750 Quiz 2
_ Act of 2018 (Sec. 50202 of the Act): elimination of therapy cap on Medicare Part B Patient Driven Grouping Model (PDGM) for home health agencies _ Driven Payment Model (PDPM) for skilled nursing facilities
Bipartisan Budget, Patient
Privatization of Medicare and Medicaid Medicare Advantage Part _ plans Medicaid expansion under managed care model
C
Describe the situation Express the emotion or effect Specify Consequences
DESC
Managed care approach to limit unnecessary healthcare services. Approval typically required.
HMO
Penalties can be applied for Medicare readmissions
Hospital Readmission Reduction Program (HRRP
Important to address because of _ Begin search on PubMed.gov using keywords Results: Addressing ADL/IADL limitation- key to reducing hospital readmissions Functional cognition, fear of falling, functional mobility, safety, vision, and overall frailty result in higher rates of readmissions
Hospital Readmissions Reduction Program (HRRP)
Quality measures & assessment data be submitted, tracked and shared by post acute settings
IMPACT Act of 2014
Use of info gained during organization and environmental assessments to validate perceptions of the wants/needs of target populations that will receive a new product or service
Markey analysis
Enacted in 1965 Jointly funded by fed govt and state Health coverage for low income persons; individuals that have LT disability 50% of beneficiaries are children State determines eligibility and coverage OT is not covered in all states Rates vary between states Home and Community Based Services (HCBS) Waiver program- available to vulnerable target populations Intent- improve quality of life OT is included in many states waivers ex: training of staff, short term restorative services CHIP: Childrens Health Insurance Program Created in 1997, part of the balanced budget act School therapy coverage Part of IEP School districts can bill Medicaid
Medicaid
Medicare Advantage Plans Managed Care model Rates for services change frequently The company can dictate DC destination, therapy and length of stay
Medicare Part C
Out - patient services Follow physician fee schedule Use of CPT coding for billing Private practice therapists - must become approved Medicare providers Once approved cannot opt out of medicareenrollment and charge for their services thru cash payments
Medicare part B
_ that align to words spoken make communication effective Kinesis Oculesics Haptics Proxemics Paralinguistics
Nonverbal cues
Addresses OT professional identity and perspective Defines the professions nature and purpose Human needs addressed by OT Problems that we solve And how we solve the problems Include theory to address these areas in a broad fashion ex. Assists in answering what the OT program focus is
OT paradigm
Tools that specify what changes, how change proceeds, the conditions under which an intervention achieves beneficial results and why a change may occur for certain groups of consumers and not others
OT paradigm
Places limits on providers an insured can access
PPO
Cost containment and shifts in fee structures _ payment model did not sustain the program therefore Development of Medicare Prospective Payment System in 1983. Intent to shorten length of acute stay Rate established: dx + hospital region=payment
Retrospective
Used frequently in nursing S-situation B-background A-assessment R-recommendation
SBAR
Fee for service has gained popularity Requires that client seek reimbursement by their insurance company Alternative medicine - often fee for service and has gained popularity
Self-pay
Application has gained momentum since 2020 E synchronous Assure you have consent Assure that your "hands" are competent Often OTA/PTA are onsite Other times use of facility staff
Telehealth
Largest integrated healthcare system 1,255 healthcare facilities 170 medical centers 1,074 OP sites Serve 9 million enrolled
VA
Mandated by federal govt in all states Each state has industrial commission Determine payment and rules regarding what the employer or the employer's insurance company must cover
WC
Groups of providers associated with a defined population of clients that are accountable for the quality and cost of care delivered to that population
accountable care organization
ex. hospital, specialists, grp of primary care physicians
accountable care organizations
individuals attempt to incorporate health behaviors into their routine.
