Lecture Notes

Community-Based Health Care

Types of health care delivery services
1. primary (health promotion and illness prevention)
  1. health care delivery services that provide generalized health promotion and specific protection against disease
  2. examples
    1. immunizations
    2. risk assessments for specific diseases
    3. health education about poisoning prevention
2. secondary (early diagnosis and treatment)
  1. health care delivery services that emphasize early detection of disease, prompt intervention, and health maintenance for individuals experiencing health problems
  2. examples
    1. encouraging regular medical and dental checkups
    2. assessing the growth and development of children
    3. teaching breast self-examination
3. tertiary (rehabilitation)
  1. health care delivery services that begin after an illness, when a defect or disability is fixed, stabilized, or irreversible
  2. examples
    1. referring a patient who has a colostomy to a support group
    2. teaching a patient who has diabetes to identify and prevent complications
    3. referring a patient with a spinal-cord injury to receive training that will maximize use of remaining abilities
Settings for nurses
1. hospital
  1. 54.9%
2. nursing home/long-term care
  1. 9.5%
3. doctor's office
  1. 7.1%
4. home health care (community-based)
  1. 5.3%
5. extended care facility/skilled nursing facility
  1. 3.1%
6. home health care (hospital-based)
  1. 2.2%
7. school
  1. 1.9%
8. mental health
  1. 1.6%
9. public health department
  1. 1.4%
10. nursing school faculty
  1. 1.3%
11. hospice
  1. 1.0%
12. occupational health department
  1. 0.8%
13. other
  1. 9.9%
Collaborative care
1. physician
  1. an individual who is prepared to prevent, diagnose, and treat disease or injury through medical or surgical interventions
2. osteopathic physician
  1. an individual who is prepared to prevent, diagnose, and treat disease or injury through medical or surgical interventions or manipulation of body structures (especially the spine) to correct derangement of tissues
3. physician assistant (PA)
  1. an individual who is prepared to assist a physician or osteopath through performance of specific diagnostic and therapeutic procedures under the supervision and direction of a physician or osteopath
4. dentist
  1. an individual who is prepared to prevent, diagnose, and treat abnormalities of the teeth, gums, and underlying bone, including conditions caused by disease, trauma, and heredity, through repair and restoration of teeth, replacement of missing teeth, and detection of the signs/symptoms of disease
5. pharmacist
  1. an individual who is prepared to good health for patients of all agest through preparation, compounding, and dispensing drugs upon a written order (prescription) from a practitioner, such as a physician, osteopath, dentist, or advanced practice nurse, and providing clinical information on drugs or medications to healthcare professionals and patients
6. registered dietitian (RD)
  1. an individual who is prepared to promote good health for patients of all ages through education about basic and modified diets necessary to meet nutritional needs and the therapeutic use of diet in the treatment of disease and design of specialized diets to meet nutritional needs
7. physical therapist (PT)
  1. an individual who is prepared to evaluate, test, and treat people of all ages whose mobility, self-care, and other functional skills necessary for daily living are challenged by physical impairment resulting from disease, disorders, conditions, or injuries through the use of special exercises, application of heat or cold, and other physical modalities
8. registered respiratory therapist (RRT)
  1. an individual who is prepared to evaluate, test, and treat people of all ages with respiratory problems through the provision of respiratory therapy treatments, mixing of specific medications for respiratory inhalation, collection and evaluation of patient data to determine an appropriate care plan, selecting and assembling equipment, conducting therapeutic procedures and modifying prescribed plans to achieve one or more objectives
9. occupational therapist (OT)
  1. an individual who is prepared to evaluate, test, and treat people of all ages whose ability to cope with acitivites of daily living is impaired by physical injury, illness, emotional disorder, congenital or developmental disabilty, or aging through desiging, fabrication and application of orthoses, guidance in the selection and use of adaptive equipment, therapeutic activities to enhance functional performance, pre-vocational evaluation and training, and consultation concerning adaptation of the physical environment for the handicapped
10. social worker
  1. an individual who is prepared to assess the social, emotional, environmental, and economic needs of patients and familes associated with illness and disability and families through counseling and referral of patients and families to appropriate private, voluntary, and official agencies
11. speech-language pathologist (SLP)
  1. an individual who is prepared to evaluate, test, and treat patients of all ages who have difficulty speaking or being understood and swallowing through the measurement and evaluation of language abilities, auditory processes and speech production, clinical treatment of children and adults with speech and language disorders, and research methods in the study of communication processes
12. unlicensed assistive personnel (UAPs) (e.g., nurse's aide, orderlies, attendants, technicians
  1. an individual who is prepared to assist a nurse through the performance of specific nursing care services to patients under the supervision and direction of a nurse
Types of health care settings
1. the home setting
  1. health care service provided in the home setting
  2. agencies that promote, maintain, and restore health, specifically maximizing independent functioning and minimizing the disabling effects of illness, including terminal illness, in the home
2. hospitals: acute care settings
  1. have traditionally provided restorative care to the ill and injured
  2. classification of hospitals
    1. by size
      1. small, e.g., 12 bed rural hospital
      2. large, e.g., 1500 bed metropolitan hospital with a 50 bed day-surgery center
    2. by ownership and control
      1. governmental (public)
        
