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When does care coordination begin and end - Prior to admission for elective procedure - 30 - 90 days after discharge. Pay for performance models have a greater emphasis on - Value based purchasing, readmission, Hospital acquired conditions What factors effect value based purchasing? - quality of care,, reduce adverse events/safety, improving patient experience, efficiency/delivering low cost care. What does the Acronym LACE stand for in the Lace Assesment tool.. - LENGTH of Stay, ACUITY of Admission, COMORBIDITY, EMERGENCY Deoartment Visits. What are the 8 ps in The Society for Hospital Medicines Project Boost Risk Assesment - Readmission Assement - Problems with Medications, Psychological, Principal Diagnosis, Physical Limitations, Poor Health Literacy, Patient Support, Prior Hospitalization, Palliative Care Components of RED ( Reengineered discharge) - Asses need for translator, sched f/u appointments, f/u on outstanding test results, coordinate post d/c out-patient services, obtaining medications national d/c guidelines, d/c teaching, educate on what to do if problems arise, assess pt understanding, d/c summary to outside providers, d/c follow up call. After Hospital Care Plan (AHCP) In regards to Value Based Pricing/payments, What factors weigh heavily in clinical care outcomes? - mortality In regards to Value Based Pricing/payments, what factors are considered in Patient experience of Care - staff communication, receiving written d/c information, warning signs, explanation of medications, pain management,
overall experience. In regards to Value Based Pricing/payments, what factors are used to determine payout based on efficiency. - spending per beneficiary, 3 days prior to admission to 30 days post d/c. Resource utilization, length of stay, post acute services. In regards to Value Based Pricing/payments, what factors are used to determine payout for safety? - Various patient safety factors and infection rates What is the definition of health literacy? - the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions. What are social determinants of health? - The structural determinants and conditions in which people are born, grow, live, work, and age which have a significant impact on health outcomes. What are the components of a psychosocial history - family composition, education, occupation, psychological and/or psychiatric functioning, living siuation, support system, transportation concerns, life changes or stressor, cooing skills, social/ community involvement, spiritual aspects and concerns, self care, cognitive or perception problems, financial concerns. What is the required assessment for admission to a nursing home for a patient with a diagnosis of mental retardation or mental illness to assure appropriate placement - Federal Pre-Admission Screening and Resident Review. Some states may require additional screening tools. What factors effect social determinents of health? - economic stability, neighborhood and built environment, education, food, community and social context, health and health care. Required assessment for admission to a nursing home for a patient with a diagnosis of mental retardation - Federal Pre-Admission Screening and Resident Review. Some states may require additional screen in ng tools. What is utilization and review? - reviewing patients clinical condition and providing decis I on support to MD on bed and billing status. ie observation, Out Pt, In-Patient. and being prepared to justify medical necessity. Additional certification is required for admission Ions longer than 20 days. components of the psychosocial history - family composition, education, occupation, psychological and/or psychiatric functioning, living siuation, support system, transportation concerns, life changes or stressor, cooing skills, social/
a 2014 act that requires submission of standardized data by long term care hospitals, SNF, home health agencies, and rehab facilities. improving Medicare post acute care transformation act More social determinents of health - employment/work conditions, education and literacy, childhood experiences, social support and social skills, access to health services, gender, biology and genetics, healthy behaviors, social environment, physical environment, income social status How is value based pricing scored? - 2 scores- Performance compared to other hospitals, improvement in their own performance Common risk stratification models - Hierarchical condition categories (icd-10), Adjusted clinic groups (Johns Hopkins) projects use of medical resources), Chronic Comorbidity counts (AHRQ) 6 categories), Elder Risk Assesment (risk for hospitalization and ED visits), Charlton Comorbidity Measure (predicts risk of 1 yearmortality based in diagnosis), Minnesota Tiering (tiers patients on complexity of major conditions) Population Specific Assessment Considerations - Workers Comp - Asses what Pt can and cannot do in their essential job functions and an occupational history. Population Specific Assessment Considerations - D/C from acute care Elderly - cognitive abilities, ADLs (selfcare), physical limitations, ADLs functional ie banking, cooking etc. Other Assessment details that are helpful - Home support, physical and environmental barriers, occupation, educational level, accessibility to resources, experience with Healthcare, previous accidents, learning barriers, language barriers, Pt goals experiences of care, fearfrustrations etc.
