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Ch1 Hlth Info Mngmt
Health Care Systems
Question | Answer |
---|---|
accreditation | voluntary process by which private, non-governmental organization/agency performs external review & grants recognition to program of study/institution that meets certain predetermined standards |
advanced directive | documented life support or treatment related wish of patient given to healthcare providers; patient must be competant at time document is prepared. |
catchment area | defined geographical area that is served by a healthcare program, project or facility; services provided usually directed at population group |
certification | refers to process by which goverment & nongovernment organizations evaluate educational programs, healthcare facilities & individuals as having met predermineted standards |
Conditions of Participation | standards published by CMS that establish minimum that organizations must meet to be eligible to receive reimbursement for providing care to Medicare beneficiaries |
Continuum of care | full range of healthcare services provided, moving from least acute & least intensive to most acute & most intensive, or vice versa |
ex officio | member of governing board/committee who does not have voting privliges |
governing body | group of individuals who have ultimate legal authority & responsibility for operation of the healthcare organization, including quality & cost of care |
the board of trustees, board of governors, or board of directors are other names for | the governing body |
inpatient | patient receiving health care services & provided room, board, & continuous nursing service in a unit/area of the hospital |
licensure | legal approval for facility to operate, or for person to practice within his/her profession |
an individual must meet eligibility requirements defined by the state before the individual is granted | a license to practice |
licensure occurs at the ____ level | state |
licensure is overseen by a state licensing ___ | board/agency |
observation patient | patient who needs assessment, evaluation, or monitoring because of significant degree of instability/disability that does not require admission to hospital as an inpatient |
patient centered care | care puts patient in change & gives them as much control as desired |
gives patients choices that allow them to express cultural traditions, personal preferences & values, family situations & lifestyles | patient centered care |
deemed status | refers to facilities that are accredited by the Joint Commission & AOA, and are in compliance with Medicare Condition of Participation (COP) for hospitals |
electronic health record (EHR) | patient records that are maintained electronically in a manner that is accessible to caregivers, the patient, & others who need access to specific information or to aggregated information to prevent illness & improve future treatment |
electronic medical record (EMR) | electronic patient records developed by an individual health care provider/organization |
composed of whole files as oppossed to individual data elements | EMR |
data from the EMR are the source of data for | the EHR |
encounter | professional contact between patient & provider during which services are delivered |
patient-/consumer-centric culture | changes occuring with shifts from inpatient to outpatient care, increased legislation on patient rights, & increase in alternative health care systems |
personal health record (PHR) | electronic/paper record of health information compiled & maintained by patient |
is not part of the health record compiled by health care provider's legal health record | personal health record (PHR) |
provider | entity that provides health care services to patients, including health care organizations & health care professionals |
the Joint Commission | private entity whose primary function is to develop & assess standards of performance by health care organizations |
organizations goal is to improve quality of health care | the Joint Commission |
in 2007 the Joint Commission changed its name from | the Joint Commission for the Accrediation of Healthcare Organizations (JCAHO) |
health defined by World Health Organization as | state of complete physical, mental & social well-being & not merely by absence of disease or infirmity |
care | management of, responsibility of, or attention to safety & well-being of another person/s |
health care services | processes that contribute to health & well-being of person |
provided in variety of settings, such as hospital, ambulatory, or home settings; to include nursing, medical, surgical, or other health-realted | health care services |
patient | individual, including one who is deceased, receiving/using, or who has received, health care services |
client | person who receives professional services |
patient in behavioral health setting, adult day care or home health care is referred to as | a client |
outpatient | patient receiving health care services at hospital without being hospitalized, institutionalized, or admitted as an inpatient |
resident | patient who resides in long-term care facility |
payer | organization or individual who provides money to pay for health care services |
founded in 1765 in Philadelphia was the | first U.S. school dedicated to train physicians |
in 1847 a group of physicians formed | American Medical Association (AMA) |
AMAs primary purpose | establishing & supporting code of ethics for physicians & thier duties to their patients & profession |
AMA membership is open to | any physician in good standing |
AMA includes medical societies in | local, city & state |
dedicated to promoting science & art of medicine, improving public health, making health care policy, and servicing professional needs of its members | AMA |
