CH 2 Health Care Delivery System

Nursing Informatics

"uses information and technology to communicate. manage knowledge, mitigate error, and support decision-making"

Examples of key provisions in the law

-All individuals are required to have some form of health insurance by 2014 or pay a penalty through the tax code -Public program eligibility, including state medicaid and Childrens Health Insurance, is expanded. Primary care physician payments for Medicaid services increased to equal Medicare payments -States will create health insurance exchanges whereby individuals and small business owners can purchase more affordable health insurance. The exchanges will also provide individuals and small employers with consumer information to aid them in making decisions regarding alternative health insurance policies -Insurance regulations that prevent private insurance companies from denying insurance coverage for any reason and from charging higher premiums based on health status and gender will be implemented. -A financial penalty will be assessed to employers of more than 50 employees if they do not offer health insurance coverage to employees -Adult children up to the age of 26, regardless of student status, are allowed to be covered under their parents' health insurance plan

Tips on making the referral process successful include the following

-Make a referral as soon as possible -Provide the care provider receiving the referral as much information about the patient as possible. This avoids duplication of effort and exclusion of important information -Involve the patient and family caregiver in the referral process, including selecting the necessary referral. Explain the service that the referral will provide, the reason for the referral and what to expect from the services of the referral. -Determine what the care provider receiving the referral recommends for the patients care and include this in the treatment plan as soon as possible.

Capitation

-Means that the providers receive a fixed amount per patient or enrollee of a health care plan. -aims to build a payment plan for select diagnoses or surgical procedures that consists of the best standard of care at the lowest cost.

Psychiatric Facilities

-Patients who suffer emotional and behavioral problems such as depression, violent behavior, and eating disorders often require special counseling and treatment in this facility

Patients require the following instructions before they leave health care facilities

-Safe and effective administration of medications -Safe and proper use of medical equipment -Instruction in potential food-drug interactions and counseling on nutrition and modified diets -Rehabilitation techniques to support adaptation to an/or functional independence in the environment -Access to available and appropriate community resources -When and how to obtain further treatment -The patients and family's responsibilities in the patients ongoing health care needs and the knowledge and skills needed to carry out those responsibilities -When to notify their health care providers for changes in functioning or new symptoms

Preventive and Primary care Services Include

-School health -Occupational Health -Physicians offices -Nurse-managed clinics -Block and parish nursing -Community health centers

Hospital Consumer of Assessment of Healthcare Providers and Systems (HCAHPS)

-a standardized survey developed to measure patient perceptions of their hospital experience -was developed by the CMS and the Agency for Healthcare Research and Quality (AHRQ) as a way for hospitals to collect and report data publicly for comparison purposes.

Ten Rules of Performance in a Redesigned Health Care System

1. Care is based on continuous healing relationships. 2. Care is individualized based on patient needs and values. 3. The patient is the source of control, participating in shared decision making. 4. Knowledge is shared, and information flows freely. 5. Decision making is evidence based, with care based on the best available scientific knowledge. 6. Safety is a system property and focused on reducing errors. 7. Transparency is necessary through sharing information with patients and families. 8. Patient needs are anticipated through planning. 9. Waste is continuously decreased. 10. Cooperation and communication among clinicians are priorities.

Medicare Part B

A voluntary medical insurance program financed in part from federal funds and in part from premiums contributed by the people enrolled in the program

Discharge Planning

Activities directed toward identifying future proposed therapy and the need for additional resources before and after returning home.

Quality Improvement

An approach to the continuous study and improvement of the processes of providing health care services to meet the needs to patients and others and inform health car policy.

Institute of Medicine (IOM)

Calls for a health care delivery system that is safe, effective, patient centered, timely, efficient, and equitable

Vulnerable populations

Children, women, and older adults are most threatened by urbanization -Although Globalization of trade, travel, and culture improves the availability of health care services, the spread of communicable diseases such as Ebola, tuberculosis, and severe acute respiratory syndrome has become more common.

National Committee for Quality Assurance

Created HEDIS to collect various data to measure the quality of care and services provided by different health plans -A database of choice for the Centers for Medicare and Medicaid Services.

