CH. 2 - Health care delivery, settings, & economics

Medicare

The federal government's health insurance program for people older than 65 years or those with certain disabilities or conditions.

Managed Care

A system of health care delivery aimed at managing the cost and quality of access to health care.

Case Management

Patient care approach aimed at coordinating the care of patients who are vulnerable, at-risk, or cost-intensive so that their specific needs are met in the most cost-effective manner while still bringing them to optimum health.

Medicaid

A federally and state-funded health insurance program for individuals who are poor and medically indigent, pregnant women, individuals with disabilities, and children meeting income level requirements.

Third-Party Payer

The insurance company that finances health care provided to a beneficiary.

Health Maintenance Organization

A cost-containment program featuring a primary care physician (PCP) as the gatekeeper to eliminate unnecessary testing and procedures.

Diagnosis-related group

A classification of illnesses and diseases that is then used to determine the amount of money paid to a hospital by Medicare.

Preferred provider organization

A group of health care providers who contract with a health insurance company to provide services to a specific group of patients on a discounted basis.

Point of service

A type of insurance program where a primary care physician serves as gatekeeper but the members are not capitated; insured people can seek care from health care providers who are both in and out of the network.

Primary care physician

The gatekeeper for access to medical services.

Skilled Nursing Facility

May be associated with a hospital or long-term care facility. Provides a less intense level of care than that found in a traditional or long-term acute care hospital.

Rehabilitation

a level of care in which the patient can receive intense physical, occupational, and speech services.

Outpatient

provided in many settings and is designed to meet the needs of the patient in one day and then allow him or her to return home.

Team Nursing

uses a team consisting of nurses and certified nursing assistants to provide care for a group of patients.

Primary care nursing

one nurse is responsible for all aspects of nursing care for his or her assigned patients.

Self Pay

Uninsured Patients

When a person stays overnight or longer in a health care facility, he or she is referred to as an

inpatient

Empowering the patient to take control of and manage his or her care is called

client-centered care

when patient care is provided by different individuals who perform tasks based on his or her skills, education, and licensure, it is called

team nursing

When care is provided to a person without admitting him or her to a health care facility, the person is referred to as an

outpatient patient

Rehab

a facility that specializes in intense physical, occupational, and speech therapy.

Insurance companies will only pay cost when a procedure is deemed medically necessary. By medically necessary, they mean:

A: The procedure has to be a reasonable intervention, given the patient's diagnosis.

B: The patient has to want to have the procedure done.

C: The procedure has to treat an illness or injury.

D: The procedure must contribute to the patient's sense of well being.

A,C

Which of the following is a criterion for admission to a skill nursing facility?:

A: The patient has made maximum progress and is considered stable.

B: The patient has been hospitalized within the last 30 days.

C: The patient requires intensive physical therapy.

D: The patient will not be able to return to independent living and will be a resident.

B

Certified in a specific area of practice; carries an advanced practice license and can diagnose illnesses, prescribe medications, and order treatments

nurse practitioners

Practices nursing within a defined scope under the direction of a physician; provides direct patient care, manages departments, and supervises other nurses and assistive personnel.

Registered nurse

Practices within a defined scope under the supervision of a physician, dentist, or RN; provides direct patient care and supervises assistive personnel

licensed practical nurse

performs patient care duties and assists nursing staff; performs more complicated tasks, including sterile procedures, in some states.

certified nursing assistant

Employed by physicians or hospitals to work closely with physicians and assisted in directing patient care.

physician's assistant

provides psychosocial support to patients, families, or vulnerable populations; advises caregivers; counsels patients; plans for patients' needs after discharge; and arranges for needed care such as home health.

medical social worker

What are the two most important factors in economic decisions about patient care?

Medical necessity and appropriate level of care

Health care provided by various companies and purchased by the individual or an employer is called

private insurance

One important consideration in managing costs in making sure the patient is placed in which of the following?

appropriate level of care

(T/F) Fragmentation of care is more likely to occur with team nursing that with primary nursing

T

(T/F) Delegation skills are helpful when leading a nursing care team but not essential because each team member knows his or her level of expertise

F

(T/F) Team leaders probably know more about each patient in his or her care because they have other staff to help.

F

(T/F) As a member of a nursing care team, but not the leader, it is important for a nurse to have good communication skills.

T

(T/F) In client-centered care, patients are encouraged to have a voice in a goal setting and in deciding how the goals will be met.

T

(T/F) In client-centered care, the nurse makes sure other members of the health-care team such as the phlebotomist, EKG technician, and respiratory therapist perform their tasks in a timely manner.

F

(T/F) Cross-training of staff is more important in primary care than it is in client-centered care.

F

(T/F) Primary care nursing means that one nurse dos all the care for one patient.

T

(T/F) Primary care works best on general care floors, not intensive care units.

F

(T/F) Primary care must be performed by an RN

F

(T/F) The main goal of case management is to make sure patients at high risk get the care they need at the least cost to the facility.

T

(T/F) The nurse case manager usually provides direct, hands-on care.

F

(T/F) A case manager's main main function is to coordinate and facilitate the care of several different patients concurrently.

T

(T/F) Collaboration and teamwork are closely associated with patient safety.

T

(T/F) Multidisciplinary teams work especially well for patients with multiple and complex health problems.

T

Blue Cross/Blue Shield, Aetna, and Prudential are examples of

private insurance programs

A primary care physician acting as a gatekeeper to eliminate unnecessary testing and procedures is a features of a

health maintenance organization