Regulatory Agencies – Flashcards
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300 divisions & programs; US Department of Health & Human Services; federal gov. principal agency for the protection of the health of all Americans and the provision of essential human services for those least able to care for themselves. FDA, CDC, AHRQ (NIH) national institutes of Health (CMS) Centers for Medicaid and Medicare
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DHHS Federal
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Agency for Healthcare Research & Quality. has established 14 EBP Centers: these centers improve the quality & effectiveness of healthcare by reviewing all relevant scientific literature, synthesizing the evidence & helping to translate the EBP research findings so that they are more readily available to those clinicians who are @ the bedside providing care.
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AHRQ Federal
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Enforces the guidelines presented by OSHA act of 1970, requiring its covered employees to report specific incidents & illnesses in a timely manner. Any work related injuries that result in days off of work, tx beyond first aid, LOC, or death must be reported with in 8 hours of incident. Hospital (in-pt) of 3 or more employees with work-related injuries must be reported, any cases of poisoning or respiratory complication as a result of working cond. other inj. including cuts, fx, sprains or amputations.
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OSHA
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Every state has their own division/department of health and human services. Oversee regulations of county health departments, healthcare settings such as hospitals and long-term care facilities, child care center, clinical labs and other service providers, ie. portable xray suppliers. Overseeing the planning & construction of med. facilities and for receiving and resolving complaints regarding the facilities that they regulate.
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State DHHS
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State offices of Emergency medical services; ensuring that local emergency med. services systems comply with the applicable regulations, state offices of emergency of medical services (DEMS) provide citizens access to high- quality emergency medical care
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EMS
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Oversee health policies and respective regulations; Responsible for disease monitoring and surveillance in their communities. -Reporting incidences of disease to state and feds and implementing disease prevention efforts; ie. immunization. Typically oversee, child care center sanitation and food safety; community wide disease and injury prevention programs. lead poisoning prevention, safety equipment, smoke detectors and helmets, infant car seats to fam @ no cost, & WIC
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State Local Health Department
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Independent, non-profit organization that sets standards for and accredits health care organizations. "continuously improve health care for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value" -Set standards for and accredits, ambulartory care centers, hospitals, behavioral health and long-term care facilities. -Address key functions: ie. inf. control and prevention, medical management and performance improvement -Ensures organization able to provide safe, effect care for its clients and does so.
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The Joint Commission Accrediting bodies
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2 national agencies; -CCNE; Commission on Collegiate Nursing Education; ensures quality and integrity of baccalaureate and grad education programs. -Accreditation Commission for education in nursing; formally the National League for Nursing, Accrediting Commission, NLNAC -provides specialized accreditation for all types of nursing education programs (clinical doctorate, Master's degree, baccalaureate degree, associate's, diploma and practical)
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Nursing Education program accreditation
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-Medicare; federally funded health insurance available to pp age 65 & older, or younger with disabilities. and end-stage renal failure. Covers 16% of Americans.
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Medicare
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Premium Free A, hospital insurance, covered ind. be 65+ ind. or spouse was employed and paid medicare taxes for 10 yrs. Covers inpatient care in hospitals and under certain cond. home; health care or care in skilled nursing facility or hospice.
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Premium Free A, hospital insurance, covered ind. Medicare Part A
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-helps cover inpatient care in hospitals. -helps cover home health care and care in skilled nursing facilities and hospice.
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Medicare A (Hospital Insurance)
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-Helps cover services provided by doctors and other healthcare providers, out patient care, home healthcare, and durable medical equipment -helps cover some services to prevent illness or detect it @ an early stage when treatment will work best (ex. pap tests, flu shots, and screening mammograms)
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Medicare Part B (medical insurance) Voluntary; consumer pays a premium (annual deductible and 20 % copay)
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-A health coverage option run by private insurance companies approved by and under contract with medicare. -includes all services covered under Parts A & B, usually includes Plan D prescription drug coverage, & may cover other services such as hearing and vision testing.
