The Health Care Delivery System – Flashcards

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Managed care organization
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Provides comprehension preventive and treatment services to a specific group of voluntarily enrolled people. Structures include a variety of models. Staff model: Physicians are salaried employees of the MCO. Group model: MCO contracts with single group practice. Network model: MCO contracts with multiple group practices and/or integrated organizations. Independent practice association (IPA): the MCO contracts with physicians who usually are not members of groups and whose practices include fee-for-service and capitated pts. Characteristics: focus is on health maintenance, primary care. All care is provided by a primary care physician. referral is needed for access to specialist and hospitalization. it may use capitated payments.
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Preferred provider organization (PPO)
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type of managed care plan that limits an enrollee's choice to a list of "preferred" hospitals, physicians, and providers. An enrolle pays more out-of-pocket expenses for using a provider not on list. Functions: Contractual agreement exists between a set of providers and one or more purchasers. (self insured employers or insurance plans). Comprehensive health services are at a discount to companies under contract. Focus is on health maintenance.
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Medicare
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A federally administrated program by the Commonwealth Fund or e Centers for Medicare and Medicaid Services. (CMS) A funded national health insurance program for people 65 yrs or older. payment is deducted from monthly SS check. it covers services from Nurse practitioners. Does not pay full cost of certain services.
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Medicare Part A
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Provides basic protection for medical, surgical, and psychiatric care costs based on diagnosis- related groups; also provides limited skilled nursing facility care, hospice, and home health care.
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Medicare Part B
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Voluntary medical insurance. covers physician, certain other specified health professional services, and certain outpatient services.
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Medicare Part C
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Managed care provision the provides a choice of 3 insurance plans.
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Medicare Part D
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voluntary prescription drug improvement
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Medicaid
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Federally Funded, state-operated program the provides: 1) health insurance to low income families. 2) health assistance to low income people with long term care disabilities. 3) supplemental coverage and LTC assistance to older adults and Medicare beneficiaries in nursing homes. Individual states determine eligibility and benefits. It reimburses nursing home funding, nurse-midwifery and other advanced practice nurses. Finances a large portion of care for poor children, parents, preg. women, and disabled very poor adults.
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Private Insurance
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Traditional fee-for-service plan. Payment is computed after patient receives services on basis of number of services used. Policies are typically expensive. Most policies have deductibles that pts have to meet before insurance pays.
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LTC insurance
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Supplemental insurance coverage of LTC services. Policies provide a set amount of dollars for an unlimited time or for as little as 2 years. Its a very good expense. A good policy has a minimum waiting period for eligibility; payment for skilled nursing, intermediate, or custodial care and home care.
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State Children's health Insurance Programs (SCHIP)
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Federally funded, state-operated program to provide health coverage for uninsured children. Individual states determine participation eligibility and benefits. It covers children not poor enough for medicaid.
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Challenges to health care leaders today are...
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reducing health care costs while maintaining high quality care for patients, improving access and coverage for more people, and encouraging healthy behaviors.
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Priorities set by the National Priorities Partnership are...
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1. Patient and Family engagement- providing patient centered, effective care 2. Population Health- Bringing increased focus on wellness and prevention. 3. Safety- Eliminating errors whenever and wherever possible 4. Care Coordination- Providing patient-centered, high value care 5. Palliative Care- Providing appropriate and compassionate care for pts experiencing advanced illnesses 6. Overuse- Reducing waste to achieve effective, affordable care.
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According to the IOM (The Institute of Medicine) report, nurses need to be transformed by:
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1. Practicing to the full extent of their education and training 2. Achieving higher levels of education and training through an improved education system that provides seamless progression. 3. Becoming full partners, with physicians and other health care providers, in redesigning the health care system. 4. Improving data collection and info infrastructure for effective workforce planning and policy making
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Professional Standards Review Organizations (PSROs)
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Created by the federal government, (which pays for Medicare and Medicaid) to review the quality, quantity, and cost of hospital care.
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Utilization review (UR) committees
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Medicare-qualified hospitals had physician supervised UR committees to review that admissions and to identify and eliminate overuse of diagnostic and treatment services ordered by physicians caring for pts. on Medicare.
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Prospective Payment System (PPS)
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This is one of the most significant factors that influenced payment for health care. Established by Congress in 1983, the PPS eliminated cost-based reimbursement. Hospitals serving pts. who received Medicare benefits were no longer able to charge whatever a pts care cost.
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Diagnosis-Related Groups (DRGs)
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The PPS grouped inpatient hospital services for Medicare patients into this. Each group has a fixed reimbursement amount with adjustments based on case severity, rural/urban/regional costs, and teaching costs. Hospitals receive a set dollar amount for each pt based on the assigned DRG, regardless of the pts length of stay or use of services. Used mostly in Rehab centers.
