Issues, Trends, and Health Policy Flashcards Preview

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Flashcards in Issues, Trends, and Health Policy Deck (159):
1

Therapeutic Relationship - What is involved in establishing rapport and professional therapeutic relationships (5)

Non-judgemental approach
Mutual trust
Professional boundaries
Confidentiality
Cultural competency

2

Therapeutic Relationship - Cultural competency -

Asian - eye contact

Does not make eye contact out of respect

3

Therapeutic Relationship -
Cultural competency -

Native american - medicine man

Let them in

4

Therapeutic Relationship
Cultural competency - Do you offer to call the clergy?

Be careful not to assume

5

Therapeutic Relationship
Cultural competency - Jehova's Witness?

They have a card that delineates that they do not want blood

6

Therapeutic Relationship - Therapeutic Communication

Listen more than talk
"Tell me..."
Never ask "why"
Focus on feelings - mad, glad, sad
No euphemisms

7

No euphemisms (example)

Use solid words like - Dead/died versus "gone or passed"

Im concerned about alcohol abuse or alcoholism versus alcoholic.

8

Therapeutic Relationship -
Crisis Intervention

Ensure safety - set boundaries
-- Put distance between you
-- Call security - not police

Establish trust/rapport
-- Offering self - reassuring patient "I AM HERE"

9

Therapeutic Relationship -
Crisis/Acute Grief Therapeutic Communication

Acknowledge feelings
-- Sad, or angry
-- DO NOT SAY "I UNDERSTAND"

Offering Self
--"I am here"
--"Is there something I can do for you?"

10

Medicare - who does medicare pay for

Elderly

11

Medicaid

Poor

Benefits vary from state to state

Medicaid payments are made after other insurance or third party payments have been made

12

Case Management

Comprehensive and systematic approach to quality care

Mobilize
Monitor
Control resources

13

What is QA/QI/CPI

Quality Assurance
Quality Improvement
Continuous Process Improvement

Management process to ensure quality

14

Process of QA/QI/CPI
(4)

Monitoring
Evaluating
Continuous Review
Improving

15

Components of QA/QI/CPI (6)

Monitoring
Care appropriateness
Effectiveness of care
Cost of care
Self-regulation
Peer review

16

Critical Path

Contains key patient care activities and time frames for those activities as needed

17

DRG

Diagnosis-related group

18

Care Map

a newer critical path
+ common problems

19

Who mandates scope of practice?

State board of nursing with state nurse practice acts

20

What are state practice Acts

Delineates what you can and cannot do

21

Where do we get our initials (AGACNP)

State board of nursing

22

Prescriptive authority

State board of nursing and specific state practice acts

23

Standards of advanced practice

ANA

24

DEA

allows numerification

but state practice acts dictate level of prescriptive authority

25

What are credentials

required education, license, and certification

minimal levels of acceptable performance

26

Licensure

Qualified -

from government agency - STATE BOARD OF NURSING

27

Certification

Mastery of information

from NON-governmental agency - ANCC/AANP/PNCB/NCC

28

Who said we could ADMIT patients

Joint commission in 1983

29

Credentialing

Process that we go through to obtain privileges

Committee is made up of Physicians

Can give partial credentials

30

Privileges

Hospital privileges

31

Medical abandonment

Termination without reasonable arrangements

32

E&M codes

Evaluation and Management

Identify the level of care provided

Match the level of service provided to the complexity of the presenting patient problem

33

Why are credentials necessary? (2)

Ensures safe health care

Comply with federal and state laws

34

Reimbursement levels, how many?

5 levels

35

Third party payers (5)

Medicare
Medicaid
Commercial indemnity insurers
Commercial management organizations (HMOs)
Businesses or schools

36

Who sets the payment standards for DRG

Medicare

37

Physical Exam documentations levels of E/M services? (4)

Problem focused
Expanded problem focused
Detailed
Comprehensive

38

Physical Exam documentations levels of E/M services

Problem focused

Most simple

a limited examination of the affected body area or organ system

39

Physical Exam documentations levels of E/M services

Expanded problem focused

Limited examination of the affected body area or organ system
AND
any other symptomatic or related body areas or organ systems

40

Physical Exam documentations levels of E/M services

Detailed

An extended examination of the affected body area or organ system and any other symptomatic
OR
related body areas
OR
organ systems

41

Physical Exam documentations levels of E/M services

Comprehensive

A general multi-system examination
OR
Complete examination of a single organ system and other symptomatic or related body areas or organ systems

42

EXAMPLE: of Physical Exam documentations levels of E/M services

Cellulitis + lower extremity assessment

Expanded problem focused

43

EXAMPLE: of Physical Exam documentations levels of E/M services

Patient says SOB, no life changes, otherwise ok. What assessment would you do

Comprehensive

44

EXAMPLE: of Physical Exam documentations levels of E/M services

New patient with a complaint

Comprehensive

45

Advanced Directive

Written statement of intent of medical treatment

46

Patient self-determination ACT of 1990.