founded in 1848 for purpose of promoting public welfare by providing better health care in hospitals | American Hospital Association (AHA) |
American Hospital Association (AHA) purposes inclduing | funding & conducting research/educational programs, maintains data on hospital profiles, & respresents hospital intrests in legal/legislative matter, all of which are directed at improving national health care system |
1910 study of quality of medical education in US; identified serious problems & existing in medical education | Flexner Report |
because of the Flexner Report the AMA | initiated accrediation process ranking medical schools according to performance |
American College of Surgeons (ACS) | founded 1913 to develop system of hospital standardization to improve patient care & recognize hospitals holding highest ideals |
founded in 1917 by ACS | Hospital Standardization Program |
1919 ACS identified essential standards for proper care & treatment of hospital patients | Minimum Standards |
Hospital Survey and Construction Act | sponsored in 1946 by Senator Lister Hill & Harold L Burton |
Hill-Burton Act | provided funding for construction of hospitals & other health care facilities on basis of state need |
founded in 1952 & adopted Hospital Standardization Program from ACS | the Joint Commission of Accreditation of Hospitals (JCAH) |
1965 Congress amended Social Security Act of 1935, Public Law 89-97 establishing | Title XVIII, Health Insurance for the Aged, and Title XIX, extending Kerr-Mills Medical Assisance Program |
Medicare | federally funded program providing health insurance for elderly & certain other groups |
Medicaid | federal government supports states in paying for health care for indigent |
indigent | one who is without the means for subsistence, poor or impoverished |
in the 1960's the JCAH | redefined standards to optimal acheivable as oppossed to minimum standards, and began development of standards for various types of health care facilities |
in the 1980's the JCAH reflected its broader scope by | changing its name to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) |
To Err is Human was published | 1999 by Institute of Medicine (IOM) |
medical errors include | adverse drug events, mismatched blood types & surgery on wrong patient/limb |
1935 legislation passed providing grants for old age assistance & benefits, unemployment compensation, & aid to dependent children, maternal & child welfare & other groups | Social Security Act |
1953 formed for purpose of addressing issues related to health, education & welfare of people of US | Department of Health, Education & Welfare (HEW) |
1970 legislation passed mandating employers to provide safe & healthy work enviroment & resulted in devlopment of standards | The Occupational Safety & Health Act |
1977 founded by AMA for purpose of accrediting allied health programs | Committe on Allied Health Education & Accreditation |
1980 HEW reorganzied into a federal cebinet0level department repsonible for health issues, including health care & costs, welfare of various populations, occupational safety & income security plans | Department of Health & Human Services (DHHS) |
1982 established as mechanism for controlling cost of Medicare program; set limit on reimbursement & required development of prospective payment system | The Tax Equity & Fiscal Responsibility Act (TERFA), PL97-248 |
known as "Patient Anti-Dumping Law" | EMTALA Emergency Medical Treatment and Active Labor Act |
1985 | COBRA estalished EMTALA |
1987 effective 1990, required nursing facilities to employ sufficient nursing personnel, 24 hr/day, to provide care to each resident according to care plans | the Nursing Home Reform Act |
1989 Omnibus Budget Reconciliation Act brought attention/support to production/dissemination of scientific & policy-relevant info that improves quality, reduces cost, & enhances effectiveness of health care & eastablished | Agency for Health Care Research and Quality (AHRQ) |
1990 resulted from Cruzan v. Missouri case in which court upheld patient wishes at end of life | Patient Self-Determination Act |
1991 DHHS commissioned the Workgroup on Electronic Data Interchange to | identify ways of increasing number of claims processed electronically, which would reduce admin costs |
1992 created for purpose of developing strategy supporting development & adoption of computer-based patient record | Computer-Based Patient Record Institute |
1996 implemented in 1998 directed at improving access, affordability & adequecy of health insurance; established fraud/abuse detection program for health plans | Health Insurance Portability and Accountability Act (HIPAA) |
licensure, like that of HCOs, is ___ to practice the profession | required |
registration & certification are ____ | voluntary |
individual HCOs may require ____ or ____ as a condition of employment | registration; certification |
professional organization for physicians that is involved in the accreditation of medical schools, residency programs, & certain allied health programs | AMA American Medical Association |
only accrediting agency for osteopathic medical education in US | American Osteopathic Association Bureau of Professional Education |
the AOA regulates its membership by | requiring a minimum number of continuing education credits to retain membership |
accredits 20 different health science occupations, more than 2000 programs, and is recognized as the largest accreditor in health sciences | Commission of Accreditation of Allied Health Education Programs |
accrediting organization for degree-granting programs in health informatic & information management | Commission on Accreditation for Health Informatics & Information Management Education |
accrediation by CAHIIM means | an educational program has volunatarily undergone rigorous review process & been determined to meet/exceed standards set by sponsoring professional organization, AHIMA |
