Structure and Changing Trends in Healthcare System

1. 1. Discuss the structure of the healthcare system and describe ways it is changing • Define the following terms: • providers • people or organizations that provide health care, including doctors, nurses, clinics, and agencies. • facilities • in medicine, places where health care is delivered or administered, including hospitals, long-term care facilities, and treatment centers. • payers • people or organizations paying for healthcare services.

2. 1. Discuss the structure of the healthcare system and describe ways it is changing Define the following terms: long-term care (LTC) care given in long-term care facilities (LTCF) for people who need 24-hour skilled care. skilled care medically-necessary care given by a skilled nurse or therapist. length of stay the number of days a person stays in a healthcare facility. terminal illness a disease or condition that will eventually cause death.

3. 1. Discuss the structure of the healthcare system and describe ways it is changing Define the following terms: chronic illness a disease or condition that is long-term or long-lasting and requires management of symptoms. home health care care that takes place in a person’s home. diagnoses physicians’ determinations of an illness. assisted living residences for people who do not need skilled, 24-hour care, but do require some help with daily care.

4. 1. Discuss the structure of the healthcare system and describe ways it is changing Define the following terms: dementia the serious loss of mental abilities, such as thinking, remembering, reasoning, and communicating. adult day services care for people who need some assistance or supervision during certain hours, but who do not live in the facility where care is given. acute care 24-hour skilled care for short-term illnesses or injuries; generally given in hospitals and ambulatory surgical centers.

5. 1. Discuss the structure of the healthcare system and describe ways it is changing Define the following terms: subacute care care given in a hospital or in a long-term care facility for people who need less care than for an acute illness, but more care than for a chronic illness. outpatient care care given for less than 24 hours for people who have had treatments or surgery and need short-term skilled care. rehabilitation care that is given by specialists to help restore or improve function after an illness or injury.

6. 1. Discuss the structure of the healthcare system and describe ways it is changing Define the following terms: hospice care holistic, compassionate care given to dying people and their families. health maintenance organizations (HMOs) a method of health insurance in which a person has to use a particular doctor or group of doctors except in case of emergency.

7. 1. Discuss the structure of the healthcare system and describe ways it is changing Define the following terms: preferred provider organizations (PPOs) a network of providers that contract to provide health services to a group of people. managed care a system or strategy of managing health care in a way that controls costs.

8. Transparency 1-1: Traditional Healthcare System

9. 1. Discuss the structure of the healthcare system and describe ways it is changing • The following major changes have a serious impact on how health care is provided: • Increased use of expensive technology • Rising costs of health care • New ways to control costs of care

10. 2. Describe a typical long-term care facility Define the following terms: activities of daily living (ADLs) daily personal care tasks, such as bathing; caring for skin, nail, hair, and teeth; dressing; toileting; eating and drinking; walking; and transferring. catheter a thin tube inserted into the body to drain fluids or inject fluids.

11. 2. Describe a typical long-term care facility REMEMBER: There are many different models of long-term care facilities, including facilities for residents with dementia and facilities with assisted living wings.

12. 2. Describe a typical long-term care facility Think about these questions: What services do you think all long-term care facilities offer? What services might some long-term care facilities offer for residents with different needs?

13. Transparency 1-2: Residents in Long-term Care Facilities • 89% are over 65 • 54% are over 85 • 11% are younger than 65 • 70% are female • More than 90% are white and non-Hispanic • About 1/3 come from a private residence • Over 50% come from a hospital

14. 3. Describe residents who live in long-term care facilities Think about this question: Why is important for an NA to know what kinds of residents he will likely be caring for?

15. 3. Describe residents who live in long-term care facilities REMEMBER: Residents with different lengths of stay may have different care needs.

16. 3. Describe residents who live in long-term care facilities Residents with a length of stay of six months or more Make up over 2/3 of residents Require 24-hour care Did not have caregivers able to give enough care at home

17. 3. Describe residents who live in long-term care facilities Residents with a length of stay of less than six months May be admitted for terminal care (will die in the facility) May be admitted for rehabilitation or temporary illness (will recover and return to the community)

18. 3. Describe residents who live in long-term care facilities Think about this question: How might care for a resident admitted for temporary care be different from care for a resident who will live in the facility for years?

19. 3. Describe residents who live in long-term care facilities REMEMBER: Many residents in LTC lack outside support. This means it is very important for NAs to care for the whole person - addressing social and emotional needs as well as physical needs.

20. 4. Explain policies and procedures Define the following terms: policy a course of action that should be taken every time a certain situation occurs. procedure a method, or way, of doing something.

21. 4. Explain policies and procedures The following are common policies and procedures in long-term care facilities: All resident information is confidential. Resident’s care plan must be followed. NAs only perform tasks in job descriptions. NAs report to a nurse. NAs should not discuss personal problems with residents or families. NAs should not accept gifts and money from residents or families. NAs must be dependable.

22. 4. Explain policies and procedures REMEMBER: It is very important for NAs to ask questions about policies and procedures or review the procedure manual when they are unsure about care.

23. 5. Describe the long-term care survey process Define the following terms: cite in a long-term care facility, to find a problem through a survey. Joint Commission an independent, not-for-profit organization that evaluates and accredits healthcare organizations.

24. 5. Describe the long-term care survey process Surveyors use these methods to study residents’ care and determine how their needs are being met: Interview residents and their families Observe staff interactions with residents and care given Review residents’ charts Observe residents’ meals

25. 5. Describe the long-term care survey process Think about these questions: Why is it very important for NAs to tell the truth when asked questions by surveyors? What should an NA do if she doesn’t know the answer to a surveyor’s question?

26. 5. Describe the long-term care survey process REMEMBER: Surveys conducted to the Joint Commission are not affiliated with state inspections. Facilities participate in Joint Commission surveys on a voluntary basis.

