TEST 2 - UNIT C - PP - HEALTHCARE DELIVERY Flashcards
Regulatory agencies in health care enforce
standards and practice requirements that play a major role in the quality and costs of care delivered.
The Joint Commission (TJC)
•An independent, nonprofit organization that accredits health care organizations in more than nine different types of health care settings.
The Joint Commission (TJC) MONITORS
•Monitors state legislative and regulatory changes and updates its standards accordingly.
The Joint Commission (TJC) publishes
•Publishes the National Patient Safety Goals annually.
The Joint Commission (TJC) partners w/
•Partners with other organizations to develop safe practices, identify the root cause of errors, and create a system to mitigate future risk.
Sentinel Event
A sentinel event is one that results in a client death or permanent or severe temporary harm.
Sentinel Events are reported to
These events are reported to TJC and are tracked to help health care organizations improve client safety and quality of care.
The National Committee for Quality Assurance (NCQA)
Widely recognized accreditation program that measures quality of care based on patient satisfaction scores and its Healthcare Effectiveness Data and Information Set (HEDIS®) tool.
The HEDIS® tool measures
90 different points across several areas of care.
These scores, or standards of care, are then compiled with a client satisfaction score to rate each organization.
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) uses a braod
•Uses a broad range of standardized questions to measure and compare client satisfaction between health care facilities.
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) adminsitered
•Administered randomly to clients between 48 hours and six weeks after discharge.
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores are publicly reported to
•Scores are publicly reported and ensure accountability and transparency of client satisfaction data.
The Press Ganey
•Popular survey tool to measure health care delivery and client satisfaction in acute care agencies.
The Press Ganey has metrics on
•Has metrics on access to care, wait times, client interactions with the health care team, and the visit itself.
The Press Ganey is delivered how
•Emailed to every client at the conclusion of their visit.
Health-care costs are paid for in one of five ways:
Public health insurance (e.g., Medicare and Medicaid)
Private health insurance (e.g., Aetna, Blue Cross, United Healthcare, Prudential)
Insurance for special populations (e.g., CHAMPVA, TRICARE, Indian Health Service [IHS], Workers’ Compensation, and disability insurance)
Charitable organizations (e.g., Shriners and the Kaiser family)
Self-pay (those who are uninsured)
•Public health insurance
(e.g., Medicare and Medicaid)
•Private health insurance
(e.g., Aetna, Blue Cross, United Healthcare, Prudential)
•Insurance for special populations
(e.g., CHAMPVA, TRICARE, Indian Health Service [IHS], Workers’ Compensation, and disability insurance)
•Charitable organizations
(e.g., Shriners and the Kaiser family)
•Self-pay
(those who are uninsured)
•Medicare
Over 65
Or those younger than 65 years who have end-stage renal disease and certain other debilitating illnesses.
Part A,B, D
Diagnosis-related groups (D R G s)
•Medicaid
Based on Income in relation to poverty level
Benefits differ by state
Children’s Health Insurance Program-
for children who may not meet Medicaid requirements but need health coverage
Private health insurance AKA
•Third-party payers
•Third-party payers
Health maintenance organization (H M O)
Preferred provider organization (P P O)
Point-of-service plans (P O S)
Health maintenance organization (H M O)
Capitation
Primary care physicians (P C P) paid set amount
Insurance for Specific Populations
Indian Health Service
TRICARE
CHAMPVA
Worker’s compensation
Disability
Charitable Organizations
Catholic and Jewish health systems
Shriners
Kaiser family
Robert Wood Johnson Foundation
Self-pay (Uninsured Patients)
Payment plans
Concierge medicine
Fee for Service (FFS)
•A health care reimbursement system whereby providers and organizations receive payment based on the volume of services provided versus providing quality care across the continuum.
•The traditional use of this model resulted in a skyrocketing of health care costs, leading the government to change from paying for volume to paying for value.
ffs - FEE FOR SERVICE
Diagnosis-Related Groups (DRGs) are part of the ____
Part of the Prospective Payment System.
•When clients are admitted to an acute care setting, they are coded into a specific DRG based on their
primary diagnosis, age, and sex.
•Health care facilities receive a fixed cost for each client based on their
DRG.
•Reward health care facilities that provide
quality care in an efficient manner.
The Affordable Care Act (ACA)
Signed into law in 2010 with the intent of
improving health care quality while
lowering its costs,
increasing access for all,
encouraging prevention, and
providing protection to those who access health care services.
Health Disparities
Age
Differences in education
Disabilities
Economic instability
Gender
Income inequality
Limited English proficiency
Limited social support
Mental illness
Race
Sexuality
Social isolation
Social Determinants of Health (SDOH)
neighborhood and built environment
economic stability
education
social and community context
health and healthcare
Levels of Care
Primary Care
Community Care
Primary Care
Physician
Nurse Practitioner
Physician Assistant
Screen and treat routine illnesses
Promote wellness
Preventative measures
Coordinates referrals, treatments and screenings
Community Care
Preventative services
Schools
Community clinics
Volunteer organizations
Inpatient Settings
Acute Care Hospital or Medical Setting
Long-term Acute Care Facility
Skilled Nursing Facility
Rehabilitation Facility
Long Term Care Hospital
Assisted Living Facility
Outpatient Care
Hospice Care
Home Health Care
Respite Care
Palliative Care
The Health-Care Team
Healthcare Providers
Nursing Staff
Therapy Staff
Healthcare Providers
Medical Doctors/ Doctors of Osteopathy
Physician’s Assistant
Nurse Practitioner
Therapy Staff
Lab Staff
Radiology Staff
Ancillary Staff
Nursing Staff
Registered Nurse
Licensed Practical Nurse/ Vocational Nurse (LPN/ LVN)
Unlicensed Assistive Personnel (UAP)
Certified Nursing Assistant (CNA)
(LPN/ LVN)
Licensed Practical Nurse/ Vocational Nurse (LPN/ LVN)
(UAP)
Unlicensed Assistive Personnel (UAP)
(CNA)
Certified Nursing Assistant (CAN)
Therapy Staff
Respiratory Therapist (R T)/ Respiratory Therapy Technician (R T T)
Physical Therapist (P T)/ Physical Therapy Assistant (P T A)
Speech and Language Therapist (S T)
Occupational Therapist (O T)/ Certified Occupation Therapy Assistant (C O T A)
Laboratory Staff
Pathology (MD)
Medical Laboratory Technologist (MLT)/ Medical Technologist (MT)
Phlebotomist
Radiology Staff
Radiologist (MD)
Radiologic Technologist/ (Rad Tech)
Ancillary Staff
Pharmacist/ Pharmacy Technician
Registered Dietitian (RD) Dietary Technician
Medical Social Worker/ Public Health Social Worker
Chaplain
