CERTIFIED
PROFESSIONAL PRACTICE – 17% (30 QUESTIONS) Terms & Definitions •Health People 2010 – to improve access too comprehensive, quality, primary care services. Goals: o Increase the quality and years of healthy life o Eliminate health disparities among Americans Goal to Promote Quality Health, Healthy Development and Health Behavior across the lifespan. •Health People 2020 - The program is an initiative that develops evidence-based practice objectives designed to improve the health of all Americans. These objectives are targeted to be followed over a 10-year period 4 foundational healthcare measures Biological, social, environmental factors and their interrelationships – influence on individuals and communities which inhibit progress towards goals. 1.General health status 2.Health-related quality of life & well-being 3.Determinants of Health – aim to create social & physical environments that promote good health for all 4.Reduce Health Disparities •The Consolidated Omnibus Budget Reconciliation Act (COBRA) (Title 1 of HIPAA) COBRA provides continuous or pre-existing group insurance coverage from the employer for the individual who looses their coverage by loss of job, quitting job, or are fired for a fixed period of time. Allows an individual to keep their insurance as long at they pay the premium to eliminate gaps in coverage for the individual •Preferred Provider Organization (PPO) The patient can visit any provider in the network without a referral. Not assigned a PCP (as in an HMO) The patient can choose his or her own PCP – no referral Is needed for a specialist if within the PPO organization. Usually more expensive coverage than HMO. •Health Maintenance Organization. (HMO) Patient is assigned a PCP who coordinates all care. PT has a set copayment for each visit; Provider is paid a set fee (per month) and receives a monthly check from the organization. 1 Specialist and consultations must be approved in advance and within the network organization. Those who were outside of this criteria our out of network or not referred by the PCP will not be reimbursed or not be reimburse at the full rate resulting in responsibilities of payment being shifted to the patient. • Electronic Medical Record (EMR) – Pros: allows for sharing of health information between healthcare entities & with
patients, thereby reducing the cost of care, improving care efficiency, avoiding readmission and decreasing duplicate testing. Cons: the potential for data loss in the event of computer or system failure • Medicaid - a government health insurance program for low-income individuals funded by federal & state entities and
administered by the state. * Varies from state-to-state. Formed by Title XIV from Social security act – Federal and state matching program. Covers families who are at poverty level, children, pregnancy, and individuals with disabilities such as blindness. Pays for health care and prescription drugs. • Medicare – Only for those who have paid premiums. If you don’t qualify you can get Medicare part B and D with premiums. The program is federally funded health insurance program for those >65yrs, those with severe disability no matter income level, or those with ESRD at any age. Qualifying conditions: US citizen, non-US citizens after 5 years
of permeant residence in the US, veterans are eligible after 65yrs. 2 • Religious exemptions for some – Amish Mennonite. A.Medicare Part A covers medically necessary inpatient care and supplies; skilled nursing facility (if medically necessary such as for dressing changes or rehab) Home health and hospice. Pays for all care related to a hospital admission and recovery. Patient has surgery – needs skilled nursing facility for rehab. Inpatient care including psychiatric hospitalization. WILL NOT pay for Custodial care – Nursing homes, Retirement homes. B.Medicare Part B (Voluntary program with required monthly premium)-(OUTPATIENT INSURANCE) Outpatient
visits – including walk in clinics, Urgent Care clinics, ER visits, Primary care visits. Laboratory service, x-ray, CT, EKG. Covers nursing home/custodial care (ADL’s), home health services, durable medical equipment (wheelchairs and walkers), out patient care & preventative services (i.e. 1 mammogram every 12 months) in women 40 and older. 3 Pays for preventative services – Flu Shot yearly, Pheumovax once in a lifetime, Screening colonoscopy or flexible sigmoidoscopy age 50 or older ever 10 years for low risk. Routine pap every 2 years – every 12 months for high risk. Yearly prostrate screening after age 50. Lipid and cardiovascular screening every 5 years. HIV screening, Yearly physical exam, Smoking Cessation. Part B DOES NOT cover eyeglasses (except following cataract surgery that implants an intraocular lens) or routine dental care. Does not cover OTC meds and most prescription drugs – cosmetic surgery – hearing aids, The Barthel Index is a measurement of ability to perform ADL’s C.Medicare Part C – HMO Medicare Advantage Plans. Available to those who have Part A and B but still requires premiums, Generally Covers Dental, vision, hearing, and prescription drugs. Requires use of doctors who participate in the system. D.Medicare Part D covers prescriptions – Only individuals who have Medicare type A or B (or both) are eligible. All plans have preferred drugs – formulary drugs. If a non-formulary drug is use the patient has to pay for it. . •A single payer healthcare system refers to a system where in essence the government runs a nationwide insurance plan that pays for all healthcare costs of its members. The American Nurses Association (ANA) Code of Ethics for Nurses Code is nonnegotiable and has an obligation to uphold and adhere to the code of ethics. Legal Issues •Ombudsman – Person who acts as in intermediary or liaisons between patient and organization (long term care or nursing homes, hospitals, governmental agencies, courts) Represents the patient and represents the best interest of the patient. •Guardian Ad Litem Court appointed guardian who is assigned by the courts and has the legal authority to act in the best interest in the “ward” The Ward is usually a person who is a child, frail, or vulnerable. 4
