Chapter 2: Healthcare Delivery Systems

Hospitalist

A physician who specializes in the care of inpatient hospital patients
Typically do not have a relationship with the patient prior to hospitalization

Allied Health Professional

Health professionals (other than RN’s, physicians, and physician’s assistants) who have received a certificate, AS degree, a BS degree, a Master’s degree, a doctorate, or postdoctoral training in a healthcare related science

Association of Schools of Allied Health Professions

A broad group of health professionals who use scientific principles and evidence-based practice for the diagnosis, evaluation, and treatment of acute and chronic diseases, promote disease prevention and wellness, and apply administration and management skills to support healthcare systems in a variety of settings

Integrated Delivery Systems (IDS)

Healthcare systems that combine the financial and clinical aspects of healthcare and use a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care
Created to provide a full range of healthcare services along the continuum of care, from ambulatory care to inpatient care to long term care

Continuum of Care

Places an emphasis on treating individual patients at the level of care required by their course of treatment and extends from their primary care providers to specialists and ancillary providers

Managed Care Organizations (MCO)

A type of healthcare organization that delivers medical care and manages all aspects of patient care or the payment for care by limiting providers of care, discounting payments to providers of care, or limiting access to care

Integrated Delivery Networks (IDN)

Comprises a group of hospitals, physicians, other providers, insurers, or community agencies that work together to deliver health services
In 2015 50% of hospitals belonged to one

What are hospitals called that have an average length of stay shorter than 25 days?

Acute-care hospitals

What are hospitals called that have an average length of stay longer than 25 days?

Long-term acute-care facilities

Bed capacity

Is used to reflect the maximum number of inpatients for which the hospital can care

Licensed Beds

The number of beds that the state has authorized the hospital to have available for patients

Staffed Beds

The number of beds for which the hospital has nursing staff to cover patient treatment

Government Owned hospital

Operated by a specific branch of federal. state, or local government as not for profit organization
Supported by tax dollars

Proprietary Hospitals

Owned by private foundations, partnerships, or investor-owned corporations

Voluntary Hospitals

Not-for-profit hospitals owned by universities, churches, charities, religious orders, unions, and other not-for-profit entities

Safety Net Hospital (SNH)

A hospital with the highest number of inpatient stays paid by Medicaid

Critical Access Hospital

Part of the Balanced Budget Act of 1997
When certain requirements are met these hospitals are allowed a separate payment system that hallows reimbursement for Medicare patients at 101 percent of reasonable costs and are not subject to the IPPS or OPPS

Criteria for a critical access hospital

Be located in a state that accepted a grant under the Medicare Rural Hospital Flexibility Program
Be located in a rural area
Furnish 24-hour emergency care services 7 days a week
Maintain no more than 25 inpatient beds that may also be used as swing beds
Have an an annual LOS of 96 hours or less per patient
Be located more than a 35 mile distance from any other hospital
Be certified as a CAH prior to January 1, 2006

Board of Directors

Primary responsibility for setting the overall direction of the hospital
Works with the CEO
Develops hospitals strategic direction as well as its mission, vision, and values

Establishing by laws in accordance with the organization’s legal and licensing requirements
Selecting qualified administrators
Approving the organization and makeup of the clinical staff
Monitoring the quality of care

Clinical privileges

Granted permission to provide clinical services in the hospital
Limited to the specific scope of practice

Medical Staff Classification

The organization of physicians according to the clinical assignment
Ex. Medicine, surgery, obstetrics, pediatrics, and other specialty services

Medical staff bylaws

State the specific qualifications a physician must demonstrate before he or she can practice medicine in the hospital
Considered legally binding

Chief Financial Officer (CFO)

Responsible for the fiscal management

Chief Operating Officer (COO)

Responsible for the high level day to day operations

Chief Information Officer (CIO)

Responsible for the management of the information resources

Ancillary Support Services

• Pharmaceutical services

• Food and Nutrition services

• Health Information Services (RHIT/RHIA)

• Social work and social services

• Environmental services

• Purchasing, central supply, and materials management services

• Engineering and plant operations

Managed care

Generic term for a healthcare reimbursement system that manages cost, quality, and access to services

• Implement various forms of financial incentives for providers

• Promote healthy lifestyles

• Identifying risk factors and illnesses early in the disease process

  • Providing patient education

What are the 3 types of managed care plans?

