PH Exam 2

What is CARE management?

the evaluation of health care interventions, including need and appropriateness of care, and the actions taken to attain effective and efficient outcomes ​

What are the aspects of care management?

-Utilization management (Manage use of services and levels of provider payment)​

-Cost containing system of health care administration​​​

-Broader umbrella under which case management fits​

What is the goal of the care management?

improve the coordination of services provided to clients enrolled in a care management program

What are examples of groups served by care management?

the elderly, children from low-income families receiving Medicaid services, groups of people with chronic illnesses

What is CASE management?

collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes

_____ management is a component of care management.

case

What is the focus of case management?

individuals

What is the aspect of case management?

Primarily disease management but can include conditions not related to disease such as maternity-related issues

What does home care allow for?

allows the medical team to see what other factors are influencing the success or failure of a patient​

What are the aspects of home care?

shelter, food, utilities, support, neighborhood safety, extracurricular

A big portion of case management is _____.

home care

What is home care?

the places and spaces where people spend their lives

What are the models of home care?

-assisted living

-home visits to the homeless

-parish/faith community nursing

-public health departments

-hospice programs

What is assisted living?

-Technically home care​

-Patients live in a senior community and have a health care team that manages them weekly, daily, or prn

What is parish/faith community nursing?

-A rapidly growing field

-Very popular with Catholic parishes and African American churches

What are the types of home healthcare agencies?

-private/voluntary (not-for-profit)

-hospital based (for-profit or not-for-profit)

-proprietary (for-profit)

-public

What is private/voluntary home healthcare agencies?

EX: visiting nurses association (VNA)

What is hospital-based home healthcare agencies?

EX: Saint Mary’s home care

What is proprietary home healthcare agencies?

-Private agencies that provide home health aides​

-Ex: Helping Hands Home Care

What are public home healthcare agencies?

health departments

How is home care financed?

-reimbursed by local, state, and federal funds; private insurance; and private individuals

-medicare (federal), largest payer

-medicaid (state), 2nd largest payer

-veterans administration (federal) for those currently serving or have served in the armed services

What is the criteria for medicare eligibility?

-Home bound (must be a taxing effort for client to leave the home)​

-Plan of care (agency generated written document that is guided by a lengthy assessment)​

-Skilled needs → client needs accomplished through professional abilities of RNs or their supervised designees (includes skilled observations, assessments, teaching, management, and evaluation)​

-Intermittent care needs → skilled care provided over several hours, days, or specified time period (medicare = 60 days with renewals as needed)​

-Necessity → services are reasonable based on the status of the client​

Generally the following groups recieve care from home health agencies the most:

-adults with complex acute or chronic illnesses

-older adults

-low income or unisured pregnent women, mothers, and newborns

-children with complex health needs

-the terminally ill

What is telehealth?

-Remote exchange of data between a patient at home and their clinician(s) to assist in diagnosis and monitoring of patients typically with chronic conditions​

-Diagnostic tools with audio/photo capabilities​

-Agencies use telehealth to send information via email/phone/etc. to patients and families. Patients can also send information to their physicians/NPs​

-Incredibly useful with rural areas and homebound clients

What is the first phase of a home visit?

initiating the visit → referral is made to home care agency

What is the second phase of a home visit?

preparation

What is included in the preparation phase?

equipment, directions, personal safety

What is the third phase of a home visit?

the actual visit

What is included in the actual visit?

-assessing for risk of medication errors

-assessing for risk of falls

-assessing for risk of abuse and neglect

-assessing for knowledge deficits

What is the fourth phase of a home visit?

termination of visit → how to contact home care agency, emergency plan established, sign contracts if needed

What is the fifth phase of a home visit?

post visit planning → establish a more specific plan of care outcomes, and organize planned visits

What does the case management pyramid model recognize?

-recognizes the tenets of risk stratification and case finding, coordination, and ultimately case management of a smaller proportion of patients in the population

-recognizes the interchange of public health and populations at risk for service intensity due to economic or care integration needs

What are the aspects of the case management pyramid model?

