Chapter 11: Healthcare Delivery Systems

A client asks a nurse about the benefit of using diagnosis-related groups (DRGs) as a reimbursement method. Which is the nurse's best response?

"DRGs have helped to reduce healthcare costs by decreasing the overall length of a client's hospital stay."

A nurse says, "We have so many drills and safety checks for everything. It is almost like we are preoccupied with the possibility of failure." How should the charge nurse respond to this statement?

"Highly reliable organizations think about the possibility of failure and what to do to avoid it."

At the last hospital unit meeting, the policy for the insertion of Foley catheters was revised based on current evidence. The new nurse on the unit just learned "the old way" and is frustrated to now have to learn a new methodology. Several other nurses comment that the change is "all about money." The charge nurse must educate the staff about the importance of this new policy. Which explanation by the charge nurse is most appropriate?

"Incorporating evidenced-based practice into our care routines links our interventions to valued outcomes, thereby increasing quality care. When we provide quality care, we can decrease cost."

Which statement regarding health care reform trends is most accurate?

"Systems are in place to pay for performance and penalize hospitals for excessive readmissions."

It is recommended that a client go to a convalescent center upon discharge following a minor stroke. The client says, "I don't want to go anywhere, I want to go home." Which information should the nurse offer?

"You will only stay until you are well enough to go home."

What are chief tasks of the home health care nurse? Select all that apply.

-Developing a nursing care plan -Providing client education and counseling -Providing continuity of care -Administering medications

What type(s) of services are provided in primary health care? Select all that apply.

-Education related to sexually transmitted infections -Health risk screenings -Administration of immunizations to children and adults

Which client would a nurse correctly refer to Medicare services?

A 66-year-old client with diabetes Medicare is a federal health care plan for individuals over the age of 65. An individual with a disability might be referred to Medicare, but other federal organizations must be involved for this to occur. A low-income family with infants needing immunizations would be referred to Medicaid. The client with cancer in this question is not noted to be over age 65.

The nurse is caring for several clients with chronic conditions that need to be evaluated for long-term care. After evaluating each client, the nurse determines which client is most appropriate to receive long-term care?

A client who suffered a stroke who has mobility issues and problems completing activities of daily living (ADLs).

A nurse demonstrates understanding of Healthy People 2030 by supporting which statement?

A client's health is affected by social, economic, and political factors.

A nurse demonstrates understanding of Healthy People 2030 by supporting which statement?

A client's health is affected by social, economic, and political factors. People believe "quality of life" to be synonymous with a healthy community. There is growing recognition that to achieve the goals of Healthy People 2030 a model inclusive of multiple health determinants is needed. Clinical care has typically focused on diagnosing and treating symptoms. Understanding health in relation to personal behaviors, social factors, and other determinants provides a holistic context and not a quick resolution of needs. As an example, it is important to know whether an individual has access to a grocery store with fresh fruits and vegetables to comprehend that client's nutritional needs. To affect social, economic, political, and educational health determinants, health initiatives are more effective if they are based in the community and incorporate community collaboration. While physical therapy can be helpful for a client in the home, it does not have a basis for the community emphasis in Health People 2030.

The nurse is providing care to several clients. For which client should the nurse include secondary care in the nursing plan of care?

A middle-aged client who presents with new-onset angina

When conducting an education program for a group preparing for retirement, the nurse would include information about applying for Social Security benefits and Medicare insurance. The nurse would include in the education that Medicare is a federally funded insurance program which bases the fee for payment on what?

A prospective payment plan based on a predetermined fixed cost The nurse must understand that Medicare is a federal insurance program for older adults. It is based on a prospective payment plan that pays a predetermined fixed amount for in-hospital costs. Medicare does not pay physician groups and is not for indigent older adults. Retrospective payment plans pay for services after they have been received.

Which is an emerging trend in health care delivery?

Active Involvement of Consumers

Which government policy addresses penalizing hospitals for readmissions of clients with certain diagnoses within 30 days after discharge?

Affordable Care Act

Which scenario is using a prospective payment plan to reimburse for services?