eastblishes standards for nursing cirriculum, incl programs for RN & licensed practical nurses | National Leaugue for Nursing Accrediting Commision, Inc. |
professional organization for nurses | National League of Nursing |
state licenses is | a permit issued by the state that authorizes a person to practice in specific area |
health occupations that require licensure to practice include | medicine, osteopathy, nursing, nusring home administration, dentistry, podiatry, & others depending on the state |
occupational therapy is a profession that is both | licensed & certified |
Practice Act | state law that defines the rights & scope of practice of each profession & the requirements to attain a license |
also define condition for endorsement (reciprocity) between states | Practice Act |
the Joint Commission defines continuum of care as | matching level & type of health care with continuing needs of individual |
primary care | most often considered care provided at the point of first contact/encounter with health care provider in ambulatory care setting |
episodes of care | care for specific condition during a period of relatively contiuous care |
primary care encompasses | preventative care & acute care |
acute care | treatment of common illnesses & injuries |
gatekeepers | refers to primary care physician who participates in comprehnsive managed-care plan & responsible for coordinating all care provided to patient |
managed-care enrollee | patient |
if a patient needs to see specialist, gatekeeper must make referral & thereby | controls access to all other care |
secondary care | implies care by specialist, usually through referral from primary care physician |
tertiary care | care provided at facilities with advanced technologies & specializes intensive care units |
teaching institutions & university medical centers are considered | tertiary care |
institutions recognized as providers of tertiary care are often involved in | biomedical research |
endocrinologists, hematologists, oncologists, thoracic surgeons & neurosurgeons are considered | tertiary care providers |
ambulatory care | comprehensive term for all types of health care provided in an outpatient setting |
care provided in (1) free-standing medical centers, & (2) organized setting functioning independent of physicians providing care are | two types of ambulatory care |
usually private practices, however can be part of managed-care programs | physician practices |
private practice | physicians or other health care providers who are established in independent practice for profit |
solo practices | self-employed & legally sole owners of their practice |
"take call" refers to | practice of one physician managing care for another's patients allowing physician to take time away from work |
partnership private practice | legal agreement btwn 2+ physicians to share certain expenses & profits |
a private practice partnership may be referred to as | group practice |
group practice | 3+ physicians entered into legal agreemnt to share certain assets & liabilities as determined by the agreement |
group practice agreement specifies that | physicians are employees of practice with all $$ generated & expenses to be pooled & redistributed to physicians according to agreement |
some group practices may have arrangements involving sharing certain central servies while | still maintaining the physicians' individual practices |
group practices may be composed of many physicians of the same speciality or | a multispeciality group |
groups of OBYGNs or ophthalmologists are examples of | same-speciality practices |
this group offers at least 2 speciality areas | multi-speciality group |
an example of a multi-speciality group would be | a women's center; which may includes pediatricians, OBs & GYNs, infertility spec., & gerontologists |
many larger multi-speciality groups have thier own | ancillary services |
clinical labs & radiology units, or radiotherapy are examples of | ancillary services |
1961 legislation provided grants for establishment of voluntary health planning agencies at local level, serving low income areas | the Community Health Services & Facilities Act |
community health centers (CHC) | designed to provide comprehensive care in catchment area having limited/nonexistent health services for certain populations, or special health needs |
funding for CHCs comes from | private, state & federal grants |
federal funds for CHCs comes from local & state health departments as well as from | Public Health Service & Bureau of Community Health Services of DHHS |
sliding scale fee | cost of health care based on patient's ability to pay |
Care provided at CHCs may be at no charge or as | sliding scale fee |
Community-Based Care refers to | delivery of services going beyond instrumental setting & reach out into community |
financing of community-based programs includes | private donations, Medicare/Medicaid, other federal & state monies, & other sources |
1965 Title III of Older Americans Act established funding for transportation & chore, homemaker, & home health aides for eldery, which are all considered | community-based care |
surgicenters or ambulatory surgery centers | free-standing surgical facilities in which surgical procedures can be safely performed on day of admission/on an outpatient basis |
urgent care, medical walk-in & convenience care centers are for patients who need | routine care or have minor, yet urget, health problems |
facilities are open at least 12hr/day, 7days/wk & do not require appt | urgent care, medical walk-in & convenience care centers |
hospital ambulatory care | "hopsital directed" health care provided to patients who are not admitted as inpatients & for which hospital is responsible, regardless of location of health care |
