Introduction to Nursing--Unit 4 Exam Healthcare Delivery Financing

What is crisis intervention?

"Systematic application of problem-solving techniques, based on crisis theory, designed to help the client move through the crisis process as swiftly and as painlessly as possible and thereby achieve at least the same level of psychological comfort as he/she experienced before the crisis" BASICALLY, problem-solving techniques to help the patient get through the crisis in the best possible way and restore them to how the person was before the crisis

What are emergency management plans? What is the nurse's role?

-Emergency management plans are response systems in place to be able to handle an emergency in the best way possible -Nurse's role: Know your plans for your community, state, facility you work at, etc. and KNOW YOUR ROLE and BE ABLE TO PERFORM THAT ROLE UNDER EMERGENCY SITUATIONS

What is meant by cost shifting?

--Unpaid costs must be covered by those who do pay so the hospital can continue operating- which is the process called cost shifting. -The poor and uninsured are less likely to use preventive services and more likely to be hospitalized for avoidable conditions than those who are not poor. The uninsured and underinsured populations generate uncompensated or indigent care costs and bad debt for health care providers. -Unpaid costs must be covered by those who do pay so that the hospital can continue operating. This causes the providers to increase their charges against households and public and private insurers who pay for care to make a contribution for the care of the uninsured population. This causes increased insurance premiums making it more difficult for many households and businesses to afford coverage. The problem of uncompensated care and cost shifting was a major factor leading to the health care reform and the passage of the PPACA (Patient Protection and Affordable Care Act) in 2010.

Who is eligible for Medicare?

-65 and over eligible for social security (must live at home!!!) -End stage renal disease -Disabled

Define pay-for-performance and what occurs with this method of reimbursement

-Aka P4P -Provides financial and non financial incentives to promote high-quality care. -Hospitals and other providers are rewarded for meeting standards of care for certain conditions such as diabetes, myocardial infarction, pneumonia, and heart failure. The Agency for Healthcare Research and Quality (AHRQ) supports P4P as a way to benchmark and find what does and does not work.

Identify potential nursing diagnoses associated with crisis and potential nursing interventions

-Anxiety -Ineffective coping -Defensive coping--"it wasn't my fault" -Situational Low Self-Esteem -Chronic Low Self-Esteem -Hopelessness Interventions: -Safety -Set goals to manage diagnosis -Counseling -Stabilize physical and emotional condition

During a crisis assessment, what things are discussed?

-Assess Situational Support Examples: With whom do you live? Who do you usually talk to when you have a problem? Who do you trust? Where do you go to worship, or to school, or other community-based activities In the past, who helps you the most? -Assess personal coping skills Examples: Have you felt like killing yourself or others? What do you usually do to feel better? What did you try this time, did it work? What helped you through difficult times in the past? What do you think might happen now? The nurse will: assess the person's perception of the event, current support persons and coping methods. **May need to manipulate the environment to prevent harm to the person (getting rid of the call light cord)

According to IOM, what are the three core functions for population health?

-Assessment: monitor health status to IDENTIFY HEALTH NEEDS OF THE POPULATION, diagnose and investigate health problems and hazards in the community, evaluate the effectiveness, accessibility, and quality of personal and population-based health services EXAMPLE: first case of the flu in a hospital, everyone who is not vaccinated needs to wear their mask -Policy development: develop policies and plans that support individual and community health efforts, enforce laws and regulations that protect health and ensure safety, inform, educate, and empower people with respect to health issues EXAMPLE: law enforcement, fire, etc makes plan of action for tornadoes, weather problems, etc -Assurance: link people to needed personal health services and assure the provision of health care when otherwise unavailable, assure a competent public and personal health care workforce, mobilize community partnerships to identify and solve health problems, and to conduct research into innovative solutions for health problems. EXAMPLE: in case of emergency, everyone has different role, like in a fire in a nursing home, what procedures are in place to assure that safety is in place

Why should nurses care about global health?