An older adult client is admitted to the hospital and treated for pneumonia. The hospital is reimbursed based on a predetermined fixed price. A prospective payment system uses financial incentives to decrease total healthcare charges by reimbursing hospitals on a fixed rate basis. Reimbursement is based on the diagnostic-related group (DRG). Therefore, the scenario in which the hospital is reimbursed is an example of a prospective payment plan. The other scenarios demonstrate other types of payment plans.

The nurse is providing care to several clients on a medical-surgical unit. For which client's plan of care should the nurse include information regarding extended care?

An older adult client who fell at home and required a hip replacement

The nurse is providing care to several clients on a medical-surgical unit. For which client's plan of care should the nurse include information regarding extended care?

An older adult client who fell at home and required a hip replacement Extended care meets the health needs of clients who no longer require acute hospital care but require rehabilitation and skilled nursing care, such as an older adult following a hip replacement surgery, who may need additional assistance with mobility and more time for physical therapy before being ready to be discharged home. The other clients do not require, or would not benefit from, extended care.

Which statement accurately reflects the findings of the 1999 Institute of Medicine report, "To Err Is Human"?`

Anywhere from 44,000 to 98,000 people are estimated to die in U.S. hospitals each year as a result of preventable medical errors.

During a hospice visit, the client's spouse suddenly begins to cry and says, "I am so tired. I just can't do this anymore. I am not getting to sleep and I just eat sandwiches when I can." What is the nurse's best intervention?

Arrange for short-term inpatient care for the client.

Which statement is most accurate in comparing nursing care provided in the acute care setting and that provided in the home care setting?

Both settings focus on the holistic care of an individual.

A nurse is caring for an older adult client in the home. The nurse concludes that the client needs an X-ray to determine whether the client has pneumonia and requires oxygen for shortness of breath. The nurse calls to inform the physician of the client's status and then makes arrangements to carry out the physician's orders. In this scenario, what role does the nurse play?

Case Manager

Unlicensed assistive personnel (UAP) include which workers?

Certified nursing assistants, orderlies, attendants, and technicians Certified nursing assistants, orderlies, attendants, and technicians are considered UAP. Volunteers, admission clerks, and housekeepers, although invaluable to hospital function, are not UAP.

Which statement regarding spiritual care providers in hospitals is most accurate?

Clergy, lay volunteers, and those with advanced spiritual care degrees can serve on the spiritual care team at hospitals.

A nurse working for a home health agency is scheduled to evaluate a client with worsening heart failure to determine whether the client is a candidate for the new "Hospital at Home" program. Which statement accurately reflects an outcome for this program?

Clients in the "Hospital at Home" program have been found to require shorter lengths of stay than when admitted to the acute care setting.

A new nurse is considering getting a job in either an acute care setting or a home care setting. Which statement about these care settings is most accurate?

Clients play a large role in helping themselves in the home care setting.

A new nurse is considering getting a job in either an acute care setting or a home care setting. Which statement about these care settings is most accurate?

Clients play a large role in helping themselves in the home care setting. In nursing practice in the hospital, client needs include physiologic monitoring, complete or partial personal care, exercise, nutritional support, pain management, treatment and medication administration, anticipatory guidance, counseling, and education, which requires the complexity of health care teams. Nurses are involved in a variety of teams and care needs are complex. Clients are not encouraged to help each other in the acute care setting. Because of the trend toward shorter lengths of stay, the clients are discharged to home, where they may be more involved in helping meet their own care needs. Communication skills are critical in both the acute care and home care settings.

Based on the Patient Protection and Affordable Care Act (ACA), nurses are to assume an important new role in health care. Which is an example of this new role?

Collaborating with all agencies to provide for the client's home health needs

Based on the Patient Protection and Affordable Care Act (ACA), nurses are to assume an important new role in health care. Which is an example of this new role?

Collaborating with all agencies to provide for the client's home health needs As the various components of the ACA are phased in, nurses have begun to play an influential role in the implementation of new health policy. The newest opportunity is collaborating with all agencies to provide for the client's home health needs. Nurses have already been involved in screening individuals for type 2 diabetes mellitus and providing postoperative teaching for ostomy care. Nurses recheck paperwork for consent prior to surgery, but this is not just limited to nurses. Other health care providers also review consent prior to surgery.

Nurses in various health care settings provide services to prevent the fragmentation of care that is occurring as a health care trend in today's society. What role of the nurse is most important in preventing this effect?