action
3 generations currently in work force What does this mean? Must understand your audience and id best methods for communication
adapting your message to the audience
•Patients dealing with difficult situations •Organizational hierarchical in nature •Must be _ for our patients •IDT
advocates
Speak loudly Are confrontational Perceived as intimidating Responses- reactionary Angry/forceful
aggressive communication style
Payment systems that incentivize value-based care by focusing on reduced costs and high-quality care
alternative payment models
Like to get along with everyone High value on relationships Frequently do not assert their views
amiable
Logical and fact oriented Accuracy is valued Objective data valued
analytical
Respectful, firm, and clear articulation of the speaker's needs A means to act in one's own interest Enables the setting of boundaries Facilitates trust Provides a way to express difficult ideas constructively
assertive communication
Thoughtful Respectful in response Direct Want to have 2-way discussion
assertive communication style
Make eye contact Maintain an open posture Own your opinions, needs, words. "I" statements Firm, clear voice State the issue and the outcome you desire Stay focused and calm
assertive communication techniques
Language differences Timing of message Use of medical jargon Conflicting nonverbal communication
barrier to communication
level of arousal can affect readiness to attempt new occupational behavior. Ie. Fatigue, over arousal due to nervousness, under the influence of meds, etc
being aware of physiological state
Encompasses all costs associated with an episode of care.
bundled payment program
Utilize resources available through the official documents from AOTA Understand documentation requirements for reimbursement by Medicare and Medicaid Specific guidelines for documentation Use of quality measures under the IMPACT Act Consider the use of organizational clinical or critical pathways for managed or episodic care Access local district- or state-level educational resources for school-based practice guidelines Investigate any pertinent facility standards required for accreditation Explore other related disciplines' studies and guidelines pertinent to client population and setting
clinical practice requirements
Plans may dictate if individuals access OT treatment Consumers are more likely to compare costs Must be aware of _ requirements Illegal to waive - negates contractual agreements between provider and insurer
co pay
Improves Access to and coordination of services Appropriate use of specialist resources Health outcomes for people with chronic disease Patient care and safety
collaborative practice
Not publicly funded Held by individuals or nongovernmental org Frequently available thru employer-sponsored plans or individually thru brokers Most are for profit Typically HMO or PPO High deductible plans (w/HSA accounts)
commercial/private insurance
As health professionals we are a part of complex environments Miscommunication within health care can have profound implications. As healthcare professionals, it is our ethical obligation to study, practice, and grow in our ability to _
communicate
Usually improves quality of care
competition
Generates theory and methods to apply the theory (these methods referred to as technology for application) Each model focuses on specific phenomena or areas of function therefore typically apply a combination of models Generate theory unique to OT
conceptual practice model
Tool used to help generate theory and methods therapists use in their work to apply that theory (eval, intervention)
conceptual practice model
persons are aware of a health problem; are considering taking action but have not committed to any specific action thinking about making a change
contemplation
Specifies the requirements for continuing education and other means to demonstrate
continuing competence
members are excited about tackling new problems in a creative manner even if mistakes are made.
creativity
Composed of persons with specific expertise and knowledge Work together to achieve an assigned goal or fulfill a specific purpose for the organization
cross-functional work teams
misinterpretation: be mindful when engaging with other cultures •Become literate in cultural norms; termed "cultural intelligence"
cultural competence
shared elements of identity and communication patterns of a group
culture
When supply is > demand= _ in cost When demand is > supply = costs _
decrease, increase
collaborative practice _ Patient complications Length of hospital stay Tension and conflict among caregivers Staff turnover Hospital admissions Clinical error rates and mortality rates
decreases
Stop talking Put the speaker at ease Do not interrupt; especially if the person is upset Empathize Paraphrase Ask open ended questions Use silence Allow reflection
development of good listening
members carry out roles and responsibilities with discipline even when it is not convenient or comfortable.
discipline
Optimal communication should be a leader's primary concern The leader's influence is continually earned, reinforced, and established through communication Impressions of leadership are built over successive interactions
discursive model of communication
Focused on task completion Efficient Do not place high value on relationships
drivers
The United States is the only industrialized country that does not have government-funded health care for all its citizens. A key concept is "_," which is a major element of the current debate on healthcare reform.
