Health Care Delivery Flashcards
the structure of the health care delivery system
- services -> the health care assistance available
- consumers -> the people who require health care
- personnel (providers) -> the people and institutions that provide healthcare services to members of the public
- payment -> the method of paying for health care
describe the financing, funding, and resource management of health care services
finance is the process of using financial resources to ensure health system can cover expenses
make sure there is the funding needed
make sure all have the proper resources
describe health care disparities and the effect of social determinants of health
the avoidable differences that result from cumulative social disadvantage, including health outcomes, health care access, coverage and quality of care between groups of people, etc.
discuss the role of interprofessional health care team members in the delivery of client care
registered nurse - oversees the nursing care given by nursing staff
provider - prescribes medications and therapies for positive outcomes
case manager -coordinates with healthcare team to coordinate needs
physical therapist - provides care directly focused on improving physical function and mobility
social worker - identifies discharge planning and solutions for afterwards
LPN - works under supervision of RN
what were some of the goals of the Patient Protection and Affordable Care Act
Making affordable health insurance available to more people
providing protection to those who are ACA-funded services
expanding the Medicaid program to adults with incomes below 138% of the poverty level
lowering the costs of health care
each state can do what
Each state is able to interpret federal definitions in a way that it feels is appropriate. In addition, states can regulate how funding for Medicaid is dispersed, as Medicaid dollars are administered at both state and federal levels. For example, each state has its own State Child Health Insurance Program (SCHIP). States can pass legislation related to pharmaceuticals, as covering drug costs can be a huge portion of their budget spending each year. For example, states can put a cap on pharmaceutical prices to help control market costs. The Inflation Reduction Act was passed by Congress in 2022, to decrease prescription drug costs for Medicare recipients by capping the cost of insulin and capping annual out-of-pocket costs.
who regulates how practitioners operate
states, they determine eligibility requirements, issue licenses, governs policies, and review disciplinary cases.
- also provide guidance on topics related to health care and wellness.
what do accreditation organizations do
- assure they have policies and procedures in place to maintain the quality of services and safety of clients
- develop operational standards, policies, and procedures that relate to everyday practice, such as environmental policies, human resources, client safety, and documentation
The Joint Commission is conducting a site visit at a facility and will be assessing client records for compliance with standards. Which of the following should the nurse be able to discuss with TJC surveyors?
- facility policies that address client assessment
- assessment documentation in the client record
- location of the client’s plan of care
- facility policies that address administration of medications
list several examples of sentinel events, as defined by TJC
A client is given blood that has been incorrectly typed in the laboratory. An infant death. A client has the wrong arm or leg amputated during surgery.
main goals of the magnetic recognition program
promoting quality in a setting that supports professional practice, identifying excellence in the delivery of nursing services to clients, and disseminating “best practices” in nursing service.
the 5 categories of the components of the magnet program
the empirical outcomes are: structural empowerment, exemplary professional practice, new knowledge, innovations, or improvements, transformational leadership, empirical outcomes
pathway to excellence program
a program for long-term or outpatient facilities to recognize excellence in nursing
sentinel event
An adverse event that should not occur:
Injection of the wrong type of blood into a patient
Death of an infant
amputation/surgery of the wrong limb
magnet recognition
- Health care organizations that provide excellence in nursing care throughout the facility
- Promote quality in a setting that supports professional practice
Identifying excellence in the delivery of nursing services to clients
Disseminating “best practices” in nursing service
- Promote quality in a setting that supports professional practice
magnet production versus pathway to excellence
Magnet
- Identifies innovations in professional practice
- Identifies organizations w/ quality outcomes
- Identifies client care excellence
Pathway
- Identifies a supportive practice environment
- Identifies a shared-governance structure
- Identifies contributions that affect nurses’ well-being
medicare
Government health care coverage for a client who is age 65 or older, under age 65 with disabilities, or any age with End Stage Renal Disease (ESRD) or amyotrophic lateral sclerosis (ALS).
the four parts of medicare
Part A (Hospital Insurance): Hospitalization, skilled nursing facilities, some hospice care, some home health care
Part B (Medical Insurance): Doctor’s services, physical therapy, occupational therapy, some home health care
Part C (Advantage Plan): Selected coverage that can include Medicare Parts A, B, and D
Part D (Medication Coverage): Extra coverage to lower costs of prescription medications
medicaid
Government health care coverage for a client who must meet eligibility requirements based on the client’s income in relation to the poverty level.
children’s health insurance program
Government health care coverage that provides for children who may not meet Medicaid’s requirements but need health coverage.
private insurance
insurance not covered by a government agency
insurance reimbursements
fee for service (FFS)
payment system
diagnosis related groups (DRGs)
Centers for medicare & medicaid services (CMS)
Inpatient prospective payment system (IPPS)
Hospital-Acquired condition reduction program (HACRP)
Hospital Acquired Infection (HAIs)
hospital acquired conditions included in condition reduction program
Central line associated bloodstream infection (CLABSI)
Catheter associated urinary tract infection (CAUTI)
Surgical Site Infection (SSI): colon & hysterectomy
Methicillin-resistant staphylococcus aureus (MRSA) bacterium
Clostridium difficile infection (CDI)
resource utilization groups
a fixed payment system for reimbursement of health care services provided in the long-term setting based upon client diagnosis and services provided
minimum data sets
A clinical assessment of a client s physical and cognitive status required to be conducted on nursing home residents who receive Medicare and Medicaid benefits
social detriments of health
Neighborhood & built environment
Health & health care
Social & community context
Education
Economic stability
Genetics
examples of physical determinant of health
the built environment
aesthetic elements
exposure to pollutants
the natural environment
- lack of green space for gardening, apartment buildings built close together
examples of social determinant to health
social and community context
health and health care
positive social interactions
education
social interaction/support
- local store does not sell fresh produce, lack of transportation to medical visits, access to food that supports healthy eating, working two jobs to pay the bills
the five main most important social determinants of health
economic stability
health and health care
neighborhood/built environment
education
social/ community context
Ms. Jones is an 86-year-old female admitted to the acute care setting after sustaining a hip fracture. She has diabetes and is insulin-dependent, and she previously had a stroke and has weakness in her right arm. She will need physical therapy for her hip upon discharge. There is one flight of stairs to go up to access her home. What level of care would you recommend for a discharge plan for Ms. Jones?
