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IOM's Six Outcomes for a New Health System for the 21st Century

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1. Safe 2. Effective 3.Efficient 4.Patient-centered 5.Timely 6.Equitable

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Safe Care

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avoiding injuries to patients

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Effective Care

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providing cared based in scientific knowledge

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Patient-centered care

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Providing respectful and responsive care that ensure that patients values guide clinical decisions

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Timely care

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reducing waits for both recipients and provides of care

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Efficient care

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avoiding waste

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Equitable care

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ensuring that the quality of care does not vary because characteristics such as gender, ethnicity, socioeconomic status, or geographic location

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Health Care: The Big Picture Issues

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1. Access to healthcare 2. Quality and safety 3. Affordability

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Characteristics of a Continuously Learning Health Care System

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1. Science and informatics 2.Patient-clinician partnerships 3.Incentives 4. Continuous learning culture

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Science and informatics

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real time access to knowledge, digital capture of the care experience

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Patient-clinician partnerships

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engaged,empowered patients

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Incentives

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aligned for value; full transparency

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Continuous learning culture

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leadership-instilled culture of learning, supportive system competencies

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IOM's 4-Tiered Strategy to Prevent Medical Errors

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1. Establish 2. Identify and learning 3. Raising 4. Implementing

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Establishing

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a national focus to create leadership research, tools, and protocols to enhance our knowledge about safety

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Identifying and learning

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from errors be developing a nationwide public mandatory reporting system

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Raising

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performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care

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Implementing

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safety systems in health care organization to ensure safe practices "just culture"

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Strategies to Promote Quality of Care

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1. Pay per performance (CMS reimbursement based on customer satisfaction scores and patient outcome) 2. Penalties for excess readmission

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Patient Protection and Affordable Care Act Goals (PPACA)

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1. Expand coverage, control health care costs, and improve the health care deliver system 2.Provide Medicaid or subsidized coverage to qualifying people with incomes up to 400% of poverty, beginning in 2014 3. Provide a new way to get health insurance: the Health Insurance Marketplace

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The Health Insurance Marketplace

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Designed to help people more easily find health insurance that fits their budget

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Frameworks for Healthcare Delivery

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1. Managed care systems 2. Case management (Milliman, InterQual) 3. Primary healthcare

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Managed care system

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HMO (Health Maintenance Organization),PPOs (Preferred Provider Organization)

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Case Management

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1. Transparency of Evidence 2. Confidence in Decision Making 3. Bringing Payors and providers together

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Primary healthcare

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essential healthcare accessible to all

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Managed care systems

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provide care that controls the cost while maintaining the quality of care

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Case management is

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a method of managed care in which nurses often identify protocols and timetables for care

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Primary healthcare is

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essential healthcare accessible to communities at a cost that is affordable

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Federally funded healthcare programs

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Medicare and Medicaid

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Managed Care Systems

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1. Controls cost of care while maintaining quality of care 2. Manager or 'gatekeeper" plans and monitors the care 3. Limits the choice of care providers 4. Requires approval for specialty care

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Case Management

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1. Coordinates 2. Controls costs 3. Improves access to healthcare 4. Uses critical pathway to identify protocols and timetables for care

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Coordinates care

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role of nurse is coordinator of care

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Uses critical pathways to identify protocols and timetables for care

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1. Evidence-based treatments for complex cases 2. Problem-oriented general recovery

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Evidence-based treatments for complex cases

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identify treatments based on the best evidence concerning comorbidities and complex symptoms or disgnoses

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Problem-oriented general recovery

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detailed clinical indication for admission when a patient has multiple illnesses, multiple traumas, or other systemic problems

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Case Managers' Role

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1.Advocacy and Education 2.Clinical Care Coordination/Facilitation 3.Continuity/Transition Management 4.Utilization/Financial Management 5.Performance & Outcome Management 6.Psychosocial Management 7/ Research and Practice Development

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Advocacy and Education

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ensuring the patient has an advocate for needed service and any needed education

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Clinical Care Coordination/Facilitation

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coordinating multiple aspects of care to ensure the patient progresses

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Continuity/Transition Management

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transitioning of the patient to the appropriate level of care needed

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Utilization/Financial Management

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managing resource utilization and reimbursement for serivices

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Performance and Outcome Management

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monitoring and if needed intervening to achieve desired goals and outcomes for both the patient and the hospital

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Psychosocial Management

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assessing and addressing psychosocial needs including individual, familial, environmental, etc.

