605: Ambulatory Care Services Flashcards
1
Q
Ambulatory care services and organizations
- Definition
- Continuum
- Settings
A
Definition:
- “Outpatient” and “ambulatory” often used interchangeably
- Medical services provided to patients in noninstitutional settings
- Not requiring overnight stay at hospital/other facility
- More routine or discretionary (tent to be less serious)
Continuum:
- A continuum of services from simple office visits to complex procedures (including surgery)
- There isn’t just one type of care that constitutes ambulatory care. . .
Settings:
- Patients go to facilities
- MD offices, clinics, urgent care centers, outpatient surgery (hospitals, freestanding facilities)
- Services go to patients
- Mobile (screenings, etc.) and home health
2
Q
Levels of care
A
Primary care
- Oriented toward initial diagnosis and continuing treatment of common illness
- prevention, diagnostic, therapeutic services
- 1st level of contact for patient
- not complex (generally doesn’t require sophisticated technology, hospital stays)
- Important for managed care (gatekeeper function)
- Coordination of care among different providers and settings
- Stuides have shown that high % primary care >>>> lower expenditures
Secondary care
- Short-term consultations with specialists
- More complex treatments than in primary care
- e.g. surgery, procedures
Tertiary care
- Highest (most complex) level of care
- Usually highly specialized services; provided in institution (e.g., teaching hospital); often technology oriented
- Conditions treated are less common
- e.g. burn care, trauma, NICU, transplants
3
Q
Patient Centered Medical Home (PCMH)
- Description
- Goals
- Providers
- Components
A
(encouraged by ACA)
- Renewed interest as way to improve patient outcome and reduce costs
- Interdisciplinary team of MDs and other providers at one site (Usual Source of Care; Medical Home)
Goals:
- Coordinate all care
- Improve outcomes
- Better management of chronic conditions
- Reduce costs
Providers:
- MDs (primary and specialist): important role of primary care MDs, greater responsibility than specialists for coordination of care
- NPs, PAs, RNs, midwives (depends on practice setting)
Components of PCMH:
- Access to care
- Easily make appointments
- Short waiting times
- Email/phone consults
- Patient engagement
- More participation
- Information on treatment plan; follow-up reminders; counseling
- More participation
- Clinical Info Systems
- Patient registries; electronic med records
- Patient Feedback
- Provide feedback to providers; inform treatment plans
- Care Coordination
- Specialist care coordinated
- Systems prevent errors when multiple MDs involved
- Follow-up care provided
- Team Care
- Provider teams used
- Communication among members
- Avoid duplication
- Publicly available information
- Accurate, standardized information on MDs
4
Q
Ambulatory visits per 100 persons in 2010
A
Overall: 408 ambulatory visits/100 people
MD office visits account for the most by far
More MD visits as age increases (lower ED visits as age increases until age 75+)
5
Q
Percentage of total surgeries performed in hospital outpatient departments (1980-2012)
A
- Over time, changes in technology have enabled outpatient surgeries to be done more.
- Rapid increase since 1980 (dramatic increase over 30 years)
- Increase partially due to DRGs, but also due to technology
- DRGs provided incentive to shift from inpt to outpt care
- Outpt care remained “cost-based” fee-for-service for a while longer - Medicare now reimburses for hospital outpt services using a prospective payment system
- Managed care and other incentive to cut costs, reduce inpt care (outpt is less costly)
- Leveled off a little after 2000 because some surgeries do require inpt hospitalization
6
Q
Factors affecting growth of outpatient care
A
- New technologies available to diagnose & treat in outpatient setting
- e.g. minimally invasive technology; same-day surgery
- Reimbursement changes
- DRGs provided incentive to shift from inpt to outpt care (outpt care remained “cost-based” fee-for-service at first, Medicare now reimburses for hospital outpt services usign a prospective payment system)
- Managed care and other incentives to cut costs - outpt care less costly than inpt care
- Decreased hospital length of stay
- Outpatient care offers potential for hospitals to expand services (new market) - way to maintain revenue lost from inpatients (also possible “feeder” for inpts - pts have been there before for outpt services, so go back to same hospital when they need to be hospitalized)
- Demand by patients for procedures performed on outpatient basis.