satellite clinics, observation units, outpatient departments, ancillary services & other speciality clinics are examples of | hospital ambulatory care |
satellite clinics | not located on campus of main hospital & established in areas convenient to patients |
observation unit | unit, department, or beds for observation patient |
CMS 24 hour benchmark | patient is expected to require hospital care for 24+ hours &/or meets inpatient criteria for hosptial admission |
physicians should admit a patient as inpatient, oppossed to an observation patient, if | they meet the CMS 24hr benchmark |
the observation period should not exceed | 36 to 48hrs |
outpatients department | care provided to patients who are not admitted |
diagnose & treat conditions not emergent in nature & yet require intervention within short period of time | outpatient department, in addition to primary care |
outpatient surgery departments | perform surgery for which admission is not required |
units within a hospital as well as satellite surgery centers are included as | outpatient surgery departments |
ancillary services | supplemental diagnostic or therapeutic medical services at request of physician to both in/outpatients |
radiology, clinic lab, physical/occupational/respiratory therapy, cardiographics, pharmacy, etc. are examples of | ancillary services |
ancillary services differ from other areas of hospital because | hospital able to charge patientm or 3rd party, directly generating revenue for hospital |
there is no single definition of the word | hospital |
AHA defines hospital as | health care facility that has organized medical/professional staff, inpatient beds avail 24hr/day |
primary function providing inpatient medical, nursing & other health-related services for surgical/nonsurgical conditions & some outpatient services, especially emergency care | hospitals as defined by AHA |
hospital classification includes | ownership, # beds, length of stay, clinical classification, patients & organization |
critical access hospital (CAH) | provides acute inpatient care, has no more than 25 beds & has annual average length of stay of 96hrs |
state certifies a CAH as | being necessary to residents in community, or no other hospital or CAH within 35 miles of CAH |
hospital ownership is | goverment or nongoverment |
goverment-owned (federal, state, or local) hopsitals | not for profit |
nongoverment owned hospitals | for/not for profit |
federally owned hospitals receive funding from | branch of government that owns them |
federal goverment finances, or goverment-funded, health care services or facilities are | contracted out or goverment operated |
Department of Veterans Affairs (VA) | medical centers federally owned providing health benefits to people served in US military |
eligibility for VA hospital care requires that the person | have a service-related condition or disability, or be unable to pay for health care |
VA is organized into 21 | Veterans Integrated Service Networks |
Veterans Integrated Service Networks | oversee & manage various VA health care facilities |
Department of Defense provides health care for | active/retired military personnel & their dependents |
facilities owned & operated by the Department of Defense include | Army, Navy, Air Force & Mairne Corps |
facilities owned & operated by the Department of Defense offer comprehensive health care | on military bases or in regional centers |
facilities for mental illness, developmentally disabled, chronic disease & medical education are | state hospitals |
established to meet health care needs of the communities & governed by locally elected officials | county, district & city hospitals |
non-goverment owned hospitals fall into | for profit or not profit types |
proprietary hospitals | private, for profit, or investor-owned |
not-for-profit hospitals are also considered | voluntary |
owned by churches & religious orders, & those owned by industries, unions, & fraternal organizations, or just community hospitals | not-for-profit hospitals |
bed size | total # of inpatient beds with which facility equipped & staffed for patient admissions |
a facility is licensed by the state for | a specific # of beds |
the average length of stay for a hospital determined whether they are classified as | short-term (acute) or long-term care facility |
short-term (acute) care facility | average length of stay less than 30days |
long-term care facility | average length of stay more than 30days |
according to AHA the major types of hospitals include | general, special, rehab & chronic disease, and psychiatric |
general hospital | provides patient services including radiographic, clinical lab & operating room services |
speciality hospital | provides diagnostic & therapuetic services for patients with specific medical condition |
rehab & chronic disease hospital | provides diagnostic & therapuetic services to patients who are disabled/handicapped & require restorative & adjusted services |
psychiatric hospital | primary purpose to provide diagnostic & therapuetic services for patients with a mental illness/psychiatric-related disorder |
behavioral health | primary focus of psychiatric hospitals; services include psychiatric, psychological & social work |
hospital patients | people receiving/using health care services for which hospital is liable/held accountable |
hospital inpatient | patient generally stays overnight & provided room, board, & nursing service in unit/area in the hospital |
historically hospitals have been orgranzied in | a hierarchial form |
hierarchial form | individuals at top have authority that passes downward through a chain of command |
in hierarchial form physicians are not employees of the hospital so | they do not fall within the chain of command |
matrix organization | supports general managers who focus on managing people & processes as oppossed to strategy & structure |
flexible & supports mutlidimensional organization | matrix organization |