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Capitation
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this means that providers receive a fixed amount per pt or enrollee of a health care plan. This aims to build a payment plan for select diagnoses or surgical procedures that consist of the best standards of care at the lowest cost.
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Resource Utilization groups (RUGs)
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Used in long term care. In all settings health care providers try to manage costs so the organizations remain profitable.
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Managed Care
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describes health care systems in which the provider or health care system receives a predetermined capitated payment for each pt enrolled in the program. In this case the managed care organization assumes financial risk in addition to providing pt care.
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Never Events
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A list of 28 events that never should happen including a pt dying from a medication error or the administration of incompatible blood products. In 2007 Medicare ruled it would not pay for medical costs caused by these errors.
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The Pt Protection and Affordable Care Act
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focuses on the major goals of increasing access to health care services for all, reducing health care costs, and improving health care quality. Provisions in the law include insurance industry reforms that increase insurance coverage and decrease costs, increased funding for community health centers, increased primary care services and providers, and improved coverage for children.
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Health Services Pyramid
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(TOP) 1. Tertiary health care 2. Secondary health care 3. Primary health care 4. Clinical Preventive services 5. Population-based health care services
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Primary Care (Health Promotion)
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Focuses on improved health outcomes for an entire population.This requires collaboration amoung health care professionals, health care leaders, and community members. Focuses on improving health care equity, making health care centers person centered, and developing reliable health care leaders. 1. prenatal and well-baby care 2. Nutrition counseling 3. Family planning 4. Exercise classes Health promotion programs lower the overall costs of health care by reducing disease, and minimizing complications.
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Preventive Care
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1. Blood Pressure and cancer screening 2. Immunizations- prevent disease 3. Mental health counseling and crisis prevention 4. Community legislation(seat belts, air bags, helmets)
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Secondary Acute Care
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1. Emergency care 2. Acute medical-surgical care 3. Radiological procedures for acute problems (ct scans, x-rays)
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Tertiary care
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1. Intensive care 2. Subacute care
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Restorative care
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Help individuals regain maximum functional status and enhance quality of life through promotion of independence and self-care. 1.Cardiovascular and pulmonary rehab 2. sports medicine 3. spinal cord injury programs 4. home care- is the provision of medically related professional and paraprofessional services and equipment to pts and families in their homes for health maintenance, education, illness prevention, diagnosis and treatment of disease, palliation, and rehab.
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Continuing Care
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1. Assisted living 2. Psychiatric and older adult day care
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Integrated delivery networks (IDNs)
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Larger health care systems have these and they include a set of providers and services organized to deliver a continuum of care to a population of pts at a capitated cost in a particular setting. An integrated system reduces duplication of services across levels or settings of care to ensure that pts receive care in the most appropriate settings.
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The Joint Commission on Accreditation of Healthcare
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accredits health care organizations across the continuum of care, home care, and behavioral health agencies. To be accredited all the workers have to earn certifications.
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School Health
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These are programs that include health promotion principles throughout a school curriculum. EX: positive life skills, counseling, crisis intervention, health screening, nutritional planning
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Occupational Health
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This is a program designed for health promotion and accident or illness prevention in the workplace setting. Aims to increase worker productivity, decrease absenteeism, and reduce use of expensive medical care. EX: surveillance video, health screening and education, counseling, communicable disease control, and physical assessment.
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Physicians' offices
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Provide primary health care (diagnosis and treatment). Focus on health promotion practices. EX: routine physical, diagnosis, health screening, treatment of acute of chronic ailments.
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Nurse-managed clinics
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These clinics provide nursing services with a focus on health promotion and education, chronic disease assessment management, and support for self-care and caregivers. EX: day care, wellness counseling, employment readiness
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Block and parish nursing
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Nurses living within a neighborhood provide primary service to older pts or those unable to leave their homes. It fills in gaps not available in tradition health care settings. EX: running errands, transportation, homemaker aides, spiritual health
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Community health centers
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These are outpatient clinics that provide primary care to a specific pt population (well-baby, mental health, diabetes) that lives in a specific community. They are often associated with a hospital, medical school, church, or other community organization. EX: health screening, physical assessment, disease management, health ed, counseling.
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Hospitals
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Hospital emergency departments, urgent care centers, critical care units, and inpatient medical-surgical units provide secondary and tertiary levels of care.
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work redesign
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more services are available on nursing units, thus minimizing the need to transfer and transport pts across multiple diagnostic and treatment areas.
