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194 Cards in this Set

  • Front
  • Back
1. professional standards review organizations
2. review quality, quantity and cost of hosiptal care
UR committees
1. utilization review committees
2. review admissions, diagnostic testing, and treatments provided by physicians caring for Medicare patients
1. prospective payment system (for Medicare)
2. established by Congress 1983 to eliminate cost-based reimbursement
1. diagnosis-related groups
2.grouped inpatient hospital services
3. 468 of them
4. hospital was paid by set rate for DRG, regardless of length of patient stay
provider paid fixed amount per enrollee of a health care plan
1. resource utilization groups
2. used in long-term care setting
In all settings, health care providers attempt to manage _______ so that organizations remain ____________.
managed care
health care systems in which there is administrative control over primary health care services for a defined client population.
The goal of managed care is to increase ________ to health care while decreasing ______.
factors that increase health care spending
1. increased wages
2. increased rx costs
3. higher insurance premiums for employees
4. increased consumer demand for better technology
Issues faced by US health care delivery system
1. rising health care cost
2. increased access to services
3. improved quality of outcomes
4. threats of bioterrorism
Health Services Pyramid
developed by the Core Functions Project (US Public Health Service)
1. population-based health care services
2. clinical preventive services
3. primary health care
4. secondary health care
5. tertiary health care
Over the last century, Americans have experienced an increase in life expectancy by ___ years, a ___ % decrease in adult deaths related to coronary heart disease and stroke, and a ___% decrease in deaths of children.
emphasis placed on wellness
1. integrated delivery networks
2. set of providers and services organized to deliver a continuum of care to a client population at a capitated cost in a particular setting
3. reduces duplication of services across levels or settings of care
Nurses are especially important as client advocates in maintaining ___________ throughout the levels of care.
continuity of care
How can health care delivery system be improved?
by finding strategies that better address client needs at all levels of care
managed care organization
Medicare MCO
program covering health care costs of seniors
preferred provider organization
In a PPO, an enrollee pays more for ________ providers.
exclusive provider organization
In an EPO, an enrollee's choice of providers is limited to _________________.
those within a particular organization (ex. WK Health Plus or Kaiser Permanente)
national health insurance plan for seniors
Medicare Part A
basic coverage for medical, surgical and psychiatric costs
Medicare Part B
voluntary medical insurance covering physician and some outpatient services
Medicare Part C
managed care provision offering choice of 3 insurance plans
Medicare Part D
rx drug benefit
federally-funded, state-operated program offering
1. health insurance to low-income families
2. health assistance for low-income people with long-term care disabilities
3. supplemental coverage and long-term care assistance to older adults and Medicare beneficiaries in nursing homes
private insurance
1. fee-for-service plan
2. expensive
3. most plans require clients to meet deductible before paying
long-term care insurance
1. very expensive
2. supplemental coverage
What's the focus of health promotion?
to keep people healthy through
1. personal hygiene
2. good nutrition
3. clean living environment
4. regular exercise
5. rest
6. positive health attitudes
3 ways health promotion programs lower the overall cost of health care
1. by reducing incidence of disease
2. minimizing complications
3. reducing need to use more expensive health care resources
primary care
health services provided on an individual basis
primary health care
focuses on improved health outcomes for an entire population
disease prevention
activities that protect people from becoming ill
health promotion
activities that develop human attitudes and behaviors to maintain/enhance well-being
primary prevention
health-promoting behaviors/activities that reduce the occurrence of an illness
public health
community and interdisciplinary care aimed at preventing disease and promoting health
secondary prevention
early diagnosis and treatment of illness
tertiary prevention
care that prevents further progression of disease
examples of primary care
1. prenatal care
2. well-baby care
3. nutrition counseling
4. family planning
5. exercise classes
examples of preventive care
1. screening
2. immunizations
3. poison control information
4. mental health counseling
5. community legislation (seat belts, bike helmets, air bags)
examples of secondary acute care
1. ER care
2. acute medical/surgical care
3. radiological procedures
examples of tertiary care
intensive care
subacute care
examples of restorative care
1. cardio and pulmonary rehab
2. sports medicine
3. spinal cord injury programs
4. home care
examples of continuing care
1. assisted living
2. psychiatric care
3. older adult day care
6 types of preventive and primary care services
1. school health
2. occupational health
3. physician's offices
4. nursing centers
5. block & parish nursing
6. community centers
What are the 2 traditionally most commonly used services in health care delivery system?
