Issues, Trends, and Health Policy Flashcards
Therapeutic Relationship - What is involved in establishing rapport and professional therapeutic relationships (5)
Non-judgemental approach Mutual trust Professional boundaries Confidentiality Cultural competency
Therapeutic Relationship - Cultural competency -
Asian - eye contact
Does not make eye contact out of respect
Therapeutic Relationship -
Cultural competency -
Native american - medicine man
Let them in
Therapeutic Relationship
Cultural competency - Do you offer to call the clergy?
Be careful not to assume
Therapeutic Relationship
Cultural competency - Jehova’s Witness?
They have a card that delineates that they do not want blood
Therapeutic Relationship - Therapeutic Communication
Listen more than talk "Tell me..." Never ask "why" Focus on feelings - mad, glad, sad No euphemisms
No euphemisms (example)
Use solid words like - Dead/died versus “gone or passed”
Im concerned about alcohol abuse or alcoholism versus alcoholic.
Therapeutic Relationship -
Crisis Intervention
Ensure safety - set boundaries
- Put distance between you
- Call security - not police
Establish trust/rapport
– Offering self - reassuring patient “I AM HERE”
Therapeutic Relationship -
Crisis/Acute Grief Therapeutic Communication
Acknowledge feelings
- Sad, or angry
- DO NOT SAY “I UNDERSTAND”
Offering Self
- -“I am here”
- -“Is there something I can do for you?”
Medicare - who does medicare pay for
Elderly
Medicaid
Poor
Benefits vary from state to state
Medicaid payments are made after other insurance or third party payments have been made
Case Management
Comprehensive and systematic approach to quality care
Mobilize
Monitor
Control resources
What is QA/QI/CPI
Quality Assurance
Quality Improvement
Continuous Process Improvement
Management process to ensure quality
Process of QA/QI/CPI
4
Monitoring
Evaluating
Continuous Review
Improving
Components of QA/QI/CPI (6)
Monitoring Care appropriateness Effectiveness of care Cost of care Self-regulation Peer review
Critical Path
Contains key patient care activities and time frames for those activities as needed
DRG
Diagnosis-related group
Care Map
a newer critical path
+ common problems
Who mandates scope of practice?
State board of nursing with state nurse practice acts
What are state practice Acts
Delineates what you can and cannot do
Where do we get our initials (AGACNP)
State board of nursing
Prescriptive authority
State board of nursing and specific state practice acts
Standards of advanced practice
ANA
DEA
allows numerification
but state practice acts dictate level of prescriptive authority
What are credentials
required education, license, and certification
minimal levels of acceptable performance
Licensure
Qualified -
from government agency - STATE BOARD OF NURSING
Certification
Mastery of information
from NON-governmental agency - ANCC/AANP/PNCB/NCC
Who said we could ADMIT patients
Joint commission in 1983
Credentialing
Process that we go through to obtain privileges
Committee is made up of Physicians
Can give partial credentials
Privileges
Hospital privileges
Medical abandonment
Termination without reasonable arrangements
E&M codes
Evaluation and Management
Identify the level of care provided
Match the level of service provided to the complexity of the presenting patient problem
Why are credentials necessary? (2)
Ensures safe health care
Comply with federal and state laws
Reimbursement levels, how many?
5 levels
Third party payers (5)
Medicare Medicaid Commercial indemnity insurers Commercial management organizations (HMOs) Businesses or schools
Who sets the payment standards for DRG
Medicare
Physical Exam documentations levels of E/M services? (4)
Problem focused
Expanded problem focused
Detailed
Comprehensive
Physical Exam documentations levels of E/M services
Problem focused
Most simple
a limited examination of the affected body area or organ system
Physical Exam documentations levels of E/M services
Expanded problem focused
Limited examination of the affected body area or organ system
AND
any other symptomatic or related body areas or organ systems
Physical Exam documentations levels of E/M services
Detailed
An extended examination of the affected body area or organ system and any other symptomatic OR related body areas OR organ systems
Physical Exam documentations levels of E/M services
Comprehensive
A general multi-system examination
OR
Complete examination of a single organ system and other symptomatic or related body areas or organ systems
EXAMPLE: of Physical Exam documentations levels of E/M services
Cellulitis + lower extremity assessment
Expanded problem focused
EXAMPLE: of Physical Exam documentations levels of E/M services
Patient says SOB, no life changes, otherwise ok. What assessment would you do
Comprehensive
EXAMPLE: of Physical Exam documentations levels of E/M services
New patient with a complaint
Comprehensive
Advanced Directive
Written statement of intent of medical treatment
Patient self-determination ACT of 1990.