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Discharge planning
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Starts as soon as the pt is admitted to a health care facility. Its a plan that moves the pt from the hospital to either a different health care center or back to home. Referrals will be given out to continue care once left the hospital. Some tips on referral process are: 1. make a referral as soon as possible 2. give the care giving receiving the referral as much info about pt as possible. 3. involve pt and family in referral process.
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Pts require the following info before leaving the health care facility
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1. safe and effective use of medications and equipment 2. instruction on potential food-drug interactions and counseling on diets 3. rehab techniques to support adaption to and/or functional independence in the environment. 4. access to available community resources 5. when and how to obtain further treatment 6. the pts families responsibilities. 7. when to notify their health care provider for changes in functioning or new symptoms.
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Rehab
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restores a person to their fullest physical, mental, social, vocational, and economic potential possible.
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Extended Care Facilities
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provides intermediate medical, nursing, or custodial care for pts recovering from acute illness or those with chronic illnesses or disabilities. For all ages.
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Skilled Nursing Facility
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Also known as intermediate care, offers skilled care from a licensed nursing staff. EX: administration of IV fluids, wound care, long term ventilator management, and physical rehab. Provide around the clock nursing coverage.
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Major Regulatory Requirements defined by the 1987 Omnibus budget reconciliation act
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resident rights administration, transfer and discharge rights quality of life & care resident assessment nursing services dietary services physician services rehab services dental services pharmacy services infection control physical environment administration
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Minimum Data Set (MDS)
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residents background cognitive, communication/hearing, and vision patterns physical functioning and structural problems mood and behavior and activity patterns mental well being bowel and bladder control health conditions disease diagnosis skin condition and medication use oral/nutritional and dental status special treatments and procedures
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Resident Assessment Protocols
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EX: Delirium falls pressure ulcers Psychotropic drugs
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Resident Assessment Instrument (RAI)
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includes the MDS, Resident assessment protocols, and utilization guidelines of each state. This informs the policy makers so they know what the long term pts need
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Assisted living
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offers an attractive long-term care setting with an environment more like home and greater resident autonomy.
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Respite care
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a service that provides short term relief or time off for people providing home care to an ill, disabled, or frail older adult. Medicare does not cover this. The health care worker either comes to your house or the person comes to a day care setting or health care institution.
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Adult day care centers
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provide a variety of health and social services to specific pt populations who live alone or with family in the community. Centers run 5 days a week during normal business hours and usually charge on a daily basis.
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Ten Rules of Performance in a redesigned health care system
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1. care is based on continuous healing relationships 2. Care is individualized based on pt needs and values 3. The pt is the source of control participating in shared decision making 4. Knowledge is shared, and info flows freely 5. Decision making is evidence based, with care based on the best available scientific knowledge 6. Safety is a system property and focused on reducing error 7. Transparency is necessary through sharing info with pts and families 8. pt needs are anticipated through planning 9. waste is continuously decreased 10. cooperation and communication among clinicians are priorities
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The National Quality Forum practices
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There are 34 health care practices organized in 7 functional areas that improve patient safety by decreasing the occurrence of adverse events. EX: hand hygiene, teamwork, training, influenza prevention, catheter associated UTI prevention, fall prevention, and medical reconciliation.
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Pay for Performance
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programs and public reporting of hospital quality data are designed to promote quality, effective, and safe pt care by physicians and health care organizations. These programs are quality improvement strategies that reward excellence through financial incentives to motivate change. EX: nurse gets aspirin order, fills it and gives it to pt in a timely manner. Many hospitals use score cards so these are available when pts are choosing health care services. They use strategies such as Six Sigma, Lean Six Sigma, and Value Stream Analysis.
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Healthcare Effectiveness Data and Information Set (HEDIS)
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This was credited by the national committee for quality assurance (NCQA) to collect various data to measure the quality of care and services provided by different health plans. It compares how well health plans perform on 71 measures across 8 domains of care in the key areas of quality and effectiveness of care, access to care, and pt satisfaction with the health plan and doctors.
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The Hospital Consumer of Assessment of Healthcare Providers and Systems (HCAHPS)
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a standardized survey developed to measure pt perceptions of their hospital experience. It was developed by the CMS (Centers of Medicare and Medicaid services) and The Agency for Healthcare Research and Quality as a way for hospitals to collect and report data publicly for comparison purposes. The survey has 27 questions about their hospitals stay and the people they interacted with while there.
