Ch.2 Health-care Delivery, Settings, and Economics

Question 1

Capitation

Answer 1

the payment system used by health maintenance organization (HMOs)

Question 2

case management

Answer 2

type of nursing care system that involves seeing each patient as an individual and each situation as unique
goal: assist patients who are vulnerable, at risk, or cost-intensive so that their care is coordinated, meets their specific needs, and is cost-effective while still bringing them to optimum health

Question 3

patient-centered care

Answer 3

care that empowers the patient to take control of and manage their care
- allows patients to achieve independence within the limits of their disability by permitting them to have voice in rehab

Question 4

diagnosis-related groups (DRGs)

Answer 4

classifications of illnesses and diseases that are used to determine the amount of money paid by Medicare to a hospital for the care of the patient with that particular illness

Question 5

health-care provider

Answer 5

people who write orders for patient care
- physicians, physician assistants , and nurse practitioners

Question 6

health maintenance organization

Answer 6

a cost containment program featuring a primary care physician (PCP) as the gatekeeper to eliminate unnecessary testing and procedures; this is a capitated system that requires the insured person to remain within the network

Question 7

home health care

Answer 7

one of the many types of health or medical services provided to patients in their homes because they are confined to their homes by illness/disability

Question 8

hospice

Answer 8

medically directed nurse-coordinated program providing a continuum of home and inpatient care for the terminally ill patient and family

Question 9

inpatient

Answer 9

stay overnight or longer in a health-care facility

Question 10

managed care

Answer 10

any method of financing and organizing the delivery of healthcare in which costs are contained by controlling the provision of benefits and services

Question 11

Medicaid

Answer 11

federal-state program in which the federal government helps states pay for the health-care of those with an income below federal poverty threshold

Question 12

Medicare

Answer 12

federal government’s health insurance program for people older than 65 years

Question 13

outpatient

Answer 13

meet the needs of the patient in 1 day (24 hrs)

Question 14

point-of-service plan

Answer 14

similar to health maintenance organization in that PCP still serves as gatekeeper; however, this plan is not capitated. Insured can seek care from physicians who are both in and out of the network
- patient pays part of the bill (20-30%) and insurance pays remaining

Question 15

preferred provider organization (PPO)

Answer 15

group of health-care providers who contract with health insurance company to provide services to a specific group of patients on a discounted basis

Question 16

primary care nursing

Answer 16

one nurse responsible for all aspects of nursing care for their assigned patients

Question 17

primary care physician

Answer 17

physician who is paid a set amount per member per month to manage the health of those members
- considered gatekeeper to health services for the individual enrolled in HMO

Question 18

referral

Answer 18

act by PCP of providing a patient with a referral to a specialist
- provides a way to controlling access to more costly care and potentially redundant testing

Question 19

rehabilitation

Answer 19

level of care which the patient can receive intense physical, occupational, & speech therapy hospital
- hospital setting or free standing facility

Question 20

team nursing

Answer 20

team of nurses and CNAs or other personnel to provide care for a group of patients

Question 21

third-party payer

Answer 21

party that pays the bills of the beneficiary cared for by the physician or hospital
ex: insurance company is sent a bill