Comprehensive Guide to Outpatient and Long-Term Care in Healthcare

Outpatient Care

Medical services provided in a setting that does not require an overnight stay.

Reimbursement

Less expensive than inpatient care.

Technological advancement

Less invasive procedures and better diagnostics make outpatient care safer and faster.

Utilization control methods

Insurance companies encourage outpatient care to reduce inpatient costs.

Social factors

Patients prefer home- and community-based care.

Outpatient services delivery locations

Private or group practice, hospital outpatient clinics, freestanding facilities, mobile facilities / telehealth triage, home care or hospice care, community health centers / free clinics.

Ambulatory Care

Wellness, diagnosis, treatment, rehabilitation.

Physician's Offices

Primary and specialty care services.

Specialty Outpatient Clinics

Condition- or system-specific services.

Hospital Emergency Services

Immediate care for urgent health needs.

Urgent Care Centers

Immediate but non-life-threatening conditions; convenient hours.

Ambulatory Surgical Centers

Outpatient surgeries; lower cost than hospital-based operations.

Home Health Services

Skilled nursing or therapy at home; Medicare = largest payer.

Primary Care

Basic, routine health services for prevention, diagnosis, and treatment.

Specialty Care

System- or disease-focused care for chronic, subacute, or acute conditions.

HPSA

A region, population group, or facility with too few primary care providers.

Primary care access issues

Lack of access leads to delayed treatment, increased ER use, worsened health outcomes and higher costs.

Improving Primary Care

Conduct evaluations, improve integrated care, use the Medical Home Model, direct primary care, and other strategies.

Medical Home Model (PCMH)

Team-based, proactive, patient-centered approach, especially beneficial for patients with chronic illnesses.

Direct Primary Care (DPC)

Patients pay a monthly/annual fee directly to their provider, removing insurance middleman.

Emergency Medical Services (EMS)

Provides immediate care for urgent or emergent health needs.

Ambulatory Surgical Centers (ASCs)

Provide surgical care without overnight stay.

Community Health Centers

Largest providers of primary and preventive care in the U.S.

Levels of Healthcare (Pyramid)

Primary Care (Base): Basic, routine services (prevention, diagnosis, treatment).

Long-Term Care (LTC)

Includes health, personal, and support services designed to meet the needs of older adults or individuals whose capacity for self-care is limited due to chronic illness, injury, or disability.

ADLs vs IADLs

ADLs measure functional dependence, while IADLs help determine level of independence and appropriate care setting.

Activities of Daily Living (ADLs)

Basic self-care tasks necessary for personal functioning.

Instrumental Activities of Daily Living (IADLs)

Tasks that support independent living but are not essential for basic functioning.

Types of LTC Settings

Continuum: Functional Independence → Functional Dependence.

Home Care

Provided by family, friends, or home health aides. Focused on ADL support, not medical care.

Community-Based Services

Adult day centers and senior centers offering meals, activities, and limited medical supervision.

Independent Living Communities

For adults (55-75) with minimal health needs; focus on social engagement and maintenance-free living.

Assisted-Living Facilities

24-hour supervision, help with ADLs/IADLs, and social activities. Not covered by Medicare.

Skilled Nursing Facilities (SNFs)

Licensed residential facilities providing full-time nursing and medical care for those unable to live independently.

Hospice Care

End-of-life comfort care for individuals with <6-month life expectancy. Focuses on quality of life and emotional/spiritual support.

Residential care communities

The largest LTC provider category.

Community-based care

A growing shift away from institutional care toward home-like environments.

Factors Affecting LTC Costs

Includes number of services, facility fees, time of day/week, and geographic location.

Medicaid

The largest payer of LTC services, covering institutional and community-based care for low-income individuals.

Medicare

Provides limited coverage for short-term skilled nursing facility stays after a 3-day hospital admission and hospice care.

Private LTC Insurance

An optional, out-of-pocket purchase that helps cover services not paid by Medicare/Medicaid; it is expensive and excludes preexisting conditions.

Out-of-Pocket Payments

Individuals pay directly until assets are depleted, then qualify for Medicaid.

Employer-Based Benefits

Includes life insurance riders that may offer some LTC coverage.

CMS Five-Star Quality Rating System

Evaluates nursing homes based on staffing levels, health inspections, and quality measures.

Aging in Place

Approximately 8 in 10 older adults prefer to remain at home as they age.

Workforce Demand

Rising need for personal care aides, home health aides, and geriatric nurses.

U.S. healthcare workforce

Approximately 17.7 million workers, mostly women and hospital-based.