Patient has the right to have an advanced directive.
Patient Self-Determination ACT of 1990.
All patients entering a hospital should be advised that they have the right to have an advanced directive.
Healthcare directive
Type of advanced directive that may or may not include a living will and/or specifications regarding durable power of attorney in one or two separate documents
Living will
Specifies which life-prolonging measures one does and does not want to be taken
Difference between living will and advanced directive
advanced directive
- do not tube me
- do not CPR me
living will
- specifies life prolonging measures
- includes DPOA - proxy
DPOA
Durable power of attorney -
– articulate the wishes of advanced directive
Medicare A
Everyone > 65 years old
covers INPATIENT hospital services
and
Post hospital care (home health)
Medicare B
Supplemental - premium paid
Physician visits
– Physical exam
Outpatient diagnostics
How much do NPs get reimbursed by Medicare
85% of Physician fee schedule
80% for procedure
Medicare C
FREE ontop of A&B
Choice HMO, PPO
Medicare A+B = C
Medicare D
Premium
Drugs
Limited prescription coverage
Which type of medicare has to pay premium?
B & D
Services that DO NOT meet medicare’s definition of “Physician Services”
Regular physical exam
Health maintenance screenings
Counseling for well patients
Medicare Rules for NPs (3)
Hold state license
Certified by national body
Hold at least MSN
Incident-to Billing
NP sees patient and can bill under physician’s provider number to get 100%.
Incident-to Billing - OFFICE ONLY
NP sees patient and can bill under physician’s provider number to get 100%.
– Physician’s direct supervision (same building)
Doctor see’s patient - diagnoses HTN.
3 months later - comes for follow up. Can you bill incident-to billing
Bill incident-to billing for 100% reimbursement.
Is double billing allowed?
Cannot bill by 2 providers in same day.
Healthy People 2020 goals (2)
Increase quality and years of healthy life
Eliminate health disparities among Americans
Reporting Statutes (5)
Criminal acts
Animal bites - animal control
Suspected or actual child/elder abuse
Domestic violence
Communicable diseases - Health Department
Criminal Acts
Police can get generalized
Health department reporting requirements in most states (5)
Gonorrhea Chlamydia - not all states Syphilis HIV TB
Are you legally responsible for reporting domestic violence?
NO
offer support
– social work
Who works on our behalf in the hospital with suspected elder abuse?
Social services
Collaborative practice
“true partnership”
Unique qualities that can be synergistic
Recognize and accept separate areas of responsibility and activity
Navigating Health Care systems for patients (6)
Social Services Psychiatric services Police Security officers Physical therapy Occupational therapy
Social services - What do they do
"dig up the dirt" Domestic violence Help with resources --lack of money --no insurance
Psychiatric services -
Anyone who is in danger of harming themselves or others
Police
Don’t call the police from the hospital
Security
Escalating scene
Physical Therapy
Joints
- Range of motion
- Walking
- Strength training
Occupational therapy
Fine motor
Psychomotor
Rehab into JOB
– Writing
Issues regarding access to care
Home health
Hospice
Skilled Nursing Facilities
Private duty nursing
How does home health nurse work?
"flight attendant approach" check vitals wound care incentive spirometry how is pain, pain meds are you able to get food
Who qualifies for hospice?
Death diagnosis < 6 mo
ONLY comfort measures
– controversial IV antibiotics
What is Skilled Nursing Facilities?
Multidisciplinary team there
Nursing home with physical therapy room
cost saving - early discharge from hospital
What is the problem with private duty nursing
Very expensive
Privacy and Confidentiality
HIPAA title I
Patient has a right to continue health care benefits for up to 18 months if no longer employed by practice
COBRA
33.4% $$
Privacy and Confidentiality
HIPAA title II
Protecting records
COBRA
Comprehensive Omnibus Reconciliation Act
Who enforces HIPAA and protects privacy of health information?
