HEIT 205 HEALTH CARE DELIVERY SYSTEMS
Organization of Hospital Services
*Board of Directors* primary responnsibility for setting the overall dicrection of the hospital. Works with the *Cheif Executive Officer (CEO)* and the leaders of the organization's medical staff to develp the hospitals strategic direction as well as its misssion. *Medical Staff*consist of physcians who have received extensive training in various medical dciplines *Administrative Staff* leader is the CEO, responsible for implementing the policies and strategic directions set by the hospital's board of directors. Commonly a *Chief Finical Officer (CFO)*, *Chief Operating Officer (COO)*, and a *Chief Information Officer (CIO)* as memebers of the executive management team, responsible for managing the hospitals finance and ensuring that the hospital complies with the federal, state, and local rule, standards, and laws that govern the delivery of healthcare services. *Patient Care Service* direct patient care is delivered by professional nurses, responsible for providing contiuous, around the clock treatment and support for hospital inpatients. *Rehabilitation Services* dedicated to eliminate the patients' disablitiy or alleviate it as fully as possible
Type of Hospital Ownership
*Goverment-owned Hospitals* operated by a specific branch of federal, state, or local goverment as not-for-profit organizations (public hospitals) e.g. Department of Veterans Affairs (VA) *Proprietary Hospitals* owned by private foundations, partnerships, or investor-owned corporations. *Voluntary Hospitals* not-for-profit hospitals owned by universities, churches, charities, religious orders, unions, and other not-for-profit entities.
For-Profit Hospitals or Not-For-Profit Hospitals
*Not-For-Profit* - used excess funds to improve their services and to finance educational programs and cummunity services *For-Profit* - privately owned, excess funds are paid back to the managers, owners, and investors in the form of bonuses and dividends
Patient Protection and Affordable Care Act of 2010
+health insureance markent reforms including: -subsidized premiums for people with pre-existing conditions -eliminating lifetime limits on benefits -the option of covering childern on parents' insurance until the age of 26 +development of state-based and state-admiistered health insurance exchanges +consumer opereated and oriented plan programs +expansion of Medicaid to indiividuals under age 65 with incomes up to 133 percent of federal poverty level +individual mandate to have mimimum acceptable coverage or pay a tax penalty +premium subsideies to individuals +small employer tax credits (CRS 2010)
Hospital
- has an oirganized mmedical staff - provides permanent inpatient beds - offers around the clock nursing - provides diagnostic and therapeutic services
Type of Hospital Service Provided
- hospitals that specialize in certain types of service and treat specific illnesses a. *Rehabilitation hospitals* - provide long-term care services to patients recuperating from debilitating or chronic illnesses and injuries such as strokes, head and spine injuries, and gunshot wounds.G b. *General hospitals* - provide a wide range of mdeical and surgical services to diagnose and treat most illnesses and injuries c. *Psychiatric Hospitals* - provide inpatient care fo patients with mental and developmental disorders. d. *Specialty hospitals* - provide diagnostic and therapeutic services for a limited range of conditions such as burns, cancer, tuberculosis, obstetrics, or gynecology.
Number of Hospital Beds:
-number of beds refers to the number of beds that are equipped and staffed for patient care a. *Bed Capacity* - The number of patients a hospital can hold. b. *Licensed Beds* - the number of bes that the sate has authorized the hospital to have available for patients. c. *Staffed beds* - refers to the number of beds for which the hospital actually has nursing staffing covered.
Types of Hospital Patients Served:
-some hospitals specialize iin serving specific types of patients. e.g Childerns Hosptial & Rehabilitation hospitals
Medicare(Title XVIII)
A federal program of health insurance for the elderly and some disabled persons
Case Management
A nursing care pattern; a case manager (an RN) coordinates a person's care from admission through discharge and into the home setting
Public Law 89-97 of 1965
Amendment to Social Security Act Medicare originally designed for people 65 years of age or older. Medicaid originally designed for medically indigent. Medicaid joint program with states
Allied Health Professionals
Health professionals that have received a certificate, an associate's degree, a bachelor's degree, a master's degree, a doctorate, or postdoctoral training in a healthcare-related science.
Public Law 98-21: 1983
Implemented perspective payments in hospitals, under the inpatient PPS, reimbursement for hospital care provided to Medicare Ptients is based on diagnosis-related groups (DRGs).
Peer Review Improvement Act of 1982
PSRO changed to Peer Review Organizations Looked at medical necessity and appropriateness of certain admissions prior to admisssion. Named changed to Quality Improvement Organization. Renamed Peer Review Organization
Quality Improvement Organizations (QIOs)
Performs utilization and quality control review of health care furnished, or to be furnished, to Medicare beneficiaries.