- Preferred to being hospitalized
7
Q
Current ambulatory settings
A
- MD [private] offices
- Hospital outpatient dept.
- Hospital Emergency Department (ED)
- Freestanding facilities
- Walk-in urgent care clinics
- Retail ambulatory centers
- WalMart; drugstores
- Surgical centers
- Community clinics and neighborhood health centers
- Lab services
- Mobile diagnostic/ screening centers
- Radiology; Screening
- Noninstitutional:
- prisons
- homes (home health)
- schools (student clinics)
- Govmt./military facilities
- PH Department
- Hospice
- Telephone/email
- Outpatient LTC
8
Q
MD Office: Solo vs. Group Practice
- Description of each - history
- Formal definition of a group practice
- Advantages to group practice - for MDs and for Pts
A
Solo: long history in U.S.
- Perception of intimate, more caring relationship
- Usually greater administration responsibilities
Group: shorter history, but rapid growth
- Due partially to managed care, increased specialization, billing and admin complexities
- Managed care organizations want to contract with group practices
Formal definition of group practice:
- > or = 3 MDs formally organized to provide medical care, consultation, dx, and/or tx
- joint use of equipment and personnel
- often share income from practice according to some previously determined method
Group practice: advantages to MDs
- Few admin responsibilities;
- professional manager
- Shared risk and expensive for equipment and admin
- lower start-up cost
- Contracting ability
- managed care contracts; patient network
- Flexible hours
- coverage by colleagues
- Interaction with colleagues
Group practice: advantages to Patients
- Multiple providers w/in single organization
- probably multiple specialities represented
- Continuity of care
- primary care and specialists
- More likely to have EMR
- Availability of specialists and ancillary services
- (labs, imaging, etc.)
9
Q
% distribution of office visits by physician specialty
A
20% Family medicine
12.7% Internal medicine
14% Pediatrics
10
Q
Time spent with physicians during office visits
A
For almost 3/4 of visits, patients spend between 11-30 minutes with the doctor.
11
Q
Physician practice sizes - percentage in each category
- Percent of physicians still in “solo practice”
- Most prevalent size of practice (how many physicians)? And second most prevalent?
- Percent of large MD practices (>6 MDs in the practice)
A
- 34% (>1/3) are still in solo practice (1 MD)
- Most prevalent size of practice is 1 MD (solo)
- Second most prevalent size of practice is 3-5 physicians: 26.3%
- Percent of large MD practices (includes groups of 6-10 and groups with 11+ MDs): Slightly less than 30% (large practices still aren’t too prevalent)
12
Q
How the % of office-based MDs with EHR systems has changed between 2001 and 2013
A
Steady growth since mid-2000s
(Diagram: basic system is actually more comprehensive than “any EHR system”
13
Q
Hospital outpatient services
A
- Clinical services, same-day surgery, etc.