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Medicare Part C
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-A prescription drug option run by private insurance companies approved by and under contract with Medicare. -May help lower prescription drug costs and help protect against higher costs in the future: excluded services are long-term care, routine dental and eye care, hearing aids and the exams for fitting them, and cosmetic surgery. People often purchase additional insurance from private comp. to supplement or fill in gaps of Medicare coverage.
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Medicare Part D (Medicare Prescription Drug Coverage)
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est 1965 under Title 19 of the Social Security Act. Available to lower income ind. and families, elderly and the people with disabilities who meet the eligibility requirements set by federal and state law. -State admin program. Ea state sets its own guidelines and covered services, Fed mandates required coverage services.
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Medicaid
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-Federal and Matching State Funding combine to provide the Children's Health Insurance Program (prev. known as SCHIP, State Child Health Insurance Program. Provides health insurance coverage to children under the age of 19 whose families earn more than the Medicaid limits, but can not afford to purchase private health care coverage. Ea. State determines design of program, eligibility requirements, benefits packages, payment levels for coverage, and admin and operating procedure. Fed. requirements: routine checkups, immunizations, dental and vision care, inpatient and outpatient, hospital care, and lab, and xray services
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CHIP
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Health Maintenance Organization: Most restrictive type, to indemnity plans, the least restrictive; must select PCP, who provides basic medical services refer clients to in-network hospitals and specialists when additional care is needed. Provide broader range of healthcare benefits for the lowest cost to both employers and consumers
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HMO's
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Preferred provider organization; considered managed care-usually more in-service providers are available within -doesn't require its insured to select a PCP. -Usual have Lg network and managed care than HMO's -PPO's provide financial incentives that encourage insured care from in-network providers.
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PPO's Preferred Provider organization
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Point-of-service (middle of the spectrum) plans and POS options than in HMO. Plan is a hybrid of an HMO and a PPO. Ea time insured seek health care, they decide which option -HMO or PPO-they will use. -Members may select a PCP under this plan, but are not required to. -Use out-of network; pay higher co-pay, co-insurance and deductibles. Flexibility and Freedom of choice. Compared to an HMO
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POS
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Plans allow the insured to self-select healthcare providers to control costs (preauthorized MRI's)
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Indemnity
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Consumer-driven healthcare plan, there is no network. They may use some managed-care techniques type of employer-sponsored coverage that combines a private insurance plan with a health policy with a high deductible that makes employees responsible for more of their healthcare expenses. -Employees than save $, so they can pay for deductibles and noncovered services.
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CDHP Consumer-driven Healthcare Plan
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Medicare Supplemental Insurance; is private health insurance designed to supplement medicare coverage. It may pay copayments, coinsurance, deductibles and "gaps" in Medicare coverage (noncoverage health-care costs). -If ind. has a medigap policy, medicare will pay it share 1st, then the Medigap will pay its share.
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Medigap policy
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Ind that are not eligible for public or private health insurance pay the insurer directly, that is make a personal payment. People who pay a high percentage of their healthcare costs themselves are apt to have higher overall.
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Personal Payment
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"a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an ind. and families comprehensive health needs through communication and available resources to promote quality cost-effective outcomes." -Goal: to reach and then maintain the ind. optimal health, quality of life and ADL's
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Case Management
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Delivery model that organizes health care around the expressed physical and emotional needs of the client- Understood to be an approach that considers clients and their families to be integral to decisions regarding healthcare delivery. -designed to improve outcomes for groups of clients
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Client focused care
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healthcare delivery system in which the goal is to provide cost-effective, high-quality care that focuses on decreased costs and improved outcomes for groups of clients. -effective managed care requires the ability to prioritize, identify clinical pathways, create concept maps and/or care plans, understand clients rights and advance directives and commit to quality improvement.
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Managed Care
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-Task oriented approach to care delivery head nurse delegates tasks to team members who complete these specific tasks rather than caring for specific clients-an efficient approach b/c it enables the nursing team to complete many tasks in a short time.