-Because issues in another country can come to our country via travel and we need to understand them and how to treat them/prevent them in our country -Become culturally sensitive, EDUCATE patients especially if they are traveling-let them know of the risks and what to avoid in that country -Volunteer globally, study abroad, advance the nursing profession

What are the cultural health disparities and how can nurses help?

-Cultural disparity: particular type of health difference linked with beliefs, religion, specific to cultural group, etc Nurses can help by: -Provide preventative education -Provide affordable access to health care -Improve the quality of patient-provider relationships -Recruit minorities into healthcare -Increase provider knowledge on minority health -Overcoming language barriers

What are ways the nurse can help reduce cost to the patient?

-Decrease duplication of services: EDUCATE the patient and treat them so they stay out of the hospital, give EFFECTIVE TREATMENT, feedback/teachback -Reduce wasted healthcare resources -Disease management: manage and improve the health status of a defined patient population over the course of a disease

What is the role of the nurse during a natural disaster?

-Definition-event that causes damage, ecological destruction, loss of human life on a scale that warrants an extraordinary from outside the effected area -Goal-get things done, prioritize -Principles

What is condition management?

-Designed to help improve quality of life -Focus is on providing EBP for a specific chronic illness like diabetes or obesity Diabetic program: Nutritional counseling Education on management of blood glucose with medications and activity Regular diagnostic evaluations (A1C, urine, BG) Annual eye exam Regular foot exam Obesity program: Nutritional counseling Behavior modification and counseling Exercise program Lifestyle management COUNSELING SHOULD BE PRESENT IN EVERY CONDITION/DISEASE MANAGEMENT

What kind of improvements did the Affordable Care Act bring about?

-Eliminate lifetime and unreasonable annual limits on benefits -Prohibit pre-existing condition exclusions: they had something before and until they get all documents you may not be covered, they try to deny you, and you have to pay out of pocket for their "preexisting conditions"...this act prohibited that -Require coverage of preventative services and immunizations-mammograms, colonoscopy, etc -Extend dependent coverage up to age 26!!!!!--make future for yourself, still take care of yourself when you are young, focus more on studying, working, etc not worrying about insurance coverage -Develop uniform coverage documents for better comparisons between health insurances

Why did healthcare costs rise?

-Fee-for-service payment method and economic incentives contributed to increased costs -The more tests or procedures performed, the greater the physician's earnings because earnings tied to procedures -Economic incentives to provide as much care as possible -Patients insulated from costs because insurance was paying the bill -Instead of allocating resources to those with the highest medical need, providers took on the thought that provide as much care possible, this caused an overuse of services and rapidly rising cost. Most patients did not care at the time because they had insurance to brunt the cost.

What are health disparities? What can nurses do to overcome them?

-Health disparity: a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage -Nurses can overcome by: learn more about the patient from family members, coworkers, etc. and share the info with the physician so we can work to provide the best care and understand the issue -ANA Code of Ethics: provision 1.3 Nature of Health, "the nurse is to collaborate with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities".

What can nurses do in regard to global health?

-Immunizations-promote them to end outbreaks and epidemics -Provide QUALITY care to YOUR population so that it stretches statewide, nationwide, and eventually worldwide

What are the 6 priority areas to address that are cross culture?

-Infant mortality -Cancer screening and management -Cardiovascular disease -Diabetes -HIV/Aids -Immunizations

Why did healthcare costs rise (part 2-dealing with patients)?

-Lack of cost consciousness contributed to increased costs -Patients not aware of costs -Providers had little incentive to be concerned about costs -Providers received more income for using more services -Providers incurred no financial risk for using additional resources

Describe a Health Maintenance Organization (HMO) insurance plan

-Member (covered individual) pays a premium -Has a fixed copayment -Member must select a primary care physician approved by the HMO -Member must be referred for treatments, specialists, and services by the primary care physician. -Services outside of "network" must be pre-approved for payment. -Plan may refuse to pay for services not recommended by primary care physician -Encourages use of preventive care

Describe a Preferred Provider Organization (PPO) insurance plan

-Member (covered individual) pays a premium for a fixed percentage of expense covered. -Includes a deductible and copayment. -Member may select physician, but pays less for physicians and facilities on the plan's preferred list. -May or may not pay for preventive care

Describe a Fee For Service (FFS) insurance plan

-Member (covered individual) pays a premium for a fixed percentage of expenses covered. -Includes deductible and copayment. -Allows member to choose physician and specialists without restraint. -May only cover usual or reasonable and customary changes for treatment and services, with member responsible for charges above that payment. -May or may not pay for preventive care.

