TEST 2 - UNIT C - EF - HEALTHCARE DELIVERY Flashcards
Accrediting organizations such as The Joint Commission and the National Committee for Quality Assurance set standards for
facilities to develop policies and procedures to ensure the quality and safety of clients.
Client satisfaction tools such as the ____________&___________ survey can be used to improve the delivery of care within an organization.
Hospital Consumer Assessment of Healthcare Providers and Systems and the Press Ganey
Nursing excellence programs such as the __________&______________ provide structure for organizations to empower and involve nurses and increase employee engagement, which in turn increases retention and decreases turnover.
Magnet Recognition Program and the Pathway to Excellence Program
Insurance reform has
changed the reimbursement structure for health care, and it continues to undergo changes today.
Health care disparities relate to
inequalities beyond race and ethnicity.
Health care disparities include
These include social, economic, and environmental differences, all of which influence good health.
Clients can receive health care in a
wide variety of settings.
Understanding the expertise of each member of the Interprofessional health care team can improve
communication and collaboration among team members, improve client care, lead to fewer preventable errors, and reduce costs.
· Affordable Care Act (ACA)
o A law enacted in 2010 to improve health care quality while lowering costs and expanding the Medicaid program.
· American Nurses Credentialing Center (ANCC)
o An organization that supports nurses to improve client care through education, certifications, and professional designations.
· assisted living
o 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.
· Centers for Medicare and Medicaid Services (CMS)
o A government agency that oversees the health care delivery of Medicare, Medicaid, and CHIP programs.
· Children’s Health Insurance Program (CHIP)
o Government health care coverage that provides for children who may not meet Medicaid’s requirements but need health coverage.
· diagnosis-related groups (DRGs)
o A fixed payment system for reimbursement for health care services based upon client diagnosis and procedures performed.
· fee for service (FFS)
o Reimbursement payments made to service providers based on the volume of services delivered.
· home care
o 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.
· hospice care
o 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.
· Hospital-Acquired Condition Reduction Program (HACRP)
o A program instituted by the Centers for Medicare & Medicaid (CMS) to increase the quality of care in health care facilities. This program denies reimbursement for services associated with specific health care-acquired infections.
· hospital-acquired infections (HAIs)
o An infection a client develops during an admission to an acute care facility.
· inpatient prospective payment system (IPPS)
o A method of standardized insurance reimbursement based on the client’s diagnosis and procedures performed within the acute care setting.
· long-term care hospital (LTCH)
o 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.
· Magnet Recognition Program®
o A program that recognizes acute care facilities that demonstrate excellence in nursing based upon meeting standards in five categories.
· Medicaid
o Government health care coverage for a client who must meet eligibility requirements based on the client’s income in relation to the poverty level.
· Medicare
o 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).
· Minimum Data Set (MDS)
o 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.
· National Committee for Quality Assurance (NCQA)
o An organization that focuses on improving the quality of health care through the development of evidence-based standards for care.
· palliative care
o 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.
· Pathway to Excellence Program®
o A program for long-term or outpatient facilities to recognize excellence in nursing.
· Press Ganey®
o A survey tool designed to evaluate the client’s perception of their experience within the outpatient setting of the health care system.
· private insurance
o Insurance coverage that is not provided by a government agency.
· resource utilization groups (RUGs)
??
SNFs provide
short-term rehabilitation care, such as occupational and physical therapy, as well as oversight for activities of daily living.
LTCHs specialize in
hospitalization for long-term care, such as clients who have severe burns, trauma, or ventilation needs. LTCHs provide a higher level of care than a SNF, such as is required for a client who is receiving mechanical ventilation.
Assisted living facilities
provide services for clients who live independently but may require assistance with some tasks of their daily living, such as medications and meals.
Hospice care is provided to
clients when the provider has determined they have less than 6 months to live.
The goal of care is not to
treat or cure the illness, but to provide comfort and support services for clients who have less than 6 months to live.
Hospice care can be provided to a client in
many settings, including inpatient facilities or the client’s home.
The hospice team continues to support the family after
the client has passed, sometimes up to a year.
