HCAM-230 Chapters 7, 8, 9, 10, 11
alternative medicine
(CAM) nontraditional remedies, for example, acupuncture, homeopathy, naturopathy, biofeedback, yoga exercises, chiropractic, and herbal therapy
closed panel
(in-network, closed access) A health plan that pays for services only when provided by physicians and hospitals within the plans network
open panel
(open access)health care plan that allows insureds access to providers outside the panel, but some conditions apply, such as out-of-pocket costs
hospice
A cluster of special services for the dying, which blends medical, spiritual, legal, financial, and family-support services. The venue can vary from a specialized facility to a nursing home to the patient's own home.
credentials committee
A committee that reviews qualifications of clinicians for admitting privileges.
executive committee
A committee within the governing body that has monitoring responsibility and authority over the hospital. Usually it receives reports from other committees, monitors policy implementation, and makes recommendations. The medical staff also have a separate executive committee that establishes policy and has oversight regarding medical matters.
medical staff committee
A committee within the governing body that is charged with medical staff relations in a hospital. For example, it reviews admitting privileges and the performance of the medical staff.
adult day care
A community-based, long term care service that provides a wide range of health, social, and recreational services to elderly adults who require supervision and care while members of the family or other informal caregivers are away at work.
medically underserved
A designation determined by the federal government. It indicates a dearth of primary care providers and delivery settings, as well as poor health indicators of the populace. The majority of this population group are Medicaid recipients.
deemed status
A designation used when a hospital, by virtue of its accreditation by the Joint Commission or the American Osteopathic Association, does not require separate certification from the DHHS to participate in the Medicare and Medicaid programs.
patient's bill of rights
A document that reflects the law concerning the rights a patient has while confined to an institution such as a hospital. Some common issues addressed in the bill of rights include confidentiality, consent, and the right to make decisions regarding medical care, to be informed about diagnosis and treatment, to refuse treatment, and to formulate advance directives.
walk-in clinics
A free-standing , ambulatory based clinics in which patients are seen without appointments on a first-come, first-served biases Non routine episodic based care Ex. Patients going in for flu symptoms, wellness screening or physical for school
free clinic
A general ambulatory care center serving primarily the poor and the homeless who may live next to affluent neighborhoods. Free clinics are staffed predominantly by trained volunteers, and care is given free or at a nominal charge.
triple-option plan
A health insurance plan that combines the features of indemnity insurance, HMO, and PPO; the insured has the flexibility to choose which feature to use when using health care services.
swing bed
A hospital bed used for acute care or skilled nursing care, depending on fluctuations in demand.
short-stay hospital
A hospital in which the average length of stay is less than 25 days.
specialty hospital
A hospital that admits only certain types of patients or those with specified illnesses or conditions. Examples include rehabilitation hospitals, tuberculosis hospitals, children's hospitals, cardiac hospitals, orthopedic hospitals, etc.
general hospital
A hospital that provides a variety of services, including general medicine, specialized medicine, general surgery, specialized surgery, and obstetrics, to meet the general medical needs of the community it serves. It provides diagnostic, treatment, and surgical services for patients with a variety of medical conditions.
teaching hospital
A hospital with an approved residency program for physicians.
Independent Practice Association (IPA)
A legal entity that physicians in private practice can join so that the organization can represent them in the negotiation of managed care contracts.
hospital
A licensed institution with at least six beds, whose primary function is to deliver diagnostic and therapeutic patient services for various medical conditions. A hospital must have an organized physician staff, and it must provide continuous nursing services under the supervision of registered nurses.
Primary Care Case Management (PCCM)
A managed care arrangement in which a state contracts directly with primary care providers, who agree to be responsible for the provision and/or coordination of medical services for Medicare recipients under their care.
medical records committee
A medical committee that is responsible for certifying complete and clinically accurate documentation of the care given to each patient.
quality improvement committee
A medical committee that is responsible for overseeing the program for continuous quality improvement.
infection control committee
A medical committee that is responsible for reviewing policies and procedures for minimizing infections in the hospital.
inpatient day
A night spent in the hospital by a person admitted as an inpatient. It is also called a patient day or a hospital day.
community hospital
A nonfederal, short-stay hospital whose services are available to the general public.
advance directives
A patient's wishes regarding continuation or withdrawal of treatment when the patient lacks decision-making capacity.
moral agent
A person, such as a health care executive, who has the moral responsibility to ensure that the best interest of patients takes precedence over fiduciary responsibility toward the organization.
chief of service
A physician who is in charge of a specific medical specialty in a hospital, such as cardiology.
