ACM Vocabulary Flashcards
Essential activities that are key to daily functioning. There are six basic: eating, bathing, dressing, tolieting, transferring (walking) and continence.
ADLs
A branch of secondary health care where a patient receives active but short-term treatment for a severe injury or episode of illness, an urgent medical condition or during recovery from surgery. Opposite of chronic care or longer term care
Acute Care
Reports that examine medical necessity for hospital admission and evaluate the healthcare services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Admission or Initial Review
Encompasses direct service to the individual or family as well as activities that promise health and access to healthcare in communities and the larger public. Advocates support and provide the rights of the patient in the healthcare arena, help build capacity to improve community health and enhance health policy initiatives focused on available, safe and quality care. Health advocates are best suited to address the challenges of patient-centered care in a complex healthcare system.
Advocacy
Level of care where patients must have had a recent event altering functional abilities, have the strength and endurance to participate in three houses of therapy per day and have the cognitive abilities to learn progressively.
Acute Inpatient Rehab (AIR)
To agree or concur. Used with regard to a minor making healthcare decisions. Minors do not have a legal right to consent to healthcare treatment and require parents or guardians to do so on their behalf. However, a knowledgeable mature minor may have the ability to understand his/her treatment risks, options, choices, prognosis, etc and participate in the decision-making process by offering agreement with recommendations.
Assent
Within the healthcare Setting, this term refers to the degree to which a patient correctly follows medical advice. Most commonly, it refers to medication or drug complicance, but can also apply to other situations such as medical device use, self-care, self-directed exercises or therapy sessions.
Compliance or Adherence
Informally referred to as “Obamacare”; aimed to primarily at decreasing the number of uninsured Americans and reducing the overall costs of health care. It provides a number of incentives, including subsidies, tax credits and fees, to employers and uninsured individuals in order to increase insurance coverages. Additional reforms are aimed at improving health care outcomes in the USA while updating and streamlining the delivery of health care; Requires insurance companies to cover all applicants and offer the same rates regardless of pre-existing conditions or gender. This will lover both future deficits and Medicare spending.
Patient Protection and Affordable Care Act (PPACA or ACA)
The action that is done for the benefit of others or a group of norms pertaining to relieving, lessening or preventing harm and providing benefit and balancing benefits against risks and costs. An ethical principal to “do good”
Beneficence
The reimbursement of healthcare providers on the basis or expected costs for clinically defined episodes of care. Often described as a middle ground between fee-for-service reimbursement (in which providers are paid for each service rendered to a patient) and capitation (in which providers are paid a lump sum per patient regardless of how many services the patient receives).
Bundled Payment
An initiative of the Centers for Medicare and Medicaid services (CMS) where organizations enter into payment arrangements that include financial and performance accountability for episodes of care. The initiative is hoped to lead to higher quality, more coordinated care at a lower cost to Medicare.
Bundled Payment for Care Improvement (BPCI) Initiative
Within the healthcare setting, this term refers to a patient’s ability to make independent decisions about his/her healthcare treatment. Includes the patient’s ability to:
1. Understand the info being disclosed, including risks, benefits and alternatives
2. Express the decision, and to do so consistently over time.
3. Weigh the consequences and evaluate the impact of the decision at hand.
Capacity
The deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care and the facilitation of appropriate delivery of healthcare services. This helps avoid waste or overuse, underuse or misuse or prescribed medications, as well as conflicting plans of care.
Care Coordination
A collaborative process that facilitates recommended treatment plans to ensure the appropriate medical care is provided to disabled, ill, or injured individuals. It refers to the planning and coordination of healthcare services appropriate to achieve the goal of medical rehab. May include, but not limited to, care assessment, evaluation of a medical condition, development and implementation of a plan of care, coordination of medical resources, communication of healthcare needs to the patient and/or family members, monitoring of an individual’s progress and promotion of cost-effective care.
Case Management
A hospital measurement representing the average diagnosis-related group (DRG) relative weight for a given facility. It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges.
