Comprehensive Healthcare Policy, Accreditation, and Quality Measures

Affordable Care Act (ACA)

Improves care quality, lowers costs, and increases access to care.

Medicaid Expansion

Expands Medicaid to adults below 138% of the federal poverty level.

Preventative Care

Emphasizes preventative care and chronic illness prevention.

American Rescue Plan (ARP)

Further lowers ACA costs.

State Regulation of Health Care

1/3 of state budgets go toward health care.

State Regulation

States regulate Medicaid, SCHIP, and nursing board policies (via the NCSBN).

Drug Cost Reduction

Can reduce drug costs (e.g., Inflammation Reduction Act) and regulate health care practices.

Accreditation

Joint Commission (TJC): Reviews facilities for quality; accreditation lasts 3 years.

Sentinel Event

A severe incident causing harm or death (e.g., wrong surgery site).

NCQA

Accredits health plans and promotes evidence-based practices.

ANCC

Magnet and Pathway to Excellence programs measure nursing quality and support staff well-being.

HCAHPS

Publicly reports client satisfaction surveys 48 hours-6 weeks after visit, random clients.

Press Ganey

Internal evaluation tool for every patient, used to improve health care delivery.

Medicare

Covers elderly (65+), disabled, and ESRD/ALS patients.

Medicare Parts

Parts A (hospital), B (medical), C (Advantage Plan), D (prescriptions).

Medicaid

Based on poverty level, any age.

CHIP

Children's Health Insurance Program: children ineligible for Medicaid.

Private Insurance

Employer-provided with tiered costs, copays, and deductibles.

Diagnosis-related groups (DRGs)

Fixed payment system based on patient diagnosis, age and sex. Assigned a length of stay.

HACRP

Hospital Acquired Condition Reduction Program: Reduces reimbursement for hospital-acquired infections.

Resource Utilization Groups (RUGs)

Used in long-term care; reimbursement based on care level, diagnosis and daily resources.

Levels of Care

Primary Care: Routine care, wellness, and prevention (e.g., family doctors).

Community Care

Public education on healthy behaviors (schools, clinics).

Acute Care

Specialized hospital services and surgeries.

Long-Term Care (LTC)

Daily living assistance (e.g., SNFs, assisted living).

Palliative Care

Supportive care, during illness - pain management/comfort.

Hospice Care

Comfort care terminal conditions, for both family and patient.

Respite Care

Temporary relief for caregivers.

Home Care

Health care services provided at home by RNs or LPNs.

Interprofessional Team Members

APRN (Nurse Practitioner): Can work independently.

Case Manager

Coordinates care and advocates for patients.

Social Worker

Provides resources and support.

Occupational/Physical Therapists

Help with recovery and functional skills.

Pharmacist

Dispenses and educates about medications.

Assistive Personnel

Provide basic care (e.g., ADLs, vital signs).

Health Care Disparities

Healthy People 2030: Focus on health promotion, disease prevention, and reducing disparities.

Social Determinants of Health (SDOH)

Categories: Economic Stability, Education Access & Quality, Social & Community Context, Neighborhood & Environment, Health Care Access & Quality.

Barriers to Health Care

Lack of insurance, transportation, language, and provider availability.

Prevention Levels in Nursing Interventions

Primary Prevention: Advocating/Educating - nutrition, healthcare services, hazards.

Secondary Prevention

Environmental assessment, screenings.

Tertiary Prevention

Transportation/insurance issues.

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.

Sentinel Event

An event that results in a client death or permanent or severe temporary harm, reported to TJC and tracked to improve client safety and quality of care.

The National Committee for Quality Assurance

Widely recognized accreditation program that measures quality of care based on patient satisfaction scores and its Healthcare Effectiveness Data and Information Set (HEDIS®) tool.

HEDIS® tool

Measures 90 different points across several areas of care, compiling scores with client satisfaction to rate each organization.

The American Nurses Credentialing Center (ANCC)

Developer of the Magnet Recognition ProgramⓇ and the Pathway to Excellence ProgramⓇ to recognize excellence in nursing practice.

Magnet Recognition

Status awarded when organizations demonstrate promotion of quality in a setting that supports professional practice and excellence in nursing services.

The Pathway to Excellence Program

A four-year designation awarded to organizations that demonstrate commitment to providing a healthy workplace for their staff.

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Uses standardized questions to measure and compare client satisfaction between health care facilities, administered randomly after discharge.

The Press Ganey

Popular survey tool to measure health care delivery and client satisfaction in acute care agencies, emailed to every client at the conclusion of their visit.