Patient has the right to have an advanced directive.

47

Patient Self-Determination ACT of 1990.

All patients entering a hospital should be advised that they have the right to have an advanced directive.

48

Healthcare directive

Type of advanced directive that may or may not include a living will and/or specifications regarding durable power of attorney in one or two separate documents

49

Living will

Specifies which life-prolonging measures one does and does not want to be taken

50

Difference between living will and advanced directive

advanced directive
-- do not tube me
-- do not CPR me

living will
-- specifies life prolonging measures
-- includes DPOA - proxy

51

DPOA

Durable power of attorney -
-- articulate the wishes of advanced directive

52

Medicare A

Everyone > 65 years old

covers INPATIENT hospital services
and
Post hospital care (home health)

53

Medicare B

Supplemental - premium paid

Physician visits
-- Physical exam
Outpatient diagnostics

54

How much do NPs get reimbursed by Medicare

85% of Physician fee schedule

80% for procedure

55

Medicare C

FREE ontop of A&B
Choice HMO, PPO

Medicare A+B = C

56

Medicare D

Premium

Drugs

Limited prescription coverage

57

Which type of medicare has to pay premium?

B & D

58

Services that DO NOT meet medicare's definition of "Physician Services"

Regular physical exam

Health maintenance screenings

Counseling for well patients

59

Medicare Rules for NPs (3)

Hold state license
Certified by national body
Hold at least MSN

60

Incident-to Billing

NP sees patient and can bill under physician's provider number to get 100%.

61

Incident-to Billing - OFFICE ONLY

NP sees patient and can bill under physician's provider number to get 100%.
-- Physician's direct supervision (same building)

62

Doctor see's patient - diagnoses HTN.

3 months later - comes for follow up. Can you bill incident-to billing

Bill incident-to billing for 100% reimbursement.

63

Is double billing allowed?

Cannot bill by 2 providers in same day.

64

Healthy People 2020 goals (2)

Increase quality and years of healthy life

Eliminate health disparities among Americans

65

Reporting Statutes (5)

Criminal acts

Animal bites - animal control

Suspected or actual child/elder abuse

Domestic violence

Communicable diseases - Health Department

66

Criminal Acts

Police can get generalized

67

Health department reporting requirements in most states (5)

Gonorrhea
Chlamydia - not all states
Syphilis
HIV
TB

68

Are you legally responsible for reporting domestic violence?

NO

offer support
-- social work

69

Who works on our behalf in the hospital with suspected elder abuse?

Social services

70

Collaborative practice

"true partnership"

Unique qualities that can be synergistic

Recognize and accept separate areas of responsibility and activity

71

Navigating Health Care systems for patients (6)

Social Services
Psychiatric services
Police
Security officers
Physical therapy
Occupational therapy

72

Social services - What do they do

"dig up the dirt"
Domestic violence
Help with resources
--lack of money
--no insurance

73

Psychiatric services -

Anyone who is in danger of harming themselves or others

74

Police

Don't call the police from the hospital

75

Security

Escalating scene

76

Physical Therapy

Joints
-- Range of motion
-- Walking
-- Strength training

77

Occupational therapy

Fine motor
Psychomotor
Rehab into JOB
-- Writing

78

Issues regarding access to care

Home health
Hospice
Skilled Nursing Facilities
Private duty nursing

79

How does home health nurse work?

"flight attendant approach"
check vitals
wound care
incentive spirometry
how is pain, pain meds
are you able to get food

80

Who qualifies for hospice?

Death diagnosis < 6 mo

ONLY comfort measures
-- controversial IV antibiotics

81

What is Skilled Nursing Facilities?

Multidisciplinary team there

Nursing home with physical therapy room

cost saving - early discharge from hospital

82

What is the problem with private duty nursing

Very expensive

83

Privacy and Confidentiality

HIPAA title I

Patient has a right to continue health care benefits for up to 18 months if no longer employed by practice

COBRA

33.4% $$

84

Privacy and Confidentiality

HIPAA title II

Protecting records

85

COBRA

Comprehensive Omnibus Reconciliation Act

86

Who enforces HIPAA and protects privacy of health information?