1. diagnosis of illness
2. treatment of illness
_________ is the most common and most expensive service in the health care delivery system.
disease management
The acutely and chronically ill account for ____% of people in the U.S. and consume ____% of health care spending.
Young adults between the ages of ___ and ____ comprise the fastest-growing age group of uninsured citizens.
ObamaCare seeks to cover the young adult age group by allowing for parents to insure their children up to age ___.
Young adult age group has incidence rate of _____, _______, and _______.
Why is acute (secondary and tertiary) care so costly?
uninsured people tend to wait longer to seek treatment, so are sicker and require more care
4 sites that provide secondary and tertiary health care
1. ER
2. urgent care center
3. critical care units
4. inpatient med-surg units
2 abilities essential for nurses in acute care settings
1. ability to think critically
2. ability to identify clients' changing problems quickly and accurately
Because of _______, the number of days clients can expect to be hospitalized is limited based on their ____ upon admission.
managed care
result of hospital work redesign
increased number of services are available on nursing units, thus minimizing need to transfer and transport clients across multiple diagnostic and treatment areas
case management model of care
1. focuses on discharge planning
2. created to contain hospital costs
When does discharge planning begin?
upon admission
2 things nurses use to achieve continuity of care
1. critical thinking skills
2. application of nursing process
discharge planning
a centralized, coordinated, multidisciplinary process that ensures that the client has a plan for continuing care after leaving health care agency
critical pathway
multidisciplinary treatment plan that outlines treatments/interventions clients need to have while in the hospital for a specific condition/procedure.
Nurses use critical pathways in acute care settings to ___________.
coordinate client care
The critical pathway helps to ensure _________ among members of the health care team.
collaboration (with aim to discharge patient asap)
Discharge planning depends on comprehensive ______ and ______ education.
Examples of instruction clients need before leaving facility
1. safe, effective use of medication and DME
2. potential food-drug interactions
3. nutritional counseling
4. rehab techniques
4.access to community resources
5.when and how to obtain further treatment
6. client's and family's responsibilities for ongoing health care and skills needed
intensive/critical care unit: hospital unit in which clients receive close monitoring and intensive medical care
Medical and nursing staff of ICU/CCUs require _________.
special training
2 reasons why ICU is the most expensive health care delivery site
1. low patient/nurse ratio
2. high number of treatments & procedures required by each client
3 conditions which may require services found at a psychiatric facility
1. depression
2. eating disorders
3. violent behavior
Clients may enter psych facilities on a ________ or _________ basis.
4 care areas needed to help clients return to a functional state in community.
1. medicine
2. nursing
3. social work
4. activity therapy
rural primary care hospital
services provided by an RPCH
1. 24-hr. emergent care
2. no more than 6 inpatient beds for care of 72 hr. or less for stabilization before transferring to larger facility
3. basic radiology and lab services
Nurses in RPCH often function ________.
3 nursing skills especially important in RPCH setting
1. physical assessment
2. clinical decision-making
3. emergent care
2 goals of restorative care
1. to help patients regain maximal functional status
2. to enhance quality of life through promotion of independence and self-care
How to insure that clients and families follow treatment plan for restorative care?
involve them!
home health
provision of medically related services and equipment to clients in their homes
6 things for which home health is used
1. health maintenance
2. education
3. illness prevention
4. diagnosis & treatment of disease
5. palliation
6. rehab
9 home health care services
1. wound care
2. respiratory care
3. vital signs
4. elimination
5. nutrition
6. rehab
7. medication
8. IV therapy
9. labs
4 knowledge areas important in home health care
1. family dynamics
2. cultural practices
3. spiritual practices
4. communication principles
restores a person to the fullest physical, mental, social, vocational, and economic potential possible
4 types of rehab services
1. PT
2. OT
3. speech therapy
4. social services
When is ideal time to begin rehab?
as soon as client enters health care setting for treatment
Initially, rehab focuses on prevention of ________ related to the illness/injury.
As condition stabilizes, rehab helps to maximize the client's _______ and level of _________.
extended care facility
provides intermediate medical, nursing, or custodial care for clients recovering from acute illness or clients with chronic illnesses or disabilities.
2 types of extended care facilities
1. intermediate care facilities
2. SNFs
The growth of extended care facilities will ______ as the number of older adults _____.
skilled nursing facility
A SNF offers skilled care from a __________.
licensed nursing staff
4 examples of care offered in a SNF
1. IV administration
2. wound care
3. long-term ventilator management
4. physical rehab
continuing care
health, personal, and social services provided over a prolonged period
3 populations who receive continuing care
1. disabled
2. those who never were functionally independent
3. those with terminal disease
3 places where continuing care is available
1. institutional settings
2. communities (adult day care, senior centers)
3. home (meal delivery, hospice)
nursing center
1. used to be called nursing home then nursing facility
2. provides 24-hr. intermediate and custodial care for residents of any age with chronic/debilitating illnesses.