Administrative Support Services
Provide business management and clerical services in several key areas: Admissions and Central Registration; Claims and Billing Accounting Information Services Human Resources Public Relations Fund development Marketing
Social Security Act of 1935
Provided old-age pension (retirement), and a program of unemployment insurance (temporary aid to help people who lose jobs to find a new job), and federal welfare program (aid for very poor). Most famous and important legacy of New Deal. Has resulted (along with Medicare) with drastic reduction in poverty among elderly in the US
Utilization Review Act of 1977
Required that hospitals conduct continued stay reviews for Medicare and Medicaid patients
Clinical privileges
The authorization granted by a healthcare organization's governing board to a member of the medical staff that enables the physician to provide patient services in the organization within specific practice limits
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.
Ancellary Support Services
The clinical support units provide the following services: - Pharmaceutical services - Food and Nutrition services - HIM services - Social work and social services - Patient advocacy services - eviromental services - purchasing, central supply, and materials management services - engineering and plant operations
Utilization Review (UR)
The process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria at time frames specified in the organization's utilization management plan
Public Law 92-603 of 1972
This legislation required concurrent review of Medicare and Medicaid patients
Cheif Nursing Officer (CNO)
a memeber of the hopsital's executive management team and usually reports directly to the CEO, a RN qualified by advanced educationand clinical and management experience ususally administers patient care services
Peer Review Organization (PRO)
a state based group of physicians working under gov guidelines to review the cases and determine their appropriateness and quality of professional care Given a new name in 2002, Quality Improvement Qrganizations
Managed care organizations (MCOs)
a type of healthcare organization that dellivers medical care and manages all aspects of patient care or the payment for care by limiting proividers of care, discounting payments to providers of care, or limiting access to care.
Physicians can be divided into two groups
a) *generalists*- those who are the first point of contact between a patient and access to health care services, such as family medicine. b) *specialists* - those who focus their practice on a very specific body system, such as cardiology
Four major components of the HITECH bill
a) meaningful use - providers are using cerified EHRs to improve patient outcomes b) EHR standards and cerifications c) reginal extension centers - used to assist providers with selection and implication of EHRs e) breach notification guidance
Health Insurance Portability and Accountability Act (HIPAA)
addressews issues related to the protability of health insurance after leaving employment, establishment of national standards for electronic health care transactions, and national identifiers for providers, health plans, and emploers. ~A portion of HIPAA addressed establishing priviacy standards to protect health information and security standards for electronic healthcare information.
Health Information Technology for Economic and Clinical Health ACT (HITECH) (Title XIII of ARRA)
allocated funds for implementation of a nation wide health information exchange and implementation of electronic health records.
Critial Access Hospitals (CAH)
by meeting certain requirements these hosptals were allowed a separate payment system that allows reimbursement for Medicare patients 101 % of reasonable costs and are not subject to the inpatient prospective payment system (IPPS) or the hospital outpatient prospective payment system (OPPS) The criteria to qualify as a CAH are as follows: a. be located in a state that accepted a grant under the Medicare Rual Hopsital Flexibility Program b. be located in a ruaral area c. furnish 24-hour ememrgency care services 7 days a week d. maintain no more than 25 inpatient beds that may also be used as seing beds e. have an annual length of stay 96 hours or less per patient for acute-care services f. be located more than a 35 mile distance from any other hospital g. be cerified as a CAH prior to January 1, 2006
Integrated delivery Networks(IDN)
comprises a group of hospitals, physicians, other providers, insurers, or community agencies that work together to deliver health services
American Recovery and Reinvestment Act of 2009 (ARRA)
concidered one of the major health information technology laws that provided stimulus funds to the US economy in the midst of a major economic downturn.
Types of Hospitals
five major ways they are classified: 1. Number of beds 2. Type of services provided 3. Types of patients served 4. For-profit or not-for-profit status 5. Type of ownership
Long-term acute care hospital (LTAC)
focus on patients who require stay more than 25 days and treatment of serious conditions: may improve to go home
intergrated delivery system (IDS)
healthcare systems that combine the financial and clinical aspects of healthcare and use a group of healthcare provviders, selected on thhe basis of quality and cost management criterica, to furnish comprehensive health services across the continuum of care.
Acute Hospital
patients that stay 25 days or less
Inpatients
patients who spend more than 24 hours in a hospital
Continuum of Care (CoC)
places an emphasis on treating individual patients at the level of care required by their course of treatment and extends from their primary caree providers to specialists and ancillary providers.
Medical Staff Classification
refers to the organization of physicians according to clinical assignment.
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
required extensive changes in the Medicare porgram, its purpose was to control the rising cost of providing healthcare services to Medicare beneficiaries. ~ TEFRA required the gradual implementation of a prospective payment system (PPS) for Medicare reimbursement.
