Health Issues Exam 2
Hospice Care
-Called "end-of-life" care and representa component of the LTC services -The services are generally brought to the patient but the patient may choose to be admitted to a freestanding hospice center -Hospice care is delivered from a hospital, home health agency, nursing home or free standing hospice
Medical Care In LTC Focuses on three Main (3) areas (UNDER LONG TERM CARE)
-Continuity of care post treatment of acute episode in hospitals -Clinical management of chronic conditions and prevention of potential complications Hospitalization when medically necessary Mental health services -Long-term care patients are often affected/suffer from mental conditions (examples: depression, anxiety disorders, dementia (memory loss), delirium (disturbed state)
Why is the Gatekeeping process important in Managed Care?
-It emphasizes preventive care, routine physical examinations, and other primary care services. -Higher levels of services are obtained on the basis of referral from the PCP.
Mental Health Services (Under Long-Term Care )
-Long-term care patients are often affected/suffer from mental conditions (examples: depression, anxiety disorders, dementia (memory loss), delirium (disturbed state) - The mental disorders range in severity from problematic, to disabling, to fatal. The mental health services are delivered by specialized providers in both outpatient and inpatient facilities
Adult Foster Care(Types Community-Based System (LTC) Services)
: Services characteri7ßd by small, family-run homes providing room, board, oversight, and personal care to nonrelated adults who are unable to care for themselves.
Hospice
: incorporates special services for terminally ill with a life expectancy of six months or less.
Discharges
:total number of patients released from a hospital's acute care beds during a given period.. Discharges measure the number of people who received hospital inpatient services
Gatekeeping
A primary-care provider, often in the setting of a managed-care organization, who coordinates patient care and provides referrals to specialists, hospitals, laboratories, and other medical services. Gatekeeping is an arrangement that requires: - a primary care physician (PCP) coordinates all health services needed by an enrollee
A Hospital MUST
A) Be licensed. B) Have an organized physician staff, C) Provide continuous nursing service under RNs, D) Have a governing body that is responsible for hospital conduct, E) Have a CEO (Administrator) with responsibility for operations, f) Maintain medical records on each patient, G) Have pharmacy services available, H) Provide food services to meet the nutritional and therapeutic requirements of the patients.
Hospital
An institution with at least 6 beds which delivers diagnostic and therapeutic services for medical conditions.
Average length of stay (ALOS):
Average number of a patient spends in the hospital.
Additionally point that is contributing to growth in "Outpatient Care"
CHANGES IN REIMBURSEMENT : financial incentives to reimburse for outpatient care, patients favoring outpatient services -DEVELOPMENT OF NEW TECHNOLOGY : Less invasive procedures, surgical procedures less traumatic, shorter-acting anesthetics, faster recovery time -UTILIZATION CONTROLS: Inpatient hospital stay has been strongly discouraged by various payers. Prior Authorization (pre-certification) required, minimizing length of stay -SOCIAL FACTORS: Patients have a strong patients for 1. Receiving health care in hoe and cummunity- based settings 2. Ginving people a sense of independence 3.Contrl over their lives(Key importance for quality of life)
Developments in Process Improvement: (Why do we continue to require healthcare institutions/providers to achieve and sustain quality improvement efforts/measures in care delivery?)
Clinical Practice Guidelines Cost-Efficiency Critical Pathways Risk Management
Coordination of Care (Domains of Primary Care)
Coordinate the delivery of health services between the patient and the myriad of components of the system, Refer patients to sources of specialized care, Give advice regarding various diagnosis and therapies, To ensure continuity and comprehensiveness, Discuss treatment options, Provide continuing care of chronic conditions
Ambulatory Care constitutes
Diagnostic and therapeutic services and treatment provided to the "walking" ambulatory patient . The term is used synonymously with COMMUNITY MEDICINE
Acute Conditions
Episodic and require short-term but intensive medical interventions Generally respond to medical treatment, treated in hospitals, emergency departments or outpatient clinic settings
PROMOTION OF FUNCTIONAL INDEPENDENCE(Characteristics / Dimensions of Long - Term Care)
Goal is to enable the individual to maintain functional independence. Restoration of function with rehabilitation therapy (when applicable)
How has Managed Care changed and is now financed delivered Identify the issue and Explain and describe the Solution & Impact
Health care has evolved in recent years into an economic form that defies comparison with other sectors of the economy—the "managed care" sector. Managed Care evolved as a result of the competitive market-driven industry — healthcare and insurance. Managed Care offered to solve two fundamental societal health issues: a) rising healthcare costs and b) fragmented healthcare delivery Managed Care spans a wide variety of organizations , but the key idea is that MCO'S are actively involved in the delivery of health care and in the provision of health insurance
Home Health Care (Types Community-Based System (LTC) Services)
Health care provided in the home of the patient by health care professionals. (examples: nursing care, short-term rehabilitation, homemaker services, provide selective medical supplies and equipment)
What information is important to YOU when considering a Provider or healthcare Organization ?
