Chapter 3: Health Care Settings


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Chapter 3: Health Care Settings

  1. 1. Chapter 3: Health Care Settings Feipei Lai National Taiwan University
  2. 2. 2 Objectives  Define hospital categories  Identify types of hospital patients  Differentiate among freestanding, hospital-based, and hospital-owned ambulatory care settings  Distinguish among various types of behavioral health care facilities
  3. 3. 3 Journal  nals/ijmi/
  4. 4. 4 Diagnosis-related groups (DRGs)  Classify inpatient hospital cases into groups that are expected to consume similar hospital resources.
  5. 5. 5 Australian National Diagnosis Related Groups (AN-DRGs)  To ensure the clinical coherence of AN-DRGs, every effort is made to assign each episode of care to one of 23 Major Diagnostic Categories ( MDCs).  Most MDCs are defined by body system or disease type, and correspond with a particular specialty.
  6. 6. 6 Acute Care Facilities  An acute care facility is a hospital that provides health care services to patients who have serious, sudden, or acute illnesses or injuries and/or who need certain surgeries.
  7. 7. 7 Acute Care Facilities  ACFs provide a full range of health care services, including ancillary services, emergency and critical care, surgery, obstetrics, and so on.
  8. 8. 8 Acute Care Facilities  Single hospitals  Multi-hospital systems  Two or more hospitals owned, managed, or leased by a single organization  Ancillary services  Diagnostic  Therapeutic  Acute care/short-term care  Long-term care
  9. 9. 9 Bed size  The hospital bed size is the total number of inpatient beds for which the facility is licensed by the state; the hospital must be equipped and staffed to care for these patient admissions.  8:1 medical center  10:1 regional hospital
  10. 10. 10 Hospital Categories  Critical access hospitals (CAH)  Located more than 35 miles from any other hospital or another CAH, or they are state certified as being a necessary provider of health care to area residents. Mileage criteria is reduced to 15 miles in areas where only secondary roads are available or in mountainous terrain.  General hospitals  Specialty hospitals  Rehabilitation hospitals  Behavioral health care hospitals
  11. 11. 11 General hospitals  Provide emergency care, perform general surgery, and admit patients for a range of problems from fractures to heart disease.
  12. 12. 12 Specialty hospitals  Concentrate on a particular population of patients or disease category.
  13. 13. 13 Rehabilitation hospitals  Admit patients who are diagnosed with trauma (e.g., car accident) or disease (e.g., stroke) and need to learn how to function.
  14. 14. 14 Behavioral health care hospitals  Specialize in treating individuals with mental health diagnoses.
  15. 15. 15 Hospital Patients  Ambulatory patients (outpatients)  Ambulatory surgery patients (day surgery)  Emergency care patients  Inpatients  Newborn patients  Observation care patients  Subacute care patients
  16. 16. 16 Ambulatory patients (outpatients)  Are treated and released the same day and do not stay overnight in the hospital.
  17. 17. 17 Ambulatory surgery patients (day surgery)  Undergo certain procedures that can be performed on an outpatient basis, with the patient treated and released the same day.
  18. 18. 18 Emergency care patients  Are treated for urgent problems and are either released the same day or admitted to the hospital as inpatients.
  19. 19. 19 Inpatients  Are provided with room and board and nursing services.
  20. 20. 20 Newborn patients  Receive infant care upon birth and if necessary they receive neonatal intensive care.
  21. 21. 21 Observation patients  Receive services furnished on a hospital’s premises that are ordered by a physician or other authorized individual, including use of a bed and periodic monitoring by nursing or other staff, which are reasonable and necessary to evaluate an outpatient’s condition or determine the need for a possible admission as an inpatient.
  22. 22. 22 Subacute care  Is provided in hospitals that provide specialized long-term acute care such as chemotherapy, injury rehabilitation, ventilator (breathing machine) support, wound care, and other types of health care services provided to seriously ill patients.
  23. 23. 23 Ambulatory and Outpatient Care  Allows patients to receive care in one day without the need for inpatient hospitalization.
  24. 24. 24 Ambulatory and Outpatient Care  Ambulatory surgical centers (freestanding)  Hospital-based outpatient department  Hospital-based emergency department  Hospital-based ambulatory surgery  Hospital-based partial hospitalization program  Hospital-owned satellite clinics
  25. 25. 25 Ambulatory and Outpatient Care  Industrial health clinics  Neighborhood health centers  Physician offices  Public health departments  Satellite clinics  Staff model health maintenance organization  Urgent care centers
  26. 26. 26 Freestanding Centers and Facilities  Ambulatory Surgical Center (ASC)  Clinical laboratory  Heart and vascular center  Staff model health maintenance organization (HMO)  Imaging center  Industrial health clinic
  27. 27. 27 Freestanding Centers and Facilities  Infusion center  Neighborhood health center  Pain management center  Physician office  Primary care center  Public health center  Urgent care center
  28. 28. 28 Infusion center  Freestanding center that dispenses and administers prescribed medications by continuous or intermittent infusion to ambulatory patients.
  29. 29. 29 Hospital-based departments and programs  Ambulatory surgery  Outpatient department  Emergency department  Partial hospitalization program
  30. 30. 30 Hospital-owned facilities  Hospital-own physician practice  At least partially owned by the hospital, and the physician participate in a compensation plan provided by the hospital.  Satellite clinics  Ambulatory care centers that are established remotely from the hospital.
  31. 31. 31 Alternate Care Facilities  Behavioral health care facilities  Home care and hospice  Long-term care  Managed care – to control cost
  32. 32. 32 Managed care  Originally referred to the prepaid health care sector (e.g., HMOs), which combined health care delivery with the financing of health care services.  Increasingly referred to preferred provider organizations (PPOs) and some forms of indemnity coverage that incorporate utilization management activities.