Managed care

Describes health care systems in which a provider or health care systems receives a predetermined capitated payment for each patient enrolled in the program. -these organizations assume financial risk in addition to providing patient care. -The focus of care of the organization shifts from individual illness care to prevention, early intervention, and outpatient care,

Health Services Pyramid

Developed by the Core Functions Project serves as a model for improving the health care of U.S. citizens. -the pyramid shows that population-based health care services provide the basis for preventive services. -These services include PRIMARY, SECONDARY, & TERTIARY health care.

Medicare

Federally funded national health insurance program in the United States for people over the age of 65 YEARS of age. The program is administered in two parts. -Payment for plan is deducted form monthly individual Social Security check -Covers services of nurse practitioners -Does not pay full cost of certain services such as skilled nursing facilities -Supplemental insurance is encouraged

Medicaid

Federally funded, operated program that provides: (1) health insurance to low-income families; (2) health assistance to low-income people with long-term care (LTC) disabilities; and (3) supplemental coverage and LTC assistance to older adults and Medicare beneficiaries in nursing homes. Individual states determine eligibility and benefits. -Finances a large portion of care for poor children, their parents, pregnant women, and disabled very poor adults. -Reimburses for nurse-midwifery and other advanced practice nurses (varies by state). -Reimburses nursing home funding.

State Children Health Insurance Program (SCHIP)

Federally funded, state-operated program to provide health coverage for uninsured children. Individual states determine participation eligibility and benefits. -Covers children not poor enough for MEDICAID.

Professional Standards Review Organizations (PSRO)

Focuses on evaluation of nursing care provided in a health care setting. The quality, effectiveness, and appropriateness of nursing care for the patient are the focus of evaluation.

Primary health care

Focuses on improved health outcomes for an ENTIRE population -Prenatal and well-baby care -Nutrition counseling -Family planning -Exercise, yoga, and mediation classes

Work Redesign

Formal process used to analyze the work group and change the actual structure of the jobs performed

Minimum Data Set (MDS)

From the Resident Assessment Instrument -Resource for nurses in determining the best interventions to support the health care needs of this growing population >Examples • Residents background • Cognitive, communication/hearing, and vision patterns • Physical functioning and structural problems • Mood, behavior, and activity patterns • Psychosocial well-being • Bowel and bladder continence • Health conditions • Disease diagnoses • Oral/nutritional and dental status • Skin condition • Medication use • Special treatments and procedures

Diagnosis-related group (DRGs)

Group of patients classified to establish a mechanism for health car reimbursement based on the following variables; primary and secondary procedures, and age.

Integrated delivery system (IDN)

Include a network of facilities, providers, and services organized to deliver a continuum of care to a population of patients at a capitated cost in a particular setting.

Medicare Part D

Is a Voluntary prescription Drug Improvement.

Medicare Part C

Is a managed care provision that provides a choice of three insurance plans.

Resource Utilization Group (RUG)

Method of classification for health care reimbursement for long-term care facilities

PDSA

Model for QI and PI Plan- review data Do- select intervention Study- evaluate Act- if successful act on it

Block and Parish nursing

Nurses living within a neighborhood provide services to older patients or those unable to leave their homes. It fills in gaps not available in traditional health care system. >Available Program/services Running errands Transportation Respite care Homemaker aides Spiritual health

Never Events

Organized in seven categories: Surgical, product or device, patient protection, care management, environmental, radiological, and critical.

Acute care

Pattern of health care in which a patient is treated for an acute episode of illness, for the sequelae of an accident or other trauma, or during recovery from surgery.

Prospective Payment System (PPS)

Payment mechanism for reimbursing hospital for inpatient health care services in which a predetermined rate is set for treatment of specific illnesses

Utilization Review Committees (UR)

Physician-supervised committees to review admissions, diagnostic testing, and treatments provided by physicians of health care providers to patients.

Pay for Performance

Programs and public reporting of hospital quality data are designed to promote quality, effective, and and safe patient care by physicians and health care organizations -A quality improvement strategies that reward excellence through financial incentives to motivate change to achieve measurable improvments.

