responsive to patient preferences, needs, and values

Tertiary Medical Care

specialized and technologically sophisticated medical and surgical care for those with unusual or complex conditions (generally no more than a few percent of the need in any service category) provided in specialty hospitals, academic health centers, or on specialized floors of general hospitals for people with illnesses such as cancer and heart disease, and procedures like heart bypass surgery