1.2 NHA handout

Health Care Systems and Settings

• The medical field can be overwhelming due to new terminology, legal concerns, direct/indirect patient care, unique processes, and high expectations.
• A holistic approach and understanding the entire health care team are crucial.
• Knowing the skills and responsibilities of various allied health and specialty providers strengthens the effectiveness of the health care team.
• Team members need to respect and assist each other to provide the best patient care.

Medical Assistant (MA) Roles, Responsibilities, Scope of Practice, and Titles

• MA Role: Primarily works alongside a provider in an outpatient or ambulatory health care setting (e.g., medical office).
• Cross-trained to perform both administrative and clinical duties.
• Administrative duties:
  • Greeting patients
  • Scheduling
  • Handling correspondence
  • Answering telephones
• Clinical duties:
  • Obtaining medical histories
  • Providing patient education
  • Performing laboratory tests
  • Preparing and administering immunizations
• Credentialing is achieved by passing a national certification exam.

MA Responsibilities

• Responsibilities vary based on the setting.
  • Can be primarily administrative, clinical, or a combination.

Administrative Duties

• Scheduling patient appointments
• Patient registration (demographics, payer information, compliance forms)
• Updating and working in patient records
• Sending claims to insurance
• Collecting patient responsibility amounts (copays, coinsurance, deductible)

Clinical Duties

• Collecting and processing lab specimens
• Performing diagnostic testing (EKG, spirometry)
• Preparing and cleaning examination rooms
• Preparing the patient for evaluation and procedure
• Measuring vital signs
• Preparing medications and administering immunizations
• The MA role is constantly changing and evolving.
• MAs are increasingly involved in patient navigation and care coordination, guiding patients through the health care system.
• This includes helping patients understand what is happening, the steps they need to take, and connecting them to the right specialists.
• MAs coordinate with other members of the patient care team within the clinic and externally with specialty care teams.
• They ask questions on the patient’s behalf to understand the plan of care and provide information to the patient in a clear way.
• When coordinating with other teams, MAs provide context about the patient’s social determinants of health and barriers to care.
• They also support patients in being scheduled appropriately and in a timely manner with specialists.

Scope of Practice

• Describes the duties delegated based on education, training, and experience.
• The scope of practice for MAs does not include the practice of medicine.
• MAs should not perform duties they have not been trained or certified to do.
• Prior to practice, review duties and restrictions, which vary by state.
• Health care organizations may have stricter policies but must comply with state regulations at minimum.

Variables for the Scope of Practice

• Regulations and policies issued by state medical boards.
• An MA with appropriate training may provide supportive services that are simple, routine medical tasks under the supervision of a licensed physician.
• Supportive services are set forth by the medical office’s organizational policies.
  • Measuring height and weight
  • Measuring vital signs
  • Performing various diagnostic and laboratory testing
• Organizational policies must adhere to state and government guidelines to comply with current laws.

Titles

• Medical providers began hiring assistants over 50 years ago for administrative support.
• The MA role evolved, combining administrative and clinical responsibilities.
• In 1956, a formal medical assistant association was formed and recognized by 15 states.
• The profession was recognized by the U.S. Department of Education in 1978.
• Training was initially completed on the job by the provider and other office staff.
• Formalized training and certification programs arose because on the job training became time-consuming and expensive for providers.
• Many clinical offices only hire those with formal training and certification.
• Offices follow guidelines requiring medical assistants to have current certification to input data regarding government insurance reimbursements into electronic health records.