due to complex growth of health care system it is difficult | for one person, CEO, to manage effectively |
matrix organization consists of | talented leaders who are focused on certain processes |
product line management | organized around product line catagories as oppossed to departments |
the discussion of the organization is specific to | the free-standing hospitals |
the governing body of a voluntary hospital usually consists of | influential business & community leaders who have vested intrest in community & skill of value to the board |
board members of a governing body are not | paid |
standing committees of governing board | executive, financing, nominating committees, medical staff, physician recruitment, & long-range planning |
special committees (task forces) of governing board | created for specific projects/task & disbanded on completion of project/task |
ultimate responsibility for quality of patient care, depending on HIM dept to provide documentation to assist in & support decision making & long-range planning for hospital | the governing board |
JCAHO identified numerous info processes for which governing body & organizational leaders are responsible | obtaining, management & using info to improve patient care, governance, management, & support processes |
governing body & administration depend on HIM dept to perform processes timely & accurately, in addition to | ensure accessibility, security, confidentiality, & integrity of data in compliance with internal/external regulations |
the Joint Commission states that the primary role of leadership is | planning, directing, coordinating, providing, & improving health care that responds to community & patient needs; improves health care outcomes |
CEO Cheif Executive Office is also called | hospital administrator or president |
recruited & selected by governing board, they are principal admistrative official of hospital, or health care facility | CEO Cheif Executive Office |
the Joint Commission standards stipulate that effective leadership of the hospital | devlops strategic plan supporting mission/values/visions & communicates mission/value/plan throughout organization, & provides framework to accomplish goals that fulfill vision |
the plan for providing patient care should be reviewed in order to determine if meets identified patient needs & consistent with hospital mission, on a(n) ____ basis | anual |
HIM dept responsible for prep of much of review documentation, with special regard to | clinical info, accreditation standards, rick mngmt, utilization review & quality of patient care |
COO Cheif Operating Officer is also called | executive vice president, vice president, or associate administrator |
COO reports directly to | CEO |
provides leadership, direction, & adminstration of operations in compliance with mission/strategic plan of organization | COO Cheif Operating Officer |
Cheif Information Officer | holds an executive position with primary responsibility for information resources mngmt in organization |
embrace financial, administrative, & clinical information needs of health care facility or organization | health information systems |
report to Cheif Information Officer | information systems, telecommunications, HIM & management engineering |
CFO Cheif Financial Offer sometimes called | director or finance or fiscal affairs director |
financial operations of health care institution are under direction of | CFO Cheif Financial Offer |
CEO & CFO also report to | finance committee within governing body |
finance committee | advisory group within board responsible for reviewing hospital's financial position & make fiscally related decisions |
the board and CEO are responsible for the control & use of all financial resources, according to | the Joint Commission |
medical staff | formally organized staff of licensed physicians & other licensed providers as permitted by law |
has authority & responsbility to maintain proper standards of medical care | medical staff |
medical staff is goverened by | its own bylaws, rules & regulations, approved by hospital's governing board |
the Joint Commission standards state that the primary responsibility of the medical staff is | quality of professional services provided by members with clinical privleges & responsibility of being accountable to governing body |
clinical priveledges of practitioners | permission granted by governing body to provide well-defined patient care services in granting institution on basis of licensure, education, training, experience, competence, health status & judgement |
organizational scheme of medical staff includes | officers, committees, & clinical services |
requires that there be anexecutive committee empowered to conduct medical staff business btwn staff meetings & responsible to governing body | the Joint Commission |
medical staff executive committee composed of | members of medical staff and an ex officio member from administration |
members of medical staff are organized into | areas of clinical service and departments usually representative of medical specialties |
patient assessment | process of obtaining appropriate & necessary info about each individual seeking entry into health care setting/service |
nursing care | based on process involves assessment, diagnosis, outcomes/planning, implementation, & evaluation of patient care; documentation in health record must reflect this process |
nurse executive | responsibility & authority to establish nursing standards, policies, & procedures in compliance with state law & professional standards |
staff nurse | provides direct patient care in specific unit with assigned patients |
clinical nurse specialist | an expert in specialized area; RN with advanced education/experience in area of expertise |