What did the HITECH portion of the American Recovery and Reinvestnent Act of 2009 promote in regards to Healthcare? - Conversion of paper based charting to computer based systems. Population Specific Assessment Considerations - ED - Identify high ED services users and developers plans to when patients present to ED with same symptoms as previous visits. Pts are often asked to sign them Population Specific Assessment Considertions - Newly Hospitalized patients - Determine appropriate level of care. Tool often used - MCG, InterQual (McKesson), Centers for Medicare & Medicaid Services National Coverage Database Population Specific Assessment Considrrations - D/C planning - all equipment, medications, and supports for safe dc to lower risk for readmission. Authorization of insurance etc. What are the medicare guidelines regarding SNF admission? - Must be inpatient status for three consecutive days. if not Pt will need to pay out of pocket. Does not include day of discharge, ED, or observation. office of inspector General - investigates medicare and medicaid fraud. How can decision of competence be determined? - Only by a court of law. Medication reconciliation - Very important to send upon transfer to reduce risk of readmission What is an example of assessing for health literacy? - Asking patient to teach back what has been taught What does the acronym LEAN stand for - Leadership, Eliminate waste, Act now, Never ending What is the "Important Message from Medicare" handout? - Notice that is given to in patient medicare beneficiaries that informs them of their righr to appeal a hospital discharge What is the Detailed Notice of Discharge? - DND explains specific reasons for DC, Given only if Pt appeals d/c What doesHINN stand for? -
Which immigration status is eligible to purchase coverage through the Heakth Insurance Marketplace?
- U.S. Citizens, U.S. Nationals, Lawfully present immigrants.
- illegal immigrants cannot purchase it for themselves but may apply on behalf of documented individuals. what is a physician advisor? - an MD with broad clinixal experience who acts a a liason between hospital staff to ensure compliance with regulatory issues, medical necessity, length of stay, denials,, icd-10 codes, peer review, and utilization of Healthcare services. CMS guidelines for Home Health Services - MD must certify the treatment is necessary and he has personally examined patient. the patient must be homebound (supporting docs required) examples of skilled homehealth needs - monitoring of new meds medication teaching pulmonary assessments wound care ostomy care diabetic care and insulin teaching PT infusion therapy respiratory care during these services Pt may eligibke to have other services such HH aid, SW what are Conditions of Coverage and Conditions of Participation? - Conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. These health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries. What is the patient self determination act (1990) - The right for patients to refuse care/right to die. Facilities participating in Medicare/Medicaid must inform patients of these rights. Advanced directives and Durable POA for healthcare uniform healthcare decisions act (UHCDA) - Addresses who can make medical decisions if patient is incapacitated and lacks advance directive. 1. Spouse 2. Adult child 3. Parent 4. Adult sibling. if no family - court appointed guardian What is decision making capacity? - The ability to make decisions. Ability may vary from situation to situation.. It is different from competency which is only determined by court of law. Pre-admossion patient assessment includes -
Pre-admossion engagement, identification of caregiver, advanced directives, discharge needs, discharge barriers. setting expectation for d/c, including selfcare abilities and expectations, assessment of home environment, potential risk factors for readmission, support system. Things to consider when a patient is in Observation - Will patient be safe and clinically ready to discharge home in 24 hours? is patient likely to need inpatient admission? Can the patient be care for in an alternative setting such as SNF, hospice, home w/ HH? can tests, procedures and consults being ordered be expedited or better coordinated to limit length of stay? post discharge follow up includes - prescriptions filled, medications, diet, activity/limitations regime understood. Follow-up or testing appt made transportation arranged Homecare or other services initiated keys to effective d/c planning - Elicit patient choice (SNF etc.) Communication w/team regarding timing, and plan for d/c. Communication with outside services/vendors Communication w/family regarding patients status, needs and next k even of care. Communication w/ health plan regarding plan of care, medications etc. Confirm outside services, medications, transportation etc are approved and ready. Secure needed orders, prescriptions, orders etc from medical team to assure timely discharge. 4 stages of case management - Assess, plan, implement/intervention, monitor/evaluation What part of Medicare covers skilled nursing facility? - Part A What part of Medicare covers DME equipment? - Part B What roles constitute integrated CM? - Includes well being, disease management, case management, prevention, triage, utilization management What are the three steps to integrated CM? - 3 functions of ----1. Track patient self management2. Tend/track population management3. Reporting, monitoring quality What is InterQual? - Clinical decision support tool determines when and how a patient progresses through the continuum.- organizes resources utilization,- objective evidence based criteria for assessing appropriate care for patients. Helps fraud/abuae