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Functional nursing
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Delivery model is the most freq. used today. Means of providing ind. care to clients and was developed in response to the fragmentation of care inherent in the functional model. The RN serves as the team leader is accountable for the care provided to the clients assigned to the team. Team leader retains responsibility and authority for the clients' overall well-being but delegates some tasks to UAP's .
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Primary Nursing
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-American Nurses Association: Representing RN's "Nursing; advancing our profession to improve health for all" Foster high-standards of nursing practice, promotes the rights of nurses in the workplace, projects a positive and realistic view of nursing, and lobbies Congress and regulatory agencies on healthcare issues affecting nurses and the public.
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ANA
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National Student Nurses Association: Nonprofit organization that mentors nursing students who are preparing for initial licensing as an RN. Dedicated to fostering the professional development of these students by conveying " the standards, ethics, and skills students will need as responsible and accountable leaders and members of the profession" -Provides students opportunities for workshop participation, networking, scholarships, exposure to well-known nursing leaders
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NSNA
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*Responsibilities of these organizations include advocacy, education, provision of networking opportunities and strengthening professional identities among members -ex. Academy of medical-surgical nurses, american assisted living nurses association -association of pediatrics oncology nurses, national associ. of orthopaedic nurses.
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Specialty organizations
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2nd Largest nursing organization in US. 1st nursing organization to fund nursing research. Membership is by invitation to baccalaureate and graduate nursing students who demonstrate excellence in scholarship and to nurse leaders exhibiting exceptional achievements in nursing. the vision is to create a global community of nurses who lead in using knowledges, scholarship, service, and learning to improve the health of the worlds pp
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Sigma Theta Tau
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-1st nursing organization inUS, founded 1893, as the American Society of Superintendents of Training School of Nurses. Its mission is promoting excellence in nursing education to build a strong and diverse nursing workforce to advance the nations health. Committed to delivering improved, enhanced, and expanded services to its members and championing the pursuits of high-quality nursing education in all types of nursing education programs. " The national League for nursing offers faculty development programs, networking,opportunities testing, and assessment, nursing research grants and public policy initiatives"
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NLN
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American Associated of Colleges of Nursing; national voice for America's baccalaurate and graduate nursing education AACN's educational, research, federal advocacy, data collection, publication, and special programs work to establish quality standards for nursing education; assist deans to improve standards, influence nursing profession to improve healthcare; promote public support for professional nursing education, research and practice in nursing; Nations largest heathcare profession
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AACN
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-Rural areas lack medical services -long driving distances and lack of pubic transportation; increase number of providers who specialize which decreases PCP's -Suburban and urban; underserved; poverty/cultural and linguistic barriers to healthcare access shortage of primary care providers, PCP's, nurse practitioners, nurse and physician assistant.
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Discussing uneven distribution of services
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All US citizens have access to affordable, quality care and to curb the growth of healthcare costs. -includes funding to improve the recruitment and training of primary care, public health, nursing and other health professionals and to increase the number of providers in medically underserved areas
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Provide highlights of the Affordable Care Act.
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Physician shortages
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Concerns related to the Affordable Care Act
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As healthcare expenditures have increase, the needs for resource allocation, distribution of resources amount competing groups of people or programs, 3 levels: 1. allocating resources to healthcare vs. other social needs 2 allocating resources with in the healthcare sector 3. allocating resources among ind. clients (AHC)
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Allocation of resources and the 3 levels
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Rationing; method used by ind., insurance co. and the govn't to prevent increase to cost of healthcare or to reduce the cost of healthcare Govn't; rations healthcare resources, such as inclusion of the coverage gap in Medicare Plan D ("donut hole") that sometimes forces beneficiaries to purchase fewer prescriptions
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Examples of resource allocation
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-Organ Procurement & Transplantation Network (OPTN) -H1N1; Vaccine Distribution (outbreak of 2009) -most vulnerable population had 1st access to vaccine. later, when sufficient quantities of vaccine become available, healthcare provider admin to anyone who asks for it
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Methods used by ind and insurance co to ration health care resources