accreditation
A private mechanism designed to assure that accredited health care facilities meet certain basic standards.
utilization review committee
A process by which an insurer reviews decisions by physicians and other providers on how much care to provide
concurrent utilization review
A process that determines on a daily basis the length of stay necessary in a hospital. It also monitors the use of ancillary services and ensures that the medical treatment is appropriate and necessary.
prospective utilization review
A process that determines the appropriateness of utilization before the care is actually delivered.
retrospective utilization review
A review of utilization after services have been delivered.
magnet hospital
A special designation by the American Nurses Credentialing Center, an affiliate of the American Nurses Association, to recognize quality patient care, nursing excellence, and innovations in professional nursing practice in hospitals.
Health Maintenance Organization (HMO)
A type of managed care organization that provides comprehensive medical care for a predetermined annual fee per enrollee.
urgent care centers
A walk-in clinic generally open to see patients after normal business hours in the evenings and weekends without having to make an appointment.
durable power of attorney
A written document that provides a legal means for a patient to delegate authority to another to act on the patient's behalf, even after the patient has been incapacitated.
do not resuscitate (DNR) order
Advance directives telling medical professionals not to perform CPR. Through DNR orders, patients can have their wishes known regarding aggressive efforts at resuscitation.
staff model
An HMO arrangement in which the HMO employs salaried physicians.
group model
An HMO model in which the HMO contracts with a multispecialty group practice and separately with one or more hospitals to provide comprehensive services to its members.
mixed model
An organizational arrangement in which an HMO cannot be categorized neatly into a single model type because it features some combination of large medical group practices, small medical group practices, and independent practitioners, most of whom have contracts with a number of managed care organizations.
average daily census
Average number of hospital beds occupied daily over a given period of time. This measure provides an estimate of the number of inpatients receiving care each day at a hospital.
days of care
Cumulative number of patient days over a given period of time.
primary health care
Essential health care that constitutes the first level of contact by a patient with the health delivery system and the first element of a continuing health care process.
licensure
Licensing of a health care facility that an organization must obtain to operate. Licensure is conferred by each state upon compliance with its standards.
nonurgent conditions
Medical conditions that do not require the resources of an emergency service, and the disorder is nonacute or minor in severity.
urgent conditions
Medical conditions that require medical attention within a few hours, a longer delay presents a possible danger to the patient, and the disorder is acute but not severe enough to be life threatening.
critical access hospital
Medicare designation for small rural hospitals with 25 or fewer beds that provide emergency medical services in addition to short-term hospitalization for patients with emergency medical services in addition to short-term hospitalization for patients with noncomplex health care needs. CAHs receive cost-plus reimbursement.
multihospital system
Operation of two or more hospitals owned, leased, sponsored, or contractually managed by a central organization.
discharge planning
Part of the overall treatment plan designed to facilitate discharge from an inpatient setting. It includes, for example, an estimate of how long the patient will be in the hospital, what the expected outcome is likely to be, whether any special requirements will be needed at discharge, and what needs to be facilitated for postacute continuity of care.
secondary care
Routine hospitalization, routine surgery, and specialized outpatient care, such as consultation with specialists and rehabilitation. Compared to primary care, these services are usually brief and more complex, involving advanced diagnostic and therapeutic procedures.
Home health care
Services such as nursing, therapy, and health-related homemaker or social services brought to patients in their own homes because such patients are generally unable to leave their homes safely to get the care they need.
palliation
Serving to relieve or alleviate, such as pharmacologic pain management and nausea relief.
conditions of participation
Standards developed by the Department of Health and Human Services (DHHS) that a facility must comply with in order to participate in the Medicare and Medicaid programs.
durable medical equipment (DME)
Supplies and equipment not immediately consumed, such as ostomy supplies, wheelchairs, and oxygen tanks.
carve-out
The assignment through contractual arrangements of specialized services to an outside organization because these services are not included in the contracts MCOs have with their providers or the MCO does not provide the services.
average length of stay (ALOS)
The average number of days each patient stays in the hospital. For individual or specific categories of patients, this measure indicates severity of illness and resource use.
tertiary care
The most complex level of care. Typically, tertiary care is institution-based, highly specialized, and highly technological. Examples include burn treatment, transplantation, and coronary artery bypass surgery.
occupancy rate
The percentage of a hospital's total inpatient capacity that is actually utilized.
gatekeeping
The use of primary care physicians to coordinate health care services needed by an enrollee in a managed care plan.
practice profiling
Use of provider-specific practice patterns and comparing individual practice patterns to some norm.