Coordinator of care

The growth in home health care is largely attributed to which factor?

Early discharge of clients from the hospital setting Home health care is one of the most rapidly growing areas of the health care system. The prospective payment system of reimbursement encourages early discharge from the hospital and has created a new, acutely ill population that needs skilled nursing care at home. Though some nurses may desire to work in the community and hospitals may have a shortage of nurses, these are not the primary factor related to the increase in home health care. It is not that hospitals cannot care for an increasing number of clients so much as it is that they will not be reimbursed by payers for costs associated with longer client stays; thus, they are motivated to discharge clients earlier even though clients are often not yet ready to provide all of their own needed care, leading to the need for and prevalence of home health care.

A nurse has an older adult home care client who lives alone with no family nearby. On a recent visit, the nurse notices that his clothes are very loose, and he has difficulty letting the nurse leave when the visit is ending. After talking with him, the nurse learns that he has not been cooking for himself and he can't get to the grocery store easily. What service could the nurse suggest as an immediate response until a long-term plan can be formed?

Enroll the client in Meals on Wheels. The best option that can be arranged quickly is to enroll the client in Meals on Wheels, a voluntary agency. The other responses may be helpful in later planning for a long-term situation.

A nurse is researching health care in rural areas. Based on a 2013 U.S. Subcommittee on Primary Health and Aging, which statement regarding access to primary health care is correct?

One in five Americans lives in an area without adequate access to primary health care due to a shortage of primary care providers.

What role does the nurse assume when gathering information for a community assessment?

Epidemiologist

A nurse is caring for a client with end-stage liver failure. Which healthcare agency should the nurse recommend for continuity of care?

Extended care

The goals of health care reform include which?

Focusing on cost containment with improved access and quality of services for everyone The goals of health care reform focus on cost containment, improved access, and increased quality of services for all citizens. Health care reform seeks to increase, rather than decrease, the number and quality of services provided.

A client has a complex medical history related to the consequences of diabetes. As a result of having diabetic nephropathy, the client now participates in the local hospital's dialysis program and has been referred to an ophthalmologist by the primary care physician following the onset of vision problems. In addition, the client receives home care nursing for the treatment of a foot ulcer that is slow to heal. This client's situation characterizes which phenomenon?

Fragmentation of Care

The Patient Protection and Affordable Care Act (ACA) was passed in 2010 and aims to provide affordable health care to everyone. Which are goals of the ACA? Select all that apply.

Health care affordability Ability to compare insurance options Accessibility to insurance services Decreased number of uninsured The ACA seeks to make health care more affordable, create competitive insurance plans and allow comparison of insurance options, provide greater accountability, end discrimination, ensure accessibility to health insurance, decrease the number of uninsured, and make the budget and economy more stable (White House, 2014). The ACA does not support high-quality insurance and allows the insurance companies to regulate themselves as they compete for uninsured clients in the various states.

A hospitalized client with advanced metastatic lung cancer states, "I want to go home. I don't have much time left. I want to be with my family." Which type of care referral by the nurse is most appropriate?

Hospice Hospice is a program of palliative and supportive care services providing physical, psychological, social, and spiritual care for dying people, their families, and other loved ones, often provided in the client's own home. Because the client is near the end of life, hospice care would be the most appropriate referral. Respite care is a type of care provided for caregivers of homebound ill, disabled, or older adults, to give them some time away from the responsibilities of day-to-day care. This type of care would not be appropriate for this client because the client has been hospitalized and wants to be with family. Extended-care services provide medical and nonmedical care for people with chronic illnesses or disabilities. Extended care occurs outside the home, however, which is not what the client desires. Palliative care evolved from the hospice experience but also exists outside of hospice programs. It is not restricted to the end of life and can be used from the point of initial diagnosis. Palliative care, which may be given in conjunction with medical treatment and in all types of health care settings, is patient- and family-centered care that optimizes the quality of life by anticipating, preventing, and treating suffering. Palliative care alone is not as appropriate as hospice care in this case, given that the client is near the end of life. Reference:

Which is the acute care setting for people who are too ill to care for themselves at home, are severely injured, or require surgery?

