303 Prof Nursing II Ex 1

Deliver coordinated services to meet population health needs.

Healthcare organization (HCOs)

Modular nursing pros or cons: Familiarity; balance between efficiency and continuity.

pros

promote wellness, prevent disease, diagnose, treat, rehabilitate. Balance mission-driven goals with financial sustainability.

Aim of Healthcare Organizations (HCOs)

Ownership Types of HCOs

For-profit, Nonprofit, Public/Government

Funded by state/federal government (e.g., Veterans Affairs).

Public/Government

Community-oriented; must reinvest earnings into services, community benefit programs, and education.

Nonprofit

Investor-owned; focus on efficiency, return to shareholders

For-profit

Service Focus of HCOs

Acute care, long-term care, rehab, ambulatory care.

type of hospital that trains medical students and other healthcare professionals (medical education & research)

Teaching Hospitals

focuses primarily on providing standard medical care to the community (higher cost but more specialized care)

Non-teaching Hospitals

Hospital mergers forming systems (e.g., merging with similar providers)

Horizontal integration

referred to as the combination hospitals + clinics + payers

Integrated Delivery Networks

Systems that combine hospitals, clinics, & payers

Vertical integration

Integration Types in HCOs

Horizontal & Vertical

Large, complex organizations with multiple stakeholders. Provide intangible products (health services) rather than goods.

Characteristics of HCOs

Governed by medically trained leaders, not business experts → focus on care vs. profit.

Governance of HCOs

Operate 24/7 → high labor costs, inefficiencies.

Operational Hours of HCOs

measured by quality indicators (mortality, morbidity, patient satisfaction).

Outcome Measurement in HCOs

Expect to distinguish types of HCOs and identify survival tactics (mergers, innovation, patient-centered culture).

NCLEX Angle on HCOs

Organized by departments (lab, nursing, pharmacy). → Efficient but siloed.

Functional Structure in HCOs

Organized around specialties (cardiology, oncology). → Improves interdisciplinary care.

Service Line Structure in HCOs

Structure in HCOs: Dual reporting to functional + service managers. → Flexible, but complex.

Matrix Structure

Structure in HCOs: Minimal hierarchy. → Promotes autonomy, but less managerial oversight.

Flat Structure

Components that allow Systems Theory in HCOs to function

input, Throughput, Output, Feedback

Component of Systems Theory in HCOs that includes: informs change → QI cycles.

feedback

Component of Systems Theory in HCOs that includes: patient outcomes, financial results.

output

Component of Systems Theory in HCOs that includes: processes of care delivery.

Throughput

Component of Systems Theory in HCOs that includes: patients, staff, supplies.

input

Key Idea of Interdependence in HCOs

A breakdown in one area (e.g., supply shortages) affects entire system.

Example of Interdependence in HCOs

A hospital cutting nursing staff (input) leads to ↓ quality of care (output) → CMS penalties for poor outcomes (feedback).

Each staff member performs specific tasks (med nurse, treatment nurse).

Functional Nursing

Fragmented care, ↓ patient satisfaction.

Functional nursing cons

Efficient, cost-effective.

Functional Nursing pros

RN leads LPNs & UAPs; care delegated by RN.

Team Nursing

Requires strong leadership & communication.

Team Nursing Cons

Efficient, uses skill mix.

Team Nursing pros

RN assumes full responsibility for patient's care plan.

Primary Nursing

Best continuity; empowers RNs.

Primary Nursing pros

Costly, requires highly skilled nurses.

Primary nursing cons

RN provides all care for assigned patients during shift.

Total Patient Care

Expensive; impractical for high patient loads.

Total Patient care cons

Accountability, continuity.

Total Patient Care Pros

Smaller patient groups cared for by consistent teams.

Modular Nursing

Ensures safe passage between settings (hospital → rehab → home). Reduces readmissions.

Transitional Care

Physician decides, insurance pays, patients insulated from cost.

Fee-for-service

Covers ≥65, disabled, ESRD. Part A: Hospital. Part B: Outpatient/physicians. Part C: Medicare Advantage. Part D: Drugs.

Medicare

Joint federal-state program for low-income.

Medicaid

Fixed amount per diagnosis → hospitals profit if costs < DRG; lose money if > DRG.

DRGs (Prospective Payment)

Set per-member-per-month payment regardless of usage.

Capitation

Incentives for quality metrics (immunization rates, ↓ readmissions).

Pay-for-performance (P4P)

Rewards outcomes; penalties for 'never events.'

Value-based purchasing

Hospitals lose up to 3% if 30-day readmissions exceed expectations.

Readmissions Reduction Program

Hospitals shift costs of uninsured to insured patients.

Cost-shifting

Working poor, part-time employees. → Less preventive care, ↑ avoidable hospitalizations.

Uninsured/Underinsured

States adopting expansion saw ↓ Medicare-financed hospitalizations, especially in dialysis/kidney failure populations.

Medicaid Expansion

Historical Shifts in Healthcare Financing

Pre-1965: Fee-for-service. 1965: Creation of Medicare & Medicaid. 1983: Medicare moved to DRGs. 1990s: Growth of Managed Care. 2010: Affordable Care Act expanded access.

Often required in Medicaid for costly drugs (e.g., opioid use disorder meds). PA creates delays and barriers.

Prior Authorization (PA)

Involves patients/families in decisions, respects cultural values.

Patient-Centered Care

Everyone gets same resources.

Equality

Resources distributed by need (fairness vs sameness).

Equity

Shared values guiding care delivery. Strong cultures improve morale, reduce turnover, and improve patient safety.

Organizational Culture

Based on acuity, census, nurse competency.

Staffing Models

Adjusts nurse-patient ratios to complexity of care.

Acuity-based staffing

Forecast staffing & budgets, match skills with patient acuity, prevent burnout, advocate safe ratios, promote staff development and teamwork.

Nurse Manager Roles

Categorize patients by needs (e.g., critical care vs. self-care). Helps justify staffing levels to administration.

Patient Classification Systems

↑ falls, pressure injuries, med errors. ↑ burnout, turnover. Poor patient satisfaction.

Risks of Poor Staffing

Focus on shareholder returns, often expand aggressively.

For-profit HCOs

Tax-exempt; required to provide community benefit (charity care, education).

Nonprofit HCOs

Fragmented: Multiple payers (private, Medicare, Medicaid). Costly: U.S. spends >17% GDP on healthcare.

U.S. Healthcare System

28M people in 2016; more likely to skip preventive care and suffer worse outcomes.

Uninsured

Hospital's risk for readmission within 30 days, reducing hospital reimbursement.

CMS penalty

Working poor employed by small businesses.

Greatest risk of being uninsured in the U.S.

Improved equity in access through insurance exchanges & Medicaid expansion.

ACA (PPACA) reform

a system for classifying hospital cases.

Diagnosis-related groups (DRGs)

Payment model where services are unbundled and paid for separately.

Fee-for-service incentives