Case Mix Index (CMI)
An agency that is part of the Department of Health & Human Services (HHS). They administer Medicare, Medicare, the Children’s Health Insurance Program (CHIP) and parts of the Affordable Care Act (ACA).
Centers for Medicare & Medicaid Services (CMS)
A cluster of related abilities, commitments, knowledge and skills that enable a person to act effectively in a variety of situations. This is a legal term and a determination made by a judge in a court of law. Not the same as decision-making.
Competence
A code describing a change in status when specific criteria are met. When the hospital UR committee reviews case and in consultation with the admitting or treating practitioner, determines the admission is not medically necessary, however, observation services are appropriate, the admission may be changed from inpatient to observation. The patient must be informed of this change in status. The change is permissible when:
1. the change in status from inpatient to outpatient (obs) is made prior to discharge from the hospital.
2. the hospital has not submitted a claim for inpatient admission
3. a physician concurs with the UR’s committee’s decision.
4. the physician and UR’s decision is documented in the patient’s record
Condition Code 44 (CC 44)
Sections of the Code of Federal Regulations that pertain to health and safety standards that healthcare orginzations must meet in order to begin and continue participating in the Medicare and Medicaid programs. These health and safety standards the the foundation for improving quality and for protecting the health and safety of beneficiaries.
Two different sections: Utilization Review and Discharge Planning.
This can be the basis for other best practice standards, such as The Joint Commission.
Conditions of Participation (CoP)
Ongoing assessment of a patient’s progress through review and evaluation of the physician documentation. Performed to determine whether continued stay should occur within the level of care in which the patient was initially placed or if a move to another level of care, or to discharge, is required.
Continued Stay Reviews
A group of evidence-based indicators that, when met, result in improved clinical outcomes for patients, decreased mortality rate and reduced healthcare cost.
Core Measures
Provides a full explanation of the reasons for hospital discharge and/or why services received are no longer covered by Medicare.
Detailed Notice of Discharge (DND Notice)
- A patient classification system used to identify resources expended for hospital services without taking into account the therapeutic approaches employed.
- Patient records are categorized into homogenous groups according to the diagnosis and healthcare expenses involved
- This uses the following data for hospital performance evaluation: average length of stay, average patient load, comparative performance index and case mix index.
Diagnosis-Related Groups (DRGs)
Requires hospitals to provide an examination, as well as needed stabilizing treatment, without consideration of insurance coverage or ability to pay when a patient presents to an ER for an emergency medical condition.
Emergency Medical Treatment and Active Labor Act (EMTALA)
Terminology used for outpatients in a bed who do not meet either Inpatient or Obs status requirements. These patients may be boarding after an uncomplicated procedure, or this classification is also used for social admissions.
Extended Stay/Recovery
The US Department of Health and Human Services issued the Privacy Rule that addresses the use and disclosure of individuals’ health information called “protected health info”.
- Major goal is to ensure that individuals’ health information is protected while still allowing for the flow of health information needed to provide and promote high quality health care and to protect the public’s health and well being.
Health Information and Portability and Accountability Act of 1996 (HIPAA)
The degree to which individuals have the capacity to obtain, process and understand basic health information needed to make appropriate health decisions and choose services needed to prevent or treat illness.
Health Literacy
A category of devices used for patients whose care is being managed from a home or other private facility managed by a nonprofessional caregiver or family member.
Home Medical Equipment (HME)
Written notices given by a hospital to tell a patient that Medicare may not cover his or her admission, inpatient status or continued stay while at the hospital because the services are not medically necessary, not delivered in the most appropriate setting or are custodial in nature.
Hospital issued Notice of Non-Coverage (HINN)
A core set of questions that can be combined with a broader, customized set of hospital-specific items. The survey items complement the data hospitals currently collect to support improvements in internal customer services and quality related activities.
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS)
Creating a mutual understanding between the patient and the provider about the care, treatment and services that may be provided. The process enables patients to actively participate in care and treatment decisions and to understand the risks, benefits, options and alternatives.