        e.g., federal, state, city, county hospitals
      2. nongovernmental
        
        e.g., church, company, community, charitable organization owned hospitals
    3. by source of support
      1. proprietary (for profit)
      2. nonproprietary (not for profit)
    4. by breadth of services provided
      1. broad range of services
        
        e.g., medical, surgical, obstetrics, pediatrics, psychiatry
      2. specialty services
        
        e.g., eye care (Wills Eye Hospital), cancer care (Sloan-Kettering Hospital), neuroscience care (Barrows Neurological Institute)
    5. by type of care provided
      1. acute
        
        e.g., treat those patients who are acutely ill and whose need for hospitalization is relatively short-term
      2. long-term
        
        e.g., treat patients who are chronically ill and who need hospitalization for longer periods of time
  3. changes all hospitals have recently undergone
    1. merged with other hospitals or have been sold to larger multihospital for profit corporations as a means of fiscal solvency
    2. developed and offered innovative services (e.g., fitness classes, daycare for the elderly, nutrition classes, alternative birth centers) to attract patients
    3. primarily are caring for only seriously ill patients while less ill patients are treated in the community
    4. developed and utilized new levels of care givers, placed under the supervision of registered nurses, to provide direct bedside care (e.g., patient care partner) as a means of needing fewer registered nurses and, consequently, cutting costs
    5. are all acting as businesses and considering the bottom line, which is always monetary, as a means of fiscal solvency, which has had serious repercussions, many negative, for nursing and patient care
3. primary care centers
  1. location
    1. free-standing private physicians' offices
  2. providers
    1. physicians
    2. nurse practitioners
  3. examples of health care services provided:
    1. diagnosis and treatment of minor illnesses
    2. minor surgical procedures
    3. obstetric care
    4. well-child care
    5. counseling
    6. referrals
4. ambulatory care centers and clinics
  1. location
    1. hospital
    2. free-standing centers or clinics in the community
  2. providers
  3. examples of health care services provided:
    1. walk-in ambulatory services
    2. walk-in urgent care services
    3. walk-in surgical services
  4. open at nontraditional times other than traditional office hours
5. specialized care centers
  1. day-care centers
    1. location
      1. free-standing well-child care centers, sick-child care centers, elder-care centers, or senior citizen centers in the community
    2. providers
    3. examples of health care services provided:
      1. administration of medications and treatments
      2. health screenings
      3. teaching
      4. counseling
  2. mental health centers
    1. location
      1. hospitals
      2. free-standing centers or clinics in the community
    2. providers
    3. examples of health care services provided:
      1. individual and group counseling
      2. crisis intervention
      3. prescription of medications
  3. rural health centers
    1. location
      1. geographically rural areas
    2. providers
    3. nurse practitioners
      1. examples of health care services provided:
      2. treatment of minor, acute illnesses
      3. treatment of chronic, stable illnesses
      4. emergency care prior to transportation to the nearest hospital
  4. schools
    1. location
      1. schools
    2. providers
    3. examples of health care services provided:
      1. health assessment
      2. health education
      3. emergency care for physical and mental illnesses
      4. administration of prescribed medications
      5. conduction of routine health screenings
      6. maintenance of immunization records
  5. industry
    1. location
      1. large industries
    2. providers
    3. examples of health care services provided:
      1. prevention of work-related injuries and illnesses
      2. health assessments
      3. wellness teaching
      4. caring for minor accidents and illnesses
      5. referrals for more serious problems
  6. homeless shelters
    1. location
      1. homeless shelters
    2. providers
    3. examples of health care services provided:
      1. immunizations
      2. teaching pregnant women
      3. treating infections and illnesses
      4. referring for diagnosis of sexually-transmitted diseases (STDs)
      5. wellness teaching
  7. rehabilitation centers
    1. location
      1. special unit in hospitals
      2. free-standing centers or clinics in the community
    2. providers
    3. examples of health care services provided:
      1. physical rehabilitation
      2. emotional rehabilitation
      3. chemical addiction rehabilitation
  8. long-term care facilities
    1. location
      1. special unit in hospitals
      2. free-standing centers in the community
    2. providers
    3. examples of health care services provided:
      1. extended care, intermediate care, or personal care to patients who are chronically ill, unable to care for themselves without some form of assistance (e.g., meal preparation, bathing, dressing), and require some regular nursing care and occasional medical attention
    4. Omnibus Budget Reconciliation Act (OBRA)
      1. established a measure of quality to extended-care facilities by instituting the following:
        