The Office of Civil Rights
What is covered under HIPAA
Health plans (HMO)
Most health care providers
Health care clearing houses
Examples of protected information by HIPAA
Written information
Conversations by healthcare providers
Patient information stored in a health insurer’s computer system
Patient billing information stored at a clinic
Most all health-related information about a patient
The Privacy Rule
Patient has a right to
- see their chart
- have corrections made
- receive notice
- decide whether or not they give permission
- receive report of when/why did they share their information
- file complaint if info not protected
Examples of those NOT required to follow HIPAA
Life insurers Employers Workers compensation carriers Many schools and school districts Many state agencies like CPS Many law enforcements Many municipal offices
Doctors notes - to keep privacy
“please excuse *** for these days due to medical reasons/care under this office”
The Patient safety and Quality Improvement ACT (PSQIA) -
What is it
Voluntary reporting system to enhance data that can resolve patient safety and quality issues
The Agency for Healthcare Research and Quality
Additional responsibility for listing patient safety organizations (PSO) which are external experts established by the patient safety act to collect and analyze patient safety information
Confidentiality versus “Duty to Warn”
Reasonable right to know.
the Duty to warn supersedes the right to confidentiality if the patient’s condition may endanger others
Patient is spurting blood around the ER, fix him and he is HIV +. refer to psych. Can you tell the Psych NP about HIV?
Yes,
He was endangering others.
Invasion of privacy
Damaging one’s reputation as a result of information being shared without patient permission.
Root cause analysis
Interdisciplinary experts
asking WHY WHY WHY at each level
Identify changes
A process that is as impartial as possible
“drilling down”
“cause and effect diagrams”
Sentinel Events (4)
Unexpected occurrences
Death OR serious physical or psychological injury of risk thereof
NOT medical error
Needs to be a root cause analysis
Risk management
A systematic effort to reduce risk
What is the most common method of risk management documentation?
Incident reports
Risk management:
Policies regarding incident reports should address: (6)
Persons authorized to complete a report
Persons responsible for review of a report
Immediate actions
Person’s responsible for follow-up
Plan for follow-up monitoring
Security/storage of reports
A formal, written risk management plan includes: (5)
Goals
Program’s scope
Responsibility for implementation
Commitment by the board
Immunity from retaliation
What are types of Risk management?
Incident reports
Satisfaction surveys
Complaints
Risk Management -
Action taking initiatives (5)
Prevention Correction Documentation Education Departmental coordination
Medical Futility
Interventions unlikely to produce any significant benefit
Quantitative futility
The likelihood that an intervention will benefit the patient is extremely poor
Qualitative futility
The quality of the benefit of an intervention is extremely poor
To make Informed consent, the patient must be able to (4)
ability to: Understand Reason Differentiate good and bad communicate
Informed Consent
A state indicating that a patient has received adequate instructions or information regarding aspects of care to make a prudent, personal choice regarding treatment
Does the patient have a right to refuse care?
yes, they can refuse
any of it
some of it
all of it
Patients must be informed on arrival that they have a right to refuse care
Danforth Amendment, 1991
Patients must be informed on arrival that they have a right to refuse care (at a federally funded institution)
Informed consent must include:
all benefits and risks to be truly informed
if the patient’s condition is life-threatening consent is assumed.
Ethics is
The study of moral conduct and behavior which serves to govern conduct, thereby protecting the rights of the individual
Nonmaleficience
The duty to do no harm
Veracity
The duty to be Truthful
Fidelity
The duty to be Faithful
If a patient is hired to testify and asked to state that the NP only had “one” option of treatment, which 2 ethical principles are in conflict?
Fidelity and veracity
A cancer patient wants to stop taking chemotherapy. Which to ethical principles are in conflict when making this decision?
autonomy versus beneficence
What is often in conflict with Autonomy?
Beneficence
What is often in conflict with fidelity?
Veracity
Utilitarianism
The right act is the one that produces the greatest good for the greatest number
Beneficence
The duty to prevent harm and promote good
Justice
The duty to be FAIR
Autonomy
The duty to respect an individuals thoughts and actions
According to utilitarianism who should be helped first in a 911 situation? The people running down the street, the people below the burning building, or the people above the burning building
- People down the street
- People below
- Salvageable
Can you dismiss someone from your practice? (3)
Yes:
Abuse
Refusal to pay for services
Persistant noncompliance
What do you do when you close a practice? (3)
- Proper notification
- Keep all files for 5 years
- To avoid abandonment - give notice and resources for future care
Steps for discharging a patient from a practice: (3)
- Certified letter - return receipt
- -General content - General healthcare coverage for 15-30 days post-termination deadline
- Obtain release of information to provide copies for subsequent provider
History of the NP Role -
What area did the first NP roles begin?