dualism
reflects the involvement of both govt and private industry in healthcare
dualism
The goal of every _ is to allocate scarce resources (Mansfield, 80). Assumption is that there is a finite amount of resources (e.g., Medicaid, Medicare, etc. have finite budgets) Much of the healthcare reform debate has been focused on access to limited services Is health care a right or a privilege? The answer lies at the intersection of values, economics, and systems
economy
Keep to 60 min; no greater than 90 min Invite only those needed Make agenda available ahead of time Assure that at meeting end all have assignments to bring to next meeting Choose appropriate meeting space
effective meetings
Acknowledges a difficult situation and attempts to redirect the conversation to the issue and to inspire action
empathic
Examination of data, info and other forms of evidence, including needs of target populations, that will guide the development and promotion of a new service
environmental assessment
Things to evaluate for your target populations: Population demographics (age, marital status, socioeconomic data, insurance status, etc.) Payer mix Targeted areas of expansion for your org Organizational plans for future space and resource allocation Strategies Id and review websites of competitors to learn about their products and services Interview leaders of community-based org or public health officials concerned with your target population Establish focus groups Engage in a health fair etc where you can collect data Id physicians and gain feedback
environmental assessment
Bundled Payments for Care Improvement Initiative (BPCI) Comprehensive Care for Joint Replacement (CJR)
episode payment models (bundled payment)
Action-oriented Follow up technique Directs the recipient of the message to complete that which is needed and explains consequences
escalating
Enthusiastic Seek attention Value relationships Like personal recognition
expressive
_: NOISE, DISTRACTIONS, SERVICE PROVIDERS VYING FOR PT ATTN _: FATIGUE, DIVIDED ATTN, EMOTION OR PERSONAL THOUGHTS Poor listening skills
external, internal
Delineates beliefs, assumptions, def and concepts within a specific area of practice. Employ existing theory and focus on dev methods of applying that theory in OT
frame of reference
Typically assumed that economies do better when people are free to choose
free choice based on information
Healthcare functions differently in the _ Involvement of 3rd party payers and managed care limit the effects of supply and competition IE. PPO - What effect can this have on quality? IE. HMO - use gatekeepers to control access to specialists (must have referral). If referred must use one of their specialists
free market
Composed of persons from several vertical levels of the organization who perform specific organizational functions
functional work teams
Exclusion as an interprofessional team member for primary care initiatives Other disciplines step forward as key players Medicare payment reductions Reduced presence in community and outpatient settings if our role in addressing SDoH is not established Failure to meet and/or exceed quality measures defined by CMS
future challenges in occupational therapy
_ : Number of individuals assembled together or having some unifying relationship, Do not share responsibility, Focus on achievement of ind goals, Typically only 1 leader, Discuss problems and delegate tasks to members _ : Group of people who perform interdependent tasks to work toward a common, Share responsibility, Focus on _ goals, Can have multiple leaders, discusses the problem and id way to solve it completing it collectively
group, team
Study of touch Can convey warmth, reassurance, caring etc May be perceived differently by different people and cultures
haptics
Perceived susceptibility Perceived seriousness Perceived barriers Perceived benefits Cue to action
health belief model
US- adult population basic or below basic _ 43% for reading and comprehension 39% for reading and using forms 55% for working with numbers _- Agency for Healthcare Research and Quality (AHRQ) define as ability to obtain/understand health information and make appropriate decisions
health literacy
Increased from 4% in 2006 to 30% 2019 Higher _ rates- $2900-$6900 Majority of ACA plans are high _ and also require co pay
high deductible health plans
Shared vision and goals Shared leadership and accountability Continuous learning and development Customer focus Capability to gather and use feedback and data
high-performing teams
value honesty and transparency about aims, decisions, uncertainty, and mistakes.
honesty
Includes ulcers, falls, med errors and infections Results in payment penalty for all Medicare DC at hospital
hospital-acquired condition reduction program
members value one another's training and do not believe that one perspective is always superior to another, relying on one another to avoid mistakes.
humility
intentional act; requires conscious attention from the listener Listening is vital to establishing trust Must set aside judgement and criticism and be open to the message Tips: Eye contact maintained Open and engaged posture Offer acknowledging responses
importance of listening
the structures within organizations and their programs, policies, and procedures
institutional
Members provide care to a common group of patient/clients. Members develop common goals for patient/client outcomes and work toward those goals. Appropriate roles and functions are assigned to each member, and each member understands the roles of the other members. The team possesses a mechanism for sharing information. The team possesses a mechanism to oversee the carrying-out of plans, to assess outcomes, and to make adjustmentsbased on the results of those outcomes.
