Prep U / Qs - Chapter 11: The Healthcare Delivery System

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." Explanation: 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.

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." Explanation: Evidenced-based practice improves client outcomes, thereby increasing the quality of care; quality care leads to decreased cost. Cost is a driver in quality health care delivery. Evidenced-based practice is not just a trend in care; it is an expectation in health care delivery. Clients are consumers of care, but they often do not understand evidenced-based care or the cost associated with care. Today's greater focus on quality makes it less likely that clients will suffer unnecessary or harmful treatment, reduces waste, and increases safety.

Which statement regarding health care reform trends is most accurate?

"Systems are in place to pay for performance and penalize hospitals for excessive readmissions." Explanation: Health care trends already include paying for performance (HEDIS, HCAHPS) and penalizing hospitals for excess readmissions. In the United States, private insurers dominate over public, unlike in most countries. The United States is first in health care spending worldwide, and it is estimated that 20% of the gross domestic product will be spent on medical services by 2021.

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." Explanation: Those entering convalescent centers remain only until they have recovered. The nurse should explain this even though the client does have the right to refuse. There is no indication that the client will not be able to care for oneself again. There is a difference between a convalescent center and a nursing home.

A nurse is providing care to several clients at the clinic. When reviewing the clients' medical records, which client would the nurse identify as meeting the criteria for Medicare reimbursement? Select all that apply.

66-year-old male with heart failure 45-year-old male with a permanent disability receiving social security benefits Explanation: The 1965 Medicare amendments to the Social Security Act established national and state health insurance programs for older adults under Title XVIII. Within a decade, almost all citizens over 65 years of age held Medicare insurance for hospital care, extended care, and home health care. Medicare coverage was increased in 1972 to include permanently disabled workers and their dependents, if they also qualified for Social Security benefits. Medicaid was established in 1965 under Title XIX of the Social Security Act. Medicaid is a federally funded public assistance program for people of any age who have low incomes; for the blind, older adults, and disabled covered by supplemental security benefits; and for beneficiaries of Aid to Families with Dependent Children.

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

A client's health is affected by social, economic, and political factors. Explanation: 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 Explanation: 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 refers to a person's ability to find and to receive care from a health care provider?

Access to health care Explanation: Access to health care services refers to a person's ability to find and to receive care from a health care provider. Access to clinics, doctors, and nurses are inclusive in access to health care; however, one may still have access to health care without having access to any one of these.

Which is an emerging trend in health care delivery?

Active involvement of consumers Explanation: 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.

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. Explanation: 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 Explanation: 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. Explanation: 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.

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. Explanation: This spouse is exhausted and needs respite care. The hospice nurse can arrange for short-term inpatient care for the client so that the spouse can rest. The other options will not be effective for exhaustion.

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. Explanation: Although the setting for care and the type of intervention may change, the nursing focus is always the same: the holistic care of an individual. Wherever the nurse practices, the primary concern is to provide for health care that focuses not only on physiologic needs but also psychosocial and spiritual needs of the person in relation to the environment. Both care settings require the participation of the client, but only the home care setting requires the participation of the client's family. The home care setting can be initiated before the client returns to full function. Both settings focus on the client's needs.

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 Explanation: Case management means the nurse coordinates many resources to maximize the opportunity for people to manage their own health care at home. A nurse does not have to be nurse practitioner, clinical nurse specialist, or other type of advanced practitioner to serve as a case manager.

Unlicensed assistive personnel (UAP) include which workers?

Certified nursing assistants, orderlies, attendants, and technicians Explanation: 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. Explanation: Clergy, lay volunteers, and providers with advanced spiritual care degrees provide spiritual care to clients, families, and members of the interdisciplinary team. Spiritual care can be provided by non-clergy, but lay volunteers are not typically the primary spiritual care providers in most hospitals.

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 Explanation: 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.

A nurse would like to work in a mental health center. The nurse should work to strengthen which skills prior to applying for this position? Select all that apply.