Medicare Part A

Provides basic protection against costs of medical, surgical, and psychiatric hospital care.

Managed Care Organization (MCO)

Provides comprehensive preventive and treatment services to a specific group of voluntarily enrolled people. Structures include a variety of models. -Focuses health maintenance, primary care. All care is provided by a primary care physician -Referral is needed for access to specialist and hospitalization. -May use capitated payments

Long-Term Care insurance

Supplemental insurance for coverage services. Policies provide a set amount of dollars for an unlimited time or for as little as 2 years. -Very expensive. -Often has a minimum waiting period for eligibility; payment for skilled nursing, intermediate, or custodial care and home care.

Patient-centered medical home

The goal is to make care for patients more efficient, effective, continuous, comprehensive, patient centered, and coordinated

Globalization

The increasing connectedness of the worlds economy, culture, and technology, is one of the forces reshaping the health care delivery system. Advances in communication, primarily through the Internet allow nurse, patients, and other health care providers to talk with others worldwide about health care issues.

School health

These are comprehensive programs that include health promotion principles throughout school curriculum. They emphasize program management, interdisciplinary collaboration, and community health principles. >Availably Program Services Positive life skills Nutritional planning Health screening Physical fitness Counseling Communicable disease prevention Crisis intervention

Community health centers

These are outpatient clinics that provide primary care to a specific patient population (e.g., well-baby, mental health, diabetes) that lives in a specific community. They are often associated with a hospital, medical school, church, or other community organization. >Available Program/services Physical assessment Health screening Disease management Health education Counseling

Nurse managed clinics

These clinics provide nursing services with a focus on health promotion and education, chronic disease assessment management, and support for self-care and caregivers. >Available Programs/services Day care Health risk appraisal Wellness counseling Employment readiness Acute and chronic care management

Continuing Care

These services are for people who were never functionally independent, or who suffer a terminal disease.

Physician offices

They provide primary health care (diagnosis and treatment). Many focus on health promotion practices. Nurse practitioners often partner with a physician in managing a patient population (e.g., diabetes, arthritis). >Available Program Services Routine physical examination Health screening Diagnostics Treatment of acute and chronic ailments

Occupational Health

This is a comprehensive program designed for health promotion and accident or illness prevention in the workplace setting. It aims to increase worker productivity, decrease absenteeism, and reduce use of expensive medical care >Available Program Services Environmental surveillance Physical assessment Health screening Health education Communicable disease control Counseling

Private Insurance

Traditional fee-for-service plan. Payment is computed after patient receives services on basis used. -Policies are typically expensive. -Most policies have deductibles that patients have to meet before insurance pays.

Preferred provider organization (PPO)

Type of managed care plan that limits an enrollee's choice to a list of "preferred" hospitals, physicians, and providers. An enrollee pays more out-of-pocket expenses for using a provider not on the list -Contractual agreement exist between a set pf providers and one or more purchasers( self-insured employers or insurance plans). Comprehensive health services are at a discounts to companies under contract -Focus is on health maintenance

Intensive care

a hospital unit in which patients receive close monitoring and intensive medical care, -Have advanced technologies such as computerized cardiac monitors and mechanical ventilators. -The most expensive health care delivery site because each nurse usually for cares for only one or two patients at a time and because of all the treatments and procedures the patients in the ICU require

Respite care

a service that provides short term relief or "time off" for people providing home care to an individual who is ill, disabled, or frail. -Medicare does NOT provide this -Medicaid has strict requirements for this.

Hospice

a system of family-centered care that allows patients to live with comfort, independence, and dignity while easing pains of terminal illness. -The focus is palliative care not curative treatment

Performance Improvement

an Organization analyzes and evaluates current performance and uses the results to develop focused improvement actions. -These activities typically clinical projects conceived in response to identified clinical problems and designed to use research findings to improve clinical practice.

Nursing Sensitive Outcomes

are patient outcomes and nursing workforce characteristics that are directly related to nursing care such as changes in patients symptom experiences, functional status, safety, psychological distress, registered nurse job satisfaction, total nursing hours per patient day, and costs.