inter professional teams
Composed of members from several disciplines working interdependently in the same setting Coordinate work and communicate more formally to contribute to an interdisciplinary plan of care Problem solving typically in team meetings Example: inpatient rehab facilities
interdisciplinary teams
relationships and interactions with persons such as friends, family, and peer groups.
interpersonal
provides for expanded knowledge, creativity, and diversity of insights Teams develop through stages Group members strengths need to be id to best utilize each member High-functioning teams have shared/clear goals, mutual trust, and respect for others
interprofessional collaboration
Recognizing need for effective communication Need to recognize factors such as jargon that can limit understanding Effective communication both written and verbal or electronic
interprofessional communication
occurs when students from two or more professions learn about, from, and with one another to enable effective collaboration and improve health outcomes
interprofessional education
individual factors and characteristics such as knowledge, beliefs, and values that may influence behavior.
intrapersonal
Teamwork Understanding role and responsibilities Shared values and ethics Effective communication skills
key to communication between OT/OTA
Study of gestures, postures and facial expressions Self assessment may be helpful if you do not know how you reflect these areas Gestures can provide animation; or at extreme can be distracting Posture/body orientation- standing or sitting upright facing others with slight lean says you are open Arms not crossed indicates openness
kinesis
Provides highest level of public protection by prohibiting unlicensed individuals from practicing OT or referring to themselves as OTs/OTAs. laws reserve a scope of practice for those _
licensure
health behaviors are successfully incorporated into daily routines, and attempting to prevent relapse.
maintenance
Method of controlling utilization of healthcare by requiring approval of services; negotiation of fees with providers is typical
managed care
Protects the public by prohibiting uncertified persons from referring to themselves as OTs/OTAs. Unlike licensure, individuals under certain circumstances can practice if they do not refer to their services as occupational therapy. _ laws may provide a definition of occupational therapy.
mandatory certification
Validate perceptions of target populations: Data, information, and evidence from your organizational assessment and environmental assessment Outcome of this will be your marketing plan Ex: dev of a hand program What would you do?
market analysis
Must consider expenses and revenue "free" service or indigent care - what does this mean? Who is covering that cost? Must look at revenue - what is the payment system around your new service?
marketing
Process of organizational assessment, environmental assessment, market analysis and marketing communications
marketing
Methods devised to reach your target populations to promote your product or service
marketing communication
State run funded by state and federal govt for individuals with limited income
medicaid
Federal program; over 65 y/o who have worked for at least 10 years and some individuals with disabilities that have been present for at least 2 yrs
medicare
Largest payer of healthcare services Managed and funded by federal govt Administered by Centers for Medicare and Medicaid Services of the Dept of Health and Human Services Requirements 65 y/o Disability and receiving social security for 2+years ESRD ALS Use of MACs _ administrative contractors Contracted for a period of 5 years Set their own requirements May require certain documentation May exclude some coverage
medicare
Hospital payments follow prospective payment model Based on dx, facility location & characteristics
medicare Part A
Incentives were created for physicians to increase efficiency and value. Led to performance measures that also apply to therapists under the Medicare Physician Fee Schedule (out-patient therapists use this system) Payment incentives provided when reporting on quality measures & improvement activities
merit based incentive payment system
Focusing the mind to be centered in the present moment Can be used to manage stress Meditation, silence Self-reflection Deliberate reflection
mindfulness
Composed of members from several disciplines so the team can offer a greater breadth of services to patients Team members work independently and interact formally Example: short stay acute care settings
multidisciplinary teams
Understanding can be gained through the sharing of stories Example: abused indiv referring to self as abuse survivor vs as one that has been abused
narrative paradigm theory
What we say is less important than how we say it as words are only 7% of our communication. Paralinguistics- the explanation of non verbal aspects
non-verbal communication
An individual's behavior is affected by those with whom the individual interacts Social norms inferred from cultural & group contexts Examples: support groups, mentoring relationships
normative social behavior theory
Define what type of supervision is required for occupational therapy assistants, including amount of time, frequency, and documentation requirements.