Additional Certifications

• Medical assistants can further their careers through continued education and additional certifications.
  • Certified Medical Administrative Assistant (CMAA)
  • Certified Phlebotomy Technician (CPT)
  • Certified EKG Technician (CET)
  • Certified Billing and Coding Specialist (CBCS)
  • Certified Electronic Health Records Specialist (CEHRS)

Provider and Allied Health Roles, Responsibilities, Scope of Practice, Titles, and Credentials

Physician Information

• Physicians, also known as doctors, must be licensed in the state where they practice.
• Requires eight years of school:
  • Four years of undergraduate college
  • Four years of medical or osteopathic school
• Residency: Two- to seven-year training period with on-the-job training under a licensed physician.
• Must pass parts I, II, and III of the U.S. Medical Licensing Examination.
• Two primary types of physicians:
  • Medical Doctor (MD): Allopathic providers, the most widely recognized type of doctor. Diagnose illnesses, provide treatments, perform procedures such as surgical interventions, and write prescriptions.
  • Doctor of Osteopathy (DO): Complete requirements like MDs. Use osteopathic manipulative therapy to treat patients in addition to modern medicine and surgical procedures.

Midlevel Providers

• Physician Assistants and Nurse Practitioners

Physician Assistant (PA)

• Must practice medicine under the direction and supervision of a licensed MD or DO but can make clinical decisions.
• Requires at least four years of college, followed by two years of PA school.
• Most PAs will focus on a specific specialty, such as cardiology or orthopedics.

Nurse Practitioner (NP)

• Provide basic patient care services, including diagnosing and prescribing medications for common illnesses.
• Require advanced academic training beyond the Registered Nurse (RN) degree and have extensive clinical experience.
• In most states, NPs must work under the supervision of a physician, but in some states, they can practice independently.

Nurses

• Found in almost every health care setting.

Licensed Practical Nurse (LPN)

• Must be licensed in their state.
• Typically requires one year of schooling through an accredited program and passing a state board examination.
• Limited in their scope of practice and designed to be assistive.
• Can measure vital signs, administer some medications, and perform clinical care such as wound care.
• Often observe patients, recording and reporting on status changes.
• Primarily used in long-term care settings due to the increasing number of older adults.
• In some states, may be referred to as a Licensed Vocational Nurse (LVN).

Registered Nurse (RN)

• Must complete more schooling (associate degree, diploma graduate, or baccalaureate degree).
• Must pass a state board examination to be licensed.
• Broader scope of practice than LPNs.
• Can work in clinical settings, public health agencies, administrative capacities, and educational settings.

Allied Health Professionals

• Medical laboratory technicians perform diagnostic testing on blood, bodily fluids, and other specimens under the supervision of a medical technologist.
• Medical receptionists check patients in and out, answer phones, schedule appointments, and perform other administrative tasks.
• Occupational therapists assist patients who have conditions that disable them developmentally, emotionally, mentally, or physically.
• Pharmacy technicians may perform routine medication dispensing functions that do not require the expertise or judgment of a licensed pharmacist and must work under direct supervision.
• Physical therapists assist patients in improving mobility, strength, and range of motion.
• Radiology technicians use various imaging equipment to assist the provider in diagnosing and treating certain diseases.

Licensing Versus Certification and Maintenance of Certification

Licensure vs. Certification

• A medical school graduate must be licensed before practicing medicine.
• Licensing ensures providers have adequate knowledge and skills.
• It is important to understand the laws and regulations within each state to avoid violations.

Health Care Licensure

• Regulated by state statutes through medical practice acts.
• An MD, DO, or Doctor of Chiropractic degree is issued upon graduation.
• Licensure for physicians is mandatory and controlled by a state board of medical examiners.
• Licensure may be accomplished by examination, reciprocity, or endorsement.
• Every state requires a written examination for MDs to practice.
• Some states grant licenses by reciprocity, recognizing requirements met by another state.
• Graduates of medical schools in the U.S. are licensed by the endorsement of the national board certification.
• Licensure by endorsement is granted case-by-case based on examinations; graduates not licensed by endorsement must pass the state board exam.
• As of 2022, no state requires medical assistants to be licensed.
• Some states require licenses for specific services like x-rays.
• For example, Florida does not require a license for MAs to collect prescribed routine laboratory specimens, but Washington requires licensing credentials for phlebotomy or EKGs, even for nationally certified MAs.
• Government may require certification for MAs to enter prescriptions into a computerized order-entry system.
• Advantages of certification:
  • Increased initial job placement
  • Higher wages
  • Career advancement opportunities

Maintaining a Certification

• Certification must be maintained to stay current.
• Ensures medical assistants have the most up-to-date information.
• Each certification has different requirements for recertification.