private duty nurse | RN or LPN employed by external agency or individual to provide care to one patient for 8-12hrs over period of time |
nurse manager | may be head nurse, nursing supervisor, or department head responsible for certains units/staff |
makes patient assingments, staffing decisions, & responsible for quality of care provided by nursing staff | nurse manager |
also works in research, education, administration & consultation | clinical nurse |
nursing assistants | work under supervision of nurse & provide basic patient care |
eligible for certification involving 2wks training & clinical experience; upon completion & examination becoming | nursing assistance |
diagnostic radiology services | diagnosing of diseases/conditions using ionizing radiation, ultrasonography, & MRI |
the Joint Commission requires health care facilities to provide diagnostic testing, including imagaing, that | is both relevant to determining patient's health care needs & treatment |
radiology department is headed by | a radiologist |
radiology technical staff | under direction of radiologist, including physicians, radiology technologists & radiation therapy technologists |
nuclear medicine | procedures involve use of radioisotopes for diagnosing/treating patient |
image created by nuclear medicine gives information not only about the structure but also about | the function of the organ/tissue under study |
dietary/nutrition services | considers all nutritional aspects of patient & patient care, providing high-quality nutrition to every patient |
according to the Joint Commission nutritional care must | be provided in a timely & effective manner |
clinical dieticians | responsible for therapuetic care of patients |
dietary staff | assist with prep, serving, & delivery of food & maintenance of dining services for staff/visitors |
pathology & clinical lab services | assists in prevention, diagnosis, & treatment of disease by examination/study of tissuee specimens, blood & body secretions & wound scrapings/drainage |
functions in serology, histology, cytology, bacteriology, hematology, blood bank, organ bank, biochemistry, & tissue prep | pathology & clinical lab services |
emergency care services | provides around the clock care to patients that present with conditions that are urgent, life-threatening, or potentially disabling |
functional areas of emergency department (ED) | trauma area. casting room, exam rooms, & observation beds |
triage | process of sorting out for purpose of early assessment to determine urgency & priority for care & determine appropriate source of care |
morbidity | extent of illness, injury or disability in given population |
mortality | death rate in a given population |
trauma center | emergency care center specially staffed & equipped to handle trauma patients |
EDs are accreditated by | American College of Surgeons |
Pharmacuetical service | maintains adaquate suplly of medications, nursing floor stock & prep/dispense medications with appropriate documentation |
floor stock | inventory of drugs maintained on each nursing unit; varies by unit needs |
hospital formulary | provides information on drugs approved & maintained by HCO; names, dosages/strengths, packaging, characteristics & clinical use |
pharmaceutical service is under direction of | state-licensed pharmacist |
physical medicine & rehabilitation | diagnosis & treatment of certain musculoskeltal & neuromuscular diseases & conditions |
physical therapists | state licensed; teach/work with patient on exercises the strengthen certain muscles groups or assist to ambulate with artificial limb |
occupational therapists | work with patient to minimize diability & teach patient to compensate for disability |
speech pathologists | teach patient how to compensate for difficulty with speech or inability to speak |
audiologist | examine, evaluate, & prescribe therapy to patients with hearing deficit |
respiratory care service | encompass diagnostic & therapuetic procedures for variety of acute/chronic lung conditions |
social services | staffed by medical & psychiatric social workers who work with patient & family on therapy & recovery |
HIM Department | management of all paper & electronic patient information |
subacute care | transitional level of care that may be necessary after initial phase of acute illness |
area of hospital or nursing facility or provided by a home health agency | subacute care |
home health care | provision of medical & non-medical care in the home or residence to promote, maintain or restore helath or to minimize effect of disease/illness |
home health services are an adjunct to | acute care |
Medicare definition of home health care stipulates | needed nursing care, physical therapy, or speech therapy must be skilled intermittent care provided under physician written direction & plan of care in residence of homebound client |
long-term care | health care provided over 30+days to patients with chronic diseases or disabilities |
facilities providing long-term care are considered | nonacute care facilities |
skilled nursing facility | long-term care facility |
wond care, intravenous injections, & physical or speech therapy are examples of | skilled nursing facility care |
to be certified as Medicare/Medicaid provider a nursing facility must comply with | the Conditions of Participation |
long-term care facilities are licensed by | the state |
assisted living facility | offers housing & board with broad range of personal & supposrtive care services |
domiciliary/custodial facility | supervision, room, & board provided for people unable to live independently |
independent living facility | apartments/condiminiums allow residents to live independently; assistance available as needed by residents |
life care centers | provide living accomodations & meals |
also called retirement communities | life care centers |