occupational therapy assistant supervision requirements
Eye contact Helps to engage audience Breaking of the gaze can break the flow of communication
oculesics
1.the _ (seek explanation of what is) questions related to what is most real for OT 2.the epistemological (theory of knowledge, minds relation to reality) questions related to what is known and understood in OT the _ (study of values and of value judgements especially in ethics) questions related to what is the right action in occupational therapy
ontological, axiological
the interrelationships between organizations or within existing social networks
organizational
Examination of the factors within an org that will influence the dev and promotion of a new product or service
organizational assessment
SWOT analysis Perspectives from stakeholders Mission statement review Assures you are in line with the org objectives If not clear - need to be ready to provide explanation for need If asked to engage in an activity that does not align - can allow you to have leverage to not complete that task Conduct informational interviews w/other dept directors to gain perspective on their needs Ask for input using newsletter, media etc Id if there is info already present to support your venture Conduct a survey of needs, resources or limitations to internal customers SWOT analysis; compare between depts Review web page from your org - id services that may have synergy w/what you are proposing
organizational assessment
First impressions Internal Telephone communication Waiting room Therapy area External Parking Travel distance
packaging
Chronemics: time ex. someone who is chronically late; always early Disposition/attitude Voice Quality Pitch, tone, volume, pace, enunciation, rhythm, use of silence
paralinguistics
Speak softly May agree even when they do not Back-down Difficult for other to know their opinion
passive communication style
IHIs: "Triple Aim" expanded to "quadruple aim" Health insurance marketplaces to provide affordable care Increase coverage by regulating insurance plans Medicaid expansion Facilitate innovation of programming and alternative payment models that generate better health outcomes
patient protection and affordable care act of 2010
Medicare Medicaid WC VA Private Insurance Out of pocket/ self-pay
payers for OT services
Do your employees understand your product and its place in the organization? Prepare employees to talk to others about your product(s). Define the distinct value of the occupational therapy or other services you are providing.
people
learning by doing; providing a hands-on opportunity for an individual to engage in the actual task.
performance accomplishments
Client testimonials Client satisfaction surveys
physical evidence
traditional clinic services: the client comes to your location. On-site: you go to the client's location. tTelehealth: client calls a phone service.
place
Tracking of outcomes for a group of people
population health
Established in 2019 Measure to evaluate and report the frequency of readmission from post acute settings Applies to SNF, HHA, IRF
potentially preventable readmission
persons are un- or underaware of a health problem or the benefit of performing a health behavior. No intention to change behavior
pre contemplation
intention to begin performance of a health behavior is combined with criteria for action that include a time frame to begin acting
preparation
Implications: Develop readmission prevention program identifying those at risk Train occupational therapy staff Track readmission data Bottom Line: OT can take a leadership role in implementing targeted evidence-based programs to minimize risk of readmissions and measure impact of programs
preventing hospital readmissions
Value Associated costs: Time costs Emotional or psychological costs Physical costs Monetary costs
price
Generate data specific to your product or service Existing customers or potential customers Referral sources, payers, employees, suppliers etc
primary data sources
Resources that generate data specific to your product or service Existing customers, referral sources, payers, employees, suppliers, consultants etc
primary data sources
Completeness- relays all the facts Conciseness- brevity Consideration-words chosen & how they may be received Clarity-clear message Concreteness-basis in fact; how literal it is Courtesy-respect toward receiver Correctness-accuracy of content
principles for effective communication
Clearly define for everyone in: Development Delivery Marketing communications Know what you can and cannot deliver
product
Seven P's of mixed marketing: _ Price Place Promotion Physical evidence Packaging _
product, people
`Develop an external action plan: 1.Who is the target population? 2.Who are internal or external customers? 3.What are your consumers' and customers' goals? 4.Who will be involved in deciding where to go for services? 5.What is the most efficient and effective way to reach your consumers and customers?
promotion
Optimal use of face- to- face engagement How to: Promptly address issues Plan ahead Focus on behavior not person; description not judgement Be specific Check to ensure message was received
providing constructive feedback
Role of personal space Intimate personal space in US: 18" or less Conversational personal-space: 18"-4' Social distance/professional: 4-8' Public distance: >12' (attending a speech)
proxemics
the policies, programs, and regulations of local, state, and federal bodies are examined for opportunities to influence or regulate behavior.