PROFESSIONAL PRACTICE – 17% (30 QUESTIONS) Terms & Definitions •Health People 2010 – to improve access too comprehensive, quality, primary care services. Goals: o Increase the quality and years of healthy life o Eliminate health disparities among Americans Goal to Promote Quality Health, Healthy Development and Health Behavior across the lifespan. •Health People 2020 - The program is an initiative that develops evidence-based practice objectives designed to improve the health of all Americans. These objectives are targeted to be followed over a 10-year period 4 foundational healthcare measures Biological, social, environmental factors and their interrelationships – influence on individuals and communities which inhibit progress towards goals. 1.General health status 2.Health-related quality of life & well-being 3.Determinants of Health – aim to create social & physical environments that promote good health for all 4.Reduce Health Disparities •The Consolidated Omnibus Budget Reconciliation Act (COBRA) (Title 1 of HIPAA) COBRA provides continuous or pre-existing group insurance coverage from the employer for the individual who looses their coverage by loss of job, quitting job, or are fired for a fixed period of time. Allows an individual to keep their insurance as long at they pay the premium to eliminate gaps in coverage for the individual •Preferred Provider Organization (PPO) The patient can visit any provider in the network without a referral. Not assigned a PCP (as in an HMO) The patient can choose his or her own PCP – no referral Is needed for a specialist if within the PPO organization. Usually more expensive coverage than HMO. •Health Maintenance Organization. (HMO) Patient is assigned a PCP who coordinates all care. PT has a set copayment for each visit; Provider is paid a set fee (per month) and receives a monthly check from the organization. 1 Specialist and consultations must be approved in advance and within the network organization. Those who were outside of this criteria our out of network or not referred by the PCP will not be reimbursed or not be reimburse at the full rate resulting in responsibilities of payment being shifted to the patient. • Electronic Medical Record (EMR) – Pros: allows for sharing of health information between healthcare entities & with
patients, thereby reducing the cost of care, improving care efficiency, avoiding readmission and decreasing duplicate testing. Cons: the potential for data loss in the event of computer or system failure • Medicaid - a government health insurance program for low-income individuals funded by federal & state entities and
administered by the state. * Varies from state-to-state. Formed by Title XIV from Social security act – Federal and state matching program. Covers families who are at poverty level, children, pregnancy, and individuals with disabilities such as blindness. Pays for health care and prescription drugs. • Medicare – Only for those who have paid premiums. If you don’t qualify you can get Medicare part B and D with premiums. The program is federally funded health insurance program for those >65yrs, those with severe disability no matter income level, or those with ESRD at any age. Qualifying conditions: US citizen, non-US citizens after 5 years
of permeant residence in the US, veterans are eligible after 65yrs. 2 • Religious exemptions for some – Amish Mennonite. A.Medicare Part A covers medically necessary inpatient care and supplies; skilled nursing facility (if medically necessary such as for dressing changes or rehab) Home health and hospice. Pays for all care related to a hospital admission and recovery. Patient has surgery – needs skilled nursing facility for rehab. Inpatient care including psychiatric hospitalization. WILL NOT pay for Custodial care – Nursing homes, Retirement homes. B.Medicare Part B (Voluntary program with required monthly premium)-(OUTPATIENT INSURANCE) Outpatient
visits – including walk in clinics, Urgent Care clinics, ER visits, Primary care visits. Laboratory service, x-ray, CT, EKG. Covers nursing home/custodial care (ADL’s), home health services, durable medical equipment (wheelchairs and walkers), out patient care & preventative services (i.e. 1 mammogram every 12 months) in women 40 and older. 3 Pays for preventative services – Flu Shot yearly, Pheumovax once in a lifetime, Screening colonoscopy or flexible sigmoidoscopy age 50 or older ever 10 years for low risk. Routine pap every 2 years – every 12 months for high risk. Yearly prostrate screening after age 50. Lipid and cardiovascular screening every 5 years. HIV screening, Yearly physical exam, Smoking Cessation. Part B DOES NOT cover eyeglasses (except following cataract surgery that implants an intraocular lens) or routine dental care. Does not cover OTC meds and most prescription drugs – cosmetic surgery – hearing aids, The Barthel Index is a measurement of ability to perform ADL’s C.Medicare Part C – HMO Medicare Advantage Plans. Available to those who have Part A and B but still requires premiums, Generally Covers Dental, vision, hearing, and prescription drugs. Requires use of doctors who participate in the system. D.Medicare Part D covers prescriptions – Only individuals who have Medicare type A or B (or both) are eligible. All plans have preferred drugs – formulary drugs. If a non-formulary drug is use the patient has to pay for it. . •A single payer healthcare system refers to a system where in essence the government runs a nationwide insurance plan that pays for all healthcare costs of its members. The American Nurses Association (ANA) Code of Ethics for Nurses Code is nonnegotiable and has an obligation to uphold and adhere to the code of ethics. Legal Issues •Ombudsman – Person who acts as in intermediary or liaisons between patient and organization (long term care or nursing homes, hospitals, governmental agencies, courts) Represents the patient and represents the best interest of the patient. •Guardian Ad Litem Court appointed guardian who is assigned by the courts and has the legal authority to act in the best interest in the “ward” The Ward is usually a person who is a child, frail, or vulnerable. 4
