prospective payment system
eliminated cost-based reimbursement by grouping inpatient services for Medicare clients into 468 diagnosis related group DRGs (established by congress in 1983)
diagnosis-related groups
groups of inpatient services with fixed reimbursement amounts with adjustments based on severity, regional costs, and teaching cost, regardless of length of stay or use of service
capitation
when providers receive a fixed amount per client of a health care plan
managed care
health care systems in which there is administrative control over primary health care services for a defined client population, aimed at reducing costs
medicare
national health insurance program for people 65 and older. prosepctive reimbursement system is based on payment calculated on the basis of DRG assignment.
medicaid
provides health insurance for low-income families, health assistance to low-income people with long-term care disabilities, and supplemental coverage to older adults and medicare beneficiaries in nursing homes
differences between primary health care and primary care
primary care focuses on health services provided on an individual basis, whereas primary health care focuses on improved health outcomes for an entire population
professional standards review organizations
review the quality, quantity, and cost of hospital care
work redesign
allowed more services to be available on nursing units, minimizing the need to transfer and transport clients across multiple diagnostic and treatment areas
case management
Because of the need to contain costs, many hospitals uses a case management model of care. In which a case manager coordinates effors to achieve the most efficient and appropriate plan of care for the client, focusing primarily on discharge planning
*discharge planning
this planning begins the moment a client is admitted to a health care facility. a centralized, coordinated, multidisciplinary process that ensures that the client has a plan for continuing care after leaving a health care agency
*critical pathway
multidisciplinary treatment plan that oulines the treatments or interventions clients need to have while in the hospital for a specific condition or procedure
instruction prior to discharge
safe and effective use of meds and equipment, instruction in food-drug interactions and diet counseling, rehab techniques, access to avilable community resources, when and how to obtain further treatment, and the client's and family's responsibilities and
*home care service
provision of medically related professional services and equipment to clients in their homes for health maintenance, education, illness prevention, treatment, palliation, and rehab
types of home care services
wound care, respiratory care, vitals, elimination, nutrition, rehabilitation, medications, intravenous therapy, laboratory studies
rehabilitation
restores a person to the fullest physical, mental, social, vocational, and economic potential possible. Drug rehabs centers help clients become free from drug dependence and return to the community.
extended care facility
provides intermediate medical, nursing, or custodial care for clients recovering from an acute illness or clients with chronic illnesses or disabilities
intermediate care/skilled nursing facility
offers skilled care from a licensed nursing staff until clients are able to move back into the community or into residential care
*restorative care
goal is to help individuals regain maximal functional status and to enhance quality of life through promotion of independence and self-care
nursing center
provides 24 hr intermediate and custodial care such as nursing rehabilitation, dietary, recreational, social, and religious services for residents of any age with chronic or debilitating illnesses
assisted living
homier environment and greater resident autonomy
respite care
short-term relief for the family members who care for the client
adult day care center
provides a variety of health and social services to specific client populations who live alone or with family in the community. Services offered during the day allow family members to maintain their lifestyles & employment & still provide home care for th
hospice
focus of care is palliative, not curative, treatment
evidenced-based practice
problem solving approach that involves the use of current best evidence, along with clinical expertise and client preferences and values in making decision about client care
research-based practice
the use of knowledge based on the results of research studies
quality improvement
a continuous process that focuses on improving the performance of all providers
nursing-sensative outcomes
client outcomes that are directly related to nursing care
seven dimensions that most affect clients' experiences
1) respect values, preferences, and expressed needs 2) coordination and integration of care 3) information, communication, and education 4) physical comfort 5) emotional support and relief of fear and anxiety 6) involvement of family and friends 7) transi
*Primary Prevention
health-promoting behaviors or activities that reduce the occurence of an illness
*Secondary Prevention
early diagnosis adn treatment of illness (e.g., screening for hypertension)
*Tertiary Prevention
Care that prevents further progression of disease
*primary care
focuses on health services provided on an individual basis. (prenatal care, well baby care, family planning, nutrition counseling, etc.
*preventive care
blood pressure and cancer screening, immunizations, poison control information, community legislation (seat belt, air bags, bike helmets, Mental health counseling and crisis prevention
*Secondary Acute Care
Emergency care, acute medical surgical care, radiological procedures
*Tertiary Care
Intensive care, subacute care
Continuing Care
These services are for person who are disables, who never were functionally independent, or who suffer a terminal diseaase. (Assisted living, psychiatric and older adult day care)
managed care system
decribes health care systems in which there is administrative control over primary health care services for a defined client population.The provider of care receives a predetermined capitated payment regardless of the service a client uses
what nurses need to do
nurses need to remain knowledgable and proactive about issues in the health care delivery system to provide quality client care and positively affect health.
Emphasis on Population Wellness
The United States health care delivery system faces many issues such as rising cost of health care, increased access to services, a growing population, improved quality of outcomes, and threats of bioterrorism.
The Health Services Pyramid
developed by the Core Functions Project (U.S. Public Health Service, 1994/2000) serves as a model for improving the health care of U.S. citizens
Integrated Delivery Networks (IDN)
includes a set of providers and services organized to deliver a continuum of care to a population of clients at a capitated cost in a particular setting.
*Disease Prevention
Activities that protect people from becoming ill because of actual or potential health threats
*Disease Management
is the most common and expensive service of the health care delivery system
*Work Redesign
To contain cost, many hospitals have redesigned nursing units. Because of work redesign, more services are available on nursing units, thus minimizing the need to transfer and transport clients across multiple diagnostic and treatment areas.
*A home care service
also coordinates the access to and delivery of home health equipment, or durable medical equipment (DME), which is any medical porduct adapted for home use.
*Assisted living
offers an attractive long-term care setting with a homier environment and greater resident autonomy. Clients require some assistance w/ADL but remain relatively independent within a partially protective setting. Assisted living provides independence, secu
Nursing Outcome Classification
NOC emphasizes outcomes that nursing interventions most affect. However, all health care disciplines can use this system.
Nursing informatics
combines the best of computer science and information science with nursing science.
Data / information
are individually distince pieces of reality Nurses gain or use information when they organize, structure, or interpret data.
Knowledge
develops when nurses combine and identify relationships between different pieces of information.
Electronic Health Record (EHR)
provides a comprehensive electronic record of a clients medical problems, treatment, diagnostic procedures, and nursing care.
Globalization
physicians adn health care providers making their services more accessible. (across state and national boundaries)