        requirements for nurses aides training
        competence evaluation of nurses aides
  9. hospice services
    1. location
      1. home setting
      2. special units in hospitals
      3. free-standing centers or clinics in the community
    2. providers
    3. examples of health care services provided includes:
      1. symptom management
      2. comfort measures
      3. family support during and after the death of the patient
Agencies providing care
1. voluntary agencies
  1. not-for-profit agencies supported by private donations, grants, or fund-raisers, e.g.:
  2. meals on wheels
  3. transportation services
  4. shopping or housecleaning services
  5. various associations, e.g.:
  6. lung association
  7. arthritis association
  8. heart association
  9. support groups, e.g.:
  10. alcoholics anonymous (AA)
  11. cancer support groups
  12. reach to recovery
2. religious agencies, e.g.:
  1. parish nursing
3. government agencies, e.g.:
  1. veterans administration and military agencies
    1. provide health care services to veterans and their immediate families
  2. public health services
    1. local (county, bicounty, tricounty) health departments whose functions include:
      1. developing programs to meet the health needs of individuals in their counties
      2. providing the necessary staff and facilities to carry out these programs
      3. evaluating the effectiveness of these programs
    2. state health departments whose functions include:
      1. assisting the local health departments
    3. federal health departments whose functions include:
      1. conducting research and training in the public health field
      2. providing assistance to communities in planning and developing public health facilities
      3. assisting state and local communities through financing and provision of trained personnel
    4. the main federal health departments are the following:
      1. Public Health Service (PHS) of the Department of Health and Human Services (DHHS)
      2. Centers for Disease Control (CDC)
      3. National Institutes of Health (NIH)
Frameworks for care
1. managed care
  1. an organization of health care that influences the selection and use of the health care services of a population that is high-quality and cost-effective
  2. elements of all managed health care plans include:
    1. integration of financing, service delivery, and administration
    2. limitations on freedom of choice of provider
    3. a comprehensive, coordinated package of medical services (including preventative care)
    4. utilization management/review
    5. "gatekeeping" or referral management by a primary care physician
    6. negotiated pricing from providers
    7. provider risk-sharing
2. case management
  1. a process of coordinating an individual patient' shealth care for the purpose of maximizing positive outcomes and containing costs
  2. elements of all case management plans include:
    1. enhancing continuity of care
    2. effectively using health care resources
    3. identification of specific protocols and timetables for care and treatment in a format called a critical pathway
3. primary health care
  1. essential health care based on practical, scientifically sound, and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation and at a cost the community can afford
  2. elements of all primary health care plans include:
    1. community-based philosophical base
    2. emphasis on universal access to health care
    3. emphasis on affordability of health care
    4. emphasis on the health of the population
    5. consumer involvement
Federally funded health care programs
1. Medicare
  1. a national health insurance plan established in 1965 which is funded partly through Social Security taxes (FICA) by way of the Medicare amendments (Title 18 of the Social Security Act)
  2. federally funded program administered by the federal government
  3. who does Medicare cover?
    1. all persons 65 and older
    2. people who have kidney failure
    3. people with approved disabilities
    4. dependents of people who are disabled
  4. what does Medicare cover?
    1. Part A
      1. hospitalization, home care, and hospice care for people 65 years and older and those who are disabled
    2. Part B
      1. provides partial coverage of physician services for a monthly premium to individuals available for Part A
  5. what doesn't Medicare cover?
    1. routine physical examinations
    2. dental care or dentures
    3. hearing tests or hearing aids
    4. eyeglasses
  6. fee payment for health care claim costs under Medicare
    1. patient
      1. responsible for a deductible and 20% (co-insurance) of the total health care claim cost
    2. federal government
      1. responsible for 80% of the total health care claim cost after the patlient has reached his/her deductible
  7. appropriateness of hospital use under Medicare is monitored by the Professional Standards Review Organization (PSRO)
  8. common to Medicare is the use of a prospective payment system
    1. the prospective payment system utilized by Medicare is known as DRGs
    2. DRGs are categories that represent all known disease entities classified according to medical diagnoses
    3. there are near 492 DRGs for prospective reimbursement for hospital services determined by Medicare
    4. for all the near 492 DRGs, the prospective reimbursement rate for hospital services for each of them has been determined by Medicare