Hospitals Hospitals are the most appropriate acute care setting for people who are too ill to care for themselves at home, are severely injured, require surgery or complicated treatments, or are having babies. An ambulatory care center, which may be referred to as an outpatient care center, is a medical care facility that provides outpatient services. These include diagnosis, treatment, consultation, and intervention services. Day care centers have a variety of purposes: some care for healthy infants and children whose parents work; some care for children with minor illnesses; some provide a place for older adults to socialize and to receive care while family members work; some provide health-related services and care to people who do not need to be in a health care institution but cannot be at home alone. Primary care is the day-to-day health care given by a health care provider and can be provided in an outpatient facility.

A hospital system has adopted the Institute for Healthcare Improvement's "Triple Aim" dimensions and has surveyed nurses for planning ideas. Which strategies will help the hospital comply with this framework? Select all that apply.

Make results of quality studies available to nurses in a timelier manner.Create outreach education programs to improve the overall health of the community served.Reduce redundancy in diagnostic tests.

he nurse understands that a diagnostic-related group is one of the reimbursement strategies in a prospective payment system. The diagnostic-related group is a part of which health care system?

Medicare The federal government implemented a system of prospective payment in 1983 for people enrolled in Medicare. A prospective payment system uses financial incentives to decrease total health care charges by reimbursing hospitals on a fixed rate basis. Reimbursement is based on the diagnostic-related group, which is a classification system used to group clients with similar diagnoses. Medicaid provides health care through funds obtained from federal, state, and local sources. In capitation strategy, a preset fee per member is paid to a health care provider, regardless of whether the member requires services. AmeriCare provides health care services through employers.

A client is being prepared for discharge from the hospital after an exacerbation of heart failure. The client needs assessment of cardiac status, instruction in medications and diet therapy as well as exercises to increase endurance and stamina. The client also needs assistance with self-care, both in performing it now and learning how to adapt to the limitations to maintain independence. The client also lives alone with an older adult, frail spouse. In addition to the client's physician, which members of the interdisciplinary team would need to be involved? Select all that apply.

Nurse Physical therapist Occupational therapist Unlicensed assistive personnel Social worker

A nurse is helping a client choose a new health care plan. The client states a preference being able to choose a physician. Which plan would be the best option for this client based on the stated preferences?

PPO

A nurse has very strong client education skills. In which health care setting would the nurse make best use of these skills?

Primary Care Center

In the 1980s, the nursing care delivery model shifted from a team nursing model to a:

Primary Nursing Model

A client who is affluent and places a high priority on maintaining freedom to choose which physicians and health care services the client uses would most likely be best served by which group plan?

Private insurance

What nursing function would be most commonly found in an ambulatory care facility?

Providing direct client care Ambulatory care centers and clinics (agencies that deliver outpatient medical care) may be located in hospitals, may be a freestanding service provided by a group of health care providers who work together, or may be managed by an advanced practice registered nurse. Although a nurse may serve as an administrator or manager in such a facility, the nursing function most commonly found in this setting is providing direct client care. Educating individuals or groups would be a nursing function more commonly found in a primary care facility. Assessing the home environment would be a nursing function more commonly found in home health care.

Which statement regarding pay for performance is most accurate?

Quality of care is measured and used to evaluate hospitals and other providers and to award reimbursement.

A nurse is providing care to a client recently admitted to the health care facility for treatment of an infection. The client experienced a traumatic brain injury several months ago that resulted in paralysis of both lower extremities and difficulty swallowing and speaking. The client's spouse is the primary caregiver. The client's spouse says to the nurse, "It's been really tough this last month caring for my spouse. Even though I have an aide who comes in to help for a couple of hours a week, I'm just spent, physically and emotionally." A referral for which service would be appropriate?

Respite Care Respite care is a type of care provided for caregivers of homebound ill, disabled, or older clients. The main purpose is to give the primary caregiver some time away from the responsibilities of day-to-day care. Although parish nursing and palliative care may be helpful in providing the spouse with support, it would not necessarily provide the respite needed. Parish nursing emphasizes holistic health care, health promotion, and disease-prevention activities and combines professional nursing practice with health ministry, emphasizing health and healing within a faith community. Palliative care evolved from the hospice experience but also exists outside of hospice programs. It is not restricted to the end of life and can be used from the point of initial diagnosis. Palliative care, which may be given in conjunction with medical treatment and in all types of health care settings, is client- and family-centered. Hospice care is typically provided to clients with less than 6 months to live. There is no indication that the client is at this stage.