Accountable Care Organization

developed to coordinate medical care by primary care and specialty physicians, hospitals, and other health care providers with the goal of providing high-quality coordinated care

American Nurses Credential Center

established Magnet Recognition Program to recognize health care organization that achieve excellence in nursing practice

Residents Assessment Protocols

examples -Delirium -Falls -pressure ulcers -psychotropic drug use

Patient Protection and Affordable Care Act

focused on the major goals of increasing access to health care services for all, reducing health care costs, and improving health care quality.

Restorative Care

goals of this facility are to help individuals regain maximal functional status and enhance quality of life through promotion of independence and self-care. The intensity of care has increased in this setting because patients leave hospitals earlier.

Patient centered care

include respect, dignity, sharing of information, participation in care and care decisions, and collaboration. By learning early what a patient expects with regard to information, comfort, and availability of family and friends, you are able to better plan care.

Rural hospital/ Critical Access Hospitals

located in a rural area and provides 24 hour emergency care, with no more than 25 inpatient beds for providing temporary care for 96 hours or less to acutely ill or injured patients needing stabilization before transfer to a larger, better equipped facility.

Skilled Nursing facility

offers skilled care from licensed nursing staff. This often includes administration of IV fluids, wound care, long-term ventilator management, and physical rehabilitation.

Adult day care centers

provide a variety of health and social services to specific patient populations who live alone or with family in the community -Services offered during the day allow family members to maintain their lifestyles and employment and still provide home care for their relatives.

Extended Care Facilities

provides intermediate medical, nursing, or custodial care for patients recovering from acute illness or those with chronic illnesses or disabilities.

Rehabilitation

restores a person to the fullest physical, mental, social, vocational, and economic potential possible.

National Quality Forum (NQF)

revised and defined a list of 29 " Never Events" that are devastating and preventable.

Secondary and Tertiary care

the diagnosis and treatment of illnesses are traditionally the most common services.

Home care

the provision of medically related professional and paraprofessional services and equipment to patients and families in their homes for health maintenance, education, illness prevention, diagnosis and treatment of disease, palliation, and rehabilitation. Health promotion and education are traditionally the primary objectives of this care, yet at present most patients receive this care because they need nursing care.

What is in the health services pyramid

top to bottom 5. Tertiary Health care 4. Secondary health care 3. Primary Health care 2. Clinical Preventive services 1. Population-based health care services

Work in Interdisciplinary Teams

• Cooperate, collaborate, and communicate. • Integrate care to ensure that it is continuous and reliable.

Apply Quality Improvement

• Identify errors and hazards in care. • Practice using basic safety design principles. • Measure quality in relation to structure, process, and outcomes. • Design and test interventions to change processes.

Use Evidence-Based Practice

• Integrate best research with clinical practice and patient values. • Participate in research activities as possible.

Nursing Quality Indicators

• Patient falls/falls with injuries • Falls in ambulatory settings • Pressure ulcers—hospital acquired, unit acquired • Pressure ulcer incidence rates from electronic health record (EHR) • Skill mix (registered nurse [RN], licensed practical nurse [LPN], unlicensed assistive personnel [UAP])—hospital units, emergency department (ED), perioperative and perinatal units • Nursing hours per patient day • Nursing care hours in ED, perioperative and perinatal units • RN surveys on job satisfaction and practice environment scale • RN education and certification • Pain assessment intervention/reassessment cycle • Hospital readmission rates • Physical/sexual assault • Physical restraints • Nurse turnover • Hospital-acquired infections of ventilator-associated pneumonia and events, central line-associated bloodstream infection, catheter-associated urinary tract infection

Provide patient-centered care

• Recognize and respect differences in patients' values, preferences, and needs. • Relieve pain and suffering. • Coordinate continuous care. • Effectively communicate with and educate patients. • Share decision making and management. • Advocate for disease prevention and health promotion.

Use Informatics

• Use information technology to communicate, manage knowledge, reduce error, and support decision-making.