    5. for all the near 492 DRGs, the prospective reimbursement rate Medicare has set for hospital services for each of them is the amount a hospital will be paid by the Medicare system to treat patients with each of them
      1. if the hospital costs to treat a patient with a particular DRG exceed the prospective reimbursement rate for that DRG, the hospital loses money
      2. if the hospital costs to treat a patient with a particular DRG are less than the prospective reimbursement rate for that DRG, the hospital keeps the excess
    6. the prospective reimbursement rate for each DRG is set in advance of the prospective year for which it will apply by Medicare
2. Medicaid
  1. a national public assistance program established in 1965 for individuals with low incomes which is funded from general tax revenues through social security taxes (FICA) by way of the Medicaid amendments (Title 19 of the Social Security Act)
  2. federally funded program administered by the states
  3. who does Medicaid cover?
    1. people with low incomes of any age
    2. beneficiaries of Aid to Families with Dependent Children (AFDC)
    3. elderly, blind, and disabled people covered by supplemental security benefits
  4. what does Medicaid cover?
    1. depends on state regulations
    2. all states must provide coverage for Medicaid participants as described in the broad, basic guidelines set forth by the federal government
    3. however, some states provide more comprehensive coverage for Medicaid participants that exceed the broad, basic guidelines set forth by the federal government
  5. what doesn't Medicaid cover?
    1. in-patient and outpatient hospital care
    2. physician services and nurse midwife services
    3. home health care
    4. at-risk pregnancy care
    5. therapy for persons who have speech, hearing, and language disorders
    6. dental, chiropractic, and vision care
    7. hospice care
  6. fee payment for Medicaid
    1. patient
      1. not responsible for any costs
    2. state governments
      1. pay a certain dollar amount for health care costs
    3. federal government
      1. provide matching funds to states that meet the broad, basic guidelines set forth by the federal government
  7. appropriateness of hospital use under Medicaid is monitored by the Professional Standards Review Organization (PSRO)
Group plans
1. private insurance (indemnity/fee-for-service plans)
  1. health care plans that provide comprehensive medical services to its enrollees for a retrospective fee for service
  2. enrollees can seek medical services from any provider
  3. after each medical service, the enrollee submits (via claim form) a request to be reimbursed for the payment
  4. the insurance company pays a % (typically 80%) of the retrospective fee-for-service
  5. the enrollee pays a deductible and the remaining % (typically 20%) of the retrospective fee-for-service
2. health maintenance organizations (HMOs)
  1. health care organizations that provide comprehensive, coordinated medical services to their enrollees for a fixed, prospective fee-for-service
  2. have been around since the 1930s, but became popular after passage of the Health Maintenance Organization Act in 1973 as an attempt to control spiraling health care costs
  3. comprehensive medical services offered by HMOs include:
    1. physician's services, including consultant's and referral fees
    2. in-patient and out-patient hospital services
    3. emergency and out-of-area health services
    4. laboratory tests and x-rays
    5. prescribed physical therapy
    6. mental health services; in-patient and out-patient
    7. prenatal, postnatal, and well-baby care
    8. immunizations, routine health evaluations, and eye examinations
    9. many also include: prescription drugs, long-term physical therapy and rehabilitative services, home-health services, extended-care facilities, dental services
  4. types of HMO models
    1. staff model HMOs
      1. providers: physicians who are salaried employees of the HMO
      2. provider arrangement: the provider is a salaried employee of the HMO
      3. providers' patients: only HMO enrollees
      4. providers' settings: one or more centralized practice settings, depending on the size of the HMO, owned and operated by the HMO
      5. number of providers: the smallest number of providers
      6. providers' payment: a fixed salary with withholds
      7. cost to expand: most expensive since the HMO invests large amounts of its own capital to staff and outfit each practice setting (they own and operate the HMO setting)
      8. cost to administer: centralized practice settings make it the least expensive to administer
      9. efficiency in use of medical services: most efficient since they are provided in centralized practice settings owned and operated by the HMO and peer review and quality assurance programs can keep close tabs on member physicians' practice patterns
    2. group model HMOs
      1. providers: one multispeciality medical group whose physicians have an economic relationship with each other: they are organized in a partnership, professional corporation, or other association
      2. provider arrangement: the provider is a contractual employee of the HMO
      3. providers' patients: generally are limited to only HMO enrollees
      4. providers' settings: one or more centralized practice settings, depending on the size of the group
      5. number of providers: a larger number than the staff model
      6. providers' payments:
        