Types of Health Care Organizations and Delivery Models

Inpatient and Outpatient

• Inpatient care occurs while the patient is admitted to a hospital or facility.
• Ambulatory care refers to any care received in an outpatient facility.

Primary Care Clinics

• Outpatient care settings where patients are seen for routine visits, including wellness checks, prevention counseling, chronic conditions, medication management, and minor acute needs.

Specialty Care Clinics

• Outpatient facilities where patients with complex or severe diseases and conditions are seen by specialists.

Home Health

• Specific types of care provided to those who cannot leave their home easily.
• Common types: Physical, occupational, and speech therapy; skilled nursing.
• Must be prescribed and overseen by a primary care provider (PCP).
• Ordered for a set period based on an acute event, usually hospitalization.
• Orders include goals such as managing medications and ambulating safely; service is complete when goals are reached.
• Medical assistants are often responsible for submitting the order, coordinating enrollment and scheduling, and assisting with administrative aspects.

Mobile Health Units

• Bring health care to communities that need it most and may lack access.
• Equipped with transportation and specialized medical equipment.
• Used for mobile stroke units, mobile urgent cares, and mobile mammogram buses.
• The COVID-19 pandemic brought mobile testing and vaccination options.

Hospice

• End-of-life care focused on comfort rather than curative efforts.
• Patients can qualify if they have a terminal illness at the end stage.
• Can be delivered as outpatient or inpatient care.
• Patients typically begin hospice outpatient but can transition to inpatient care near the end of life.

Patient-Centered Medical Home (PCMH)

• A care delivery model in which a PCP coordinates treatment to ensure patients receive the required care when and where they need it in a way they can understand.
• Encompasses all aspects of care, from prevention and wellness education to acute illness and chronic disease management to end-of-life care.
• A team-based approach to health care in which a provider leads an interprofessional team to work collaboratively and effectively.
• Medical assistants are an integral piece of the PCMH team, assisting with direct patient care, care coordination, patient education, and administrative tasks.

Technology-Based Methods for Providing Health Care and Information

Telehealth and Virtual Visits

• Telehealth is health care delivered virtually, most commonly via video call.
• Expanded to eliminate contact with communicable diseases, provide convenience, and allow patients in rural areas to obtain specialty care.
• Medical assistants may have responsibilities:
  • Scheduling virtual visits will require gathering or confirming the patient’s email address, ensuring the link has been sent, and reviewing instructions.
  • Some offices offer patients a test visit in which an administrator or MA will log into the link to ensure the patient can access it when it is time for their appointment.
  • Gathering a history, verifying medication and pharmacy information, setting an agenda, and following up with the patient on the next steps, such as referral or diagnostic testing coordination.

Patient Portals

• Patient portals are a common feature in electric health records.
• It allows patients to log into a patient-facing aspect of the EHR to view their personal health information, such as test results, visit notes, and patient education materials.
• Many patient portals include an option to securely message the health care team about concerns and plans of care.
• Some portals also allow patients to schedule appointments directly without needing to call the office.
• Benefits:
  • Increased transparency about care
  • Decreased wait times for patients to receive results
  • Reduced demand on office staff
  • Medical assistant may be responsible for uploading information to the portal and/or assisting the patient with enrolling and getting set up with an account.

Health Care Payment Models

Fee for Service

• The U.S. health care system is largely based on the fee-for-service model in which providers and medical facilities bill insurance and patients for the services provided.
• Every examination, medical service, test, and procedure has an associated procedural code and charge.
• Insurance then charges the patient a predetermined amount for which they are responsible.
• These charges are managed through the provider’s medical billing department and sent to the insurance (or directly to the patient) for payment.

Value-Based Plans

• The health care system is increasingly moving toward value-based plans.
• Goals of value based care are summarized in Quadruple Aim:
  • Improved patient outcomes
  • Improved patient satisfaction
  • Lower cost
  • Health care professional well-being
• Prioritizes prevention and early intervention over complex intervention.
• Clinics and systems are rewarded financially for keeping patients healthy.