The Office of Civil Rights

87

What is covered under HIPAA

Health plans (HMO)
Most health care providers
Health care clearing houses

88

Examples of protected information by HIPAA

Written information

Conversations by healthcare providers

Patient information stored in a health insurer's computer system

Patient billing information stored at a clinic

Most all health-related information about a patient

89

The Privacy Rule

Patient has a right to
-- see their chart
-- have corrections made
-- receive notice
-- decide whether or not they give permission
-- receive report of when/why did they share their information
-- file complaint if info not protected

90

Examples of those NOT required to follow HIPAA

Life insurers
Employers
Workers compensation carriers
Many schools and school districts
Many state agencies like CPS
Many law enforcements
Many municipal offices

91

Doctors notes - to keep privacy

"please excuse *** for these days due to medical reasons/care under this office"

92

The Patient safety and Quality Improvement ACT (PSQIA) -
What is it

Voluntary reporting system to enhance data that can resolve patient safety and quality issues

93

The Agency for Healthcare Research and Quality

Additional responsibility for listing patient safety organizations (PSO) which are external experts established by the patient safety act to collect and analyze patient safety information

94

Confidentiality versus "Duty to Warn"

Reasonable right to know.

the Duty to warn supersedes the right to confidentiality if the patient's condition may endanger others

95

Patient is spurting blood around the ER, fix him and he is HIV +. refer to psych. Can you tell the Psych NP about HIV?

Yes,

He was endangering others.

96

Invasion of privacy

Damaging one's reputation as a result of information being shared without patient permission.

97

Root cause analysis

Interdisciplinary experts
asking WHY WHY WHY at each level
Identify changes
A process that is as impartial as possible

"drilling down"
"cause and effect diagrams"

98

Sentinel Events (4)

Unexpected occurrences

Death OR serious physical or psychological injury of risk thereof

NOT medical error

Needs to be a root cause analysis

99

Risk management

A systematic effort to reduce risk

100

What is the most common method of risk management documentation?

Incident reports

101

Risk management:

Policies regarding incident reports should address: (6)

Persons authorized to complete a report

Persons responsible for review of a report

Immediate actions

Person's responsible for follow-up

Plan for follow-up monitoring

Security/storage of reports

102

A formal, written risk management plan includes: (5)

Goals

Program's scope

Responsibility for implementation

Commitment by the board

Immunity from retaliation

103

What are types of Risk management?

Incident reports
Satisfaction surveys
Complaints

104

Risk Management -
Action taking initiatives (5)

Prevention
Correction
Documentation
Education
Departmental coordination

105

Medical Futility

Interventions unlikely to produce any significant benefit

106

Quantitative futility

The likelihood that an intervention will benefit the patient is extremely poor

107

Qualitative futility

The quality of the benefit of an intervention is extremely poor

108

To make Informed consent, the patient must be able to (4)

ability to:
Understand
Reason
Differentiate good and bad
communicate

109

Informed Consent

A state indicating that a patient has received adequate instructions or information regarding aspects of care to make a prudent, personal choice regarding treatment

110

Does the patient have a right to refuse care?

yes, they can refuse
any of it
some of it
all of it

Patients must be informed on arrival that they have a right to refuse care

111

Danforth Amendment, 1991

Patients must be informed on arrival that they have a right to refuse care (at a federally funded institution)

112

Informed consent must include:

all benefits and risks to be truly informed

if the patient's condition is life-threatening consent is assumed.

113

Ethics is

The study of moral conduct and behavior which serves to govern conduct, thereby protecting the rights of the individual

114

Nonmaleficience

The duty to do no harm

115

Veracity

The duty to be Truthful

116

Fidelity

The duty to be Faithful

117

If a patient is hired to testify and asked to state that the NP only had "one" option of treatment, which 2 ethical principles are in conflict?

Fidelity and veracity

118

A cancer patient wants to stop taking chemotherapy. Which to ethical principles are in conflict when making this decision?

autonomy versus beneficence

119

What is often in conflict with Autonomy?

Beneficence

120

What is often in conflict with fidelity?

Veracity

121

Utilitarianism

The right act is the one that produces the greatest good for the greatest number

122

Beneficence

The duty to prevent harm and promote good

123

Justice

The duty to be FAIR

124

Autonomy

The duty to respect an individuals thoughts and actions

125

According to utilitarianism who should be helped first in a 911 situation? The people running down the street, the people below the burning building, or the people above the burning building

1. People down the street
2. People below
3. Salvageable

126

Can you dismiss someone from your practice? (3)

Yes:
Abuse
Refusal to pay for services
Persistant noncompliance

127

What do you do when you close a practice? (3)

1. Proper notification
2. Keep all files for 5 years
3. To avoid abandonment - give notice and resources for future care

128

Steps for discharging a patient from a practice: (3)

1. Certified letter - return receipt
--General content
2. General healthcare coverage for 15-30 days post-termination deadline
3. Obtain release of information to provide copies for subsequent provider

129

History of the NP Role -

What area did the first NP roles begin?

