Unit 1 American Healthcare Delivery System Flashcards
What are the levels of care?
Primary:
- Primary care MD’s, NP’s
- Pediatricians, OB/GYN’s
Secondary:
- Speciality care
- Referrals (cardiologists, oncologists)
- Screenings
Tertiary:
- High specialized care
- Open heart Sx
- Dialysis
- Neurosurgery
What are the types of managed care?
HMO:
- needs referral, uses “gatekeeper”
- more restricted than PPO
- employer negotiates set price with company for employee
PPO:
- No referrals “gatekeeper”
- More expensive
What is Medicare? Who is it for? What are the four parts?
-Largest single payer healthcare
- Insurance 65 yoa and older
- Disabled, renal failure, ALS, etc. (need to be permanently disabled)
Part A = Hospital
Part B = Outpatient
Part C = Medicare Advantage (supplemental)
Part D = Medications
What is Medicaid?
Healthcare for those with limited recourses
Describe what is long term care and how it works.
- The individual pays until funds are $2,000 than Medicaid kicks in.
- HMOs, PPO’s, and Medicare do NOT pay.
- Short subacute stays 100 days/incident are paid.
- Social services like meals on wheels can be used.
-Most is not medical care , but rather assistance with ADL’s
What are the good things brought in by the ACA?
Insurance reforms:
- Prohibit use of “pre-existing conditions”
- Children/Depends can stay on parent’s insurance until age 26
- No lifetime limits
- No dropping sick pt’s allowed by insurance companies
- No copay for wellness checks (pap smears, etc)
What does case management do?
- Transitions between care
- Works with the entire healthcare team to meet PT needs
- Reviews charts and resources to ensure proper PT care
- Expert on public and private insurance reimbursement policies
- Facilitate admission and discharge process
What are clinical/critical pathways?
Map the focuses on treatments and outcomes for the illness/issue/disease.
What is a variance and what are the types?
Patient does not follow the approved critical pathway.
Patient variance ex: PT does not take medication
Provider variance ex: MD does not prescribe Rx
System (hospital) variance ex: Testing machine broken
Community variance ex:
-PT about o be discharged however, cannot return to nursing home because it’s Sunday and not open so they have to wait until Monday.
What is the Clinical/Critical pathway for CVA?
- Head CT within 10 minutes of arrival
- NIH stroke scale is completed within 15 minutes
- Fingerstick glucose and EKG completed within 30 minutes
- Weight patient
- TPA within 60 minutes
- Nurse perform bedside swallow evaluation by day 2
- ) DC telemetry by day 3
- ) Notify PT/family of stroke education class
What is Evidence Based Practice?
-Use of current best evidence in making decisions about client care
What are the steps to evidence based practice?
- Ask question
- Search
- Critically appraise
- Implement
- Evaluate
What is collaborative/interdisciplinary management?
Interaction of two or more health professionals, who bring their unique skills and knowledge to assist patients/clients and families with health decisions.
What is Risk Management?
Process of reducing or financing the cost of predictable losses; example: CAUTI
Includes identification, evaluation, and treatment of possible and actual risk situations to reduce change of loss
Incident report/occurence report used a documentation tool NOT part of PT record
What is continuous quality improvement (CQI)?
- Evaluates outcomes of care
- Ensures each PT receives predetermined high quality standard of care
- Similar to the nursing process (Plan, Do, Check, Act) with the focus on evaluation