Other Health Care Models

General vs. Specialty Health Care and Services

General Health Care Services

• General Practitioners (GPs): Treat acute and chronic illnesses and provide patients with preventive care and health education. May take a holistic approach considering biological, psychological, and social aspects.
• Family Practitioners: Offer care to the whole family, from newborns to older adults. Familiar with a range of disorders and diseases; preventive care is their primary concern.
• Internists: Provide comprehensive care for adults, diagnosing and treating chronic, long-term conditions. Offer treatment for common illnesses and preventive care. Must have a broad understanding of the body. May focus on pediatric or adult medicine.

Specialty Health Care Services

• Used when a disease or diagnosis escalates beyond the area of expertise of a PCP.
• Specialists are providers focused on diagnosing and treating diseases and disorders of specific body systems.

Specialist Care

Ancillary Services and Complementary Therapies

Ancillary Services

• Providing ancillary services in the provider’s office adds convenience for patients and increases revenue for the organization.
• Ancillary services meet a specific medical need for a particular population.
• Urgent care provides an alternative to the emergency department, costing less, with shorter wait times and convenient locations. Appropriate for non-life-threatening acute injuries and illnesses.
• Laboratory services perform diagnostic testing on blood, body fluids, and other specimens to conclude a diagnosis.
• Diagnostic imaging machines such as x-ray equipment, ultrasound machines, magnetic resonance imaging (MRI), and computerized tomography (CT) take images of body parts to further diagnose a condition.
• Occupational therapy assists patients who have conditions that disable them developmentally, emotionally, mentally, or physically, helping patients compensate for loss of function.
• Physical therapy assists patients in regaining mobility and improving strength and range of motion, often impaired by an accident, injury, or disease.

Complementary Therapies

• Acupuncture involves pricking the skin or tissues with needles to relieve pain and treat various physical, mental, and emotional conditions.
• Chiropractic medicine diagnoses and treats pain and overall body function through spinal manipulation and alignment.
• Energy therapy is the calm method of clearing cellular memory through the human energy field, promoting health, balance, and relaxation. It centers on the connection between life’s physical, emotional, and mental states found in various holistic healing techniques.
• Dietary supplements contain one or more dietary ingredients, including vitamins, minerals, herbs, or other botanicals. A plant or part of a plant (flowers, leaves, bark, fruit, seeds, stems, roots, amino acids) is used for its flavor, scent, or potential therapeutic properties.

Team-Based Patient Care

• Team-based health care creates a partnership between providers and patients, ensuring patients are educated and actively involved in their care.
• Every team member is accountable for providing quality care with the shared goal of patients receiving the right care from the right person at the right time.
• This approach requires communication among all members of the team.

Roles and Responsibilities

• Implementing payment models such as “pay for performance” requires a specific mindset for those delivering health care; the patient’s health is everyone’s responsibility.
• Team members work collaboratively to provide seamless care.
• Everyone works at the top of their license or credential by aligning staff responsibilities to their credentials.
• Effective team-based care requires multiple clinicians to address all needs of the patient.
• Primary care providers include a provider, nurse practitioner, or physician assistant.
• Other health care providers include mental health specialists; physical, occupational, and speech therapists; pharmacists; nutritionists; and dentists.
• Patients with chronic conditions usually have a nurse case manager to follow their progress, treatment, and specific needs.
• Support staff (medical assistants, administrative staff members) also provide valuable and essential services.

Patient-Centered Medical Home (PCMH)

• The care delivery model coordinates patient treatment through the primary care provider to ensure the patient receives the necessary care as they need it.
• The goal of a PCMH is to have a centralized setting that facilitates partnerships between the patient, provider, and patient’s family (when appropriate).
• The long-term goal of PCMH is to improve patient outcomes and reduce costs.
• PCMHs improve the patient experience and save money by reducing emergency department visits, hospital admissions, and readmissions.