-case managment of the 10-20% of the population needing economic or care integration case management

-care coordination of those identified as a risk

-risk identification and stratification on measures of health and well being. Uses principles of primary prevention for lifestyles and behavioral change

What are the steps of the nursing process?

assessment, diagnosis, planning for outcomes, implementation, evaluation

What is a broker?

acts as an agent for provider services that are needed by clients to stay within coverage according to budget, cost limits of plan

WHat are the tools of case managers?

-five “rights” of case management

-case management plans

-critical path

-care maps

-life care planning

What are the five “rights” of case management?

care, time, provider, setting, price

What is the process of advocacy?

-informing

-supporting

-affirming

-illuminating values

-generating alternatives

What is the informing stage of the process of advocacy?

information exchange process (amplifying, clarifying, verifying)

What is the affirming stage of the process of advocacy?

-skill development

-systematic problem solving

What is the goal of collaboration?

to amplify, clarify, and verify all team members’ points of view 

What are legal issues for case management?

-liability for managing care

-negligent referrals

-experimental treatment and technology

-confidentiality/security

-fraud and abuse

What are problems faced by rural communities?

-maldistribution of health professional

-poverty

-limited access to services

-ignorance

-social isolation

What is rural?

defined in terms of the geographic location and population density, or it may be described in terms of the distance from (e.g., 20 miles) or the time (e.g., 30 minutes) needed to commute to an urban center

What are the rural population demographics?

-Primarily Caucasian with “diversity pockets”​

-Less college degrees​

-Higher high school drop out rates​

-Income $7000 per capita less than urban individuals​

-Decreased employment opportunities​

-Higher proportion of younger (under 18 years of age) and older residents (over 65 years of age)​ → Due to outward young adult migration​

-More likely to be married​

-More likely to be widowed

What are the rural population concerns?

-Increased rates of 8th month prenatal care initiation​

-Increased rates of prematurity and infant mortality​

-Less likely to be covered by Medicaid even if they qualify​

-Decreased access to mental health care​

-Increased rates of youth smoking and alcohol use.

What are the rural barriers to care?

-Lack of health care providers and services​

-Great distances to obtain services​

-Lack of personal transportation​

-Unavailable public transportation​

-Lack of telephone services​

-Unavailable outreach services​

-Inequitable reimbursement policies for providers​

-Unpredictable weather and/or travel conditions​

-Inability to pay for care/lack of health insurance​

-Lack of “know how” to procure publicly funded entitlements and services​

-Inadequate provider attitudes and understanding about rural populations​

-Language barriers (caregivers not linguistically competent)​

-Care and services not culturally and linguistically appropriate

What are the aspects of rural elderly?

-Most do not live on farms, often isolated to homes without caregivers​

-Incomes 20% lower than urban seniors because of lower ss payments, lower pensions, and lack of part-time employment options​

-Less options for leisure and recreation​

-Fewer healthcare professionals, especially specialists. ​

-Lack of public transportation to assist nondrivers

What are the rural health priorities?

-1. access​

-2. heart disease​

-3. Diabetes​

-4. Mental health and mental disorders​

-5. Oral health ​

-6. Tobacco use​

-7. Substance abuse​

-8. Education and community-based programming​

-9. Maternal, infant, child health​

-10. Nutrition and overweight

What does a nurse do for a rural area?

-1. Availability → Insufficient number and divesity of formal services and providers.​​

-2. Accessibility → Shortages of adequate, appropriate, and affordable transportation​​

-3. Affordability → Poverty and inability to pay for services​​

-4. Awareness → Low levels of information dissemination; literacy issues​​

-5. Adequacy → Lack of service standards and evaluation​​

-6. Acceptability → Reluctance to ask for help​​

-7. Assessment → Lack of basic information on what is needed using research rigor​

What are the rural occupational health concerns?

-Farming uses chemicals, so, by default, does the farmer​

-Farming is outdoors, and year-round​ (Extremes of heat, cold, precipitation)​

-Farming is hazardous!

What are the basic concerns for migrant workers?

-Santitation concerns​

-Lack of ability to access care​

-Inability to leave work during high harvest times regardless of illness​

-Often undocumented status creates an atmosphere of servitude​

What is the migrant lifestyle?

-Travel throughout the country seeking employment​

-Uncertainty regarding work and housing​

-Isolation in new communities​

-Lack of resources

What are the three migratory streams?

-Eastern, originating in Florida​

-Midwestern, originating in Texas​

-Western, originating in California​

What are the housing aspects for migrant workers?

