Health Systems

Triple Aim

patient experience (quality), population health, lower costs

Quadruple aim

triple aim + physician wellness

fee for service model

paid for service independent of the quality of that service

Abraham Flexner report (1910)

report about training medical personnel with 2 years of science and then 2 years of clinical learning

Health Systems Science

the study of how healthcare is delivered, how healthcare professionals work together and how they can improve patient care and delivery

Engel’s Biopsychosocial model

promote healing, relieve suffering, encourage and educate on behaviors

7 core domains of HSS

structures and processes, health systems improvement, value in health care, population public and social determinants of health, clinical informatics, policy and economics, and patient family and community.

HSS 4 foundational domains

teaming, leadership, ethics and legal, Change management

HSS linking domain

systems thinking

self transforming HSS

mediate conflicts, review and integrate multiple perspectives, understand context, and be flexible

hidden curriculum

institutional structure and culture influence on learning environment

population health

An approach that focuses on interrelated conditions and factors that influence the health of populations over the life course, identifies systematic variations in their patterns of occurrence, and applies the resulting knowledge to develop and implement policies and actions to improve the health and well-being of those populations.

Public health

What society does collectively to assure the conditions in which people can be healthy.

often tied to government policies

premium

The cost of insurance plan participation.

deductible

how much you pay out of pocket before the insurance will cover it

co-pay

pay a certain amount out of pocket up front before insurance covers

increase with more specialized/ intense care to steer people to lower-cost services

Co-insurance

portion of the bill that you pay after the deductible is paid

What are the 3 ways people get insurance?

private, through employer, from the government

What was the first tax-financed government insurance?

Medicare/ medicaid 1965

Medicare part A

covers hospital services

Medicare part B

physician services, outpatient, durable medical equipment

Medicare part D

covers prescription coverage

Medicaid

federal program administered by states

covers most all healthcare services for low income people and disabled

What are some reasons for the rising healthcare costs?

aging population, medicalization, expanded healthcare access

Revenue act of 1954

excludes employers contributions to employee’s health plans from taxable income

1974 Hawaii prepaid Health Care Act

requires employers to cover any employee working > 20 hrs/week

EMTALA (1986)

requires hospitals who receive money from medicare to screen and stabilize all persons who use their ER regardless of pay.

1996 HIPPA

restricts use of pre-existing conditions in HI coverage determinations. set standards for medical record privacy.

Health savings Accounts 2003

allow individuals to set aside Pre-tax dollars to pay for current and future medical expenses. Used with high deductible health plan.

2010 patient protection and Affordable care Act

mandated all individuals have health insurance in 2014 or be taxed.

medicaid expansion, government subsidies, employers not mandated to provide coverage but penalized if employees have to receive subsidies, no denial of coverage for any reason, may be on parent’s insurance until 26

4 pillars of population health

chronic care management, quality and safety, public health, health policy

determinants of health

multiple factors that influence an individuals health and the health of populations

behavior, genetics, social factors, environment, healthcare

5 key areas of SDOh as defined by Healthy people 2020

economic stability, education access and quality, social and community context, health and health care access and quality, and neighborhood/ built environment

6 Limitations to population health

1. focus on sick care over prevention and wellness

2. fragmented efforts

3. inadequate assimilation and use of data

4. suboptimal patient engagement

5. inequity in health and health outcomes

6. fee-for service reimbursement and maintaining the status quo

% of GDP spent on healthcare

17.8 or 18

health disparities

particular type of differences in health and health outcomes between groups of people specifically linked to social, economic, and/or environmental disadvantage

PCMH patient centered medical home

provider based model of primary care that provides comprehensive team based patient centered, coordinated, accessible, care focused on quality and patient safety

ACO accountable care organization

entity in formal agreement with a payer to care for a population of patients accountable for quality, costs, and outcomes

population medicine

design, delivery, coordination, and payment of high quality health care services to manage to the triple aim for a population using the best resources available within the health care system

population health management

iterative process of strategically and proactively managing clinical and financial opportunities to improve health outcomes and patient engagement while also reducing costs

equality versus equity

equality- treating everyone the same by providing identical resources and opportunities

equity- fairness by providing resources tailored to individual needs and circumstances recognizing that people face different barriers.