PCMH Core Function and Attributes

• Comprehensive care includes care for the patient’s needs— the whole patient and not just certain medical and physical concerns. This involves the providers as well as the entire health care team.
• Patient-centered care positions patients and their families as core members of the team, focusing on the individual needs and preferences of the patient throughout various stages of life.
• Coordinated care means the provider-directed medical practice oversees all specialty care, hospital, home health care, and community services. The PCMH works to create and maintain open communication between the patient and other members of the team. This is aided by information technology, such as electronic health records (EHRs).
• Accessible services include tools (open scheduling, extended hours, communication with providers) provided through patient information web portals.
• Quality and safety commitments include delivering quality health care that is met by delivering evidence-based medicine accessed by collecting safety data and measuring and responding to patient experiences and satisfaction.

Accountable Care Organizations (ACOs)

• Made of providers associated with a defined patient population; accountable for the quality and cost of care delivered to those patients.
• At the delivery system level in response to payment reforms instigated by the Affordable Care Act.
• Similar to PCMHs, but with many practices within one organization.
• May include multiple providers, hospitals, and specialty clinics; ambulatory, inpatient, or emergency care services.
• Focus extends beyond patients in medical practice to the community, with an emphasis on public health issues.
• ACO may have outreach programs (smoking cessation, weight loss, nutrition, online education) available to the public to promote wellness.

Specific Roles of Team Members

• Many medical providers can be part of the health care team providing services to a patient.

Primary Care Provider (PCP)

• The first provider from whom a patient will seek care and services.
• One of the PCP’s main goals is coordinating preventative health care services (regular check-ups, screening, tests, immunizations, health coaching).
• PCPs can be family practitioners, internal medicine physicians, medical doctors (MDs), doctors of osteopathy (DOs), or pediatricians.
• Pediatricians offer preventative care services and treat common pediatric conditions such as viral infections or minor injuries from birth through age 18 or 21.

Specialist

• A provider that diagnoses and treats conditions that require a specific area of expertise and knowledge.
• Primary care providers may refer patients to specialists to diagnose or treat a specific short-term condition.
• Patients may work with specialists for an ongoing period for chronic diseases.
• Examples: dermatologists, oncologists, cardiologists, or gynecologists.

Physician Assistant/Physician Associate

• Physician assistants (PAs) have similar training to physicians and are licensed to practice medicine as long as a licensed doctor (MD, DO) supervises them.
• PAs can conduct physical exams, provide preventative care, prescribe diagnostic tests, assist with surgical procedures, diagnose illnesses, and prescribe medicine.

Advance Practice Nurse

• Advanced practice nurses (APNs) have more education and experience than RNs and can usually perform many of the same tasks as a physician assistant.
• Clinical nurse specialists, nurse anesthetists, nurse practitioners (NPs), and nurse midwives are common APNs.

Registered Nurse

• Licensed by individual states and have an associate or bachelor’s degree in nursing.
• RNs can perform more complicated clinical tasks and usually oversee the case management of patients who have complex chronic conditions.

Licensed Practical Nurse

• Licensed practical nurses (LPNs)—sometimes referred to as vocational nurses—are licensed by individual states.
• LPNs usually train for approximately 1 year at a community college or vocational school, receiving a diploma or associate degree.
• Often triage phone calls, administer medications, and assist with other clinical duties in the clinical setting.

Pharmacist

• Pharmacists prepare and dispense medications prescribed by authorized providers.
• They must be knowledgeable of individual and various combinations of medicines to educate patients on their use and answer questions about side effects.

Dentist

• Diagnose and treat issues relating to the teeth and mouth.
• Educate patients on ways to prevent problems associated with oral health.
• Many community health centers include oral health services to patients that are free or on a sliding scale based on patient income.

Therapist

• Some clinics offer rehabilitation services.
• Convenient for patients and improves communication between providers and therapists.

Occupational Therapists

• Assist and educate patients on performing everyday tasks after a physical, mental, or developmental disability or injury.

Physical Therapists

• Assess a patient’s pain, strength, and mobility and then develop a treatment plan to improve movement and pain management.
• Trained to use hands-on therapy, exercises, electrical stimulation, ultrasound, and other techniques to help improve patient movement.