Describe a Point of Service (POS) insurance plan

-Offered by HMO or FFS -Allows use of providers outside the plan's preferred list or network, but requires higher premiums and copayments for services.

Themes that have driven healthcare financing

-Physician was primarily responsible for decision making -Physicians controlled all access to health care services -Tests or procedures were provided if physician determined that any marginal benefit might be obtained -Objective was to provide the best care to everyone -Sophistication and cost of medical technology rapidly increased Physician's made decisions and along with the fee for service method this contributed to a lack of being cost conscientious on the part of the provider. The provider never discussed cost with the patient so cost never really came up until the bill arrived.

What is the nurse's role when responding to a community epidemic?

-Prevention: by EDUCATION, planning for an epidemic, hand washing, masking, immunizations -Response: giving the best care, getting as many people healthy as possible -Recovery: get things back to how they were before the epidemic, restore the health of the whole person

What are the levels of prevention for crisis intervention? Example of each?

-Primary care: promotes mental health and lowers incidence of crisis. EXAMPLE: Evaluation of life stressors. -Secondary care: intervening during a crisis to prevent prolonged anxiety from diminishing personal effectiveness and personality organization. Primary focus is to ensure safety of the client. EXAMPLE: Employee assistance programs. -Tertiary care: Provides support for clients who have experienced a disabling crisis and are recovering. EXAMPLES: rehab centers, sheltered workshops, day hospitals and outpatient clinics

Identify the levels of healthcare (IN THE FACILITY/HOSPITAL) and describe each

-Primary- Preventative- Wellness, preventative care focuses on reducing and controlling risk factors while wellness is keeping healthy people healthy. Physical exam, eye exams Examples of: General Dr., school nurse, occupational nurse, Nurse managed clinics, parish nursing, community health centers -Secondary- is disease management Examples: hospital- OB, ER, X-ray, OT, PT, Speech, Psych -Tertiary- specialized hospitalized -ICU, Cancer unit, tertiary hospital -Restorative: recovery from illness/disability Examples: Home Health, Rehab, Intermediate, Skilled, Long-term, Assisted Living -Continuing Care: for people who are disables, functionally dependent on others for care or suffering a terminal illness. Examples: Nursing Home, Assisted Living, Respite care, Adult Day Care, Hospice

What are the levels of prevention (PREVENTION AS A CONCEPT)? Example of each?

-Primary: Prevent disease from ever occurring. REFERS TO HEALTHY, PREVENTION EXAMPLE: water treatment and sanitation prevent the spread of communicable diseases. Educating people about healthy diets is an aim of primary prevention. Immunizations not only help the individual but also the community by stopping the spread of transmittable diseases. -Secondary: Early identification of health problems through screenings and prevention of complications because of illness. REFERS TO DISEASE/CONDITION MANAGEMENT EITHER ACTUALLY HAPPENING OR AT RISK FOR EXAMPLE: Think of fall risk screenings in the nursing home population. -Tertiary: focuses on preventing long term disability and restoring functional capacity. DISEASE MANAGEMENT TO PREVENT A COMPLICATION- YOU HAVE THE DISEASE EXAMPLE: Rehabilitation facilities

What changes occurred with the 2010 Affordable Health Care Act and how did it impact nursing?