HMO’s
PPO’s
POS

Health Maintenance Organization (HMO)

Provides healthcare within a closed network

Preferred Provider Organization (PPO)

Provide reduced costs in the plan member stays within the network but will contribute at a reduced cost in the member goes outside the network

Point of Service (POS)

Allows patients to choose between and HMO or PPO each time they have a medical encounter

Accountable Care Organizations (ACO)

Describes a group of providers who are willing and able to take responsibility for improving the overall health status, care efficiency, and healthcare experience for a defined population

What are 3 ACO models?

Medicare shared savings program
Advance Payment
Pioneer

Medicare Shared Savings

Gives Medicare fee-for-service providers an opportunity to become an ACO

Advance Payment ACO

Designed as a supplementary incentive program for selected participants

Pioneer

Created for early adopters of coordinate care, though CMS is no longer accepting applications for this model

Ambulatory Care

The preventative or corrective healthcare provided in a practitioners office, a clinic, or a hospital on a nonresident bases

Private Medical Practice

Physician owned entities that provide primary care or medical or surgical specialty care services in a freestanding office setting

Medical Home

A mode of primary care physician practices that is patient-centered, comprehensive, team based, coordinated, accessible, and focused on quality and safety

Home healthcare

Fastest-growing sector
Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment and other services

Skilled Nursing Care

Defined as technical procedures, such as tube feedings and catheter care, and skilled nursing observations

Intermittent

Defined as up to 28 hours per week of nursing care and 35 hours per week for home health aide care

Voluntary Agencies

Provide healthcare and health services usually at the local level and to low income patients
Range from giving immunizations to offering family planning counseling.

Subacute care

Offers patients access to constant nursing care while recovering at home.

Long-Term Care

Non acute care facility
Patients who require inpatient nursing and related services for more than 30 consecutive days
Encompasses a range of health, personal care, social, and housing services provided to people of all ages and health conditions that limit their ability to carry out normal daily activities with assistance

Skilled Nursing Facilities (SNF)

Provide medical, nursing, or rehabilitative care, in some cases, around the clock
Owned by for-profit organizations

Hospice

Palliative care
Family is the unit of treatment
Control pain, maintain independence, and minimize the stress and trauma of death

Telehealth

The use of electronic information and telecommunications technologies to support and promote long distance clinical healthcare, patient and professional health related education, public health, and health administration
Include: video conferencing, the internet, store and forward imaging, streaming media, and terrestrial and wireless communications

Big data

Refers to large amounts of data that are collected from sources and then processed and used for analytics

Artificial Intelligence (AI)

The ability of a computer program or machine to think and learn
Most common use has been speech recognition

Healthy People 2020

Improve the nation’s health to improve the nation’s health with a vision of “a society in which all people live long, healthy lives

• Attain high quality, longer loves free of preventable disease, disability, injury and premature death

• Achieve health equity, eliminate disparities, and improve the health of all groups

• Create social and physical environments that promote good health for all

• Promote quality of life, healthy development, and healthy behaviors across all life stages

Social Determinants of Health

Conditions such as environment and age that impact a wide range of health, functioning, and quality-of-life outcomes and risks

• Availability of resources to meet daily needs

• Access to educational, economic, and job opportunities

• Availability of community based resources

• Exposure to crime, violence, and social disorder

• Socioeconomic conditions

• Language and literacy

• Access to mass media and emerging technologies

• Culture

What are the five key determinants of health?