Pediatrics

d/t physician shortages

130

History of the NP Role -

How did the ACNP role movement begin? (3)

Results of managed care
Hospital restructuring
Decreases in medical residency programs

131

History of the NP Role -

Who and when was the first NP program initiated

Loretta Ford and Henry Silver in 1964, pediatric NP program at University of Colorado Health Sciences Center

132

History of the NP Role -

What are the 4 distinct roles for NP?

1. Clinician
2. Consultant/collaborator
3. Researcher
4. Educator/instructor

133

EVIDENCE BASED PRACTICE and RESEARCH

Where does the AGACNP participate in the research process?

Any and all of them

134

EVIDENCE BASED PRACTICE and RESEARCH

How many major steps in the research process?

11

135

EVIDENCE BASED PRACTICE and RESEARCH

What are the types of research (broad)

Experimental
Non-experimental
Qualitative

136

EVIDENCE BASED PRACTICE and RESEARCH

What are the subcategories of Non-experimental?

"No experiment"

Ex post facto/Correlational - "in the past"
- examines relationships among variables

Descriptive - aims to describe

137

EVIDENCE BASED PRACTICE and RESEARCH

What are the Ex post facto types of research (3)

Ex post factos is non-experimental

Cross sectional

Cohort

Longitudinal

138

EVIDENCE BASED PRACTICE and RESEARCH

What is cross sectional research?

examines a population with a very similar attribute, but differs in one specific variable - to find relationships between variables at a specific point in time

139

EVIDENCE BASED PRACTICE and RESEARCH

What is an example of cross sectional research? like an onion

A SURVEY for asthma in children and adults

140

EVIDENCE BASED PRACTICE and RESEARCH

What type of research is - pulling the surgeons records for the last 6 months to describe a situation?

Ex post factos

141

EVIDENCE BASED PRACTICE and RESEARCH

What is a cohort studies

Study that compares a particular outcome

What is the outcome of your graduating class?

142

EVIDENCE BASED PRACTICE and RESEARCH

Longitudinal

Over time - taking multiple measures of a group to find relationships
1 year, 5 year, 10 year follow up

143

EVIDENCE BASED PRACTICE and RESEARCH

Experimental

Randomized control group trial

144

EVIDENCE BASED PRACTICE and RESEARCH

What is a randomized control group trial?

Experimental

145

EVIDENCE BASED PRACTICE and RESEARCH

Quasi-experimental

Manipulation of variables but lacks a comparison group or randomization

146

EVIDENCE BASED PRACTICE and RESEARCH

What is Qualitative research?

Open-ended questions - "feelings"

Low sample sizes - question generalizability

Researcher bias is a potential problem

Produces rich data through no other means

147

RESEARCH

Level of significance

p level

p <0.05 - significantly different

148

EVIDENCE BASED PRACTICE and RESEARCH

Level of evidence hierarchy - list in order 1-6

1. Meta-analysis of RCT
2. RCT
3. Quasi-experimental
4. Qualitative cohort studies
5. Case controlled studies
6. Editorial/expert opinion

149

RESEARCH

Confidence interval

An interval with limits at either end, with a specified probability of including the parameter being estimated

A small confidence interval implied a very precise range of values

150

RESEARCH

Standard deviation

Indicates the average amount of deviation of values from the MEAN

68% of the sample within 1 standard dev
95% of the sample within 2 standard dev

151

RESEARCH

Perfect correlation

Perfect positive correlation +1

Perfect negative correlation is -1

closer you get to 1 the better you are

152

RESEARCH

t-test

statistical test to evaluate the difference between MEANS of 2 groups

153

RESEARCH

Reliability

The consistency of a measurement

alpha - > 0.7 - the closer to 1 the higher the reliability

154

RESEARCH

Validity

The degree to which a variable measures what it is intended to measure.

155

What is the most important research term to focus on whether to change your practice after reading publication?

Level of significance - p value

p < 0.05

156

RESEARCH

Terminal ill bone cancer patients in the final stage of illness have between 2.8 and 3.2 episodes of nausea every 24 hours. What are the numbers I am examining?

Confidence interval

157

RESEARCH

normal distribution - Bell curve - the mean age in the room is 40 +/- 10, with a standard deviation of 5.

95% are between 30-50
5% are 25-55

158

RESEARCH -

p-value

Level of significance

p <0.05

Usually don't put in research if > 0.05 because there is no statistical significance in the research

159

RESEARCH

2 ways to test reilability

Test/re-test - 2 administrations should yield same score

Internal consistency - estimates reliability by grouping questions