HLTH 2030 Exam 3

Ambulatory care

• Diagnostic and therapeutic services for the walking patient

• Used synonymously with community medicine

Outpatient Services

Services are not provided with and overnight stay

• Exception: Emergency room

The foundation for ambulatory health services

Primary care

What was the key driver of ambulatory care settings?

Technological advances allowed for many advanced treatments

Primary Level of Care

• 75-85%

• PCP

• See them first

• Wellness checks

• “Gatekeepers”

• Seeing for a long time

Secondary Level of Care

• 10-12%

• Sporadic consultation from a specialist

• Short term

• Includes hospitalization, routine surgery, specialty consultation, and rehabilitation

Tertiary Level of Care

• 5-10%

• Most complex level of care

• Uncommon conditions

• Institution based, highly specialized, technology-driven

• Includes trauma care, burn treatment, neonatal intensive care, tissue transplants, and open heart surgery

3 elements of primary care (WHO)

• Point of entry

  • contact to enter health system

  • gatekeeper

• Coordination of care

  • health system and the patient

• Essential care

  • optimize health

  • decrease disparities

  • increase access

IOM definition of Primary Care

• Comprehensively addresses any health problem at any stage of patient’s life

• Coordination ensures a combination of health services to best meet the patient’s needs

• Continuity of care administered over time but a single provider or team

• Emphasizes accessibility and accountability

US Primary Care Practitioner

• Not restricted to physicians trained in general and family practice

• Includes internal medicine , pediatrics, and obstetrics and gynecology

Non-physician practitioners (NPPs)

• Ex. nurse practitioners (NPs), physician assistants (PAs), and certified nurse-midwives (CNMs)

How are Primary Care and Public Health Integrated

• Primary care and essential public health functions as the core of integrated services

• Multisectoral policy and actions

• Empowered people and communities

Patient-centered medical homes (PCMH)

• Consists of an interdisciplinary team of physicians and allied health professionals

• A “medical team” originally referred to a team-oriented approach for special needs children requiring constant care coordination

Primary Care Assessment Tools

• Measures primary care performance at various scales and settings

• Consumer-client surveys, facility surveys, provider surveys, and system-level surveys

New Directions in Primary Care

Community oriented primary care elements

• Reducing exclusion and social disparities

• Organizing health services around people’s needs

• Focus on community

• Pursuing collaborative models of policy dialogue

• Increasing stakeholder participation

Primary care and pandemics

• Takes on a crucial triage role

• Clinic located in underserved communities act as a safety net

• Continuity: Fosters trust with patients, encourages them to seek out and follow medical advice

• Emphasis on preventive care helps reduce burden of chronic disease and comorbidities

Growth in Outpatient Services

• Reimbursement (money, paying less, changes in ways to pay in 1980s, goes back to how hospitals were paid because they are picking up more services)

• Technological factors

• Utilization control factors

• Physician practice factors (want to branch out and do more outpatient services)

• Social Factors (prefer outpatient over being in a hospital for a night)

Outpatient Care: Private practice

• Backbone of primary care; came first

• Privately owned, not associated with a hospital system

Outpatient Care: Hospital-based services

• Affiliated with health systems

• Clinical services (Doctors offices)

• Surgical services (Outpatient surgical centers)

• Emergency services

• Home health care (go into patients homes)

• Women’s health centers

Outpatient Care: More

-Retail clinics (CVS, Walgreens)

-Mobile medical, diagnostic, and screening services

-Home Health care (see patient’s way of living)

-Hospice services

• Comprehensive services for the terminally ill with life expectancies of 6 months or less

• Palliation (pain management) with psychosocial and spiritual support

Outpatient Care: Long term

• Case management: Navigate a loved one through the health system, good for people who live afar away

• Adult daycare: People need respite and can send elders to a 9-5 daycare

Outpatient Care: Public Health services

• Local health departments

• Everyone offers something different

• Services include: well baby, venereal diseases, TB, mental health family planning, immunizations

Outpatient Care: Freestanding facilities:

• Walk-in clinics

• Urgent care centers

• Surgicenters

Outpatient Care: Free Clinics

3 Characteristics

• Services provided at no charge or nominal charge

• Clinic not directly supported or operated by a government agency or health department

• Services delivered by trained volunteer staff

• Not guaranteed 

Outpatient Care: Community Health centers

• Government operated and gets more money from CMS

• RHCs(owned through hospitals), FQHS (100% owned by gov)

• In areas that are medical underserved

Outpatient Care: Telephone access

• First before telehealth

• You would call and leave a message on a nurse’s line

• Great for new parents

Complementary and Alternative Medicine Growth

• Western treatment have not helped

• Want to avoid/delay complex surgeries or toxic allopathic treatments

• Feel in control when empowered with medical and health-related information

• Want practitioners to take time to listen and deal with their personal life as well as their pathology

• NCCIH

What are other countries doing in terms of care

• Primary care as gatekeeper to the rest of the healthcare system

• Multidisciplinary and team-based care

• Cost-accessibility: little to no cost-sharing in many countries, ex. Canada, U.K., Spain

De Facto Model

• When you are trying to educate but not specialists in the field (mental health)

• Not enough mental health providers so PCPs have to take over

Acute Care Facilities

hospitals: an institution with at least six beds and that delivers diagnostic and therapeutic services for medical conditions

Medical center

• A hospital that has achieved specialization and offers a wide scope of services 

• often engages in teaching and research

Multiunit affiliation

• Multihospital chains (multihospital system-MHS)_ Two or more hospitals are owned, leased, or contractually managed by a central organization

• Offers more services

• More than 65% of all U.S. hospitals are part of a chain

Qualifications to be a hospital

• Be licensed (state)

• have an organized physician staff

• provide continuous nursing service under RNs

• Have a governing body that is responsible for hospital conduct (BOT)

• Have a CEO with responsibility for operations

• Maintain medical records on each patient

• Have pharmacy services available

• Provide food services to meet the nutritional and therapeutic requirement of the patients

Construction and operations of a hospital are governed by

• Federal laws

• State health department’s regulations

• city ordinances

• JCAHO

• Fire codes

• sanitation

Licensure

• A legal requirement to operate a hospital

• Only takes self pay & private

• State government (state departments of health) oversees with own set of standards

• Emphasizes physical plant compliance with:

  • building codes

  • fire safety

  • climate control

  • space allocations

  • sanitation

Certification

• Public, private, and self pay

• Allows a hospital to participate in Medicare and Medicaid

• Compliance with the federal “Conditions of Participation” is necessary

  • Health, safety, quality

Accreditation

• Joint Commission (JCHAO) accredits a variety of health care facilities

• DNV (Det Norske Veritas) accredits

• Both are private nonprofit organization

• Accreditation confers deemed status on hospitals

  • Do not deal directly with CMS

• 30 or 90 days to fix what is wrong

• Not necessary but is very good

Magnet Recognition Program

• Designation conferred by the American Nurses Credentialing Center

  • Affiliate of the American Nurses Association

• Recognizes

  • Quality patient care

  • Nursing excellence

  • Innovations in professional nursing practice in hospitals

  • Research

Hospital Organization: Externally

• The community: patient population

• Government:CMS

• Insurers: private

• Managed care organizations

• Accreditation agencies: joint comission

Hospital Organization: Internally

• Board of trustees

• CEO: CNO, CFO,COO

• Medical staff: chiefs ex. general, surgery, peds