1. Economic stability

2. Education

3. Social and community context

4. Health

5. Healthcare and neighborhood and built environment

National Institute of Health

The nation’s medical research agency
Goals of this agency are:
-Foster fundamental creative discoveries, innovative research strategies, and their applications as a basis for ultimately protecting and improving health
-Develop, maintain, and renew scientific human and physical resources that will ensure the nation’s capability to prevent disease
-Expand the knowledge base in medical and associated sciences to enhance the nation’s economic well-being and ensure a continued high return on the public investment in research
-Exemplify and promote the highest level of scientific integrity, public accountability, and social responsibility in the conduct of science

Cell based technologies include:

-Tissue engineering, which involves the use of biomaterials to develop new tissue and even whole organs with or without transplanting cells
-Human embryonic stem cells or adult stem cell used for transplantation and in regenerative medicine
-Gene therapy or cell transplantation

National Human Genome Research Institute (NHGRI)

Established in 1989 to carry out the role of the NIH in the International Human Genome Project (HGP)

International Human Genome Project (HGP)

Began in 1990
map the human genome

National Academy of Medicine (NAM)

Formerly known as the Institute of Medicine
Established in 1970 as the nongovernmental agency to provide unbiased advise to decision makers and the public
Written over 1,000 reports

Centers for Disease Control and Prevention (CDC)

Leading federal agency charged with protecting the public health and safety

• Detecting and responding to diseases and conditions, sexually transmitted diseases, cancer, heart disease, diabetes, flu

• Promoting healthy living

• Providing information for travelers health

• Educating for emergency preparedness

Patient Centered Outcomes Research Institute (PCORI)

Created in 2010 from the passage of the Patient Protection and Affordable Care Act (ACA)
Non profit, nongovernmental organization mandated to improve the quality and applicability of evidence available to help all stakeholders to make knowledgeable healthcare choices

Public Law 89-97 of 1965

Amendments of the Social Security Act
Brought about Medicare and Medicaid

Medicare

A federal program that provides healthcare benefits for people age 65 and older who are covered by social security
Inaugurated by July 1, 1966

Medicaid

Established at the same time to support medical and hospital care for persons classified as medically indigent
Targets disabled, pregnant women, poor adults, including those 65 and older

Public Law 92-603 of 1972

Required concurrent review for Medicare and Medicaid patients
Established the professional standards review organization (PSRO)

Utilization Review (UR)

The process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria at time frames specified in the organizations utilization management plan
Mandatory component of the original Medicare legislation

Utilization Review Act

In 1977
Made it a requirement for hospitals to conduct continued stay reviews for Medicare and Medicaid patients

Continued Stay

Determine whether it is medically necessary for a patient to remain hospitalized

Peer Review Organizations (PRO)

Now called quality improvement organizations (QIO)

Quality Improvement Organizations (QIO)

Ensure the quality, efficiency, and cost-effectiveness of the healthcare services provided to Medicare beneficiaries in its locale

Tax Equity and Fiscal Responsibility Act (TEFRA)

To control the rising cost of providing health services to Medicare beneficiaries
Required the gradual implementation of a prospective payment systems (PPS) for Medicare reimbursement

Public Law 98-21 of 1983

Acute hospital care (inpatient) services was implemented on October 1,1983
Made inpatient services based off of DRG’s

American Recovery and Reinvestment Act of 2009 (ARRA)

Major health information technology laws that provided stimulus funds to the US economy in the midst of a major economic downturn
Established the National Coordinator for Health Information Technology

1. Meaningful Use

2. EHR standards and certifications

3. Regional Extension Centers

4. Breach notification guidance

Health Information Technology for Economic and Clinical Health (HITECH) Act

Came from the American Recovery and Reinvestment Act of 2009
Allocated funds for implementation of a nationwide health information exchange and implementation of electronic health records

Patient Protection and Affordable Care Act (ACA)

Signed on March 23, 2010

• Medicaid expansion to 138 percent of the federal poverty level

• Creation of health insurance exchanges through which individuals who do not have access to public coverage or affordable employer coverage will be able to purchase insurance with premium and cost-sharing credits available to some people to make coverage more affordable

• New regulations on all health plans that will prevent health insurers from denying coverage to people for any reason, including health status, and from charging higher premiums based on health status and gender

• The requirement that most individuals have health insurance beginning in 2014 with tax penalties for those without insurance

• The penalties to employers that do not offer affordable coverage to their employees, with exceptions for small employers