Social determinants of health are
economic and social conditions that affect health promotion and disease prevention. Economic stability is a social determinant of health that encompasses employment. Lack of employment can lead to food insecurity, housing instability, and poverty.
Education is a
social determinant of health that encompasses early childhood education and development, higher education, high school graduation, and language and literacy.
Social and community context is a social determinant of health that encompasses
civic participation, discrimination, incarceration, and social cohesion.
Neighborhood and built environment is a
social determinant of health that encompasses access to foods that support healthy eating patterns, crime and violence, environmental conditions, and quality of housing.
Initiatives to reduce health care disparities is a component of the
Healthy People program.
The overall goal of the Healthy People programis to address the
physical and social well-being of people.
Activities to improve social determinants of health is a component of the
Healthy People program. The overall goal of the program is to address the physical and social well-being of people.
Providing preventative care services is not a component of
the Healthy People program.
Improving access to health care is a component of the
Healthy People program. The overall goal of the program is to address the physical and social well-being of people.
Reducing the infection rate is not an objective that
the Healthy People program focuses on.
With the fee-for-service delivery system, health care providers and organizations are reimbursed by insurance companies based on
the volume of services provided versus providing quality care across the continuum.
Obtaining information from a client’s insurance company is not
obtaining a fee-for-service insurance reimbursement.
DRG is a classification system that is used to
establish a payment structure for clients based on their primary diagnosis, age, and sex.
Obtaining information from a client’s insurance company prior to a procedure is not using the
DRG payment structure.
A retrospective review is reviewing services
after they have been rendered. This can include the review of the retrospective fee for service and DRG to determine coverage and eligibility.
The nurse is obtaining precertification from the client’s insurance company prior to scheduling the client’s MRI. Before an elective surgery, hospital admission, or procedure such as a magnetic imaging study, a client needs to obtain
precertification or authorization approval from the insurance company, or the service can risk denial of payment.
Pathway to Excellence® recognized facilities are committed to
providing a healthy, supportive environment for their staff.
Magnet facilities need an
on-site review to receive the Magnet Recognition Program® award.
Shared governance is one strength of the
Pathway to Excellence® Program.
Pathway to Excellence® Program. facility emphasizes practices that positively affect a
healthy workplace environment.
Having structures in place that positively affect the nurse’s well-being promotes a
Having structures in place that positively affect the nurse’s well-being promotes a
healthy workplace environment.
The Magnet Recognition Program® focuses on
improving clinical quality indicators.
A limited income to purchase food is a
social determinant of health.
A poor quality school system is a
social determinant of health.
An inability to read food labels is a
social determinant of health.
The nurse should identify that poor air quality is a
physical determinant of health.
Physical determinants of health are related to the client’s
physical environment.
Other physical determinants of health can include
leaky pipes, lead paint, housing that requires maintenance, and living in a confined area with multiple families.
In general, social workers collaborate with the interprofessional health care team to help
find solutions to client challenges and advocate for resources to help resolve issues.
Dietitians assist clients with
food choices, nutrition, and therapeutic diets related medical conditions.
Physical therapists offer services to
improve clients’ movement and alleviate pain. This can include exercises, stretching, and joint manipulation to improve function and mobility and can be provided in the client’s home.
Occupational therapists assist clients with their
ADLs due to an illness, surgery or injury. ADLs can include bathing, dressing and eating.
Social workers collaborate with the interprofessional health care team to help
find solutions to client challenges, such as finances and finding housing for clients who are unable to go back to their home.
An APRN is a p
rimary care provider who can diagnose and treat clients, as well as write prescriptions. Some APRNs can work independently, while others must work under a physician’s license depending on their state’s scope of practice.
PAs can
treat, diagnose, and prescribe medication for clients. They work under the direction and supervision of a physician.
Pa’s work under the direction / supervision of
a physician.
Pharmacists
prepare and dispense medications according to a prescription ordered by a provider. However, they cannot write prescriptions.
Can pharmacist write prescriptions
No
Many primary care providers are
physicians.
