RN 500 week 1

Access to Healthcare

  • Many individuals face barriers related to the cost of healthcare despite the Affordable Care Act (ACA), also known as Obamacare.

    • Premiums under ACA are generally lower than average insurance companies.

    • However, these premiums can still be considered high.

    • There are waivers available that could lower premiums further, making ACA more affordable.

Case Example: Pediatric Care Access Issue

  • A significant example mentioned involves a two-year-old boy with chronic ear infections needing a myringotomy (surgical procedure to drain fluid) and an adenoidectomy.

    • The boy's mother faced a $7,000 deductible before surgery, which was part of her healthcare plan.

    • The mother was anxious and unaware of this financial responsibility upon enrollment in the plan.

    • A nurse (assumed case manager) acted to find resources to assist the child, highlighting the emotional and financial burdens families face under such healthcare systems.

  • This example illustrates how large economic policies impact individuals and raises the question of what interventions a case manager could implement in such situations.

Definition of a Healthcare Organization

  • A healthcare organization consists of a system of people, institutions, and resources designed to meet the health needs of a population.

    • Provides two main types of services: restorative illness care and preventative care.

    • Shift in focus from treating illness to promoting wellness and prevention.

    • Exemplified by organizations like Kaiser, which are noted for leading preventative care initiatives.

The Quadruple Aim

  • Healthcare organizations aim to achieve the "Quadruple Aim":

    • Better Care: Enhance the quality of care.

    • Better Outcomes: Improve patient health outcomes.

    • Lower Costs: Reduce healthcare expenditures.

    • Job Satisfaction: Ensure healthcare provider satisfaction and minimize burnout, recognizing that workforce morale is essential for achieving the first three aims.

Classification of Healthcare Organizations

  1. By Type of Services

    • General Care Facilities: Provide a wide range of services (e.g., general hospitals).

    • Specialty Care Facilities: Focused on specific diseases or populations (e.g., oncology clinics like St. Jude).

  2. By Length of Stay

    • Acute Care: Focused on stabilizing patients for discharge; caters to immediate health needs.

    • Chronic Care: Long-term management of chronic conditions, aiming to maintain quality of life.

      • Different nursing skill sets are involved in these settings, with acute care needing a higher proportion of registered nurses compared to long-term care, which may involve more Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs).

  3. By Ownership

    • Public Institutions: Funded by government (federal, state, or local). Examples include county hospitals and the Veterans Affairs (VA) system.

    • Private Not-for-Profit Organizations: Generate profit but reinvest in community services; crucial distinctions from nonprofit organizations explained.

    • For-Profit Organizations: Operate to provide returns for shareholders; might prioritize profitability over certain healthcare services and must pay taxes on profits.

  4. By Teaching Status

    • Teaching Hospitals: Affiliated with medical schools; provide clinical education for students. Notable experiences include exposure to cutting-edge technology and collaboration with less experienced interns.

    • Accreditation: A formal process certifying organizations meet healthcare standards; voluntary but essential for reimbursement from major payers like Medicare.

Differences in Nursing Experience Across Settings

  • Acute Care: Fast-paced environments focusing on immediate health conditions.

  • Long Term Care

Managed Care Overview

  • Definition of Managed Care

    • A system involving a network of providers who manage a population's health while considering costs and delivering quality care.

    • Incorporates health insurance companies and involves navigating the healthcare system efficiently.

Health Maintenance Organizations (HMOs)

  • Definition

    • A prepaid health plan wherein members pay a fixed fee for comprehensive health services.

  • Care Coordination

    • Aims to organize all care through a primary care provider (PCP) acting as a gatekeeper.

    • Patients need a referral from their PCP to see specialists within the HMO network.

    • Out-of-network care is often not covered or covered at a significantly reduced rate (e.g., small fraction).

  • Pros and Cons

    • Pros: Lower premiums.

    • Cons: Restricted freedom of choice; care is managed strictly by the HMO.

Preferred Provider Organizations (PPOs) and Independent Practice Associations (IPAs)

  • PPOs

    • Provide flexibility and choice at higher prices.

    • Patients benefit from a preferred network with lower co-pays and can see out-of-network providers without referrals, although at higher costs.

  • IPAs

    • A structure allowing independent private practice doctors to collaborate with managed care plans, like HMOs and PPOs.

    • Relationship with PPOs: Both provide a balance of cost control and choice for patients.

Community Service Organizations

  • Purpose

    • Focus on the health of entire communities rather than individuals; historically aimed at controlling infectious diseases and offering preventive services.

  • Key Services Provided

    • Maternal and child health care, mental health services, and environmental health inspections.

  • School Health Programs

    • Serve as primary healthcare points for children who do not qualify for insurance.

Home Health and Subacute Care Organizations

  • Growth Factors

    • Increase due to hospitals discharging patients too soon, resulting in the rise of home health services.

    • Subacute Care: For patients with complex needs post-hospitalization.

    • Home Health Organizations: Provide skilled nursing and therapy at home, critical for safe transition from hospital to home care.

  • Nurse's Role in Home Health

    • Essential for assessing patient care, self-care abilities, and family support systems.

Prospective Payment System (PPS) and Diagnosis Related Groups (DRGs)

  • PPS Overview

    • A method employed by Medicare where hospitals receive a fixed amount based on diagnosis instead of billing for every service provided.

  • Impact of DRGs

    • Each DRG corresponds to a diagnosis, determining the fixed payment amount; e.g., treatment for a broken hip.

    • If complications arise (e.g., pneumonia), hospitals still must treat but only receive payment for the primary DRG.

  • Consequences

    • Incentivizes quick discharges; patient care may be compromised as hospitals aim to minimize costs.

Palliative, Long-Term Care, and hospice care

  • Definitions and Differences

    • Palliative Care: Comfort care for serious illnesses, can accompany curative treatments.

    • Hospice Care: Focuses on dignity and comfort at the end of life, inherently includes palliative care principles.

    • Long-Term Care Facilities: Offer skilled nursing and residential non-skilled care.