Communication Counseling Referral Explanation: All five of these skills are important for nursing, but communication, counseling, and referral skills are particularly necessary for the nurse working in a mental health center.

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 Explanation: The most important role of the nurse in preventing fragmentation of care would be coordinator of care. Care coordination is the deliberate organization of client care activities between two or more participants (including the client) involved in a client's care to facilitate the appropriate delivery of health care services. The roles of care provider, counselor, and educator are all important roles, but the priority role is as the coordinator of care.

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 Explanation: Extended care services meet the needs of clients who no longer require acute hospital care, including rehabilitation, skilled nursing care in a person's home or nursing home, and hospice for dying clients. HMOs are corporations that provide health care for members in exchange for preset, fixed, or yearly fees. PPOs are agents for health insurance companies that control healthcare costs on the basis of competition. A client with end-stage liver failure would not require emergency care.

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 Explanation: Fragmentation of care occurs when multiple, specialized practitioners are involved in various aspects of a complex client's care. This creates the potential for miscommunication and conflicting advice and treatment with the lack of a unified plan of care. This situation is not indicative of primary care and it is not necessarily a consequence or manifestation of case management or managed care.

A nurse is reviewing the different types of health care delivery services available in the community. Which method would the nurse identify as having the primary care goal of reducing costs by preventing illness?

Health maintenance organization (HMO) Explanation: Health maintenance organizations (HMOs) are prepaid, group-managed care plans that allow subscribers to receive all the medical services they require through a group of affiliated providers. Their primary care goal is to reduce costs by preventing illness. Preferred provider organizations provide services at a lower fee in return for prompt payment and a guaranteed volume of clients and services. Accountable care organizations offer incentives to provide integrated, well-coordinated care. Community health centers ensure that everyone who needs care has access regardless of the ability to pay.

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. Explanation: The Triple Aim framework has three dimensions: 1) improving the client experience of care (including satisfaction and quality); 2) improving the health of populations; and 3) reducing the per capita cost of health care. Making quality information available more quickly would encourage nurses to change practices that result in poorer quality. Reducing redundancy would reduce per capita costs. Educating the public would eventually increase the health of the population. Doing away with client satisfaction surveys would make satisfaction data difficult to track trends. There is no indication that increasing staff salaries would help meet these goals.

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 Explanation: Based on the client's condition, the following members would be involved: nurse to assess cardiac status and teach about medications and diet; physical therapist to assist with exercises; occupational therapist to assist with self-care adaptations; unlicensed assistive personnel to assist with self-care now; and social worker to assist with supportive services for the couple since the spouse is elderly and frail. Respiratory therapy would be indicated if the client needed oxygen or respiratory medications/treatments.

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 Explanation: Preferred provider organizations (PPOs) allow a third-party payer (agencies that pay health care providers for services provided to people, such as a health insurance company) to contract with a group of health care providers to provide services at a lower fee in return for prompt payment and a guaranteed volume of clients and services. The client may choose to use a physician within the PPO for a lower service fee or choose a provider outside the PPO and pay a higher service fee. A point of service (POS) plan is a mix between an HMO and PPO, but the client usually does not have the ability to choose the primary health care provider. Health maintenance organizations (HMOs) are prepaid, group-managed care plans that allow subscribers to receive all the medical services they require through a group of affiliated providers. The client would not be able to choose the provider in most HMOs. Long-term care (LTC) is not a type of health care plan.

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 Explanation: Primary health care provides care for common health problems and provides preventative measures. Client education is a common part of the nurse's activities in this setting. While teaching does (and should) occur in the other environments, the nurse does not have the opportunity to see the client repeatedly to teach and reinforce teaching.

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

Providing direct client care Explanation: 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. Explanation: In pay for performance, quality of care is measured and used to evaluate hospitals and other providers and to award reimbursement. Financial incentives are offered to health care providers for achieving certain clinical measures established by the payer, not client objectives. These clinical measures include not only delivery efficiencies, improved quality, and patient safety, but also submission of data to the payer. Pay for performance is not limited to any particular hospital size.