skilled nursing facility
skilled nursing facility
Sometimes referred to as a nursing home or long-term care, may provide for short term rehabilitation care such as occupational and physical therapy as well as oversight for activities of daily living.
long-term care hospital
A facility that specializes in providing care for stable clients who require a lengthy period of treatment such as for severe burns, trauma, or ventilation needs.
assisted living
Provides services for clients who are mostly independent in their living but who choose to live in a community setting for assistance with some part of their daily life—for example, with meals, medication management, laundry, housekeeping, or transportation.
hospice
Services provided to clients when it is determined the client has less than six months to live. The goal is comfort and support services for the client and family, not curative.
palliative
Services provided to clients to promote comfort while in the last stages of life. Services can be received during active treatment. A treatment approach that is focused on the management of symptoms of chronic or life-threatening illnesses while maintaining the highest level of quality of life possible for the client.
respite care
Allows the client to be cared for apart from the caregiver, to allow the caregiver a break from the responsibilities of client care for a short time for vacations to travel or to simply stay at home without caring for the client.
home care
The delivery of continued health care services within the client s home. Services can include nurse visits as well as occupational therapy, physical therapy, and social work.
the primary six people involved with a patients care
the primary care physician
nurse case manager
lab, radiology, pharmacy
hospital
dietician
specialty physician
The interprofessional team is collaborating to address Mr. Marino’s needs. What sequence of actions should the team take when applying the nursing process to Mr. Marino’s situation? (Order the options by matching each with the desired order number.)
1) review health history for chronic illness and cognitive deficits
2) determine as a team what is highest priority
3) identify a goal to work towards
4) Assist when needed especially when out of bed
5) meet again later on to discuss discharge
a nurse is teaching a newly licensed nurse about medicare reimbursement. what should be taught
reimbursement amounts will be adjusted for clients who contract hospital-acquired conditions
A community health nurse is teaching newly licensed nurse about the social determinants of health. Which of the following should the newly licensed nurse identify as a physical determinant of health?
poor air quality
A nurse is teaching about Medicaid to a client who is concerned about paying for health care. Which of the following statements should the nurse make?
your income will determine if you are eligible for medicaid
A nurse in a provider’s office is calling a client’s insurance company to obtain permission prior to scheduling a magnetic resonance imaging MRI test. Which of the following is the nurse obtaining?
precertification
A home health nurse is caring for a client who is receiving hospice care. The client’s parter reports feeling overwhelmed from caring for the client. Which of the following types of facilities should the nurse recommend?
respite care
A nurse is teaching a newly licensed nurse about The Joint Commission (TJC). Which of the following information should the nurse include?
TJC ensures organizations remain up to ate with state guidelines
A nurse working in an acute care facility is caring for a client who has a total brain injury and is receiving mechanical ventilation. Which of the following facilities should the nurse anticipate the client to be transferred to for further treatment.
long term
A nurse is teaching a client about hospice care. Which of the following statements by the client indicates an understanding of the teaching?
I understand that services provided will include just what is needed to keep me comfortable
A nurse is discussing hospice care with a newly licensed nurse. Which of the following should the nurse identify as the goal of hospice care?
provide care for a client who has less than 6 months to live
A graduate nurse notes that a hospital with Pathway to Excellence recognition is hiring staff. Which of the following should the nurse expect from this facility?
-The facility has practices in place that lead to a healthy workplace environment.
-The facility emphasizes shared governance.
-The facility emphasizes practices that positively affect a nurse’s well-being.
A nurse at a community health center is providing an in-service for a group of residents about the Healthy People program. Which of the following information should the nurse include?
-Improving access to health care
-Activities to improve social determinants of health
-Initiatives to reduce health care disparities
A nurse is reviewing a report by the Institute of Medicine (IOM). Which of the following competencies should the nurse identify health care professionals need in order to reduce errors?
cooperation
communication
coordination
A nurse is hired to be a case manager in a facility. Which of the following services should the nurse expert perform?
facilitate transfer of clients to meet required level of care
A nurse is competing the Minimum Data Set (MDS) assessment for a resident in a skilled-nursing facility. Which of the following information should the nurse include in the assessment?
-Input from members of the interdisciplinary team.
-Client’s cognitive status.
-Each physical therapy visit.
-Clients need for assistance with ADLs.
A nurse is caring for a client who reports that they have lost their job and do not have insurance. Which of the following social determinants of health is challenging for this client?
economic stability
A nurse is caring for a client who has Parkinson’s disease and needs assistance with ADL’s. Which of the following referrals should the nurse anticipate the provider to prescribe?
(Select all that apply)
dietician
physical therapist
occupational therapist
A nurse is discussing social determinants of health with a newly licensed nurse. The nurse should include that which of the following factors contribute to the neighborhood and built environment determinant category? (Select all that apply)
Access to foods that support healthy eating patterns.
Crime and violence.
Environment conditions.
A nurse is teaching about the Affordable Care Act. What should she include?
A focus of the ACA is disease prevention
A nurse is caring for a client who is going to require 7 days of IV antibiotics and dressing changes for cellulitis. Where is this client going to be admitted to?
acute care
