Prep U Chapter 11: The Healthcare delivery system

A nurse demonstrates understanding of Healthy People 2020: Understanding and Improving Health by supporting which statement?

People believe "quality of life" to be synonymous with a healthy community. There is growing recognition that to achieve the goals of Healthy People 2020: Understanding and Improving Health, 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 an individual's access to a grocery store with fresh fruits and vegetables to comprehend the 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 2020.

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

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.

Prospective Payment System (PPS)

System for Medicare patients by which a predetermined level of reimbursement is established before services are provided

Diagnosis-related groups (DRGs)

System that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay

parish nursing

promotes health and wellness within populations of faith communities -work with: pastoral care staff, professional health care members, and volunteers to provide holistic approach to healing Functions: -personal health counseling -health education -liaison between faith & community & local resources -facilitate support groups -spiritual support

acute health care

short-term medical treatment, usually in a hospital, for patients having an acute illness (psychological or physical) or injury or recovering from surgery

hospice care

treatment of the terminally ill in their own homes, or in special hospital units or other facilities, with the goal of helping them to die comfortably, without pain

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 requires a referral to a cardiologist and probably additional testing. Secondary care occurs when the primary caregivers refer clients for consultation and additional testing, such as with the referral of a client to a cardiac catheterization laboratory. The remainder of the clients require only primary care.

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

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.

Which six trends in health care reflect the Institute of Medicine's (IOM) focus?

A safe, effective, efficient, patient-centered, timely, and equitable system is what the IOM envisions.

Which of the following illustrates a systems view of a person's health care?

A systems view acknowledges that a person's health care occurs within the context of family, friends, and the community around them. These factors affect the well being of the individual and vice versa. John's illness affects those that live in his neighborhood and how they react to him can affect how John copes with his symptoms.

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

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 therapist is most likely to focus on teaching a client to hold a toothbrush with an adaptive device and brush the teeth?

An occupational therapist assists physically challenged clients to adapt to limitations and use a variety of adaptive devices and strategies in carrying out activities of daily living. The occupational therapist is the health care professional who would assist the client in using an adaptive device to brush the teeth. A speech therapist assists clients with speaking and swallowing problems. A physical therapist seeks to restore function or prevent further disability after an injury or illness. A respiratory therapist is trained in techniques that improve lung function and oxygenation.

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

As part of the Affordable Care Act, hospitals may accrue penalties for readmissions of clients with certain diagnoses within 30 days of discharge. To improve client outcomes and avoid penalties, care transitions are being implemented to improve the continuity of services from hospital to home and to reduce readmissions. A collaborative discharge plan that includes the client's primary care services as well as any home care is essential for transitional care to be successful. The Americans with Disabilities Act (ADA) became law in 1990. The ADA is a civil rights law that prohibits discrimination against individuals with disabilities in all areas of public life, including jobs, schools, transportation, and all public and private places that are open to the general public. American Nurses Association (ANA) bylaws are rules established by the ANA to govern members of the ANA. The National Commission for Minorities is an organization based in the country of India.

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?

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.

pallative care

Care designed not to treat an illness but to provide physical and emotional comfort to the patient and support and guidance to his or her family.

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 who receieve care in their own homes, surrounded by familiar family and friends, have been found to recover more quickly than those in inpatient acute care settings. The other statements are not accurate.

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 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.

A middle-aged couple is considering enrolling in a long-term care insurance plan. What will this insurance cover?

Long-term care insurance plans cover a variety of services, such as nursing home care and home care, as well as services that help prevent the institutionalization of older, debilitated, and chronically ill people. Adult day care centers and respite care are also services often covered by such a plan. Pharmaceutical costs and inpatient and outpatient services are covered in the elder years by Medicare.

Which client would a nurse correctly refer to Medicare services?

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.

A nurse manager is working as part of a quality improvement team to address issues that could impact reimbursement by Medicare. Which situation would warrant the team's attention? Select all that apply.

Medicare no longer reimburses hospitals for conditions that result from preventable errors and lead to increased costs. Such conditions include pressure injuries, injuries caused by falls, infections associated with indwelling urinary catheters, vascular catheter-associated infections, infections of the mediastinum after coronary artery bypass graft, air embolisms, and adverse reactions to incompatible blood.

While at a clinic visit, a client asks the nurse, "I'm going to be eligible for Medicare soon. Can you help explain what this involves?" Which information would the nurse likely include in the explanation? Select all that apply.

People who receive Medicare pay both a deductible cost and a monthly premium for full insurance coverage. Part A of Medicare, which pays most inpatient hospital costs, is paid by the federal government. Part B of Medicare, which is voluntary, is paid by a monthly premium; it covers most outpatient costs for physician visits, medications, and home health services. Because the full cost of some services is not covered by Medicare, a supplemental insurance policy offered by a private insurance company is recommended. Also, because Medicare is federally funded, benefits may change annually according to Congressional decisions related to the federal budget.

