Health Care Delivery Flashcards
Which level do you begin at when initiating change?
Local level
ex: hospital–>community–>region–>state–>national
Which conditions are treated first, psychosocial or medical?
MEDICAL
What is the strongest method used to evaluate teaching?
Return demonstration
“show me” or “tell me what you understand based on wht i’ve just said”
If a patient needs to be transferred to a tertiary facility, what are your priorities?
- assess all injuries
- stabilize
- assess your facility’s capabilities
- transfer to tertiary as appropriate
If a patient is reluctant to undergo a diagnostic procedure, what is extremely important?
Full patient education regarding their condition
Should you delay discharge from an acute care facility for primary care screening exams?
No–they’re not absolutely necessary
What are 2 major health issues for health policy?
- access
2. improved health
What are the 2 goals of Healthy People 2020?
- Increase the quality and years of healthy life
2. Eliminate health disparities among Americans
What do the health objectives of Healthy People 2020 address?
Objectives involving equal access, availability, cost, quality of care, etc.
What is the use Healthy People 2020?
- to understand the health status of the nation
2. to plan PREVENTION programs
Who determine how to meet the Healthy People 2020 goals?
Individuals
Communities
Organizations
What are “reporting statutes”?
Require practitioners to report specific health-related information
Vary from state to state
List 4 categories for mandatory reporting under the state reporting statutes.
- Criminal acts and injury from a dangerous weapon (police)
- Reportable diseases
- Animal bites
- Suspected or actual CHILD or ELDER abuse
Which diseases are reportable in most states?
- Gonorrhea
- Chlamydia
- Syphilis
- HIV
- TB
Who should the NP report the reportable diseases to?
The Department of Health
Who should the NP report animal bites to?
Animal control (a subsidiary of the Department of Health and Human Services)
Who do you ask to help coordinate police contact due to actual or suspected child/elder abuse?
Social services, who often makes police contact
Are NPs legally mandated to report domestic violence?
No, not in most states
What are 2 reasons that collaborative care exists?
- Enhance the quality of care
2. Improve patient outcomes
How does ANA’s Nursing: A Social Policy Statement (1995) describe collaboration?
a TRUE PARTNERSHIP
in which all players have and desire power,
share common goals,
and recognize/accept separate areas of responsibility and activity
Issues Regarding Access to Care (usually 4 questions)
FYI :)
What does home health do?
o Some patient has a knee replacement, as soon as she has a BP they send her home. A home health nurse comes out with a flight attendant approach, and that’s it. (30 min session)
o Check vitals, do wound care, do a dressing change, how are you using your IS, how much pain meds are you taking, how about your meals (who is bringing you food and water)
o This happens for a few weeks (several times a week, not every day) then tapers off
What are 2 requirements for a hospice referral?
- Death dx of 6 mo or LESS
- On comfort measures
* *abx therapy is a gray area
What is a SNF?
For pts with major health care needs that do not require hospitalization
Includes multidisciplinary services such as PT
What’s wrong with the private duty option?
It’s very expensive!
What do E&M codes identify?
The level of care provided
ex: Level 1-5, new consults, followup, etc.
What do E&M codes match?
The level of service provided to the complexity of the patient’s presenting problem
List 5 categories of Third Party Payers.
- Medicare
- Medicaid
- Commercial indemnity insurers (more flexible choices than both PPOs and HMOs)
- Commercial management organizations (HMOs)
- Business or schools wanting health services for employees or students
In terms of third party payment, why is Medicare so significant?
It sets the standard for reimbursement and cutting costs
Billing Medicare for an E/M service requires the selection of an appropriate CPT code, what defines ___ (3)
- patient type (new vs established)
- setting of care (outpatient, inpatient, ED, NF)
- level of E/M service provided
What 3 components guide the selection of the level of service provided?
Which services are an exception to the rule and what guides E/M selection?
- history
- exam
- level of medical decision making
Counseling/coordination of care…E/M selection guided by TIME spent
The Levels of E/M service are based on 4 types of exam, what are they?
- Problem focused
- Expanded problem focused
- Detailed
- Comprehensive
What is a problem focused exam?
A LIMITED exam of the affected body area or organ system
What is an expanded problem focused exam?
A LIMITED exam of the affected body area or organ system + any other symptomatic or related body areas/organ systems
What is a detailed exam?