        group is paid either:
        
        a discounted fee for services
        a discounted fee for services with withholds
        a schedule of fees
        capitation
        
        then, the group compensates its member physicians
      7. cost to expand: less expensive than the staff model since the HMO does not invest large amounts of its own capital to staff and outfit the group's practice settings (they do not own and operate the HMO setting)
      8. cost to administer: centralized practice settings make it less expensive to administer
      9. efficiency in use of medical services: efficient since they are provided in centralized practice settings and peer review and quality assurance programs can keep close tabs on member physicians' practice patterns
    3. network model HMOs
      1. providers: two or more community-based multi-speciality medical groups whose physicians do not have an economic relationship with each other to provide wider geographic coverage
      2. provider arrangement: the provider is a contractual employee of the HMO
      3. providers' patients: both HMO and non-HMO enrollees (their largest volume)
      4. providers' settings: two or more centralized practice settings, depending on the size of the groups
      5. number of providers: a larger number of providers than both the staff and group models
      6. providers' payments:
        
        groups are paid either:
        
        a discounted fee for services
        a discounted fee for services with withholds
        a schedule of fees
        capitation, then
        
        the groups compensate their member physicians
      7. cost to expand: less expensive than the staff model since the HMO does not invest large amounts of its own capital to staff and outfit the groups' practice settings
      8. cost to administer: centralized practice settings make it less expensive to administer
      9. efficiency in use of medical services: efficient since they are provided in centralized practice settings and peer review and quality assurance programs keep close tabs on member physicians' practice patterns
    4. independent practice association (IPA) model HMOs
      1. providers: physicians in decentralized independent practices or a panel of physicians who are loosely associated through the local medical society, hospital, or some other professional organization
      2. provider arrangement: the provider is a contractual employee of the HMO
      3. providers' patients: both HMO and non-HMO enrollees (their largest volume)
      4. providers' settings: numerous private physicians' offices
      5. number or providers: the largest number of providers
      6. providers' payment:
        
        each member physician is paid either:
        
