5. Hospitals Flashcards
Most common cause of hospitalization in childhood?
Asthma
General organization task facing all health care systems?
One of “assuring that the right patient receives the right service at the right time and in the right place”…(and by the right caregiver)
Primary v. Secondary v. Tertiary care?
Primary = preventative measures and common health problems (sore throats, diabetes, arthritis, depression, HTN). Secondary = more specialized expertise (acute renal failure). Tertiary care (rare and complex disorders)
2 contrasting approaches can be used to organize a health care system around primary/secondary/tertiary levels of care?
1) The Dawson model of regionalized health care (e.g. British) 2) Free-flowing Model (e.g. USA)
Dawson Model - general overview?
Different types of personnel and facilities are assigned to primary, secondary, and tertiary tiers, and flow of patients occurs in an orderly, regulated fashion.
Alternative Model - general overview?
More
British System - Primary Tier?
General Practitioners (GPs, like PCPs), are 2/3 of docs. Practice in small-to-medium sized groups
British System - Secondary Tier?
Less docs, each covers more area, mostly in hospital clinics. Consultants from GPs who specialize in internal med, pediatrics, neuro, psychiatry, OBGYN, Gen Surg
British System - Tertiary Tier?
Fewest docs, each covers a crapload of area in few tertiary care centers - cardiac surgeons, immunologists, etc.
British System - Patient flow?
All pts are first seen by GP (except emergencies), who steer patients towards more specialized levels of care through referrals (can’t refer themselves)
British system - multidisciplinary approach?
GPs work with nurses and other HCPs, teams have a defined population, universal health care coverage, immunization tracking system
US Free-flowing Model - Referrals?
Insured patients can take their symptoms directly to the specialist of their choice without the referral of the PCP - this happens a lot
US Free-flowing Model - PCPs?
Have a broadened role - “GPs” do ambulatory care, but also provide substantial amounts of inpatient care. Only 1/3 of the docs in US. Other tier docs, NPs, and PAs fill this gap.
US Free-flowing Model - Hospitals?
Compete with each other and provide a wide range of secondary and tertiary services in the middle
Criticism of US Free-flowing model (dispersed system)?
Lack of organization and team approach, too top-heavy on secondary-tertiary care…all contributes to high cost of health care, and quality of care suffers. Also, too much tertiary training gives those HCPs an unrepresentative view of the health care needs of the community.
Defense of US free-flowing model (dispersed system)?
Diverse care options promote flexibility/convenience, emphasis on specialization and high tech shit - patients like that
Cost v. Tiers of care?
Most health care resources are allocated to secondary/tertiary care, but most people have health care needs at the primary care level.
4 key tasks of primary care?
1) First contact care 2) Longitudinality (sustaining a lasting patient-caregiver relationship) 3) Comprehensiveness (manage a wide range of health care needs, diff from specificity of specialty care) 4) Coordination (referral, follow up)
Core elements of good primary care advanced what “triple aims” of health care improvement?
Better patient experience, better patient outcomes, and lower costs
Pros to primary care approach?
Better perceived access to care, better health outcomes, more preventative measures, adherence to treatment, satisfaction with care, just overall better stuff
Describe the context around playing “gatekeeper”
Pejorative connotations with managed care, when PCPs are provided incentives to “shut the gate” in order to limit specialist referrals and diagnostic services
Explanation of the new patient-centered “medical home?”
4 cornerstones: Primary care (And all those good qualities it should have), patient-centered care (e.g. same day scheduling option), new-model practice (e.g. reengineer workflows/tasks), and payment reform (blend fee-for-service with partial capitation/quality incentives)
Example of medical home - patient centered care.
Same day scheduling options to see patients quicker, team-care models that reengineer workflows/tasks
ACA and Primary Care?
Several measures to strengthen, including 1) Increases in MCARE fees for primary care and 2) Support of patient-centered medical home reforms
What forces drive the organization of US health care? (3)
Biomedical model, financial incentives, professionalism
3 financial incentives?
1) Insurance benefits cover hospital costs more than physician/outpatient visits 2) Higher cost procedures are under specialty care realm, high fees means higher specialty salaries…disparity between PCP/specialty incomes is continuing to grow 3) Federal health care involvement has led to expansion of hospital/specialty care instead of ambulatory services (MCARE & MCAID pay higher reimbursement for specialists)
Explain the “professionalism” force.
Unlike other countries, the US govt provides much of the financing for health care but without much administrative control…docs emerged as the health care authority as a result. Professionalism is a social contract: in return for the privilege of autonomy, docs bear the responsibility for acting as the patient’s agent, and the profession must regulate ITSELF to preserve the public trust…more than just a business.
Hospitals in the 1950s relationship with docs?
Docs were usually most dominant power in the hospital cuz they would work for several hospitals and would admit the patients (hospitals without pts had no income, and there was always the implicit threat of taking patients to another hospital).