U.S. Health‐Care Systems & Nursing Roles – Key Vocabulary

This set covers foundational vocabulary about U.S. health-care systems, financing models, levels of care, quality initiatives, and nursing roles, equipping learners for exam preparation.

Institute of Medicine (IOM) Six Aims

A vision for 21st-century health care that is safe, effective, patient-centered, timely, efficient, and equitable.

Access to Health Care

The ability of individuals to obtain needed medical services when required.

Quality and Safety

Measures of how well health services increase desired outcomes while minimizing risks and harm.

Affordability

The degree to which the price of health services is within a patient’s financial means.

Reliable Care Accountability Matrix (RCAM)

A framework used by organizations to track and improve reliable, high-quality care.

Pay-for-Performance (Value-Based Purchasing)

Payment model that rewards providers for meeting quality and efficiency benchmarks.

Readmission Penalties

Financial penalties levied on hospitals for excessive patient readmissions within a set period.

Multi-Payer System

A financing structure in which multiple public and private insurers reimburse providers.

Single-Payer System

A national health financing model with one public agency handling health-care payments.

Diagnosis-Related Groups (DRGs)

Medicare payment categories that set fixed reimbursement amounts based on patient diagnosis.

Resource Utilization Groups (RUGs)

Classification system that determines payment rates for long-term-care patients based on resource needs.

Bundled Payments

A single, predetermined payment that covers all services for an episode of care.

Rate Setting

Government or insurer determination of standardized prices for medical services.

Comparative Effectiveness Analysis

Research comparing health interventions to identify which work best for specific populations.

Patient Cost Sharing

Out-of-pocket expenses patients pay (copayments, deductibles, coinsurance) alongside insurance coverage.

Primary Health Care

Frontline treatment of common problems and preventive services such as vaccines and routine visits.

Secondary Health Care

Specialized outpatient or short-stay services—e.g., same-day surgery—for conditions needing expert care.

Tertiary Health Care

Highly specialized care for rare or complex disorders, often in teaching or specialty hospitals.

Multispecialty Group Practice

Organization where physicians of different specialties share facilities and support services.

Community Health Center

Local clinic providing primary care and preventive services, often to underserved populations.

Prepaid Group Practice

Health plan in which members prepay a fixed fee for a package of medical services.

Health Maintenance Organization (HMO)

Managed-care plan offering comprehensive services through a network for a set prepaid fee.

Preferred Provider Organization (PPO)

Insurance plan that contracts with ‘preferred’ providers; patients pay less when using the network.

Accountable Care Organization (ACO)

Group of providers jointly responsible for quality and cost of care for a defined population.

Medical Home

Primary-care model emphasizing comprehensive, coordinated, patient-centered services.

Medical Neighborhood

The larger community of specialists and facilities that collaborate with the medical home.

Out-of-Pocket Payment

Direct payment by patients for medical services without insurance reimbursement.

Individual Private Insurance

Health coverage purchased by individuals directly from an insurer.

Employer-Based Insurance

Health benefits provided to employees and often partially funded by employers.

Medicare

Federal insurance for people 65+, certain disabilities, and ESRD; uses DRGs for hospital payment.

Medicaid

Joint federal-state program offering medical coverage to eligible low-income individuals.

Children’s Health Insurance Program (CHIP)

Low-cost insurance for children in families that earn too much for Medicaid but cannot afford private insurance.

Veterans Health Administration (VHA)

Integrated system providing health services to U.S. military veterans.

Quality Improvement (QI) Tools

Methods such as PDSA cycles and root-cause analysis used to reduce waste and enhance safety.

Care Transitions

Coordinated movement of patients between settings to prevent errors and readmissions.

Fraud and Abuse

Intentional deception or misuse of funds in health-care billing and delivery.

Population Health

Health outcomes of a group of individuals and the distribution of those outcomes.

Direct Care Provider (Nurse Role)

Nurse delivering hands-on assessment and interventions to patients.

Nurse Manager

Registered nurse overseeing staff, budgets, and daily unit operations.

Nurse Administrator

Nurse in executive leadership responsible for organizational policy and strategic planning.

Nurse Practitioner (NP)

Advanced practice nurse providing primary or specialty care, including diagnosis and prescribing.

Clinical Nurse Specialist (CNS)

Advanced nurse expert in a specialty area who improves patient outcomes through consultation and education.

Patient Educator

Nurse responsible for teaching patients and families about health, treatments, and self-care.

In-Service Educator

Nurse who plans and conducts ongoing education for hospital staff.

Nurse Researcher

Nurse who conducts scientific studies to generate evidence for practice.

Home Health Care

Skilled nursing and support services delivered in a patient’s home, often after early hospital discharge.

Extended-Care Facility

Institution providing sub-acute, assisted living, or long-term care for populations with ongoing needs.

Respite Care

Short-term relief services for primary caregivers of ill, disabled, or elderly individuals.

Hospice Care

Holistic, supportive services for terminally ill patients focusing on comfort, not cure.

Palliative Care

Interdisciplinary care that relieves symptoms and stress of serious illness at any stage.

Voluntary Agency

Nonprofit organization offering specific health services or education, often staffed by volunteers.

Support Group

Collective providing shared emotional or practical help for people with similar health conditions.

Public Health Service

U.S. federal agency that promotes and protects community health through policy and programs.

Centers for Disease Control and Prevention (CDC)

Federal body that monitors, prevents, and responds to public health threats.

Local Public Health Agency

Municipal or state department delivering immunizations, screenings, and community health programs.