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secondary and tertiary care; short-term care for medical conditions.
attractive long-term care setting with a homier environment and greater resident autonomy.
method of paying a physician, hospital, or managed care system for annual services based on a fee per client.
model of care; the case manager advises nursing staff on specific nursing care issues, coordinates the referral of clients to services provided by other disciplines, ensures that client education has been implemented, and monitors the client’s progress through discharge
tool used in managed health care that incorporates the treatment interventions of caregivers from all disciplines who normally care for a client. Designed for a specific case type, a pathway is used to manage the care of a client throughout a projected length of stay. (example on pgs. 395-396)
process of assisting another member of the health care team aspects of client care (example. assigning nurse assistants to bathe a client)
Diagnosis-Related Groups DRG’s
groups of clients classified for purposes of measuring a hospitals delivery of care. (example: box 2-1 pg. 16)
set of decisions and activities involved in providing continuity and coordination of nursing care when a client is discharged from a health care agency.
the provision of medically related professional and paraprofessional services and equipment to clients and families in their homes for house maintenance, education, illness prevention, diagnosis and treatment of disease, palliation, and rehabilitation.
a system of family-centered care designed to allow clients to live and remain at home with comfort, independence, and dignity while alleviating the strains caused by terminal illness
Managed Care Organization/Managed Care
health care system in which there is administrative control over primary health care services. Redundant facilities and services are eliminated, and costs are reduced. Preventive care and health education are emphasized.
state medical assistance based on Title XIX of the Social Security Act. States receive 50% in matching federal funds to provide medical care and services to people meeting categorical and income requirements; covers home care services based on Medicare guidelines. Many innovative homecare programs can be covered by Medicaid, as long as the meet the recipient’s needs and costs less than institutionalization. (memory aid: Medicaid: id= indigent, low income)
federal government insurance coverage for persons over 65 years of age (or disabled under 65) who have paid into the Social Security or Railroad Retirement System; covers inpatient hospital charges and some home care services. (memory aid: Medicare: re= retired, 65 or older)
Minimum Data Set (MDS)
part of the Resident Assessment Instrument (RAI) discussing the most appropriate health care interventions to support the health care needs of the residential population
Nursing Center/Nursing Facility/Nursing Home
provides 24-hour intermediate and custodial care such as nursing, rehabilitation, dietary, recreational, social and religious services for residents of any age with chronic or debilitating illnesses.
a nontraditional setting where preventive and primary care can be found. Churches and synagogues offer the site and support system for the programs activities.
Prospective Payment System (PPS)
method of reimbursement for health care services. It involves a fixed reimbursement for a medical condition/procedure regardless of client’s length of stay.
care that gives the primary care provider the opportunity to have time away. Respite services can take place in the client’s home, a hospital, or extended care facility.
care settings that include but are not limited to inpatient and outpatient rehabilitation facilities, subacute care facilities, clinics, and home care agencies. The services provided in restorative care settings are designed to bring the client to the maximal level of health and function.
Skilled Nursing Facility (SNF)
institution or part of an institution that meets criteria for accreditation established by the sections of the Social Security Act that determine the basis for Medicaid and Medicare reimbursement for skilled nursing care, including rehabilitation and various medical and nursing procedures. Law requires that policies designate which level of caregiver is responsible for the implementation of each policy; that the care of every client be under the supervision of a physician; that the physician be available on an emergency basis; that records be maintained regarding the condition and care of every client; that nursing services be available 24 hours a day; and that at least one full-time registered nurse be employed.
Secondary Care and Tertiary Care (Acute Care)
secondary and tertiary care; short-term care for medical conditions
assisted living; psychiatric and older adult care
Preventive and Primary Care
first contact in a given episode of illness that leads to a decision regarding a course of action to resolve the health problem.
Integrated Delivery Network (IDN)
a set of providers and services organized to deliver a coordinated continuum of care to the population of clients served at a capitated cost.
Preferred Provider Organization (PPO)
one that limits an enrollee’s choice to a list that is “preferred” hospitals, physicians, and providers. An enrollee pays more out-of-pocket expenses for using a provider not on the list.
(box 2-9 pg. 27)
Dimensions of Client-Centered Care
- • Respect Values, Preferences, and Expressed Needs
- • Coordination and Integration of Care
- • Information, Communication, and Education
- • Physical Comfort
- • Emotional Support and Relief of Fear and Anxiety
- • Involvement of Family and Friends
- • Transition and Continuity
Explain the advantages and disadvantages of managed health care.
• The advantage is if people stay healthy, the cost of medical care declines. The disadvantage is that since people are becoming more ill the cost is rising.
Explain regulatory and competitive approaches used to control health care costs.
• The regulatory and competitive help to control health care cost through two ways: professional standards review organization (PSROs) [regulatory] and utilization review (UR) committees [competitive]. PSRO maintains that hospital care’s quality, quantity, and cost are at their best. UR review that admission, diagnostic testing, and treatment for clients under Medicare. Both groups allowed us to find the holes and get rid of extra or overuse treatment services while creating guidelines.
Explain the concept of prospective reimbursement.
• Prospective reimbursement is also known as prospective payment system (PPS). PPS were able to divide inpatient hospital services for Medicare clients into 468 diagnosis-related groups (DRGs). The groups had a fixed reimbursement based on the client’s severity, rural/urban/regional cost, and teaching costs. DRG would give a certain amount regarding stay or use of services in the hospital.
Describe the six levels of health care in the U.S.
- 1. preventive- disease prevention, school nurse teaching dental health, clinics
- 2. primary- health promotion, physical exams
- 3. secondary- hospital care for short term services, ex. ER visit (FWBMC)
- 4. tertiary- hospital care for higher level of complexity, ex. ICU (UAB)
- 5. restorative- help to regain maximal function to enhance quality of life. (rehabilitation).
- 6. continuing care- services for disabled or those who suffer a terminal disease.
Describe the types of service found within each level of health care
- 1. preventive- blood pressure and cancer screening, immunizations, poison control information, mental health counseling and crisis prevention, community legislation (seat belts, air bags, bike helmets).
- 2. primary (health promotion)- prenatal care, well-baby care, nutrition counseling, family planning, exercise classes.
- 3. secondary- emergency care, acute medical-surgical care, radiological procedures.
- 4. tertiary- intensive care, subacute care
- 5. restorative- cardiovascular and pulmonary rehabilitation, sports medicine, spinal cord injury programs, home care.
- 6. continuing care- assisted living, psychiatric and older adult day care.
Discuss health care issues that have implications for nursing.
• Health care issues range from maintain health care quality while reducing costs, nurses need to acquire the knowledge, skills, and values to practice competently and effectively. Quality Health Care is important because we use the information of surveys of the client’s satisfaction to improve the system. As nurses, we are the frontline of the quality the client received. Evidence-based practice provides nurses with evidence-based data to provide effective and efficient client care, assists nurses in resolving problems in a clinical setting, innovative care, and great decision-making processes.
Explain the role of nursing in promoting client satisfaction.
•Nurses are a major part of a client’s care in the hospital from the time they enter and leave. There are seven dimensions to client satisfaction: respect/preferences/expressed needs, coordination and integration of care, information/communication/education, physical comfort, emotional support and relief of fear and anxiety, involvement of family and friends, and transition and continuity. The nurse’s plan will contain all of these dimensions. Nurses will constantly ask the client’s expectations to evaluate the nursing care.
Discuss the current status of health reform in the U.S.
•The current status of health reform in the U.S. is not perfect. The United Stateshas many people uninsured and underinsured and do not have access to necessary services. Health care organizations are trying to better service the people to allow them to get the care they need in a timely manner.