Informed Consent
“Second level” activities that support an independent lifestyle. Includes: cooking, driving, using the telephone or computer, shopping, keeping track of finances, managing medications
Instrumental Activities of Daily Living (IADLs)
A contractor responsible for ensuring that paid claims were 1. Services provided and properly documented, 2. services billed properly, using correct and appropriate procedure codes and 3. covered services. Three types: review, audit and education.
Medicaid Integrity Contractors (MIC)
The authorization generated when services are rendered.
Concurrent Authorization
Measuring the effectiveness of an intervention rather than monetary savings.
Cost-effective analysis
A Medicare hospital spending claim that includes all of Medicare Part A and Part B claims paid during the period from three days prior to a hospital admission through 30 days after discharge.
Medicare Spending per Beneficiary (MSPB)
Set of indicators providing information on potential in-hospital complications and adverse events following surgeries, procedures and childbirth
Patient Safety Indicators (PSIs)
A 1991 federal law requiring healthcare facilities that receive Medicare and Medicaid funds to inform patients of their right to execute an advance directive concerning their end of life care.
Patient Self-Determination Act (PSDA)
Providing financial incentives to clinicians who achieve, improve or exceed their performance on specified quality and cost measures, as well as other benchmarks
Pay-for-Performance
A plan that establishes a systematic approach to achieving quality measures in performance, process, analysis or service.
Performance Improvement Plan (PIP)
A group of health quality experts, clinicians, and consumers organized to improve the care delivered to people with Medicare.
Quality Improvement Organization (QIO)
Contracted providers who identify and recover alleged improper Medicare payments paid to health care providers and organizations under fee-for-service Medicare plans.
Recovery Auditors (RAs) or Recovery Audit Contractors (RACs)
The identification, analysis, assessment control, avoidance, minimization or elimination of an unacceptable risk.
Risk Management
An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.
Sentinel Event
Comprehensive goal-oriented inpatient care designed for a patient who has has an acute illness, injury or exacerbation of a disease process. Care is rendered either immediately after or instead of acute care hospitalization.
Subacute Care
Ethical principal grounded in truth
Veracity
This act consolidates various state laws dealing with all decisions about adult healthcare and healthcare power of attorney. It aims at assisting individuals and the medical profession in better assuring a person’s right to choose or reject a particular course of treatment.
Uniform Health Care Decisions Act of 1993 (UHCDA)
Evaluation of the appropriateness, medical need and efficiency of healthcare services, procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan. Describes proactive procedures including discharge planning, concurrent planning, pre-certification and clinical case appeals. Also covers proactive processes such as concurrent clinical reviews and peer reviews, as well as appeals introduced by the provider, payer and patient.
Utilization Management
Reviews against utilization issues brought forth by medical director. They often approve or review policy regarding coverage, review utilization patterns or providers and approve or review the sanctioning process against providers. The only medical staff committee mandated by the CMS Conditions of Participation.
Utilization Management Committee (UM)
A demand side strategy to measure, report and reward excellence in healthcare delivery. Part of the Centers for Medicare & Medicaid services (CMS) long-standing effort to link Medicare’s payment system to a value-based system to improve healthcare quality, including the quality of care provided in the inpatient hospital setting.
Value-Based Purchasing (VBP)
A basic acronym offered by AHRQ (Agency for Healthcare Research and Quality) for introducing patients and their caregivers to this role.
IDEAL
Include the patient and family as full partners in the discharge planning process.
Discussed with the patient and family key areas to prevent problems at home
Educate the patient and family in plain language about the patient’s condition, the discharge process and next steps at every opportunity throughout the hospital stay
Assess how well doctors and nurses explain the diagnosis, condition and next steps in the patient’s care to the patient and family, and use teach back
Listen to and honor the patient and family’s goals, preferences, observations and concerns
A reimbursement model with a greater emphasis on quality of care, efficient processes of care, and better and safer patient outcomes.
3 major categories:
1. Value-Based Purchasing (clinical care outcomes, patient experience, efficiency, safety, clinical care process)
2. Readmissions
3. Hospital Acquired Conditions
Pay-for-performances (P4P)
Four basic principles of healthcare ethics should be practiced when delivering healthcare services.
Autonomy, Beneficence, Non-maleficence and Justice