-Trouble locating available, decent, and affordable housing​

-May live in cabin, tent, house, apartment, car

Migrant workers have a high risk for:

-Chronic disease​

-Poor dental health​

-Mental health problems​

-Higher rates for certain diseases​ (Tuberculosis, anemia, diabetes, hypertension)​

-High levels of work injuries and chemical exposures​

-Detrimental physical and social environments for children​

What is the access to health care for migrant workers?

-Migrant Health Act (1962)​

-Migrant health centers​

What are the factors that limit adequate provision of health services for migrant workers?

-Lack of knowledge about services​

-Inability to afford care​

-Availability of services​

-Transportation​

-Hours of service​

-Mobility and tracking​

-Discrimination​

-Documentation​

-Language​

-Cultural aspects of health care

What are the migrant worker’s occupational health risks?

-Injuries​

-Exposure to chemicals (pesticides)​

-Inadequate surveillance system​

-Physical demands​

What are the specific health problems for migrant workers?

-High prevalence of diabetes (three to five times greater than the general population)​

-Dental disease​

-Mental health​ → Stress​, Depression​, Anxiety​

-Drug and alcohol use/abuse​

-Tuberculosis​

-HIV/AIDS​

-Little to no prenatal care​

-Food insecurity

What are the specific health problems for migrant worker children and youth?

-Malnutrition​

-Infectious diseases ​

-Dental caries​

-Inadequate immunization status​ (Both over and under vaccinated at the same time!)​

-Pesticide exposure​

-Injuries​

-Overcrowding and poor housing conditions​

-Disruption of their social and school lives increases anxiety problems​

-Adolescent farmworkers​

-Older siblings staying home to care for younger siblings​

Health promotion and disease prevention may be difficult concepts for migrant workers to embrace because of: 

-Their beliefs regarding disease causality​

-Their irregular and episodic contact with the health care system​

-Their lower educational level

What is the role of the nurse for migrant workers?

-Primary, secondary, and tertiary activities​

-Social and political advocate for migrant populations

What are vulnerable populations?

Populations at substantially greater risk for poor physical, mental, and social health, and have higher rates of morbidity and mortality than the remainder of the population​

Vulnerable populations have a greater exposure to health risks because of marginalization of:

-sociocultural status

-access to economic resources

-age

-gender

People in certain groups are not served equitably by public and private healthcare infrastructure because of:​

-Lack of access​

-Racism​

-Sexism​

-Homophobia​

-Fear of the unknown​​

_____ is another word for vulnerable.

underserved

What is social justice?

equitable sharing of both the common burdens and the common benefits or advantages in society​

What is social injustice?

a denial of economic, sociocultural, political, civil, or human rights of certain populations or groups based on the belief of those with power that others are inferior

What are some health injustices?

-Negative, condescending attitudes of health personnel​

-Red tape for safety net coverage​

-And “us and them” attitude of who deserves care and not​

-Different treatment for different insurance plans​

-Long wait times for coverage

What are the four reasons health care providers should focus attention on vulnerable populations?

-Increased risk for poor physical and mental health leads to greater rates of morbidity and mortality. ​

-The number of vulnerable groups is increasing.​

-It is a social issue and is best solved not at the individual but at the community/population level.​

-The health-care needs of vulnerable populations place an increased demand on the limited capacity and resources of our health-care system.​

What is an medically underserved area?

Area that is determined with a calculation of a ratio of primary medical care physicians per 1,000 population, infant mortality rate, percentage of the population with incomes below the poverty level, and percentage of the population age 65 or above

What are the medically underserved population?

U.S. federal designation for those populations that face economic barriers (low-income or Medicaid-eligible populations) or cultural and/or linguistic access barriers to primary medical care services​

What are detention centers?

inmates await arraignment or care decisions (high turnover)

What are correction facilities with minimum security?

state run, lesser offenses, shorter sentences

What are correction facilities with maximum security?

state run, larger offenses, longer stay

What are penitentiaries?

federally administered prisons where inmates are held for crimes against government

What are the considerations for populations in jails and prisons?

