Week 6 Flashcards
1
Q
Healthcare services delivered in home
A
Home Health
2
Q
Where are patients normally coming from prior to receiving home health services?
A
Just coming out of hospital or referred by healthcare provider
3
Q
Who has access to home healthcare?
A
For Medicare:
-Under care of doctor
-Intermittent skilled care (nursing, PT, OT, SLP)
-Homebound: can’t leave without help or leaving isn’t indicated due to medical condition
Also covered under Medi-Cal and private insurance
4
Q
T/F: To access home health under medicare, an individual must be under the care of a doctor, receiving skilled care services, or is homebound
A
False! To access home health, pt must be under the care of a doctor, receiving skilled care services, AND homebound
5
Q
Federal primary medical coverage provider for many persons aged 65 and older and for those with a disability
A
Medicare
6
Q
Joint federal and state program that helps low-income individuals and families pay for the costs associated with medical and long-term custodial care
A
Medicaid.
7
Q
T/F: Unlike Medicare, which is available to everyone, Medicaid has strict eligibility requirements
A
True. Requirements vary by state
8
Q
What is the most common form of funding for home health care?
A
Medicare
9
Q
Highest paying setting for OTs
A
Home health. Pay per visit is highly competative
10
Q
The following are all roles for OTs in which setting?
- Ability to perform daily activities (shower, cook, walk)
- Home safety assessment and falls risk (modifications?)
- Reduce risk for additional injury or decline
- Management of chronic health conditions (medication, diabetes, heart failure, COPD, cognitive conditions, behavioral health)
- Educate family members
A
Home health
11
Q
What are possible emerging areas for home health?
A
- Discharge from hospital: can send pt home with home health care. Much cheaper!
- Home health is in high demand!
12
Q
Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility
A
Programs of All-Inclusive Care for Elderly (PACE)
13
Q
What are the 3 facets of the PACE program?
A
- In home services: Includes caregivers, meals, all inclusive care, DME, transportation, primary care needs, social work
- Community: Remain in community rather than nursing home. Caregiver comes out to home assessments, specialist appointments
- PACE center-receive skills services
14
Q
Who is part of the interdisciplinary team in PACE ?
A
- PCP (Primary Care Provider)
- RN
- MSW (social worker)
- PT
- OT
- Reaction Therapist/Activity Coordinator
- Dietitian
- PACE center manager
- Home Care Coordinator
- Personal Care Attendant
- Driver
15
Q
Who has access to PACE?
A
- 55 or older
- Live in service area of PACE program
- Certified as needing nursing home-level care
- Be able to live safely in community with PACE services
16
Q
Purpose of this program is to keep people out of nursing homes because it is $$
A
PACE
17
Q
The following are all roles of OTs in what setting
- Perform assessments
- Home visits and home safety assessments
- Evaluate need for DME
- Skilled treatment
- Supervise maintenance exercises and groups
- Report progress, problems, and recommendations to IDT
- Caregiver education
A
PACE
18
Q
What is the funding source of PACE?
A
- Medicare and Medical, usually low income
- Also private pay
19
Q
Program in CA that offers free or low-cost health coverage for children and adults with limited income and resources
A
Medi-Cal
20
Q
Community-based program serving older adults and adults with chronic conditions and disabilities that might otherwise require a high level of care
A
Adult Day Health Care (ADHC)
21
Q
Program which does not provide home and community services, but monitors pt while he/she is in the program
A
Adult Day Health Care (ADHC)
22
Q
Goals of Adult Day Health Care (ADHC)
A
- Restore or maintain optimal capacity for self-care to frail elderly persons or people with disabilities-keep independent for as long as possible!
- Delay or prevent stay at institution, keep them living in the community with needed services
- Provide relief to caregivers
23
Q
In this program, individuals receive educational and recreational services e.g., stroke classes and receive services for management of conditions rather than specialized care
A
ADHC
24
Q
How is ADHC funded?
A
Provided via MediCal or private pay
25
Offers persons 60 years of age or older a long term continuing care contract that provides for independent living units, residential care/assisted living services, and skilled nursing care, usually in one location, and usually for a resident’s lifetime
Continuing Care Retirement Communities (CCRC). Everything you need in one community!
26
What is the biggest obstacle for entering a CCRC (continuing care retirement community) ?
Money! Most CCRCs require a substantial entrance fee (e.g., from a low of $100,000 to over a million) to be paid by the applicant upon admission along with monthly fees.
27
Model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety
Patient Centered Medical Home (PCMH). Patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand.
28
The objective of this model is to have a centralized setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Link patients to the services they need!