nursing facility | comprehensive term for long-term care providing nursing care & related services for resident who require nursing. medical or rehab care |
swing beds | designated beds in hospital that hace flexibility of serving as acute care or postacute long-term beds |
concept of hospice means | given to hospitality |
hospice | multidisciplinary health care program responsible for palliative & supportive care program of terminally ill patients/families |
palliative care | health care services that relieve or alleviate patients symptoms & discomforts, not curative |
respite care | type of short-term care; focused on giving caregivers time off & yet continue care of patient |
complementary & alternative medicine (CAM) | therapies that may/may not have been proven effective |
complementary medicine | practices that could be used along with conventional therpy |
alternative medicine | practices that would be used in lieu of conventional medicine |
CAM therpies include | herbal medicines, massage, natural food diets, acupunture, & biofeedback |
National Center for Complementary & Alternative Medicine | established by National Institutes of Health to explore science, train, research, & disseminate authorative info to public & professionals regarding CAM |
E-health | use of emerging info & communication technology, especially Internet, to improve/enable health & health care |
adult day care services | health care program provides supervision, medical & psychological care & social activities for older adults who reside at home |
mobile diagnostic services | mobile units from larger health care facilities transport advanced diagnostic equipment & staff to small/rural communities |
outsourcing | use of contract services |
integrated delivery system (IDS) | various ownership & linkages among hospitals, physicians, & insurers |
vertical integration | network of HCOs provide/arrange continuum of services ro a population; network assumes clinical/fiscal responsibility for outcomes & health status of the population |
horizontal integration | merging of HCOs at the same point of continuum of care |
Wilson & Neuhauser define health care professionals as having | certification/licensure for profession, national/reg prof assoc esists, define body scientific knowledge & tech skills required practice, code of ethics, & member profession practice degree of authority/expertise for decision making in area of compentence |
health care team composed of | individuals who work wither directly/indirectly to accomplish goals of patient care |
technologst & therapist | education at or above bachelor's degree |
technician & assistant | above associate degree level |
assistant & aide | on-the-job training |
independent practitioner | those who by law provide range of services with consent/approval of 3rd party |
dependent practitioner | those who by law may deliver a limited range of services under supervision/authorization of independent practitioner |
midlevel practitioner | dependent practitioner |
supporting staff | function under supervision/authorization of independent or dependent practitioners |
noncaregiving group | includes all people who have no direct patient contact yet make significant contributions to healthcare systems |
physician | qualified by formal education & legal authority through licensure to practice medicine |
evidence-based medicine | guidlines/medical decision making is supported by research |
clinical guidlines & policies | primarily derived from expert opinion & clinical judgement |
Doctor of Medicine (MD) & Doctor of Osteopathic Medicine (DO) | licensed by each state as medical practitioners who may diagnose, treat, perform surgery & prescribe medications |
complete 4 yrs medical education, supervised internship/residency program & state licensing exam | MD &DO |
practices comprehensive medicine that uses manipulative therapy along with more traditional forms of therapy | DO only |
the Federation Licensing Examination (FLEX) | standardized licensure test developed by Federation of State Medical Boards of US in 1968 |
alternative to FLEX | exam developed by National Board of Medical Examiners |
residency is considered to be | graduate medical education |
hospital residency programs are accredited by | Accreditation Council on Graduate Medical Education |
to become board certified a physician must meet certain requirements established by | the Board of Certification |
NBME examination | allows for student to be tested at intervals during training |
in order to apply for state licensure a physician must have | passed NBME?FLEX & completed 1yr residency |
depending on the speciality a physicians residency can last | 3-7 years |
hospital residency programs are accredited by | Accreditation Council on Graduate Medical Education |
physician assistant (PA) | midlevel practitioner trained to assist physician; ewvaluating, monitoring, & diagnosing patients |
surgeon assistant | PA specialized in surgery |
single largest health care profession in the US | nursing |
nursing care standards by ANA include | policies, procedures, & written mechanism |
nursing practice is regulated by individual states as stipulated by | the Nurse Practice Act |
nursing care models | primary nursing, patient-focused nursing, & team nursing |
primary nursing | implies one nurse responsible for mngmt of care for each assigned patient |
in primary nursing, they are responsible for the entire patient stay; 24 hrs a day | the RN |
registered nursing & licensed practical nursing | 2 major types of nursing |
most allied health professionals function | by order of physician |
self-pay, out-of-pocket, or direct pay | payment by patient to the provider |
indirect pay | payment by a 3rd party on behalf of patient |
insurance | purchased contract in with purchaser is protected from loss by the insurer's agreeing to reimburse for such loss |
coinsurance | insured is partially liable for the debt |
