2 Healthcare Organizations and Structures

Characteristics that describe a healthcare organization?

• just list 5

type of service

length of stay

teaching status

accreditation status

ownership

Types of services

Length of direct care services

Types of services: diseases or needs of client

• eg heart hospital, children’s hospital, general hospital

Length of direct care services

• acute care: <30 days (hospitals); long term care: > 30 days

teaching status

accreditation status

Teaching status:

• teaching institution: have a medical school or other health professions eg IU, UIUI

• affiliate: provide clinical education eg ascension, community, eskenazi

Accreditation status: Are they accredited for having a structure and processes to support high quality care

Ownership types:

• not for profit (4) vs for profit

Not-for-Profit: tax-paying status

• care for paying and non-paying clients

• profits are reinvested back in organization eg buildings

• must demonstrate community benefit

For-profit: Goal is to make a profit

• Pay investors/ shareholders

Public Institutions:

Run/owned by Federal, State, or Local government

• VA Hospitals, IHS (Federal), Eskenazi (marion county)

Other healthcare organizations/owenerships:

Ambulatory care

Public Health Department

School Health

Day care

Long term care- skilled vs. assisted living

Self help eg AA, NA, etc

Regulatory organizations

• what are they?

• examples 4

set standards of operation to ensure compliance, investigate complaints, and license healthcare providers

• Center for Medicare & Medicaid Services (CMS)

• U.S Food & Drug Administration

• Occupational Health & Safety Administration

• Boards of Nursing

Center for Medicare & Medicaid Services (CMS)

Set guidelines that organizations must meet to ensure quality and protect the health of clients that receive medicaid and medicare services.

• they also investigate and accredit to ensure they meet those standards

accrediting bodies

investigate and certify that an organization is meeting certain standards

• CMS

• JCO (had deeming status for CMS)

• American osteopathic association

third party payers/financial organizations

• what do they do?

• overcharged?

• examples 3

pay for or reimburse healthcare services on behalf of the patient, rather than the patient paying directly.

• if health care system charges more than they are willing to pay, the client is responsible for the differences

• examples: medicare, medicaid, private insurance

medicare

• what is it

• payment is based on

• eligibility 4

Federally funded health insurance program

Payment is based on Conditions of Participation

eligibility

• Age 65 or older

• Certain disabilities

• End-stage renal disease (ESRD) or ALS

• Must have paid into the system for 10 years (40 quarters)

PARTS A, B, C, D

A: hospital- Inpatient hospital care, Skilled nursing facility (SNF), Rehab services, Home health care, Hospice care

B: Medical- Physician services, Outpatient care, Medical equipment/supplies, Preventive services (primary prevention & wellness)

C: Medicare Advantage

• Private insurance plans approved by Medicare

• May offer additional benefits (vision, dental, hearing)

medigap: Covers costs not paid by Medicare (copays, deductibles)

D: Prescription drug coverage

medicaid

• how is it funded

• eligibility 4

chip

• how is it funded

medicaid: Joint federal and state program (state-run under federal guidelines)

• covers: Low-income adults and children, pregnant people, OAs, People with disabilities

CHIP: A form of Medicaid;

• Covers children from families who earn too much to qualify for Medicaid

• cannot afford private insurance for their children

Health Insurance organizations

• HMO, PPO, HDHP

HMO Health maintenance organization

• Must use network, referral needed, lower cost

PPO Preferred provider organization

• Can see out-of-network, no referral, more flexibility

HDHP High deductible health plan

• High deductible, lower monthly cost, can use HSA

levels of care: primary, secondary, tertiary

P: preventative, first access to care

S: Treatment; disease-restorative process

T: Very specialized care; Requires specialty care center or rehabilitation center

Integration of healthcare organizations

• Consortiums

• Consolidations

Consortiums: Multiple organizations work together to increase purchasing power and share resources

• Example: Hospitals sharing research or resources.

Consolidation: Organizations come together to streamline services and develop a network that meets client needs while preventing duplicate services among nearby facilities

Horizontal vs vertical integration

Horizontal integration
→ Same type of organization joins together
→ Example: PCP group joining a larger PCP or hospital system

Vertical integration
→ Different levels of care combine to provide a full continuum of services
→ Example: one network owns insurance, hospitals, surgery centers, home care, and hospice

Acquisitions vs mergers:

A: → One organization purchases and takes over another

M: → Two organizations join to form a new entity with shared mission, vision, and values

economic factors that affect healthcare 3

Uninsured

Therapy / Diagnostic costs

Personnel costs

social factors 3

Client participation

Health promotion

Customer service expectancy

demographic factors 4

Where clients live vs. access to care (rural vs urban area)

Aging client population/ workforce

Income

Uninsured/ underinsured

systems theory vs chaos theory 3 each

• dynamics/Event Perspective

• Predictability

• focus

systems

• Linear view: input → throughput → output

• Clear cause-and-effect relationships = more predictable outcomes

• Focus on structure, technology, people, and environment

chaos theory

• unpredictable random event

• change is inevitable = Organizations must be self-organizing and adaptable

• Emphasizes risk-taking and creative problem-solving

mission, vision, strategic plan

Mission: mission defines what a company does now (its purpose

• 5 Ws of the organization = why, who, what, where, and when

Vision: long-term aspirations and ideal future state)

strategic plan: Connects current state (mission) to future goals (vision)

• Shows specific steps to achieve the vision

organizational values vs culture

Values: beliefs/foundation for behavior and operations

• supports the mission: shows what we believe, how we work, and why

Culture: Shared norms, traditions, and behaviors

Organizational Chart

Shows the structure of an organization

Demonstrates chain of command (who reports to who), span of control (how many direct reports a position has) and relationships of jobs/positions

centralized vs decentralized structure

Centralized: Decisions made at the top and flow down

• Bureaucracy is an example, formal hierarchy, low autonomy at lower levels

Decentralized: Staff at the point of care involved in decision-making

• Flat organizational structures often decentralized

• Key part of Magnet status, shared governance, staff involved in decisions