History, Quality, Education, Licensing, Consumer ratings, Rating within the Health organization, Cost
(Types Community-Based System (LTC) Services)
Home Health Care Adult Day Care Adult Foster Care Senior Centers
Describe the important roles in outpatient services and primary care in today's health care delivery
In recent years, the process of health care delivery has increasingly shifted away from expensive stays in acute care hospitals, and many intensive procedures are increasingly performed on an outpatient basis
Integrated Care (Domains of Primary Care)
Integrated Care embodies the concepts of comprehensive, coordinated and continuous services that provide a seamless of process of car. Primary care is comprehensive because it addresses any health problem at any given stage of a patient life cycle The coordinating function ensures the provision of a combination of health services to best meet the patients needs
Primary Care
It is the foundation of outpatient care.
(Institutional Long-Term Care )
LTC refers to myriad services designed to provide assistance over prolonged periods to compensate for loss of function due to chronic illness or physical or mental disability
Senior Centers(Types Community-Based System (LTC) Services)
Local community centers for older adults where seniors can congregate and socialize, Support activities: wellness programs, health education, counseling services, recreational services etc..
What role does Primary Care play in the healthcare deliverysystem?
Main function of Primary Care is to A) Coordinate the delivery of health services between the patient and the myriad of components of the system to maintain the long-term viability of a patient's health, B) support (provide) Continuity of care over a period of time is essential, C) represent comprehensive care (outside of the specialized services — referred), D) Primary care plays a central role in a health care delivery system and is linked to improved patient health status and cost-effectiveness
(5) distinct types of services provided under LTC
Medical Care Mental health services Social support Residential Amenities Hospice Services Social Support
(Institutional Long-Term Care)
Medically oriented care provided by a licensed provider (nurse/therapist)
Personal Care Facilities (Institutional Long-Term Care)
Nonmedical custodial care (basic assistance in a protective environment). Provide assistance with monitoring and medications
Private Practice
Office- based physicians , Form the backbone of ambulatory care, It is the vast majority of primary care services. limited examination and testing. Visits are short in duration. Solo pratices merged into groups due to: A) Uncertainties of the health care delivery system, B) Comeption form large health organization C. High cost of establishing a new practice D). Complexity of billings and collections E.) Increased external controls over private practice
What are Outpatient Care? What is Ambulatory Care?
Outpatient and Ambulatory care are interchangeably
Inpatient
Overnight stay when the patient is formally admitted with a physician's order
Who are clients served by Long Term Care ( LTC)
People living with chronic health problems that affect them to perform everyday activities
Chronic Conditions
Persist over time and are generally irreversible (note: critical/disease/symptom management Potential serious complications may result if not managed/controlled.
Retirement Facilities(Institutional Long-Term Care )
Physically supportive environment that promote independence. Do not deliver nursing care (arrangements made with home health agency)
Essential Care (Domains of Primary Care)
Primary care is regarded as essential as essential health care. When it is available to the vast majority of a nations population, it optimizes population health countries whose health systems are more oriented toward primary care achieve better health outcomes, higher satisfaction with health services among their populations, and lower expenditures in the overall delivery of health care
Skilled Nursing Facilities (SNF):(Institutional Long-Term Care)
Provides "Full-range" of clinical Long-term care services extending from skilled nursing care to rehabilitation to assistance with All daily living (ADLs
Assisted Living Facilities (Institutional Long-Term Care)
Residential setting providing personal care services, 24-hour supervision, scheduled and unscheduled assistance, and some nursing care services
USE OF CURRENT TECHNOLOGY(Characteristics / Dimensions of Long - Term Care)
Safety technology (to preventfalls: nonslipfootwear and hip protectors). Systems technology (summon assistance, bathing systems, tracking/wandering management systems)
Outpatient
Services provided while the patient is not staying overnight in a healthcare istitution
Average daily census
The average census over a given period oftime. Average daily census Patient days over a given period + number of days in the period
Patient days (days of care):
The cumulative census
Capacity
The number of beds set up, staffed and made available by a hospital for inpatient use
Census
The number of patients in a hospital on a given day (number ofbeds occupied).
Occupancy rate
The percentage of capacity utilized during a defined period of time. Derived by dividing the average daily census for that period by the capacity.
