Outpatient and Primary Care Services
Inpatient Facilities and Services
Inpatient Facilities and Services
Managed Care and Integrated Organizations
MCOs and Long-Term Care
100
-Outpatient existed before hospitals and nursing homes -Hospitals major player in outpatient services -Hospitals capitalized on technology to compete on an outpatient basis -Hospital labs and diagnostic better equipped -Solo practices consolidated to cope -Outpatient helps serve underserved population -Community health centers receive federal and state money to serve rural and inner cities -“Outpatient” is more comprehensive -Ambulatory care more diagnostic and therapeutic to the “walking” (ambulatory) -Outpatient and Ambulatory care used interchangeably
What are outpatient and primary care services?
100
- an institution with at least 6 beds whose function is to deliver patient services that include diagnostics and treatment must be licensed have an organized physician staff provide continuous nursing services supervised by RNs -Other Characteristics: a governing body is legally responsible for hospital conduct a CEO is responsible for operations medical records on each patient pharmacy services supervised by a registered pharmacist food services to meet nutritional needs
What is a hospital?
100
-Discharges -Inpatient Days -Average Length of Stay -Capacity -Average Daily Census -Occupancy Rate
What are the utilization measures and operational concepts that impact hospitals?
100
- The National Committee for Quality Assurance (NCQA) - Participation is voluntary, but about half are accredited - A national committee of physicians supervises the accreditation process - A rating system assigns 6 status categories
What does the accreditation of MCOs include?
100
Prospective UR Concurrent UR and discharge planning Retrospective UR
What are the 3 types of utilization review?
200
- Plays a central role in a health care delivery system - Focus on the type or level of services, prevention diagnostic therapeutic services health education counseling, and minor surgery - Coordination of care Delivery of health services between the patient and the different components of the delivery system Refer patients to sources of specialized care Give advice regarding various diagnosis and therapies Discuss treatment options Provide continuing care of chronic conditions
What is primary care or primary care services?
200
These consume the biggest share of national health spending; hence, were the first to be targeted with PPS. Subsequently, outpatient services mushroomed.
What are hospitals?
200
-Over half are private nonprofit (voluntary) -State and local government owned are the next largest group -For-profit or investor-owned come next -Federal hospitals are the fewest in number -Numerous ways to classify -Classifications are not mutually exclusive
What are types of hospitals?
200
- Healthcare Effectiveness Data and Information Set (HEDIS) - HEDIS results are used by employers, the general public, public insurers, and regulators - Over 90% of health plans use HEDIS - 2013 HEDIS has 80 measures in 5 domains: Care effectiveness Access to and availability of certain services Client experience of care Utilization and resource use Information on the health plan
What does quality assessment in MCOs include?
200
Staff Group Network Independent practice associations (IPAs)
What are HMO models?
300
True or False? All primary care is outpatient, but not all outpatient care is primary care. Give examples
What is True? Examples: emergency room, urgent care treatment, outpatient surgery, rehabilitation, renal dialysis, chemotherapy
300
1. Social welfare almshouses and pesthouses 2. Care for the sick public and voluntary institutions 3. Medical practice medical science and technology hospital administration, organization, efficiency 4. Medical training and research collaboration between hospitals and universities 5. Consolidated systems organizational integration service diversification
What are the 5 dominant functions that impacted the evolution of hospital transformation in the U.S.?
300
Public (Government ownership) Private nonprofit Private for-profit (Proprietary)
What are hospital classification by ownership type?
300
Two main factors: Flaws in fee for service Weakened economic position of providers
What are the factors that have impacted growth of managed care?
300
Personal care—basic ADL assistance (e.g., bathing) Custodial care—nonmedical care to maintain function and prevent decline Restorative care—help regain or improve function; professional therapies Skilled nursing care—clinical care provided by licensed nurses under the direction of a physician Subacute care—postacute, technically complex services
What are the levels of long-term continuum?
400
-Changes in reimbursement constraining inpatient services favoring outpatient services -Fewer payment restrictions surgery, dialysis, chemotherapy paid as fee-for-service - Development of New Technology less invasive procedure quicker recuperation from surgery - Utilization Controls Managed care restriction on utilization, quicker discharge prior authorization (precertification) utilization review - Social Factors Preference for obtaining services at home or in community based settings, especially long term care
What are reasons for growth in outpatient primary care services?
400
1) advances in medical science 2) development of specialized technology and surgical services 3) advances in medical education 4) development of professional nursing 5) growth of health insurance 6) role of government
What are the 6 main factors that have led to the in the growth of hospitals from the Late 1800s to Mid-1980s?
400
1) general hospital 2) specialty hospital 3) psychiatric hospital 4) rehabilitation hospital 5) children’s hospital
What are the types of service for hospital classifications?
400
Choice restriction Gatekeeping Case management Disease management Pharmaceutical management Utilization review Practice profiling
What are the cost control methods for MCOs?
400
Home health care Adult day care Adult foster care Senior centers Home-delivered and congregate meals Homemaker services Continuing Care at Home Case management
What are the types of community-based LTC services?
500
1. Clinical Services: Special consultation 2. Surgical Services 3. Emergency Services for Acute Services - Emergent require immediate attention - Urgent require attention within a few hours - Non urgent, non emergency (used by mostly uninsured as a substitute for primary care) 4. Home Health Care 5. Women’s Health Center - Women are major users of health care due to a female majority Change in culture towards women’s equality A national priority
What are the 5 main types of hospital based outpatient care services?
500
- Changes in Reimbursement From cost-plus to PPS Decrease in inpatient utilization - Impact of Managed Care Emphasis on cost containment Efficient utilization of resources (care in alternative settings) - Hospital Closures Economic constraints Many rural and urban hospitals had to close Other hospitals closed wings or used them for alternative purposes
What are the reasons for hospital downsizing from the mid 1980s onward?
500
1) ? - A hospital must be licensed to operate - State government oversees w/ own set of standards - Emphasizes physical plant compliance with: building codes fire safety climate control space allocations sanitation 2) ? - Not mandatory (required only if a hospital wants to participate in Medicare and Medicaid—most do) - A federal function - Hospitals must comply with the conditions of participation—federal standards for health, safety, and quality - Currently revised conditions focus on quality of care delivered and the outcomes of that care 3) ? - Joint Commission or American Osteopathic Association - Accreditation is a private undertaking - It is voluntary for the hospital - It confers deemed status on hospitals - Deemed status is not conferred on nursing homes
What are licensure, certification and accreditation?
500
Three main strategies: Drug formularies Tiered cost sharing Pharmacy benefits management companies
What are the 3 main strategies for MCOs pharmaceutical management?
500
- Brokerage model—Case managers are freestanding agents who assess client needs and make referrals; minimal coordination and monitoring Medicaid Preadmission Screening and Resident Review (PASRR) - Managed care model—Services are delivered through a social managed care plan. All services are received through the MCO. Have been shown to postpone institutionalization But, only 4 such programs participate in Medicare - Integrated care model—PACE — focused on frail elderly already certified for nursing home placement under Medicare and/or Medicaid
What are case management models?