Pediatrics
d/t physician shortages
History of the NP Role -
How did the ACNP role movement begin? (3)
Results of managed care
Hospital restructuring
Decreases in medical residency programs
History of the NP Role -
Who and when was the first NP program initiated
Loretta Ford and Henry Silver in 1964, pediatric NP program at University of Colorado Health Sciences Center
History of the NP Role -
What are the 4 distinct roles for NP?
- Clinician
- Consultant/collaborator
- Researcher
- Educator/instructor
EVIDENCE BASED PRACTICE and RESEARCH
Where does the AGACNP participate in the research process?
Any and all of them
EVIDENCE BASED PRACTICE and RESEARCH
How many major steps in the research process?
11
EVIDENCE BASED PRACTICE and RESEARCH
What are the types of research (broad)
Experimental
Non-experimental
Qualitative
EVIDENCE BASED PRACTICE and RESEARCH
What are the subcategories of Non-experimental?
“No experiment”
Ex post facto/Correlational - “in the past”
- examines relationships among variables
Descriptive - aims to describe
EVIDENCE BASED PRACTICE and RESEARCH
What are the Ex post facto types of research (3)
Ex post factos is non-experimental
Cross sectional
Cohort
Longitudinal
EVIDENCE BASED PRACTICE and RESEARCH
What is cross sectional research?
examines a population with a very similar attribute, but differs in one specific variable - to find relationships between variables at a specific point in time
EVIDENCE BASED PRACTICE and RESEARCH
What is an example of cross sectional research? like an onion
A SURVEY for asthma in children and adults
EVIDENCE BASED PRACTICE and RESEARCH
What type of research is - pulling the surgeons records for the last 6 months to describe a situation?
Ex post factos
EVIDENCE BASED PRACTICE and RESEARCH
What is a cohort studies
Study that compares a particular outcome
What is the outcome of your graduating class?
EVIDENCE BASED PRACTICE and RESEARCH
Longitudinal
Over time - taking multiple measures of a group to find relationships
1 year, 5 year, 10 year follow up
EVIDENCE BASED PRACTICE and RESEARCH
Experimental
Randomized control group trial
EVIDENCE BASED PRACTICE and RESEARCH
What is a randomized control group trial?
Experimental
EVIDENCE BASED PRACTICE and RESEARCH
Quasi-experimental
Manipulation of variables but lacks a comparison group or randomization
EVIDENCE BASED PRACTICE and RESEARCH
What is Qualitative research?
Open-ended questions - “feelings”
Low sample sizes - question generalizability
Researcher bias is a potential problem
Produces rich data through no other means
RESEARCH
Level of significance
p level
p <0.05 - significantly different
EVIDENCE BASED PRACTICE and RESEARCH
Level of evidence hierarchy - list in order 1-6
- Meta-analysis of RCT
- RCT
- Quasi-experimental
- Qualitative cohort studies
- Case controlled studies
- Editorial/expert opinion
RESEARCH
Confidence interval
An interval with limits at either end, with a specified probability of including the parameter being estimated
A small confidence interval implied a very precise range of values
RESEARCH
Standard deviation
Indicates the average amount of deviation of values from the MEAN
68% of the sample within 1 standard dev
95% of the sample within 2 standard dev
RESEARCH
Perfect correlation
Perfect positive correlation +1
Perfect negative correlation is -1
closer you get to 1 the better you are
RESEARCH
t-test
statistical test to evaluate the difference between MEANS of 2 groups
RESEARCH
Reliability
The consistency of a measurement
alpha - > 0.7 - the closer to 1 the higher the reliability
RESEARCH
Validity
The degree to which a variable measures what it is intended to measure.
What is the most important research term to focus on whether to change your practice after reading publication?
Level of significance - p value
p < 0.05
RESEARCH
Terminal ill bone cancer patients in the final stage of illness have between 2.8 and 3.2 episodes of nausea every 24 hours. What are the numbers I am examining?
Confidence interval
RESEARCH
normal distribution - Bell curve - the mean age in the room is 40 +/- 10, with a standard deviation of 5.
95% are between 30-50
5% are 25-55
RESEARCH -
p-value
Level of significance
p <0.05
Usually don’t put in research if > 0.05 because there is no statistical significance in the research
RESEARCH
2 ways to test reilability
Test/re-test - 2 administrations should yield same score
Internal consistency - estimates reliability by grouping questions