Patient Centered Medical Home (PCMH). Social work, mental health, physicians all under one roof!
29
Who is eligible for Medicare?
-65+ years or with disability
30
Where does funding come from for Medicare?
Federally run. Funding comes from younger individuals' income tax
31
Setting where someone may receive Medicare services under Part A:
- Inpatient Hospital
- SNF Rehab
- Skilled is medically necessary, not custodial (bathing, toileting, ADLs)
- Hospice
- Home Health with skilled services
32
Under part ____ Medicare services, individuals are eligible to receive skilled medically necessary services in inpatient hospital, SNF, or home health
Part A of Medicare. May also receive hospice care.
33
How long does coverage last for an individual receiving Part A Medicare services?
Benefits start when individual first enters hospital and ends when there has been a break of 60 consecutive days since inpatient hospital or skilled nursing care was provided (coverage resets after 60 days)
34
T/F: Under Part A of Medicare services, an individual who is eligible may only receive services twice in one year
False. there is no limit to the number of benefit periods
35
Under part _____ Medicare services, eligible individual receives outpatient and supplemental services
Part B
36
Benefits to Part B Medicare include all except which of the following?
```
A. Out-patient MD
B. Yearly wellness visits
C. Therapy (PT/OT, etc)
D. Inpatient services
E. DME
F. ED (educational services)
G. HHS (Human health services)
H. Labs
I. Ambulence
J. Ambulatory Surgical centers
K. Supplies and screening
```
D. Inpatient services fall under part A of Medicare
37
T/F: If you receive Medicare part A services, you also must get part B services.
False. If you get part A services, you don't need part B, but you can pay extra for them.
38
What is Medicare Part C?
Medicare-approved private health insurance plans for individuals enrolled in Part A and Part B. Includes HMOs and PPOs
39
Under which part of Medicare does private insurance that covers all Medicare services fall under?
Part C. May also offer extra coverage
40
Why might someone opt to receive Part C Medicare serviccs in addition to Part A and Part B?
If part A and part B don't provide all the services they need e.g., vision or dental. It is optional
41
Provides a prescription drug plan coverage for individuals who have Medicare part A and B
Medicare part D
42
If someone who gets Medicare part A and B services but needs drug coverage, what are the options?
- Under part D, join a specific drug plan that provides only coverage for drugs OR
- Join part C health plan that also provides prescription drug coverage
43
How is Medicare part A funded?
Mandatory payroll deduction (FICA tax) of 1.45% of taxable earnings (paid by each employee and the employer for each). So...mainly income tax
44
How is Medicare part B funded?
Premium payments deducted usually from monthly SS benefit checks for those who are voluntarily enrolled in the SMI plan (25%) and through contribution from the general revenue of the federal government (75%). Participants pay monthly premiums via private that covers all Medicare services and may also offer extra coverage
45
How is Medicare part B funded?
Premium payments deducted usually from monthly SS benefit checks for those who are voluntarily enrolled in the SMI plan (25%) and through contribution from the general revenue of the federal government (75%). Participants pay monthly premiums of about $105 (private insurance) for Part B medical coverage as well as Part D prescription drug coverage.
46
How are premiums (part B, C, D) in Medicare payed for?
Private health insurance
47
Who is eligible for Medicaid services?
- Targets low income population
| - But also older adults, disabilities
48
Where does funding for Medicaid services come from?
- State-federal partnership
- The federal government sets the basic requirements and the state makes its own requirements (eligibility standards; services e.g, type, scope, amounts; payment rates)
49
What does Medicaid provide?
- Hospital services
- Physician Services
- Nursing home care (including custodial)
- Home health care
- Lab and X-ray services
- Some optional programs also include services e.g., dental and vision care (unlike Medicare A and B)
50
T/F: Medicare part A and B covers dental and vision while Medicaid does not
False. Medicaid covers dental and vision while in Medicare, must get part C or D
51
When pt has both Medicaid and Medicare, they are called ________?
Dual Eligible patients, Medi-Medi
52
Who qualifies as a Dual Eligible?
- Low income AND
| - Over 65
53
T/F: With Medi-Medi, Medicare is the first payer and Medicaid covers benefits that Medicare doesn't
True. Medicaid supplements by paying premiums, co-days, and deductibles
54
T/F: The Medicare population is poorer and in general worse health than people of comparable age in Medicaid or in commercial plans
False! The MediCAID population is poorer and in geral worse health than people of comparable age in MediCARE or in commercial plans
55
T/F: Medi-Medi benefits are rich in terms of benefits but is generally uncoordinated
True
56
Long-term care services provided primarily by Medicaid as a result of disabling conditions and chronic illnesses.