27. 6. Explain Medicare and Medicaid Define the following terms: Centers for Medicare & Medicaid Services (CMS) a federal agency within the U.S. Department of Health and Human Services that is responsible for Medicare and Medicaid, among many other responsibilities. Medicare a federal health insurance program for people who are 65 or older, are disabled, or are ill and cannot work. Medicaid a medical assistance program for low-income people.

28. Transparency 1-3: Facts About Medicare and Medicaid Medicare Medicare is for people 65 or older and people under 65 who are disabled and cannot work. Part A helps pay for care in a hospital or skilled nursing facility or for care from a home health agency or hospice. Part B helps pay for doctor services and other medical services and equipment. Part C allows private health insurance companies to provide Medicare benefits. Part D helps pay for medications prescribed for treatment. Medicaid Medicaid is a medical assistance program for low-income people. People qualify based on income and special circumstances.

29. 6. Explain Medicare and Medicaid Home Care Focus Medicare and home care work together in the following ways: Medicare pays for intermittent, not continuous, services. Services must be provided by a certified home health agency. To qualify for home care, Medicare recipients generally must be unable to leave home. Doctors determine whether Medicare recipients need home health care. Medicare will not pay for round-the-clock home care.

30. 7. Discuss the terms culture change and person-directed care and describe Pioneer Network and The Eden Alternative Define the following terms: culture change a term given to the process of transforming services for elders so that they are based on the values and practices of the person receiving care; core values include choice, dignity, respect, self-determination, and purposeful living. person-directed care a type of care that places the emphasis on the person needing care and his or her individuality and capabilities.

31. 7. Discuss the terms culture change and person-directed care and describe Pioneer Network and The Eden Alternative These are the core values of culture change: Choice Dignity Respect Self-determination Purposeful living

32. 7. Discuss the terms culture change and person-directed care and describe Pioneer Network and The Eden Alternative The Pioneer Network Was formed in 1997 by a small group of people in LTC Advocates for person-directed care Called for change in how elders are treated everywhere in the community

33. 7. Discuss the terms culture change and person-directed care and describe Pioneer Network and The Eden Alternative The Eden Alternative Was founded in 1991 by Dr. William Thomas Seeks to improve the lives of elders and their caregivers Creates environments that support growth and development and eliminate loneliness, helplessness, and boredom Offers education, resources, and consulting services

34. Exam Multiple Choice. Choose the correct answer. 1. Which of the following healthcare settings is generally for people who will die in six months or less? (A) Hospice care (B) Long-term care (C) Outpatient care (D) Acute care 2. Which of the following statements is true of long-term care? (A) People with terminal illnesses do not live in long-term care facilities. (B) Most conditions in long-term care facilities are chronic. (C) People who live in long-term care facilities are never able to return home. (D) Long-term care takes place in a person’s home.

35. Exam 3. Where is long-term care offered? (A) In adult day services facilities (B) In hospitals (C) In skilled nursing facilities (D) In ambulatory surgical centers 4. ___________ is care given by specialists to help restore or improve function after an illness or injury. (A) Subacute care (B) Acute care (C) Adult day services (D) Rehabilitation

36. Exam 5. A resident has purchased a special gift for her nursing assistant (NA). What would be the best response by the nursing assistant? (A) The NA should refuse the gift but thank the resident for thinking of her. (B) The NA should accept the gift because she is unsure about her facility’s policy on gifts. (C) The NA should accept the gift if the resident will keep it confidential. The NA should refuse the gift and tell the resident that her employer is very unfair about employees accepting gifts from residents. 6. The abbreviation HMO means (A) Home maintenance organization (B) Health management organization (C) Health maintenance organization (D) Home medical organization

37. Exam 7. The group with the longest average stay in long-term care facilities is (A) Men (B) Developmentally disabled (C) Caregivers (D) Residents with heart disease 8. Which of the following statements is true of acute care? (A) Acute care is normally given in adult day services facilities. (B) One advantage of acute care is people do not have to leave their homes to receive it. (C) Acute care is given to people who do not have a serious illness. (D) Acute care is given in hospitals for people who require immediate care.

38. Exam 9. A ______ is a method or way of doing something. (A) Policy (B) Procedure (C) Survey (D) Cite 10. Medicare will pay for (A) All care requested by the recipient (B) All care requested by the doctor (C) All care requested by the long-term care facility (D) Only care that it determines to be medically necessary

39. Exam 11. _____ is a medical assistance program for low-income people. (A) Medicare (B) Medicaid (C) CMS (D) OSHA 12. Regular inspections performed in facilities to make sure they are following state and federal regulations are called (A) Surveys (B) Citations (C) Procedures (D) Licenses

40. Exam 13. Which of the following is a core value associated with culture change? (A) Doing everything for residents (B) Treating all residents the same way (C) Promoting self-determination and personal choice (D) Making sure all residents participate in the same activities

41. CHAPTER 1 PRACTICE • 1. Which of the following healthcare settings is generally for people who will die in six months or less? • (A) Hospice care • (B) Long-term care • (C) Outpatient care • Acute care • 2. Which of the following statements is true of long-term care? • (A) People with terminal illnesses do not live in long-term care facilities. • (B) Most conditions in long-term care facilities are chronic. • (C) People who live in long-term care facilities are never able to return home. • Long-term care takes place in a person’s home. • 3. Where is long-term care offered? • (A) In adult day services facilities • (B) In hospitals • (C) In skilled nursing facilities • (D) In ambulatory surgical centers

42. CHAPTER 1 PRACTICE-ANSWERS • A-HOSPICE CARE • B-MOST CONDITIONS IN LONG-TERM FACILITIES ARE CHRONIC • C-IN SKILLED NURSING FACILITIES