-Mostly male​ (Of the females, 52% are in on prostitution or drug charges)​

-75% of prisoners are nonviolent, and are incarcerated due to drugs, bribery, and extortion​

-Most inmates are African American or Latino​

-The average age of inmates is 37 years​

-After release from incarceration, inmates often face social injustices and economic problems​

-Higher comorbidities of substance use and psychiatric disorders​

What is the ratio for people in prison serving a life sentence?

1 in 7

_____ increase in US jail and prison population in the last 40 years.

500%

What are the health problems of inmates?

-40% under care for serious chronic illness​

-Security and violence risks​

-Substantial mental health and substance abuse issues​

-Despairing attitudes​

-Fragmentation of families​

-Substantial literacy problems​ (60% of people entering prison are illiterate)​

-Increased risk of communicable diseases​

What makes up the homeless population?

-Deinstitutionalization efforts of the 1960s to mainstream the mentally ill into society​

-Unemployment and underemployment​

-Domestic violence​

-Abandonment​

-Natural disasters and fires​

-Disability​

-Substance abuse and addiction​

-Immigration​

-Political unrest and wars​

What is poverty?

having insufficient financial resources to meet basic living expenses

_____ has physical, psychological, and spiritual consequences.

poverty

What are other “poor” terms?

TANF, WIC, near poor, persistent poverty, neighborhood poverty

How does poverty affect health and wellbeing?

-Higher rates of chronic illness​

-Higher infant morbidity and mortality​

-Shorter life expectancy​

-More complex health problems​

-More significant complications and physical limitation from chronic diseases, such as asthma, diabetes, and hypertension​

-Hospitalization rates greater than those for persons with higher incomes​

What are unique needs of the poverty population?

-Healthcare complications increased due to decreased hygiene, extreme weather conditions​

-Increased rates of HIV, TB, lice, scabies, substance abuse and addiction​

-Trimorbidity: substance addiction, mental illness, another chronic condition

What are the aspects of caring for the homeless?

-Nurse must be mobile​

-Trust building is essential​

-Do not make assumptions​

-Often harm reduction strategies are step one to “getting in”​ (Ex: needle programs)​

-Show respect and use positive, compassionate approach​

-Above all else, remember that homeless clients are simply humans, too​

What are the aspects of implementing primary prevention?

-Working with high-risk youth in the communities to prevent the crime that would result in incarceration​

-Advocacy surrounding suspension and expulsion programs in schools 

What are the aspects of implementing secondary prevention?

Community-level health screening to diagnose and treat mental health issues early​

What are the aspects of implementing tertiary prevention?

Providing more addiction services​ (Harm reduction programs)

What is the prevention of LGBTQ social determinants of health?

-Health concerns from a prevention perspective include obesity, injury, violence, and access to healthcare facilities​

-The leading cause of death for all men, including gay men, is heart disease and cancer 

What is the LGBTQ mental health social determinants of health?

-3x more likely to experience depression and anxiety​

-4x more likely to attempt suicide or engage in self harm. 

What are the top health issues for WSW?

-Behavioral health/suicide​

-Heart disease: same risk factors in relation to non-lesbian women​

-Obesity:​ Specifically, AA WSW, and those living in rural areas and areas with lower education​

​-WSW are at significantly higher risk of developing breast cancer: fewer pregnancies, higher obesity rate, lower mammogram rate​

What is aggraveted assault?

an unlawful attack by one person upon another for the purpose of inflicting severe or aggravated bodily injury​

What is the goal of injury and violence prevention?

Prevent unintentional injuries and violence, and reduce their consequences

Why is violence a public health problem?

-It affects the person injured, but also affects family members, friends, coworkers, employers, and communities​

-About 8% of global mortality is attributable to injury​

-Annually in the US, more than 51,000 deaths are attributable to violence​

-Can lead to disability, increased health-care costs, and increased need for emergency care​

-Beyond death and injury, exposure to trauma, particularly in childhood can increase lifetime risks of mental illness, suicide, as well as chronic illness​

-In people 5-29 years of age, 2 of the top 5 causes of death worldwide are homicide and suicide.​

What are the social and community factors influencing violence?

-Work​

-Education​

-Media​

-Population​

-Community Facilities​

More diverse populations tend to increase violence because of differences in:

culture, age, SES, religion, etc. disrupt community stability​

How is surveillance of injury and violence conducted?

via various mechanisms at the local, state, and national levels