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Ch1 Hlth Info Mngmt

Health Care Systems

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
Created by: lfrancois