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The Picker Institute
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identified 8 dimensions of pt centered care that most affect pts experiences with health care. The institution mails surveys after people have left to see how their experience was. These include: 1. Respect Value, Preferences, and Expressed Needs 2. Coordination and Integration of Care 3. Information, Communication, and Education 4. Physical Comfort 5. Emotional Support and Relief of Fear and Anxiety 6. Involvement of Family and Friends 7. Transition and Continuity 8. Access to Care
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Respect Values, Preferences, and Expressed Needs
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1. Pts expect to be treated with dignity, respect, sensitivity to cultural beliefs, values, and quality of life issues 2. pts want to be informed and share in decisions about their care 3. pts perception of needs should not be that different from the care provider.
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Coordination and Integration of Care
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1. A competent and caring staff reduces feeling of powerlessness. 2. pts look for someone to be in charge of care and communicate clearly with other health care team members. 3. pts expect to have services and care well coordinated. This includes areas of clinical care, front line pt care, and ancillary and support services 4. pts need to know at all times whom to call for help
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Information,; Communication, and Education
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1. Pts expect to receive accurate and timely info about their clinical status, progress, or prognosis 2. pts and families need to be informed of major changes in therapies or status 3. pts need tests and procedures explained clearly in language they understand 4. pts and family members want to know how to manage care on their own.
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Physical Comfort
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1. Physical care needs to provide comfort for pain management 2. Nurses need t respond in a timely and effective way to any request for pain meds, explain the extent of pain pts can expect, and offer alternatives for pain management 3. pts expect privacy and to have their cultural values respected 4. pts often need help to complete activities of daily living 5. The health care setting environment needs to be clean and comfortable, with accessibility for visits by family.
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Emotional Support and Relief of Fear and Anxiety
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1. pts look to care providers to share their fears and concerns 2. pts need to understand the impact that illness will have on their ability to care for themselves and their family 3. pts worry about their ability to pay for their medical care. Identify staff that will help alleviate this worry
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Involvement of family and friends
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1. Care providers need to recognize, respect, and meet the needs of pts, family and friends 2. pts have the right to determine if family members are to be involved in decisions about their care 3. pts expect family and friends who will provide physical support and care after discharge to be properly informed.
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Transition and Continuity
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1. Pts want info about meds to take, physical limitations, dietary or treatment plans to follow, and danger signals for which to look after hospitalization or treatment. 2. pts expect to have their continuing health care needs net after discharge with well coordinated services 3. pts and family members expect access to necessary health care resources on a continuing basis.
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Access to Care
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1. Pts want to get hospitals, clinics, and physicians' offices easily and without hassle 2. pts need to be able to find transportation when going to different health care settings. 3. Pts want to schedule appointments at convenient times without difficulty. 4. Pts want to be able to see a specialist when the referral is made 5. pts expect to receive clear instructions on how to obtain referrals to other health care providers
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Magnet Recognition Program
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The American Nurses Credentialing Center (ANCC) established this to recognize health care organizations that achieve excellence in nursing practice. Health care organizations that apply for Magnet status must demonstrate quality pt care, nursing excellence, and innovations in professional practice. The Magnet Model has 5 components: Transformational Leadership, Structural Empowerment, Exemplary Professional Practice, New Knowledge, Innovations and Improvements, and Empirical Quality Outcomes. They have to show achievement of the 14 forces of magnetism.
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Forces of Magnetism
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1. Quality of nursing leadership 2. Management style 3. organizational structure 4. personnel policies and programs 5. community and the health organization 6. image of nursing 7. professional development 8. professional models of care 9. consultation and resources 10. autonomy 11. nurses as teachers 12. interdisciplinary relationships 13. quality improvement 14. quality of care
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Nursing Sensitive outcomes
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are pt outcomes and select nursing workforce characteristics that are directly related to nursing care such as changes in pts symptom experiences, functional status, safety, psychological distress, RN job satisfaction, total nursing hours per pt day, and costs.
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The National Database of Nursing Quality Indicators (NDNQI)
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was developed by the ANA to measure and evaluate nursing sensitive outcomes with the purpose of improving pt safety and quality care.
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Nursing Quality Indicators
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1. pt falls 2. Pt falls with injury 3. Pressure ulcers 4. staff mix 5. nursing hours per pt day 6. RN surveys on job satisfaction and practice environmental scale 7. RN certification and education 8. Pediatric pain assessment cycle 9. Pediatric intravenous infiltration rate 10. psychiatric pt assault rate 11. Restraint prevalence 12. nurse turnover 13. Hospital acquired infections of ventilator associated pneumonia, central line associated bloodstream infection, catheter associated UTI
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Nursing Informatics
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uses info and technology to communicate, manage knowledge, mitigate error, and support decision making.
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Vulnerable populations
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this includes children, women, and older adults. They are most threatening by urbanization.
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Globalization
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the increasing connectedness of the worlds economy, culture, and technology, is one of the forces reshaping the health care delivery system.
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