Chapter 7 (Part 1): Outpatient Services and Primary Care

Introduction 

• Health care delivery has increasingly moved away from expensive acute care hospitals

• Hospitals have been major players in outpatient services as the range of services has expanded

• Solo practices have consolidated to cope with competition 

• Government agencies have sponsored limited outpatient services to meet the needs of underserved populations 

What is Outpatient Care?

• The terms “outpatient” and “ambulatory” are used interchangeably

• Ambulatory care: Diagnostic and therapeutic services and treatment for the walking patient

• Outpatient service: Any health care service that does not require an overnight stay in a health care institution

What is Outpatient Care?

Ambulatory Care:

• Care rendered to patients who come to the:

  • Physician’s office

  • Clinics

  • Outpatient surgery

Mobile Diagnostic Units and Home Health

• Take services to patients

Scope of Outpatient Services 

• Hospital inpatient services continue to decline 

• Executives see outpatient care as an essential, no longer supplemental, service line 

• Intensified competition between hospitals and community-based providers for patients using outpatient medical services 

• Reasons for growth 

  • Reimbursement

    • Financial incentives to reimburse for outpatient care

    • Patients favoring outpatient services

  • Development of new technology

    • Less-invasive procedure; surgical procedures less traumatic

    • Shorter-acting anesthetics

    • Faster recovery time

Scope of Outpatient Services 

Reasons for Growth 

• Utilization Controls 

  • Inpatient hospitals stay has been strongly discouraged by various payers

  • Prior authorization (precertification) required, minimizing length of stay

• Social Factors

  • Patients have strong preference for receiving health care in home and community-based settings, as it gives people a sense of independence and control over their lives

  • Important for quality of life

Outpatient Care Settings and Methods of Delivery 

• Private Practice 

  • Office-based physicians

  • Backbone of ambulatory care

  • Vast majority of primary care services

  • Limited examination and testing

  • Visits are short in duration

  • Solo practices have merged into groups due to:

    • Uncertainties of the health care delivery system

    • Competition from large health organizations

    • High cost of establising a new practice

    • Complexity of billing and collections

    • Increase external controls over private practice

Outpatient Care Settings and Methods of Delivery 

• Hospital-based outpatient services 

  • Prominent particularly in inner-city areas

  • Community’s safety net, providing primary care to the indigent and uninsured

  • A key source of profits for hospitals

  • Main types:

    • Clinical (typically for uninsured or research)

    • Surgical (same day surgery)

    • Home health (post-acute care and rehabilitation)

    • Women’s health

    • Traditional emergency

Outpatient Care Settings and Methods of Delivery 

• Free-standing facilities 

  • Walk-in clinics

    • Ambulatory care from basic primary to urgent care

    • Non-routine, episodic basis

  • Urgent care centers

    • Accept patients without appointments

    • Wide range of routine services

    • First come, first served

  • Surgi centers

    • Freestanding, independent of hospitals

    • Full range of services for surgeries

    • Outpatient, no overnight

Outpatient Care Settings and Methods of Delivery 

• Mobile medical, diagnostic, and screening services 

  • Mobile health units

    • Transported to patients (i.e., ambulances with emergency medical technicians)

  • Mobile diagnostic care unit

    • Mammography

    • Magnetic resonance imaging

Outpatient Care Settings and Methods of Delivery 

• Telephone or Internet triage 

  • Provide expert opinion and advice to the patient, especially during hours when a physician’s office is usually closed

  • Nurses have:

    • Access to patient records

    • Guidance using protocols

    • Consults with physicians

Outpatient Care Settings and Methods of Delivery 

• Home care

  • Service brought into the home

  • Nursing care

  • Change dressings

  • Medication monitoring

  • Bathing

  • Short-term rehabilitation (PT, OT, ST)

  • Homemaker services (meal prep, shopping, transportation, medical equipment, chores)

  • Curable medical equipment (wheelchairs, oxygen, beds, walkers, commodes)

• Alternative to institutionalization

• Maintaining people in the least restrictive environment possible

Outpatient Care Settings and Methods of Delivery 

• Hospice care 

  • Provides services for the terminally ill with life expectancy of 6 months or less

  • Provides services that address the special needs of dying persons and their families

  • A method of care, not a location

  • Services include:

    • Medical, psychological, and social services provided in a holistic context

    • Access to supplies

  • Two areas of emphasis

  • Palliation (pain management)

  • Psychosocial and spiritual support

Outpatient Care Settings and Methods of Delivery 

• Outpatient long-term care services 

  • Nursing homes

  • Case management

    • Coordination adn referral

    • Find most appropriate care

  • Adult day care

    • Complements informal care provided at home at a center during the day

Outpatient Care Settings and Methods of Delivery 

• Public Health Services 

  • Typically provided by local health departments

  • Services include:

    • Well-baby care

    • Venereal disease clinics

    • Family planning services

    • Screening and treatment for tuberculosis

    • Outpatient mental health

Outpatient Care Settings and Methods of Delivery 

• Community Health Centers

  • Authorized in the 1960s to serve the medically underserved

  • Operate under the Bureau of Primary Health Care, U.S. Public health Service, U.S. Department of Health and Human Services

Outpatient Care Settings and Methods of Delivery 

• Free Clinics 

  • Modeled after the 19th-century dispensary

  • Provide general ambulatory care to the poor

  • Services provided at little to no charge

  • Not directly supported or operated by the government or the health department

  • Services delivered by trained volunteers

Outpatient Care Settings and Methods of Delivery 

• Alternative Medicine Clinics 

  • Complementary or alternative medicine

  • Not endorsed by Western medicine

  • Nontraditional

  • Treatments include:

    • Homeopathy

    • Herbal formulas

    • Products as preventive and treatment agents

    • Acupuncture

    • Meditation

    • YoGA

    • Spiritual guidance

    • Prayer

    • Chiropractic

Primary Care

Conceptual foundation for outpatient health services 

• Not all outpatient care is primary care

Focuses on the type of level of services:

• Prevention

• Diagnosis

• Therapeutic services

• Health education

• Counseling

An approach to providing health care, not a set of specific services

Secondary Care

Secondary Care

• Usually short-term

• Sporadic consultation from a specialist

• Includes hospitalization 

• Routine surgery 

• Rehabilitation 

Tertiary Care

Tertiary Care

• Most complex level of care, primarily for conditions that are uncommon

• Usually institution based, often at large teaching hospitals

• Highly specialized

• Technology driven

• May be for long-term care (e.g., trauma, burnt treatment, NICU, transplants, open heart surgery)

WHO’s Definition of primary Health Care

• Essential health care based on scientific methods

• Universally accessible and acceptable

• Affordable cost to maintain health at every developmental stage

• The first level of contact

• Bringing health care as close as possible to where people live and work

• First element of a continuing health care process

Institute of Medicine on the Future of Primary Care

Primary Care Should Be: The provision of integrated, accessible health care services by clinicians who address health care needs and develop a partnership with patients, the family, and community