        a discounted fee for services
        a discounted fee for services with withholds
        a schedule of fees
        capitation
      7. cost to expand: least expensive since the HMO does not invest large amounts of its own capital to staff and outfit each private physician's office
      8. cost to administer: decentralized practice settings make it the most expensive to administer
      9. efficiency in use of medical services: least efficient since they are provided in numerous private physicians' offices and peer review and quality assurance programs cannot keep close tabs on member physicians' practice patterns
3. preferred provider organization (PPO)
  1. providers: physicians, dentists, pharmacists, and hospitals who provide a single type of service and are organized by an insurance carrier to provide health care simliar to an HMO but through a larger provider network that offers enrollees more choice
  2. coverage for enrollees is reimbursed according to a negotiated prospective fee-for-service schedule (usually discounted 25%)
  3. there is no use of a primary care physician "gatekeeper"
  4. enrollees can choose who they want to seek health care from:
    1. an "in-network" provider (including specialists)
    2. an "out-of-network" provider (including specialists)
  5. benefits vary depending on which provider is used:
    1. if an "in-network" provider is used, enrollees receive full benefits and pay the lowest deductible, co-payments, or co-insurance (usually 80/20)
    2. if an "out-of-network" provider is used, enrollees receive less benefits and pay a higher deductible, co-payments, or co-insurance (usually 60/40)
4. exclusive provider organization (EPO)
  1. one provider of care, usually a hospital or "center of excellence" (e.g., an eating disorder center), who contracts with an insurer, employer, or third-party administrator, or other sponsoring group to provide a certain set of limited services to their enrollees (e.g., treatment of anorexia and bulimia)
  2. coverage for enrollees is reimbursed according to a negotiated prospective fee-for-service schedule
  3. there is use of a primary care physician "gatekeeper" for "in-network" provider use
  4. enrollees choose who they want to seek health care from:
    1. an "in-network" provider (including specialists)
    2. an "out-of-network" provider (including specialists)
  5. benefits vary depending on which provider is used:
    1. if an "in-network" provider is used, enrollees receive substantial benefits (usually discounted 20% or more)
    2. if an "out-of-network" provider is used, enrollees pay the entire cost out-of-pocket
5. point-of service plan (POS) (also known as a HMO-PPO hybrid or an open-ended HMO [OEHMO])
  1. network of contracted hospitals, physicians, and other providers who contract with an insurer, employer, or third-party administrator, or other sponsoring group to provide health care coverage to their enrollees
  2. coverage for enrollees is reimbursed in one of two ways:
    1. according to a negotiated prospective fee-for-service schedule with withholds
    2. capitation with withholds
  3. there is use of a primary care physician "gatekeeper" for "in-network" provider use
  4. enrollees choose at the point-of-service who they want to seek health care from:
    1. an "in-network" primary care physician "gatekeeper" or a specialist referred by him/her
    2. an "out-of-network" provider (including specialists)
  5. benefits vary depending on which provider is used:
    1. if an "in-network" provider is used, enrollees receive full benefits and pay a lower deductible, co-payments, or co-insurance
    2. if an "out-of-network" provider is used, enrollees receive less benefits and pay a higher deductible, co-payments, or co-insurance
Trends and Issues in health care delivery
1. focus on self-care and wellness
2. consumer movement
3. cost containment, e.g.:
  1. prospective payment system (DRGs)
    1. a process in which facilities are given a fixed dollar amount for health care services to be provided for a patient before any health care services are actually provided to the patient
  2. managed care
    1. a process in which a broad range of health care services provided to a patient is closely monitored to assure that it is appropriate and provided in the most efficient and inexpensive way
  3. capitation
    1. a process in which an individual or employer pays a fee for a broad range of health care services that can be provided to a patient during a specific time frame
  4. fragmentation of care, e.g.:
    1. increased specialization of services
    2. patients may receive care from 5 to 30 people during their hospital experience
4. changes in patient care needs
5. health care: a right or a privilege?
Health care for the 1990s and the millennium
1. American Nurses Association (ANA) recommendations
2. encourage consumer partnerships so that consumers can take an active role in their health, health care, and decisions about their health care
3. allow all US citizens and residents access to basic health care services
4. increase health care access by the use of physician and non-physician providers

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This page was last modified on 6/1/03