Long Term Services and Supports (LTSS)
57
T/F: 50% of LTSS consumers in US are 65 years or older
True
58
What are the settings that LTSS can be received in?
-Nursing home
-Community (home and community-based services)
-Consumers home/apartment
-Assisted living
They want to remain in the community!
59
The majority of LTSS is funding via...?
Medicaid. Can be very expensive if private funding. Can also be by informal caregivers, long-term care insurance, or medicaid waiver programs
60
Who is eligible for LTSS?
Chronic health conditions
61
Funding source that has become a long term care program serving an increasing percentage of frail elders
Medicaid. Originally established to serve low-income individuals.
62
Enacted in 1965 to improve community social services for older persons by establishing grates to states for community planning and social services, research and development, personal training in aging
Older American's Act (OAA). Also included the beginning of the Administration on Aging (AOA)
63
Part of the Older American's Act enacted ________to serve as the Federal focal point on matters concerning older person
Administration on Aging (AoA). In this role, the Administration on Aging works to heighten awareness among other Federal agencies, organizations, groups, and the public about the valuable contributions that older Americans make to the nation.
64
Examples of Older American's Act programs
- Nutrition programs
- Area Agencies on Aging
- Senior centers
- State long-term care ombudsman programs
- Prevention of elder abuse, neglect, and exploitation
- Elder rights and legal assistance development
- Intergenerational problems
65
Part of the Older American's Act that helps coordinate range of services for older adults e.g., provide referrals. Local focal point for concerns.
Area agencies on aging. Each country has its own.
66
A civil rights law that was passed in 1990 and
prohibits discrimination against individuals with disabilities in all areas of public life including:
-Jobs
-Schools
-Transportation
-Public and private places open to general public
-State and local government services
-Telecommunications
Americans with Disabilities Act (ADA). Makes sure everyone has same rights and opportunities !
67
Gives civil rights protections to individuals with disabilities similar to other protected groups on the basis of:
- race, color
- age, sex,
- national origin
- religion
Americans with Disabilities Act (ADA).
68
This act is based off of the triple care act and includes 3 areas of focus:
1. Improved health (better outcome)
2. Efficient high-quality care (value-based care)
3. Improve patient's experience (Increased transparency , public reporting)
Affordable Care Act (ACA).
69
Healthcare reform is calling a shift to what kind of care?
Value-based care!
70
What does the transition in pay, part of the healthcare reform, look like?
Payments based on providing high-quality care, not volume of care
- Fee-for-service (e.g., minutes of therapy) -->
- Value-based payment (e.g., performance)
- Looking at quality rather than quantity
- More accountability of services and increased awareness of quality
71
In value-based healthcare, what is reimbursement based on?
- Achieved rates of pre-specified patient outcomes
- Adherence to patient-centered scientifically grounded best practice guidelines
- So, Quantity > Quality
72
In value-based healthcare, how are healthcare providers incentivized to provide high-quality care?
- Facility or provider payments are tied to performance or defined outcomes
- Poor performance is tied to financial penalties
- Must highlight value you're providing via documentation
73
What is care collaboration?
- Engaging patient and caregiver
- Shared decision making
- Caregiver and patient training
74
A bundled payment initiative including groups of doctors/hospitals/health care providers who come together voluntarily to give coordinated care to patients
Accountable Care Organizations
75
Bundled care for hip-joint replacement
Comprehensive Joint Replacement Initiative. Pay one amount for all services they need
76
Requires the reporting of standardized patient assessment data with regard to quality measures, payment, and discharge planning. Data must be standardized to allow for exchange of data among post-acute and other care providers (e.g., functional status, cognitive function, skin integrity, major falls, medical needs and conditions)
Impact Act of 2014
77
Initiative that rewards SNFs for providing quality of care
SNF Payment Initiative
78
T/F: As the population ages, the number of people needed home care is expected to rise
True. Especially as more older people who have chronic conditions are living longer.
79
According to Robnett, what feature is starting to provide opportunities to streamline the home health system?
Telehealth. By allowing close monitoring of patients in their homes through ordinary physiological assessment devices e.g., stethoscopes, blood glucose meters. This would save skilled medical professionals a trip to every patient's home
80
According to Robnett, we can expect continued growth and options in what area of service delivery?
The delivery of home or community based long-term care services. Cost-effective alternative to nursing homes and what most Americans prefer.
81
According to Robnett, what are some criticisms to the Program of All-Inclusive Care for the Elderly (PACE) ?