INDIVIDUALIZED SERVICES(Characteristics / Dimensions of Long - Term Care)
The services are "tailored" to the individual needs of the patient post an assessment inclusive of past history, medical and psychosocial conditions, cultural factors language, former occupation etc
Days of care
Total number of inpatient days incurred by a population over a given period of time. Overview: equals discharges x Average Length of Stay (ALOS)
USE OF EVIDENCE-BASED PRACTICES (Characteristics / Dimensions of Long - Term Care)
Use of standardized clinical practice guidelines from clinical research to design standardized protocols indicated for treatment of specific clinical circumstances
Accountable Care Organizations (ACOs)
a set of health care providers—including primary care physicians, specialists, and hospitals—that work together collaboratively and accept collective accountability for the cost and quality of care delivered to a population of patients -ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. ^^^The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.^^^^^^
Ambulatory Care
a type of medical care that is provided to patients who do not need to admitted to a hospital for treatment / the types of treatment are sometimes referred to as "outpatient care" .....Outpatient services do not require overnight inpatient stay.
Domains of Primary Care
a) point of entry b) coordination of care c) essential care d) integrated care e) accountability
Managed Care
an approach to the delivery of healthcare services supportive of the use of services or scarce resources with the goal of optimizing patient care and outcomes
Critical Pathways
are outcome-based and patient-centered clinical management tools used by the healthcare provider team (interdisciplinary) and serve to support coordination of care among multiple clinical departments and caregivers within a health care facility. KEY: Be prepared to provide an example
Community health Centers(CHC)
are private, nonprofit organizations that directly or indirectly (through contracts and cooperative agreements) provide primary health services and related services to residents of a defined geographic area that is medically underserved.
Predisposing characteristics (Vulnerability)
are represented by demographic characteristics, belief systems, and social structures (examples: genetic, attitudinal, personality, and environmental factors) that are associated with health, or lack of health. They exert their effects prior to a behavior occurring, by increasing or decreasing a person or population's motivation to undertake that particular behavior
Enabling characteristics ( Vulnerability)
are represented through their relationship and include socioeconomic status, individual assets, and mediating factors associated with healthcare and services impacting outcomes
Adult Day Care (Types Community-Based System (LTC) Services)
community-based, group program designed to meet the needs of functionally and/or cognitively impaired adults, provide partial respite to family caregivers
Quality improvement (QI)
consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups
Clinical Practice Guidelines
evidence-based practice guidelines reflective of clinical process for managing a clinical problem/ treatment guidelines
Point of Entry (Domains of Primary Care)
first contact a patient makes with the health care delivery system. This first contact feature is closely associated with the gatekeeper role of the primary care practitioner. Gatekeeping implies that patients do not visit specialists and are not admitted to a hospital without being referred for such care by their primary care physician
Improved Patient Health (clinical) outcomes (Why QI Program Essential important )
involve both process outcomes (e.g., provide recommended screenings) and health outcomes (e.g., decreased morbidity and mortality).
Vulnerable populations
is "the state of an individual or population being vulnerable to a particular disease or event. The factors determining risk may be environmental, psychosocial, psychologic, or physiologic. • are defined by socio-economic status, geography, gender, age, disability status, risk status related to sex and gender, and among other populations identified to be at-risk for health disparities
Supportive Housing
is critical and serves as a key component of LTC. Addresses functional and safety features designed to compensate for disabilities and promote independence. (examples: access ramps, wide doorways and corridorsfor navigating wheelchairs, extra-large bathrooms, grab bars to preventfalling)
Community Health Centers ( CHC) Scope
is to provide quality patient-centered primary care services to vulnerable and underserved individuals regardless of their ability to pay.
How did Vulnerability define population?
l) Is impacted by the current healthcare delivery system. 2) Could be linked to innovative approaches for improving access to care and shared responsibility 3)Reflects ongoing challenges with the business model vs. needs model in care access, quality of life, and improved outcomes.
MANAGING QUALITY OF CARE (Characteristics / Dimensions of Long - Term Care)
ongoing process based on regulatory standards, evidence-based clinical practice guidelines. Quality of care delivery is evaluated or measured to identify areas for improvement, design supportive action plans and implement updates
Vulnerability
represents the interaction of multiple factors, over many of which individuals have little or no control (likelihood of experiencing poor health or illness)
Utilization Review
the process of evaluating the appropriateness of services provided. The main objective is to review each case and to determine the most appropriate level of services. There are three (3) main types of utilization review: 1. prospective 2. concurrent 3.retrospective
What is Long- Term Care ?
to a continuum of medical and social services designed to support the needs of people living with chronic health problems that affect their ability to perform everyday activities. Long term care services include traditional medical services, social services, and housing. The goals of long term care are much more complicated and considerably more difficult to measure than the goals of acute medical care. While the primary goal of acute care is to return an individual to a previous functioning level, long term care aims to prevent deterioration and promote social adjustment to stages of decline Long term or chronic care includes a much broader range of services than acute care, emphasizing social as well as medical services. While acute care is usually confined to specialty providers, the providers of long term care are more wide ranging. They include traditional medical providers such as physicians and hospitals, formal community caregivers such as home care agencies, facility providers such as nursing homes and assisted living facilities, and informal caregivers such as friends or family members.