3. a resident's temporary/permanent home with surroundings made as home-like as possible
The philosophy of nursing center care is to provide a ______________ approach to _________ to help residents reach and maintain their highest level of ______.
planned, systematic, and interdisciplinary
nursing care
According to the US Bureau of the Census, ___% of people age 65 and older live in nursing centers and other facilities.
The nursing center industry has become one of the most highly ________ industries in the United States. Why?

substantiated claims of inadequate care and abuse
resident rights
residents and family members must be considered active participants and decision makers in care and life in the institutional setting
What's the cornerstone of clinical practice within nursing centers?
interdisciplinary functional assessment of residents
Resident Assessment Instrument
3 components of RAI
1. minimum data set (MDS)
2. resident assessment protocols (RAP)
3. utilization guidelines (by state)
minimum data set required for resident functional assessment
goals of functional assessment
to determine each resident's ability to perform ADLs

focus on long-term physical and psychosocial well-being
assisted living
attractive long-term care setting with
1. a homier environment and
2. greater resident autonomy
Assisted living is one of the _______ US industries.
fastest growing
Assisted living provides _______, _________, and _________, all at the same time.
Assisted living facilities promote _______ and ________ health.
With no government fee caps and little regulation, assisted living is not always an option for individuals with limited ____________.
financial resources
respite care
service that provides short-term relief for caregivers
The need to care for family members within the home creates great _______ and ________ problems for adult caregivers.
adult day care centers
provide health and social services to specific client populations who live alone or with family in the community
Nurses working in day care centers provide _________ between care delivered in the home and in the center.
In a day care center, the nurse's knowledge of community _________ and _______ is essential in providing adequate support of clients.
system of family-centered care that allows clients to live with comfort, independence, and dignity while easing pains of terminal illness
The focus of hospice is ________, not ___________.
palliative care
curative treatment
The hospice's interdisciplinary team works to manage _________ ensure ________.
Hospice nurses provide _______ for the client and family during the illness and at time of death and continue to offer _________ after the client's death.
care and support
The _______, _________ and ________ agree that further treatment will not reverse the disease process.
health care provider
Those who provide client care are the most qualified to __________ in the health care delivery system.
make changes
3 expectations a consumer of health care has regarding the standards of nursing care and practice
that the standards are
1. appropriate
2. safe
3. efficient
A nurse's 4 responsibilities in terms of health care delivery
1. to follow policies and procedures
2. to know the most current practice standards
3. maintain competency
4. obtain necessary continuing education and certifications
3 things emphasized by Pew Health Professions Commission in "21 Competencies for the 21st Century"
1.public service
2. caring for health of the communities
3. developing ethically responsible behaviors
Evidence-based practice
a problem-solving approach to clinical practice utilizing
1. current best evidence
2. clinical expertise
3. client preferences and values
to make decisions about client care
research-based practice v. evidence-based practice
RBP: use of knowledge based on results of research studies
EBP: adds nurse's clinical experience, practice trends, and client preferences
quality improvement
QI focuses on improving ________ of all providers.
QI is a ___________ process.
The definition of quality health care differs for _________ and _______.
Centers for Medicaid and Medicare Services
CMS used to be called ______.
HCFA (Health Care Financing Administration)
CMS created ways for Medicaid and Medicare to make sure that health care providers used only ____________.
medically needed services
CMS also created __________ for health care facilities, as well as health care providers.
quality standards
Health Plan Employer Data and Information Set
Who created HEDIS?
National Committee for Quality Assurance (NCQA)
purpose of HEDIS
to collect data to measure quality of care and services provided by different health plans
HEDIS is the database of choice for _____.