Speech Therapists or Speech-Language Pathologists

• Work with patients who have problems with speech and swallowing due to an injury, cancer, or stroke.
• Focus on improving, regaining, and maintaining the ability to communicate, chew, and swallow.
• Also assess and treat patients who have speech, language, voice, and fluency disorders.

Psychiatrist

• Physicians who diagnose, prescribe medications for, and treat mental, behavioral, and emotional disorders.

Psychologist

• Not physicians, but have a Doctor of Psychology (PsyD) or a Doctor of Philosophy (PhD) degree.
• Work with patients experiencing mental health challenges, such as bipolar and personality disorders.

Social Worker

• Assist patients and families in times of transition or crisis.
• Assist patients in a clinical or hospital setting with physical, emotional, and financial issues related to an illness or injury.
• Often coordinate additional services (transportation, housing, access to meals, financial resources, long-term care, hospice services).
• Providers on the mental health team that work in the PCMH or ACO usually contract with the facility to work a specific number of hours per week.
• Clinics with a large census can include a full-time social worker as part of their permanent staff.

Dietitian

• A registered dietitian nutritionist (RDN) is an expert in diet and nutrition.
• RDNs educate patients on the connection between chronic disease and nutrition, assist with menu planning, and help low-income patients obtain healthier foods at lower prices.

Support Staff

• Administrative and clinical staff professionals are also key players in providing the best possible experience for health care consumers.
• Common job titles for support staff include the following:
  • Clinic coordinator
  • Medical administrative assistant
  • Clinical medical assistant
  • Medical records specialist
  • Medical billing specialist
  • Financial counselor
  • Scheduler

Patients and Family Members

• The role of the patient and family members is more essential in patient-centered health care than the traditional delivery of health care.
• The patient's and family’s wants and needs are the focus areas in this type of delivery.
• The patient decides how they receive treatment, what those treatments will be, the desired outcome, and education and counseling to achieve these goals.
• Include family members and caregivers in the process if they are involved and have the patient’s approval.
• Effective communication is key to achieving the full participation of patients and their families.
• When this is successful, patients report improved symptoms and overall better outcomes.
• Patients feel like they are in partnership with their medical provider, they have increased satisfaction with their overall care.
• Fewer hospitalizations, less testing, and fewer treatments are also achieved with successful patient-family-centered health care.
• As a result, health care costs are also decreased.

Participate in the Transition of Care for Patients

• Successful transitional care occurs when there is appropriate coordination and continued quality in health care as a patient moves from one care provider to another.
• Lack of communication between providers regarding patient histories, medication therapies, and overall patient needs is directly associated with an increased risk of rehospitalizations, adverse clinical events, increased spending, and poor quality of care.
• Communicate effectively with the referring provider, other providers, and the patient.
• Educating patients regarding managing their own care and encouraging the patient and their family members to take an active role in health care decisions is empowering and leads to more adherence.
• Key is excellent communication between the primary care provider, patient, and new or additional providers associated with the patient’s care.

Resources and Procedures to Coordinate Care and Outpatient Services

Coordinating Care With Community Agencies

• Many services within the community can benefit patients.
• Provide contact information for those services to patients who will benefit from them.
• Keep a list of community resources in an easily accessible location.
• Lists can be organized according to patient condition, age, or socioeconomic status.
• The Centers for Disease Control and Prevention (CDC) website has resources that provide services within specified geographic locations.
• Local hospital websites also provide information regarding outreach programs offered in the community.
• Document all information provided to the patient in the health record to promote continuity of care.

Teamwork

Facilitate Teamwork and Team Engagement

• Effective teamwork and engagement are a must for any health care organization; contribute to a positive environment and patient satisfaction.
• Each member of the health care team makes an impact on the overall health care experience for patients.
• Working together in a cooperative environment helps to engage each of the team members, which increases the patient satisfaction levels.
• Quality health care services are provided to patients by a team that works well together where each member is involved in the process.