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Definition
| Spends more than 17% GDP on healthcare, $9000 per American. Rank 7th out of 7, fragmentation, organizational strategy and team work. Medical errors 3rd leading cause of death. |
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| Inpatient - Patients stay overnight and outpatient - patients do not stay overnight. One situation (medicare part b) - observation status = stays outpatient. |
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| observation status, subject to copays as if they were outpatient setting. If no part B, person is responsible for the entire bill. Since Mar 8, 2017, required to give Moon, medicaidre outpatient observation notice within 36 hours, myust orally explain. Will stay observation until admitted. Some limit it to 48 hours. |
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Term
| Outpatient status and Medicare |
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Definition
When patients are too sick to go home but not sick enough to be admitted, observation care gives doctors time to figure out what’s wrong. It is considered an outpatient service, like a doctor’s visit. Unless their care falls under a new Medicare bundled-payment category, observation patients pay a share of the cost of each test, treatment or other services.
And if they need nursing home care to recover their strength, Medicare won’t pay for it because that coverage requires a prior hospital admission of at least three consecutive days. Observation time doesn’t count. |
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| If Observation status is not met |
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Definition
| Speak to discharge coordinator - ask to admit, have Mr. G apply for financial assistance, look for options for the SNF |
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Term
| A hospital can be publicly or privately owned. |
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Definition
| Publically owned hospitals operated by either the Federal, state or local government. Dept of Defence for active military members, the Indian Health Service for native Americans and the Veterans Health Administration for Military Veterans. |
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| Are typically long-term facilities for psychiatric patients. Most public hospitals are safety net, general hospitals that maintain a primary focus on free or reduced-cost care for underserved populations |
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| Administered by federal, state or local governments or by private contractors. |
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| Not for profit nonreligious civic organizations and governed by a board of directors comprised of locally prominent citizens. |
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| Not for profit - reinvested into the institution. 14% of hospitals in the US are religious organization owned. |
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Definition
| Own for-profit hospitals, some profit given to shareholders. They pay taxes, over 260 physician owned hospitals. Typically single specialty |
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Term
| HealthCare delivery System or network. |
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Definition
| The organization owns and operates multiple hospitals and/or outpatient facilities. |
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Definition
| A conglomeration of multiple institutions of the same type. An example is Shriners Hospitals. |
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| Vertical Hospital Network |
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Definition
| Different types of services. An example is Kaiser Permanente. a network of organizations the function variously as an insurer, an owner of hospitals and outpatient centers and an employer of physicians |
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Term
| Patient-centered medical home |
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Definition
| a single-center through which al of a patient's care is coordinated with bundled payment. |
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Term
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Definition
| Less than 40% of physicians are primary care. Disagreeable workload, less reimbursement than a specialty doc. 60 million lack of primary care. Disparity to areas for access to care. |
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| Patient-Centered Medical Home |
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Definition
| New model, single-center, all patient care, bundled payments. |
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Definition
| over 400,000 people die each year from medical errors |
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Term
| medicare discharge readmit |
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Definition
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Definition
40% couldn't describe why they were in
54% didn't remember their discharge instructions. |
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Term
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Definition
| At risk of readmission: Length of stay, acuity, comorbid illness, number of times patient has been in the ER in the last 6 months |
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Term
| H.O.S.P.I.T.A.L Screening tool. |
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Definition
| Hemoglobin or oncology service, sodium at discharge, procedure during stay, index admission type, admissions in previous year, length of stay |
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Term
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Definition
8 Ps risk assessment tool. Problems with medications, psychological, principal, diagnosis, physical limitations, poor health literacy, patient support, prior hospitalization, palliative Care.
Know the score |
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Term
| Patient advocates should be aware of risk assessment tools or risk identifier tools used |
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Definition
| The higher the score the greater the chance of readmission. Ensure a safe transmission by ensuring that all aspects of an effective discharge are followed. Make sure the PCP has the discharge summary, any outlying test results are communicated. Validate that the client understands the after care instructions and that medications have been reconciled. Ensure the khows who to notify if problems arise and what those problems might look like. |
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Term
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Definition
| List of drugs approved for use in a health care institution or a health plan and a pharmacy benefits manager (PBM) is a for profit company that manages pharmaceutical sales for a health care plan. . |
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Term
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Definition
| Delivery and payment differ significantly in the inpatient and outpatient settings. In the hospital the formulary is regulated by the hospitals Pharmacy and therapeutics (P&T) committee. Drugs approved by the P&T are purchased and stocked by the hospital pharmacy. Providers may prescribe the medication the formulary for a patient while she or he is in the hospital. These drugs aren't billed separately but are bundled in to the price for the entire episode of care as with a diagnosis-related group (DRG) |
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Term
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Definition
| Most insurance companies contract with PB |
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Term
Tiered formulary
(Largest PBM is express scripts). |
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Definition
| Classifying drugs by copay |
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Term
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Definition
Deductible - paid by beneficiary.
Copay - fixed $ amount must pay for certain services
Co-insurance - percentage rather than fixed amount |
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Term
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Definition
Medicare and Self Insured Employer - Federally regulated.
Individual plans : Some governed by state law. |
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