reimbursement formula | agreement between 3rd party payers & providers concerning what will be paid and for how much |
often referred to as the contracted amount | reimbursement formula |
retrospective payment system | charged for health care services is determined after health care provided |
fee-for-service | reimbursement method which cost is based on provider's charge for each service |
usual, customery & reasonable charges | based on physician's usual charge for service, amount physicians in area charge for same, & whether amount is resonable |
capitation | prepair, fixed amount paid to provider for each person served, regardless of how much/often patient receives services |
managed care | generic term for health care reimbursement system that designed to minimize use of services & contain costs while ensuring quality of care |
managed care encompasses continuum of practice arrangements including | HMOs, PPOs & other alternative delivery systems |
preferred provider organizations PPOs | network of physicians &/or HCOs enter into agreement with payers/employers to provide health care services on discounted fee schedule for increased patient volume |
the oldest managed care plan is | HMOs |
HMOs | integrates health care delivery with insurance for health care |
staff model | salaried physicians employed by HMO provide care for only HMO subscribers |
group model | HMO contracts with group practices & hospitals to provide comprehensive health care services to subscribers |
network type | HMO contracts with variety of providers to provide health care to subscribers |
independent practices association (IPA) | group of physicians organized into health care provider organization furnishing services to patients who have signed up for prepayment plan where physician services provided by IPA |
case management | all activites including assessment, treatment planning, referral, & follow-up ensures provision of comprehensive & continuous services & coordinationg of payment & reimbursement of care |
case manager | experienced health care professional knowledgable about clinical aspect of patient;s condition & available resources |
point-of-service POS | requires enrollee select provider at the time, & each time, care is provided |
point-of-enrollment-plan | if enrollees are required to sselect provider at time they are enrolled in managed-care plan |
utilization review | process of evaluating efficiency & approriateness of health care services according to predetermined criteria |
beneficiaries | people enrolled in Medicare/Medicaid programs |
Medicare Part A | hospital insurance to help pay inpatient hospital care, inpatient care in nursing facility, home health care, and hospice care |
physician's fees are not covered by | Medicare Part A |
Medicare Part B | voluntary insurance designed to supplement cost of inpatient/outpatient care not covered under Medicare Part A |
Medicare Part B covers | physicians fees for diagnostic tests, medical/surgical services, radiography, durable medical equipment, ambulance service, home health, radiation therapy, & other outpatient services |
durable medical equipment (DME) | wheelchairs, oxygen equip, walkers, & other devices prescribed by physician used at home |
Medicare Part C | available to beneficiaries enrolled in Part A&B |
Medicare Advantages is | Medicare Part C |
Medicare Modernization Act (MMA) | expanded coverage providing outpatient prescription drug coverage, expanded health plan options, improved access to health care for rural US, & covers preventative care services |
Medicare Part D | prescription drug coverage; cost depending on plan selected |
Medicare prescription drug coverage is available through | Part C or D |
fiscal intermediary | through which hospitals, physicans, & other health care providers are reimbursed for services deleiver to Medicare beneficiary |
organization contracted to process claims & payments to providers for Medicare Part A, per federal regulations | intermediary |
Medicare Part A is financed | primarily by payroll tax, unless beneficiary does not qualify for federal retirement benefits |
Medicare Part B is financed | by federal appropriations with monthly premiums paid by medicare beneficiary |
prospective payment system PPS | reimbursement method where amount of payment is determined in advance of services rendered |
1982 Congress pass Tax Equity and Fiscal Responsibility Act (TEFRA) Public Law 97-248 | mandated development of mechanism for controlling cost of Medicare program & created PPS |
diagnosis-related groups (DRG) | classification scheme by which reimbursement for hospital inpatient care of Medicare patients is determined |
resource-based relative value scale (RBRVS) | reimbursement for physician services of Medicare patients is determined |
Medicaid | joint program btwn state & federal government providing health care to welfare recipients |
medically indigent | those whose incomes are above what would normally qualify for Medicaid but whose medical expenses are high enough to bring their adjusted income to the poverty level |
Balanced Budget Act of 1997 created | State Children's Health Insurance Program (SCHIP) |
State Children's Health Insurance Program (SCHIP) | offers health insurance for uninsured children up to age 19 |
Tricare | health care for active duty & retired miltary personnel & families |
point-of-care clinical information systems | caregivers to capture & input data where health care service is provided & may be at the time of patient care |
electronic data exchange | provides ability to edit, submit, & pay health care claims by way of electronic transfer |
decision support system (DSS) | computerized system that gathers information from various sources & uses analytical models to assist providers in clincal decision making regarding administrative, clinical & cost issues |