LPN / LVN

Requires a 12-14 month program and NCLEX-PN; has a limited scope often in LTC settings.

RN

Requires ADN or BSN, NCLEX-RN, and state license; the largest group in the healthcare workforce.

APRN / NP

Requires MSN or DNP and APRN license; can diagnose, prescribe, and manage patient treatment.

MD (Doctor of Medicine)

An allopathic physician with a disease-centered, curative focus.

DO (Doctor of Osteopathy)

A holistic physician focused on whole-person, preventive care, emphasizing musculoskeletal health.

Physician Assistants (PAs)

Educated in a Master's-level PA program (~2-3 years); scope includes diagnosing, treating, and prescribing under physician supervision.

CNA (Certified Nursing Assistant)

State-approved training; certification

CNA Responsibilities

Assist with ADLs (bathing, feeding, mobility) under RN/LPN supervision

CNA Limitations

Cannot prescribe medications.

Social Worker (BSW / MSW / LCSW)

Bachelor's or Master's; clinical licensure (LCSW)

Social Worker Responsibilities

Counseling, case management, connect patients to social & mental health resources

Community Health Worker / Patient Navigator

Health education, advocacy, coordination, and resource linkage

Community Health Worker Impact

Improves access & equity in underserved populations.

Scope of Practice

Must practice within scope of training and licensure.

Continuing Education

Continuing education required for license renewal.

Mandatory Reporting

Mandatory reporters of suspected abuse, neglect, or exploitation (children, elderly, dependent adults).

Out-of-Pocket

Direct payment by patient

Private Insurance

Employer-sponsored or individual plans

Public Programs

Government-funded Medicare, Medicaid, CHIP, Tricare, VA.

Consumer-Driven Plans

High-deductible plans paired with savings accounts

Out-of-Pocket Expense

Expenses that are not paid for by your insurance plan.

Premium

Monthly amount paid to be enrolled in the health insurance plan.

Deductible

The amount of money you pay before your health insurance starts to pay for benefits.

Copayment/Copay

The amount of money you pay for services after your deductible is met.

Coinsurance

The percentage of the cost you pay after your deductible is met.

Annual Out-of-Pocket Maximum

The maximum amount you will pay for health services in a year. After reaching this limit, the plan pays 100% of covered costs.

HMO (Health Maintenance Organization)

Emphasizes prevention; must select PCP

PPO (Preferred Provider Organization)

Greater flexibility

EPO (Exclusive Provider Organization)

Hybrid; limited provider network

POS (Point of Service)

Combines HMO & PPO

CHIP

Children under 19 not eligible for Medicaid

Tricare / VA

Military members, veterans, and families

Affordable Care Act (ACA) - 2010

Expanded Medicaid eligibility (up to 138% FPL).

Cost-Control Strategies

Gatekeeping: PCP manages referrals and care coordination.

Gatekeeping

PCP manages referrals and care coordination.

Utilization Review

Pre-authorization and ongoing review of care.

Bundled Payments / Capitation

Pay per patient or diagnosis, not per service.

Value-Based Care

Reimbursement linked to outcomes and quality measures.

Centers for Medicare & Medicaid Services (CMS)

Federal agency under the U.S. Department of Health & Human Services (HHS).

Medicare Part A

Hospital insurance (inpatient, hospice, some home health) with a monthly premium required.

Medicare Part B

Medical insurance (outpatient, preventive, doctor visits).

Medicare Part C

Private plans that combine A & B (and often D), may include vision, dental, wellness.

Medicare Part D

Prescription drug coverage, must enroll through approved private plans.

Supplemental Insurance (Medigap)

Optional private plan covering copays, coinsurance, and deductibles not paid by Parts A/B.

ACA Expansion

States can cover adults up to 138% of the Federal Poverty Level (FPL).

CHIP (Children's Health Insurance Program)

For children under 19 not eligible for Medicaid, provides comprehensive coverage.

Fee-for-Service

Payment per service delivered, rewards volume, not outcomes.

Prospective Payment

Fixed amount per diagnosis or day, encourages cost efficiency.

Bundled Payments

One payment for all services for a condition or episode, encourages coordination and quality.

Value-Based Purchasing (VBP)

Payment linked to performance & quality metrics, rewards outcomes and patient satisfaction.

Capitation

Provider paid per patient per month, regardless of service use, promotes prevention and cost control.

Hospital Readmissions Reduction Program (HRRP)

Part of CMS's value-based care initiatives, penalizes hospitals with high 30-day readmissions.

Healthcare Quality

The degree to which health services increase the likelihood of desired health outcomes.