Community Health Centers (CHC) Efficiency/ Values
to accomplish the mission without imposing the financial barriers to care found in many of today's health care delivery systems and we make efforts to provide care to insured and uninsured patients.
Issue : Rising healthcare costs Solution & Impact:
• Promised cost savings for healthcare purchasers compared to traditional insurance • Supported healthcare resource(s) utilization through control measures • Implemented the concept: "inclusive list" of services and benefits -Used resources in a cost-effective manner impacting the use of resources/services: ^^^Preventing over or unnecessary utilization^^^^^^
Issue : Fragmented healthcare delivery Solution & Impact
• Supported an integrated financing and delivery system approach Addressed a comprehensive model of resource and services access Improved deliver of quality care Achieving clinical, quality & financial outcomes Coordinated Care impacted Costs (positive outcomes) -Implementation of population-based healthcare screening programs -Use of disease and care management -Reduction in "practice" variation -Cost-beneficial expenditure of healthcare resources
Social Support (Under Long Term Care)
-Refers to a variety of assistive and counseling services to support the individual/patient cope with situations that may be attributing or causing stress, conflict, grief or other emotional imbalances -Goal is to assist with the adjustments to changing life events fie su includes mental and emotional assistance -Additional support may extend to assisting with coordination of tasks, daily actions, counseling and spiritual guidance (when requested) Residential Amenities
What are Community- Based System(LTC) Services?
-To deliver LTC in the most economical and least restrictive setting based on patient's care needs. -To supplement informal care giving when more advanced skills are required. -To provide temporary respite to family members suffering or affected by caregiving stress (ex: adult day care, home health, temporary institutionalization) - To delay or prevent institutionalization.
Managed Care Organizations (MCOs) use three (3) main approaches to monitor & control the utilization of services:
1) Expert evaluation of what services are medically necessary. 2) Determination of how services can be provided most inexpensively (e.g., outpatient vs inpatient). 3) Review the course of medical treatment (e.g., when a patient is in the hospital).
Vulnerability is determined by a convergence
1) predisposing characteristics 2) enabling characteristics 3) need characteristics at both individual and ecological (contextual
3 Types of Long Term Care
1. Community Care 2. Institutional Care 3. Informal Care
Types of Outpatient Care Settings and methods of Delivery
1. Private Practice 2. Hospital-based services 3.Free standing facilties 4.Mobile medical 5. Diagnostic 6. Screening Services 7. Home health care 8. Hospice services 9. Ambulatory long-term care services 10. Public health services 11. Public and voluntary clinics 12. Telephone access 13. Alternative medicine
Residential Amenities
1. Supportive Housing 2.Congregate Housing
Select three (3) of the "Types Of Outpatient Care Settings and Methods of Delivery" and explain key descriptive points.
1.Freestanding Facilities-walk in clinics, Urgent Care Centers, Retail Clinics....... 2.Telephone Triage-a means of bringing expert opinion and advice on health care to the patient, especially during the hours when physicians offices are generally closed. staffed by trained nurses 3.Hospice Care- cluster of comprehensive services for terminally ill patients who have a life expectancy of 6 months or less.
(Characteristics / Dimensions of Long - Term Care)
1.INDIVIDUALIZED SERVICES 2.WELL-COODINATED TOTAL CARE 3. PROMOTION OF FUNCTIONAL INDEPENDENCE 4.EXTENDED PERIOD OF CARE 5.USE OF CURRENT TECHNOLOGY 6.USE OF EVIDENCE-BASED PRACTICES 7.MANAGING QUALITY OF CARE Maximizing Quality of Life
Why is a QI Program Essential to a Health Care Organization?
1.Improved patient health (clinical) outcomes 2.Improved efficiency of managerial and clinical processes 3.Avoided costs associated with process failures, errors, and poor outcomes 4.Proactive processes that recognize and solve problems before they occur ensure that systems of care are reliable and predictable. 5.• Improved communication with resources that are internal and external to an organization
Community Health Centers (CHC) Challenges
ACA has changed the role of community health centers the financial solvency of these centers changed with health reform high-deductible plans on community health centers Rural Patient Migration The Obesity Battle in Rural America
What were the factors leading to the evolution (development) of Integrated Delivery Systems?