3 key areas in which health plans are compared by HEDIS
1. care quality
2. access to care
3. client satisfaction witht he plan and the doctors
The Joint Commission requires health care organization to determine how well an organization meets ____________.
client needs and expectations
client satisfaction
being used to redesign how organizations manage and deliver care
Health plans rely on _______ as a quality measure.
nursing-sensitive outcomes
client outcomes directly related to nursing care
Nursing-sensitive outcomes have a major effect on ________ and __________.
client safety
quality of care
Nursing Outcomes Classification
NOC helps nurses to define and measure the _____________.
impact of their interventions
American Nurses Credentialing Center
Program established by ANCC to recognize health care organizations that achieve excellence in nursing practice
Magnet Recognition Program
7 examples of nursing-sensitive outcomes
1. incidence of hospital-acquired pneumonia
2. DVT
3. UTI
4. pressure ulcers
5. falls
6. failure to rescue
7. 30-day mortality
2 findings of recent AHRQ research studies
1. higher level of staffing of RNs corresponds with fewer negative nursing outcomes
2. increased nurse staffing increases nurse satisfaction
3 things for which nurses and health care facilities use nursing-sensitive outcomes
1. improve nurse workload
2. enhance client safety
3. develop sound policies re: nursing practice and health care
7 dimensions client-centered care
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. transition and continuity
The 7 dimensions of client-centered care are those that most affect ______________.
client's experiences with health care (client satisfaction)
Picker/Commonwealth Program for Patient-Centered Care
1. identified the 7 dimensions and
2. has survey tool which measures client satisfaction
Client expectations are an important measure of the ________ of nursing care.
3 areas of client expectations important for nurses to better plan client care
1. information
2. comfort
3. availability of friends/family
3 times when nurses routinely ask about client expectations
1. beginning of care
2. middle of treatment
3. end of care
Technological advances influence ______ and ____ nurses provide care to clients.
Technology makes nursing care easier in many ways but does not replace the nurse's _________.
Many QI studies are conducted due to __________.
client satisfaction findings
It is crucial that nurses help health care agencies develop an effective way to manage the _________, __________, and _________ of information.
nursing informatics
combination of computer and information science with nursing science
Nursing informatics provides nurses with a way to _________ and _______ nursing data, information & knowledge
individually distinct pieces of reality
gained when data is
1. organized
2. structured
3. interpreted
relationships are combined and identified between difference pieces of information
The focus of informatics is not on the technology or the computer; but is on the _____________ of _______.
organization, analysis & dissemination

electronic health record
The EHR is replacing the traditional ___________.
printed health record
EHR provides a comprehensive record of what 4 things?
1. medical problems
2. treatment
3. diagnostic procedures
4. nursing care
EHR enhances ____________, resulting in _____________.
health care team communication
better client care
EHR also provides valuable information for _________ and ___________ activities.
Remember: the focus of nursing care is the ______, not the ________.
The use of electronic information systems require strict _____________.
confidentiality protocols
Despite improved technology and communication, the poorest areas in the world are still _________.
underserved by the health care delivery system
What's the most frequent reason for death in the world?
3 problems resulting from urbanization
limited access to:
1. vaccines
2. clean water
3. standard medical care
3 vulnerable populations most threatened by urbanization
1. children
2. women
3. elderly
Globalization of trade, travel, and culture improves availability of health care services, but has increased _________________.
the spread of communicable diseases such as
1. tuberculosis
Changes in climate and natural disasters threaten _________ and allow rapid spread of ___________.
food supplies
infectious disease
3 ways nurses can work together to overcome globalization issues
1. improve worldwide nursing education
2. recruit and retain nurses
3. advocate for changes that will improve health care delivery
What's the ultimate issue in designing and delivering health care?
ensuring the health and welfare of the population
8 goals of health care reform (1-4)
1. decrease long-term growth of health care costs
2. protect families from bankruptcy/debt due to health care costs
3. guarantee choice of drs & plans
4. invest in prevention & wellness
8 goals of health care reform (5-8)
5.improve pt safety & care quality
6. assure affordable, quality health coverage for all Americans
7. maintain coverage when you change/lose job
8. end barriers to coverage for those with pre-existing medical conditions
_________ and _________ ensure safe and effective care.
Critical pathways
care plans
____% of the American population (chronically ill) uses ____% of medical resources.
Technological advances make the nurse's work easier but do not replace the nurse's _________.
7 dimensions of patient-centered care
1. respect values, preferences & expressed needs
2. coordination & integration of care
3. info, communication & education
4. physical comfort
5. emotional support & relief of fear/anxiety
6. involvement of family/friends
7. transition/continuity
3 areas emphasized by Pew Health Commission in 21 competencies
1. importance of public service
2. caring for health of community
3. development of ethically healthy behaviors
3 things standards of nursing care must be
1. appropriate
2. safe
3. efficacious
4 responsibilities of nurses
1. follow policies/procedures
2. know most current EBP
3. ongoing competency
4. maintain continuing education & certifications