Chapter 2: Health Care Systems (3)

Case Management
A type of nursing care system that sees each patient as an individual and each situation as unique.
A program in which the federal government helps states pay for the health care of those with an income below the poverty level, as well as certain other individuals.
The federal government’s health insurance program for people older than 65 years of age or those with certain disabilities or conditions.
Primary care Physician (PCP)
A physician paid a set amount per member per month to manage the health care of those members.
Third- party payer
A party that pays the Bills of a beneficiary cared for by a physician or hospital; when a bill is sent to an insurance company, the insurance company is referred to as a third party or a third-party payer.
Affordable Care Act of 2010 was created to Solve:
1. Lack of health insurance for many
2. Denial of coverage du to pre-exiting conditions
3. Costly employee illness or injury that cause huge rate increases for small businesses. which leaves them unable to provide health insurance for its employees.
4. Lifetime limits of coverage
5. People who needed insurance the most were least likely to have it.
Provisions of Phase 1 and 2
1. Some preventative services are free to consumers.
2. Young adults can stay on parent’s policy until age 26.
3. Tax breaks for small businesses to pay for insurance.
4. No lifetime limits.
5. No denials due to pre-existing conditions.
6. All Americans MUST have health care by 2014.
7. Health-care Exchange
* New Provision
*Allows for clear, fair competition for consumer to by insurance .
* It is believed that this competition will decrease the cost of premiums for consumers.
* Not all states will have exchanges; people in these states will automatically be enrolled in the federal program.
Factors Guiding patient care decisions
1.Medical Necessity
2. Appropriate level of Care
Medical Necessity
Defined as services or items reasonable and necessary for the diagnosis or treatment of illness or injury to improve the functioning of malformed body member. This means that the services must seem reasonable and necessary to the entity paying for them.
Appropriate Level of Care
Navigating the continuum of care so that the patient may travel in his or her efforts to reach an optimal level of health, function, and wellness. It is important that the patients is cared for at the most cost-effective, yet safe and effective level.
Stay overnight or longer in a health-care facility.
Types of Inpatient Care Facilities
1. Acute medical or mental health-care hospital
2. Skilled nursing facility in a nursing home or hospital
3. Long-term acute care hospital
4. Rehabilitation facility
Acute Care Hospital or Medical Center
An acute care hospital may be the only hospital for many miles, or it may be one of several hospitals in a medical center complex where a number of different specialty hospitals are grouped together and share resources.
Long-Term Acute Hospital
Provides a level of care similar to that of an acute care hospital. However, an LTACH focuses on patients with serious medical problems that require intense, special treatment for a long period of time, usually about 20 to 30 days.
Skilled Nursing Facility
The SNF provides a less intense level of care than that found in a traditional or long-term acute care hospital. It usually is a transitional care setting. Patients may stay in an SNF for a few days or as long as 100 days, but they eventually move to a rehabilitation, nursing home, or home-care setting.
Rehabilitation Facility
Often shortened to rehab, is a level of care which the patient can receive intense physical, occupational, and speech therapy services. May be part of the hospital or a freestanding facility. Physical specialist oversees patient care usually a physical therapist. Patients should be capable of participating in 3 hours of care per day.
Long-term care facilities
Also called nursing homes or convalescent homes, these facilities are where residents often live for many years. Nursing care is provided around the clock for the residents in these facilities.
Assisted Living facilities
These facilities proved less nursing care than that found in long-term care facilities. Residents are assisted with medications and personal care such as bathing and dressing. Meals are provided, and a choice of activities may be available.
Independent Living facilities
These Facilities do not provide nursing care. They generally have staff available around the clock to respond to urgent situations by contacting emergency medical services for the residents. Meals usually are available, as well as transportation and activities.
Two Types of Rehabilitation Settings
1. Maybe an inpatient setting for intense physical, occupational, and speech therapy services, such as after a stroke.
2. May be a facility that focuses on treating patients with chemical dependency and metal health issues. May be an inpatient or an outpatient setting.
Criteria for Payment of Service in a Skilled Nursing Facility
1. Hospitalization 3 days prior to admission
2.Entrance to nursing home with in 30 days of hospitalization.
3.100-day maximum per year related to any one hospitalization or diagnosis.
4. Patient progress documented by medical staff
Outpatient Facilities
1. Provided in many types of settings.
2. Designed to meet patient medical needs in the span of one da, with return to home follow up care.
Types of Outpatient Facilities
*Hospital outpatient department.
*Outpatient mental health services
*Cardiac rehabilitation
*Pulmonary rehabilitation
*Health departments
*Physician’s office
*Home health care
* Hospice
Nursing Care delivery Systems
*Team Nursing
* Client-centered nursing
*Case management
Team Nursing
*Consists of nurses and nursing assistants (UAPs)
*Used in acute care hospital, rehabilitation setting, and long-term care setting.
*Each member provides care based on his or her skills, education, and licensure.
*Disadvantage: Fragmented care without proper communication.
Client-Centered Care
*Empowers the client to manage own care.
*often seen in rehabilitation settings.
*Goal in acute setting: Decrease the number of caregivers and provide care as soon as needed.
*Disadvantage: Time and education need to cross-train in all areas.
Primary Care Nursing
* One Nurse is responsible for all aspects of nursing care for an assigned patient.
*Often used in intensive care units.
*Disadvantage: Works best with a limited number of assigned patients; does not work well outside critical care areas.
Case Management
*Associated with managed care strategy.
* Nurses act simultaneously as coordinators, facilitators, impartial advocates, and educators.
*System found in hospitals, rehabilitation facilities, home health agencies, and workers’ comp agencies.
* Disadvantage: options may be limited.
Methods of Payment for Health-care costs
*Public health insurance
*Private health insurance
*Insurance for special populations
*Charitable organizations
* Self-pay
Medicare Programs
Part A: Insurance for hospitalization and home health and skilled nursing facilities.
Part B: Supplementary insurance to pay participating providers.
Part C: Medicare Advantage Plans administered by private insurance companies.
Part D: Medicare prescriptions drug coverage.
Populations Assigned by Medicaid
* Poor and medically indigent individuals
*pregnant women with income below the poverty level
*Children meeting certain income level requirements
* Certain disabled individuals meeting income level requirements.
Common Types of Health Insurance Programs
* Health Maintenance Organization (HMO)
*Preferred Provider Organization (PPO)
* Points of Service (POS)
Health Insurance Plans for Specific Populations
* TRICARE: Active and retired military service members and their families.
*CHAMPVA: Veterans of military services
* Workers’ Compensation: People injured on the job.
*Disability Insurance: People who cannot work due to disability.

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