A group of first semester nursing students is preparing for a class presentation on the role of the school nurse. They ask their instructor to look over the content prior to the presentation. Which inclusion will require the students to perform some additional research?

School nurses perform home visits on students.

A client is admitted to the facility after fracturing a hip. The client has undergone surgery to repair the fracture and is receiving services to promote healing of the surgical site and regain mobility. Which discussion should the nurse have with a member of the interdisciplinary team member to promote the goal of regaining mobility?

Speak with the physical therapist about exercises to strengthen muscles. The nurse should discuss the goal of regaining mobility with a physical therapist. A physical therapist assists with restoring mobility, strengthens muscle groups, and teaches ambulation with new devices. Respiratory therapists are trained in techniques that improve pulmonary function and oxygenation. Occupational therapists evaluate functional level and teach activities to promote self-care in activities of daily living. Speech therapists deal with swallowing difficulties and help clients speak more clearly.

Which statement most accurately reflects the intent of secondary care?

Specialists provide psychiatric care, same-day surgery, and general hospital care.

The nurse is a member of the multidisciplinary team in a large primary healthcare setting. The nurse understands that which healthcare team member is responsible for a client's swallow evaluation following a cerebral vascular accident?

Speech pathologist/therapist

A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Since the early introduction of stroke rehabilitation, the client has seen significant improvements in both medical status and activities of daily living (ADLs). This morning, however, the nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the client's chest reveals the presence of coarse crackles. Which practitioner should the nurse consult with to obtain a swallowing assessment?

Speech therapist

A nurse is a member of an interdisciplinary team providing home health care to a client who was discharged home after experiencing a stroke. The client has been receiving services to assist with swallowing. The nurse would collaborate with which member of the team to discuss the client's progress?

Speech therapist A speech therapist diagnoses and treats swallowing problems in clients who have had a head injury or a stroke. A physical therapist seeks to restore function or to prevent further disability in a client after an injury or illness. Occupational therapists evaluate the client's functional level and teach activities to promote self-care in activities of daily living. Social workers assist clients and families in dealing with the social, emotional, and environmental factors that affect their well-being.

The nurse shares with the health care team the need for a client, diagnosed with cancer and receiving chemotherapy, to attend an adult child's wedding. What discussion does the nurse have with the health care team to advocate for the client attending the wedding?

To affirm that the decision is consistent with client goals

The nurse is providing care to an older adult client approaching discharge following a surgical procedure to repair a fractured hip. The client requires continued skilled nursing care and physical therapy to improve mobility. When planning care for this client, which prescription should the nurse anticipate?

Transfer to Extended Care Facility

A home health nurse is scheduled to make a visit to a client who was discharged from the hospital yesterday following an appendectomy. The nurse understands that the scope of practice for a home health nurse allows the nurse to perform which psychomotor tasks?

Wound care, medication administration, teaching, and ensuring a reasonably safe environment

An example of primary health care is:

a hearing screening in the school setting.

Medicare part A is:

an insurance program that pays a set amount based on the diagnosis and approved care for in-hospital services.

One of the primary advantages of the managed care model is:

economic, quality care. The primary advantage of the managed care model is provision of high-quality care in the most efficient and economic manner. Managed care often results in decreased client satisfaction due to a lack of choice of health care provider. Managed care is provided by a diverse health care team with many different specialties and areas of care represented, not an all-RN staff or only one distinct area of care.

The Nursing Agenda for Health Care Reform (American Nurses Association [ANA]) identifies the recipients of health care. This reform's main focus is on:

health promotion. Recent health care reform efforts, in particular the Affordable Care Act (ACA), have made strides toward realizing nursing's vision of health care that is focused on health promotion, delivered where the individual needs it, and focused on wellness rather than disease management; however, there is much work still to be done as the effects of the ACA become known. Health care is currently focused on high-quality disease management and technology and not the prevention of disease. Accurate assessments are already part of the admission process in all health care settings.