Patient protection and affordable care act (PPACA)

increased access, insurance regulation, cost containment, quality improvement, public health ans prevention support, research support

nurse care managers

coordinate clinical care (clinical)

community health workers

adapts care to the needs of the community, work in the community

patient navigator

helps the patient navigate the health care system and related resources (not clinical)

CHNA (Community Health Needs Assessment)

process that uses quantitative and qualitative methods to systematically collect and analyse data to understand health within a specific community

Hospital Acquired Condition reduction program (HAC)

secretary of health is required to adjust payment to hospitals that rank in the worst performing 25% of all subsection hospitals

Hospital Readmission Reduction Program (HRRP)

medicare value based program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and reduce avoidable readmissions.

linear thinking

logical sequential manner. identify problem then apply solution to get end result

systems thinking

holistic approach, visualizes the seen and unseen drivers and consequences, and interconnectedness of a situation

14 habits of a systems thinker

1. seeks to understand the big picture

2. observes how elements change and the trends and patterns

3. recognizes that a systems structure leads to behavior

4. identifies circular nature of cause and effect relationship

5. makes meaningful connections between systems

6. changes perspectives to increase understanding

7. surfaces and tests assumptions

8. considers issue fully and resits the urge to come to a quick conclusion

9. considers how mental models affect current reality and future

10. uses understanding of systems structure to identify and leverage changes

11. considers short term, long term, and unintended consequences

12. pays attention to accumulations and their rates of change

13. recognizes the impact of time delays when exploring cause and effect relationships

14. checks results and changes actions if needed “successive approximation”

health equity

highest level of health for all people

Whitehall studies

employment grade was strongly related to health outcomes

Allosteric Load

cumulative effect of experiences in daily life that involve ordinary events and environmental challenges. When they become to much for the individual to cope = allosteric load

implicit bias

the attitudes and stereotypes that affect our understanding, actions, and decisions in an unconscious manner, subconscious and learned through socialization

6 dimensions of health care quality

STEEEP: safe, timely, effective, efficient, equitable, patient centered.

care pathways

standard care protocols or best practice avenues often embedded in EHR

production model

group systems and processes are present, finalized product

value based care

keep professionals accountable by, measuring quality, service, and cost

Value=

quality (outcomes, safety, service) / cost

manual system

group processes present

craftsman model

individual experts or craftsman

Merit based incentive payment system (MIPS)

a Medicare program outlined in MACRA, provides additional remuneration based on

“shared savings” for providers who meet performance targets for quality, safety, use of

EHRs, and cost

population management

management and payment for healthcare services for defined population

microsystem

interface with frontline care teams (visits, phone calls, connected care)

problems with patient handoff

mesosystem

integrated specialty groups, support personnel (integrated microsystem teams)

Macrosystems

regional and national systems (integrated mesosystems)

Donabedian Model

structures (facilities, equipment, personnel, resources etc.), processes (work being done) , and outcomes (result of care provided)

advanced practice providers

nurse practitioners and physicians assistant

care coordinator

Rn who coordinates with insurance, medications, home health, and other HC workers

Health maitinence organizations (HMO)

insurance plans that allow only physicians who are in network

Preferred provider organization (PPO)

allows physicians who are out of network

HITECH Act (2009)

mandate the use of EHRs

Comanagement

surgical team remains the primary for patients with many medical issues who are admitted and the hospitalist acts as a consultant who can still put in orders.

medicare versus medicaid

Medicare- federal program, same everywhere in US, run by CMS, insurance program, bills paid from trust funds that pts have paid into, serves over 65 some disabled, pay part ofd costs and a small monthly premium

Medicaid- federal state program, varies based on location, run by state and local w/in federal, assistance program, paid for by taxes, serves low income people, pts usually pay nothing or a small copayment.

NAM reports

document healthcare harms from paper based reports

CPOE

computerized provider order entry

HIE

health information exchange

bioinformatics

cellular and molecular biology

consumer health informatics

mobile health technology

CDS clinical decision support

component of the EHR that detects errors and adverse events within the CPOE

includes information display, reminder system, alerts, clinical practice guidelines

HL7

international standards for the exchange, integration, sharing, and retrieval of electronic health information

telemedicine versus telehealth

telemedicine- delivery of health care online (diagnosis)

telehealth- larger aspect, all telecommunications

descriptive analytics

standard types of reporting that describe situations and problems

predictive analytics

simulation and modeling technique that identifies trends and future actions

prescriptive analytics

optimizing clinical, financial, etc outcomes to make recommendations.

machine learning

build systems and algorithms that learn from data

deep learning

based on neural networks and AI stuff idk

precision medicine

medications that are more specific to patients

metadata

data used to identify data, how its linked, and how data are utilized

Clinical data registries

data about patients with a similar disease or therapeutic process

efficacy versus effective

efficacy- performance under idealized circumstances

effective- performance under real world conditions

shared decision making

clinicians and patients share the best available evidence and patients are supported to consider options and achieve informed preferences

assisted living facility

provide private, home-like housing, meals, and 24/7 support with daily tasks (bathing, dressing, medication) for seniors who cannot live entirely independently

skilled nursing facility

provides 24-hour, short-term inpatient rehabilitation and medical care for individuals recovering from hospital-related conditions

Augmented intelligence

reflects the enhanced capabilities of human clinical decision making, boosted by computers

interoperability

systems capability to seamlessly exchange data

FHIR

a standard championed by HL7 to electronically exchange health care information