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Research and Practice Development

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identifying practice improvements and using evidence based data to influence needed practice changes

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Primary Healthcare

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1.Essential healthcare based on acceptable methods and technology 2.Universally accessible and affordable to individuals and families on the community 3.Brings healthcare close to where people live and work

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Healthcare Settings

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1.Hospitals 2.Primary care centers 3.Ambulatory care centers and clinics 4.Home healthcare 5.Long-term care facilities 6.Specialized care centers and settings 7.Healthcare services for caregivers and end-of-life care 8.Healthcare agencies

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Hospital Settings

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1.Provide inpatient and outpatient care 2.Vary in size and services 3.Classified as profit or nonprofit,public or private 4.Employ more nurses than any other facility

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Roles of Nurses in Hospitals

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1.Direct care providers 2.Manager of other members of healthcare team 3.Administrator 4.Nurse practitioner 5.Clinical nurse specialist 6.Patient educator 7.In-service educator 8.Researcher

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Roles of Nurse in Primary Care Centers

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1.Make health assessments 2. Perform technical procedures 3.Assist the physician 4. Provide health education

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Roles of Nurse in Ambulatory Care Centers

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1. Provide technical services 2.Determine the priority of care needs 3.Provide teaching about all aspect of care

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Long-term care Facilities

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1. Transitional subacute care 2.Intermediate and long-term care 3.Nursing home 4.Retirement centers 5.Residential institutions for mentally physically disabled 6."Aging in place"

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Specialized Care Centers

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1. Daycare centers 2.Mental health centers 3.Rural health centers 4.Schools 5.Industry 6.Homeless shelters 7.Rehabilitation centers

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Hospice

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provides physical,psychological, social, and spiritual care for dying persons

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Respite care

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is provided for caregivers of homebound ill, disabled, or elderly patients

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Parish nursing

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emphasize holistic care, health promotion, and disease prevention activities

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Voluntary agencies

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are community agencies that are often nonprofit and provide a setting for support groups

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Home Healthcare

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1.Most rapidly growing area of the healthcare system 2.Driven by payment system of reimbursement-early discharge from hospitals 3.Serves increasing number of older people with chronic illnesses 4.Provides for a dignified death at home

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Caregiver and End-of-life Care

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1.Respite care 2.Hospice care 3.Bereavement care 4.Palliative care

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Healthcare Agencies

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1.Voluntary agencies 2.Parish nursing 3.Government agenicies 4.Veterans administration and military agencies 5.Public health service 6.Public health agencies

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Members of the Healthcare Team

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1.Physician, physician assistant 2.Physical, respiratory, occupational, and speech therapist 3.Dietitian 4.Pharmacist 5.Social worker 6.Unlicensed assistive personnel

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Role of the Physician

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1.Diagnosis of illness 2.Medical or surgical treatment of illness **prescribing medications** **interpreting results of lab and diagnostic tests** **performing procedures and surgery**

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Payment funded programs

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1.Federally funded programs 2.Group plans 3.Private insurance 4.Long-term care insurance

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Federally funded programs

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1.Medicare-DRGs 2.Medicaid

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Group plans

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1. Health maintenance organizations 2. Perferred provider organizations

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HMOs

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are provided group[managed care providers that subscribe to receive care through affiliated providers

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Preferred provider

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organization allow members to choose an outside physician for an additional cost

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Private insurance

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allow members to choose their own physicians

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Federally funded healthcare programs

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use a prospective payment plan based on diagnosis-related groups

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Healthcare Issues

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1.Focus on preventive care 2.Knowledgeable consumers 3.Cost containment 4.Fragmentation of care 5.Healthcare -a right or a privilege?

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Goals of Healthcare Reform

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1. Cost containment 2.Improved access to care 3.Increased quality of services for all

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Nurse's Role in Healthcare Reform

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1.Stay informed about current issues and legislation 2. Write members of congress to support legislation to improve nursing care 3.Belong to nursing organization 4.Document the outcomes of nursing care 5.Be a leader in nursing and consumer groups 6.Advocate for the right of all to healthcare

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Strategies to Reduce Health Care Costs/Reimbursements and Regulations

answer

1.DRGs and RUGs prospective payment system 2.Capitation and manged care 3.Bundle payments 4.Rate setting 5.Comparative effectiveness analysis 6.Increasing patient cost sharing

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Strategies to Reduce Health Care Costs/Changes in Care Delivery

answer

1.Utilizing quality improvement tools to reduce waste and improve safety 2.Improving transitions across settings 3.Making the delivery of medical services more efficient and less costly 4.Eliminating unnecessary costs such as fraud and abuse 5.Improving population health

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