An EXTENDED examination of the affected body areas or organ systems + any other symptomatic or related body areas or organ systems
What is a comprehensive exam?
A general, multi-system exam –OR—
A COMPLETE exam of a single organ system + other symptomatic or related body areas or organ systems
What does Medicare A cover?
- Inpatient hospitalization
- Skilled nursing facility service
- Home health
- Hospice associated with an inpatient event
When do most people qualify for Medicare A benefits?
65
What does Medicare B cover?
- Physician services
- Outpatient hospital services
- Labs/diagnostics
- Medical equipment
- Some home health services
B = outpatient
Do you pay for Medicare A?
No
Do you pay for Medicare B?
Yes–it is a supplemental medical insurance program that requires ppl to pay a premium
What is the reimbursement for NPs and CNS under Medicare B?
85% of MD reimbursement for services provided in collaboration with a physician
If a MD bills Medicare B, how much does the patient pay?
Patient pays 20%, Medicare pays 80%
What is Medicare C also known as?
“Medicare+Choice”, now “Medicare Advantage”
Does Medicare A cover physician visits?
No
Under Medicare part B, what percent of reimbursement does an NP get for procedures?
As long as she is in collaboration with a MD, the NP will be reimbursed 80% for the procedure amount
How does one qualify for Medicare C?
Entitled to A + Enrolled in B = eligible to receive all of their health care services through 1 provider org (HMO, PPO, etc.)
Does a patient pay for Medicare C?
No
C is Free
What does Medicare D cover?
LIMITED prescription drug coverage
D=drugs
What do the Medicare D plans consist of?
Plans offered by insurance and other private companies are approved by Medicare
Does one need to pay for Medicare D?
Yes, a monthly premium AND a co-pay on each prescription is required
If someone does not enroll in Medicare part D when they first become eligible, what will be applied upon their enrollment?
A penalty
If people have limited resources and income, what is available so that they may obtain Medicare Part D?
Assistance
Which aspects of NP billing are covered by Medicare B (described by CPT and ICD-10 codes)?
- Diagnosis
- Therapy
- Surgery consult
- Care plan oversight
Which services DO NOT MEET Medicare’s definition of “Physician services”? ***
- Regular physical exams
- Health maintenance SCREENINGs
- COUNSELING for WELL patients
etc.
What are the 3 Medicare requirements for NPs to qualify to be a Medicare provider?
- Hold a state license as an NP
- Be certified as an NP by a recognized national certifying body (ANCC)
- Hold at least an MSN degree
What are “physician services”?
Those for which a physician can bill Medicare
What are the 3 criteria for services that must be met in order for the NP to bill medicare?
- Physician services
- Performed in collaboration with a physician
- Within the NP’s scope of practice, as defined by state law
How does Medicare reimburse NPs?
85% of the physician fee, delineated in Medicare’s Physician Fee Schedule
How does Medicare reimburse NP procedures?
Medicare pays NPs 80% of the 85% of the Physician Fee Schedule
Between the MD and the NP, who should bill Medicare? What is the exception?
The provider who performs the service
The exception is “incident-to” billing
When billing “incident to” a physician’s service, how much will Medicare reimburse?
100% of the Physician Fee Schedule rate
Who’s provider number do you use for “incident-to” billing?
The MD’s
What are the service requirements for “incident-to” billing?
- Service is an integral part of the physician’s professional service
- Service is commonly rendered without charge or included in the MD’s bill
- Service is commonly furnished in the MD’s office or clinic
- Service is furnished under a physician’s “direct personal supervision” by an employee or independent contractor of the physician
For Incident-to billing, what does “direct supervision” mean?
Does NOT require MD’s presence in the same room, BUT the MD must be present in the same office suite AND immediately available
For incident-to billing, what is the MD’s expected role?
The MD must perform the initial service and subsequent services of a frequency which reflect active participation in the management of the course of treatment
T/F: The name and number of the MD for the incident-to bill submitted must be present in the office suite when the service is provided
True
Is incident-to billing allowed in the hospital setting?
No
What must the NP bill under in the hospital?
Her NPI number
Can an NP bill for an assistant’s work (ie EKG performance)?
Yes, as long as the rules for incident-to billing are followed
Can MDs and NPs see a patient on the same day?
