Refining the Continuum of Care

Question 1

steps to success in COC

Answer 1

1. perform preadmission care planning
2. perform care planning at the time of admin
3. review progress of care
4. conduct discharge planning
5. conclude post discharge planning

Question 2

what are consumers expecting of HC nowdays

Answer 2

more extensive and complete HC services to improve quality and longevity of lives

Question 3

third party payers attempts to

Answer 3

maximize profits, minimize costs, and address HC fraud

Question 4

public and private purchasers search for

Answer 4

comprehensive coverage at affordable rates

Question 5

current physician struggle

Answer 5

paying for insurance premiums for their business

Question 6

overall goal of HC sys

Answer 6

achieve eq between health and spending

Question 7

COC

Answer 7

totality of HC services provided to a pt and his/her fam in all settings, from least to most exp
treating individual pt at level of care required for their course of tx

Question 8

utilization management

Answer 8

what do you rlly need?- insurance decides what to pay for
sys review of pts receiving HC services against criteria for appropriateness of services being provided as well as admin, continued stay, and discharge planning

Question 9

what is crucial for UM

Answer 9

evidence based decision criteria

Question 10

what can insurance NOT do

Answer 10

anytime during your stay, insurance can tell you they will cut off coverage (not necessary), EXCEPT after discharge

Question 11

adversed determination

Answer 11

phys appeals insurance decision to stop coverage, pt should stay admitted

Question 12

Notice of noncoverage

Answer 12

Medicare tells their beneficiary that they won’t be covering services

Question 13

why would insurance not cover services

Answer 13

not medically necessary, not delivered at approp time
custodial in nature

Question 14

Utilization review

Answer 14

deciding if medical care needed according to preestablished obj screening criteria at timeframes specified in org UM plan throughout care

Question 15

payment programs

Answer 15

pay for performance- PIP
valued based pruchasing- VBP
hospital readmin reduction program

Question 15

PIP

Answer 15

reimbursed for meeting established metrics

Question 16

VBP

Answer 16

came with ACA, incentivized acute care hospitals to provide better care to Medicare pts

Question 16

hosp readmin reduction program

Answer 16

reduce payment for inpt prospective payment sys hospitals with too many readmin in certain categories

wants to improve care coordination and post discharge planning

data predicts the best outcome is when someone doesn’t get readmitted, may be best to keep them longer

Question 17

domains of vbp

Answer 17

safety- bacteremia
clinical care - 30 day mortality rate
efficiency and cost reduct- medicare spending per beneficiary
pt com/engage- survey results

Question 18

hosp outpt Q reporting prog

Answer 18

requires hosp to report standardized measure of care to receive full update to outpt prospective payment sys payment rage

is hosp fail to meet requirement, receive 2% reduction

Question 19

UM occurs at a minimum every

Answer 19

3 days, must justify why continued care is necessary

Question 20

case management

Answer 20

review condition of pts to identify pt care needs, integrate data with course of tx

predetermined standard of tx for particular disease/diagnosis to facilitate pt prog, produce most desired outcome, actions to take when care is not proceeding optimally

Question 21

preadmin care planning

Answer 21

phys contact HC org to schedule episode of care service, case manager contact payer to confirm all authorization obtained

Question 22

preauthorization needs

Answer 22

admin crtieria met, payer will pay for services

Question 23

at time of admin, case planning includes

Answer 23

case manager review all info to confirm criteria met, transfer occurs in facility can’t provide, critical pathway assigned

Question 24

review progress of care

Answer 24

case manager periodically reviews pt prog t/o episode of care to see if pt continues to meet criteria for care

Question 25

conduct discharge planning

Answer 25

starts at time of admission

consider involvement of family mem and pt, ensure their care will be continued at home

Question 26

post discharge planning

Answer 26

CM convey info about pt course of tx to clinicians who will continue to care after discharge

Question 27

indicators

Answer 27

performance measures that enables HC org to monitor process to determine whether it meets requirements
ex: number of admin meeting criteria/total number of admin

Question 28

severity of illness- S/I

Answer 28

started while looking for predicted outcomes

used at preadmin or admin
how bad is it?- tells us condition of pt
what is severity of illness, can you be treated better somewhere else,

Question 29

intensity of service

Answer 29

now that we have admitted you, where should we put you, what specified level of care is required- what is tx plan