An example of primary health care is:

Primary prevention or primary health care involves health promotion, basic care, and health prevention, including screening clients to detect disease early and prevent it from developing further. Care of a client in the intensive care unit or on rehabilitation is secondary care. Diagnostic testing for HIV/AIDS is tertiary care.

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?

The DRG system has been largely responsible for marked decreases in hospital lengths of stay. If hospital costs exceed the DRG payment for a client's treatment, the hospital incurs a loss, but if costs are less than the DRG amount, the hospital makes a profit. Decreasing hospital admission rates has not been shown to reduce the costs of health care. Health maintenance organizations (HMOs) focus on preventing illness through screening and health promotion.

A nurse is leaving a primary health care system to practice in a tertiary health care system. Which area of nursing would the nurse most likely be entering in this new job?

The U.S. Department of Health and Human Services Division of Nursing has analyzed current nursing practice and education in relation to population health care needs. Levels of health care are categorized as primary, secondary, and tertiary. Most current resources, services, nursing practice, and nursing education exist within the category of secondary health care: emergency care, acute and critical care (including community clinic nursing), diagnosis, and treatment. The population's needs, however, fall mostly within the categories of primary health care (health promotion, education, protection, and screening) and tertiary health care (rehabilitation, long-term care, support services, and hospice care).

A nurse recommends palliative care for a client who is being discharged following a diagnosis of cancer. What is the chief focus of this type of care?

The chief focus of palliative care is relief or management from physical, mental, and spiritual distress. The goal of palliative care is to prevent and relieve suffering by early assessment and treatment of pain and other physical problems (such as difficulty breathing, nausea, fatigue, and problems with sleeping). Like hospice care, palliative care is provided by an interdisciplinary team. Physical rehabilitation and occupational therapy would be the goal of home care, moving the client from the functional level at discharge from the hospital to a higher level of functioning, closer to the level prior to the hospitalization. Provision of a dignified death experience would be the goal of hospice.

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

The chief tasks of the home health care nurse are developing a nursing care plan, providing client education and counseling, providing continuity of care, and administering medications. The home health care nurse is not tasked with collecting payment for nursing care. The home health care nurse is not tasked with providing for a dignified death at home. This is the role of the hospice nurse.

The 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?

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.

When the client's primary care physician does not have hospital privileges, a service is available to provide the client's care and communicate with the client's physician. This service is provided by physicians called:

The hospitalist is a physician who provides care to the client in the emergency room and after admission to the hospital. The hospitalist communicates with the client's primary care physician but manages the hospital care. An admitting physician is one who is responsible for admitting a client to a hospital or inpatient health facility. A referral specialist is a health care office worker who is responsible for making sure that a client's health care insurance will cover expenses related to care from a specialist to whom the client's primary care provider has referred the client. An on-call physician is simply one who is scheduled to be available to come to the hospital on a moment's notice to provide emergency care to a client on an as-needed basis.

The implementation of diagnosis-related groups (DRGs) by Medicare in 1983 affected hospitals in which way?

The implementation of DRGs by Medicare in 1983 resulted in a system in which health care providers receive a fixed payment for services provided that is predetermined by the medical diagnosis or specific procedure, rather than the actual cost of hospitalization and care. The plan pays only the amount of money preassigned to the treatment for a diagnosis. If the cost for hospitalization is greater than that assigned, the hospital must absorb the additional cost. If the cost is less than that assigned, the hospital makes a profit. Medicare is federally funded, and benefits may change annually according to decisions related to the federal budget. Part A of Medicare, which pays most inpatient hospital costs, is paid by the federal government. Part B, which is voluntary, is paid by a monthly premium and covers most outpatient costs.

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?

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.

Medicare part A is:

The nurse must understand that Medicare is a federal insurance program for older people. Medicare part A is based on a prospective payment plan that pays a predetermined fixed amount for in-hospital costs. Medicare part A is admininstered federally, not locally. Medicare part B, not A, covers outpatient physician visits, medications, and home health. Medicare part A does not limit enrollees to certain providers with a group plan. Medicaid, not Medicare, is a federally funded public assistance program for low-income people.

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

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. Manged 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.

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

The report states that 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. It is the fragmented, rather than centralized, nature of health care that has contributed to medical errors. The report recommends a national, rather than local or regional, focus on leadership to improve outcomes. Voluntary reporting is encouraged.

What is one of the most significant trends in health care today?

The shift to community-based care is related to the public's desire to participate more actively in health care decisions, issues, and choices.

Which is an emerging trend in health care delivery?

Trends in health care delivery include the active involvement of consumers, continuing nursing shortage, increased complexity of client care, and a technology explosion. Other trends include changing demographics, increasing diversity, globalization of economy and society, increasing costs of health care, and the effects of health policy and regulation

respite care

a type of care provided for caregivers of homebound ill, disabled, or elderly patients

primary health care

combination of primary and public health care that is accessible to individuals and families in a community and provided at an affordable cost