public policy
Use of _ to demonstrate positive outcomes across the healthcare continuum Capture meaningful measures that demonstrate: Safe community discharge Reduced length of hospital stays Prevented hospital-acquired conditions Adopt more service delivery options, such as population health, primary care, telehealth, and disaster relief
quality metrics
Incentivizes providers to meet quality measures by the potential of earning a bonus or incurring a penalty reduction in future payments
quality payment program
Specify if a physician referral is necessary for evaluation and/or treatment.
referral requirements
Comes from outside of OT Investigated by other disciplines ex. Motor learning OT applies this information to allow persons following CVA to dress; relearning familiar activities
related knowledge
Must know own role Understand the role of the other disciplines IPEC focus: the need to address complex health promotion/illness problems, in the context of complex care delivery systems, calls for recognizing the limits of professional expertise and the need for cooperation, coordination and collaboration between professionals
roles and responsibilities
Defines the domain of OT, such as defining the roles of OTs and OTAs. May include specifics (such as orthotics, physical agent modalities, activities of daily living intervention, and environmental modification), or may be more general in nature.
scope of practice
Already exist - reports, stats, surveys etc
secondary data sources
Research that already exists Govt census reports, economic statistics about a potential target population, info from news sources etc Stakeholders persons, groups, org that support OT practice and the mission of OT
secondary data sources
Face-to-face meetings Brochures and direct mail Telephone solicitations Seminars TV/radio/print ads Website Social media
selecting promotional media
Operate with a high level of autonomy and responsibility Still held accountable for outcomes and projects assigned to the team
self-directed work teams
Behavior is determined by expectancies and incentives Efficacy expectations related to one's confidence about performing a behavior Incentives related to the value an individual places on an outcome
social cognitive theory
nonmedical factors that influence health provide an incentive for healthcare providers to address population-wide needs Create the justification for addressing population health Track the health outcomes of groups of people Acknowledgment that medical models must recognize social factors related to health of populations
social determinants of health
Communication is for mutual benefit Example: therapeutic use of self or outcomes from a good support group
social exchange theory
Relates to online relationships Can achieve the same or > intimacy as in-person but will take longer Example: may be applied to telehealth
social information processing theory
Internal customers External customers Clients: Persons Organizations Populations Patients Third-party payers
target populations
Cooperation Working to avoid duplication of service Working toward consensus Recognizing expertise of others Shared accountability Working to maintain positive relationships
teams and teamwork
Defines the process for unlicensed personnel to obtain permission to work while waiting for their licenses.
temporary license/work permit
Explanation of how or why a particular phenomenon occurs and how that might be influenced
theory
explanation of how or why a phenomenon occurs and how it may be influenced Key: explanation, •Providing a reason for how something works Found in paradigm, frames of reference, in conceptual practice models, and in knowledge
theory
Managed care controls utilization of healthcare services by requiring approval Fees are negotiated at reduced rate Aim is to improve efficiency and reduce costs Competition and choice in a free market are restricted What are some examples of the various types of managed care?
third-party payers
Accept that superior communication abilities require a lifelong learning perspective Reflect, self-assess Seek continual improvement and learning to become a better communicator Practice; engage with others
to be a better communicator
engage in teaching and learning across disciplinary boundaries May train others to complete some work tasks or functions in their absence Example: community-based settings
transdisciplinary teams
2018 - 10.4% under age 65 28 million _!
uninsured
Purchasers of health care hold providers accountable for delivering a hi-quality level of care in a cost effective manner
value-based payment
Codes of Ethics OT- includes altruism, equality, freedom, justice, dignity, truth, prudence, beneficence, nonmaleficence etc IPEC indicated a need for a focus on the values that should undergird relationships among the professions, joint relationships with patients and the quality of cross professional exchanges in delivering health care and in establishing policies
values and ethics
learning by listening; trying to convince someone to adopt a behavior.
verbal persuasion
learning by observation; best if the "model" is perceived as being like the client and to achieve mastery through effort rather than ease.
vicarious experience