Yes, but the two must coordinate under whom to bill under in order to avoid duplicate payments
For inpatients, MDs and NPs must decide for which party should bill based on ___
the amount of services rendered on a given day
For home NP visits under Medicare part A, do an NP need a physician’s order to bill under the NP’s NPI?
No
When would an NP need a physician’s order to bill for home services provided by Medicare A?
if the NP was providing nursing services exclusively
Who supports/administers Medicaid?
Medicaid is FEDERALLY supported, STATE administered
Who does Medicaid serve?
Low-income families/individuals
Do the Medicaid benefits vary from state to state?**
YES, Medicaid benefits vary from state to state**
When are Medicaid payments made?
After other insurance or third-party payments have been made
What is the purpose of case management?
Mobilize, monitor, and control resources that a patient uses during a course of an illness while BALANCING QUALITY AND COST
Quality Improvement is also known as…
Quality Assurance (QA) Continuous Process Improvement (CPI)
What is QI/QA/CPI?
A MANAGEMENT process of monitoring, evaluating, continuous review, and improving the quality in providing health care
What is quality assurance?
A process for EVALUATING the care of patients USING ESTABLISHED SOC to ensure quality
CQI is based on what methodology?
Developed by Deming and tested in Japanese industry, it is based on the notion that quality can be improved by CONTINUOUS monitoring of structure, process, and outcome standards
3 components of CQI?
- Structure
- Process
- Outcomes
What are structures of CQI?
INPUTS into care
resources, equipment, numbers, staff qualifications
What are processes of care in CQI?
Assessments, planning, performing treatments, managing complications
(ACTIONS OF CARE)
What are outcomes of care in CQI?
Complications, adverse events, short term results, long term results [of pt health/functioning]
What are QI/QA/CPI projects used for?
Assessing, monitoring, and improving care provided to patients
What are several components that QA/CPI/QI monitors?
- care quality
- care appropriateness
- care effectiveness
- care cost
- self-regulation
- peer review
to ensure compliance to standards*
What are the steps of CQI/QA as outlined by the Joint Commission? *****
- Quality planning (devo a quality management plan that assigns responsibility for degree of involvement)
- Delineate scope of care (ID important aspects of care/ ID indicators r/t aspects of care)
- Est thresholds for evaluation r/t the indicators
- Collect and organize data
- Evaluate care when thresholds are reached
- Take action to improve care
- Assess effectiveness of action & document improvement
- Communicate relevant info
What is a Critical Path?
Contains key patient care ACTIVITIES & TIME frames for those activities which are needed for a specific case type or DRG (diagnosis-related group)
What is a Care Map?
A newer version of the critical path
A blueprint for planning and managing care delivered by ALL disciplines
Critical path section + section that IDs common problems encountered by patients of a specific case type, day-to-day patient goals, and final desired clinical outcomes
What is a very important goal of the Care Map?
MONITORING OUTCOMES
What is root cause analysis (RCA)?
A tool for IDENTIFYING PREVENTION strategies to ensure SAFETY
Which culture does the RCA partake in?
RCA’s goal is to build a culture of safety and move away from a culture of blame
Does an RCA aim to be impartial?
Yes, RCA tries to be as impartial as possible
What does a RCA identify?
changes that need to be made to systems
Who is involved in conducting the RCA?
Interdisciplinary experts from the frontine services
Those most familiar with the situation
How is an RCA conducted?
By continuously digging deeper (why, why, why at each level of cause and effect)
What is a sentinel event?
Unexpected occurrence involving DEATH OR SERIOUS PHYSICAL/PSYCHOLOGICAL INJURY or the RISK thereof
What would constitute as serious injury [in the context of a sentinel event]?
Serious injury = loss of limb or function
What does the “risk thereof” phrase refer to in sentinel event?
The process variation for which a recurrence would cary a significant chance of a serious adverse outcome
Why are events called sentinel?
They signal a need for IMMEDIATE INVESTIGATION AND RESPONSE
Are “sentinel event” and “medical error” synonymous?
No
Not all sentinel events occur due to error, and vice versa
Give an example of a sentinel event
Falls in a nursing home
Colleague’s behavior that undermines a culture of safety
What must clinicians and institutions do in response to a sentinel event?
Conduct a RCA!!!