-Provided insurance coverage for 32 million uninsured Americans. -Made medicare more expanded/eligible for more people -New payment and delivery methods -increasing clinical preventative services for prevention of chronic diseases -increase number of nurses-MORE NURSES -transparency and program integration-so taxpayers know what is going on, less fraud, waste, abuse, patients more in charge -improved access to care-better and less expensive for meds-urgent care clinics -community living assistance-insurance for LTC living, home health -revenue provisions-pay for performance For nursing: -Ensure positive patient outcomes and maximize reimbursement, make a good impression -care should be aimed toward primary care, not secondary or tertiary, -use of a team approach to solve crisis with an affordable health care system -safety, effective, efficient, timely, patient-centered care

Define hospital readmissions reduction program (HRRP) and what occurs with this type of reimbursement

-Reduces Medicare payments to hospitals with excessive readmissions (admission to a hospital within 30 days of a discharge from the same or another hospital). -Nurses are responsible for proper education of patients when discharging so patient and family are prepared to recover at home. Readmissions can cause costly penalties to the hospital.

What is population health? Examples?

-Referred to assessing the health care needs of a specific population and making health care decisions for the population as a whole rather than for individuals -Examples: 33 year olds with diabetes, high BP in young adult males, stress in nursing students

What is the IOM (Institute of Medicine)? What do they do?

-The institute of medicine is a committee that believe nursing is best positioned to partner actively to ensure that we achieve accessible, high quality healthcare and believes we cannot achieve that goal without exceptional nursing care and leadership--BASICALLY, COMMITTEE THAT BELIEVES THAT ACHIEVING HIGH QUALITY CARE COMES FROM GREAT NURSING CARE AND LEADERSHIP -The IOM called for radical changes shortly after its birth because it found an increase in chronic disease processes, growing complexity of science and technology, poorly organized delivery system for care, and constraints on getting on board with information technology. -The committee made recommendations to help bridge the gap in quality of care. -The most recent recommendations involved changes to nursing education and having nurses work at their highest educational capacity.

Define value-based purchasing and what occurs with method of reimbursement

-Value based purchasing (VBP)- is CMS reimbursement that rewards inpatient hospitals for providing quality care to include patient satisfaction. -VBP are based on two domains- 1) the patient experience of care and 2) clinical processes of care. The patient experience of care is based on the hospitals scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) which is essentially a standardized patient satisfaction survey. -Clinical process of care measures include such items as discharge instructions for heart failure patients, fibrinolytic therapy received with 30 minutes of hospital arrival for a patient with acute myocardial infarction, and prophylactic antibiotic received within one hour prior to surgical incision.

What are some of the goals for a patient in crisis?

-Will remain safe -Return to pre-crisis level of functioning -Will develop outside support Continued Evaluation is NECESSARY throughout the whole process!!!!!

What is global health?

-definition from IOM: health problems, issues, and concerns that has no national boundaries and may best be addressed by cooperative actions by countries -consider health problems from a global perspective

What is Healthy People 2020? Why is it important to nursing?

-refers to what kind of needs our population will need to address -federal government's agenda for building a healthier nation -Nursing importance: educate your patients on how to be healthier and the BENEFITS of being healthier, encourage yearly physicals and check ups, educate to reduce injury: wear your seat belt, wear a helmet, wear sunscreen

What is the role of the nurse during an act of bioterrorism?

-role is to triage

What are ways consumers/patients can reduce the cost of healthcare to themselves?

-use emergency care ONLY in emergencies -use urgent care for non emergency stuff -know health risks for lifestyle choices: drinking and drug use, dietary habits, behaviors at home, driving

History of healthcare financing

1847: Massachusetts Health Insurance of Boston offers group policy 1861-1865: Insurance plans available during Civil War 1929: First group health coverage for a monthly charge for teachers in Dallas, Texas; beginning of Blue Cross/Blue Shield 1950s: Employee benefit packages initiated to attract workers 1965: Creation of Medicare and Medicaid programs, making comprehensive health care available to millions of Americans 1980-1990: Managed care plans emerge 1993: Hospitals come under DRGs 2003: Medicare Prescription Drug Improvement and Modernization Act of 2003; most significant expansion of Medicare since its enactment 2006: Pay-for-performance introduced 2008: Medicare no longer pays hospitals for treating preventable errors known as never events 2010: Congress passes sweeping health care reform legislation: Patient Protection and Affordable Care Act

What is SCHIP?