disease management
Used primarily by health plans, this is a population-oriented strategy involving patient education, training in self-management, ongoing monitoring of the disease process, and follow-up aimed at people with chronic conditions, such as diabetes, asthma, depression, and coronary artery disease.
discharge
a patient who has received inpatient services, the total number of discharges indicate access to hospital inpatient services as well as the extent of utilization
emergent conditions
an acute condition that requires immediate medical attention
community oriented primary care (COPC)
combination of the elements of good primary care delivery with population-based approach to identifying & addressing community health problems
patient-centered care
delivery of health care that respects & responds to patient's wants, needs, preferences so that they can make choices about their care that best fit their circumstances
quanternary care
extension of tertiary care, highly specialized medicine not widely accessed, experimental in nature, research, uncommon diagnostic or surgical procedure, only offered in a limited number of places
indemnity insurance
fee-for-service health insurance; health insurance plan that allows the insured to obtain health care services anywhere & from any physician or hospital. Indemnity insurance & fee-for-service reimbursement to providers are closely intertwined
proprietary hospitals
for-profit hospitals owned by individual, partnership, corporation
surgicenters
freestanding ambulatory center independent from hospital, provide various types of surgical procedures that can be performed on outpatient basis
informed consent
fundamental patient right to make informed choice regarding medical treatment based on full disclosure of medical info. by the providers
board of trustees (board of directors)
governing body of a hospital; is legally responsible for hospital operations, & is charged with defining the mission & long-term direction of the hospital
outpatient services
health care services that are not provided based on an overnight stay in which room and board are incurred
rural hospitals
hospitals located in counties that are not in metropolitan areas
urban hospitals
hospitals located in counties that are part of a metropolitan area
public hospitals
hospitals owned by the federal, state, or local government, serve special groups of beneficiaries
rehabilitation hospitals
hospitals that specialize in providing restorative services to rehabilitate chronically ill and disabled individuals to a maximum level of functioning
ethics committee
interdisciplinary committee responsible for developing guidelines & standards for ethical decision making in the provision of health care & for resolving issues related to medical ethics
living will
legal document, patient puts into writing what their preferences are regarding treatment of terminal illness & use of life sustaining technology. gives physician directive to withhold or discontinue medical treatment when the patient is terminally ill & unable to make decisions
fee schedule
list of fees charged for various health care services
formulary
list of prescription drugs approved by health plan
pint-of-service (POS) plan
managed care plan that allows its members to decide at the time they need medical care (POS) whether to go to a provider on the panel or to pay more to receive services out of network
chief of staff
medical director; physician who supervises the medical staff in a hospital
voluntary hospitals
nonprofit hospitals that required charitable contributions from private citizens or religious organizations
academic medical center
organization of one or more hospitals around a medical school. Apart from the training of physicians, research activities, and clinical investigations become an important undertaking in these institutions
network model
organizational arrangement in which a HMO contracts more than one group practice
IPA model
organizational model in which a HMO contracts with an independent practice association for the delivery of physician services
case management
organized approach for evaluating & coordinating care, particularly for patients who have complex, potentially costly problems that require a variety of services from multiple providers over an extended period
ambulatory care
outpatient services; (1) rendered services to patients who come to physician's office, outpatient departments of hospitals & health centers to receive care. (2) outpatient services intended to serve the surrounding community. (3) certain services that are transported to the patient
utilization review
process of evaluating the appropriateness of services provided
panel
providers selected to render services to the members of a managed care plan; the plan generally refers to them as "preferred providers"
medical home
quality features of primary health care delivery in the primary care settings such as physician office or community health center
accountability
responsibility of clinicians & patients, respectively for the patient & receipt of efficient & quality health care
long stay hospitals (LTCHs)
special type of long-stay hospitals described in sections 1886 of the social security act. LTCHs must meet Medicare's conditions or participation for acute hospitals and must have an average length of stay greater than 25 days. LTCHs serve patients who have complex medical needs and may suffer from multiple chronic problems requiring long-term hospitalization
certification
status conferred by DHHS, which entitles a hospital to participate in Medicare & Medicaid . necessary condition is for the hospital to comply with conditions of participation
telephone triage
telephone access to a trained nurse for expert opinion & advice, especially during the hours when physicians offices are closed
inpatient
term used in conjuncture with an overnight stay in a health care facility such as a hospital
preferred provider organization (PPO)
type of MCO that has panel of preferred providers who are paid according to a discounted fee schedule, enrollees have the option to go to out-of-network providers but incur a higher level of cost sharing for doing so
