Exam 1 Flashcards
Insurance company pays provider set amount of money each month to provide a defined set of Healthcare Services
Capitation
Reimbursement for healthcare services based on predetermined fixed Price–per–case/ diagnosis
DRGs
Providers reimbursement based on the patient’s diagnosis; most common method of payment in today’s healthcare system
Perspective payment system
Method of reimbursing healthcare providers based on each individual service provided; a.k.a. Fee-for-service.
Retrospective payment system
What is the impact of rising healthcare costs on families?
–rely on home remedies/ OTC’s
–skipped dental care
–postponed needed healthcare
–skip medication doses
–did not get prescriptions filled
–skipped recommended treatments/tests
Possible reasons for rising healthcare costs in US:
– aging population
–better technology= increased cost
–wasteful spending
–more chronic illnesses
–Pt’s A lower share of expenses
Method of reimbursing providers based on quality of care provided w/an emphasis on disease prevention and reduction of complications. Better patient outcomes= increased payment.
Pay-for-performance
Disadvantage: noncompliant patients= decreased reimbursement for provider
Medicare provides coverage for:
Persons over 65
Certain disabilities
end-stage renal disease
Joint Federal/State program to provide health insurance for impoverished families and people with certain disabilities.
Primary payer of LTC nationwide.
Fastest-growing component in most state budgets.
Medicaid
Federal entitlement program funded by wages from employees:
Medicare
Provider agrees to or is required by law to accept the Medicare approved amount as full payment for services.
Assignment
Neither Medicare A or B cover:
LTC (unless receiving dialysis)
Dental care/ dentures
cosmetic Sx
acupuncture
hearing aids/exams
Medicare A covers:
Hospitalization:
Inpatient in hospital/SNF
hospice care
Home healthcare
Medicare B covers:
Outpatient/MD services:
Ambulance services
preventative services
mental health inpatient/ outpatient
Pt pays premiums/ deductibles
Medicare D covers:
Prescription drugs:
Voluntary
Pt pays premium/ deductible
Medicare C/ medigap covers:
What Medicare A/B/D do not
Pricing discounts given to a Pt by the hospital they’re typically determined by income, Family size, and debt level:
Charity care:
Required for nonprofit hospitals
Five major reasons people over 65 experience medication related problems:
Physiologic changes: altered Pharmokinetics
Polypharmacy: Often by Multi-provider
incorrect dosage/ med errors
self-medication/ nonadherence
Any injury/Harm occurring during a patient’s therapy as a result of medications:
Adverse drug event
And unforeseen/Unintended/Undesired effect of a drug that occurs during therapy:
Adverse drug reaction
Any undesirable condition in a patient occurring as a result of treatment by a healthcare professional; pertaining to an illness or injury result from medication
Iatrogenic event
Causes for polypharmacy:
Increased number of doctors
Increased number of pharmacists
increase number of chronic conditions
OTC not considered
Pt equate going to the doctor with getting pills
decreased knowledge about meds by Pt
sharing meds
inappropriate scripts/ underused Meds
Reasons for adverse drug events in elderly:
Physiological change/ pharmokinetics
Drug absorption changes
drug distribution changes: reduced proteins/Albumin
slower drug metabolism
decrease drug elimination/GFR
Creatinine levels decrease in the elderly d/t loss of lean body mass could appear normal d/t:
Decreased GFR:
Allows buildup of creatinine which could mask the reduced creatinine levels; normal indicator of renal dysfunction
BUN levels: 10-20
??= dehydration
>??= renal
A low BUN, ??, & ?? may indicate malnourishment.
20-30s= dehydration
>30= Renal
Low BUN/Protein/Albumin
Three essential nursing competencies needed to increase safety:
Critical thinking
Safety
teaching
Collaboration with the interdisciplinary team:
Streamlines the decision-making process
Allows achievement of goals
ensures continuity
An informal, achieved roll that has influence over others with no real authority; Part of every nurses responsibility
Leader
Formal, designated role that helps others to develop and has authority over others; Improved by developing leadership skills
Manager
Authority position of the unit responsible for developing healthcare professionals of delivering the highest quality of care compliance
Nurse manager
What are the five major management functions?
- Planning: defining goals/objectives; resource allocation
- Organizing: coordinating people/time/work
- Staffing: hiring/ training/Scheduling/Development
- Directing: communicate/Delegate/Motivate/Manage conflict
- Controlling: performance reviews monitoring financials and quality of care
This type of allocation takes but the highest levels of administration policy a.k.a. government, and determines what funds to expand, Good to make available, and methods of distribution; Affects large numbers of people.
Macroallocation
This type of allocation focuses on deciding who will be the recipient of scarce resources; often occurs at patients bedside.
Microallocation
What are the four types of healthcare resources?
Labor: nurses/doctor/technicians
Capital: medical facilities/equipment/supplies
Land: property for the hospital/facilities
Entrepreneurship: vision and skill to manage the hospital as a business
What are the three top chronic diseases?
Diabetes
Lung disease
Cardiovascular disease
What are the four theories of justice?
Utilitarian: greatest good for the greatest number
Libertarian: fix the rights of each individual; citizens improve their own circumstances
Communitarian: places the community above individual, state, or nation
Egalitarian: promotes the idea of equal distribution amongst similarly situated people
What is the six IOM quality aims?
STEEEP
Safe
timely
effective
efficient
equitable
patient-centered
Community oriented nurse
VS
Community-based nurse
Community oriented: Focus on at risk people families and groups and community as a whole; works on the primary and secondary care levels.
Community-based: focuses on individuals and families illnesses, and management of acute/chronic conditions in settings were individuals/Families/Groups live; works on a tertiary care level
Public health nursing
VS
Community health nursing
Public-health: promote/ maintain health through disease prevention of the whole community; focuses on disease prevention
Community health: promote/maintain the health of populations by the delivery of health services to individuals families and groups; delivery of health services
Ocupational Health Prevention
Primary=??
Secondary=??
Tertiary=??
P= prevention/Immunizations/ protective equipment
S= ID-ing hazards/ early detection/ counseling and referrals
T= restoration/rehabilitation ex: Limited duty programs
Primary=??
Secondary=??
Tertiary=??
p= prevents initial occurrence
s= early detection/ assessment
t= recovery/rehab
Epidemiology
Agent:??
Host:??
Environment:??
a: animate or inanimate object that causes the disease
h: living being that is affected by the agent
e: setting or surrounding that sustains the host