- Not easily affordable for middle income older adults, whereas it does help those eligible for Medicaid
- Requirement of using adult day services and giving up own primary care provider too restrictly
- Lack of awareness
- Lack of funding
82
T/F: According to Robnett, outcomes from the PACE programs have been positive
True. This includes:
- Lower nursing home admissions
- Better self-care reported health
- Lower mortality rates
- Lower healthcare costs
- Able to die in own home
83
Community-based group programs with specialized plans of care designed to meet daytime needs of individuals with functional and/or cognitive impairments
Adult Day Services
84
T/F: According to Robnett, Adult Day Services are highly fragmented
True. This is because they are not currently regulated in teh US. at the federal level
85
How are most adult day services payed for?
Most are paid for privately, although some state programs, long-term care insurance policies, Medicaid, and Veterans' Affairs programs can help
86
According to Robnett, what are some benefits of adult day services?
- Offered structured care in a protective setting, but more than "babysitting"
- Can help people with disabilities live at home
- Allows caregivers time to work or rest-less stress!
- Opportunities for social engagement, activities, meals in an environment that offers staff assistance when needed
- Delay institutionalization b/c give caregivers a break
87
Facility specifically designed to provide lifetime care within one community
Continuing Care Retirement communities (CCRC). Homes arranged in community and may be free-standing houses, condominiums, or apartments and include residential treatment facilities). Offer medical, personal care, housecleaning, meals, recreational, transportation, laundry, rehab, nursing, etc
88
TF: Continuing Care Retirement Communities (CCRC) are on the lower end of the housing payment spectrum.
False. They are on the housing end, so not an option for all older adults
89
What was DeJong's view on the IMPACT Act?
Argued that much of the legislation was not needed given what has already been put in motion as a result of the Patient Protection and Affordable care Act of 2010, the nation's health care reform law
90
According to DeJong, both the IMPACT act and ACA point in the same direction of....
-Toward value-based care, episode-based management, and bundled payment
91
According to DeJong, in what way does the ACA go further than the IMPACT act?
the ACA moves toward care management and payment that is episode based and population based, while the IMPACT Act shifts the timing of this transition with respect to postacute care
92
According to DeJong, how do therapists such as OTs need to change in order to shift to value-based payment?
- Therapists need to measure their productivity not in terms of therapy hours per day or some other unit, but in terms of how they will add value for all stakeholders, especially patients
- Requires therapists to become "smart" clinicians and be able to provide real value for patient
93
What does DeJong mean when he states that therapists must be "Smart"?
Therapists must become sophisticated users of "big data" analytics needed to customize and improve care in ways that will enhance patient experience and patient outcomes
94
According to Kane, the bedrock of these services are ADLs (assistance with daily tasks of bathing, dressing, walking, toileting, transferring, eating) and IADLs
Long Term Services and Supports
95
According to Kane, what are the three factors that provide a framework against which LTSS can be judged ?
1. Environment (private, public and shared space)
2. Philosophy (control and choice in services, control and choice in daily life)
3. Service capacity (Specialized services like medical, dental, vision, hearing, mental health, rehab, legal)
96
T/F: According to Kane, NF service capacity has gotten worse over the last 50 years
False. NF service capacity has improved markedly over 50 years
- OBRA 87' enhanced the regulation of nursing homes and included new requirements on quality of care, resident assessment, care planning
- the 2010 Affordable Care Act requires NFs to implement data-based proactive quality assurance and performance improvement
97
According to Kane, what did he state was the trend in terms of where older adults are now living?
LTSS for seniors is no longer so lopsided in favor of NFs. More options are available for housing for seniors including public housing, Naturally Occurring Retirement Communities (NORC), Senior Retirement Communities, Apartment-style assisted living
98
According to Kane, what are the concerns of LTSS receiving services in institutions?
- Environmental hallmarks that are not home like, but institutional like e.g., no private space
- Residents rarely leave settings
- Over-emphasis on safety
- Under-emphasis on Physical Environment (Should look at individual in the space and assess what works and doesn't)
- Strict regulations and professional rigidity that limit consumer choice
- Poor communication and information, especially at transitions (pts get little information and time to process it)
99
What did Kane state as possibly the greatest problem in NF environments?
Shared bedrooms! Medicaid standard is shared accommodations. Private bedrooms and bathrooms promote physical health and psychological well-being
100
Overall, how does Kane feel about LTSS?
LTSS needs to be radically reimagined. States that the next 50 years of LTSS need to begin with in-depth exploration of how to deliver LTSS to older people in a way that doesn't undermine value of the experience
101
According to Kane, the solution for better LTSS care must begin with the understanding and acceptance of what?
Understanding and accepting that LTSS needs to be adapted to individual and family needs and preferences. Must look at 3 facets: Environment, Philosophy, and Service Capacity
