Ch. 6-Health Care Delivery Systems

Front 1

Case management

Back 1

Describes a range of models for integrating health care services for individuals or groups.

Front 2

Coinsurance

Back 2

Is the percentage share (usually 20%) of a government-approved charge that is paid by the client; the remaining percent is paid by the plan.

Front 3

critical pathways

Back 3

An interdisciplinary assessments, interventions, treatments, and outcomes for health-related conditions across a time line. Also called critical paths, interdisciplinary plans, anticipated recovery plans, and action plans.

Front 4

Diagnosis-related groups (DRGs)

Back 4

there is a limit to the amount paid to hospitals that are reimbursed by Medicare. Reimbursement is made according to a classification system known as _". The system has categories that establish pretreatment diagnosis billing categories. Under this system, the hospital is paid a predetermined amount for clients with a specific diagnosis. Amounts are set in advanced of the year and are considered fixed except for major, uncontrollable occurrences.

Front 5

Differentiated practice

Back 5

Is a system in which the best possible use of nursing personnel is based on their educational preparation and resultant skill sets. thus, differentiated practice modules consist of specific job descriptions for nurses according to their education or training.

Front 6

Health care system

Back 6

Is the totality of services offered by all health disciplines. It is one of the larges industries in the united states.

Front 7

Health maintenance organization (HMO)

Back 7

Is a group health care agency that provides health maintenance and treatment services to voluntary enrollees. A fee is set without regard to the amount or kind of services provided.

Front 8

Independent practice association (IPAs)

Back 8

Are somewhat like HMOs and PPOs. The _' provide care in offices, just as the providers belonging to a PPO do. The difference is that clients pay a fixed prospective payment to the IPA, and the IPA pays the provider. In some instances, the health care provider bills the IPA for services; in others, the provider receives a fixed fee for services given. At the end of the fiscal year, any surplus money is divided among the providers; any loss is assumed by the _'.

Front 9

Integrated delivery system

Back 9

A system that incorporates acute care services, home health care, extended and skilled care facilities, and out patient services. most provide care throughout the lifespan. Insurers can contract with _' to provide all required services, rather than the insurer contracting with multiple agencies for the same services. Ideally, an _' enhances continuity of care and communication between professionals and various agencies providing managed care.

Front 10

Licensed vocational (practical) nurse (LVN/LPN)

Back 10

provides direct client care under the direction of a registered nurse, physician, or other licensed practitioner.

Front 11

Managed care

Back 11

Describes a health care system whose goals are to provide cost-effective, quality care that focuses on decreased costs and improved outcomes for groups of clients.

Front 12

Medicaid

Back 12

Is a federal public assistance program paid out of general taxes to people who require financial assistance, such as people with low incomes. ___is paid by federal and state governments. Each state program is distinct. Some states provide very little coverage, whereas others pay for dental care, eyeglasses, and prescription drugs.

Front 13

Medicare

Back 13

Is a plan divided into parts: Part A is available to people with disabilities and people 65 years and over. It provides insurance toward hospitalization, home care, and hospice care. Part B is voluntary and provides partial coverage of outpatient and physician services to people eligible for Part A. Part D is the voluntary prescription drug plan begun in January 2006. Most clients pay a monthly premium for Parts B and D coverage. All _clients pay a deductible and coinsurance.

Front 14

Patient-focused care

Back 14

Is a delivery model that brings all services and care providers to the clients.

Front 15

Preferred provider arrangements (PPAs)

Back 15

Similar to PPOs. the main difference is that the _' can be contracted with individual health care providers, whereas PPOs involve an organization of health care providers. It can be limited or unlimited. If limited, _' restricts the client to using only preferred providers of health care; an unlimited _' permits the client to use any health care provider in the area who accepts the contractual agreement of the plain. The more choices in health care providers, may mean the more it will cost.

Front 16

Preferred provider organization (PPO)

Back 16

consists of a group of providers and perhaps a health care agency (often a hospital) that provide an insurance company or employer with health services at a discounted rate.

Front 17

Supplemental Security Income (SSI) benefits

Back 17

Persons with disability or those who are blind may be eligible for special payments called "_". These benefits are also avioable to people not eligible for social security, and payments are not restricted to health care costs. Clients often use this money to purchase medicines or to cover costs of extended health care.

Front 18

Team nursing

Back 18

Is the delivery of individualized nursing care to clients by a team led by a professional nurse.