Began with hospital mergers and acquisitions during 1990's. Consolidation with physician group practices was viewed as beneficial for both hospitals and physicians as health care services increasingly moved form the inpatient sector to the outpatient sector. Diversification into services that an organization had not offered before was the next step in integration. Many of these transformations can be attributed to the growth of managed care. -manage care gained enormous bargain power over independent hospitals -physician clinics, and these organizations came under growing pressure to reduce costs and deliver services -ACA added another twist by requiring certain intergraded organizations to be held accountable for people's health
Accountability (Domains of Primary Care)
Both clinicians and patients have accountably. On the one hand, the clinical system is accountable for providing quality care, producing patient satisfaction, using resources efficiency , and behaving in an ethical manner. On the other hand, patients are responsible for their own health to the extent that they are capable of influencing it. Patients also have the responsibility to be judicious in their use of resources when they need health care. A desirable patient- provider relationship is based on mutual trust, respect, and responsibility
Improved efficiency of managerial and clinical processes(Why QI Program Essential important )
By improving processes and outcomes relevant to high-priority health needs, an organization reduces waste and costs associated with system failures and redundancy. Note: Often Qlprocesses are budget-neutral, where the costs to make the changes are offset by the cost savings incurred.
EXTENDED PERIOD OF CARE(Characteristics / Dimensions of Long - Term Care)
LTC delivers various services over an extended period of time. Required ongoing monitoring, identification of any deterioration and address emergency needs. The needs and timeframe for receiving care various based on the individual
WELL-COODINATED TOTAL CARE (Characteristics / Dimensions of Long - Term Care)
LTC providers are responsible for managing the total health care needs ofthe individual. Health care need is recognized, evaluated and addressed by appropriate clinical professionals. Coordination of care across the continuum of care
Describe the "growth of "outpatient care. Why has this evolution in care delivery supported access to services/providers, cost efficiency and revenue generating , improved quality of care?
THERE HAS BEEN EXRODINARY GROWTH IN THE: Volume of outpatient services, Emergence of new types of settings Type and ownership o of non- hospital- based facilities offering ambulatory care. When looking at the evolution , growth 'Scope of Outpatient Care", keep in mind the following -Hospital inpatient services continues to decline -Executives see Ambulatory Care as an essential, no longer a supplemental, service line - Hospital survival can depend heavily on Ambulatory Care -Competition from home health agencies, Ambulatory Care, urgent care, outpatient surgery in : -
integrated delivery system (IDS)
a network of health care providers and organizations which provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the clinical outcomes and health status of the population served A fully integrated health network typically includes: -One or more acute care hospitals -Ambulatory care facilities -One or more physician group practices One or more long-term care facilities Home health services Ownership or contract with one or more MCOs
Risk Management
are proactive efforts to prevent adverse events related to clinical care and facilities operations. One example is avoiding malpractice. KEY: Be prepared to explore this further with overutilization, underutilization and cost of healthcare today. How is Precision Medicine impacting costs, quality of care delivery and patient outcomes
Palliation
medical care focused on relieving the unpleasant symptoms such as pain, discomfort and nausea
Tertiary Care
most complex level of care required for conditions that are relatively uncommon. Tertiary care is intuition base, highly specialized, and technology driven.
Congregate Housing
multi-unit housing with support services. Serves as an option for seniors and disabled adults. The services are basic assistive services. (examples: meals, transportation housekeeping, building security, social services etc.)
Inpatient Day
night spent in the hospital by a patient
Secondary Care
usually short term in nature , involving sporadic consultation from a specialist to provide expert opinions and/or surgical or the advanced interventions that primary care physicians are not equipped to perform. Secondary care includes hospitalization , routine surgery, specialty consultation , and rehabilitation
Cost-Efficiency
when the benefit received is greater than the cost incurred in providing the service. (keep in mind both underutilization (underuse) and overutilization (overuse)). KEY: What are the pros and cons?
Overview of Long Term Care
• represents a "variety " of individualized and well-coordinated total care services that promote the maximum possible independence for people with functional limitations the services are provided over an extended period of time the delivery of services utilize evidence-based practices • supports current technology appropriate for care delivery (patient-focused) guided by the quality of clinical care while addressing the individual's "quality of life" Long-term care services are provided in both institutions and community-based settings. • The development of an individualized plan of care is based on an individualized assessment Utilization of services is designed based on the current and changing needs of the individual. Involves both therapeutic and preventive services