  33. 33. 33 Behavioral health care  Chemical dependency program  Crisis service  Day treatment program  Developmentally disabled/mentally retarded facilities  Emergency care facilities  Family support services  Home health care
  34. 34. 34 Behavioral Health Care  Hospital treatment  Intensive case management  Outpatient clinic  Partial hospitalization program  Residential treatment facility
  35. 35. 35 Behavioral Health Care  Respite care  Patient care provided in the home or institution intermittently in order to provide temporary relief to the family home care giver.  Therapeutic group home  Any group of patients meeting together for mutual psychotherapeutic, personal development, and life change goals.
  36. 36. 36 Home care and hospice  Home care allows people who are seriously ill or dying to remain at home and receive treatment from nurses, social workers, therapists, and other licensed health care professionals who provide skilled care in the home.
  37. 37. 37 Skilled care  Includes services that are ordered by a physician and provided under the supervision of a registered nurse, or physical, occupational, or speech therapist.  Skilled care service include:  Assessment/monitoring of illnesses  Intravenous (IV) and medication administration  Insertion of catheters 導管  Tube feedings  Wound care
  38. 38. 38 Home care and hospice  Home health care also covers the use of durable medical equipment (DME), which includes the following:  Canes  Crutches ( 架在腋下的 ) 拐杖  IV supplies  Hospital beds  Ostomy supplies 人工肛門  Oxygen  Prostheses 義肢  Walkers  Wheelchairs
  39. 39. 39 Personal care and support services  Provide assistance in performing daily living activities  Bathing  Dressing grooming  Going to the toilet  Mealtime assistance  Travel training  Accessing recreation services
  40. 40. 40 Home infusion care  Provided by home health care agencies when intravenous administration of medication is medically appropriate for the patient’s condition, and treatment is administered in the home instead of on an inpatient hospital basis.  E.g. chemotherapy, drug therapy, hydration therapy, pain management, total parenteral nutrition (TPN) 非經腸
  41. 41. 41 Hospice care  Provides comprehensive medical and supportive social, emotional, and spiritual care to terminally ill patients and their families.  The goal of hospice is palliative care (comfort management) rather than curative care (therapeutic).
  42. 42. 42 Long-term care  Includes a range of nursing, social and rehabilitative services for people who need on-going assistance.
  43. 43. 43 Managed care models  Exclusive provider organization (EPO)  Integrated delivery system (IDS)  Group practice without walls (GPWW)  Medical foundation  Integrated provider organization (IPO)  Management service organization (MSO)  Physician-hospital organization (PHO)
  44. 44. 44 Exclusive provider organization (EPO)  Provides benefits to subscribers who receive health care services from the network providers, which are physicians and health care facilities under contract to the managed care plan.
  45. 45. 45 Integrated delivery system (IDS)  An organization of affiliated provider sites that offer joint health care services to subscribers.
  46. 46. 46 Group practice without walls (GPWW)  Managed care contract in which physicians maintain their own offices and share services to plan members.
  47. 47. 47 Medical foundation  Nonprofit organization that contracts with and acquires the clinical and business assets of physician practices.
  48. 48. 48 Integrated provider organization (IPO)  Manages health care services provided by hospitals, physicians, and other health care organizations.
  49. 49. 49 Management service organization (MSO)  Provides practice management services, including administrative and support services, to individual physician practices.
  50. 50. 50 Physician-hospital organization (PHO)  Managed care contracts are negotiated by hospital(s) and physician groups.  Physicians maintain their own practices and provide service to plan members.
  51. 51. 51 Managed care models  Health Maintenance Organization (HMO)  Group model HMO  Staff model HMO  Direct contract model HMO  Individual practice association (IPA)  Network model HMO
  52. 52. 52 Group model HMO  Participating physicians who are members of an independent multi- specialty group provide health care services.  Physician groups either contract with the HMO or they are owned or managed by the HMO.
  53. 53. 53 Staff model HMO  Physicians are employed by the HMO, premiums are paid to the HMO, and usually all ambulatory care services are provided within HMO corporate buildings.
  54. 54. 54 Direct contract model HMO  Individual physicians in the community deliver contracted health care services to subscribers.
  55. 55. 55 Individual practice association (IPA)  Physicians who remain in their independent office settings provide contracted health care services to subscribers.  The IPA negotiates the HMO contract and manages the capitation payment.
  56. 56. 56 Network model HMO  Two or more physician multi-specialty group practices provide contracted health care services to subscribers.
  57. 57. 57 Managed care models  Point-of-Service Plan (POS)  Preferred provider organization (PPO)  A network of physicians and hospitals join together to contract with third-party payers, employers, and other organization to provide health care to subscribers for a discounted fee.  Triple option plan  Provides subscribers and employees with a choice of HMO, PPO, or traditional health insurance plan.
  58. 58. 58 Federal, State, and Local Health Care  Correctional facilities  Military Health System (MHS)  Veterans Health Administration (VHA)  U.S. Public Health Service (PHS)
  59. 59. 59 U.S. Public Health Service (PHS)  Administration for Children and Families (ACF)  Administration on Aging (AoA)  Agency for Healthcare Research and Quality (AHRQ)  Agency for Toxic Substance and Disease Registry (ATSDR)  Centers for Disease Control and Prevention (CDC)
  60. 60. 60 U.S. Public Health Service (PHS)  Food and Drug Administration (FDA)  Health Resources and Services Administration (HRSA)  Indian Health Service (IHS)  National Institutes of Health (NIH)  Office of Public Health and Service (OPHS)  Office of the Secretary of Health and Human Services (OS)  Program Support Center (PSC)  Substance Abuse and Mental Health Services Administration (SAMHSA)