The nurse is providing care for a client who has a tracheostomy and whose pulse oximeter has recently alarmed, showing the client's oxygen saturation to be 77%. The nurse has repositioned the client and applied supplementary oxygen, interventions that have raised the client's oxygen levels to 80% and have somewhat decreased his work of breathing. The client is not in immediate distress, and his level of consciousness remains high. The nurse should page which practitioner?

Respiratory therapist Explanation: A respiratory therapist is an expert in lung function and oxygenation whose expertise is needed in the care of this client. Because the client is not experiencing severe distress or respiratory arrest, the nurse is justified in foregoing contact with the physician in the short term. A physical therapist or occupational therapist is not likely able to provide needed interventions at this time.

During a home care visit to a home-bound older client, the client's spouse, who is the caregiver, verbalizes anger, fatigue, and sleeplessness. Which recommendations by the nurse would be most effective in relieving caregiver role strain?

Respite care Explanation: Hospice, voluntary services, and palliative care would all be helpful to the client and spouse, but only respite care directly provides the spouse with a break from caregiving duties.

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 Explanation: 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.

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 Explanation: It is within the speech pathologist's/therapist's scope of practice to conduct a swallow evaluation for a client but outside the scope of the occupational therapist, the physical therapist, and the physician assistant.

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 Explanation: 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.

A client has a rare neurological disorder and will require complex management with specialists. Which level of care should the nurse anticipate this client requiring?

Tertiary Explanation: The client will require tertiary health care due to the complex and rare nature of the disease process. Primary health care deals with more common health care issues and preventive measures. Secondary health care would be related to issues that require more specialized clinical expertise than those addressed by primary health care but less specialized care than those addressed by tertiary care. "Complex referral" is not a level of health care.

A client's primary care provider has advertised that the provider follows the medical home model of primary care. As the client learns more about medical homes, which occurrences make the client question whether the model is being followed as intended? Select all that apply.

The office has stopped staying open on Saturday and Thursday evening. It is common to have to wait 2 to 3 weeks for an appointment time. Explanation: Components of a medical home are that it is client-centered, coordinated, comprehensive, accessible, and has a systems-based approach to quality and safety. Long waits for appointments and decreased hours make the office less accessible. The remaining options support the components.

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 Explanation: In the role of an advocate, the nurse actively works to protect the rights of clients. The nurse would express to the health care team that the decision to attend the weeding is consistent with client goals. The final step of advocacy is to affirm with the client that the decision is consistent with client values and goals. In the role of educator, the nurse provides teaching so the client understands the ramifications of the decision. The client wishes to see the child married; seeking other alternatives is not an option. In the role of counselor, the nurse engages in active listening with the client and offers empathy and emotional support.

A nurse is considering accepting a new position in an ambulatory care center. What roles does the nurse understand are likely in this setting? Select all that apply.

Triaging walk-in clients Teaching clients about wellness and illness Assisting with minor surgical procedures Performing physical assessments Explanation: Prioritizing patient care tasks, teaching, assisting in surgery, and performing physical assessments are all within the registered nurse's (RN) scope of practice. Prescribing medications is outside the RN scope of practice.

Medicare part A is:

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

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

health risk screenings administration of immunizations to children and adults education related to sexually transmitted infections Explanation: Screening, health promotion, and prevention (e.g., immunizations and education on sexually transmitted infections) are components of primary health care; emergency care is a component of secondary health care, and complex disease management and rehabilitation are components of tertiary health care.

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

primary nursing model. Explanation: In the 1980s, the nursing care delivery model shifted from a team nursing model, in which a team of nurses collaboratively provide care to a given client during a stay, to a primary nursing model, in which one registered nurse (RN) is responsible for providing all care needed by a given client during the client's stay (either directly or by delegating to others). The managed care model is an approach to health care delivery that seeks to contain the costs of health care while providing quality care. Modular nursing is similar to team nursing except that the clients assigned to a given team of nurses are grouped according to geographical location on the unit. A clinical specialist is a nurse who has additional training in a medical specialty, such as cardiology.