Fee for Service (FFS)

A health care reimbursement system where providers receive payment based on the volume of services provided, leading to increased health care costs.

Diagnosis-Related Groups (DRGs)

Part of the Prospective Payment System, coding clients into a specific DRG based on diagnosis, age, and sex, with fixed costs for each client.

Resource Utilization Groups (RUGs)

Payment system in long-term care settings where reimbursement is based on the client's DRG and expected resource utilization.

Minimum Data Set (MDS)

Client assessment tool evaluating cognitive status, need for assistance with daily living activities, treatments, and diagnosis.

The Affordable Care Act (ACA)

Signed into law in 2010 to improve health care quality while lowering costs, increasing access, encouraging prevention, and providing protection.

What is the primary purpose of the Affordable Care Act (ACA)?

To improve health care quality, lower costs, and increase access for all.

When was the Affordable Care Act signed into law?

In 2010.

What does the ACA encourage in health care?

Prevention and protection for those accessing health care services.

What does FFS stand for in health care insurance?

Fee-for-Service.

What is CMS in the context of health care?

Centers for Medicare & Medicaid Services.

What does DRG stand for?

Diagnosis-Related Group.

What does RUG refer to in health care?

Resource Utilization Group.

What is the purpose of MDS in health care?

Minimum Data Set, used for assessing the needs of residents in nursing facilities.

What does TJC stand for?

The Joint Commission.

What does DHHS represent in health care?

Department of Health and Human Services.

What is the role of the nurse in health care delivery systems?

To provide care, advocate for patients, and engage in health care policy.

What are Social Determinants of Health (SDOH)?

Conditions in which people are born, grow, live, work, and age that affect health outcomes.

What are some themes of Social Determinants of Health?

Median income, poverty rate, and employment.

What is the significance of designing a neighborhood in health care?

To assess community resources, transportation, and barriers to health care access.

What is the debate topic regarding health care mentioned in the notes?

Whether health care is a right, privilege, or obligation of a moral society.

What ethical question is raised about health care allocation?

Should vaccination status be used as a criterion for allocating critical care resources?

How can lack of transportation affect patient treatment?

It can lead to missed follow-up appointments and lab tests, resulting in worsening health outcomes and emergency hospitalizations.

What impact does food insecurity have on patient recovery?

It can cause malnutrition, leading to slow wound healing and increased risk of infections, extending hospital stays.

How do crowded living conditions contribute to patient health issues?

They increase exposure to environmental triggers, leading to recurrent infections and frequent hospital visits.

What is the effect of lacking health insurance on patient care?

It can prevent access to preventive care, resulting in severe conditions that require costly hospital treatment.

How do language barriers impact patient outcomes?

They can lead to miscommunication regarding medication instructions, increasing the risk of medical errors and complications.

What role does economic stability play in patient health?

Patients from low-income backgrounds may delay seeking care due to cost concerns, leading to advanced illness and longer hospital stays.

How does education access affect health literacy?

Limited education can hinder a patient's understanding of their diagnosis and treatment, leading to poor management of chronic conditions.

What challenges do patients face in poorly built environments?

Inadequate infrastructure can hinder access to follow-up care and exacerbate existing health conditions.

How does access to healthy food influence chronic disease management?

Limited access can lead to poor dietary choices, worsening conditions like hypertension and heart disease.

What is the impact of social and community support on elderly patients?

Lack of support can hinder medication management and follow-up care, increasing the risk of hospital readmissions.

What are some examples of social determinants of health (SDOH)?

Examples include economic stability, education access, neighborhood environment, food access, and social support.

How can social determinants delay patient care?

Factors like transportation issues, financial constraints, and lack of support can lead to delays in seeking and receiving care.

What is the relationship between food deserts and patient health?

Living in food deserts can limit access to nutritious food, impacting dietary adherence for chronic conditions.

How do social determinants affect hospital readmissions?

They can lead to complications and poor management of health conditions, resulting in increased hospital visits.

Why is addressing social determinants important in healthcare?

They significantly influence patient outcomes, length of hospital stays, and overall quality of care.

What strategies do hospitals use to address social determinants of health?

Hospitals employ case managers, social workers, and community programs to help mitigate the effects of SDOH.

What is the impact of delayed treatment on patient health?

Delays can lead to complications and more severe health issues that require intensive treatment.

How can poor nutrition during recovery affect patients?

It can lead to slower healing, increased infection risk, and longer hospital stays.

What are the consequences of frequent hospital readmissions?

They place a financial burden on the healthcare system and disrupt patients' lives.

How can structural challenges of SDOH be addressed?

By implementing community programs and policies that improve access to resources and support for patients.