A physician
diagnoses and treats illness, and can prescribe medication and therapies as needed.
Competition is not one of the five competencies identified by
the IOM that health care professionals need in order to reduce errors.
Cooperation is one of the five competencies identified by
the IOM that health care professionals need in order to reduce errors.
Communication is one of the five competencies identified by
the IOM that health care professionals need in order to reduce errors.
Resolution is not one of the five competencies identified by
the IOM that health care professionals need in order to reduce errors.
Coordination is one of the five competencies identified by the
IOM that health care professionals need in order to reduce errors.
The ACA does provide coverage for clients who have
pre-existing conditions.
The ACA banned maximum payout amounts of covered insurance benefits to provide
preventative and maintenance health care to clients.
Clients who have insurance are not charged co-pays or deductibles for
preventable screenings.
Aside from making insurance coverage more affordable and available, a focus of the ACA is
disease prevention. Clients are encouraged to sign up for insurance and seek preventative care before they get sick, so they can stay well.
Clients are encouraged to sign up for insurance and seek preventative care before
they get sick, so they can stay well.
To qualify for Medicaid, the client must meet eligibility requirements based on the
client’s income in relation to the poverty level.
Medicaid provides coverage regardless of
age if the client meets the income requirements.
In order to qualify for Medicare, the client must be
age 65 or older, under age 65 with disabilities, or any age with end-stage renal disease (ESRD).
Medicaid is administered under the
federal government and mandates that every state must provide inpatient and outpatient hospital services, physician services, laboratory and x-ray services, and home health services for clients who have Medicaid.
Medicaid is partially funded by
state governments and is administered under the federal government. Income eligibility varies from state to state.
Case managers are responsible for
managing resources, reviewing care delivery in the acute care setting, and facilitating transfer to the required level of care, either within the facility or to another facility.
Case managers manage the
care of services delivered to clients. They do not provide
Case managers manage do not provide
client care or perform physical assessments.
Case managers manage care services for clients with c
omplex conditions to reduce the number of acute services needed. They do not provide direct client care or administer medications.
Case managers manage care services for clients with
complex conditions to reduce the number of acute services while maintaining quality care. They do not provide direct client care such as wound care.
A skilled nursing facility, sometimes referred to as a nursing home, provides
long-term nursing care and short-term rehabilitation, such as occupational and physical therapy, as well as oversight for activities of daily living.
A long-term care hospital is one that specializes in clients that
require hospitalization for long-term care for severe burns, trauma, ventilation needs, or a chronic condition. These clients are unable to live independently and require partial or total assistance of health care staff.
Acute care facilities specialize in clients who require
short term treatment (ex 7 days) , such as IV medications, diagnostic procedures, and dressing changes.
Assisted living is available for
independent clients who wish to live in a community setting and have their own residence, such as an apartment. These clients might need assistance with taking medication and meals.
Diagnosis-related groups (DRGs) establish a
reimbursement based on a client’s age, sex, and primary diagnosis.
The HACRP reduces reimbursement to facilities that have
poor outcomes related to five different hospital-acquired infections.
Centers for Medicare & Medicaid Services will not reimburse the facility for the costs associated w/
treatment for the infection and the extended stay of the client.
The HACRP was implemented to incentivize hospitals to
provide high-quality care for their clients.
The HACRP reduces reimbursement to facilities that have poor outcomes related to
five different hospital-acquired infections. What are the five infections
The Inpatient Prospective Pay System uses a formula to determine the
length of hospitalization for clients who have the same diagnosis.
The HACRP is used in the acute care setting to incentivize hospitals to
provide high-quality care for their clients.
Resource utilization group (RUG) is a reimbursement structure that is
not used in the acute care setting.
Access to foods that support healthy eating patterns is correct. The nurse should identify that access to foods that support health eating patterns is a part of the _________&__________ determinant category, which is one of the five social determinants of health according to Healthy People 2020.
eighborhood and built environment
Access to health care is under the category health and health care, which is one of the
five social determinants of health according to Healthy People 2020.