Children's Health Insurance Program. It is the part of Medicaid that covers children.

What is a crisis? Identify different types of crisis that a nurse could be involved with

Crisis: Defined as an acute, time-limited phenomena experienced as an overwhelming emotional reaction to: Stressful situational event Developmental event Societal event Cultural event Catastrophic event Different types of crisis that a nurse could be involved with: Individual crisis Community epidemic Natural disaster Bioterrorism Mass casualty event

What is a DRG? How do they work?

DRG is a diagnostic related group. Their whole thing is: If patient stays longer, hospital pays If patient leaves early, hospital keeps money Elderly or chronic illness stay longer Not much money is made off this Keep patient healthy! Get them OUT

What happens when an individual experiences a crisis? What is the priority assessment for the individual?

Individual crisis experiences: Assault to self-concept-taking things personal, thinking it's an attack on you, know that you are a good nurse no matter what Personalized experience--Meaning of the event to the person--trying to relate to the patient/situation Inability to cope Change in normal behavior pattern Time limited--don't allow the person to stay in the crisis for a long period of time Priority assessment for the individual: SAFETY Are they at risk to harm themselves or others? This would warrant immediate interventions

What is a mass casualty? What is the nurse's role during a mass casualty?

Mass casualty: any incident in which emergency medical services resources, such as personnel and equipment, are overwhelmed by the number and severity of casualties--more deaths than resources/EMS services available Nurse's role: TRIAGE

What is the criteria to meet Medicaid eligibility?

Medicaid is health-care for impoverished families, especially those with children. -Those eligible are pregnant women, children and parents, persons with disabilities, and seniors who meet certain income criteria. -Each state administers its own Medicaid program within minimal federal income guidelines, some variances can occur from state to state. -MEDICAID IS PRIMARY COVERAGE OF LTC

Define never events and what occurs with this method of reimbursement

Never events- means that Medicare will not longer pay hospitals for the extra costs of treating preventable errors. -Hospitals are no longer paid for the cost of treating medical errors that are largely preventable and have serious consequences for the patients. --Examples being: hospital acquired infections, injuries from falls, wrong site surgery, and mismatched blood transfusions. --THINGS THAT HAPPEN DUE TO THE CARE THAT WE GIVE

What is Medicare based on and what are the different parts of Medicare?

Part A - Hospitalizations Part B - Outpatient Services Part C - Medicare Advantage Part D - Drugs With the overuse of healthcare resources and a growing elderly population, Medicare became overtaxed with expenses. This lead to relooking at how the Medicare payment system was being run and things changed. So Medicare in 1983 moved from a fee for service system to a prospective payment system that was based on diagnostic related groups or DRG's. Medicare does not require the individual to meet certain financial and need for care criteria like Medicaid. A: Hospital insurance B: Supplemental medical insurance- covers outpatient and is optional C: Medicare advantage plan D: Outpatient drug coverage

What is triage, the colored tags associated with it, and what are some examples for each color of triaging?

Triage: the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment *nurses and emergency personnel will assess each patient and assign them a tag based on the extent of their injury(ies), then designate tents/areas to each color of patient Colored tags: Green: Mainly healthy, can walk, SPO2 is greater or equal to 96%, BP is within or close to normal range, pulse is good and strong Yellow: Caution in place, minor injuries, BP will be elevated, but no higher than 160/100, SPO2 less than 96%, but higher or equal to 93%, has pulse-may be effected Orange: "effected", visible injuries and possibly life threatening, BP elevated, no higher than 180/110, SPO2 less than 93% but greater or equal to 90%, pulse may be rapid or weak Red: Emergency, life-threatening injuries, BP greater than 180/110, SPO2 less than 90%, pulse may be rapid or weak or "going in and out" Black: death has already happened or is in near future, pulse is lost or very faint