Chapter 2 Health-Care Delivery and Economics

The Healthcare Team

All members of the healthcare team have a common goal of providing quality, cost
efficient care to all patients in order to restore their patients to their optimal level of
functioning and wellness. One way that all members communicate with one another
is during patient care conference which allows discussion of patient needs and
involves input from all team members.
Health-care Delivery
Payment for medical care is most often through one of these three major entities:

Medicare- federal government health insurance program for people over 65

years old
Medicaid- federal state health insurance program for low income families
Private insurance insurance purchased individually or through employer

Case Management- a type of nursing care system that sees each patient as an
individual and each situation as unique
Medicaid- federal government program that helps to pay healthcare for low income
individuals
Medicare- health insurance program for people older than 65 years of age.
Primary Care Physician(PCP)- managed healthcare physician that is paid per
month per member
Third Party Payer- party that pays bills of a beneficiary care for by a physician.

Affordable Care Act

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Preventive care
Young adults can stay on policy till age 28
Tax break for small businesses
No lifetime limits

Healthcare Exchanges
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these exchanges allow people to shop for insurance that offers the best
coverage for them

Factors Guiding Patient Care Decisions

Medically necessary-serves deemed a necessary care for the diagnosis and
treatment to meet optimal level of care
Appropriate level of care- most cost effective, yet safe and effective level of care

Types of Residential Care Facilities

Long Term Care Facility- also called nursing home or convalescent homes, a facility
where residents often live for many years for around the clock care
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24-hour care
For patients with chronic illnesses or disability, particularly older people who
have mobility and eating problems who cannot be cared for at home

Rehabilitation Facility- facility where patient receives intense physical, occupational,

and speech therapy services. May be part of a hospital or free standing facility.
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Must be able to participate in at least 3 hours of therapy per day

Assisted Living Facility- provide relatively independent seniors with assistance and
limited healthcare services in a home-like atmosphere.
Skilled Nursing Facility- a transitional care setting where patients stat for a few
days or as long as 100 days but eventually move to a rehabilitation or long-term
care ex: elderly man falls at home and suffers from a fractured hip, surgery for hip
successful but patient not eating and feeding tube placed. Eventually continues to
eat gradually for about 40 days and then is discharged to go home.
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Usually covered by Medicare and most private insurers

Must be hospitalized for at least 3 days prior to admission
The patient must enter the nursing home within 30 days of a hospitalization
There is a 100-day stay maximum per year to any one hospitalization and
diagnosis
The patient must be making regular progress as demented by the medical
professionals

Acute Care Hospital or Medical Center- provides emergency care, surgeries,

impatient care, diagnosis, and usually some types of outpatient care services.
Long Term Acute Care Hospital- focuses on patients with serious medical problems
that require intense, special treatments for a long period of time, usually about 20
to 30 days. Ex: patient transferred to LTACH for continuous treatment of infection
and ventilator support

Delivery of Nursing Care

Team Nursing- group of health care team members to provide nursing care on a
group of patients. Example: an RN, LPN, CAN or UAP give care and are responsible
for the care of 10 patient

Client-Centered Care- empowers the patient to take control of and manage his or
her care. It allows the patient to achieve independence within limits of their
disability.
Primary Care Nursing- one nurse is responsible for all aspects of nursing care for
their assigned patients. This type of care is mostly given in ICU
Case Management- handles the insurance, workers comp claims for the patient

Healthcare Economics
Medicare ProgramsPart A- insurance for hospitalization, hospice, home health and skilled nursing
facility services
Part B- supplemental health insurance to help pay for lab tests, x-rays, home health
nurses, medical equipment
Part C- Medicare advantage, health insurance plans administered by private
insurance
Part D- Medicare prescription drug coverage
Common Types of Health Insurance Programs
HMO- requires a primary care physician
PPO- provides services for a specific group of patients
POS- needs PCP but is not capitalized and patient can seek care in and out of
network.

Chapter
2: Health Care Delivery and Economics