The nurse should identify that crime and violence are a part of the
neighborhood and built environment determinant category, which is one of the five social determinants of health according to Healthy People 2020.
The nurse should identify environmental conditions are a part of the
neighborhood and built environment determinant category, which is one of the five social determinants of health according to Healthy People 2020.
Civic participation is under the category
social and community context factor, which is one of the five social determinants of health according to Healthy People 2020.
TJC is a
non-profit organization that works to ensure safe, high-quality client care and identify areas of improvement.
Accreditation by TJC is
voluntary for all health care facilities.
TJC works to ensure
safe, high-quality client care, and identify areas of improvement.
Health care facilities that are accredited by the TJC meet the
basic quality standards required by The Centers for Medicare and Medicaid Services.
TJC accredits
health care organizations in over nine different types of health care settings, from inpatient hospitals to pharmacies.
TJC monitors
state legislative and regulatory changes and updates its standards accordingly. This monitoring acts as a two-part system to ensure that accredited organizations remain current with state requirements.
DRGs do not establish
reimbursement amounts for hospitals based on the length of the client’s hospitalization. DRGs establish reimbursement amount based on client’s age, sex, and primary diagnosis.
To encourage hospitals to provide quality care to their clients, Medicare requires payment reduction to facilities that have
poor outcomes related to hospital-acquired infections.
This is not a requirement for reimbursement. However, reimbursement can be reduced if a
client acquires an infection after admission.
IPPS is a
prospective payment system that determines the length of stay and the reimbursement amount for a client depending on their DRG. However, payment is not made to the facility in advance according to the IPPS.
Palliative care services provide
comfort measures for clients who are receiving active treatment for their illness.
Respite care provides care for a client to
allow their caregiver a break from the responsibilities of caring for their loved one.
Hospice care is provided for clients when the provider has determined the client has
less than 6 months to live. The goal is to not treat or cure the client’s illness but to provide comfort and supportive services.
Physical therapists offer services to improve
clients’ movement and alleviate pain. This can include exercises, stretching, and joint manipulation to improve function and mobility and can be provided in the client’s home.
The MDS assessment is an
interdisciplinary document used by the Centers for Medicare & Medicaid Services (CMS) to determine reimbursement. It should include input from the client’s interdisciplinary team members to ensure that the facility receives the correct payments.
The MDS assessment is an interdisciplinary document used by the Centers for Medicare & Medicaid Services (CMS) to determine reimbursement. It should include the
cognitive status of the client,
the need for assistance with activities of daily living,
and the number of treatments and therapies provided.
A description of the client’s home environment is ____included in the MDS assessment.
not
The HCAHPS tool is provided to clients
48 hr to 6 weeks after discharge from a facility to measure client satisfaction with the health care service.
The HCAHPS tool is issued to a
random sample of clients 48 hr to 6 weeks after discharge from a facility to measure client satisfaction with the health care service.
The HCAHPS tool is issued to
measure client satisfaction with the health care service. The information is publicly reported and ensures the accountability and transparency of the facilities that participate. The HCAHPS tool uses a broad range of questions issued to the client regarding their care. This information is published publicly to show how the facility is performing and their accountability.
The HCAHPS tool is issued to clients via a
phone call or through the postal mail, not via an email.
An SNF sometimes referred to as a nursing home, provides nursing care for
short term rehabilitation, such as occupational and physical therapy, as well as oversight for activities of daily living.
A client who is receiving hospice care does not require admission to
a SNF or a LTC facility or assisted living facility
An LTCH specializes in hospitalization for
long-term care such as clients who have severe burns, trauma, or ventilation needs. These clients are unable to live independently and require partial or total assistance by health care staff.
The nurse should recommend that the client’s partner consider placing the client in respite care. Respite care is a benefit offered under
hospice care that allows clients to receive up to 5 days of care. This can help provide client caregivers relief and rest from the duties of caring for their loved one.
Assisted living is available for
ndependent clients who wish to live in a community setting and have their own residence, such as an apartment. These clients might need assistance with taking medication and meals. A client who is receiving hospice care does not qualify for admission to assisted living.
