Exam 4 Health Care Delivery and Financing PDF

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This talks about health care delivery and financing....

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Health Care Delivery and Financing NUR255 Dok Woods

New technology and pharmaceuticals has caused health care cost to greatly increase. Third party payers and health care institutions continue to apply pressure to reduce cost. Health care has become less service oriented and more business oriented.

Health Care Regulation And Competition Professional standards review organization (PSRO). established to review the quality, quantity, and cost of hospital care provided through Medicare. Utilization Review Committee (UR) review admissions, diagnostic tests and therapies provided by physicians to clients. aim of UR is to identify and eliminate overuse of diagnostic and treatment services.

Prospective Payment System (PPS) established by Congress in 1983, eliminated cos based reimbursemen . Diagnosis Related Groups (DRGs) Hospital services for Medicare clients were bundled into 468 DRGs. Each group has a fixed reimbursement amount. Adjustments are made based on severity, regional cost (urban/rural), and teaching cost.

Managed Care (Capitation) Describes health care systems in which there is administrative control over primary health care and services are provided to a defined population. The provider or health care system receives a predetermined payment for each client enrolled in the program. Ex: $50/client/mo If: 300 clients, the physician or system will receive $15,000/mo

National Quality Forum (2006) Defined a list of 28 “Never Events” that are devastating and preventable Medicare will no longer pay for these events Ex: death, serious injury related to med error; administration of incompatible blood product

Pt Protection and Affordable Care Act (2010) Focuses on increasing access to care for all, reducing costs, and improving quality Insurance industry reforms to decrease costs and increase coverage increased funding for community health centers, increased primary services/providers, and improved coverage for children (P&P, p15)

Levels of Care 1 Preventive Care (education and prevention) – Services: B/P screening, immunizations, community legislation, Poison control information

2 Primary care (Health promotion) – Services: health screening, nutrition counseling, prenatal care, exercise classes

3 Secondary Care (acute care) – Services: ER, Me Surg unit

4 Tertiary Care (Special Care) – Services what secondary can not provide like burn center, psychiatry, intensive care

5 Restorative Care (rehab, home care, intermediate follow up care) – Services: swing bed, home health, rehab, sports medincine

6 Continuing (lon term care, chronic care, personal care, hospice care) – Services: Assisted Living, Respite care, Hospice, and Adult Day Care Centers (provides intermediate and custodial care)

Key Terms Extended care facilit provides intermediate medical, nursing, and custodial care. Respite Car a service that provides sho term relief or time off for caregiver. Outlier clients with extended lengths of stay, well beyond inpatient DRG days

Vulnerable populatio clients who are more likely to develop health problems as a result of excess risk, are dependent on others for health care EX: poor, homeless, mentally ill Medicare/Medicai government programs. The government has strict regulations governing reimbursement (Medicare – federal run) (Medicaid – state run)

Issues in Health Care Delivery Nursing Shortage – Largest HC profession in the US – Over 500,000 new nursing positions by 2018 – Slight easing of shortage but will not last due to aging workforce and retirements – Slow growth of nursing school enrollments due to nursing faculty shortages, space limitations, and clinical site availability

Issues in Health Care Delivery Competency Pew commission(1998) listed 21 competencies for HC workers IOM (2001) identified 5 essential competencies Consumers’ expectations Continued education and certification

Issues in Health Care Delivery Patien centered Care goal is to improve the quality of care while reducing cost Evidenc Based Practice based on research, clinical experience, practice trends, and patient preferences

Issues in Health Care Delivery Quality and Safety – improving processes to improve quality and safety, performance outcomes ex: readmissions, rate of infections, functional health status of client post discharge

HEDIS (Health Plan Employer Data and Information Set provides vital statistics on more than 70 indicators, allowing payers to check on performance of different health plans

Issues in Health Care Delivery Client Satisfaction – Picker/Commonwealth Program for Patien Centered Care identified 7 dimensions of clien centered care (conducted through telephone interviews) – Other companies distribute surveys in the mail – Staff receive feedback regarding their success in meeting client’s expectations

Discharge Planning Is a centralized, coordinated, multidisciplinary process that helps in the transition of client’s care from one environment to another and begins on admission Discharge planning begins the moment a patient is admitted to the health care facility.

Technology in Health Care Technology makes nurses job easier Technology does not replace nurse’s astute, critical eye and clinical judgment Electronic medical information systems offers valuable information to care provider Clinical information system allows you to enter information quickly on special flow sheets and nursing care plans

All health care team members have access to electronic record. The use of electronic information systems requires strict confidentiality protocols. An electronic system does not minimize your responsibility for ensuring that clinical information about a client is documented accurately and completely in a timely manner and that it is protected.

Future of Health Care Professional nursing is an important player in the future of health care delivery. Professional nursing makes a difference in improving quality care. Nursing Sensitive Indicators patient outcomes directly related to nursing care...