No if you qualify, But there are deductibles for 2020 the deductible was approximately $1400 each episodes What are the guidelines to qualify for Medicare Part A - You must have worked a certain number of "quarters of coverage to qualify. If you are a U.S. citizen or permanent resident and have not worked long enough to qualify for Medicare, you may able to buy into the program by paying a Part A premium. You may qualify if you apply under a spouse. Is there a coverage premium for Medicare? - Part A no, unless you have not worked long enough. There is a deductible for each occurrence. Part B - yes + annual deductible + 20% copay for services. Part C - Medicare Advantage has all parts - premiums through private insurer Part D - Covers drug. Must buy through private insurer. Usually has deductible, co-pays (5-25%) and types of out of pocket maximums where copays decrease. How do you qualify for Medicaid? - Financial requirements and those determined by each state and must be a citizen or an immigrant with 5 years legal residency. Based on income and financial resources.If you've already been receiving government Social SecurityIf a child less than 21 years old and has a disability severe enough to meet disability standards under Social Security disability. Parental income is disregarded capitation - type of payment to a provider for a group of people assigned to them where there is a fixed cost per person, per time period , not dependent on how often that person utilizes the resources. The provider is contracted under a HMO.per member, per mont Diagnostic related group (DRG) - pricing formula used by medicare that reimburses a fixed amount based on a diagnosis. Utilization review department case managers evaluate if a diagnostic test is medically necessary. Prospective Pay - type of payment that changed medicare reimbursement from a fee for service to a fixed payment based on DRG (diagnostic related group)_. How are DRG payments determined? - DRGs categorize patients with respect to diagnosis, treatment and length of hospital stay. The assignment of a DRG depends on the following variables: Principal diagnosis Secondary diagnosis(es) Surgical procedures performed Comorbidities and complications Patient's age and sex Discharge status What is six sigma - data driven quality management process to eliminate defects: define, measure, analyze, improve/design, control/verify Peer Review Quality Improvement Organization (QIO) -
private not for profit organization contracted by the center for medicare and medicaid services consisting of health care professionals who review complaints about care and implement changes for medicare patients. They ensure the patient right care for the right person at the right time is safe, patient centered, timely, and equitable. Part of the US department of health and human services. HIPAA individual right #3 is the individual's right to their health information to do what? - access, inspect, copy
- Ask to see and get a copy of your health records' Have corrections added to your health information Receive a notice that tells you how your health information may be used and shared Decide if you want to give your permission before your health information can be used or shared for certain purposes, such as for marketing Get a report on when and why your health information was shared for certain purposes If you believe your rights are being denied or your health information isn't being protected, you canFile a complaint with your provider or health insurer What is Medicare part C - medicare part C + choice program, also knows as the medicare advantage plan, is a managed care option that allows new types of health plans under private companies to cover medicare benefits at a capitated (per enrollee) amount to include hospital and medical, parts A and B. What is the emergency medical treatment and active labor act (EMTALA)? - a law in 1986 that requires hospital receiving medicare and have an ER to asses, provide treatment and stabilize a patient before determining their ability to pay. An amendment in 1989 requires hospitals to accept transfer of a patient requiring special treatment regardless of ability to pay. FMLA - a law that requires employers (50 or more employees) to provide up to 12 weeks of unpaid job- protected leave in a 12 month period for employees who have worked for at least 1 year for a certain family or medical reason.They may also work fewer hours a week or work day if medical condition warrants. This must be granted for births, adoption, foster care, family is sick, to attend to a serious health condition. Doesn't protect your particular job. When should medication reconciliation be done? - It should be done at each stage of health care delivery:
- Admission
- Status
- Patient transfer within or between facilities/provider teams
- Discharge Discharge follow up calls should include - Review of d/c plan,
