knr 278 exam 3
CPT codes
current procedural technology, 5 digit code
DRG
diagnostic related group, inpatient
not covered services
diversion, recreation, leisure skill acquisition, non goal directed
human rights
equal opportunity and ADA
managing for accountability
fiscally responsible, document, policies
non-intervention programs
focus on attendance, based on number of times participated or client enjoyment
intervention programs
focus on participation, changes in client behavior as a direct result of participation
evaluation types
formative and summative
alternative funding
fundraisers, sponsorships, grants, nonprofit
TR services not covered
recreation diversional activity palliative care most areas - outpatient physical rehab outpatient rehab (car accident in michigan)
TR implications
reduce length of stay, increase outpatient, increase community services, increase productivity, increase documentation, billing of services
maintenance
safety, risk, upgrade
specific program evaluation types
self report, interview, observation
universal billing code
uniform claim form, used by hospitals with major 3rd party payers, TR-941, 940/949 - other TR services
managed care
up-front premium costs, predesignated and preferred providers, gatekeepers, pre-admission criteria
case manager
usually a nurse, assists patient in getting best health care, some is outside of insurance, can deny costs as unreasonable
negligence
willful and wanton neglect
risk management program
•Purpose is to minimize occurrences of loss or injury •Provide the best possible risk free environment for clients & staff •Minimize legal liability & lawsuits •Review incidents & attempt to prevent future losses or injury •Complies with Organizational Standards •CQI, JCAHO,CARF PDRMA, IPARKS
summative
a method of evaluation that occurs at the conclusion of an activity or program
formative
a method of evaluation that occurs during an activity or program
supplies and equipment
acquisition, inventory, replacement
capital request (large equipment)
acquisition, maintenance, depreciation, typically one a year
rising health costs
aging population, medical technology, rising expectations, waste, defensive medicine, inflation, cost to meet standards
TR program planning model
analysis - conceptualization - investigation - determination - SPD - implementation plan - evaluation plan
contractual losses
breach of service contract being provided
utilization reviews
clinical setting, frequency, duration, intensity
prospective payment
cost determined by 3d party, medicare sets pace for insurance, PPO & HMO
3 hour rule
- "intense level of rehabilitation services" - Interpreted as 3 hours per day
implementation plan and description
-content and process descriptions -sequence sheet/session format -implementation description
comprehensive program
-created from client outcomes -analyze -conceptualization -investigation -determination
specific program
-each program is implemented and evaluated independent of other programs -addresses leisure ability areas (or other models too)
specific program plan contents
-program plan -implementation plan and description -evaluation plan
specific program plan
-puts comprehensive goals and purpose into action -maybe 1 or more programs per comprehensive goal -very detailed so desired outcomes are directly related to the planned interventions
client goals
-smaller behavioral units -used for measurement -must be logical to comprehensive program goal -target actual performance or knowledge -add up to overall program outcomes
evaluation plan
-specific program evaluation -performance sheet (client evaluation)
evaluation
-systematic process -gathering and analyzing select info -make decisions about quality, effectiveness, outcomes
5 program domains for evaluation
1. need for program 2. design of program 3. delivery of program 4. program outcome 5. program efficiency
reimbursement process
1st party - service provider 2nd party - client 3rd party - ?
Medicaid
A federal and state assistance program that pays for health care services for people who cannot afford them.
accident
An unexpected happening that may result in injury, loss, or damage.
CMS
Centers for Medicare and Medicaid Services
gross negligence
Conduct that constitutes a willful or reckless disregard for a duty or standard of care.
types of negligence
Ordinary and gross
RUGS
Resource utilization groups - used in long term care
incident
Something that happens in real life or in a story; an event, often of little importance.
Medicare
health insurance for people over 65 or disabled, Part A: hospital insurance, inpatient, skilled nursing, home health, hospice
product lines
hospitals borrow from business procedures, recognize competition, concentrate on certain quality product lines
how to create a risk management plan
identify/rank risks assess best method to handle risk devise a plan decide who is in charge
covered TR services
inpatient psych outpatient psych partial hospitalization inpatient physical rehab acute care public school TR functional in nature community reintegration sessions life management task session prescriptive therapy sessions
what's included in risk management plan
insurance facility/equipment inspections orientation/training accident/incident reports emergency plans
objectives
minimum thresholds, most natural environment, condition, criteria, degree, ABCD
property loss
natural and human causes
tort liability
negligence and malpractice
ordinary negligence
negligence that is a failure to act, or a simple mistake that causes harm to a patient
risk management plan
policies, organization wide, formal or informal, planned approach
what is risk
possibility of loss or injury
coverage
services must be reasonable and medically necessary, individualized, prescribed, supervised
systems design
specific, consistent, accountability
program plan
statement of purpose, outcomes, goals and objectives
professional duty
the commitment to meeting one's obligations to provide effective physical therapy services to patients/clients, to serve the profession, and to positively influence the health of society.
financial business losses
theft and employee injuries
covered sevices
those intended to restore, remediate, rehabilitate, or eliminate problems associated with particular diagnosis
retrospective payment
traditional cost based system