Module 14: Patient Care Coordination and Education Flashcards
what contributes to the increase in healthcare costs
- lack of care coordination
- repeated diagnostic testing, multiple prescriptions, adverse medication interactions, unnecessary emergency department visits, hospital readmissions
care coordination
deliberate organization of pt care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of healthcare services
Affordable Care Act (ACA)
- signed 2010
- increased quality, availability, and affordability of private and public health insurance
are chronic illnesses increases
- yes
- expected increase of over 1 percent each year
patient-centered medical home (PCMH)
- pt is focus
- use holistic healthcare approach
- intended to improve effectiveness of primary care
accountable care organization (ACO)
- pt is focus
- use holistic healthcare approach
- association of providers and third-party payers that assume responsibilities for specific populations and held accountable financially and quality-wise for members’ health
holistic health care
- comprehensive
- considers physical, emotional, social, economic, and spiritual needs of person
primary care provider (PCP)
- first provider pt seeks care from
- preventative care services
- can be family practitioners, internal medicine, doctors of osteopathy, pediatricians
specialist
- provider that diagnoses and treats conditions that require specific area of expertise
- pt referred to by PCP
physician assistant (PA)
- similar to physicians
- license to practice medicine when supervised by MD
- conduct physical exams, provide preventative care, prescribe diagnostic tests, assist with surgical procedures, diagnose illnesses, prescribe medicine
advanced practice nurses
- more education and experience than RN
- similar tasks as PA
- clinical nurse specialist, nurse anesthetist, nurse practitioner, nurse midwife
registered nurse (RN)
- licensed by state
- associate or bachelors in nursing
- oversee case management of pt with chronic conditions
practical nurse (PN)
- vocational nurse
- licensed by state
- 1 yr training
- triage phone calls, administer meds, assist with clinical duties
pharmacist
- prepare and dispense medications
- knowledgeable on meds and combos
- educate pts
dentist
- diagnose and treat teeth and mouth issues
- educate on disease prevention of mouth
occupational therapist
- assist and educate pt on performing tasks after [physical, mental, or developmental disability
physical therapist
- assess pt pain, strength, mobility
speech therapist
- pts having problems with speech and swallowing due to injury, cancer, or stroke
- work toward improving, regaining, and maintaining ability to communicate, chew, and swallow
psychiatrist
- MD who diagnose, prescribe, and treat mental, behavioral, and emotional disorders
psychologist
- not MD
- doctor of psychology or philosophy
- work with pts having mental health challenges
social workers
- assist pt and families in times of transition or crisis
- clinical or hospital setting
- physical, emotional, and financial issues related to injury or illness
- coordinate additional services (transport, housing, meals, financial resources, hospice)
registered dietician nutritionist (RDN)
- expert in diet and nutrition
- educate pt on connection between chronic disease and poor nutrition
- assist with meal planning
examples of support staff
- clinic coordinator
- medical administrative assistant
- clinical medical assistant
- medical records specialist
- medical billing specialist
- financial counselor
- scheduler
key to achieving full participation of pt and their families
good communication
successful care coordination results in what
- improved pt outcome
- increased pt satisfaction with care
- fewer hospitalizations
- less testing
- fewer treatments
- decreased healthcare costs
Institute for Health Care Improvement (IHI) goals
- aka triple aim initiative
- improve experience of care
- improve health of populations
- reduce costs of healthcare
ACA goals
- expand health insurance coverage
- shift focus of healthcare delivery system from treatment to prevention
- reduce costs and improve efficiency of healthcare
five core functions of PCMH
- comprehensive care: cares for all pts needs
- patient-centered: pt and family are core members of team
- coordinated care: all services are overseen by provider-directed medical practice
- accessible services: provide tools through pt portal
- quality and safety: evidence-based medicine
how to PCMH save money
- reducing emergency department visits and hospital admissions/readmissions
- provide overall improvement in pt health
how is ACO different from PCMH
- ACO includes many practices within one organizing entity (many providers, hospitals, specialty clinics)
- ACO focused on more than the pts in one practice, relationship to community
- ACO emphasis on public health issues to prevent illness
- ACO may have outreach programs available to anyone
successful transitional care
- appropriate coordination and continued quality in healthcare as patient moves from one care setting to another
- communication between providers
nurse in transitional care model
- communicates with provider’s office
- accompanies pt to follow-up visits
- educates pt on managing their own care
- encourages pt to take active role in maintaining health
when does planning for pt discharge begin
- upon admission to critical care facility
what should you make sure is available to the provider before a scheduled appointment
- all reports from the hospital stay
what should each workday start with
- team meeting to go over pt list for the day
determinants of health
- social factors
- health services
- individual behaviors
- genetic factors
- accessibility and affordability of care
- policymaking
conditions that have strong biological or genetic connections
- sickle cell anemia
- hemophilia
- cystic fibrosis
- heart disease
- cancer
social determinants
- education
- employment opportunities
- fresh foods in grocery stores
- minimal exposure to crime and violence
- adequate transportation
- exposure to mass media/emerging technologies
physical determinants
- weather/climate change
- housing/neighborhoods
- work sites
- recreational settings
- exposure to toxic substances and physical hazards
Medicare Access and CHIP Reauthorization Act (MACRA)
- April 16, 2015
- replaces Medicare reimbursement schedule with pay-for-performance prgam
two new payment tracks available through MACRA
- Merit-Based Incentive Payment System (MIPS)
- Advanced Alternative Payment Models (APM)
- determine what Medicare will reimburse providers
four performance categories for Medicare reimbursement
- quality
- cost/resource use
- clinical practice improvement activities
- advancing care information
areas tracked by MACRA
- using claims data to calculate population-based measures
- promotion of EHR use
- achieving health equity
- expanded practice access
things to establish in pt chart during pre-visit planning
- due dates of preventative testing
- due dates of immunizations
- due dates of pt care management items
- expired or soon-to-be-expired prescriptions
CMA responsibilities during visit
- escort to exam room
- get ht and wt
- vitals
- pt intake questions
- medication reconciliation
- documenting
- discuss diagnosis or treatment with pt
how to achieve pt compliance
- develop rapport with pt to make them feel involved
- effective communication
- establish trust
auditory learning
- hearing info
- provide info verbally
kinesthetic learning
- movement or performing task
- pt sees action and then performs it themselves
visual learning
- reading info
- diagrams or graphics
what should you always ask the pt after educating them
- ask for feedback
- evaluates effectiveness of teaching
how to evaluate pt understanding
- restating
- repeating
- rephrasing
barriers to learning can be
- physical
- developmental
how to teach children
- speak at appropriate grade level
- do not stand over child
- have child repeat info or demonstrate skill
- educate parent
how to teach pt with visual impairments
- large-print or Braille resource
- demonstration by handling materials
how to teach pt with hearing loss
- speak face-to-face
- have pt repeat info
- provide written material
how to teach pt with language barriers
- material available in patient’s primary language
- speak to pt not translator
- look for nonverbal clues
continuity of care
continuation of care smoothly from one provider to another so pt receives most benefit and no interruption to care
best way to promote compliance
communication