- Hospital-based (instead of office-based) services historically were viewed as lower quality
- Serving poor and uninsured patients - “safety net”
- Recent changes
- Outpt services are a new source of profit (since there is no longer as much reimbursement for inpatient care)
- Source of patients in a competitive environment (and can act as a feeder to inpt care if pt needs to pick a hospital)
- Source of patients (income) for MDs and residents/medical students at academic medical centers
14
Q
Freestanding Outpatient Facilities
- Urgent Care Clinics
- Same-day surgery centers (surgi-centers)
- Walk-in clinics (e.g. supermarkets/drugstores)
- Outpatient rehabilitation
A
- Urgent Care Clinics
- Began to spread in 1980s
- Walk-in or same-day appointment
- Convenient hours
- Wide range of services
- Often used in managed care to avoid more costly hospital ED for nonemergent after-hours care (or when people can’t get an appointment with usual MD)
- Same-day surgery centers (surgi-centers)
- Usually freestanding; some loosely affiliated with hospital
- Provide minior procedures that don’t require hospital stay (many of these procedures were previously provided in inpt settings, but changes in technology and reimbursement have increased outpt surgery)
- Potential benefits: lower cost of care, increased convenience (for both MD and pt)
- The # of Medicare-certified ambulatory surgi-centers in the U.S. increased from 400 (in 1983) to 5,260 (in 2013)
- Walk-in clinics (e.g. supermarkets/drugstores)
- Recent movement to provide low-cost ambulatory services at retail establishments
- Designed to appeal to individuals with no insurance or high deductibles/copays (offer low cost alternative)
- Also appeal to those who may have transportation barriers
- Offer limited scope of services
- Some insurers are now relying on them for immunizations
- May be less intimidating than formal medical providers
- Outpatient rehabilitation
15
Q
Mobile services
A
- Ambulance services (911)
- EMTs
- Paramedics
- Mobile diagnostic services
- Radiology: mammography, MRI
16
Q
Home Health
- Description of home health and services provided
- % expenditure on home health by payment source
- Age of home health patients
A
Services provided in patients home - noninstitutional, valued by patients
- Nursing care, medication monitoring, bathing, short-term rehab, homemaker services (meal prep, etc.)
- Durable medical equipment (DME): wheelchairs, oxygen, beds, walkers, etc.
**Large increase in Medicare coverage for home health in late 1980s (HH payments subsequently reduced by Balanced Budget Act of 1997
% expenditure on home health by payment source
- Medicare: 43% (Over $2 of every %5 spent for HH is from Medicare)
- Medicaid: 36.5%
- Private insurance: 7.9%
- Out-of-pocket: 8%
**Medicare and Medicaid jointly account for almost $4 of every $5 spent on HH
Age of home health patients
- Half of all HH patients are 75+ years old
- Patients 85+: 21.8%
- Patients 75-84: 29%
17
Q
Hospice Services
A
Hospice is a method of care; not a location
- Patients might reside in a hospice facility, SNF, hospital, or at home
Services provided to:
- Terminally ill patients
- Life expectancy < 6 months
- Focus: palliative care (management of pain and other symptoms)
- Families
- Psychosocial and spiritual care; social services
Funding:
- Medicare has been the major source of funding since 1983 - pays for more than $4 of eveyr $5 spent on hospice services
18
Q
Outpatient (Noninstitutional) Long-Term Care
A
Not in SNFs or other institutions
- Case management: coordination of services, referrals
- Adult day care: services and acitivities at day care centers focusing on needs of elderly (may complement informal care provided at home, give respite time to family)
19
Q
Community Health Centers
A
“Community clinics”
- Provide comprehensive range of services
- Focus on primary care services provided to persons in medically underserved areas (areas where there are relatively few primary care providers)
- Traditionally relied heavily on Medicaid, self pay/uninsured patients (sliding scale)
- Implications of Medicaid expansion with ACA? More income?
20
Q
Federally-Qualified Health Centers (FQHCs)
A
- Authorized in 1960s to serve medically underserved
- Includes Community Health Centers and other centers targeting underserved (homeless, migrants, etc.)
- Receive funds from federal government
- Also reimbursement for Medicaid pts
21
Q
Management challenges for outpatient care?
A
- Staffing
- Managing/using medical records
- info systems
- sharing data
- Cost containment and revenue reduction - how to provide serves profitably?
- New technology
- staff training and purchase cost
- Changing demographics: impact on outpt care?
- Train staff regarding cultural competence
- Competition for pts from: other outpt organizations, hospitals (outpt dept’s)
- Coordination of care
- Maintain high quality care in face of increased competition and decreased reimbursement
- Legal environment
- malpractice; regulatory compliance; health reform
